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European Health Property Network

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The European Health Property Network

Design Impact Study

A European comparative study of design in relation to context:

What is the relationship between design and context, and how does this impact on performance in healthcare environments?

Commissioned by: Plan & Projectpartners Author and photographer: Kaethe Burt-O�Dea

September 2005

© The European Health Property Network 2005, except where indicated otherwise in the text

Author and photographer:

Kaethe Burt-O�Dea

Editor:

Jonathan Erskine

Centre for Clinical Management Development

Wolfson Research Institute

Durham University

Layout:

Janet Starkey

Published by:

The European Health Property Network in collaboration with Plan & Projectpartners

Printed by:

Prontaprint Durham

85 New Elvet

Durham DH1 3AQ

Contents

Plan & Projectpartners 4

Samenvatting 6

Executive Summary 10

Introduction 14

The Origin of the Design Impact Study 14 The Original Brief 14 A Necessary Revision 15 The European Health Property Network 15 Some Definitions 16

Methodology 17

Phase One 18 Definition of the Study�s Central Question 18 Desktop Review and Assessment of Evidence 18 Exploration of the tool base 19 Preliminary Study of One of the Submitted Projects 19 The Design of a Project Specific Tool 20 Selection of Five Case Studies 21 Phase Two 22 Case Studies and Review 22 The Pre-Visit Questionnaire 22 Case Study On-Site 23 Review, Analysis, Report Writing 23

Analysis 24

Environmental Tensegrity 24 Dynamic Relationships that Influence Wellbeing in Healthcare Buildings 25 Context: The Pre-Visit Questionnaire and Walk-Through Interview 28 Signals : The Multi-User Questionnaire 33

Case Studies 36 St Joseph�s at Mount Desert, Republic of Ireland 37 Oulu City Hospital, Finland 53 Sykehuset Telemark, Norway 69 Ter Reede, The Netherlands 83 Mater Hospital, Northern Ireland 99

Outcome 115 Response From Participating Organizations 115 Client Focus 115 What Tools Are Necessary To Get The Local Community Involved? 116 What Are The Benefits? 116 What Are The Risks? 116 Are There Shared Benefits/Risks? 117 Suggested Growth Areas 117

Final Review 117

Conclusion 121

Acknowledgements 122

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Plan & Projectpartners

Plan & Projectpartners is een onafhankelijk adviesbureau op het gebied van huisvesting. Onze dienstverlening strekt zich uit over alle facetten van het ontwikkel- en bouwproces. Van bepaling van het huisvestingsbeleid tot en met oplevering en nazorg van een gebouw. De opdrachtgevers van Plan & Projectpartners zijn met name organisaties in de gezondheidszorg.

Transparant

Onze projectaanpak is heel transparant. U weet bij Plan & Projectpartners precies waar u aan toe bent. Zo heeft u de zekerheid dat uw ideeën binnen de gestelde randvoorwaarden en financiële kaders gerealiseerd kunnen worden.

Ontstaan

Plan & Projectpartners is ontstaan vanuit het werkverband van zorginstellingen De Open Ankh, stichting dienstverlening gezondheidszorg. Ons bureau verleende in het verleden de adviesdiensten aan aangesloten stichtingen binnen het werkverband van De Open Ankh.

Door een toenemende vraag van zorginstellingen buiten het werkverband is in 1994 een zelfstandig bureau opgericht met de naam Plan & Projectpartners. Vanaf dat moment voorzien wij dus ook klanten buiten het werkverband De Open Ankh van huisvestingsadviezen. In deze periode werkten er ongeveer 15 tot 20 medewerkers bij ons bureau.

Huidige situatie

Plan & Projectpartners is vandaag de dag uitgegroeid tot een middelgroot, onafhankelijk adviesbureau op het gebied van huisvesting waar ongeveer 35 professionals werken. Wij kunnen organisaties met huisvestingsplannen begeleiden van locatiekeuze tot en met realisatie van een gebouw en de bijbehorende exploitatiegevolgen.

Uitgangspunt in onze dienstverlening is een transparante opstelling naar onze klanten, we zien onszelf dan ook graag als partner van onze klanten in plaats van externe adviseur.

Door onze achtergrond voelen wij ons bijzonder goed thuis in de gezondheidszorg. De opdrachtgevers van Plan & Projectpartners zijn dan ook met name organisaties in de gezondheidszorg.

Stichting

Plan & Projectpartners is een stichting. Wij gebruiken onze bedrijfsresultaten mede voor het behoud en de ontwikkeling van de expertise van onze medewerkers. Daarnaast dragen wij bij aan innovatieve of ideële projecten op het raakvlak van zorg en huisvesting.

De ondersteuning van de totstandkoming van deze studie is een voorbeeld van een dergelijke bijdrage aan de verdere ontwikkeling van ons vakgebied.

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Plan & Projectpartners

Plan & Projectpartners is an independent consultancy firm that specializes in accommodation. The services we provide cover all aspects of the development and construction process, from determining accommodation policy to completing and maintaining a building. Most of Plan & Projectpartners� clients are organizations that operate in the health care sector.

Transparency

Our project approach is totally transparent. With Plan & Projectpartners you know precisely where you stand, and you also have the assurance of knowing that your ideas can be realized within established constraints and financial parameters.

Origins

Plan & Projectpartners emerged from the De Open Ankh association, which is made up of, and provides services for, a group of foundations that operate in the care sector and their affiliated institutions. Plan & Projectpartners started out as a bureau that provided advisory services for the foundations that make up the De Open Ankh association.

In light of the increasing demand from care institutions outside of the association, in 1994 the bureau was set up as an independent consultancy firm known as Plan & Projectpartners. At that point we also started providing accommodation advisory services for clients outside of the De Open Ankh association. In those days there were approximately 15 to 20 staff working for the bureau.

Today

These days Plan & Projectpartners is a medium-sized independent consultancy firm that employs approximately 35 professionals who specialize in accommodation. We can advise organizations on their accommodation plans � from the choice of location to the completion of a building, and the corresponding consequences in terms of running the building.

The services we provide are based on the principle of being totally transparent to our clients. We like to see ourselves as a partner to our clients rather than as an external advisor.

Given our background, we feel very much at home in the health care sector. Most of Plan & Projectpartners clients are organizations that operate in the health care sector.

Foundation

Plan & Projectpartners is a foundation. Our profits are used to maintain and develop the expertise of our staff. We also support and contribute to innovative and/or exemplary projects at the interface between the provision of care and accommodation.

The Design Impact Study is a typical example of how we contribute to the further development in our area of expertise.

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Samenvatting

�Kwaliteit is geen handeling, het is een gewoonte� (Aristoteles)

Dit onderzoek, uitgevoerd in opdracht van Plan & Projectpartners, is voortgekomen uit een eerder door het European Health Property Network (2002) opgesteld vergelijkend rapport waarin enkele essentiële vraagstukken inzake ontwerpen werden onderzocht met betrekking tot de architectuur in de gezondheidszorg. Het rapport uit 2002 concludeerde dat, hoewel er natuurlijk overeenstemming is over de functionele aspecten van gebouwen in de gezondheidszorg, er tussen de verschillende landen aanzienlijke verschillen bestaan wat betreft de nadruk die men op vraagstukken m.b.t. architectuur legt. Dit leidt tot grote complicaties zodra men probeert een vergelijking te maken tussen de verschillende invloeden die architectuur in de gezondheidszorg heeft op de zorgresultaten, de motivatie van het personeel, en de verwachtingen van de burger. De uiteindelijke opdracht in dit rapport, die na kritische bestudering op hoog niveau binnen de eigen beroepsgroep tot stand kwam, was het geven van een antwoord op de vraag �wat is de relatie tussen ontwerp en context, en welk gevolg heeft dit voor de prestaties in zorgomgevingen?�

In principe is er hier sprake van een kwaliteitskwestie. Hoe worden we het eens over gemeenschappelijke criteria voor de ontwerpkwaliteit in een ziekenhuis, verpleeghuis of een gezondheidscentrum? Hoe moeten we kwaliteit beoordelen en meten, en is dit per definitie wel mogelijk? Als we kunnen komen tot een aantal factoren dat ervoor zorgt dat er bij projecten in de gezondheidszorg gelet wordt op een hoge ontwerpkwaliteit, hoe garanderen we dan dat deze factoren goed begrepen worden en onder de aandacht komen van een breed publiek?

In dit onderzoek concluderen we dat de antwoorden op, onder andere, bovengenoemde vragen gevonden kunnen worden in een dynamische driehoeksrelatie tussen zorgmodel, plaats en het �gebouw als resultaat�. Als het moeilijk of onmogelijk is de invloed en kwaliteit van het ene gebouw in de gezondheidszorg, binnen z�n eigen context en met z�n eigen unieke gebruikersgroep, met de andere te vergelijken, dan moeten we dit wellicht ook niet proberen te doen. Misschien is het verstandiger een gemeenschappelijk instrument te zoeken waarmee we het succes (of het ontbreken ervan) van een gebouw kunnen beoordelen binnen z�n eigen referentiekader, met als achtergrond de oorspronkelijke opdracht en de plaatselijke cultuur, en aan de hand van een beoordeling na ingebruikname van het gebouw.

© Kaethe Burt-O�Dea 2005

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Het bovenstaande schema verdient enige nadere toelichting:

• Het �Zorgmodel� heeft betrekking op de klinische functies die het gebouw geacht wordt te faciliteren, met daarbij de sociale, generationele, esthetische en therapeutische verwachtingen van patiënten, bezoekers, personeel en de bevolking in het algemeen.

• �Plaats� bestaat uit meer dan alleen de locatie: het betreft bijvoorbeeld ook de plaatselijke architectonische gebruiken, de relaties met andere gebouwen/organisaties, en de wisselwerking met bevolkingsgroepen en hun fysieke omgeving.

• De term �Het gebouw als resultaat� geeft aan dat een gebouw kan worden beschouwd als een reeks antwoorden op de vragen die worden opgeworpen door de beoogde functies en de context van het gebouw en door z�n uiteindelijke relatie met de gebruikers ervan.

Als een gebouw een voorbeeldfunctie moet krijgen, dan moeten de planologen, ontwerpers en eigenaren ervan een goed inzicht hebben in zowel Plaats als Zorgmodel. Uiteindelijk (zoals dit onderzoek laat zien) hangt de kwaliteit van �het gebouw als resultaat� niet alleen af van de financiële middelen, maar ook van de mate waarin zij die het gebouw ontwerpen, bouwen en exploiteren zich met deze twee kernpunten verbonden voelen.

De Design Impact Study (d.w.z. het onderzoek naar de invloed van het ontwerp) kwam tot haar conclusies na een uitputtend beoordelingsproces met betrekking tot de instrumenten die op dat moment beschikbaar waren voor het beoordelen van de ontwerpkwaliteit en voor het uitvoeren van de evaluatie na het moment van ingebruikname. Deze conclusies worden volledig onderbouwd in het centrale deel van het rapport. Opgemerkt moet echter worden dat, ondanks het nut en de voordelen ervan, er geen enkel instrument was dat exact kon beantwoorden aan de eisen die aan dit project werden gesteld. De driehoek was dus ontwikkeld als een algemeen toepasbaar, kwalitatief instrument dat door de culturen heen kan worden gebruikt voor zowel toekomstgerichte als retrospectieve doeleinden.

Om de relatie tussen � ontwerp en context� te kunnen onderzoeken werd voor een pan-Europese aanpak gekozen waarbij de EuHPN-leden een voorstel deden ten aanzien van 19 voorbeeldprojecten. Deze lange lijst werd tot een vijftal casusonderzoeken teruggebracht, op grond van:

• Beschikbaarheid van gedetailleerde informatie over de indeling en bouw van het gebouw

• Beschikbaarheid van een EuHPN-deskundige om de lokale toegankelijkheid te bevorderen

• Betrokkenheid van projectmanagers, faciliteitmanagers, medisch ziekenhuispersoneel en anderen

• Vertegenwoordiging van verschillende culturen en therapeutische modellen.

Er werd een verkennend onderzoek uitgevoerd om de projectmethodiek te controleren, en de leden van de werkgroep EuHPN-architectuur kwamen bijeen om de technieken die een rol speelden bij de beoordeling van elk gebouw verder op elkaar af te stemmen en te becommentariëren. Daarom bezocht de onderzoeker elke casus gedurende in totaal drie dagen om te kunnen voortbouwen op de antwoorden die uit een aan het bezoek voorafgaande enquête verkregen waren. Voor elke casus werden patiënten, personeel en bezoekers geïnterviewd aan de hand van een enquête, die als stimulans was bedoeld om een groot aantal antwoorden te krijgen en �onverwachte waarde� bloot te leggen. De onderzoeker verzamelde de antwoorden uit deze enquêtes en analyseerde de �afstemming� tussen de oorspronkelijke plannen voor het gebouw en de door de gebruikers waargenomen sterke en zwakke punten ervan. Daarbij maakte de onderzoeker

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voor elke locatie uitgebreide foto-essays, wat op zichzelf al een verhelderende en waardevolle onderneming bleek te zijn.

