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detract from quality of care, and raise costs to intolerable levels." ... • Emerging Issues
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Hospitals are the most complex of building types. Each hospital is • Major Resources
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Hospital comprised of a wide range of services and functional units. These
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Nursing Home include diagnostic and treatment functions, such as clinical
Outpatient Clinic laboratories, imaging, emergency rooms, and surgery; hospitality functions, such as food service and
Psychiatric Facility housekeeping; and the fundamental inpatient care or bed-related function. This diversity is reflected
in the breadth and specificity of regulations, codes, and oversight that govern hospital construction
Land Port of Entry and operations. Each of the wide-ranging and constantly evolving functions of a hospital, including
Libraries highly complicated mechanical, electrical, and telecommunications systems, requires specialized
Office Building
knowledge and expertise. No one person can reasonably have complete knowledge, which is why
specialized consultants play an important role in hospital planning and design. The functional units
Parking Facilities
within the hospital can have competing needs and priorities. Idealized scenarios and strongly-held
Research Facilities individual preferences must be balanced against mandatory requirements, actual functional needs
Unaccompanied Personnel (internal traffic and relationship to other departments), and the financial status of the organization.
Housing (Barracks)
In addition to the wide range of services that must be
Warehouse
accommodated, hospitals must serve and support many
different users and stakeholders. Ideally, the design
SPACE TYPES process incorporates direct input from the owner and
from key hospital staff early on in the process. The
DESIGN DISCIPLINES
designer also has to be an advocate for the patients,
PRODUCTS & SYSTEMS visitors, support staff, volunteers, and suppliers who do
not generally have direct input into the design. Good
hospital design integrates functional requirements with
the human needs of its varied users.

The basic form of a hospital is, ideally, based on its

VAMC Bay Pines, FL
functions:

• bed-related inpatient functions

• outpatient-related functions
• diagnostic and treatment functions
• administrative functions
• service functions (food, supply)
• research and teaching functions

Physical relationships between these functions determine the configuration of the hospital. Certain
relationships between the various functions are required—as in the following flow diagrams.

These flow diagrams show the movement and

communication of people, materials, and waste.
Thus the physical configuration of a hospital
and its transportation and logistic systems are
inextricably intertwined. The transportation
systems are influenced by the building
configuration, and the configuration is heavily
dependent on the transportation systems. The
hospital configuration is also influenced by site
restraints and opportunities, climate,
surrounding facilities, budget, and
available technology. New alternatives are
generated by new medical needs and new
technology.

In a large hospital, the form of the typical

nursing unit, since it may be repeated
many times, is a principal element of the
overall configuration. Nursing units today
tend to be more compact shapes than the
elongated rectangles of the past. Compact
rectangles, modified triangles, or even
circles have been used in an attempt to
shorten the distance between the nurse
station and the patient's bed. The chosen
solution is heavily dependent on program
issues such as organization of the nursing
program, number of beds to a nursing unit,
and number of beds to a patient room.
(The trend, recently reinforced by HIPAA, is to all private rooms.)
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BUILDING ATTRIBUTES
Regardless of their location, size, or budget, all hospitals should have certain common attributes.

Efficiency and Cost-Effectiveness

An efficient hospital layout should:

• Promote staff efficiency by minimizing distance of necessary travel between frequently used
spaces
• Allow easy visual supervision of patients by limited staff
• Include all needed spaces, but no redundant ones. This requires careful pre-design
programming.
• Provide an efficient logistics system, which might include elevators, pneumatic tubes, box
conveyors, manual or automated carts, and gravity or pneumatic chutes, for the efficient handling
of food and clean supplies and the removal of waste, recyclables, and soiled material
• Make efficient use of space by locating support spaces so that they may be shared by adjacent
functional areas, and by making prudent use of multi-purpose spaces
• Consolidate outpatient functions for more efficient operation—on first floor, if possible—for direct
access by outpatients
• Group or combine functional areas with similar system requirements
• Provide optimal functional adjacencies, such as locating the surgical intensive care unit adjacent
to the operating suite. These adjacencies should be based on a detailed functional program
which describes the hospital's intended operations from the standpoint of patients, staff, and
supplies.

