Hospital Design – a brief insight on the development of hospitals in Malaysia in comparison to projects overseas

1. Hospital Design – a brief insight on the development of hospitals in Malaysia in comparison to projects overseas Presented by Assoc. Prof. Datin Ar. Norwina Mohd Nawawi International Islamic University Malaysia PAM CPD 9th August 2008

2. Outline • Introduction • Healthcare • Hospital Architecture • Development of Hospital Abroad • Malaysian Healthcare Services • Development of Malaysian Hospitals pre and post independence • Current issues in hospital development • Summary PAM CPD 9th August 2008

3. Introduction Healthcare and Hospital Architecture PAM CPD 9th August 2008

4. Introduction • “Health care presents a different problem in every country for the way it is organised is a response to geography, climate, historical development, economic situation and social, cultural and political conditions… • Appreciation of these differences is fundamental to understanding of the situation which prevails in a country.” Anthony Cox, Philip Groves.1990. Hospitals and Healthcare Facilities. Gt.Britain.Butterworth & Co. PAM CPD 9th August 2008

5. Definition on Health “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” W.H.O. “Health, as we define it today, is a state of complete physical, psychological, social and spiritual well being.” Islamic worldview ……………………Thus, provides the overview that health isnot just the absence of disease in physical sense but encompass the whole well-being of the person. PAM CPD 9th August 2008

6. What is healthcare? • “Essential health care based on practical, scientifically sound and socially acceptable methods and technologies made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self determination” The Declaration of Alma Ata in 1978 PAM CPD 9th August 2008

7. Health Pyramid • Healthcare buildings encompass the predefined healthcare strata of PRIMARY, SECONDARY and TERTIARY level of care. Tertiary Secondary Primary PAM CPD 9th August 2008

8. The Level of Care • Primary care embraces all the general health practices, educational, preventive and curative, that are offered to the population at the point of entry into the System. • Secondary Care comprises the care provided by more specialised services to which people are rendered by the primary care services. • Tertiary Care includes highly specialised services not normally found at secondary level, including super-specialities such plastic surgery, neurosurgery and heart surgery. Anthony Cox, Philip Groves.1990. Hospitals and Healthcare Facilities. Gt.Britain.Butterworth & Co. PAM CPD 9th August 2008

9. Principle of Referral of Patients • The principle of referral of patients from a lower level of care to a higher level as a method of sorting them according to their need for specialist diagnosis or the nature or the degree or their disabilities is also universally recognised. • Another is aim to work in both direction for which the reverse is meant for convalescence. PAM CPD 9th August 2008

10. Basic Hospital Forms and Configurations Outpatient entry Emergency Entry The Outpatient Zone visitors Visitors Control Visitors Diagnostic & Treatment zones Inpatient zones Naturally ventilated areas are normally long and thin while fully air conditioned areas are thick and wide Medical and Non Medical Support Zones Supplies and Disposal In the tropics PAM CPD 9th August 2008

11. Ward Layout natural ventilation and natural lighting. Clinic Layout Patient Waiting Area C/E rooms C/E rooms Treatment Room Dirty Utility Stores Linking to Main Entrance or Hospital Street Staff corridor Linking to staff areas Procedure Room C/E rooms C/E rooms C/E rooms Clean Utility reception Natural Day light PAM CPD 9th August 2008

12. Development of Hospital Architecture Abroad UK, USA, EUROPE,JAPAN, SOUTH AFRICA, BRAZIL… PAM CPD 9th August 2008

13. British Experience • In the early 50s-60s during the energy crises,the British embarked on several hospital development program starting from • the Greenwich experience, • through the Harness system, • the Best Buy Mark I, then Best Buy Mark II, • through the varied Nucleus Hospital program including the energy efficient Nucleus Hospital of St. Mary on the Isle of Wright. • Now ..one off designs through……Private Finance Initiative (PFI) PAM CPD 9th August 2008

14. Greenwich hospital PLAN Interstitial Service floor floor The construction methods would be revolutionary - all lateral engineering services were to be contained in a 6-foot gap between floor and ceiling of each pair of floors so that repairs and maintenance works could be carried out without disturbing ward or department routine. All wards would have natural light but the service departments e.g. x-ray, pathology and operating theatres would be in the centre and artificially lit. The whole hospital was to be ventilated mechanically and none of the windows would open so that the air in the wards would be as ‘pure’ as possible. closed on 31st March 2001. PAM CPD 9th August 2008 http://mysite.wanadoo-members.co.uk/offkilter/page6.html retrieved 070808

15. USA Experience • Being on private insurance based healthcare system, architects in the United States had to convince the facility management that good healing design is profitable. • Extensive campaign or crusades on both sides of the Atlantic to market the will of healing environment through provision of good view, music therapy, good interior design, lots of sunlight, fresh air and energyefficiency through passive design strategies are done with many researches being conducted to provide evidence that environment do indeed improves the person health outcomes. PAM CPD 9th August 2008