Er kwamen uit de combinatie van observatiebezoeken en enquêtes een aantal gemeenschappelijke thema�s tevoorschijn. Terwijl enkele daarvan wellicht voorspelbaar waren (zoals plaatselijke cultuur, dienstverlening aan de patiënt en toepassing van technologie), kwamen andere als een volslagen verrassing. Het belang van de planning van voedsel en voedingssystemen was bijvoorbeeld iets dat vele gebruikers bezighield. Eveneens werd duidelijk dat zowel de contacten met de plaatselijke bevolking, in de zin van het inspelen op vrijwilligershulp, als het instandhouden van regelmatig terugkerende activiteiten (zoals uitstapjes, �s middags theedrinken of meehelpen bij de dagelijkse werkzaamheden) van groot belang waren voor het herstel van de patiënten. De gebouwde omgeving bleek van grote invloed te zijn op het al dan niet met succes verwezenlijken van dergelijke thema�s.

Het rapport Design Impact Study bevat een grote hoeveelheid materiaal en we hebben getracht het zo te structureren dat het proces net zo duidelijk is als de analyse:

• In de inleiding bespreken we de oorsprong van het onderzoek, geven een overzicht van het proces van revisie en beoordeling door de collega�s binnen de eigen beroepsgroep, en bieden wat achtergrondinformatie over de opdrachtgevende organisaties en onderzoeksorganisaties.

• Het hoofdstuk methodiek voert de lezer naar de afbakening van de centrale vraag in het onderzoek, geeft een samenvatting van het desktoponderzoek, beschrijft hoe de beschikbare instrumenten zijn onderzocht, en doet verslag van de wijze waarop de casusonderzoeken werden geselecteerd.

• Analyse geeft een overzicht van de conclusies die uit het onderzoek kunnen worden getrokken. In dit hoofdstuk staan gedetailleerde beschrijvingen van de toepassingen van de enquêtes die aan de bezoeken voorafgingen, en die door de gebruikers werden ingevuld. En er staat ook een beargumenteerd verslag in van de dynamische verbanden die het welzijn in gebouwen in de gezondheidszorg beïnvloeden.

• Aan elk van de vijf casusonderzoeken wordt een hoofdstuk gewijd. Deze omvatten niet alleen de principes van kosten, managementstructuren, personele bezettingsgraad, beddenaantallen, etc., maar ook zoveel mogelijk de relatie tot organisatorische of architectonische vernieuwingen. Voor elk gebouw richt de discussie zich op de thema�s die uit het onderzoek als geheel naar voren komen, met daarbij fotomateriaal en architectonische plannen.

• Het hoofdstuk met resultaten vergroot de reikwijdte van de analyse aan de hand van een bespreking van de reacties van de deelnemende organisaties, een mogelijke ontwikkeling van de onderzoeksmethodiek, en een beoordeling van risico�s en voordelen.

• De eindbeoordeling onderzoekt in hoeverre het onderzoek heeft voldaan aan de oorspronkelijke doelstellingen, en hoe de onderzoeksgegevens naar een beoordeling van toekomstige projecten zouden kunnen worden teruggekoppeld.

• De conclusie geeft een korte samenvatting van de globale uitkomst van het gebruik van de driehoek (met zorgmodel, plaats en �gebouw als resultaat�) om te kunnen begrijpen wat het succes (of het ontbreken ervan) van de gebouwen in het casusonderzoek is.

• In een aantal bijlagen zijn alle voorgestelde gebouwen bij elkaar gebracht, voorbeelden van vragenlijsten gegeven, en een groot aantal dankbetuigingen opgenomen.

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Conclusies

Samengevat concluderen we in dit onderzoek dat goede gebouwen in de gezondheidszorg mogelijk worden wanneer er sprake is van een dynamisch, gedetailleerd inzicht in zowel het zorgmodel als het �landschap� eromheen. Kwaliteit is een proces en hangt samen met de bereidheid zich aan te passen aan, en te leren van de plaatselijke omstandigheden. Wisselwerking met de lokale bevolking(sgroepen) is van het grootste belang op het punt van planning, ontwerp en exploitatie, heeft als voordeel dat het een hoge mate van aanpassingsvermogen en duurzaamheid stimuleert, en kan wellicht zelfs leiden tot creatieve financieringsinitiatieven.

Om de betrokkenheid van de lokale gemeenschap te verwerven en te behouden, hebben projecten het volgende nodig:

• Krachtig leiderschap en sterke betrokkenheid • Een doelgerichte visie en een duidelijk gecommuniceerd zorgmodel • Een multidisciplinair ontwikkelingsteam, inclusief alle gebruikersniveaus • Haalbaarheidsstudies met studiereisjes waarbij andere werkmodellen worden bezocht

met volledige deelname van het hele ontwikkelingsteam, en waarbij tijd wordt uitgetrokken voor sociale contacten

• Een beoordeling van de behoeftes van de deelnemende plaatselijke bevolking, gekoppeld aan een rol in de ontwikkeling en het management van het project

• Permanente herbeoordeling en bijstelling t.a.v. de deelnemers, vóór, tijdens en na de bouw.

De voordelen van het bovengenoemde zijn:

• Het project is eigendom van de lokale bevolking; gezamenlijke verantwoordelijkheid • Uitwisseling van diensten en andere symbiotische verbanden • Sociale en culturele stimulans en uitwisseling • Vrijwilligerscultuur • Groter therapeutisch rendement • Afname van energieverbruik

Bovenstaande punten zijn concrete aanbevelingen ter overdenking van ieder die betrokken is bij het plannen van gebouwen in de gezondheidszorg. In het kader van de beoordeling van (de bijdrage in) dit rapport, vinden we twee aspecten van groot belang.

Ten eerste biedt het een methodiek die een antwoord kan geven op de in de oorspronkelijke opdracht gestelde vraag, en die kan worden aangepast aan toekomstige evaluaties van gebouwen, ook los van de architectuur in de gezondheidszorg. Het extra pluspunt van de methodiek was dat het punten van �onverwachte waarde� blootlegde.

Ten tweede was het proces van uitvoering van het onderzoek een waardevolle inspanning wat betreft het samenbrengen van ontwerpers en planologen uit diverse landen, en het stimuleren van een leerzaam samenwerkingsverband tussen de gebruikers en de managers van gebouwen in de gezondheidszorg. Beide uitkomsten kunnen een vruchtbaar vertrekpunt vormen voor verder onderzoek en samenwerking in de toekomst.

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Executive Summary

�Quality is not an act, it is a habit� (Aristotle)

This study, commissioned by Plan & Projectpartners, has its roots in an earlier, comparative report produced by the European Health Property Network (2002), which examined some critical design issues in the field of health care architecture. The 2002 report concluded that, while there must necessarily be common ground in the functional aspects of health care buildings, the focus on design issues varies considerably from country to country. This fact complicates greatly any attempt to make comparative assessments of the impact of health care architecture on patient outcomes, staff morale, and the expectations of the public. The final brief for this report, arrived at after high-level peer review, was to provide an answer to the question �What is the relationship between design and context, and how does this impact on performance in health care environments?�

Essentially, the issue in play is that of quality. How do we agree upon common criteria for design quality in a hospital, a nursing home, or a community clinic? How should we evaluate and measure quality, and is it even possible to do so? If we can arrive at a set of factors that predispose health care projects to excellence of design, how do we make sure that these factors are clearly understood and widely disseminated?

This study concludes that answers to the above questions, and many others, are to be found in a dynamic, triangular relationship between care model, place, and the built response. If it is difficult or impossible to judge the impact and quality of one health care building, set in a particular context and with its own unique set of users, against another, then perhaps we shouldn�t attempt to do so. Perhaps it makes more sense to find a common tool that allows us to judge a building�s success (or otherwise) in terms of itself, set against a background of the original brief and local culture, and with the aid of post-occupancy evaluation.

© Kaethe Burt-O�Dea 2005

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The above diagram deserves some further explanation:

• The �Care Model� comprises the clinical functions that the building is expected to enable, plus the social, generational, aesthetic, and therapeutic expectations of patients, visitors, staff, and the wider community.

• �Place� is more than simple location: it also encompasses local architectural traditions, relationships with other buildings/organizations, and interaction with communities.

• The term �Built Response� indicates that a building can be seen as a set of answers to the questions posed by its intended functions, and by its eventual relationship with its users.

If a building is going to achieve exemplar status, then its planners, designers, and owners must have deep understanding of both Place and Care Model. In the end (and as shown in this study), the quality of the built response depends not only on financial resources, but also on the extent to which those who design, construct, and operate the building are committed to these two fundamental elements.

The Design Impact Study arrived at its conclusions after an exhaustive process of assessing the existing tools available for judging design quality, and for carrying out post-occupancy evaluations. These are documented fully in the main body of the report, but it is worth noting that, while each has its uses and advantages, no one tool responded exactly to the needs of the brief for this project. The triangle was therefore developed as an open-ended, qualitative tool, applicable across cultures and for both prospective and retrospective use.

In order to examine the relationship between �design and context�, a pan-European approach was adopted, with some 19 exemplar projects proposed by EuHPN members. This long list was reduced to five case studies, on the basis of:

• Availability of in-depth information about the building�s planning and construction • Availability of a EuHPN expert to facilitate local access • Commitment from project managers, facilities managers, clinicians, and others • Representation of different cultures and therapeutic models.

A pilot study was carried out to test the project�s methodology, and EuHPN design working group members met to fine-tune and critique the techniques involved in assessing each building. As a result, each of the case studies was visited by the researcher for a total of three days, to build on the answers obtained from a comprehensive pre-visit questionnaire. Patients, staff, and visitors were interviewed in each case, using a questionnaire designed to encourage wide-ranging answers and to uncover �unexpected value�. The researcher collated the answers from these questionnaires, and analyzed the �fit� between the original intentions for the building, and its strengths and weaknesses as perceived by its users. In addition, the researcher produced extensive photo-essays for each site, which proved to be an illuminating and valuable exercise in its own right.

A number of common themes emerged from the combination of observational visits and questionnaires. While some were perhaps to be expected (local culture, patient services, use of technology, for example), others were a genuine surprise. The importance of planning for food and food systems, for instance, was a preoccupation of many of the users. Likewise, it became clear that both community links, in terms of provision for volunteer involvement, and maintenance of routine activities (such as outings, taking afternoon tea, or helping with everyday tasks) were of great importance in the rehabilitation of patients. The built environment turned out to have a significant influence on whether or not such themes emerged successfully.

The Design Impact Study report contains a great deal of material, and we have endeavored to structure it so that the process is as clear as the analysis:

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• The introduction discusses the origins of the study, outlines the process of revision and peer review that took place, and gives some background information on the commissioning and research organizations.

• The section on methodology takes the reader through the definition of the study�s central question, summarizes the desktop research, describes how the tool base was explored, and gives an account of how the case studies were selected.

• The analysis gives an overview of the conclusions to be drawn from the study. In this section there are detailed descriptions of the uses of the pre-visit and user questionnaires, and a discursive account of the dynamic relationships that influence well being in health care buildings.

• The five case studies have a section each. These include not only the basics of cost, management structure, staffing level, bed numbers, etc, but also as much as possible in relation to organizational or design innovations. The discussion of each building focuses on the themes that emerged from the study as a whole, supported by photographic evidence and architectural plans.

• The outcome section widens the scope of the analysis, by discussing the responses from participating organizations, possible development of the study�s methodology, and an assessment of risks and benefits.

• The final review examines the extent to which the study has met its original aims, and how the study data could be fed back into a review of future projects.

• The conclusion is a brief summary of the overall outcome of using the triangle of care model, place, and built response to understand the success, or otherwise, of the case study buildings.

• The acknowledgements section lists and thanks the considerable number of those who have helped in the preparation of this report.

Conclusions

In brief, this study concludes that good health care buildings are made possible where there is a dynamic, in-depth understanding of both the care model and the contextual landscape. Quality is a process, and it depends on a willingness to adapt and learn in response to local circumstances. Interaction with local communities, in planning, design, and operation, is of the greatest importance, has the advantage of encouraging high levels of adaptability and sustainability, and may even lead to creative funding initiatives.

In order to acquire and maintain community involvement, projects need:

• Strong leadership and commitment • A focused vision and a clearly communicated care model • A multidisciplinary development team inclusive of all user levels • Feasibility studies with research trips to visit other working models with full

participation of the complete development team, with time allowed for social exchanges

• Participatory community needs assessment linked to a role in project development and management

• On-going participatory re-evaluation and modification, before, during, and after construction.

The benefits of the above are:

• Local ownership of the project, shared responsibility • Exchanged services and other symbiotic relationships • Social and cultural stimulation and exchange • Volunteer culture

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• Increased therapeutic performance • Reduction in energy use.