Flexibility and Expandability

Since medical needs and modes of treatment will continue to
change, hospitals should:

• Follow modular concepts of space planning and layout

• Use generic room sizes and plans as much as possible, rather
than highly specific ones
• Be served by modular, easily accessed, and easily modified
mechanical and electrical systems
• Where size and program allow, be designed on a modular
system basis, such as the VA Hospital Building System. This
system also uses walk-through interstitial space between
occupied floors for mechanical, electrical, and plumbing
distribution. For large projects, this provides continuing
adaptability to changing programs and needs, with no first-cost VAMC Albuquerque, NM
premium, if properly planned, designed, and bid. The VA
Hospital Building System also allows vertical expansion without
disruptions to floors below.
• Be open-ended, with well planned directions for future expansion; for instance positioning "soft
spaces" such as administrative departments, adjacent to "hard spaces" such as clinical
laboratories.

Therapeutic Environment
Hospital patients are often fearful and confused and these
feelings may impede recovery. Every effort should be made
to make the hospital stay as unthreatening, comfortable, and
stress-free as possible. The interior designer plays a major
role in this effort to create a therapeutic environment. A
hospital's interior design should be based on a
comprehensive understanding of the facility's mission and its
patient profile. The characteristics of the patient profile will
determine the degree to which the interior design should
address aging, loss of visual acuity, other physical and
mental disabilities, and abusiveness. (See VA Interior Design
Manual.) Some important aspects of creating a therapeutic
interior are:

• Using familiar and culturally relevant materials wherever

consistent with sanitation and other functional needs
• Using cheerful and varied colors and textures, keeping in mind that some colors are
inappropriate and can interfere with provider assessments of patients' pallor and skin tones,
disorient older or impaired patients, or agitate patients and staff, particularly some psychiatric
patients .
• Admitting ample natural light wherever feasible and using color-corrected lighting in interior
spaces which closely approximates natural daylight
• Providing views of the outdoors from every patient bed, and elsewhere wherever possible; photo
murals of nature scenes are helpful where outdoor views are not available
• Designing a "way-finding" process into every project. Patients, visitors, and staff all need to know
where they are, what their destination is, and how to get there and return. A patient's sense of
competence is encouraged by making spaces easy to find, identify, and use without asking for
help. Building elements, color, texture, and pattern should all give cues, as well as artwork and
signage. (As an example, see VA Signage Design Guide.)

For an in-depth view see WBDG—Therapeutic Environments.

Cleanliness and Sanitation

Hospitals must be easy to clean and
maintain. This is facilitated by:

• Appropriate, durable finishes for each

functional space
 • Careful detailing of such features as
doorframes, casework, and finish
transitions to avoid dirt-catching and
hard-to-clean crevices and joints
• Adequate and appropriately located
housekeeping spaces
• Special materials, finishes, and details
for spaces which are to be kept
sterile, such as integral cove base.
The new antimicrobial surfaces might
be considered for appropriate Cross-section showing interstitial space with deck above an
occupied floor
locations.
• Incorporating O&M practices that
stress indoor environmental quality (IEQ)

Accessibility
All areas, both inside and out, should:

• Comply with the minimum requirements of the Americans with Disability Act (ADA) and, if
federally funded or owned, the GSA's ABA Accessibility Standards
• In addition to meeting minimum requirements of ADA and/or GSA's ABA Accessibility Standards,
be designed so as to be easy to use by the many patients with temporary or permanent
handicaps
• Ensuring grades are flat enough to allow easy movement and sidewalks and corridors are wide
enough for two wheelchairs to pass easily
• Ensuring entrance areas are designed to accommodate patients with slower adaptation rates to
dark and light; marking glass walls and doors to make their presence obvious

Controlled Circulation
A hospital is a complex system of interrelated functions requiring constant movement of people and
goods. Much of this circulation should be controlled.

