No matter how fast we construct buildings the time it takes from planning to use, means that the building is dated at the time it is handed over. This time frame will vary according to the nature and circumstances of the contract and or construction. In private healthcare it will average 24 months (2 years) In public healthcare its longer 36 months – 60 months (5 years) There is no value judgement simply a comment of the process, and regardless of cause or the actual time frame it is simply out of date by the time of handover. This paper explores explores the notion that out of date hospitals ( crocodiles) are better than hospitals that are extinct (dodo).

2. No matter how fast we construct buildings the time it takes from planning to use,
means that the building is dated at the time it is handed over. This time frame will
vary according to the nature and circumstances of the contract and or construction.
y g
In private healthcare it will average 24 months (2 years)
In public healthcare its longer 36 months – 60 months (5 years)
There is no value judgement simply a comment of the process, and regardless of
cause or the actual time frame it is simply out of date by the time of handover.
Theory is continually growing
building
This paper explores the notion that out of date hospitals (crocodiles)
This paper e plores the notion that o t of date hospitals ( ro odiles)
are better than hospitals that are extinct (dodo).

3. Dodo
D d
From Wikipedia, the free encyclopaedia
Dodo
The dodo (Raphus cucullatus) was a flightless bird endemic to the Indian Ocean island of Mauritius. Related to pigeons and doves, it stood about a meter (3.3 feet)
tall, weighing about 20 kilograms (44 lb), living on fruit, and nesting on the ground.
The dodo has been extinct since the mid‐to‐late 17th century.[2] It is commonly used as the archetype of an extinct species because its extinction occurred during
recorded human history and was directly attributable to human activity.
The dodo had a flawed design (it couldn‘t, that over time meant it didn't adapt to
the threat in its environment and thence disappeared due to its inability to avoid
predators, humans.

4. Crocodile
From Wikipedia, the free encyclopaedia
A crocodile is any species belonging to the family Crocodylidae (sometimes classified instead as the subfamily Crocodylinae). The term can also be used more
loosely to include all extant members of the order Crocodilia: i.e. the true crocodiles, the alligators and caimans (family Alligatoridae) and the gharials (family
loosely to include all extant members of the order Crocodilia: i.e. the true crocodiles, the alligators and caimans (family Alligatoridae) and the gharials (family
Gavialidae), as well as the Crocodylomorpha which includes prehistoric crocodile relatives and ancestors.
Member species of the family Crocodylidae are large aquatic reptiles that live throughout the tropics in Africa, Asia, the Americas and Australia. Crocodiles tend to
congregate in freshwater habitats like rivers, lakes, wetlands and sometimes in brackish water. They feed mostly on vertebrates like fish, reptiles, and mammals,
sometimes on invertebrates like molluscs and crustaceans, depending on species. They are an ancient lineage, and are believed to have changed little since the time
of the dinosaurs. They are believed to be 200 million years old whereas dinosaurs became extinct 65 million years ago; crocodiles survived great extinction events.[1]
The crocodile has a tried and tested design that is quite stable and adapted over
g q p
time to conditions in its environment relevant to its continued survival.

5. A building is the spirit of the that age, theory
and functionality frozen at a point in time

6. design
adaptability
time
Out of date versus extinction is a product of design and adaptability over time

7. Thus we can look at the issues that will impact the adaptability of the organism
(healthcare buildings) and that will over time result in extinction or adaptation :
1. contract period
2. Changing disease profiles
3.
3 Information technology
I f i h l
4. Equipment (beds, diagnostics)
5.
5 Electrical supply and usage in healthcare environment
Electrical supply and usage in healthcare environment
6. Staffing skills and shortages
7. Global trends versus local solutions
8. Architectural style (7yrs facelift – 14yrs refit)
9. Building evolution over time

8. • contract period – project timeframe
The form of contract will determine the period of the construction and thus influence the perception of the
relevance of any particular building.
l f ti l b ildi
Fast track contracts will deliver a lot quicker and in a sense the client will feel that the building at completion is
relevant to the ideas they had at the planning stages.
Conversely a slower contract will leave a client feeling that the trends in the medical field have supplanted their
building and that they will need to change or update the facility to stay current with the trends in their field.
This will not necessarily result in extinction but the perception of the client will be closer to wanting some form of
evolution rather than the feeling that the facility is functional and doesn t need to adapt just yet.
evolution rather than the feeling that the facility is functional and doesn't need to adapt just yet.

