Healthcare architecture research

Johan van der Zwart

MSc Architecture
PhD Real Estate Management
MSc Healthcare Management
Postdoc Architecture & Health
 Societal challenge
The European society is aging
... but …
as people are getting older, they spend more
time in sickness
….. in addition …..
healthcare professional as a group are aging
faster than society itself
….. and this implies that ….
there will be less healthcare professionals to
take care of more patients.
Dutch and Norwegian demography
 201 0 202 0 2030 204 0 205 0

250 000

0 100
citizen nursing days
2010 2020 2030 2040 2050
250 000 500 000

0 100 0 100
Building for a better hospital
value-adding management & design
of healthcare real estate
Johan van der zwart
design context
initiation briefing &
design

physical environment
society stock
stakeholders

organisation demand supply building

individuals place

use & construction

management

value manage
context
general context

legislation economy society demography technology

sector specific context

trends scenarios

organisation specific context

objectives internal stakeholders

objectives external stakeholders

manage
 context value managing design
check

impact on
organisation

human resources
society

act plan do
customer key performance key issues leadership policy & strategy process
satisfaction results for success

employee resources
satisfaction

(1) stakeholders’ objectives (2) success factors (3) organisational change (4) primary process

(A) (B) (C) (D)

real estate

(5) real estate perspectives (6) added value (7) accommodation management (8) building design

functional strategic current demand current supply

act plan do
CREM real estate accommodation
added values

physical financial future demand future supply

check

capital
employed capital
capital cost work capital fixed capital
debt equity building
optimising use of available work spaces
with the purpose of maximal utilisation of
building as return on investment
utilisation of buildings.
use of resources and services
available capacity
localisation of resources
localisation of staff
localisation of activities
1) use of rooms compared to design
2) outpatient rooms on wards
3) localisation of wards and back offices
Economic Value Added
net operating profit after tax
inventory operating costs
equipment other labour
reducing distances of patients' and
healthcare professionals' paths within the
architectural plan in order to optimise
efficiency of healthcare processes
layout efficiency.
time-stamps
process definitions
distances between resources
distances for staff
distances between activities
1) distances for different disciplines
2) interaction between different disciplines
3) spread out of clinics between centers
4) distances compared to other hospitals
5) visual connection between workstations
tax revenue
material prize volume
effective employment of proffessionals
and planning of patients with the purpose
of optimising volume of healthcare
services within the build environment
healthcare process.
intervals between time-stamps
proportion and amount treated patients
necessary staff as resource
total distances staff and support services
amount and distances patient transport
interactions between staff and patients
intercations between staff
1) amount of patient transports
2) out-of office hours transports
3) amount of nurses on the ward
4) patient contact time
5) organisation wards (#beds & fte)
6) amount of movement on ward
Utilisation of the building
Utilisation describes the assessment of the use of the available spaces in order to optimise resource
allocation and capacity. This includes the comparison of current use of spaces with the intended use
during the initiation and design of the building, as an indicator if the rooms are fit for their use. One
part of this assessment is the localisation of resources, staff and activities in the building. This
assessment gives also an overview of dispersity of activities within the building.
Layout efficiency
Layout efficiency describes the assessment of the impact of the layout on distances between activities
in order to gain information about the activities within the system and the potential effects of
organisational changes. This includes the relation between the activities within the healthcare paths of
patients and the localisation of these activities in the building. Part of this assessment are the actual
distances for resources, staff and patients in distance and time based on the time-stamps within the
patient administration system, but without the frequency of transfers depending on the number of
patients treated.
Healthcare process
Healthcare process describe the assessment of the impact of volume of treated patients in relation to
the amount of healthcare professionals needed for these treatments. These indicators connect staff
scheduling and appointment system to the available resources. This category of performance
indicators combine the localisation of activities (utilisation of the building) with distances between
activities (layout efficiency) and the number of patients treated. One part of this assessment is the
interaction between staff members, but also between staff and patients due to the amount of planned
activities.
 ER
GZ
AD MR MA DD GD RD
innovation VS
UG