The above points are concrete recommendations for consideration by anyone involved in planning health care buildings. In terms of judging the contribution of this report, we feel that two aspects are of significant value.

First, it provides a methodology that can answer the question posed by the initial brief, and which can be adapted to future evaluations of buildings, even outside the field of health care architecture. The methodology had the added strength of uncovering areas of �unexpected value.�

Secondly, the process of carrying out the study was a valuable exercise in bringing together designers and planners from a number of different countries, and in encouraging a learning partnership among the users and managers of health-care buildings. Both of these outcomes may provide fruitful avenues for further research and collaboration.

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Introduction

The Origin of the Design Impact Study

The original brief for this study, which was conducted between September 2004 and February 2005, was driven by final conclusions made in the European Comparative Study on the Design of Health Care Buildings carried out for the European Health Property Network in 2002. Key points emerging from this study�s findings were as follows:

• Focus on design issues differs dramatically from country to country. What drives these issues in each country?

• The study set out 5 criteria (Functionality, Technical Performance, Value for Money, Impact, and Sustainability) but there may be more to consider.

• These five criteria may not have equal rating: sustainability and value for money are actually overreaching issues; design quality is achieved when the three key criteria of functionality, technical standard, and impact, overlap.

• There is a need to focus and develop definitions and criteria to arrive at a robust EU framework.

Important comments and recommendations emerged from the 2002 work:

�From the theoretical exercise the most highly rated issues were related to functionality yet from the exemplar projects the overwhelming issues related to impact.�

�The study has sought to explore further the issues of design quality theory and practical projects. Whilst it is clear that there is broad agreement about the framework for defining design quality, much greater clarity is required about their definitions and interpretations. The framework provides a good basis for developing a set of European Design Quality Indicators. But there are differences of approach between the various countries. Some of the countries that declined to participate in this study pointed out their countries put greater emphasis on regional rather than central planning. This means that it is hard for them to develop a set of national criteria. It explains why the survey involved two responses from Italy. This emphasis on regional responsibility is similar in Germany, Spain, and Portugal. In order to extend this study to include more countries, this issue would need to be clarified.�

�Finally, the study has progressed the issues about the definition of design quality further, and has sought to develop an understanding from a European perspective. It has shown the need for further linking of the theoretical ideas with assessment and evaluation systems to the development of practical projects.�

The Original Brief

Based on the findings above, EuHPN developed the concept for further study. The following is an account of the original brief for the Design Impact study prepared in the summer of 2004:

• The project will pose the questions

o What is good design?

o How is design impact assessed?

o How it might be measured?

o How effective are contemporary quality assurance tools?

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• It will give an answer to the question: how does the built environment affect the attitude of the users of the health facility (patients, employees, visitors and the local community) and how this might be represented in terms of satisfaction?

• The project will aim to identify those factors that predispose projects to design excellence and high impact and conversely those factors that act against good outcomes.

A Necessary Revision

At the original meeting with the EuHPN design reference group at the Future Hospitals symposium in Den Haag the substance of the study�s aims were clarified, so as to:

1. Record how the original intention of the design brief ultimately influenced design impact.

2. Uncover �unexpected� value

3. Analyze how interaction between a healthcare facility and the local community (environmental and cultural) works to enhance a �person � environment fit� and influence recovery.

4. Suggest how the study data could ultimately be fed back into future design.

On the basis of this definition the project manager conducted a series of meetings with a selection of leading specialists in the post occupancy evaluation of buildings to obtain advice on the capacity of the project in relation to timescale and resources. Based on the astute analysis of these experts the focus of the brief changed. Reasons for this are as follows:

• The study�s main question needed clarification before the appropriate tools and methodology could be selected. Once this was agreed the project brief needed to be realigned to meet the aims of the study.

• The objective of the project was to study buildings through the experience of the users, setting this against the site specific �context� of the healthcare building. This is primarily a socio-cultural study, attempting to make clear the relationships, which contribute to the success of a therapeutic environment, between the healthcare facility and the local community.

• AEDET (the tool originally suggested for the study) in its original or revised form, AEDET Evolution (released in October 2004), reviews and audits. For this reason, along with the obvious difficulties of translation, the experts universally considered these tools unsuitable for a cross-cultural study designed to facilitate the emergence of opinion from a diverse range of individuals (patients, staff, public, hospital/facilities management, and healthcare organization).

The European Health Property Network

The study drew on expertise and experience from members of the European Health Property Network (EuHPN). EuHPN comprises European governmental and research organizations that are concerned with the planning and provision of all forms of health property. EuHPN operates in the mainstream field of planning, design, procurement and financing of health infrastructure, and in the cross-over area of translating service need into sustainable and effective strategic asset planning (SAP) policies. It also contributes to the debate on cultural change implicit in modernizing health care systems and facilities.

EuHPN enables its members to pool and share knowledge, and to keep pace with leading edge developments in this central dimension of health care. Members benefit from bi-annual workshops, a dedicated website, an advice and support service, collaborative research, and partnerships with complementary organizations within Europe.

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Some Definitions

Throughout this report a number of phrases are used with meanings that are specific to the context of health care and design:

Care Group A group of people with similar requirements for care and support

Community

The social, cultural, and physical resources and flows within a geographical location

Care Model

Organizational concept for delivering health services to a care group

Dynamic Constantly active or changing

Operational Culture The style in which an organization delivers its service

Tensegrity

Tensional integrity, an organization made up of components that use tension and compression in combination to yield strength and resilience beyond the sum of their components.

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Methodology

The study�s methodology was refined and adjusted in the light of the iterative process of consultation and review outlined in the Introduction. Essentially, however, two phases were involved.

Phase One (September�December 2004) consisted of:

• Re-evaluation of the project�s brief, aims, and methodology • Definition of the study�s central question • A desktop review of evidence and research • Assessment of available tools • A preliminary study • Production of an interim report • Development of a study specific tool • Selection of five case studies • Piloting the methodology at St Joseph�s at Mount Desert, Ireland.

Phase Two (January�March 2005) involved gathering information on each of the five case study sites by means of questionnaires, interviews, and a 3-day visit by the project manager. Analysis of the findings was facilitated by meetings with the EuHPN design reference group members as well as other professionals working in this field.

Phase One

Re-evaluation of the project�s brief, aims, and methodology

The process of revision was carried against the background of a methodology inherited from the genesis of the project:

�The principle will be to identify exemplar projects from throughout Europe that seem to have established reputations for design excellence and evaluate them against project intentions using a variety of tools, measures and survey techniques.

The critical success factors that form the basis of successful outcomes will be analyzed and identified. Many of those factors are described in the Quind-tool of The Netherlands Board for Hospital Facilities and the AEDET-tool of the English NHS Estates service.

The projects to be studied are already realized designs that are in operation. They give a better idea of the influence of the building on the environment, how it works and how people feel. The Quind and AEDET factors will however also be used � for retrospective assessment and evaluation of these designs. This is critical because not everybody is capable of translating fully the architectural drawing of a design to the realized building.

In more detail the survey will involve:

o Surveying 11 Countries that represent membership of EuHPN for 3 examples each of exemplar projects; together 33 projects.

o A sample group will be selected (between 6 and 8 projects from these 33).

o Design quality measurement tools (Qind, AEDET) will be applied to each study project and results analyzed.

o Users will be surveyed (utilizing questionnaires) and will include:

! Commissioning agencies for the buildings e.g. government departments / owners

! Representatives of the workforce (including those that may have been involved in contributing to design briefs and the iterative process of project development)

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! Patients, relatives, and other visitors

! The public in the local community.

Professional commentary will be reviewed (where available), e.g., journal articles and media-coverage on the buildings in question.

Results from these steps will be reviewed, analyzed and compared with previous studies (general or specific) that may be relevant to the projects in question.

A final report will be produced on the basis of the study findings.�

Definition of the Study�s Central Question

Interviews, focus groups, and brainstorming sessions, were carried out between the EuHPN design reference group (see acknowledgements) and leading international experts in post occupancy evaluation, to re-define the study question as:

A European comparative study of design impact in relation to context:

What is the relationship between design and context and how does this impact on performances in healthcare environments?

Once the study question was agreed the subsequent demands on the methodology were discussed. The pros and cons of other systems familiar to the experts were weighed against the demands of the study and recommendations were made.

Desktop Review and Assessment of Evidence

Because of the abstract and complex nature of the subject to be studied it was necessary to secure a sound philosophical and scientific understanding of the entity. A desk-top study of the current evidence base was conducted. Pertinent databases, books, reports, papers, summaries, articles, and bibliographies, on the physiological and psychological influences of environmental features on human behaviour, recovery, and performance, were consulted, including information collected by the following experts in this field: Stephen Boyden, Judith Herwagen, Gordon H. Orians, Roger Ulrich, Brian Lawson, Peter Scher, Stephen Kaplan, Nick Baker, Fergus Nichols, Susan Roaf, Lisa Heschong, Edward O. Wilson, Paolo Portoghesi, Grant Hildebrand, Christopher Alexander, Gary Coates, and others. In general this evidence, often based on biological links to aesthetic preference, was not as helpful as expected in the onset.

The intention of this study was to explore deeper issues at the source of design Quality as linked to socio-cultural context. This is a very different from the research above which attempts to provide taxonomy of generic design Qualities.

Exploration of the tool base

Prior to the methodology development a wide range of tools from different sectors were scanned. The tools considered include:

• Design Quality Assurance Tools: DQI, AEDET, Quind, ADVICE, AEDET evolution, ASPECT

• Socio-Environmental Assessment tools: NEAT, PEAT, LEED, GRI • Qualitative Research Methodology: Action Research, Grounded Theory • Semantic Differentials and key word association • Space syntax • Ranking studies • Post Occupancy Evaluation: PROBE (Usable Building Trust)

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• �Closing the Loop� an International Post Occupancy Evaluation Conference, UK, April 04, Papers, MARU POE of Macmillan Cancer Relief Projects

• Product Development and visualization tools: Taghuchi, Triz, Robust design, House of quality, Quality function deployment, Voice of consumer

The first tools explored where the design quality assurance tools have been developed for the healthcare sector. These tools almost exclusively focused on Design as a �product.� This is to say that AEDET, Quind, ASPECT, (all NHS based) broke down design excellence into the existing design �qualities,� as determined by an evidence base, but they did not provide a description of what this was in relation to (other buildings). Care model or location are not documented in any depth, and when user opinion was asked for (the IMPACT section of AEDET and QUIND, and AESPECT) they did not take into account differences between types of users (staff, patient, public, facilities management, healthcare institution, etc.), and what impact this had on their opinion. The DQI does differentiate between users, visualizing this in their final spider diagram, but again, place and, critically, care model, are not defined.

The MARU POE studies of Macmillan Cancer Relief Projects were designed to look at one very specific care model and organization. This meant that �process� and functionality, as related to space utilization, became a strong focus. The building in use analysis used in this methodology provides a valuable way of looking at the adaptation of building use post commissioning, offering an excellent way of monitoring �flexibility� and �future proofing.�

The ten-year-long PROBE study, carried out by Usable Building Trust, focused on �energy� and functionality over time based on user opinion. A wealth of valuable POE experience, information, and tools, have been fine-tuned by this team (much of this freely available on the web). Though the �model,� or �what the building was designed to do� was the first question they asked, the study did not cover design quality per se, and never looked at healthcare buildings.

The 1/5/200 Ratio

It is noteworthy that there have been many more effective tools commissioned to guide design in relation to customer needs in the product development sector. In 1998 the Royal Academy of Engineering published a �Report on the Long Term Costs of Owning and Using Buildings�. It proposed a generic ratio between the costs of construction and use. If initial constructions costs are 1, then 5 times as much is spent over 20 years in operating and maintaining the facility and 200 times as much is spent on the staff who work in the building over the same 20 years (Evans, R., Haryott, R., Haste, N., Jones, A., 1998). This view provides a way of looking at value and energy in comprehensive terms with time and �human� energy, factored in, for example: �acute hospitals cost roughly $250 per square foot to build, about $5 per square foot each year for power, ventilation, heat and light, and about $200 per square foot each year to staff� (Pradinuk and Marion, 2003).

Preliminary Study of one of the Submitted Projects: St Josephs, Mount Desert, Cork, Ireland

The purpose of visiting this award-winning �care village� was to visualize the use of the tools through interviews with a range of staff, patients, and public. The preliminary findings based on casual interviews were significantly different from those anticipated based on the pre-visit information gathered from the design team, Health Board, and national newspapers.

Despite the media attention that has resulted in an enthusiastic national opinion of the project and generated architectural tours, many of the occupants expressed feelings of isolation, some were less happy than they had been in the previous building, an outdated tuberculosis hospital of very poor standards. The adjacent nine independent living units were under-utilized. It was felt that this may be due to lack of �community� integration. As

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a result the building is not working at capacity and requires higher staffing levels, making it expensive to run. This situation impacts on the staff, particularly the management, who feel their reputation as care givers has been affected. There is a palpable sense of resentment toward the design of the building as a result.