9. Contract period
Contract period
Addition/changes

10. • Changing disease profiles
Over time disease profiles change.
In the 1500’s the leading cause of death was infection, poor hygiene, poor diet and poverty.
In the 1700’s the leading cause of death was consumption (TB), ague and smallpox
In the 1900 the leading cause of death was the flu, TB and diarrhoea.
In the 1960’s the leading cause of death was heart disease, cancer and degenerative diseases.
In the 2000 the leading cause of death is lower respiratory infections, heart disease, diarrhoea, HIV
Currently we have seen viral infection from various strains of influenza and closer to home the emergence of
multiple drug resistant TB.
Statistics from the WHO

11. Disease profiles are determined by region , the social norms and affluence of a society.
Each of these diseases requires its own treatment regime and specific design factors that allow for effective
treatment without infecting or endangering the staff who are treating the patients.
g g g g p

12. Florence nightingale was an accomplished statistician and through careful recording of infection rates introduced the
notion of cleanliness in hospitals and bed spacing to reduce cross infection, the cause of most deaths in 1850.

13. Ideas like isolation rooms or wards for treating infectious diseases or other more specific diseases influence design.
Thus the buildings design and layout adapts to the people and their diseases at that point in time.
Currently we are focusing on design to assist in the treatment of TB and through design to prevent cross
contamination of patients and staff.
Here we start to see that you need 12 air changes / hour or
better in a room or 60 litres a second / person in a space.
That is the volume of air per room per hour and the size of the
openings through which the air changes move.
openings through which the air changes move.
So large openings that allow unobstructed air flow is good or
larger volumes that will diffuse the droplet nuclei per volume,
alternatively both.
Thus we see that the old hospitals with large windows and high
ceilings could be better than the newer more efficient deep
Image courtesy of the CSIR space planned and mechanically ventilated facilities.

14. Thus the buildings design and layout adapts to the people and their diseases at that point in time.
Specialised treatments differentiate the design process between high care, maternity, paediatrics, cardiac, medical
and surgical ward configurations.
d i l d fi ti
ICU / high care has wider bed spacing to allow for more intense monitoring with machines and or ventilators.
Surgical wards will have a larger store to accommodate specialised equipment, they tend to have a more
comprehensive treatment room to wash and treat wounds following surgery.
Medical wards have patients with less invasive treatments and therefore will adapt according to the medical profile
of the illness. TB, cancer and HIV although not invasive will have design input that is different to a wider range of
medical illnesses.
At any given time, hospitals need to be responsive to the communities they are situated in, hence when the
communities are young, there is a focus on paediatrics and maternity, over time (10‐20 years) when the community
has aged the medical profile changes and the hospital needs to accommodate a different set of patient needs.
In societies that have an aging population profile, the design input with regards medical care will be integrated into
the residential unit at varying levels and has become a sub speciality all of its own with people living longer and a
decline of staff moving into the nursing profession. This is relevant in both developed and developing societies the
reasons and cost centres vary.

15. In South Africa there is talk of a triple burden of disease...
The first is primary healthcare diseases, which are high mother and child mortality, TB and malaria.
The second is chronic lifestyle diseases, heart conditions, diabetes and or strokes and other stress related illnesses.
The third is the high trauma from motor vehicle accidents and crime.
South Africa shows primary healthcare diseases the same as developing counties with lifestyle diseases more
associated with developed countries, high trauma is an anomaly for both, usually developing countries don't sustain
MVA and crime because of a shortage of resources (other than conflict areas) and developed counties don't have this
either due to a developed policing system and law enforcement.
This means that designers are exposed to varying degrees of healthcare planning, competing needs, and need to
differentiate which is the most appropriate for an area and what is likely to change over time.
Often the difference between obsolescence and flexibility is experience or a vision by the
i ii b h
designers that prevent buildings being locked into singular function facilities that are unable to change and
become inefficient in new roles.