16. European Experience • In Europe, apart from access to daylight and fresh air, strategies for passive design include the choice of building materials for healthcare buildings that has rigorous requirements. • The material is specifically specified to be environment friendly e.g.the choice of wall and floor finishes should not be from material that can burn nor emit toxic fumes. • Building services system should promote the recycle of waste water; retention of natural water before gradual discharge; recycle heat energy of air condition to radiators; use of solar power with photo voltaic, wind energy and others. PAM CPD 9th August 2008

17. The Asian Experience • There have been movement in the Asian scene about going back to tradition and local Asian values when designing hospitals. • The deep rooted wisdoms on the use of Feng Shui (literally means wind, water) by the Chinese and Vaastu Shastra by the Indians had made significance come back in this millennium. • Both values, are basically based on the planning of the environment that deals with orientation and provision of good healthy living. PAM CPD 9th August 2008

18. Worldwide experience summary More hospital planning layouts are going away from deep planning and massive concept to thinner blocks with courtyardsto provide • opportunity for all habitable rooms or spaces to have a natural daylight and view to the outside; PAM CPD 9th August 2008

19. More patients’ spaces are accessible to the gardens or sizeable courtyards whether it is on the roof-tops or on the ground floors; Nortalie Hospital, Sweden Albert Einstein Hospital, Sao Paolo PAM CPD 9th August 2008

20. Sunderby Hospital, Sweden • More external cladding, although of high tech material, provides the shades and light at their openings through provision of retractable blinds or hoods as and when necessary. PAM CPD 9th August 2008

21. Atriums with gardens and natural daylighting are a common feature. Due to their four seasons and differential natural day-lighting intensity throughout the year, ventilation systems need to be boosted with mechanical means to provide the space with the required thermal comfort level. PAM CPD 9th August 2008

22. Malaysian Healthcare Services System PAM CPD 9th August 2008

23. Malaysia – Vital Statistics Other Vital Statistics Land Area: 330,252 sq km Population ( 2006): 26,640,200 Population Density: 81 / sq. km Population Growth: 1.5% 14 States 15-64 years –63% 65 years & above-4% Below 15 years – 33% Source: Health Facts 2006, Ministry of Health Malaysia PAM CPD 9th August 2008

24. Malaysian Health Vision Ministry of Health Malaysia • “ Malaysia is to be a nation of healthy individual, families, and communities, through a health system that is equitable, affordable, efficient, technological appropriate, environmentally adaptable and consumer friendly, with emphasis on quality, innovation, health promotion and respect for human dignity, and which promotes individual responsibility and community participation towards an enhanced quality of life” PAM CPD 9th August 2008

25. The health vision is not static but dynamic that sets in place framework to ensure that the health system could develop and adapt to the changing environment • Health care facilities were pragmatically plan and developed to provide the support towards that vision PAM CPD 9th August 2008

26. Spectrum of Healthcare Facilities PAM CPD 9th August 2008

27. Private Sector 20-25 % Government / Public Sector 75-80% PRIVATE HEALTH CARE FACILITIES FEDERAL GOVERNMENT Public health/ medicine Disease Control Law Enforcement STATE/ LOCAL GOVERNMENT Environmental Sanitation, Housing Standards, Implementation,Law enforcement Min. of Health Armed Forces Dept. of Aborigines Min. of Home Affairs Min. of Education Source: Ministry of Health Malaysia PAM CPD 9th August 2008

28. Introduction • On the macro level, the paper relate on the national referral system then, in place and in the process of planning; • On micro aspect, the design development of these hospitals were discussed on the rationale of its development as outcome of the country’s health trend. PAM CPD 9th August 2008

29. Malaysian Healthcare Referral System National Referral Hospital TERTIARY CARE Just over 1000 beds State/General Hospital Not more than 1000 beds Large District Hospital Emergency referral Normal referral 500-750 beds Medium District Hospital SECONDARY CARE 300-500 beds Small District Hospital 150-300 beds 26-150 beds Health Clinic PRIMARY CARE With and without Alternative Birthing Centre Community Health Clinic / Rural Health Clinic PAM CPD 9th August 2008

30. Bed Numbers PAM CPD 9th August 2008

31. The Private Sector PAM CPD 9th August 2008

32. Private Healthcare Facilities and Services Act 1998 PRIVATE HEALTHCARE ( URBAN BASED) Mid 1970s- 1990s Pre Colonial Period post independent period 1957-1970s Medical Tourism After care Hospices Colonial Period 1700-1957 Shops change to hospital Home based Shop lots to clinic and maternity homes Purpose built hospital Simple structures Tropical Architecture Non Standard Single, low rise sprawling structures in Estates/ Plantations medium rise donation based hospitals in capital cities for the poor • New Hospitals • (Maternity/ Chinese) • GPs (Clinics) • Support Services • Nursing Homes • Integrated within commercial • Centres for GPs, • Nursing homes with the • suburbs • Customised design for • hospitals • More GPs Clinics • Pharmacies • Laboratory Services • X ray services • Teaching (Medical/ • Nursing schools) Architecture PAM CPD 9th August 2008 5yrs x 1,2,3,4,5,6,7,8,9.. Malaysia Plans 50yrs 1957

