Hospitals and Nursing Homes: Planning, Organisations and Management Syed Amin Tabish
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1Healthcare Facility Planning: Past, Present and Future
Health is a social value. This is reflected in provision of services, which need to consider ethical and philosophical issues as well as medical-scientific and medical-behavioral issues. Concern for the care of the human being as a whole in the hospital needs contribution of all the human services.
The Hospital should reflect the rhythm of the local culture, civilization and historical heritage and simultaneously be flexible enough to accommodate modern methods of health-care facilities.
The planning of any segment of the health service system should be determined by and shaped around the life patterns and value systems of the population to be served.
Growth
• The Art and Science of Medicine 3
• The Hospital 9
• Hospital Organization and Structure 20
• Growth of the Modern Hospital 36
• Changing System of Health Services Concepts 62
• Changing Concepts in the Health Facility Planning 70
2Planning
• Regional Planning
– The planning organization machinery 88
• Planning Health Facilities 93
• Renovation 101
• The Process of Planning 104
Emerging Approaches
• Towards Total Health Care 120
• The Patient-centred Approach 125
• Patient-focused Hospital 127
• Emerging Approaches in Hospital Design 142
• Nucleus Concept 152
• Modular Building Concept 156
• Hospital Modernization 158
• Cutting Construction Costs163
Recent Trends
• Humanising Health Care Facilities 166
• Autonomous Health Care Facilities 168
• Recent Trends in Hospital Architecture 170
• Furure Trends 183
• The Hospital of Tomorrow 188

The Art and Science of Medicine1

Growth
Health is a social value. This is reflected in provision of services, which need to consider ethical and philosophical issues as well as medical-scientific and medical-behavioral issues.
Medicine and other subjects associated with health have a fascinating story, reaching far into the past, and progressing with increasing speed after innumberable false starts and tragic disappointments.
Medicine deals with health and disease. Four phases are discernible in its history: (1) primitive ignorance and superstition with resulting fear of disease; (2) accumulation of experience in managing disease, culminating in a professional group specially trained in ministering to the sick; (3) gradual growth of verifiable knowledge of the causes of illness, with recent application to the prevention of disease; and now (4), with knowledge applied to the control of disease, the effort to promote optimum health places emphasis on preventive rather than curative medicine.
There have been more advances in medicine in the past 100 years (twenty-first century) than in the 500 years before that, and that there were more advances in that 500 years than in the previous 5000 years. The twenty-first century may prove to be the golden age of medicine. The result of all this progress has been added years to the life and life to the years of the individual. The twentieth century has been a period of revolutionary change in medical therapy. Before 1900, there were few drugs which were specific treatment for specific diseases. However, the drug industry has become one of the largest industries. Today, the strength and purity of drugs are rigidly standardized. Much of the research that goes into discovery of new drugs is carried on by the drug industry. After a new substance has proved useful in treatment, the drug companies use their individual skills to make the drug available at a practical price.
Development of a strong public health system involving immunization, early warnings of epidemics and quarantine has greatly reduced the threat of worldwide pandemics. The prime weapon in prevention is vaccine for children. Viral vaccine development has progressed most since 1930's after a yellow fever vaccine, which was produced by Max Theiler.
With the development of measures to prevent and treat surgical shock, and measures to prevent infection made possible by the antimicrobial, many surgical operations that were not attempted in the previous century, are being performed routinely now-a-days.
4Open heart surgery, surgery of brain, organ transplantation (kidney, liver, cornea, heart, pancreas, etc) hip and joint replacement, advances in plastic surgery, fetal surgery, minimal access (key-hole) surgery, bone marrow transplantation, prosthetics (Artificial limbs), telemedicine, molecular genetic interventions in vitro fertilization, etc. have also been introduced in the twenty-first century.
Advances in radiodiagnosis, imaging and nuclear medicine ultrasonography, CT Scan, magnetic resonance imaging, digital subtraction angiography, positron emission tomography, C-arm fluoroscope, color doppler, tread mill, cardiac catheterization, angiography, laparoscopy, fibrotic endoscopy, lithotriopsy, ERCP, linear accelerator, the cobalt therapy machine, gamma camera, computerized treatment planning system, brachytherapy, gamma knife, etc. have revolutionized diagnostic facilities. Laboratory medicine has also flourished. The advent of electron microscopy, multichannel auto-analyzers, spectrophotometers, etc. are of a great help to the clinician.
Advance in anesthesia (like ventilators, potent and safe anesthetic agents), psychiatry, pharmaceuticals, nephrology (dialysis), hematology, telemedicine, medical laser immunology, monoclonal antibodies, immunology the mapping of the human genome, cloning and preparation of various parts of human body, etc. have substantially reduced the mortality.
Medicine of the recent decades has been faced with rapid experience of biophysics, bioengineering, biomathematics, molecular biology and the integration of skills of the biologist and the engineer. The application of energy sources such as ultrasonic laser light beam, radioactive energy and heat-sensitive crystals, is reflected in the automatic sampling and analysis of body fluids, monitoring for critical care, artificial organs, prosthetic devices, physical therapies and computer technology. When properly performed, for the right reasons and at the right time, surgery ranks as the uppermost echelon of effectiveness in medicine.
A hospital is an integral part of a social and medical organization. The function of which is to provide for the population complete health care both preventive and curative and whose outpatient services reach out to the family and its home environment; the hospital is also a center for biosocial research (WHO).
Hospitals arouse strong emotions. Doctors, nurses, paramedics remembering the excitement of their early training years, associate hospitals with youth, vigor and the possibilities presented by a new career. The heady mixture of large numbers of young men and women exploring new ideas together remains as an affectionate memory with most medical professionals for the rest of their working lives.
For the general public the perception is different. Most people fear the prospect of entering a hospital, even as a visitor. This is ultimately, because numbers of people who enter hospitals die there. Hospitals have an alien feel for most members of the general public, which is not understood by people who work in them.
Health is a fundamental human right, the essence of productive life, an integral part of development and central to the concept of quality of life.
 