Some of the aspects of the design responsible for these problems were features developed by the architects to accommodate design criteria set by published design quality indicators. Particularly significantly, most of these issues have to do with community and cultural integration.

The preliminary study emphasized the importance of the study and its ultimate aim (to channel post occupancy evaluation based on users, into future design briefs). It also provided important feedback on the methodology developed for the case studies.

The Design of a Project-Specific Tool

Care Group and Cultural Considerations

Based on the pilot project and the desktop research phase described above, an essential element, not accounted for in the original brief, entered the project description. There was a need to develop a tool to facilitate the emergence of �rich� information regarding design preference and performance in relation to the socio-cultural and environmental �context� across a selection of European case studies. Gleaning this site-specific information from a variety of users (from children to the elderly) would require a carefully constructed, simple, open methodology.

Using the Project Direction to Attain Added Value

Managing the contextual complexity involved in exploring these subjective performance indicators in a range of different cultures would be difficult. It was generally felt that time spent developing the project testing methodology would be a valuable focus in itself. In this case it would be worth limiting the number of site visits to gain the additional value of testing a new method and allow for a more rigorous result. On the basis of these observations the experts gave the following advice:

�The questionnaires should be kept as simple as possible and be designed to facilitate the emergence of �unexpected� design impact criteria in relation to cultural context for comparative analysis.

The main purpose in conducting a study lies in its practical application into future design. The methodology development should work back from: �how will the study feed back into the design process?��

When developed the model should be tested in a pilot project and, depending on resources, applied to as many submitted projects as time allowed. Through this process the study would fine-tune the methodology as a prototype for a cyclical �design assessment and briefing system�. It was felt that this outcome would represent a first step in the development of an invaluable and necessary resource currently lacking in the industry.

On the basis of a successful trial run of this exercise recommendations would be made for a larger study to further test and refine the methodology in collaboration with European Universities.

Since this study was specifically commissioned to explore design impact in relation to context (�community�) and obtain a broad picture of trends across Europe, it was agreed that this study would require two separate study specific tools:

1. A pre-visit questionnaire to collect the �context� within which the building developed (what it aimed to achieve) and establish its relationship with �place.�

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2. A multi-user questionnaire: a qualitative tool, to facilitate the emergence of cross cultural user opinion.

It was hoped that a comparison between the two would give an indication of where these trends were/should be heading which would, in turn, be useful in briefing future healthcare design.

Selection of Five Case Studies

The exemplar projects proposed by EuHPN members to take part in the study are shown below. Those in bold were selected as case studies.

Project Type Country

Ash Green Learning Disabilities Centre Learning Disabilities Centre England

Braunstone Integrated Health and Social Care Centre

Integrated Health and Social Care Centre

England

Kidderminster Treatment Centre Diagnostic and Treatment Centre

England

Main Health Centre, Espoo Primary Care (no wards) Finland

Oulu City Hospital (1st Stage) Primary Care Finland

Azienda Ospedaliera Sant�Andrea General Hospital Italy

Het Houtens Erf, Houten Nursing Home The Netherlands

Humanitas-Bergweg, Rotterdam Apartments for the elderly The Netherlands

Ter Reede, Vlissingen Nursing Home The Netherlands

South and East Belfast Trust, Community Treatment and Care Centers

Community Treatment Centers

Northern Ireland

Mater Hospital (Phase I Development)

Acute Hospital Northern Ireland

Psychiatric Department, Haugesund Psychiatric Department in a General Hospital

Norway

Acute Psychiatric Unit, Sykehuset, Telemark

Acute Pyschiatric Department

Norway

Dunshaughlin Health Care Unit Community Care Centre Republic of Ireland

St Joseph�s Hospital, Mount Desert High Dependency & Intermediate Care

Republic of Ireland

Swords Health Centre Community Health Centre Republic of Ireland

The (new) Royal Aberdeen Children�s Hospital

Children�s Hospital Scotland

Vidarkliniken, Jarna Anthroposophic Hospital Sweden

Welshpool Community Hospital Community Hospital Wales

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Selection Criteria

Since this study process was influenced by �action research and �grounded� theory techniques which derive their themes from within the research itself, the selection criteria, in some ways, developed alongside the project. The initial criteria, based on the original brief set out the first four requirements:

• Considered an exemplar project by a member of the EuHPN network • A new model built within 4 years • Occupied for at least one year. • Good mix of countries represented

When guidance and support during for the qualitative approach to the questionnaires/interviews became an issue, it became clear that the selection of case studies must be based on the post occupancy evaluation experience of the EuHPN member who had put the project forward along with his or her willingness to assist �on the ground� in the study process. Additionally it was felt that the member�s established experience would further enhance potential for the project to develop a design feedback system for future use.

In optimum circumstances it may have been preferable to limit the study to one care group, but the submitted projects matched with the POE expertise of the members did not allow this. Due to the additional complexity this contributed to the study, set against different types of healthcare models, the project was subsequently limited to five case studies.

In retrospect, there were unexpected advantages specific to the decision to look at a range of care models. The most obvious was our ability to explore closely the role of the care model against a range of successful design strategies. As well as this, working with different models in different locations/cultures gave us a wider range of information on the influence of local context and the potential advantages of community integration.

Phase Two

Case Studies and Review: January � March 2005

This phase of the study consisted of:

• Submission of a pre-visit questionnaire (PVQ) • A 3-day on site visit to each of the 5 case study projects, involving use of a �multi-

user questionnaire� (MUQ) • A process of review, analysis, and report writing.

Both a general analysis of the findings and a photo essay on each of the case studies is provided in the middle section of this report.

The Pre-Visit Questionnaire

This information was formulated by the EuHPN Member �on site� in collaboration with the organization facilities manager, and, when possible, members of the original design team. In some cases the questionnaire was completed as part of a structured interview conducted by the project manager with the facilities manager, on location. Additional contextual information was gathered during the walkthrough interview.

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Case Study on Site

The case studies were conducted by the project manager in collaboration with the EuHPN member �on site�; key members of staff in each building were available as necessary.

Day One

Local Context The project manager spent 1/2 a day doing a walking tour of the local community where the healthcare building was situated. A photographic record was made of the regional architecture and design, its materials and themes.

Day Two

Walk-Through Interview The project manager and the EuHPN member were given a walk through introductory tour of the premises. Generally this was done by the director of nursing or the facilities manager. This tour provided an introduction to key personnel and a description of how the building was being used.

Structured Interviews and Questions

The Multi-User Questionnaire was used by the project manager to guide a series of structured interviews with as many members of staff as possible in the time allowed. When language difficulties arose this was assisted either by a member of staff or the EuHPN member. Usually these took place in the staff member�s workspace. Casual observations of activity and building use were noted.

Overnight When possible the project manager spent the night in the building. This made it possible to interview staff when they were less busy and also to observe how user perceptions changed during different times of day under different working conditions.

Day Three

Structured Interviews and Observation

Additional interviews, observations, and photography, were documented and any further relevant contextual data was collected

Feedback In some cases a spontaneous feedback session was arranged between the project manager, EuHPN member, and interested members of the organization and staff.

Review, Analysis, Report Writing

Amsterdam: Context Group Session

The EuHPN Design Reference group met with the Project Manager in February 2005 to hold a day-long peer group review of the project. This was facilitated by Jonathan Erskine, the EuHPN Research Associate.

Rotterdam

A post review meeting took place between the project manager and project director to discuss the larger implications presented by the preliminary findings.

London: Maru, The Medical Architectural Research Unit, South Bank University

From February 28 to 3 March the project manager worked on data input and analysis in the unit. MARU offered general feedback on the study process and guidance on the format of the report writing.

Report Writing

The final stage of the report writing was carried out by the project manager with the advantage of feedback from the EuHPN design reference group.

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Analysis

Environmental Tensegrity

Do Buildings Really Make A Difference?

The findings suggest that a good healthcare building can, in fact, make a dramatic difference, and, in the case of some exceptional examples, inspire further creativity in the ongoing development of a therapeutic model. Nonetheless, the information gleaned from this study qualifies this statement and suggests that an exemplar building can only be achieved when the design is developed in tight relationship with therapeutic model and place (community in its broadest sense) around a realistic knowledge of the care group and respect for the individual (his/her clinical, cultural, and generational needs). This triangular relationship is held in tension by the operational culture that maintains the functionality of the building.

The stronger the therapeutic model and place fit the more unexpected value can be achieved by the built response. In fact, a well-integrated understanding of the model working in efficient collaboration with the local resources of �place� can compensate for many inadequacies in the building.

Contrary to this, architecture will never successfully overcome insufficient grounding in these two fundamental elements. The earlier this foundation of knowledge is nurtured and incorporated in the design process the more sustainable the project will be over time.

© Kaethe Burt-O�Dea 2005

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Making the Relationships Transparent

From the onset the multicultural focus of the project was a determining factor. It set the stage for looking beyond the design qualities that were often tied to locality, to exploring design Quality, the deeper overriding relationship present in successful therapeutic environments.

It also led us to the importance of limits in the design process. Any good designer knows that a tightly defined brief demands a higher level of creativity in a project. The limitation of language as a determining factor in the methodology design instigated our diversion from the use of the available design quality assessment tools, which were too linguistically challenging, to a simple qualitative technique.

The advantage of working with simple tools became a strong theme throughout the breadth of the project and quite unexpectedly demonstrated by the interviews with acute psychiatric patients at who responded with astonishingly �raw� precision to the pared down questions.

The multicultural dimension combined with the stripped down qualitative technique demanded in depth knowledge �on the ground,� collaboration with designers who not only had an intimate knowledge of the �place� (with all its socio-cultural characteristics), but were also experts in healthcare design, and familiar with post occupancy research. This has been the greatest advantage working through the EuHPN network, the ability to work with well recognized experts on an individual basis, studying buildings in their own turf, as well as collaboratively in a review group in high caliber brainstorming sessions.

The team�s astute analysis of the contextual information gathered by the Pre-Visit Questionnaire and walk-through was set against the qualitative Multi-User Questionnaire user signals and through this contrasting exercise it was possible to distil these messages into a simple triangular relationship.

Finally, it was ironic that this approach also quite successfully highlighted the critical importance of local preferences (or qualities) attached to place. Though the study was designed to be open enough to catch unexpected value, their potential impact on healing was a surprise to everyone. These preferences appear to represent deeper regionally based needs, and, it was generally felt, should not be regarded as trivial.

Dynamic Relationships that Influence Wellbeing in Health-Care Buildings

The Triangle

This study revealed that design quality is not a product but a process. The successful buildings developed integral connections between the essential elements of the therapeutic environment so that they can be easily maintained. This suggests that there may be as many ways to create an excellent building as there are buildings. Since the formula for success was never the same, it was impossible to judge one building against another. Therefore, every building was measured against itself (what it aspired to do, its core mission), and every building had a story, successes and failures, and lessons. We have visualized this phenomenon as a triangular relationship between the following three elements, care model/care group, place, and built response. The therapeutic model and operational culture fit is the human element that holds this together.

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Care Model/Care Group

Illness, therapy, age group, time

Beyond the essential clinical model, generational aspects of a care group had a special influence on environmental preference. This was particularly noticeable in the patient�s response to architecture and art in the buildings. Another, often overlooked, factor was time. The longer a patient stayed in the building the more critical she/he became. A deep understanding of the clinical, therapeutic, and generational needs and preferences of the client group the building was designed for was the most influential aspect of successful design than architectural prowess or budget.

Place

Environmental, socio-cultural, and site specific

This is where most potential for added or unexpected value was found and choice of location when possible, was a revealing aspect in the study. Symbiotic relationships featured in the majority of the buildings to mutual benefit. Also, as mentioned previously, regional and traditional preferences were more influential than originally assumed.

Built Response

The design of the building

The word �response� is the key here. Design �quality,� in relationship with care model and place, was more important to users than design �qualities� or the architectural statement. It was also noticeable that the amounts of money or time invested did not necessarily

© Kaethe Burt-O�Dea 2005

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assure the presence of design �quality.� A true understanding of the care group and place was what assured exemplar status.

Therapeutic Model and Operational Culture Fit

This �fit� is determined by how well the organization managed to define, communicate, and integrate the therapeutic (care) model into their day to day operations.

This study did not provide enough time to explore this mechanism any depth, but in many cases �signals� from users referred to this relationship, rather than design qualities, during their attempt to describe how the building worked for them.

Their comments highlight a respect for strong leadership and clear commitment to the therapeutic ethos. This is reminiscent of the �ten commandments� used in Renzo Piano�s principles for healthcare design: Humanism, Urbanism, Sociality, Organization, Interactivity, Appropriateness, Reliability, Innovation, Research, Training. The presence of this �fit� instills confidence in the organization and lays the ground for a volunteer culture to develop.

