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Overseas observations: while healthcare facilities around the globe incorporate certain core design principles, variables like culture, climate, and locally available resources create regionally unique facilities.

Naturally, architecture, sustainability, and culturally driven design vary widely in healthcare facilities around the world; however, a number of commonalities still ring true from Melbourne, Australia, to Beijing to Tel Aviv, Israel, to London.

"As a general theme, we have come to validate the extremely important and universal role of natural illumination and daylight, a connection to the natural environment, openness and the simplicity of design within a successful hospital or healthcare environment," says Allyn Stellmacher, AIA, LEED AP, and design partner with ZGF Architects in Seattle.

And while, generally speaking, Europe tends to be ahead of the sustainability curve, with the Middle East and China gaining ground, Jean Mah, FAIA, FACHA, LEED AP, and principal of Los Angeles-based Perkins+Will, says green design has become a significantly growing trend across the board. "There is more focus on conservation and reuse of water, less demand for air-conditioning and growing interest in generating less waste and recycling more. In fact, many projects are self-sufficient, with their own sewage treatment plant, water treatment, and/or electrical generation," she says.

Sustainability aside, before taking a snapshot of healthcare trends in different regions of the world, Mah says it's also important to note the significant and unique role that culture, climate, and locally available resources play in the overseas healthcare design process.

"Cultural issues such as family size, distance to the healthcare facility, separation of sexes, privacy norms, and esteem for nurses and other nonphysician providers can have a significant impact on facility design," Mah says. Consequently, things like larger waiting areas and gender-segregated wings will affect building configuration, wayfinding, and access.

Middle East

Perhaps the place where culture plays in most significantly is the Middle East. As a result, preferences for privacy, lounging, and visiting must all be accommodated, while, simultaneously, facilities must consider the fast-growing, diverse, and foreigner-based populations of places like Israel and the Persian Gulf states, says Michael Arnold, AIA, and senior principal with Stantec of Philadelphia.

Another interesting trend, Arnold adds, is the explosion of technology in some of these developing countries. The desire to establish world-class medical centers is coupled with an absence of legacy systems, allowing technological change to occur fairly rapidly.

"Unlike their U.S. counterparts, they are not afraid to take aggressive stands on incorporating technology, because they see technology as an avenue that allows them to leapfrog competitors in the U.S. and the U.K. Consequently, the concept of high-tech and high-touch are on full display in hospitals in the Middle East," says Henry Chao, healthcare practice design principal with HOK of New York City.

However, these hospitals must deal with operational challenges, including the fact that a stable supply of replacement parts and other resources often found in North America and Western Europe is not conveniently available to the Middle East. Similarly, naturally based resources and construction materials--with the exception of concrete and stone--are largely absent in the region. As a result, the vast majority of materials, finishes, and building systems are commonly imported from the Far East and Europe.

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At the same time, considering the hot, intense Middle Eastern sun, "most materials are selected for their lifecycle and maintenance, as they are subjected to harsh environments," says Norman Soto, AIA, MRAIC, principal/director of healthcare for the Middle East/North Africa region for Burt Hill.

Similarly, building orientation, glazing, shading, and insulation materials with a high R-value are critical to keeping solar heat gain in check. "An understanding of severe temperature peaks and the mechanical systems capabilities to condition zones differently throughout the building--as well as the lighting schemes--combined with a design strategy that responds to harsh wind, sand storms, and dust build-up present the project team with design and construction challenges of the highest degrees," Arnold says.

Zvi Mosessco, owner of the Herziliya, Israel-based firm Z. Mosessco Architect & Townplanner LTD, says older hospitals in Israel used to incorporate porches and verandas for natural ventilation, but air conditioning has led to the replacement of those open spaces with small windows, which limits daylighting. "The plan now is to get back to where we used to be and bring in the cool night air in place of the air conditioning. In addition, we need to make sure that building orientation will let in the sun in the winter, but not the heat gain in the summer," he says.

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Another interesting design byproduct of the Middle East's blazing sun is a commonly used palette of rich, bold colors. In some cases, strong shades of gold, blue, or green are applied to the exterior facade, even though they will inevitably fade from the incessant sun and create a "city of beige" within the sandy and dusty environment, Chao says. Consequently, the bold color schemes are often continued throughout the interior, not only in the entry area and lobby but also in the diagnostic and patient areas.