 
 
Culture, Health and Illness
To the members of all societies, the human body is more than just a physical organism, fluctuating between health and illness. It is also the focus of a set of beliefs about its social and psychological significance, its structure and function. The body image (used to describe all the ways that an individual conceptualises, and experience, his or her body), then, is something acquired by every individual as part of growing up in a particular family or society. The body image is influenced by social and cultural background and can have important effects on the health of the individual.
In most societies people suffering from physical discomfort or emotional distress have a number of ways of helping themselves or of seeking help from other people. Within these societies there are many groups or individuals, each offering the patient their own particular way of explaining, diagnosing and5treating ill health. To the ill person the efficacy of the health care system in relieving suffering is important.
In most countries, scientific medicine is the basic of the professional sector, which comprises the organised, legally sanctioned healing professions such as allopathy.
The dominant system of health care of any society cannot be studied in isolation from other aspects of that society, because the medical system or professional sector of health care does not exist in a social or cultural vacuum. Rather, it is an expression of and to some extent a miniature model of the values and social structure of the society from which it arises. Different types of societies therefore, depending on their dominant ideology, produce different types of medical system, and different attitudes to health and illness. One society may see free (or relatively inexpensive) health care as a basic right of citizenship, or the basic right only of the very poor or the very old, while another may see medical care as a commodity to be bought only by those who can afford it. In the latter case, the pursuit of profits in health care will exclude many of the poorer members of society who do not have the resources to pay for it. Whatever the type of society, the medical system not only reflects these basic values and ideologies, but in turn helps also to shape and maintain them.
In most countries, the main institutional structure of scientific medicine is the hospital. The ill person is removed from family, friends and community at a time of personal crisis. In hospital they undergo a standardized ritual of depersonalization’ becoming converted into a numbered ‘case’ in a ward full of strangers. The emphasis is on their physical disease, with little reference to their home environment, religion, social relationships, moral status, or the meaning they give to their ill health. Hospital specialization ensures that they are classified, and allocated to different wards, on the basis of age (adults, pediatrics, geriatrics), gender (male, female), condition (medical, surgical or other), organ or system involved (neurosurgery cardiology), or severity (intensive care units, accident and emergency departments). Patients of the same sex, similar age range and similar illness often share a ward. All of them have been stripped of the props of social identity and individuality, and clothed in a uniform of pajamas, nightdress or bathrobe. There is a loss of control over one's body, and over personal space, privacy, behavior, diet and use of time. Patients are removed from the continuous emotional support of ‘family and community, and cared for by healers whom they may never have seen before. In hospitals, the relationship of health professionals, doctors, nurses, technicians with their patients is largely characterized by distance, formality, brief conversations and often the use of professional jargon. Hospitals have been seen as ‘small societies’; with their own implicit and explicit rules of behavior. Patients in a ward form a ‘temporary community of suffering’ linked together by commiseration, ward gossip, and discussions of one another's condition. The health involves individual, state, and international responsibilities and is worldwide social goal. Health care refers to a multitude of services rendered to individuals, families or communities by the agents of health services or professions, for the purpose of promoting, maintaining, monitoring or restoring health.
Medical care refers chiefly to those personal services that are provided directly by the physician or rendered as a measure of physician's instructions.
The hospital should reflect the rhythm of the local culture, civilization and historical heritage and simultaneously be flexible enough to accommodate modern methods of health care facilities.
A hospital building, being an embodiment of life, should be conceived as a living entity where from follows function. A building without comfort, safety, and inviting quality, peace, silence, beauty and proper atmosphere has no significance as architecture.
The art and science of medicine, concerned with man as man, requires pleasant and peaceful environment that will restore the dignity of a man who has lost his own in the operation theatre or other patient care area.
 