33. Healthcare Facility • “….means any premises in which one or more members of the public receive healthcare services..” Part 1, Preliminary, Section 2. Interpretation,Private Healthcare Facilities and Services Act 1998 Proposed HUKM teaching block Damansara Arkitek PAM CPD 9th August 2008

34. What is Government Healthcare Facility • …” GHF Means any facility used or intended to be used for the provision of healthcare services established, maintained, operated or provide by the Government but excludes privatised or corporatised Government healthcare facilities;” Part 1, Preliminary, Section 2. Interpretation Private Healthcare Facilities and Services Act 1998 PAM CPD 9th August 2008

35. Private Sectors in the Industry Miriam Hospital,Penang Island Hospital, Penang Upgrading and expansion PAM CPD 9th August 2008

36. Private Sectors in the Industry Mahkota Medical Centre, Melaka Damansara Specialist Centre Tower and podium, atrium/lobby, cafeteria, shops, Services Outpatient (general and Ssecialist) and Inpatient PAM CPD 9th August 2008

37. The Public Sector PAM CPD 9th August 2008

38. PUBLIC HEALTHCARE NATION WIDE Package Deal Procurement Paperless Hospitals Masterplans Telemedicine late 90s-early 2000s Greening Healing environment up-grading, customised design building 2007-to date Conventional Procurement Pre Colonial Period Early post independent period 1957-1970s Upgrading works 1970s- 1990s Colonial Period 1700-1957 homebased Architecture High-rise, High-tech, art décor, post modern, retro, urban based, smaller land lots for Bigger Hospitals Simple structures Tropical Architecture Non Standard Single, low rise sprawling structures in small towns and medium rise in capital cities • Standard Architecture • Design for • Nation Building • Hospitals • Clinics • Support Services • Staff residence • Medical & Nurisng • schools • Single, low rise sprawling • structures in small towns • New Standard • Architecture • Design for • Nation Building • District Hospitals • Clinics • Support Services • Staff residence • Teaching facilities Customised Architecture Design for Nation Building PAM CPD 9th August 2008 5yrs x 1,2,3,4,5,6,7,8,9.. Malaysia Plans 50yrs 1957

39. Facility Planning Norms Rural Health Clinic • State Hospital at every State • Regional Hospital • Hospital for every district • Network of facilities for sub-specialties Community Clinic For 2,000 to 4,000 population. Health Centre For 15-20,000 population PAM CPD 9th August 2008

40. General Guide • Base on the principles of total planning & development, the general guide to planning healthcare facilities are as follows: • Site planning • Minimum area or acreage • Component of healthcare facilities • Support facilities PAM CPD 9th August 2008

41. Site Planning • Healthcare facilities should be provided complete according to its hierarchy: a) Hospital-includes general hospital, district hospital, with orwithout specialists. These are provided at state and district level. b) Health Clinics are provided at local level, and c) Rural Health Clinic is provided at the rural areas. PAM CPD 9th August 2008

42. Site Planning ii) The planning on the type of healthcare facilities must be according to the region and the catchment area as shown in the Table A; iii) The location of healthcare facilities should be suitable and appropriate in terms of its accessibility, quality of the environment, and safe for the community; iv) The healthcare site should be access by the network of roads and near to the public transportation system; PAM CPD 9th August 2008

43. Site Planning TABLE A PAM CPD 9th August 2008

44. Site planning v) The location of a hospital need not necessarily be in the town centre to avoid traffic congestion; but accessible vi) The location of hospital is not suitable at noisy and polluted areas; vii) The site planning of healthcare facilities must be in accordance to the proposed and development strategy in the local plan as well as approved by the state authority. PAM CPD 9th August 2008

45. Site Sizing and Acreage • The minimum size varies according to the hierarchy of the facilities as shown in the Table A; • The lot size should be able to accommodate the main building, the car park, the landscape, the support facilities as well as the probable expansion; • The acreage for healthcare facilities should be adequate as to include planned activities and the required components as per prescribed in accordance to its hierarchy. PAM CPD 9th August 2008

46. Layout Plan and Design • The design of healthcare facilities should be a functional design to serve as the health centres for all communities; the building should reflect friendliness; • The design should take note the function and adjacency of the various work area or departments base on the workflow of patients and medical procedures so as not to obstruct; PAM CPD 9th August 2008

47. Layout Plan and Design iii) The design should consider the requirements of emergency treatment by providing emergency access for vehicles in cases of emergencies; iv) Healthcare facilities design should consider the local culture that is clean, organised and beautiful whilst establishing a community park; v) The circulation for the facilities should be clearly organised and without obstruction with provision for safe pedestrian crossing, the disable, the elderly and children; PAM CPD 9th August 2008