16. • Information technology
This is a relatively new phenomenon but one that changes exponentially faster than the rest due to the rapid
changes in the technology itself.
h i th t h l it lf
Information technology allows an interconnectedness that wasn't part of facilities previously, now designers have
server rooms and control centres where a host of electronic data interfaces with the patients, staff and building
management systems. This connectivity adds a whole other layer of servicing, specialised spaces and support infra
structure.

17. • Information technology
These systems are moving towards a paperless hospital reducing large stores for patient files but increasing other
aspects like the electrical loading and back up systems to keep the electronic systems operational.
t lik th l t i l l di db k t t k th l t i t ti l
These systems envision a total integration into a singular operating and or management system, items like:
security monitoring
access for staff
patient data and various levels of access
staff data and time management
reporting via diagnostics, x‐ray and pathology
electronic load monitoring on electrical supply
building management systems that control the building environment
building management systems that control the building environment
integrated stock control and remote ordering
statistical reporting on patient profiles and occupancies
pharmacy control via integrated networks that monitor patients
(it might be a point to ponder if an emerging society needs more information technology or tried and tested systems
that can be upgraded at a later date if there is sufficient understanding that record stores will eventually become
server rooms for building management systems and control rooms for the information technology.)
If your facility cant adopt or embrace this technology then its more likely to go the way of the dodo ....

18. Staff /
Patient
access
Building management
system security
Patient data + records
Electrical load
Electrical load
management
Statistical reporting
Statistical reporting stock management
stock management Diagnostic data
Diagnostic data

19. • Equipment
Along with information technology the support equipment is changing as well.
Beds are increasing in length and width to accommodate the extra electronic monitoring as well as more functions
that make the bed more adaptable to a variety of medical functions within a singular facility as well as easier for staff
to manage patient comfort.
This impacts on the norms and standards that surround minimum spacing at the attending and non attending sides
as well as openings, lifts and the various corridors sizing in a facility.
Bed sizing 1000 x 2100mm Bed sizing 1100 x 2200mm

20. • Over simplified two
bed sample
Taking a 2 bed ward sample and
Taking a 2 bed ward sample and
applying the R158 norms we would
arrive at a minimum room sizing of
15.02m²
Applying a newer model bed sizing
to the same R158 norm example we Bed sizing in the 1995
end up with a minimum room size of
16.15m²
This is a 6% increase on the room
size, take a 210 bed hospital with a
foot print area of 19 250m² (one of
our recently completed projects)
and add a 6% extra to the area,
and add a 6% extra to the area
simply as a rule of thumb.
That's an additional 1155m² for a
facility just because the bed has
increased marginally in size.
R 20 000.00/m² = R 23.1 million Bed sizing in the 2010

21. • Example, paediatric hospital
In one of our early projects, originally a dedicated stand alone paediatric hospital was bought by a hospital
group and they wanted to convert portions of the facility into adult beds(patient profile had changed) that
d th t dt t ti f th f ilit i t d lt b d ( ti t fil h d h d) th t
had a better return on income.
The problem in most of the ward configurations was that the wards where designed for children's hospital
cots, which were in the order of 1600x800mm. The beds had the correct distances between each other and
the attending and non attending sides but when we tried a standard hospital bed we either had too little
space for bed to bed layouts or too much space for one bed layouts.
In most cases the concrete structure was designed around the original ward sizes (children's cots)and thus
limited the flexibility and adaptability of the facility to an efficient adult configuration. This meant that we
limited the flexibility and adaptability of the facility to an efficient adult configuration. This meant that we
lost beds in the new ward layouts in terms of the original bed count.
Subsequently we design paediatric wards for standard hospital beds and that way the ward
can adapt in 5‐10 years time as the hospitals demographics change.
The additional area in this case is always used by concerned parents and means that later
the ward adapts more easily into a different types of wards , avoiding an extinct facility.