• Outpatients visiting diagnostic and treatment areas should not travel through inpatient functional
areas nor encounter severely ill inpatients
• Typical outpatient routes should be simple and clearly defined
• Visitors should have a simple and direct route to each patient nursing unit without penetrating
other functional areas
• Separate patients and visitors from industrial/logistical areas or floors
• Outflow of trash, recyclables, and soiled materials should be separated from movement of food
and clean supplies, and both should be separated from routes of patients and visitors
• Transfer of cadavers to and from the morgue should be out of the sight of patients and visitors
• Dedicated service elevators for deliveries, food and building maintenance services

Aesthetics
Aesthetics is closely related to creating a therapeutic environment (homelike, attractive.) It is
important in enhancing the hospital's public image and is thus an important marketing tool. A better
environment also contributes to better staff morale and patient care. Aesthetic considerations include:

• Increased use of natural light, natural materials, and textures

• Use of artwork
• Attention to proportions, color, scale, and detail
• Bright, open, generously-scaled public spaces
• Homelike and intimate scale in patient rooms, day rooms, consultation rooms, and offices
• Compatibility of exterior design with its physical surroundings

Security and Safety

In addition to the general safety concerns of all buildings, hospitals have several particular security
concerns:

• Protection of hospital property and assets, including drugs

• Protection of patients, including incapacitated patients, and staff
• Safe control of violent or unstable patients
• Vulnerability to damage from terrorism because of proximity to high-vulnerability targets, or
because they may be highly visible public buildings with an important role in the public health
system.

Sustainability
Hospitals are large public buildings that have a significant impact on the environment and economy of
the surrounding community. They are heavy users of energy and water and produce large amounts of
waste. Because hospitals place such demands on community resources they are natural candidates
for sustainable design.

Section 1.2 of VA's HVAC Design Manual is a good example of health care facility energy
conservation standards that meet EPAct 2005 (PDF 1.3 MB, 550 pgs) and Executive Order 13693
requirements. The Energy Independence and Security Act of 2007 (EISA) (PDF 740 KB, 310 pgs)
provides additional requirements for energy conservation. Also see LEED's (Leadership in Energy
and Environmental Design) USGBC LEED for Healthcare

Related Issues
The HIPAA (Health Insurance Portability and Accessibility Act of 1996) regulations address security
and privacy of "protected health information" (PHI). These regulations put emphasis on acoustic and
visual privacy, and may affect location and layout of workstations that handle medical records and
other patient information, paper and electronic, as well as patient accommodations."

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EMERGING ISSUES
Among the many new developments and trends influencing hospital design are:
 • The decreasing numbers of general practitioners along with the increased use of emergency
facilities for primary care
• The increasing introduction of highly sophisticated diagnostic and treatment technology
• Requirements to remain operational during and after disasters—see, for example, VA's Physical
Security Manuals
• State laws requiring earthquake resistance, both in designing new buildings and retrofitting
existing structures
• Preventative care versus sickness care; designing hospitals as all-inclusive "wellness centers"
• Use of hand-held computers and portable diagnostic equipment to allow more mobile,
decentralized patient care, and a general shift to computerized patient information of all kinds.
This might require computer alcoves and data ports in corridors outside patient bedrooms. For
more information, see WBDG Integrate Technological Tools
• Need to balance increasing attention to building security with openness to patients and visitors
• Emergence of palliative care as a specialty in many major medical centers
• A growing interest in more holistic, patient-centered treatment and environments such as
promoted by Planetree. This might include providing mini-medical libraries and computer
terminals so patients can research their conditions and treatments, and locating kitchens and
dining areas on inpatient units so family members can prepare food for patients and families to
eat together.
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RELEVANT CODES AND STANDARDS

Hospitals are among the most regulated of all building types. Like other buildings, they must follow
the local and/or state general building codes. However, federal facilities on federal property generally
need not comply with state and local codes, but follow federal regulations. To be licensed by the
state, design must comply with the individual state licensing regulations. Many states adopt the FGI
Guidelines for Design and Construction of Hospitals and Health Care Facilities, listed below as a
resource, and thus that volume often has regulatory status.

