Contract - Designing for Health: The differences between U.S. and U.K. clinical planning models

design - essay



Designing for Health: The differences between U.S. and U.K. clinical planning models

02 February, 2012

-By Coulomb Chang, LEED AP, and Courtney Johnston, IIDA, RID, LEED AP



The United States and United Kingdom share many commonalities; we are tied together through history, cultural references and not least, our language.  Although the U.S. inherited many practices and models from the U.K., there are also significant differences, for instance medical and clinical planning. Authors Coulomb Chang and Courtney Johnston were able to compare U.S. and U.K. clinical planning models side by side while collaborating on several projects in the U.K. for a long-time U.S. health system client.  Concurrent projects in London provided the ideal setting to compare and contrast best practices for a diagnostic/outpatient center and a hospital ICU expansion.
 
While medical treatments and program spaces are similar to U.S. standards, the most notable difference in the U.K. is the spatial allocation of the program. Hospitals in the U.K. typically do not have the luxury of creating sprawling medical campuses where growth and expansion can be easily met with adding a new extension or building. Instead, more development is in adaptive reuse of existing buildings.  In the current U.K. economic climate, new ground-up hospitals, which are inherently more capital intensive than refurbishments, have become increasingly rare to non-existent. In many hospitals across the U.K., facilities are often shoe-horned into historical buildings which were not built for medical purposes.  This often leads to smaller spaces than U.S. equivalents, such as operating rooms, or “theatres” in U.K. terminology.  Additionally the trend for increased efficiencies in the NHS’s (National Health Service*) existing building portfolio has led to even more spatial constraints and creative solutions in reorganizing hospital adjacencies.
 
An example of spatial deviation from the U.S. equivalent is evident in the privately-funded outpatient center in London which includes reduced area for outpatient surgery rooms—these rooms were designed at approximately 400 square feet verses a U.S. standard around 650 square feet. During the design phase, when asked if they would like to increase the size of the operating rooms, the users said it was not necessary, they would simply work with the amount of space to which they are accustomed. In contrast, American surgical staff often requests more space. Another unique planning model in the U.K. is the combined consultation and exam room; this combination in the outpatient center resembles a complete physician’s office with exam capabilities integrated into one side of the room. This independent clinic allowed physicians to schedule the rooms at varying times, similar to leasing a conference room or a hoteling concept that allow multiple physicians to share the space. Typically, the U.S. model is to separate functions to keep patients moving.  The very concept of the freestanding outpatient center in the U.K. is rare. The outpatient facility was created to relocate outpatient functions from a hospital to maximize space for inpatient services. One of the major challenges was to educate the staff, physicians and patients to what is a true U.S.-style outpatient center.
 
Similar to the outpatient clinics, hospitals in the U.K. have some notable differences, again most likely derived from the limited space available. Some hospitals occupy buildings hundreds of years old, which may or may not have been originally designed as hospitals and are now not always able to fully meet more stringent modern guidelines on accessibility. Instead, these facilities typically need to incorporate more robust operational plans that allow for access and safe and effective egress in emergency situations.
 
One significant difference between U.K. and U.S. hospitals is the idea of open-plan“wards” (multi-bed rooms) in the NHS. While there has been a relatively recent trend in U.K. hospitals towards private rooms due to concern for privacy and infection control, proponents of ward care cite patients’ preferences for spaces that allow for social interaction. This concept is supported by research that social support for patients should tend to alleviate stress and improve patient outcomes. Due to the nature of socialized medicine, efficiency in caring for multiple patients simultaneously and ease of patient monitoring are also beneficial in ward type arrangements.
 
In hospitals, the size of the ward can vary; typical wards in NHS hospitals are made up of 24 beds which are further broken down into a combination of multi-bed rooms of four, semi-private rooms of two, and single bed rooms, thus providing a range of accommodation choices for patients and a more efficient use of space.  Multi-bed rooms of four offer an increased level of privacy and gender separation within a large ward as they can be efficiently planned to allow for a neighbor on one side only. Each multi-bed room would also have access to a shared “en-suite” (patient toilet) and informal social area to provide patients the opportunity to leave the bed.
 
With a shortage of ICU and critical care beds generally throughout the U.K., the need for space-efficient multiple bed units is a necessity for the foreseeable future. The provision for small numbers of isolation rooms is still required for more highly infectious patients, however, due to space constraints, these rooms do not all necessarily have “air locks” (ante rooms). Instead, isolation rooms switch between positive and negative air pressures as required.
 
The differences between U.S. and U.K. planning models seem to stem from a general lack of space in the latter, and the fundamental differences between private healthcare and socialized medicine. In the U.K., having less room to work with has forced clinicians to be more efficient with the individual spaces they have and challenged designers to look for architectural solutions that are flexible and possibly serve multiple roles. With socialized healthcare, doctors and nurses are constantly under increasing pressure to care for more and more patients. Clinical planning in the U.K. has traditionally accommodated group care and nursing arrangements which allow clinicians to efficiently care for and monitor a larger number of patients simultaneously.  Although not as spatially constrained, the U.S. might consider adopting some U.K. size standards for an increased sustainable effort.       
 