Medical Care
6Medical Care cannot be separated from the buildings in which it is delivered. The quality of space in such buildings affects the outcome of medical care, and architectural design is thus an important part of the healing process.
Hospitals are spaces for healing. Their functional and spatial requirements differ from those of other public buildings. Yet, because of the technical complexity of hospitals and their immense cost, optimal orientation, scale, and symbolic meaning are often not achieved. It is possible to provide both successful function and good architecture by listening to patients (suggestions from patients are critical to designing spaces that enable patients to heal). This patient-centered approach is part of a larger movement towards involving patients in the healing process. Hospitals also improve by learning from their experience. Good architecture can be created in expansion or renovation projects, as well as in new facilities.
Many of the qualities of space that are pleasing in hospitals are fundamental to good design in all types of buildings. In this regard a well-designed hospital reflects the art and skill of architects in the practice of their craft. A balance between function and anesthetics is essential.
It is of increasing importance for hospital buildings and facilities to be available in such quality and quantity as these will permit and indeed promote all reasonable economies without denying any applicant the immediate benefit of the multiplying improvements in patient care.
The language of medical care can influence legislation, philanthropy, trusteeship, medical practice, and all else that makes up the hospital effort on the planning or operational level. The word hospital must be defined workably before the job of functional planning is begun.
The hospital is an indispensable communal institution, brought into existence in response to an environmental need. The hospital is maintained for the centralized, collective, sheltered, expert care of the sick who cannot, or should not be cared for anywhere else.
There must be an understanding of the methods by which the variables in a programme can be isolated, evaluated, and reflected in the final building plan, all in proportion to their relative importance. This calls for full knowledge of the functional programme and of the whole planning process. A competent architect can design any space if he knows what is to be done in the space, what persons are expected to do it and what special equipment and physical conditions are required. The architect has to meet the challenge of satisfying the highly demanding functional requirements and still to create a beautiful building.
 
Challenges
In addition to the share size and complexity of its technical planning problems, hospital design presents a challenge to administrator, hospital consultant and architects. The design has to have sufficient clarity of form to be understood by all who use it.
No matter how complex a hospital may be, its map must be easy to understand by all its users. Each separate department needs its own identity and within it, its own map, its own public and private spaces as well as its own front door. The hospital must be designed so as to allow the identity of the many ‘families ‘ which form its work force to be identifiable, physically, from inside the complex. Hospital should be designed as a complex with separate parts, just as a village is constructed of separate, identifiable buildings. A hospital needs to absorb change, as a continuous process of change occurs throughout its life, which causes modification to be made to each of the individual departments.
The physical form of the hospital will change over a period of time as it responds to internal and external forces and will acquire complexity as it ages. The architect must bring order to the process of change by designing the building round a binding 7center. The architect must design a street system, locate the front doors and allow the inhabitants of each of the departments to effect the changes required to serve changing functions without distorting the image of the whole.
Different patients have different needs, and different clinicians have different methods of treating their patients. This freedom of method of choice must be preserved.
Complexity and a high degree of technical mechanization have often been mistaken for qualitative superiority. Modern medicine, with its emphasis on technology and specialization, is threatening to dehumanize hospital care. Increased specialisation in hospitals has led to a form of alienation from the border aims of the health service. Hospital care must be rehumanised. Concern for the care of the human beings in a whole as the hospital needs contribution of all the human sciences.
The medical need is a matter of judgment and not an absolute state. Patients generally desire convenient access to immediate, considerate, and knowledgeable medical care, which should also be comprehensive, co-ordinated and continuous. The planning of any segment of the health service system should be determined by and shaped around the life patterns and value systems of the population to be served.
The availability of medical personnel and economic resources have to be analyzed to make an efficient medical and social service possible. Trained personnel, material resources, and all other forms and measures of help to the patient should be coordinated, so that the assistance could be delivered rapidly and competently. Objective criteria are needed for establishing each patients diagnosis and the status of his condition when he enters the health care system.
Every citizen should be able to enter the healthcare system within reasonable time at any time and, with the certainty that the appropriate level of care for him is available.
The hospitals should invariably be designed in support of the needs of the health centers and other healthcare units rendering primary care at the peripheral level.
The hospital with its specialized facilities and staff has to limit itself to the functions that cannot be performed elsewhere, channeling a number of functions to a closely associated, carefully planned, less expensive satellite facility network and not to divert scarce resources to uses for which they are not needed.
Hospitalization ought to be reserved to the greatest extent for patients whose conditions require highly qualified staff and complicated apparatus, whereby the quality levels of hospitals and other healthcare facilities have to be made distinct.
In the effort to assign the patient to a service area according to the extent of care required, six elements have been introduced: critical care, intermediate care, self-care, long-term care, home care, and ambulatory (outpatient)care. The inpatient care has three broad levels: critical or intensive, intermediate and minimal.
Specialist hospitals promote high standards. The fact that the staff deal only with a small range of disease, leads to their developing special skills.
The categorization and differentiation of hospitals on the availability of medical expertise and proper use of facilities will most likely become a major healthcare planning feature.
 