The Individual in Balance: �No� may mean �Yes�

Inside this triangular relationship is the individual, a complex bundle of sensory equipment. How he responds to the environment is uniquely based on his history and condition. His well-being is of interest to him, but not to him alone, because he has an influence on the well being of the people around him. This is particularly significant in the case of health-care staff members who are administering care. If they are under pressure because they cannot do their job well this will impact on the total environmental experience and also on the financial success of the building.

Open, qualitative, methodology proved to be a particularly useful tool with which to study this relationship. Often the answers were confusing and a NO! (I don�t not like this building / this building makes my work harder) which actually meant YES! (but I am facing my problems and getting better because of this / but I know its better for the patient, therefore my job satisfaction is much higher), but interpreting these mixed messages led to a much deeper understanding of what constitutes success in a particular therapeutic environment. Again, well being presented itself as a dynamic process balancing the following elements:

Comfort

An individual�s state of well-being in any environment is constantly in a state of flux. When a person is ill they need to feel comfortable and safe and surrounded by things that are familiar. When a person is well they crave �edge� or stimulation, a challenge.

In this study what made users feel comfortable was determined by a cocktail of factors, many of them related to familiarity or �home,� (which may be the driver in the current trends toward �normalization� in healthcare models), or, in the case of staff, environments that helped them do a job well.

The more ill a patient became, or the busier/more frustrated a staff member became, the more inward his thoughts became and the less he noticed design �qualities.� This does not mean they were unaffected by the warmth and full spectrum of natural light (the most commonly desired element mentioned), but their interest in stimulation and tolerance of the �edge,� created by challenging architectural features (or art), certainly diminished.

Edge

Stimulation, innovation, �mystery�, �surprise�, the ability to be inspired or to learn from a space, has more recently been linked to views, exposure to nature, and the use of

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atriums. This project showed that an active interface/communication with �outside� can generate added value on many levels if explored. This relationship extended beyond the expected health gain from the natural elements and social activity into the ability to access shared services, volunteer culture, and other benefits of collaboration.

Choice

The importance of the previous two factors in therapeutic environments is determined by the ability to choose. Adaptive Opportunity, the ability to adjust the physical environment to control comfort (temperature, air quality, light, etc.), to personalize or make the space one�s own, or to determine levels of social interaction (public/private, social/personal, communal/individual), were all features that surfaced in the interviews.

As a person begins to recover, he needs to be drawn out of his safe state toward re-establishing an independent existence within society. The more successful therapeutic environments in this study provided both the ability to retreat (single rooms, patient meeting rooms, private lounges), to the familiar and safe, as well as potential contact with outside (atriums, public restaurants, terraces, balconies), the stimulation of social activity and community.

Context: The Pre-Visit Questionnaire and Walk-Through Interview

Face to Face

It should be mentioned here that the most successful Pre-Visit Questionnaires were completed during a structured interview rather than in isolation before the visit as originally intended. In most cases important information to augment a sketchy Pre-Visit Questionnaire was picked up during the Walk-Through Interview (with the director of nursing, project manager, or facilities manager) when aspects of the building triggered memories of the development process.

The most thorough introductory session took place in Norway where most of the original development team (project manager, architect, organization director, doctors, and assorted members of staff) provided a focus group discussion about how the project had been developed. Similarly, the most productive walk-through interview was conducted with a team of individuals who had vested interest in the project. Lead by the facilities manager, it was attended by the young architect who worked on the building design, along with a researcher, head architect, and student from the architectural practice that designed the building.

It became evident that the process of post occupancy evaluation is something architects rarely have the luxury of doing and that this team were very grateful of the opportunity. The group walkthrough triggered a high level of interaction and detailed discussion on the why�s and how�s of the now functioning building and healthcare design in general. The exercise appeared to be as interesting and instructive for the architects as it was for the researcher and building facilities manager. It would be useful to see how this process carried through to influence future design in the architectural practice involved.

It was intended at the outset that the case studies would be done in two visits: the first to collect the contextual information (Pre-Visit Questionnaire and Walk-Through Interview) and build a relationship of trust with the organization, and the second to do the user interviews and photography. Budget and time factors made this plan impossible, but in retrospect, it is still felt that this would be a more effective approach.

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Processes

Site Strategy

Having a strategy for the site development or establishing a master plan was not an intrinsic element in all of the case studies. The McAuley building, for example, did not have one but actually became part of a master plan through the successful progress of its development. The inclusive nature of this building�s development heightened community and organizational self esteem and confidence to such an extent that they now feel capable of aiming toward the incorporation of this building as phase one of a sixty million pound phase two. This has, in turn, generated a knock on effect kick starting a community wide project for redevelopment.

One of the projects that excelled in site strategy was St Joseph�s. Nevertheless the interviews suggested that, in retrospect, their master plan to develop a site specific �community� to house the Bonsecour�s vision of a � continuum of care� may be contributing to the very lack of � community� they were aiming for. Their choice to develop on the stunning but isolated site outside of Cork, disconnected from public transport, social activity, and volunteer culture, was based on the ability of the site to realize the entire Master Plan. Financing the next phase of the Master Plan is currently on hold, and as a result the existing building (intended as the central hub, servicing the community at large) is suffering from a lack of the activities the full community would offer.

This phenomenon also came up in Ter Reede, also part of an ambitious �campus� for the elderly. The next phase containing the �heart� of this campus, an atrium service centre, containing a restaurant, shops, fitness, hairdresser, etc., will be finished in 2006. In the meantime Ter Reede is feeling the pinch. Concern was expressed that this wait has been too long.

Based on these findings it is apparent that the more integrated a site strategy is with what the care group/therapeutic model can gain from what already exists in the local �community� (other medical facilities, amenities, services, social activities, etc.) the more successful it will be. Significant potential for �added value� is located in this area demonstrated in Oulu by its symbiotic relationship with the University Hospital.

Location

Choice of location, or the luxury of being able to choose location, was not as much of an advantage as might have been thought. The majority of these projects were not governed by choice of location but were built on the site of a building they were replacing/extending, or on the grounds of an established complex of medical buildings. As mentioned above, the one project that had a choice of locations is now struggling with their decision.

The main factor in location was accessibility, and proximity to other organizations, to facilitate cooperation. Issues such as scale, nature, views, and other aesthetic aspects, were far down the list of priorities from needs that might appear mundane, such as public transport. The recent focus on �healing� or �therapeutic� environments might make this seem remise, but the ability to create an atmosphere that promoted recovery was not unilaterally heightened by extensive dramatic landscape, it lay in how the limitations of the location were used and developed to support the therapeutic model, rather than by the location in itself.

The Brief

Strong vision and leadership along with an in-depth understanding of the care group was an overriding feature in the briefing process for all the case studies, though the format of the leadership was quite different between buildings, and though leadership was a key factor, when �vision� took precedence over a realistic understanding of care group the result was less successful.

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Two of the projects were primarily female led with the director of nursing acting as project manager in one. These projects excelled in design for function but did not guarantee a �cozy� atmosphere, as one would assume of the feminine touch!

The most important finding was the impact of a multi disciplinary, inclusive, briefing process. This concept first came up in the EuHPN brainstorming sessions when the five client groups (patients, staff, public, hospital/facility management, Health Authority) that needed to be satisfied in the development of an exemplar project were acknowledged. The two projects that excelled in an inclusive briefing process exhibited a higher level of ownership of the project and a commitment to the building. No building is perfect and the advantage in these projects was that they felt both proud and responsible for the building. This prompted a willingness to acknowledge flaws and adapt without resentment or �blame.�

Time, a factor that one would believe would influence the ability to do a thorough brief with multi-level involvement, did not seem to be influential. The most inclusive briefing program took place in Sykehuset Telemark where project length from start to finish was a quarter of the time spent on the project that employed the least inclusive briefing process. It was felt that the accelerated learning curve and bonding exercise facilitated by participation in a multi-disciplinary project team was ultimately far more efficient.

Monitoring of Development

What was true of the brief was also true of the project management, monitoring, and commissioning of the project development. The use of a multidisciplinary team representing a wide range of users diminished the need for interventions or made it possible to spot and initiate crucial interventions during the process. This eliminated the necessity for expensive retrospective alterations.

Nevertheless, the advantage of using the depth of expertise and experience present in the staff body was often sadly overlooked when it came to the final commissioning of the building. Physiotherapists and occupational therapists were dismayed that their opinions were under-utilized. This led to furniture that did not support patients adequately and highly functional spaces, such as bathrooms, that were awkwardly designed and impacted on patient dignity.

Services

This was one of the weaker questions on the Pre-Visit Questionnaire. What �services� were being referred to might have been better defined, but again, the intention had been to bring out what first came to mind and gather �unexpected� information. Volunteer services, for instance, were brought up here, but only as an aside, by one of the projects. As it turned out this organization hired someone full time to manage their relationship with over 130 volunteers from whom they gained enormous benefit. Perhaps the questions in this section could have been better posed to tease out unique potential for service exchange.

Strong symbiotic relationships with other organizations were maintained in most of the buildings. In three of the buildings a tunnel or covered connecting corridors were built between the buildings to facilitate this process. The most common services brought in were clinical, technical, laundry, food, and waste. Added value from the standpoint of convenience and economy was offered to both establishments in these arrangements, though food preparation and delivery was one area that seems to be making a shift. Many of the buildings had integrated communal meals in an alcove next to a staff kitchen and offered the experience of food preparation into their therapeutic regime.

The most underused amenity provided by several buildings were restaurants attached to large public areas, often atriums. The purpose of these was to create a hub of social activity in the core of the building. They were intended to be as much of an enticement to the public as to the patients, luring them out of their beds into a stimulating space for

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social exchange. Though these restaurants were largely underused there was an overriding belief that this facility would eventually become a popular amenity and attract not only social, but cultural exchange with the local community. The buzzing café in the McAuley building, where everyone (from the CEO to the cleaner) relaxed together, was an exception. This may have been due to scale, or the exceptional community presence in the building in general.

In many cases a deficiency of voluntary support was mentioned. The pressure on healthcare provision in relation to our changing demographics will increase this need. Ter Reede and the McAuley building offer lessons in how to nurture a culture of interaction in this area.

Influences

Ecological

This was the weakest influence considered by the Pre-Visit Questionnaire, although the use of natural light and ventilation were considered in the design strategy of all the buildings and the presence of natural light was one of the most mentioned elements by all users. Ecological considerations, on the other hand, were almost universally driven by government pressures. Clinical waste was the primary concern with energy conservation following in the list of priorities.

Concerns regarding the lack of ecological strategy were expressed by some of the staff in the Multi-User Questionnaire, and it is likely that this awareness will grow as personnel become more conscious of these issues at home. In general the relationship between human health and ecological stability remained largely unexplored and though this relationship may very well be affecting therapeutic performance in buildings there was little conscious awareness of this documented here.

Social

Interactivity with local community was highly sought after by all buildings though some accomplished this far better than others. This was even the case at Sykehuset Telemark where they aimed to �normalize� attitudes in the community toward psychiatric patients as much as possible by cultivating the landscape surrounding the building, used by some of their patients, as a public park.

Nurturing a volunteer culture, as mentioned before, was facilitated by public areas within the buildings offering space for social exchange and cultural events, but it was evident that the ability to manage these relationships and spaces was not a talent common to the clinical profession. This may point toward a new growth area in the development of hospital management.

Integrating social systems, such as the many traditional rituals around food or spirituality, into the therapeutic routine is a growing theme in all projects. This was the over-ridding specialty at Ter Reede where visitors were invited to take an active part in the care process (folding laundry, feeding the more helpless, doing the odd D.I.Y. job). Patients were trusted in the kitchen (peeling potatoes, washing dishes) and asked to take part in selecting and buying the groceries each day.

The Mater/McAuley is well known as a training hospital with a unique care ethos, the most highly respected in Northern Ireland. They carry this further by offering their building as a venue to an extensive list of local interest groups for meetings and educational courses that focus on health issues. Many members of the staff take part in local groups and on the board of community bodies.

The chapel at St Joseph�s was the core social focus in that building. This catered to the generational traditions and culture of their care group but also was their prevailing

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connection with the outside community. Mass was commonly attended by visitors as well as patients particularly on weekends, and was an added benefit of visiting.

Economic

The case studies offered a range of five different funding models:

• National Government / City • County • Community • Private • Private / National Government

The influence of these varied arrangements had a palpable presence in the degree of ownership and commitment shown toward the building. The most impressive example of this was at the McAuley/Mater where a community pool, originally set up by a group called the Young Philanthropists to fund the ongoing expenses of the Nuns (who established the first Victorian red brick hospital in the locality), entirely funded the new development when government support was vacillating.

The exception to this theory was Sykehuset Telemark. This project was completely government funded and yet the level of intimate involvement by all members of staff in this building was inspiring. The reason for this may have its roots in other aspects such as: the inclusive project development process undertaken there and the bonding this established, the strong organizational culture, or other socio-cultural aspects not explored here.