* National Health Service is the publicly-funded (socialized) health care system in the United Kingdom, funded through taxes.

Photos (from top to bottom)
Photo 1: Conceptual design rendering of main lobby for a London outpatient clinic
Rendering: Perkins+Will

Photo 2: Illustration of combined physician office/exam room in London outpatient clinic
Rendering: Perkins+Will

Photo 3: Floor plan of four-bed "ward," a multi-bed hospital room in the U.K.
Rendering: Nightingale Associates

Photo 4: Conceptual rendering for ITU (Intensive Treatment Unit) room in London hospital
Rendering: Perkins+Will
 

Sources
Department of Health Gateway Review Estates & Facilities Division, “Health Building Note 00-03 – Clinical and clinical support spaces,” (January 2010)
 
Department of Health Gateway Review Estates & Facilities Division, “Multi-bed room: Design Manual Version: 0.4: England,” (2011)
 
Department of Health Gateway Review Estates & Facilities Division, ”Adultin-patient accommodation: Planning and Design Manual, Version: 2.5: England,” (2011)
 
Ulrich, R. S. (1997). A theory of supportive design for healthcare facilities. Paper presented at the 1996 Ninth Symposium on Healthcare Design.
 
 
Bios
Coulomb Chang, LEED® AP serves as the healthcare practice leader in the Perkins+Will London office.  He has experience in the design and delivery of a range of healthcare facilities in both the public and private sectors in the UK and the US. He can be reached at Coulomb.Chang@perkinswill.com.
 
Courtney Johnston, IIDA, RID, LEED® AP is the Director of Design for the Interiors Studio of the Perkins+Will Dallas office.  She is responsible for managing the design process for projects and collaborating with other design disciplines for the best possible project solutions.  Courtney’s experience includes healthcare, education and corporate work, and incorporating evidence-based design into the overall design strategy of all projects.  She can be reached atCourtney.Johnston@perkinswill.com.

"Designing for Health" is a monthly, web-exclusive series from the healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments. Past installments of "Designing for Health" include (click on title to access the full article):

Widening a Circle of Natural Inclusion
Mentoring the Next Generation of Healthcare Design Professionals
When the Professional Becomes the Patient--An Insider's Perspective
The Evolving Role of the Design Professional Through Public Private Partnerships
Are Best Healthcare Design Practices Transferable to the Middle East? 
Best Strategies for the EDAC Exam


 





Designing for Health: The differences between U.S. and U.K. clinical planning models

02 February, 2012


rendering by Perkins+Will

The United States and United Kingdom share many commonalities; we are tied together through history, cultural references and not least, our language.  Although the U.S. inherited many practices and models from the U.K., there are also significant differences, for instance medical and clinical planning. Authors Coulomb Chang and Courtney Johnston were able to compare U.S. and U.K. clinical planning models side by side while collaborating on several projects in the U.K. for a long-time U.S. health system client.  Concurrent projects in London provided the ideal setting to compare and contrast best practices for a diagnostic/outpatient center and a hospital ICU expansion.
 
While medical treatments and program spaces are similar to U.S. standards, the most notable difference in the U.K. is the spatial allocation of the program. Hospitals in the U.K. typically do not have the luxury of creating sprawling medical campuses where growth and expansion can be easily met with adding a new extension or building. Instead, more development is in adaptive reuse of existing buildings.  In the current U.K. economic climate, new ground-up hospitals, which are inherently more capital intensive than refurbishments, have become increasingly rare to non-existent. In many hospitals across the U.K., facilities are often shoe-horned into historical buildings which were not built for medical purposes.  This often leads to smaller spaces than U.S. equivalents, such as operating rooms, or “theatres” in U.K. terminology.  Additionally the trend for increased efficiencies in the NHS’s (National Health Service*) existing building portfolio has led to even more spatial constraints and creative solutions in reorganizing hospital adjacencies.
 
An example of spatial deviation from the U.S. equivalent is evident in the privately-funded outpatient center in London which includes reduced area for outpatient surgery rooms—these rooms were designed at approximately 400 square feet verses a U.S. standard around 650 square feet. During the design phase, when asked if they would like to increase the size of the operating rooms, the users said it was not necessary, they would simply work with the amount of space to which they are accustomed. In contrast, American surgical staff often requests more space. Another unique planning model in the U.K. is the combined consultation and exam room; this combination in the outpatient center resembles a complete physician’s office with exam capabilities integrated into one side of the room. This independent clinic allowed physicians to schedule the rooms at varying times, similar to leasing a conference room or a hoteling concept that allow multiple physicians to share the space. Typically, the U.S. model is to separate functions to keep patients moving.  The very concept of the freestanding outpatient center in the U.K. is rare. The outpatient facility was created to relocate outpatient functions from a hospital to maximize space for inpatient services. One of the major challenges was to educate the staff, physicians and patients to what is a true U.S.-style outpatient center.
 
