Known for its modern architecture, manicured landscaping, and business friendly climate, Singapore, a country roughly three times the size of Washington, DC, may soon have another reason to boast: It's working to create one of the most advanced healthcare systems in the world. In 2003, Singapore Medicine, a multiagency government initiative, outlined a plan to develop Singapore into one of Asia's leading destinations for healthcare services. As in the United States, major drivers include a surge in the aging population, longer life expectancies, and anticipated population growth.

Singapore's scrape with SARS in 2003, its challenging climate of year-round high humidity and average 85°F temperatures, and its proximity to politically delicate situations have added complexity to government plans for healthcare innovation and leadership modernization. With environmental conditions and geopolitical tensions as part of the equation, Singapore's healthcare institutions are now exploring some of the most advanced sustainable design techniques, disease control practices, and security measures in the world. A prime example is the new Alexandra Hospital @ Yishun, currently on the boards at Hillier Worldwide Architecture and CPG Consultants Pte, Ltd. The 102,245-square-meter, 550-bed replacement hospital is being designed to enhance patient care and staff efficiency as a “hassle-free” hospital. It will be a model of energy-efficient design, planned to consume less than half the average kilowatt hours per bed per month when compared to the current Singapore average. The hospital will mark a shift in attitude from treatment to prevention, including prominently located outpatient facilities which feature a “Healthy Living” zone complete with a Geriatric Center, a Rehabilitation Suite, a Sports Injury Center, and a Wellness Center.

Alexandra Hospital also breaks new ground in sustainability and disaster preparedness-issues that resonate deeply with U.S. healthcare institutions, many of which are already grappling with rising energy costs and potential biological threats. With its novel approach to climate control, disease, and disaster management, Alexandra Hospital will become a model of state-of-the-art facility design for healthcare institutions in the United States and around the world.

The Healthcare Hub of Asia

Singapore's evolution into a leading healthcare destination for Asia has much to do with its geographic location, technologic sophistication, and desire to maintain national competitiveness among Asian economies.

Following its independence in 1965, Singapore launched a rapid industrialization program and became a major economic hub for Southeast Asia. As national wealth increased, the government invested in the modernization of its healthcare infrastructure. Since the late 1980s, the country has seen a steady increase in the number of international patients, according to the government. By 2003, with Singapore's reputation solidified as the top quality healthcare provider in East Asia, the number of international patients had climbed to over 200,000. By 2012, the government expects Singapore to treat as many as one million international and domestic patients per year.Singapore now aims to use its improving capabilities in healthcare delivery to lead innovation in biomedical research, translational medicine, and pharmaceutical development. Advances will benefit the health of all Singaporeans, foster an entrepreneurial climate, and generate new high-tech jobs.

The reconstruction of Alexandra Hospital @ Yishun as part of this healthcare infrastructure upgrade is an essential part of this new policy. However, national concerns for energy independence, disease prevention, and emergency preparedness are sometimes conflict with the design process. In addition to satisfying goals for patient convenience and efficiency, the design team is also producing a project that will use half as much energy as existing hospitals, be capable of immediate identification of communicable diseases, and continue to function even in times of dire emergency.

A Hospital that Breathes

Singapore's year-round hot and humid climate poses a particular challenge to healthcare providers. To minimize operating costs and maximize resources available for patient care, the architects incorporated ventilation and exterior envelope strategies as part of a total building performance design. The result will be a permeable, “breathing” building that will allow air flow both horizontally and vertically throughout the building.

A major factor in minimizing hospital energy consumption is reducing the overall amount of the building that needs to be mechanically cooled. Through careful building orientation, exterior detailing, and interior planning, only 30% of Alexandra Hospital will require air conditioning. These air-conditioned portions of the building, such as operating rooms and laboratories, will be colocated to minimize their external surfaces and heat gain. Ancillary spaces, such as balconies and circulation routes, are designed to be naturally ventilated. Green roofs, green walls, and landscaping will also be used to help lower heat gain.

Building orientation and high performance exterior envelopes are critical to achieving this goal. Alexandra Hospital's east-west façades will be fitted with intricate sunscreens to shield the perimeter from direct sunlight. Meanwhile, fenestrations on the north and south faces, which receive less sun, will incorporate light shelves to redirect light deeper into the building and reduce heat gain from artificial lighting. Portions of the building will also be shaded by deep overhangs to remain largely transparent and maximize daylight and views.

Alternative energy sources are another part of the strategy. Alexandra Hospital's on-site cogeneration plant will be the first of its kind in a major public building in Singapore. Designed to handle both base electrical and cooling loads, the gas-fired cogeneration plant will satisfy Alexandra Hospital's needs 15 hours a day, freeing it from reliance on the electricity grid. Only during peak weekday usage will electricity from the grid be required to supplement the cogeneration plant. The plant efficiency will be boosted by a full complement of exhaust gas heat-recovery systems.

A First Line of Defense

Singapore learned a tough lesson when it was almost shut down by SARS in 2003. The country has since become vigilant about controlling infectious disease, particularly in light of avian flu threats. Singapore's Ministry of Health recently committed over S$205 million to develop hospital “clusters” specifically designed to treat infectious diseases.

A major challenge in designing Alexandra Hospital was to create a facility that would maintain hospital operations even during infectious disease outbreaks and enhance the hospital's ability to identify potential threats before they escalate. To answer this challenge, the design team first investigated how and where people enter hospitals.

As in the United States, the majority of inpatients-85%-come directly through the emergency department while only 15% enter through prescheduled appointments. The design philosophy of the hospital reflects that the emergency department becomes the de facto front door to the hospital.

Having a single public-access point can also be the key to isolating potential biological threats. With these factors in mind, the project team established an entry protocol and an accompanying layout to facilitate the identification and isolation of infected individuals.From Alexandra Hospital's main entrance, all patients and visitors will undergo passive thermal scans before moving to a triage area that separates into two paths-one for noninfectious individuals, another for those potentially infected. The latter will be directed through three decontamination units before presenting in an isolation ward with negative airflow.

Converting for Crises

Natural disasters like Hurricane Katrina and the December 2004 tsunami, as well as the threat of political disasters, are testing hospital capacities and disaster preparedness plans around the world.

After 9/11, the United States crafted provisions for surge hospitals-facilities designed to supplement existing hospitals during large-scale emergencies. Based on Israeli models, Singapore has gone one step further by subtly incorporating protected facilities into their new hospitals to buttress the hospital's role in a national emergency response and maintain key functions during direct attack.

In Alexandra Hospital, the 10,000-square-meter Hospital Protected Vital Facilities (HPVF) will be located two floors below grade and operate on a completely separate mechanical and electrical system. During regular operation, the facility will house ambulatory surgery units and a parking structure. In emergencies, the HPVF can be quickly and securely transformed into a fully functioning hospital complete with operating theaters, diagnostics services, inpatient wards, and a civil defense shelter.

As political forces, healthcare demands, and design aesthetics continue to influence hospital architecture and operating procedures, hospital and government officials will continue to look for the next innovative step. Singapore, with its technological ingenuity and political savvy, is leading the way. HD

Steve Gifford, AIA, is Managing and Planning Principal at the New York City office of Hillier Architecture, an international design firm. Mitch Green, AIA, is director of Healthcare Planning at Hillier's New York office. Jesse McCarter is an associate at Hillier's New York office.

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Healthcare Design 2006 October;():26-30