In addition, the use of pattern, texture, and textiles is both part of the region's cultural style and a way to soften the hard stone materials often used. "Intricate designs familiar to the Islamic world are very appreciated and can be successfully used in patterning of floors, walls, and screens--both glass and wood," Mah says.

Steven G. Jacobson, AIA, LEED AP, associate principal and senior vice president at Dallas-based HKS, says the integration of retail and high-end hospitality design elements into the healthcare solution is also a growing trend. "Patient rooms often look and feel like a high-end hotel, catering to a clientele willing to spend more money on healthcare," he says.

China

As China embarks upon a huge healthcare building initiative with a government commitment to build 31 large, new hospitals, U.S. architects and engineers are playing an important role by bringing design expertise.

At the same time, Bob Zimmerman, AIA, managing partner of ZGF Architects of Seattle, says that even though China's initiative is of considerable magnitude, it is proceeding at a much slower rate than the rapid development currently occurring in the private sector. "This is due in part to government involvement in the healthcare system and its slower decision-making process. Progress is slowed further in urban areas because residents typically have to be relocated from older buildings before development can begin," he says.

In addition, while China is anxious to incorporate state-of-the-art medical technology and processes, and many Chinese physicians have taken the initiative to seek out Western medical training, the administrative and support stafflag behind. Since most of the nursing, facilities, and administration staff have not received this Western-based training, this great difference in backgrounds, education, and experiences impacts both the pace and type of decisions made in healthcare facility design, according to Zimmerman.

For example, when ZGF proposed a radiology suite in the Beijing Children's Hospital Leukemia Center, the nurses assumed that the nursing staff ratios would be impossible. But after the architects explained the efficiencies leveraged by the new technology, Zimmerman said the group was willing to compromise on a modified version of the design.

Another unique aspect of the vast country of China is the fact that climate varies greatly from the North to the South. "The South region is fairly temperate and the people there are accustomed to very little heating and cooling, while the population in the colder North region is accustomed to heated facilities in the colder months," he says.

One other noted reality of the world's most populous country is the masses of people served by its universal healthcare system. With such a significant influx of patients and families into emergency departments, clinics, and admitting areas, interior materials must be extremely durable. "Stone, granite, and painted concrete are used extensively because they are durable, available, and relatively inexpensive resources," Zimmerman says.

Northern Europe

One big advantage that many European countries possess over the United States is a climate more conducive to sustainable design. In fact, in Scandinavian countries, "green design isn't an exception, it's a rule," says Chris Flint Chatto, associate AIA, LEED AP, sustainable designer at ZGF Architects of Portland, Oregon. "With some of the highest energy prices in the world, sustainable design is endemic in the way the country's economy and design culture works."

For example, natural ventilation is a big trend in Northern Eu- rope, where operable windows are standard, unlike in the United States, where infection-control concerns limit their use. Outside of the milder Scandinavian climate, the difference between the two countries lies in a cultural belief that the health benefit of a patient's access to fresh air and a connection to nature outweighs the risk of infection from an open window, according to Chatto.

Another popular energy-saving strategy is decoupling ventilation from thermal conditioning, which provides a more localized, efficient way of healing and cooling air, potentially saving 25% or more of a hospital's energy use, Chatto says. Similarly, external sun-shading is very frequently used, creating a different architectural aesthetic as operable Venetian blinds commonly accent the building exterior.

Yet another noted difference is a greater use of atria and pavilions to maximize daylighting and create more vibrant public spaces. In addition, light-colored interior materials with reflective qualities are often specified to enhance natural light. Cultural differences once again come into play here as the benefits of these open spaces are typically not significant enough for Americans to tolerate the greater walking distances between surgery, diagnostic suites, and patient towers.

However, the neighboring United Kingdom appears more similar to the United States in this regard, according to Craig Beale, FAIA, FACHA, FACHE, FAAHC, executive vice president, healthcare group director for HKS of Dallas, as British hospitals tend to avoid multistory public spaces, opting instead for a more practical layout.

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Australia

Another place where sustainable healthcare design is alive and well is Down Under. In addition to the cultural value placed on environmentalism, the country is battling a severe drought, so water and energy conservation are top priorities, says Beale's HKS colleague Ronald W. Dennis, FAIA, FACHA, principal, senior vice president, director, health facility design at HKS.