The buildings that were partially, or entirely, privately funded displayed different characteristics and stresses, as would be expected. In these buildings the attitude of the staff responsible for the financial stability of the organization showed a very different attitude toward the design qualities of the building than the clinical staff whom were freer to enjoy the delights offered by the design.

Any lack of understanding of the care group in the design of the building had an impact on the economics of the buildings. Deficiencies in design lead to more labor intensive models requiring higher staffing levels highlighting the importance of the 1/5/200 ratio.

Institutional

The institutional influences that governed the buildings were based both inside and outside the organization, the �outside� influences being the national and regional system that governed the building, and �inside� influences coming from the traditional and historical background of the organization.

In Finland, where the healthcare model is changing and becoming more regional, regret was expressed over the loss of sound government directives based on ongoing nationally funded healthcare research. When the city/regional authority took over, the organization�s ability to adapt to new thinking was slowed down and often curtailed. It was felt that city fathers, less experienced in the cutting edge issues of healthcare, tend to cling to traditional views.

A historical ethos around care, previously established in a region or organization, continued to generate influence within the organizations studied. It was mentioned that Sykehuset Telemark has been built on the site of a monastery and that this history might be contributing to the calm felt in the space, but this influence was especially prevalent in the projects that had been established by the work of a religious order, as represented by St Joseph�s and the McAuley/Mater.

In St Joseph�s where the building was entirely modern and few vestiges of the past, other than furniture, remained, the chapel still stood out as the core element in the design, and, along with the �continuum of care� model, the remote aspect of a spiritual community

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prevailed in the Master Plan development. Though the recreation of �chapel� was a popular socio-cultural fixture and the patients consistently mentioned the high level of care, the isolated location, intended to inspire spiritual contemplation, less successfully addressed the clientele�s needs which centered round the stimulation of company and community.

Signals: The Multi-User Questionnaire

Background

The decision to use the open qualitative approach of this questionnaire was carefully considered before application. The intention was to avoid guiding the subject, allowing new information to emerge spontaneously. From this standpoint the questionnaire was very successful. To assist in the analysis it soon became apparent that one question requesting more detailed background information about the profile of the respondent (working history, cultural affiliation, male or female) would have been useful. These details would have given us an idea what the respondent was comparing this environment to (for example: a previous working environment, a hospital in another country, a time when they were less acutely ill).

Because these questionnaires where used as structured interviews it was possible to compensate for this deficiency by asking for these details, and we did. This was one of the many advantages that came out of our methodology. As mentioned previously the importance of working face to face also factored in the use of the Pre-Visit Questionnaire.

Choice of Respondents

Though, a wide selection of users was targeted as much as possible, the ability to make consistent selection of respondents from case study to case study was not achievable. Each building presented a different model and different restrictions on the researcher. In the case of Ter Reede (home for Alzheimer�s and Dementia patients) it was not possible to interview any of the patients effectively. Nevertheless this deficiency was compensated for by the ample time devoted to observation. At Ter Reede the researcher joined the clients for meals in alternating units over the three day stay and spent the 7 evenings in one of the living rooms chatting with the clients.

Observation

In as many of the buildings as possible the researcher slept in the building. This was done to experience how the atmosphere of a building changes from day to night over the twenty four hour period, and to facilitate interviews with busy staff or patients undergoing demanding treatment who were often freer during the evenings. Even when staff were unavailable time spent just sitting still and experiencing the space in use, without verbal feedback, was hugely educational. What can be learned from simple observation can not be stressed enough.

For the reasons mentioned it is questionable that an internet based questionnaire could be used as effectively to conduct a rigorous examination of buildings in use through the full range of occupants. This was also the opinion of Bordas and Leaman at the conclusion of their ten year PROBE study.

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Themes

The following are the main themes that prevailed when we analyzed the data collected in the design study interviews. Though these themes have been mentioned in parts of the previous discussion a list and brief definitions follow here for convenient reference.

Culture

Examining a diverse range of projects in a similarly diverse range of countries augmented the discovery of place-based tendencies. Socio-cultural aspects of preference, based in local aspects of community, tradition, religion, customs, routines, were much more prevalent than initially anticipated. Obviously these were also tied to generational trends which harbored the effect of historical events such as war, or a particular economy.

Limits

An open acceptance and respect for the restrictions that surround a project generally led to more creative solutions and added value during the design process. This was particularly well demonstrated by the Mater/McAuley where the politically volatile nature of the local community demanded an acute level of diplomacy which, in turn, produced many knock-on benefits for the organization, the building, and the community.

Community/Routine

Contact with people (visitors, volunteers, children) and the news (information or the ability to experience a piece of what was happening in the community, both local and global) outside the building, was a resounding need expressed by patients. Visible, cyclical, daily, activity focusing social inclusion and familiar recurring tasks had an important place in patterns for recovery, particularly in the case of psychiatric care, Alzheimer�s disease, and dementia.

Food and Food Systems

The rule and role of food, a primary requirement for health is famously neglected in hospitals. The therapeutic and social aspects of this medium have been supremely under-utilized in the design of healthcare building and systems design. This study shows that this situation is changing.

Shelter and Safety

The need to withdraw or escape when ill is a common theme. This along with the urgent need to curb hospital enquired infection has led to an almost exclusive application of en suite single rooms in recent healthcare buildings. This study showed that unilateral application of single rooms is not the desire of patients or staff.

Although psychiatric patients almost universally responded to private rooms, in general, safety was more often sensed in the ability to observe or be observed particularly when acutely ill (which lead to a revised design of the �nightingale ward� at the McAuley/Mater). The desire for single rooms also was influenced by culture and region. The Nordic countries showed a more defined preference in comparison to Ireland, for instance.

A sense of shelter and safety can also be expressed by design features that communicate the essence of an environment that has formally/traditionally provided protection. Both cultural and generational preferences may be predominant here as different cultures and age groups have different memories and requirements (e.g., cave, camp, cottage, oasis, etc.).

Materials and Memory

There appears to be an intuitive meaning in the vernacular that has therapeutic potential. A sense of this was noted in patient response to materials (the obvious one being wood in Norway), design, and art (the echoed features of the original Victorian building, and the

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popular local art, in the McAuley/Mater). This theme was not necessarily considered and applied by the architects, but often cropped up intuitively.

Normalization

Providing a mainstream lifestyle, designing out risk in standard features (such as showers in psychiatric wards), creating a safe but deliberately unsupported environment (encouraging independence), integration with local community, and appropriate organizational scale, all were facets of this dominant theme.

Normalizing the patient experience was seen to provide the individual with a sense of dignity and respect. In the case of the psychologically ill the presence of normality, in contrast to previous hospital experiences, brought a sense of sanctuary, trust, and ultimately increased levels of self-esteem. In some cases the benefit of this was delayed by an initial feeling of resentment. The trust displayed by the environment insisted that the patient reciprocate by showing a similar level of respect in return. This could be demanding initially, but was ultimately found to be therapeutic.

Several of the projects that were more adventurous in their use of � normalization� as a therapeutic technique claim that recovery times are diminishing as is the necessity for drug therapy and rehabilitation equipment.

�Services to Patients� Versus �Patients to Services�

Another example of �no� that meant �yes,� this trend created a more difficult working environment for the staff but brought more staff satisfaction. Many of the buildings had designed out large separate departments for clinical services, such as physiotherapy, and brought these services to the patient�s own room or to a communal space on the ward. This was facilitated by the larger space allowed per patient. The knock on effect was surprising: it gave the patient more privacy, ward staff and patient could be trained together to support the exercise regime when the physiotherapist was unavailable, and the ability to move around the building and socialize more brought greater satisfaction to the job.

Sustainability

The use of integral planning and design appears to be producing increased value over time. Symbiotic relationships with other organizations and the community make financial sense and compares well against the more self-sufficient models. Creative staffing methods supported by design for multitasking brought both economy and a higher level of staff satisfaction, recruitment, and retention. In general staff performance was improved by a tight building/care model/place �fit.� This impacted positively on patient experience and the therapeutic environment, but also represents significant added value when considering the 1/5/200 ratio.

Strong patient preferences for natural ventilation, light, and local materials, suggest potential for energy efficient design solutions (considering that the majority of energy is currently spent recreating these elements artificially).

Technological Dependence

This trend, though dominant, was not always wholeheartedly welcome by the respondents. There is no doubt that technological developments support and even lead design potential, for example: the ability to supervise a large proportion of single rooms providing the ability to lower staffing levels at night. Some staff claimed they could not have functioned without the assistance of electronic aids. Other users expressed distrust of technology and felt uneasy with their dependence on it. They suggested that technology was replacing the more personal support staff could offer, isolating the patient, and eliminating the use of touch.

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Case Studies

As stated, the purpose of this study was not to compare one building another but to study healthcare design in relation to a specific community, its context, and healthcare model. An analysis of the main findings from the case studies has been given above. What follows is set of information specific to each case study. This includes: a condensed description of the main themes highlighted by the project, combined with a photo essay and a short analysis of the environmental balance achieved.

The preliminary tables of factual information on the building, its function, and why it was put forward for this study, were the responsibility of the organization itself and EuHPN member who submitted the project for participation in the study.

Country Republic of Ireland

Project St Joseph�s at Mount Desert

Address Mt Desert, Cork

Owner/Operator Bon Secours Health System

Type of Healthcare Building

High Dependency Unit and Intermediate Care Unit

Size/Capacity 62 beds

Catchment population

Capital Cost �12 million

Date Completed January 2003

Procurement Method Traditional

Contact Name In Facility

Denis O�Sullivan

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Details of Design Team

BDP: Master-planner, Architect, Landscape Architect

Design Team: Tony McGuirk, Benedict Zucchi, Malcolm D�Crus, Danilo Zecevic, Sophie Godber, Andrew Tindsley

Details of Main Contractor

Rohcon Ltd, Cork

Reason For Selecting Facility

A Healthcare Village at Mount Desert inspired above all by the intrinsic qualities of the hillside site, the mature woods to the north, the wonderful prospect over the Lee River valley to the south and the ideal micro-climate.

Descriptive Keywords Shaped by the nature of the site, topography, existing planting, accessibility, scale, proximity, and view.

Innovation/ Characteristics: Organizational

St Joseph�s Hospital is a 60 bed long-term high dependency unit for the elderly at Mount Desert near Cork. The Hospital, which also includes some sheltered housing in the form of an Intermediate Care Unit, is part of a larger Master Plan designed by BDP to create a Healthcare Village on the wonderful hillside site for the Bon Secours Sisters, a private charitable health trust. Planning permission has already been obtained for a future phase of sheltered housing and outline proposals drawn up to include a hospice, conference and administrative centre for Bon Secours, health spa and further housing to create a complete community.

The Master Plan and hospital design were inspired by the greenbelt site: the mature woods to the north, the wonderful views over the Lee Valley to the south and the ideal micro-climate which originally led to its development as a centre for tuberculosis treatment in the 1930s. The initial brief for the hospital was that it should feel more like a retreat or a resort hotel with the majority of patients enjoying the south-facing views. It should also cater for convalescent and respite patients as well as the existing longer-term residents.

Innovation/ Characteristics: Design

From this grew the concept of the hospital as a �village� made up of distinct residential clusters, each with about ten single rooms and their own communal lounges and support facilities. Clusters were arranged to maximize the views and incorporate a number of mature trees within the composition. The lounges are all located at the southern tips of the clusters for the best views and sunlight and are highlighted externally by their curving form and cedar cladding. An internal �village street� arcs round from the visitor entrance, reception and restaurant at the eastern end to the clusters, chapel and staff entrance at the western end, all within about 2-3 minutes� walking time. The south side of the street has full-height windows that look out onto intimate terraced gardens between the clusters and panoramic valley views beyond. The street�s crescent form departs deliberately from the institutional corridor and is intended to become a place in its own right in which residents, staff and visitors will naturally mix and linger. Like the lounges the other communal spaces are given a common identity by their timber finish and their freer forms which mark them out from the more domestic clusters. This distinction is reinforced by the roof materials: clay pan-tiles for the clusters and standing seam zinc for the communal spaces.

On the northern side of the street the communal spaces wrap around the village green, which will become the external focus for the Care

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Village as a whole where residents will enjoy outdoor games, eating with relatives or open-air masses by the chapel.

Innovation/ Characteristics: Impact

Included in the description above.

Value For Money Simple palette of materials. Spend the money where it is appreciated most, don�t reinvent the wheel. Maximizes natural ventilation and natural light, minimizing use of expensive M & E systems. Circulation space doubles up as waiting areas, social space, and staff bases, making the overall space efficiency as high as possible.

Statement of what the building is about official (mission statements) definition of care group and therapeutic model

The mission of the Bon Secours Sisters and the Bon Secours Care Village is to care for the sick and dying and their families in a Catholic Ethos.

Inspired by the Gospel and as part of the healing mission of Jesus, they strive to recognize the dignity and uniqueness of each person, seeking to provide a quality of care and service which is characterized by love, compassion, respect, justice, and hope.