Similar to the outpatient clinics, hospitals in the U.K. have some notable differences, again most likely derived from the limited space available. Some hospitals occupy buildings hundreds of years old, which may or may not have been originally designed as hospitals and are now not always able to fully meet more stringent modern guidelines on accessibility. Instead, these facilities typically need to incorporate more robust operational plans that allow for access and safe and effective egress in emergency situations.
 
One significant difference between U.K. and U.S. hospitals is the idea of open-plan“wards” (multi-bed rooms) in the NHS. While there has been a relatively recent trend in U.K. hospitals towards private rooms due to concern for privacy and infection control, proponents of ward care cite patients’ preferences for spaces that allow for social interaction. This concept is supported by research that social support for patients should tend to alleviate stress and improve patient outcomes. Due to the nature of socialized medicine, efficiency in caring for multiple patients simultaneously and ease of patient monitoring are also beneficial in ward type arrangements.
 
In hospitals, the size of the ward can vary; typical wards in NHS hospitals are made up of 24 beds which are further broken down into a combination of multi-bed rooms of four, semi-private rooms of two, and single bed rooms, thus providing a range of accommodation choices for patients and a more efficient use of space.  Multi-bed rooms of four offer an increased level of privacy and gender separation within a large ward as they can be efficiently planned to allow for a neighbor on one side only. Each multi-bed room would also have access to a shared “en-suite” (patient toilet) and informal social area to provide patients the opportunity to leave the bed.
 
With a shortage of ICU and critical care beds generally throughout the U.K., the need for space-efficient multiple bed units is a necessity for the foreseeable future. The provision for small numbers of isolation rooms is still required for more highly infectious patients, however, due to space constraints, these rooms do not all necessarily have “air locks” (ante rooms). Instead, isolation rooms switch between positive and negative air pressures as required.
 
The differences between U.S. and U.K. planning models seem to stem from a general lack of space in the latter, and the fundamental differences between private healthcare and socialized medicine. In the U.K., having less room to work with has forced clinicians to be more efficient with the individual spaces they have and challenged designers to look for architectural solutions that are flexible and possibly serve multiple roles. With socialized healthcare, doctors and nurses are constantly under increasing pressure to care for more and more patients. Clinical planning in the U.K. has traditionally accommodated group care and nursing arrangements which allow clinicians to efficiently care for and monitor a larger number of patients simultaneously.  Although not as spatially constrained, the U.S. might consider adopting some U.K. size standards for an increased sustainable effort.       
 
* National Health Service is the publicly-funded (socialized) health care system in the United Kingdom, funded through taxes.

Photos (from top to bottom)
Photo 1: Conceptual design rendering of main lobby for a London outpatient clinic
Rendering: Perkins+Will

Photo 2: Illustration of combined physician office/exam room in London outpatient clinic
Rendering: Perkins+Will

Photo 3: Floor plan of four-bed "ward," a multi-bed hospital room in the U.K.
Rendering: Nightingale Associates

Photo 4: Conceptual rendering for ITU (Intensive Treatment Unit) room in London hospital
Rendering: Perkins+Will
 

Sources
Department of Health Gateway Review Estates & Facilities Division, “Health Building Note 00-03 – Clinical and clinical support spaces,” (January 2010)
 
Department of Health Gateway Review Estates & Facilities Division, “Multi-bed room: Design Manual Version: 0.4: England,” (2011)
 
Department of Health Gateway Review Estates & Facilities Division, ”Adultin-patient accommodation: Planning and Design Manual, Version: 2.5: England,” (2011)
 
Ulrich, R. S. (1997). A theory of supportive design for healthcare facilities. Paper presented at the 1996 Ninth Symposium on Healthcare Design.
 
 
Bios
Coulomb Chang, LEED® AP serves as the healthcare practice leader in the Perkins+Will London office.  He has experience in the design and delivery of a range of healthcare facilities in both the public and private sectors in the UK and the US. He can be reached at Coulomb.Chang@perkinswill.com.
 
Courtney Johnston, IIDA, RID, LEED® AP is the Director of Design for the Interiors Studio of the Perkins+Will Dallas office.  She is responsible for managing the design process for projects and collaborating with other design disciplines for the best possible project solutions.  Courtney’s experience includes healthcare, education and corporate work, and incorporating evidence-based design into the overall design strategy of all projects.  She can be reached atCourtney.Johnston@perkinswill.com.

"Designing for Health" is a monthly, web-exclusive series from the healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments. Past installments of "Designing for Health" include (click on title to access the full article):

Widening a Circle of Natural Inclusion
Mentoring the Next Generation of Healthcare Design Professionals
When the Professional Becomes the Patient--An Insider's Perspective
The Evolving Role of the Design Professional Through Public Private Partnerships
Are Best Healthcare Design Practices Transferable to the Middle East? 
Best Strategies for the EDAC Exam


 


 


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