Similarly, a natural look often pervades through Australia's healthcare interiors, where woods are commonly used in addition to more natural colors.

Another interesting trend is a fairly new approach to healthcare delivery, which involves greater integration with the community. For example, at the HKS-designed Royal Children's Hospital in Melbourne, which is now under construction, the lobby will feature a two-story saltwater aquarium and dinosaur bone exhibit. In addition, animals from the nearby Melbourne Zoo will periodically be brought to the hospital gardens for the patients and their families to enjoy.

"Australia is a very exciting, vibrant place," says Dennis, adding that great lighting, colors, and learning experiences are integrated into the healthcare facilities there.

India

Unlike progressive Australia, the country of India is much more practical in its approach to healthcare construction as cost is the primary focus, says Beale. As a result, the facilities tend to be very operationally and clinically efficient, and sustainable design is unlikely to be a big priority, with the exception of strategies like natural ventilation.

"In India, the climate also greatly affects the environmental issues," says Perkins + Will's Mah. Consequently, "open passageways, grillwork, open-block walls, and operable windows are all cultural trends."

In terms of interiors, Mah says rich, vibrant colors and sharp contrasts in textiles and tiles, neutrals in block and walls, and richness and texture in wood and blocks are often used.

It's a small world

At the end of the day, regardless of whether the healthcare facility is in Europe, the Middle East, China or Australia, a few key principles ring true.

"Clarity of organization, wayfinding, the design of systems, and programmatic zoning are simple, yet hugely important principles at the foundation of any successful healthcare facility creation," says ZGF's Stellmacher. "The simple use of natural materials, where appropriate, that are durable and long-lasting will provide a sense of permanence, simplicity, and a timeless design for these very important and intensively used facilities."

And while Western design expertise will continue to be sought after, Mah notes the growing influence of overseas healthcare designs. "As the global village becomes smaller, it will be exciting and interesting to see if the design and operational influences of other countries will have a significant impact on the design of U.S. facilities," she says.

Barbara Horwitz-Bennett is a frequent contributor to publications and organizations dealing with building and construction. She can be reached at bbennett@bezeqint.net.

RELATED ARTICLE: Israel's Newest Hospital

An example of translating regional cues into modern architecture and creating a natural continuum between the outside and inside worlds was executed in the recent design of the new Assuta Medical Center in Tel Aviv, Israel.

Bordering the city's Hayarkon Park, the Toronto-based Zeidler Partnership decided to create a U-shaped glass atrium to capitalize on great views and better promote natural healing.

"It was also important to bring the exterior inside as much as possible, which was achieved in the design of the patient rooms and waiting areas on the upper floors that have ample daylight and views back to the park," says Tarek El-Khatib, senior partner with Zeidler.

Similarly, the hospital features a rooftop garden that is accessible to patients.

Other themes that play prominent roles in the architectural design are the way in which the building mimics both a Mediterranean village and the rock passageways of the ancient city of Petra, Jordan.

Hinting at the style of white houses sitting on a red mountain base in a typical Mediterranean village, the hospital is comprised of two bodies: a lighter white block that rests on top of a heavy, reddish mass, creating a sense of massive sculpted boulders anchoring the building to the site, according to El-Khatib.

An angled cut in the bottom block serves as the hospital's main entrance, resembling the angled stone passageways in Petra, Jordan. In addition to serving as a shading device, the shape creates a natural flow toward the building.

The rectangular-cut stone is a repeating motif in the main circulation space, bringing the texture of the city outside to within the building and serving as an essential part of the wayfinding and building circulation, says EI Khatib. "As commonly done in this region, the stones and terrazzos of the exterior are repeated on the interior. For example, the reddish stone of the plinth is continued inside in the atrium space while the sidewalk rhythm and material patterning is repeated in the atrium paving material," he says.

The new, state-of-the-art medical center features both outpatient and inpatient facilities with 16 operating rooms, a 30-bed intensive care unit, 260 inpatient beds, 40 day-surgery beds, imaging, catheter labs, radiation therapy, and 25 dialysis positions.

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Title Annotation:FEATURE
Author:Horwitz-Bennett, Barbara
Publication:Healthcare Design
Geographic Code:8AUST
Date:Oct 1, 2010
Words:2449
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