The English word “design” generally indicates planning in a broader sense, particularly the formal connotation of what is planned. How does one translate this multiplicity of meaning- and the co-presence of shape and meaning- in the design of healthcare spaces?
In 1991 Vittorio Gregotti wrote in Dentro l’Architettura (Inside Architecture) that the architect’s actions distinguished themselves from other artistic practices and from project management thanks to his “universe of specialised competencies, which by tradition beckon him to shape meaningfully the array of transformational techniques of the physical world”. This meaning, in a healthcare space, cannot be reduced to the reassuring image of a hotel or a shopping centre, but needs to draw from aesthetics instead – which is meant as the universal experience of beauty; that same relationship that beauty has with health and feeling well, that neurobiology investigates and that the architecture of hospitals has known about for a long while. It is true that the rationalist hospital architecture of the last century advantaged technical and functional aspects: the machine à guérir (the healing machine). However, Alvar Aalto’s lesson at the Paimo Sanatorium in 1928, where he married functionality with light and nature, was followed at times, for example in the UK during the ‘50s. That’s how in the ‘80s we went back to asking architects to add to the technical and healthcare competencies by “shaping meaningfully” the healthcare spaces. Putting patients first, evidence-based medicine, healing environments movement and evidence-based design became well asserted practices. Nonetheless, at times the design of healthcare spaces also appeared to have been confined to the search of an “image”: communicating and representing, hiding pain, anxiety and stress. The coexistence of shape and meaning must originate from the ability of a project to unite architecture with the ten principles that Renzo Piano proposed in 2001 for a new hospital model. These were inspired by a new vision that seems rather modern: guarantying care, developing a culture of health, working within a network, and guarantying, even in emergencies, the efficacy of care, and humanity for the carers and those who receive the care.
How does the integration of knowledge and competences help to create a project “knowledge”?
For a long time, the design of healthcare spaces has been experimenting approaches that integrate the disciplinary and professional experience and the “inner knowledge” of those who use these spaces, both in the project research and the planning phases. An interdisciplinary approach is necessary to investigate multiple environmental factors that influence the quality of care, as shown by the scientific programs of the Centre for Health Design in California, the Centre for Health Facility of the University of Clemson and the Inter-university Tesis Centre based at the University of Florence. The Californian Centre developed tools such as the clinic design post-occupancy evaluation and the patient room design checklist. Architects, physicians, nurses, human factor specialists and engineers from the University of Clemson developed prototypes for the inpatients room and the surgery theatre. At the Tesis Centre we had collaborations between architects, physicians, legal experts, sociologists, and environmental psychologists on themes such as the right to health, stress reduction, humanization, safety and accessibility. Even during projects, the complexity of issues at play does not allow one to delegate the mixture of needs and know-hows to a professional figure anymore. The ‘collaborative’ project that involves the experts, the operators, the commissioner and companies increasingly utilize information and communication technologies: the Bim (Building information modelling) and the Bkm (Building knowledge modelling). The basics are composed by the (specialised, shared and common) “knowledge” and the way this is formalized, elaborated and communicated to the planning team. There are several examples of projects that used the Bim. I will mention two of them: the Palomar Medical Centre in California, innovative in terms of its functional, environmental and sustainable planning, and the Paediatrics Hospice of the Seràgnoli Foundation in Bologna. In the latter the Bim was utilized in the initial briefing phases all the way to the executive phases, accompanied by the important presence of the architect’s “workshop” tools: sketches, physical models and prototypes.
The complexity of issues at play does not allow to delegate the mixture of needs and know-hows to a professional figure anymore.
In what way and in what measure does healthcare planning grant more universal access to healthcare services and treatments?
An increased access to services and treatments revolves around a series of requirements and specifications for the healthcare systems that are defined by organizations such as WHO, OECD and AHRQ. In order to plan the facilities these, translate into localization and sizing criteria, functional and spatial organization, technologies and availability of equipment, and these aspects need to take in consideration developing and emerging dynamics.