Their aim is to provide the highest standard of care to all residents in a dignified and respectful environment which promotes independence and individuality.

Definition of case load, acute, long-stay, mixed, (general)

Caseload: 63 patients; 58 are long term

4 of the 58 are chronically sick, severely disabled by diseases such as MS and Parkinson's.

The balance consists of convalescent patients who are partially covered by VHI or BUPA, usually post surgery.

Average length of stay Care given in St Joseph's can be termed as acute, since a lot of intervention is done in the line of peg feeds (direct feed into the stomach), end stages of death, subcutaneous infusions etc.

Only 4% of long term patients can walk, and that with aid.

Average length of stay. �The good Lord is our discharge co-coordinator!�

Single room ratios 48 single rooms and 5 double rooms.

Lists of staff (+ ratios) 25 Nurses and 40 carers. Ratio for care given is: 4.

Few full time as flexibility is the name of the game in the recruitment of nurses, (a world wide problem).

Volunteer Culture About 6 volunteers (Friends of St Joseph's) The 5-6 Bon's Sisters help out in reception activities stores and mission.

Management structure 1. Bon Secours Provincial and Team

2. Board of Directors

3. CEO Bon Secours Health System

4. Hospital Manager

5. Three Department Heads (Administration, Nursing, Mission & Value)

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6. Three Administrators

7. Heads of Clerical, Security, Maintenance, CNMI, Reception

8. Senior Staff Nurses

9. Coordinator of services

10. Care Assistants, Cleaning Services, Laundry, Catering Department

Healthcare Community

A private/public community hospital.

17 Private patients fund their stay and the balance is sourced from the Rehab. Community Hospital, St Finbars in Cork, with the Geriatrician having the main say in admissions.

Users interviewed 6 Nurses

6 Assorted staff (receptionists, administration, security, cleaner, chief)

7 Patients

3 Visitors

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Context

The �continuum of care� ethos established by the Bon Secours has earned the order an international reputation in healthcare servicing. The brief for this building came out of an original plan to replace one of their properties, a deteriorating tuberculosis hospital. This initial plan evolved over time into the development of a �flagship� project to fully realize an ultimate vision of this broad therapeutic model. The project integrated care for the elderly into community housing with three stages of care: independent living (sheltered housing); semi-dependent; and dependent. This was the driving force behind the Master Plan and the ultimate selection of the location.

The development of the brief took place at board level with little community or user involvement. It was a protracted process spread over 13 years. Several early designs by a local architect for another site located inside Cork City were dismissed over this period as the prospect of government funding and interest waned. Inspired by a new building at Limerick University a Doctor on the board invited Building Design Partnership to take over the project. The property at Mount Desert (site of the previous tuberculosis hospital) was subsequently favored to adequately fulfill the Bon Secour dream in its entirety with the advantage of evidence based therapeutic design. Throughout the development process was monitored by a senior staff member (who no longer works in the building), the facilities manager, and the board.

The hospital is perched on a hill in a magnificent position overlooking the Lee River Valley surrounded by cultivated fields with little civilization in view other than the lights of Cork City at night. The development of the site incorporated many of the existing mature trees. The existing building represents the first stage of the master plan housing the dependent wards, semi dependent apartments, a chapel, and an elegant restaurant (for 60), wrapped around a landscaped central area intended to function as a community square.

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The hospital is privately funded by the Bon Secours and the second phase of the Master Plan is currently on hold. This has had a knock on effect on the economic environment of the building. The semi dependant units are now being promoted as independent units, but remain largely unfilled. The reason for this may be the location, which lies fifteen minutes by private taxi from town (�15) with very limited public transport available. Unfortunately transportation is difficult to and from the building, and the subsequent sense of isolation, along with a low level of community presence, were mentioned often in the interviews.

The hospital is privately funded by the Bon Secours and the second phase of the Master Plan is currently on hold. This has had a knock on effect on the economic environment of the building. The semi dependant units are now being promoted as independent units, but remain largely unfilled. The reason for this may be the location, which lies fifteen minutes by private taxi from town (�15) with very limited public transport available. Unfortunately transportation is difficult to and from the building, and the subsequent sense of isolation, along with a low level of community presence, were mentioned often in the interviews

Themes

As you approach the building by car, the way most people tackle the long steep incline, the height created by the dramatic cantilevered unit extensions can distract you from finding the main entrance which is tucked into the side of the hospital. Since this building is currently the only building on site, the turning space feels limited, and though one aspect of the public restaurant and the reception both face onto this entrance there was little sign of activity present around this area during the study visits.

The design is build around the provision of shelter and safety, maximizing the therapeutic effect of views and gardens. This was accomplished by inserting the building into the side of an extensively landscaped hillside. The contribution of landscape to the care model was taken very seriously by the architectural team and is featured in the brochure. Finger-like units extend out from the main central corridor that wraps around the community square. Each unit contains ten patient rooms, five on either side.

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At the end of each of the unit extension is a communal lounge, cantilevered on several supports, offering expansive floor to ceiling views of the valley, countryside, ground, and sky (all features encouraged by evidence based design). These rooms were one of the main features addressing the desire to create a private place, shelter and safety, for intimate communal activity including meals, contemplation, family gatherings, and the therapeutic advantage of views.

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In these public and private spaces, experimentation with materials, color, and the psychological impact of spatial technique has been used to produce a stimulating range of ceiling detail.

The use of warm wooden paneling, and angled ceilings that slant toward the ground, provides a cottage or cave-like sense of protection. Unfortunately the fire officer insisted that the small kitchen units, with hatches open to these lounges, be made smaller to allow space for a fire door and corridor, limiting some aspect of their functionality.

During the study period these spaces were, more often than not, unoccupied. Some patients found the long-range views of empty landscape lonely. It was also mentioned in the interviews that many of the patients, who are confined to wheelchairs, find the cantilevered views similar to a cliff edge, and unnerving.

The one lounge that was situated facing the communal courtyard, in the centre of a unit, in an alcove at ground level, opposite the busy nursing station, was far more popular.

Second to that was another lounge that was also on ground level and facing walking paths adjacent to the forest edge. All the factors mentioned above indicate that a ground level position, preferably near activity, is favored by this care group.

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Materials and memory were an important theme in the design strategy for the Bon Secours. As mentioned, wood paneling was used to define the warmth of social spaces such the lounges, Chapel, and restaurant. In particular, Canadian Cedar was chosen for the exterior of these spaces for its analgesic properties and care has been taken to retain the original ironwork and crest on the main entrance dating back to the Dunscombe Family who owned the site in 1596. Though well intended, these features appear to be missed by the average user.

In between each unit are accessible terraced gardens that have been elaborately designed and maintained. These are popular in the summertime. Many of the bedrooms have glass doors directly onto these terraces making it possible to wheel patients out to take the air.

All the design signals here are about normalization and choice, yet many of the details do not back this up. For example, many of the terraces are on a second story level with stairs providing access to the grounds below, but, for security reasons, the gate at the top of the stairs must remain locked, diminishing the freedom of movement intended. The advantage of therapeutic horticulture (cultivation, touch and smell) could be further encouraged by the provision of raised beds, a necessity for the wheelchair dependent. Potentially dangerous split-level surfaces on the semi-dependent terrace were marked with warning strips. All of which makes one question if the existing care group, who are only 4% ambulant, was sufficiently understood.

Surprisingly, when asked �how does this building relate to the outside?� many patients replied, �TV,� implying that the views and gardens where not foremost in their thoughts. What they missed most was information about what was happening in the world outside, community/ routine. Every patient room and lounge is equipped with a large television. Even activities inside the building could be watched on television. On of the most mentioned advantages of technological dependence was the use of closed circuit television to transmit a view of the chapel all day long.

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The most popular view in the building lay at the main crossroads of the building in between reception and the chapel, next to the physiotherapy department and the hairdressers. This area of plate glass overlooks the staff parking lot and has a view of airplanes coming and going from Cork airport. This area was not designed to accommodate seating but represents the central hub of the building, the area that provides the greatest sense of routine/community. It has been so popular that a gas fireplace has been installed in front of the window to make the space feel cozier. It is interesting to note that the view here had the same cliff edge quality of ones mentioned previously but, presumably, because the patients felt safely nested in this active hub, this aspect was not as worrying. This says something about the balance of preference in relation to choice (see: The Individual in Balance).

A large lounge area for communal dining and meeting has been provided adjacent to the restaurant with views of the central garden. This was intended to facilitate daily activity amongst the semi dependent community members. The space was subsequently adapted for the storage of 4 self-cleaning food trolleys not provided for in the kitchen area. This means that the space is noisy while the machines are active, often used as a passageway for the catering staff, and not used as initially intended. At the moment it is more often used for staff meetings.

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A weekly soak in a bath is a routine that brings comfort to many elderly people. To encourage this, an independent bathroom containing sophisticated bathing and lifting equipment has been installed in each unit. Though extremely well equipped, these rooms lack the detailing found in other parts of the building. No natural materials were used and few had windows. Many were inactive and being used to store surplus equipment. In interviews it was mentioned that the care group were of a generation that didn�t bathe much. In addition, the use of the en suite shower rooms may be negating the need for this expensive equipment. Comments like this, regarding the provision of surplus bathing and lifting devices, were made in many of the buildings that featured single rooms.

Most of the examples of routine/community at St. Joseph�s are provided by the Bon Secours order in the style of a religious community. Visitors are welcomed by members of the Bon Secours Order who work as volunteers at reception, mass is the social activity around which the daily schedule is organized, and the chapel is the most popular feature in the building. The room has been designed without fixed seating making it possible for virtually everyone, even the bedridden, to attend. The majority of patients are of a generation that attended daily mass and keeping this tradition intact instills deep reassurance, a strong sense of their own culture, and normalization, during this difficult stage of their lives.

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Lining either side of the units the single rooms are designed with privacy, security and safety, as top priority. The en-suite shower-room conceals the patient from the corridor leaving only their feet visible. Fire laws also demand that the doors be kept shut which also has a soundproofing effect. This means that there is no view of the corridor available to the residents. Because they cannot observe the activity in the hall they are hardly aware of nursing presence until one enters the room. Although great admiration of the staff was present, a sense of isolation was mentioned in many of the interviews and in at least one case a patient expressed preference for proximity to the nursing station over a room with a better view. In some instances the doors are kept open to alleviate anxiety. As seen is several of the projects studied, providing this level of privacy makes observation and maintenance a labor intensive job, and more so in this high dependency care group.

This is more of a worry to the administration of the building who shoulder the financial responsibilities, but is also noticed by the nursing staff who feel many of the patients are lonely and less stimulated, an possibly less active, than they were in the previous building where they lived in wards. Extra demands are placed on staff who are already busy, to provide attention and entertainment to those confined to their rooms. Technological dependence on an elaborate communication system helps manage the demands of getting around the long distances and keeping patient needs met.

The need for more social activity has been noticed by the physiotherapist who has assumed the role of activities organizer. Her room is bright, well equipped, and appropriately situated for the purpose, located in the central hub of the building, facing on to the community green. She feels a second staff member in this department would make a big difference to what she was able to achieve. Though many of the staff spoke highly of the design, specifically its light, landscaping, and views, many commented that they had little time to appreciate these features.

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Food and food systems are the other main focus in this building. Patients are given a weekly menu with three options for each day. Several described the pleasure they derived from the ability to select their meals as well as where they would eat them (their room, the lounge, or the public restaurant. The latter is at its most active on Sunday for lunch after mass when patients are joined by visitors and family. This coming together is the social highlight of the week and combines many of the themes we observed: normalization, food, routine / community, and culture.

The restaurant is designed to facilitate the �community.� It can seat sixty people and can also spill into terraces facing into the central community garden in the summertime. At the moment, again, due to the incomplete master plan, it is rarely used to capacity and must close after lunch due to staffing demands. Food and drink machines are used to service the visitors in the later part of the day. Evening meals are ordered in advance and prepared for collection for the independent residents and delivery to the patients by the nurses.

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The strong emphasis on food and ceremony, highlighted by this state-of-the-art restaurant available for both residents and public is not carried through in the kitchen itself. This space is not large enough to service its demands and has no windows to provide natural light or ventilation. The staff felt working there was no different than in any other restaurant. Nevertheless, they enjoy getting out of the kitchen to deliver meals around the building when they can take in the environment created for the clients, and they expressed pride in being able to work in this prize-winning building that has attracted so much media attention, as did all the staff interviewed.

Environmental Tensegrity

The social strategy for a �care village� envisioned in the master plan for St Joseph�s at Mount Desert currently remains incomplete. The section of the complex that does exist has had to adapt its functionality to accommodate this state. Without the population intended to activate this intentional community for the elderly the location feels remote. The surrounding area, which is populated by wealthier residents who protect their independence, does not engage in community activities, and will not fill this gap.