satisfaction

culture
PEOPLE DD
MR
MA

AD
GZ VS

DD
VS
RD
AD
ER
UG

GZ
MR
UG
RD

GD ER
GD

MA

GZ AD
costs RD ER GD DD MR VS
MA UG

productivity

flexibility
PROCESS
RD ER
MR
DD

UG
GD
VS
GD
VS MA

GZ
ER
AD RD DD
AD
GZ
UG

MR
MA

VS
UG AD RD DD GZ MR GD MA
image ER

financing
risk GD

MA
GZ

GD
PLACE AD
MA
UG

MR
RD

AD
UG
RD
DD
VS MR
ER

DD
VS GZ
ER

high priority low

Van der Zwart, J., Building for a better hospital: Value-adding management & design of healthcare real estate. 2014, Delft University of Technology
 cluster definition hospital real estate added value
The way the physical environment organisational culture & Encouraging communication and innovation by
is experienced by people and innovation improving interpersonal relationships within the
USER-VALUE

evaluated in daily use. This organisation.

connects directly to the patient satsifaction & Positively influencing the healing process by
organisation as a form of healing environment pleasant accommodation facilities for patients.
cooperation between different
employee satsifaction Functional, enjoyable and comfortable
people who want to achieve their
workspace for employees.
goals.
Functional suitability and reduce accommodation Reduction of accommodation costs such as
PRODUCTION-VALUE

effectiveness in use means that a costs investment, capital, operating and maintenance
building is effective in a functional costs.
sense and meets the desired
increase productivity Increasing productivity through more effective
usage. Appropriate dimensions,
and efficient use of the accommodation.
positioning of the program and
routing within the complex are
use flexibility Spatial and technical flexibility to adaptteh
important aspects.
accommodation to changes in healthcare
processes.
Efficiency in time, which implies support image Propagating organisational values ​by using the
FUTURE-VALUE

sustainability of the design and building as an icon of the organisational culture.

suitability for re-use so that the
Reduce risk and increase Anticipating on future technical and financial
building can maintain quality and
financial possibilities risks by considering real estate as an asset.
value.
sustainability Reducing energy, water and materials usage
to maintain affordable healthcare with
increasing commodity prices.
design
spatial form

visible form
basic form
functional floorplan spatial configuration

(2) staff zone (3) inter action zone (2) staff

waiting area 8
reception area (3) interaction
8 4 6
7 6
circulation area
consulting room 3 2 5
4
7
2
1
reception
3 1 5 office (1) public
0
(1) public zone zoning
0

axial map connectivity

4
6
5 11
crossing axis

10 5

4 8 9 7 10
11
3
6 3 2 3 4 5 6
9
2 7 2 1
#

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Van der Zwart, J., Building for a better hospital: Value-adding management & design of healthcare real estate. 2014, Delft University of Technology
 people
HEALTH PROMOTING ARCHITECTURE
St Olav’s Hospital as a best practice case study place process

What is the contribution of architecture of St Olav’s

Hospital to the healing process of patients and the
effectivity of healthcare professionals?

three perspectives:
hospital’s social construct
where people meet and interact

hospital’s infrastructure
in which clinical processes are efficient and
effective

hospital’s architectural quality

the physical environment where professionals
Source: TSO
work and patients receive treatment
https://www.arkitektur.no/st-olavs-
hospital?tid=158202
 user-behaviour

building healthcare
utilisation PEOPLE process
impact of impact of
built environment process
on people on people

healing healthcare
architecture
case logistics
hospital
smart
architecture

PLACE PROCESS
impact of
built environment
on process
built environment big-data

layout efficiency
 user-behaviour

building patient healthcare

well-being
utilisation process process
PEOPLE
use
human personas healthcare
behaviour operations
actors
simulation modelling
smart
hospital
facility spaces architecture activities operational
design management
architecture
organisation technology
PLACE design PROCESS
enterprise
form function
building information
model
built environment big-data

layout efficiency
 people
HOSPITAL’S SOCIAL CONSTRUCT
when people meet and interact place process