State and local building codes are based on the model International Building Code (IBC). Federal
agencies are usually in compliance with the IBC except NFPA 101 (Life Safety Code), NFPA 70
(National Electric Code), and Architectural Barriers Act Accessibility Guidelines (ABAAG) or GSA's
ABA Accessibility Standards takes precedence.

Since hospitals treat patients who are reimbursed under Medicare, they must also meet federal
standards, and to be accredited, they must meet standards of the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO). Generally, the federal government and JCAHO
refer to the National Fire Protection Association (NFPA) model fire codes, including Standards for
Health Care Facilities (NFPA 99) and the Life Safety Code (NFPA 101).

The American with Disabilities Act (ADA) applies to all public facilities and greatly the building design
with its general and specific accessibility requirements. The Architectural Barriers Act Accessibility
Guidelines (ABAAG) or GSA's ABA Accessibility Standards apply to federal and federally funded
facilities. The technical requirements do not differ greatly from the ADA requirements. See WBDG
Accessible

Regulations of the Occupational Safety and Health Administration (OSHA) also affect the design of
hospitals, particularly in laboratory areas.

Federal agencies that build and operate hospitals have developed detailed standards for the
programming, design, and construction of their facilities. Many of these standards are applicable to
the design of non-governmental facilities as well. Among them are:

• Department of Veterans Affairs (VA), Office of Construction & Facilities Management Technical
Information Library contains many guides and standards, including:
◦ Design Guides for planning many different departments and clinics, design manuals of
technical requirements, equipment lists, master specifications, room finishes, space planning
criteria, and standard details.
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MAJOR RESOURCES

WBDG

Federal Mandate
Executive Order 13693, "Planning for Federal Sustainability in the Next Decade"

Products and Systems

Building Envelope Design Guide

Websites
See WBDG Health Care Facilities for generic health care facilities websites

Publications
• Design Details for Health: Making the Most of Design's Healing Potential, 2nd Edition by Cynthia
A. Leibrock and Debra Harris. New York: John Wiley & Sons, Inc., 2011.—Innovative design
solutions in key areas such as lighting, acoustics, color, and finishes
• Design Guide for Improving Hospital Safety in Earthquakes, Floods, and High Winds: Providing
Protection to People and Buildings. FEMA, 2007.
• Development Study—VA Hospital Building System by Building Systems Development and Stone,
Marraccini & Patterson. Washington, DC: U.S. Government Printing Office, rev. 1977.
• Emergency Department Design: A Practical Guide to Planning for the Future by John Huddy and
Michael T. Rapp. Irving, Texas: ACEP (American College of Emergency Physicians) 2000.
• Healthcare Facility Planning: Thinking Strategically by Cynthia Hayward, AIA, FAAHC, ACHA.
Health Administration Press and the American College of Healthcare Executives, 2005.
• Hospitals, The Planning and Design Process, 2nd ed. by Owen B. Hardy and Lawrence P.
Lammers. Rockville, Md.: Aspen Publishers, 1996.
 • Hospital Interior Architecture: Creating Healing Environments for Special Patient Populations by
Jain Malkin. New York: John Wiley & Sons, Inc., 1992.
• Healthcare Design—A quarterly magazine with design articles and presentations of recent
projects
• Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment, and Clinical
Procedures, 3rd Edition, by Jain Malkin. New York: John Wiley & Sons, Inc., 2002.
• Sound & Vibration: Design Guidelines for Health Care Facilities by the Acoustics Research
Council. 2010.
• UFC 4-510-01 Design: Medical Military Facilities
• See WBDG Health Care Facilities for generic health care facilities publications

Tools
• SpaceMedGuide-A Space Planning Guide for Healthcare Facilities—a popular planning tool
providing state-of-the-art planning methodologies, industry benchmarks, and planning tips.
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