22. • Equipment
Items in diagnostics like x‐ray machines and the support equipment is getting smaller and accommodated in smaller
spaces with more electronics. Large expense pieces of equipment are reducing in price which means that it becomes
ith l t i L i f i t d i i i hi h th t it b
obsolete sooner (term of financing)and more likely to be replaced and the space adapted accordingly.
Items that lasted 10 years now turn over in 6 years, this impacts on the spaces and their re‐use.
The increase in monitors for patients means that there needs to be more or larger equipment stores built into a ward
to accommodate the equipment when not in use or when charging the rechargeable batteries.
This has also lead to the addition of clinical stores and workshops where this specialised electronic equipment is
serviced or repaired on site.
More and more the inclusion of these items is to reduce staff work loads but also requires specialised training rooms
More and more the inclusion of these items is to reduce staff work loads but also requires specialised training rooms
where the staff are updated on the equipment, their use and problem solving or reporting.
The specialised equipment also needs extra electrical loading and often extra mechanical ventilation to cool the
electronics.

23. • Electrical usage and short supply
There seems to be cut backs on everything and given the recent ESKOM outages this effects essential services like
hospitals most acutely.
h it l t t l
On the one hand we have shortage of supply as a resource issue and on the other hand we have an increase in need
determined by the additional electronic monitoring and sophisticated electrics to supply this specialised equipment
often as a result of staff shortages.
A solution is the integrated building management systems that cut down on unnecessary electric usage and manages
the power consumption via various management strategies. Heat pumps, solar heating and solar control to reduce
heat loading.

24. • Electrical usage and short supply
All of these items require a more detailed knowledge of what is available and where to house these extra items that
do effect the planning and service area allowances.
d ff t th l i d i ll
UPS and back up generators become integral to the electrical solution within a facility and the electrical
requirements. This has changed over the last few years world wide with a stronger emphasis on the backup systems.
On the other hand the increase in the cost of electricity has also developed a heightened awareness that has
facilitated efficiency in other areas. Lights are moving towards LED technology which increase life span and reduces
electrical loads and thus heat loads requiring less mechanical input. Heat pumps and solar heating also reduce the
reliance on electrically generated heat and more on efficient heating with the systems that are in place.

25. • Skilled staff shortages
This is a world wide phenomena and unfortunately the developed countries do attract skills away from developing
countries on an economic bias, thus we are forced to plan with this in mind.
ti i bi th f dt l ith thi i i d
In developing countries planning makes the difference between extinction and adaptation.
Designing to allow shorter travel distances for less staff means that your staff as a resource is looked after.
Electronic monitoring also allows for less staff to deal with more patients but the reliance on electronic monitoring is
feasible in private facilities and developed counties but not so in a developing country, this paradox is particular to
SA which straddles both first and third world in one society.

26. Efficiently planned facilities allow staff to circulate over less distance between various zones and careful planning
linking symbiotic functions together is also a good planning tool to assist staff, the 30/60 rule for duty station
placement in a general ward layout.
Overflow portion Bulk of staff travel
The area that is
filled last
filled last
4 bed configuration
Patient assisted Travel distance travel distance
nursing
Duty station
Staff zone
Image courtesy of A3 Architects,
Moses Kotane Hospital, surgical ward

27. • Global trends versus local solutions
In developed counties the trend is towards a hotel like environment and with patients having single rooms and more
privacy. This leads to a higher staff complement to service the one bed units or electronic monitoring, both are
i Thi l d t hi h t ff l tt i th b d it l t i it i b th
expensive options that are affordable in developed economies.
In developing economies we see more 2, 3, 4 and even 6 bed ward options. These require less staff to see the same
amount of people and as a spin off the patients become part of the nursing staff through their communal concern.
Locally we have a society that has a strong social basis and that 2‐4 bed ward configurations are more appropriate
for SA . Social awareness for fellow patients means that your fellow patient is as likely to assist in the monitoring of
patients as nursing staff, this reduces the load on staff and works within the social norms of our society.
The 4‐6 bed ward options use less space per patient to their 1 or 2 bed layouts and that translates to savings in
capital cost amounts as well as reducing staff and staff circulation distances.
Global trends have vertically stacked hospitals because of the cost of land, locally we can still afford to have well
designed horizontally spread hospitals with less reliance on mechanical circulation and servicing, only in dense urban
designed hori ontally spread hospitals with less reliance on mechanical circulation and servicing only in dense urban
environments should we be looking at vertically stacked solutions.
It is easy to copy inappropriate solutions to give the idea that we are delivering sophisticated healthcare in a
resource constrained environment but this will eventually lead to extinction due to an inability to afford and maintain
these systems.
Appropriate and affordable solutions are home grown and not copied from first world healthcare.

