By Steve Gifford, AIA, & Mitch Green, AIA

The Future of Healthcare

A view of the hospitals main entrance showing the proximity and layout of an inpatient ward, left, and the specialist outpatient clinic, right.

Singapore offers new strategies for disease control, disaster preparedness and sustainability

Today, facilities like Khoo Teck Puat Hospital, a 102,245-squaremeter, 550-bed replacement hospital on the boards at RMJM Hillier and CPG Consultants Pte Ltd., are prime examples of this movement, offering novel approaches to environmental sustainability and climate control, patient care, and disease and disaster management new strategies that will become the model of cuttingedge facility design for healthcare institutions in the United States and around the world.

Becoming the Healthcare Hub of Asia

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With aging facilities, a graying baby boomer population, and heightened demands for quality care and improved crisis management in a post Sept. 11 and Hurricane Katrina world, the U.S. healthcare industry is at a crossroads. In 2003, so was Singapore. Facing drivers similar to those in the United States a surge in its aging population, longer life expectancies and anticipated population growth as well as a scrape with SARS (severe acute respiratory syndrome) that same year, Singapore turned challenge into inspiration and embarked on a plan to develop the nation into one of Asias leading destinations for healthcare services.

Known for its modern architecture, manicured landscaping and business friendly climate, Singapore a country roughly three times the size of Washington, D.C. already is considered a major economic force in Southeast Asia, the result of a rapid industrialization program following its independence in 1965. As national wealth increased, the government turned its attention to modernization of its healthcare infrastructure. Since the late 1980s, according to the government, the number of international patients has steadily increased, with the number climbing to more than 200,000 by

2003. By 2012, the government expects Singapore to treat as many as 1 million international and domestic patients per year. Such increased demand, in concert with issues like Singapores bout with SARS, its challenging year-round climate of high humidity and average 85 F temperatures, and its proximity to politically delicate situations have added complexity to plans by Singapore Medicine, a multiagency government initiative, to develop Singapore into one of Asias leading destinations for healthcare services. However, it also means that Singapores healthcare institutions now are exploring some of the most advanced disease control practices, security measures, and sustainable design techniques in the world. At the same time, healthcare

institutions in Singapore are being designed around patients and the community in order to address the wellness demands of patients in incremental steps from home to family physicians, general hospital to community hospital and possibly senior living. Managing the spectrum of healthcare providers in order to create a holistic range of seamless patient-centric care is a new challenge. Traditionally located in the south, Singapores new general hospitals are relocating north to address the geographical imbalance of medical supply and demand, starting with Khoo Teck Puat Hospital. At Khoo Teck Puat Hospital, the 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 Singaporean 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 Wellness Center, a Rehabilitation Suite, a Sports Medicine Center and a Geriatric Center. As Singapore now aims to use its improving capabilities in

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A view from Yishun Pond through the specialist outpatient clinic, left, and an inpatient ward, right, to the inner courtyard.

healthcare delivery to lead innovation in biomedical research, translational medicine and pharmaceutical development, the reconstruction of Khoo Teck Puat Hospital is an essential part of this new policy. It will satisfy goals for patient convenience and efficiency, while producing a project that will be capable of immediate identification of communicable diseases, continuing to function even in times of dire emergency and using half as much energy as existing hospitals.

A good defense is the Best offense

Almost shut down by SARS in 2003, Singapore has emerged stronger and more vigilant about controlling infectious disease, particularly in light of avian flu threats as evidenced by the commitment of more than S$205 million by the Ministry of Health to develop hospital clusters specifically designed to treat infectious disease. At Khoo Teck Puat Hospital, creating a facility that would maintain hospital operations even in infectious disease outbreaks and enhance the hospitals ability to identify potential threats before they escalate was a major challenge. To solve the problem, designers took a look at how and where people enter hospitals. As in the United States, the team found that the majority of inpatients 85 percent come directly through the emergency department, with only 15 percent entering through prescheduled appointments, making the emergency department the de facto entrance. Keeping this in mind and that having a single public access point also can help isolate potential biological threats, the Khoo Teck Puat project team established an entry protocol and layout to facilitate the identification and isolation of infected individuals. From the Khoo Teck Puat Hospitals entrance to the Emergency Medicine Department, all patients and visitors will undergo passive thermal scans before moving to a triage area that separates into two paths: one for noninfectious persons and another for those potentially infected. The latter will be directed to an isolation wing within the EMD.

surge hospitals facilities designed to supplement existing hospitals in the case of large-scale emergencies. Based on Israeli models, Singapore has gone one step further by subtly incorporating protected facilities into its new hospitals in order to buttress a hospitals role in a national emergency response and maintain key functions during direct attack. Located two floors below grade, Khoo Teck Puat Hospitals 10,000square-meter Hospital Protected Vital Facilities area will operate on a completely separate mechanical and electrical system. During regular operation, the facility will house ambulatory surgical units and a parking structure. In emergencies the HPVF quickly and securely can be turned into a fully functioning hospital complete with operating theaters, diagnostic services, inpatient wards and a civil defense shelter.

Breath of Fresh Air

Hot and humid year-round, Singapores climate poses a significant challenge to healthcare providers. To minimize operating costs and maximize resources available to patient care, Khoo Teck Puat Hospital incorporates ventilation and exterior envelope strategies as part of a Total Building Performance design. Reducing the overall amount of a building that needs to be mechanically cooled is one of the most efficient ways to minimize energy

crisis management
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. Following Sept. 11 the United States crafted provisions for

project teAm Minister of Health, Singapore Khoo Teck Puat Hospital RMJM Hillier CPG Consultants Pte Ltd. PM Link Pte Ltd. Center for Total Building Performance Pte Ltd. project stAts Project Cost S$400 million Project Area 102,245 square meters

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consumption. Through careful building orientation, exterior detailing and interior planning, only 30 percent of Khoo Teck Puat Hospital will require air conditioning. These portions of the building, such as operating rooms and laboratories, will be co-located to minimize their external surfaces and heat gain. Ancillary spaces like balconies and circulation routes are designed to be naturally ventilated. Green roofs, green walls and landscaping also will help lower heat gain. The hospitals east-west facades also will be fitted with intricate sunscreens to shield the perimeter from direct sunlight, while 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 be shaded by deep overhangs

to largely remain transparent and maximize daylight and views. Khoo Teck Puat Hospital even incorporates alternative energy. The facilitys cogeneration plant will be the first of its kind in a major public project in Singapore. Designed to handle both base electrical and cooling loads, the gas-fired cogeneration plant is aiming to satisfy the hospitals needs 16 hours a day, freeing it from reliance on the electricity grid. Only during peak weekday usage will electricity be drawn from the grid to supplement cogeneration, and plant efficiency will be enhanced by a full complement of exhaust gas-heat recovery systems. 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. n

Steve Gifford, AiA, is managing and planning principal at the new York city office of rmjm Hillier, the north American division of rmjm group, an international architecture and design firm. Mitch Green, AiA, is director of healthcare planning for rmjm Hilliers new York office. to learn more, visit rmjmhillier.com.

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