I would like to answer the question with a specific example, and I will link this to the data from a study we conducted at the University of Florence between 2011 and 2013, “Spaces – the Space of Rights. The efficacy of the right to health in healthcare facilities”. During this research project an interdisciplinary group studied the “public” spaces of the hospital that have been becoming increasingly more important for the healthcare architecture. By focusing on these the research aimed to value the meaning of the space in which the behaviours and the relationships happening constitute the first step towards fulfilling the right to health. They represent the link between the people requesting care and support and the organizations that provide the required services. Aside from the public space, the organization manages the individual person following regulated support routes, while in the “public space” – a hall, a main street, a waiting space – you can favour relationships and behaviours that interpret the needs and expectations of each person in a flexible, inclusive and universal way. The public spaces of each facility can also open and project – physically and virtually – into the territory, they can shape and provide tools to the knowledge of the accessible network of services, for the continuity of care.
Public spaces represent the link between the people requesting care and support and the organizations that provide the required services.
The Covid-19 emergency implies a question: during the planning of a healthcare space will it become more relevant, in the future, to think about and foresee the flexibility of the space based on the new health challenges?
Flexibility has been for years a central theme in the planning of healthcare building construction work, particularly for hospitals. Flexibility is necessary because the changes that take place during the planning phase last for the whole lifespan of the building. In principle it imposes a hierarchical logic to the project that establishes different degrees of constraints/modifiability of the spaces and the technologies: there is a “support” that has a high degree of permanence and a low impact on the flexibility of the stopgap, partition and preparation subsystems.
However, you’re asking me whether such approaches will suffice during emergencies. I believe that in this case one should discuss, not so much flexibility but rather resilience, meaning the ability of the system to temporarily modify its way of working to face a relevant and unexpected event. Recently there has been talk of shortage of beds in intensive care units, of inadequate A&E departments, and then little by little it emerged that there the issue wasn’t so much with the spaces or the facilities but it was an issue with the equipment and the personnel instead. What also emerged is that the healthcare system on its whole is not resilient because its governance is quite rigid: the network is not adaptable or reconfigurable to face the emergency and the programs remain guidelines that do not translate to practical applications.
In terms of healthcare planning is it recommended to restructure already existing hospitals or to plan new ones and change the intended use of those we currently have?
Whether hospitals are new or restructured they almost always must deal with a pre-existing infrastructure. A new facility substitutes those smaller and obsolete hospitals, a hospital organization gets transferred to a new facility, a pre-existing facility that’s become inadequate gets expanded, it is decided to proceed conserving and restructuring. What also happens is that all of these processes intersect, such is the case of interventions happening in big hospitals with multiple pavilions, where it’s decided that some get restructured, some get build anew, the routes are modified and often the pavilions left unused get revamped for new purposes. At times temporary solutions are necessary to transfer a department in a place prior to its destination. In the meantime, the services of the pre-existing infrastructure can keep functioning, despite the issues arising from the co-existence of the construction site and the healthcare activities. The project takes place over long periods of time, in phases and subprojects, which differ by the funding, professional assignments and commissioning. Variations of the healthcare programme, technologies development and setbacks typical of the building renovation work also interfere. In the meantime, it is necessary to manage the communication with operators and users. It is evident that intervening with reconstruction work is more complex and often more expensive than making an ex novo intervention. Nonetheless, one aspect can prevail over anything else and direct the reconstruction work, and that’s the town-planning aspect, the relationship with the city, the services and the accessibility, and last but not least the “meaning” that citizens attribute to the existing hospital. If all of these have value, then the historical hospital – after being resized, better inserted in the network, functionally reconverted – can remain and contribute to keep the city centres alive. There are frequent examples of this type of work in Italy: the intervention on the Hospital Santissimi Giovanni e Paolo in Venice, that can be accessed from the Saint Marco’s Scuola Grande, and the work on the Hospital of Santa Maria Nuova in Florence, just a few steps away from the Duomo.
Whether new or restructured, hospitals almost always have to deal with a pre-existing infrastructure.
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