28. one bed wards as legislated in some US states
Appropriate 4 bed ward configurations

29. • Architectural style
In private healthcare there used to be a rule of thumb that you would do a facelift on a facility approximately every 7
years and a refit every 14 years, reinventing a facility within a style matrix for a fluid and style orientated market.
d fit 14 i ti f ilit ithi t l ti f fl id d t l i t t d k t
In public healthcare i would argue that we need to resolve primary need first and concern ourselves with style only
after we have a fully operational healthcare network.
Maintaining this network is more of a challenge than just re‐inventing.
In Abu Dhabi we where exposed to a facility that is 30 years old and very well maintained, it is stylistically out of date
In Abu Dhabi we where exposed to a facility that is 30 years old and very well maintained, it is stylistically out of date
but functionally providing a healthcare service to the community.

30. Tawam hospital, Abu Dhabi UAE ‐ 2001

31. Tawam hospital, Abu Dhabi UAE ‐ 2001
• Rates of change as presented by Jane Carthey
g p y y
• Site 50‐500 years
• Structure 30 – 50 years
• Skin 20 – 30 years
• Services 10 – 20 years
• Space plan 5 – 20 years
• Stuff 0 – 1 year
Carthey, J. Health asset and facility management. Slide 41, www.chaa.net.au
C h J H lh d f ili Slid 41 h (accessed 2011‐03‐11)
( d 2011 03 11)

32. University of Iowa hospital ‐ 1900
U i it f I h it l Wharmcliffe hospital, Sheffield ‐ 1900
h l ff h l h ff ld
1900
Changing a dressing in 1900
Bloemfontein hospital ‐
Bloemfontein hospital 1900

33. St. Vincent’s Hospital, Los Angeles ‐ 1930 Colonial hospital, Rochester Minnesota ‐ 1930
1930
Victoria ward ‐ 1930
Groote Schuur
Groote Schuur ‐ 1930

34. St. Clara’s hospital ‐
St Cl ’ h it l 1960 Concordia Hospital, Canada ‐
Concordia Hospital Canada 1960
1960
Patient in traction ‐ 1960
Chris Hani Baragwaneth Hospital ‐ 1960

35. First Peoples Hospital, Shanghai ‐ 1990
Fi t P l H it l Sh h i Tan Tock Seng Hospital, Singapore ‐ 1990
k l
1990
Theatre ‐ 1990
Inkosi Albert Luthuli Hospital ‐
I k i Alb L h li H i l 1990

36. Images courtesy of A3 Architects + NBBJ joint venture collaboration
2010
Proposal for a children's hospital , JHB ‐ 2010

37. • Building evolution
The most basic evolution is simply that a facility will grow and expand beyond the borders and boundaries of the
original envelope. Careful planning will not always cover these eventualities but flexible design strategies will
i i l l C f l l i ill t l th t liti b t fl ibl d i t t i ill
accommodate future extensions.
In 1994 we did a major addition to the existing hospital, over the next 17 years an additional 4 major phases were
added to the facility as it out grew its original shell and then added additional beds and support services.

38. existing

39. Phase 1

40. Phase 2

41. Phase 3

42. Phase 4

43. • More for less
There is an inherent paradox in a hospital in as much as a hospital is a purpose
p p p p p
made building were form is often determined by medical function and efficiency
and not necessarily its ability for flexibility and adaptation.
If the building is too purpose built this will effect future adaptation and result in a
Dodo that will be extinct/demolished sooner than a building that is purpose built
with enough flexibility to adapt and morph into a crocodile.
A new generation of hospitals, INO Hospital in Bern, Switzerland, are looking at
flexible construction solutions that will allow cost effective permutations and
flexibility over the life cycle of the hospital.
fl ibili h lif l f h h i l
In hospital terms, the client that gets a crocodile, will eventually get more for less.