Duke Medical School is now operating in Singapore. The Mayo Clinic has opened a new campus in Dubai. And Harvard has forged an alliance for a for-profit hospital in India. Top quality medicine is now a global product and traditional centers of excellence such as Houston, Chicago and Philadelphia are competing for physicians and patients with well-funded emerging medical complexes in Asia and the Middle East.
But is it business-as-usual? Are the facilities and the people who run them designed, funded and operated the same way as in North America? The answer is yes, and no — design for medical innovation around the globe is in many ways the same, but with sometimes subtle adjustments that tune this international product to the needs, preferences and pre-occupations of the local situation.
Do these exotic healthcare projects hold interest for us here in North America? The answer is yes; current replacement hospital, medical school, research laboratory and healthcare campus development projects in Singapore are providing lessons in sustainability, communicable disease response, practice re-organization, and design for staffing that we are applying to our work in Alabama, North Carolina and New Jersey.
Sustainability and energy conservation are now mainstream concerns to healthcare providers around the world. In the United States, the United States Green Building Council is preparing a specialized rating program for healthcare facilities. Sustainable design inspiration doesn't just come from a guidebook; location, weather and energy availability are often driving factors in sustainable projects abroad.
As an island nation whose only significant natural resource is its people, Singapore prioritizes energy efficiency as a key element in its national defense strategy. Singapore has created its own version of Leadership in Energy and Environmental Design called GreenMark; the national government actively encourages developers and designers toward sustainable designs. The 400,000-sq.-ft. Yong Loo Lin School of Medicine at the National University of Singapore will achieve Green Mark Gold through a combination of passive and active design features, including a high-performance exterior envelope, air handling units with heat recovery, locally-produced sustainable materials and finishes, water conserving toilet fixtures and naturally ventilated circulation spaces between shaded exterior arcades and air-conditioned functional spaces.
Applying these lessons at home, Duke University Medical School's new research building does double-duty as a high-tech advanced laboratory designed to Leadership in Energy and Environmental Design Silver status. The Medical Science Research Building II isn't your average green building. The five-story, 160,000-sq.-ft. laboratory facility implements sustainable building practices that conserve energy, minimize waste and utilize environmentally friendly building materials — an effort to counteract the notoriously high energy usage of typical laboratory buildings. By using a wide range of sustainable systems and materials, MSRB-II uses 35 percent less energy than a similar lab building — enough to power 100 average sized homes for a year — saving the university more than $200,000 annually.
Communicable disease response
Preventing the accidental transmittance of communicable diseases or infection in the course of operations is a major liability and economic concern for administrators, physicians and insurers. Policies and prevention can only go so far; how can design assist?
For the 550-bed, 1,100,000-sq.-ft. Khoo Teck Puat Hospital, communicable disease response focuses on isolation against unknown pathogens and decontamination facilities against large scale threats. Following Singapore's serious bout with SARS in 2003, the Ministry of Health revised operational guidelines for isolation. Patients and visitors entering Khoo Teck Puat's accident and emergency departments will undergo passive thermal scans as part of a triage area that separates flow into two paths — one for non-infectious individuals, another for those potentially infected. The latter will be directed to an isolation zone within accident and emergency.
At a large teaching hospital in New Jersey, the focus is more every day on the coming and goings in the project's 100+ exam and procedure rooms. Working together with staff, we're considering same-handedness, where all rooms of a given type have the same internal layout from the point of entry. Pioneered in patient bedrooms, the project team believes extending the principle of unconscious predictability to outpatient areas will reinforce good behavior regarding gloving, gowning and hand washing and lower incidence of infection.
How can we make healthcare simultaneously more personalized and more efficient? By changing to a patient's-eye-view of healthcare interactions and considering new technologies. Practice reorganization aims to do both.
Toyota's Kaizen approach was chosen by Khoo Teck Puat Hospital staff to begin their programming and planning effort. For a full year before we were engaged, each department examined all types of patient, staff, goods and information flow. The result was a combination of spaghetti diagrams that charted flow, decision-tree charts that examined interactions from the patient's point of view and three-dimensional models made of Lego bricks and clay. Armed with this practice reorganization self-generated knowledge, staff were much better prepared to partner with us in the design phase to evaluate whether our ideas would achieve their objectives.
At the University of South Alabama Mitchell Cancer Institute, almost complete in southern Alabama, we've applied practice reorganization to the process of translational medical research. Transparency is the theme; patient clinical care areas, educational facilities and research laboratories are connected by a multi-story entry and lobby space. The result emphasizes the direct connection between research and treatment, creating an atmosphere of urgency and hope.
Design for staffing
When the American Association of Retired Persons recently published their study, “Who Will Care for You?,” they granted public recognition to a problem hospitals have been dealing with for years — shortage of qualified staff able to be assigned to the right place at the right time with the right training.
Not only are staff in short supply, but the growth in team-based medicine and growth in non-invasive treatments results in the frequent change in patient status even during a short stay. With patients potentially transitioning from critical-to-stable-to-good within 18 hours, resources are no longer available to staff complete stand-alone units whose occupancy fluctuates daily.
Yong Loo Lin vertically combines research, teaching and clinical care facilities with the aim of improving the efficiency of Medical School staff. Battling the horizontal layout within the adjacent University Hospital, physicians waste time moving from patient care areas to labs to lecture theatres across the street. Yong Loo Lin's MD6 building stacks these three functions, particularly the two-floor Virtual Hospital for teaching and two floors of Clinical Trials facilities, including a National Imaging Centre.
For the teaching hospital we're designing in New Jersey, our design response focuses on flexibility and changeability of nursing unit size. Instead of three discreetly designed nursing units with boundaries fixed by stairs and elevator cores, the new nursing floor uses subtle formal distinctions to create core bed zones with flexibly-assignable bed modules between. The result is greater responsiveness, as unit size becomes much more fluid and able to respond to staffing requirements as well as changing disease patterns. Patients will benefit from the new arrangement because the variable acuity rooms will allow many of them to stay in one place, avoiding the stress (and medical risks) of intra-hospital transfer.
Some parts of the world may be flat — IT and finance platforms translate surprisingly well across borders — but healthcare provision isn't there yet. As diseases and threats remain specific to countries and locales, so too must healthcare techniques. However, these techniques can start to feed together in larger global strategies to address international issues, such as sustainable design, staffing and disease prevention. HBISteve Gifford is a principal in the New York City office of RMJM Hillier, an international design firm headquartered in Edinburgh, Scotland. Mitch Green leads the healthcare planning for RMJM Hillier's New York office. They can be reached at 212.629.4100. Healthcare Building Ideas 2007-08 December-January;4(2):60-62