Hospital Planning
An efficient hospital requires a well-balanced organization for compassionate care within an adequate technical and environmental framework.
In the field of hospital planning three quite distinct worlds—the ordinary physical world; the mental world; and the world of actual or possible objects of thought, the world of concepts, ideas, theories, arguments and explanation are clearly felt.
The hospital works under the control of two distinct boundary systems; the higher one is the hospital organization, which harnesses the lower 8one, which in itself consists in several levels of functions and functional procedures on which the success of the hospital depends. Each level is relying for its working on the level above it.
Planning involves and requires understanding and evaluation of the current cultural mainstreams, the economic and technological conditions, and the goals of the community.
Total project cost considerations are planning, financing, construction, and equipment. The equipment costs alone account for about 30 percent of the total.
The hospital planning process concentrates on the designing of buildings and their architectural appearance and devotes inadequate attention to the planning of organizations and equipment as well as accommodating them and generating spaces to meet policies. The long-term cost of operating a hospital can be greatly increased by the initial failure to plan proper systems and equipment.
The objectives of hospital planning should be fully understood. The implications of planning ideas, data and designs, when they progress from the idea to a staffed and maintained hospital should be predictable.
A hospital emerges in three interdependent processes: analysis-planning-programming, designing and construction. Maximum efficiency should be sought for every precise function. The known depths of all involved factors have to be viewed at from a proper angle simultaneously and synthetically. The concurrent requirements of complex systems have to be assembled and balanced.
To secure a good facility, during the initial period of planning the main medical, ecologic, managerial, economic, social demographic, and technological factors and possibilities have to be identified.
Planners and architects must also take into account existing and emerging trends (that shape the health facilities) for the provision of health care. Technologies can be created to satisfy recognized demands. The basic decisions to be taken concern the character, the size and the siting of the hospital as well as the degree of the hospital's adaptability to future developments.
The programme should include the facts, intentions, and assumptions about the organization stated so early that a facility can be drawn from it. It is important to dress the hierarchy of the requirements, necessities and solutions. A functional programme can be used to clarify terminology, common understanding, and agreement among the parties involved. The programme is a reference to original intent for years to come, and is also an instrument to determine the staffing levels for selection of equipment and thus may serve as a means for organization of capital and labour.
The value of a brief should be measured by how well the strategic lines along which the hospital can be designed, are specified.
In a dynamic programme, the criteria for the physical design and the qualitative requirements on the medical standard and other standards should represent a range of realistic variables, the assignment of priorities, and the phase mode if such is a value.
The final phase consists of an explicit description of the hospital at a chosen point in time. The care needs of patients should directly dictate the character of every care function throughout the hospital.
FURTHER READING
  1. Helman, Cecil: Culture, Health and Illness: An introduction for Health professionals, 2nd edn. Butterworth & Co.  London  1990.
  1. Norman Vetter: The Hospital: from the centre of excellence to community support. Chapman & Hall.  London  1995.