How do patients and employees experience, perceive

and appreciate the public and communal areas of the
St Olav’s Hospital?

objectives:
psychosocial wellbeing of patients & professionals.

public areas and communal spaces.

approach:
survey patients and staff

naturalistic observations

walk along interviews

Source: Alvaro et al (2015) Design and evaluation:
the path to better outcomes.
http://www.bridgepointhealth.ca/en/what-we-
architectural analysis communal places
do/resources/research/Bridgepoint_Report_-
_FULL_-_March_13.pdf
From spaces to places, domestication
processes of hospital architecture
Marianne E. Fostervold, Johan van der Zwart
Gutten skjermer ansiktet mot sola, henger
over rullestolkanten, sutrer:
«Men det er så varmt!».

Hun sier i telefonen:

«Hvis noen sier at du
har gjort noe feil, så
kan du si at du bare
skal gi opp, men du
kan jo bare gå
videre».

En annen kommer og sier:" jeg satt inne

og ventet jeg, jeg så ikke meldingen din".
De har et møte om en sykepleier i
praksisperiode som har gjort noe feil.
 people
HOSPITAL’S INFRASTRUCTURE
efficient and effective clinical processes place process

How efficient is the architectural layout of St Olav’s

Centre Model in relation to the clinical processes?

objectives:
process of clinical pathways & patient flows.

outpatient clinic, diagnostics, treatment & wards.

approach:
modelling patient flows as clinical processes in an
Building Information Model (BIM)

patient information meta-data analysis

architectural analysis one clinical centre

Source: Walter et al (2013) Masterplan: a different
view on elctronic Data, ECHE Conference Bern.
 smart hospital architecture, data driven
simulation model for hospital infrastructure
Johan van der Zwart, Aneta Fronczek-Munter, Tor Åsmund
Evjen, John Krogstie, Jorulv Rangnes, Dominique Brodbeck
 Enterprise BIM
Tor Åsmund Evjen, Jorulv Rangnes, John Krogstie,
Aneta Fronczek-Munter, Johan van der Zwart
real estate client
owner
EBIM
building
healthcare project
organisation organisation

patients and construction

professionals company
sensors

real
occupancy design and
user phase building construction
 project data process place people
+-
-

+
+

-
HOSPITAL DATA
+-
+-

+
-
-
+

+-

organisational view clinical process model configuration dashboard capacity dashboard

f h

e g

d b c

systematic view configuration simulation data architectural layout model occupancy dashboard

people
+
patients

time

- time

chronological view capacity simulation data occupancy simulation data patient flow model
 Hospital architecture simulation: evaluation
of two inpatient units in Norway & Israel
Nirit Putievsky Philosof, Johan van der Zwart

Lauvnes (2012)
Sengetun, et
Schaumann, D., Pilosof, N. P., Date, K., & Kalay, Y. E. (2016). A study of human brukbart konsept?
behavior simulation in architectural design for healthcare facilities. Annali SINTEF A22564
dell'Istituto Superiore di Sanità, 52(1), 24-32. åpen report.
 people
HOSPITAL’S ARCHITECTURAL QUALITY
a place for professionals and patients place process

How does the architectural design of the single

patient rooms organised in sengetun wards support
the initial objectives of St Olav’s Hospital?

objectives:
evaluation place on staff and patients outcomes.

single patient room and hospital wards.

approach:
staff observations, travel distances and interviews

patient interview

architectural analysis wards

Source: illustration Svein Erik Tøien/BOARCH;

Photo St Olav working station www.SINTEF.no
 Usability evaluation of hospital architecture
Geir Hansen, Aneta Fronczek-Munter, Johan van der Zwart
 My questions for you ….
1. How does your design react to its context?
2. How does the design connect to the organisation?
3. Does the building add values to the organisation?
4. Can you make added values visible in drawings?
5. How is people’s behaviour influenced by design?
6. How are processes organised in the design?
7. How do places connect people and processes?