At present only 4% of the residents are ambulatory leaving the majority unable to take advantage of the spectacular natural resources of the location. Despite a considerable investment in landscaping there are few paths suitable for wheelchairs. The mismatching expressed by many of the design features in the building would lead one to believe that the needs of the care group were not sufficiently understood. Yet, as mentioned, this may well be the result of the site strategy remaining unfinished. For these reasons pressure is placed on the organization and staff to compensate, creating a labor-intensive building to maintain. Technological dependence helps them meet this demand, and the building has been well equipped. It will be interesting to see how things change once the plan is complete.

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Quotes

�The dignity and quality of life offered by St Joseph�s is like a rare and delicate flower ��

�The design requires twice as many staff�

�This building was designed for an ambulant care group ... but the patient profile is only 3% ambulant. ... The maximum dependent care group here has a serious need for stimulation. The location is an impediment.�

�Patients isolated in single rooms ... lose contact with body and touch. Rehab has to replace this and keep vital activities going�

�It is easy to visualize the needs of the elderly, their preferences are very similar to children� �Good to have convalescent and respite patients mixed with long term�

�consistency in ethos is reassuring�

�Analgesic aesthetic, pleasing to the eye, design and site provide an uplifting working experience�

�Good to have convalescent and respite patient mixed with long term, the feedback from short-term patients is useful�

�Beautiful building to approach, but once inside it is like any other. I don�t feel connected. Is it time? I have no time to appreciate the surroundings. If I were a patient would it be different?�

�Views were interesting at first but not anymore ... they quickly become boring, nothing changing or moving�

�I love building and the scope it offers for work. I enjoy walking around the building on good days, a benefit of the isolated location�

�Open door policy is good for my mother�s condition�

�A view of the central area offers a sense of community�

Country Finland

Project Oulu City Hospital (1st Stage)

Address Kiviharjuntie 5, FIN-90220 Oulu

Owner/Operator City of Oulu

Type Of Healthcare Building

Primary care hospital (short term care for elderly patients)

Size/Capacity 6383m2 (available)/12490m2 (gross)

142 beds

Specialist's consultation rooms

Catchment population

125 970 (1.1.2004)

Capital Cost �17 210 000

Date Completed June 2002

Procurement Method Traditional contract

Contact Name In Facility

Irma Toivanen, Project Manager (Director of Nursing), City of Oulu, e-mail: irma.toivanen@ouka.fi

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Details of Design Team

Uki Arkkitehdit Oy, Architects, e-mail: antti.vanhala@ukiark.fi

Details of Main Contractor

NCC Finland Oy, Mika Sipola, Project Manager,

e-mail: mika.sipola@ncc.fi

Reason For Selecting Facility

Special care model for older people (rehabilitative, supportive, activating, increasing well being)

Descriptive Key Words

Patient focused, accessible, versatile facilities

Innovation/

Characteristics: Organizational

Special care model, close cooperation with the university hospital

Innovation/ Characteristics: Design

Lightness, healing ambience

Innovation/Characteristics Impact

Good feedback both from patients and staff

Value For Money Positive image for the City of Oulu and also for the care profession

Statement of what the building is about official (mission statements) definition of care group and therapeutic model

Oulu City Hospital is specialized in examination, care, and rehabilitation, of acutely ill elderly patients over 65 years to be able to manage at home again. Many of the patients are referred from the Oulu University Hospital for short-term care and rehabilitation in the city hospital.

The approach is to rehabilitate patients in all daily activities and improve their general welfare. This active approach to nursing also achieves its goals through the application of modern technology. In all possible ways the patients are encouraged to recognize and utilize their own mental and physical capacities.

Definition of case load, acute, long-stay, mixed, (general)

142 beds, all beds for short-term care

Average length of stay

In 2003 the average length of stay was 15 days in short-term care and rehabilitation wards.

Single room ratios 77 single rooms, 30 double rooms, one observation room (with partitions) for 5 patients.

Lists of staff (+ ratios)

! Medical doctors from GPs to specialists 17, 1 in administration, 5 in specialists� consultation, 11 working in the wards of Oulu City Hospital, long-term care and in the 28 bed ward in the University Hospital.

! The staff / patient ratio in the wards is 7�9 professional staff members for every ten patients.

! 1 director of nursing

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! 5 head nurses (1/ ward)

! 71 nurses

! 44 practical nurses

! 4 physiotherapists

! 3 occupational therapists

! 1 physiotherapy assistant

! 4,5 assistants (secretaries)

! 19 hospital attendants

Volunteer Culture ! Some volunteer groups visit wards acting, playing or singing

! Some volunteer groups visit the main hall acting, singing or playing

! Students from the music conservatory or music school visit singing or playing piano etc.

! Other volunteer groups such as senior citizens, students, pupils, children from kindergarten and organizations

! Sometimes patients' relatives or visitors have liked to perform for ward patients or all patients in the hospital

! Just after opening of the hospital they used to have small scale market selling in the main hall

Management structure

1. Board of social welfare and health

2. Director of social welfare and health services

3. Elderly care/director of elderly care

4. Hospital and institutional care/head of service division

5. OCH/ Senior medical officer

6. The head of service division is the senior medical officer of Oulu City Hospital. He is the head of all doctors and nurses in the hospital

7. In Oulu City Hospital there are three senior medical officers; two in internal medicine (one of them is the head of service division) and one in geriatrics

8. Director of Nursing is responsible for nursing

Healthcare community

Oulu City Hospital takes care of citizens over 65 years in the City of Oulu. Also younger patients will stay in the city hospital for palliative care. In the rehabilitation ward and department some patients under 65 years are treated also.

At the City Hospital, there are four outpatient departments where specialized doctors have their consultation rooms. This also supports the work of general practitioners at the city's health centers.

Surrounding the Oulu City Hospital there are many other services, health care development units, and a unique concentration of medical know-how. Research and enterprises in the field of modern technology support the work done at the hospital (the Medical Faculty of the University of Oulu, Medipolis, Tieto Enator, Nokia etc.).

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Users interviewed 3 Nurses

1 Doctor

9 Patients

2 Visitors

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Context

The functional expert and project manager of this project was the Director of Nursing. She has acted as project manager on several facilities including another hospital in Lapland and a local nursing home. The director of nursing was in the group that developed the �Oulu Model.� She describes this process here:

�We didn't borrow the care model directly from anyone. The Board of Health Services decided in 1999 to separate the long-term care and acute care of old people. The aim was to decrease the number of beds and change the care model from care in bed to active and supportive care. One of the units we visited was Harkatie health centre ward (close to Turku), which is quite like Danish nursing homes. We decided to decentralize long-term care in Oulu and build several smallish local units.

We wanted to centralize short term care close to the university hospital. This is the model we were using already in the former hospital building. In 1989 Oulu had beds for 18% of those over 75 years who required long-term care in either a hospital or nursing home. Now we have no hospital beds for long-term care, which was our aim. Long-term beds are only provided in nursing homes (6%). In the meantime the number of service homes and flats and homes for people with dementia has increased.

The project manager, who is now the director of nursing, collected both functional information and information on care environment through discussions with several experts, articles, seminars and visiting hospitals and nursing homes in Sweden, Denmark, Belgium, the Netherlands, Germany, and of course in Finland. All these experiences have been melded into the planning of Oulu City Hospital.

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We have also tried to follow up the social changes in the society and future needs (e.g. families used to live in a house with one room; now each one in the family has his own room). The society changes and the needs of people change. We wanted to have a hospital with the maximum amount of flexibility, for example: the placing of patients is easier when it is not necessary to think: is the patient male or female? Hospital infection was not such a burning issue during the planning period but now it's quite easy to isolate an infectious patient.

Because we have intensively developed the care of the elderly since 1989, it's difficult to say how the idea was born, but the reason why we only have single and double rooms is the model from Harkatie, from the experiences from the nursing home which we built in the 1990�s. The whole planning committee, architect, HVAC consultants, and inspectors, visited Visby and Norrtalje hospitals in Sweden. The visit supported the idea of building only single and double rooms and the design of an observation ward with separating glass walls.�

As she has described, the brief was devised and the development monitored by herself, as project manager and the nursing staff with involvement from the doctors, the health authority, politicians, and the hospital district on the development committee. The nursing staff had a strong influence and the functional emphasis on the design development remained dominant throughout.

The city hospital is part of a larger site strategy housing a medical campus of centralized social and health services. It is tightly linked and dependent on the neighboring University Hospital to which it is connected by an underground tunnel. Most of its patients are transferred from the University Hospital and many of its services are sourced there, including acute clinical services, general laundry, catering.

In return the city hospital provides a fertile teaching ground where University Hospital students can see the effects of disease on lifestyle and begin to think beyond disease to life-function capacity. Cutting-edge technology provides the ability to video conference weekly lectures from Oulu city hospital to other health facilities around the country on a weekly basis.

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Surrounding the Oulu City Hospital in the Kontinkangas area are other service and health-care development units. A unique concentration of medical know-how, research and enterprises in the field of modern technology support the work done at the hospital � the Medical Faculty of the University of Oulu, Oulu Polytechnic School of Health and Social Care, Medipolis, TietoEnator, Nokia, etc.

The institutional and economic environment is now dominated by the Oulu city (60% city/ 40% national financing). This has meant that Finnish hospitals are less research led than in the past when the government which commissions medical research dictated more of the policy decisions.

Themes

The first part of the new city hospital was opened in 2002. Oulu City Hospital is primarily for short-term hospital care and rehabilitation of the elderly. In this �Oulu Model�, hospital care, examination and rehabilitation have been strictly separated from the long�term hospitalization of the elderly.

Normalization is an overriding theme in this building. Patients are expected to get out of their beds as soon as they are able and eat in communal dinning alcoves situated between the nursing station and ward kitchen where staff activity is always present. Visitors often join patients here for coffee and cake, available to everyone between two and four in the afternoon. Support rails have been eliminated from the corridors to promote walking without assistance. Patients are encouraged to wear their own clothes and washing facilities are provided on the ward to facilitate this. The spacious bathrooms have been conscientiously designed to facilitate independent use by the disabled.

The rehabilitation unit works hand in hand with the University hospital in cutting-edge geriatric research and development, testing new approaches to re-training the elderly in life-skills after accidents and illness. There is an open door policy in the physiotherapy department. It is considered important that patients become familiar with the department and staff before they start to visit it as an outpatient. Patients in the hospice ward are encouraged return to the hospital immediately, if anything goes wrong at home, providing a sense of safety and integration of care.

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Technological dependence was highly developed in this hospital. Wireless technology and sophisticated sensory, closing, and locking devices, were a leading influence in the design, making it possible to provide most patients with single en-suite rooms with unusually spacious dimensions, and heavy doors that remain shut at night for noise control. They believe this has decreased the use of sleeping medicines and boosted the patients� sense of dignity.

Approximately 100 of the more vulnerable elderly patients are provided with buttons mounted on wrist bands to notify the hospital during a crisis. Despite the obvious benefits, the difficulty posed by adjustment to new technologies is still very evident, and in some cases staff expressed anxiety about its accuracy, or the event of a power failure. The logistics posed by the need to cover the distances (met by the use of scooters at night!) combined with stripped down staffing levels at night (effective economics) diminished patient awareness of staff presence.

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The Oulu area is known throughout Finland for its unique design style and the character of this building certainly reflects the influence of this clear flat landscape of water and snow on the edge of Lapland. The preferences of the regional culture, materials and memory were expressed in the way the design catered for independence, cleanliness, functionality, and, above all, light. The subtle glacial colors found in the landscape must have inspired the colors chosen for the walls, the mosaic mural on the wall of the swimming pool, and the curtains designed by a local Oulu textile artist. Color was one of the features most mentioned by patients.

Each ward has a small lounge at the end of the corridor with views to the outside and a cozy fireplace that burns wood. Patients and relatives like to visit there just looking out or watching TV.

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It is felt that a change of environment and view, the ability to see there is life and nature outside, the thought of how nice it would be to feel the chilly Nordic air again, transmits an incentive to get back to normal life.

Traditional wooden saunas, where visitors and relatives often join the patients for relaxation and deep cleansing, are another extremely popular feature, especially in the hospice ward where this facility would have been deemed risky in other parts of Europe.

Regret was expressed regarding the location of the Chapel and Mortuary situated in the basement level of the building with limited access. There has been an ongoing discussion in Finland about the rights and dignity as communicated by the way the dead exit the building. Generally it is now felt that they should not leave through the back door.

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The bright open white Atrium with its high glass roof has been designed to resemble a street-scape complete with street lights and signage. The adjacent restaurant spilling into this avenue and has been given the feel of a neighborhood café with a piano, tables, potted trees, with a stimulating collection of commissioned art floating in the background. This welcoming space is targeted to promote community/routine (social life, entertainment) and the ability to easily connect with the outdoors.

While we were there it was not very busy. Perhaps this could also be put down to the time of year (February!). This remains to be seen. Filling a space this large space with social activity on a daily basis may require dedicated staff to develop and maintain a schedule of events. Nonetheless, both patients and the staff expressed pride when speaking of the City Hospital. They felt privileged to be able to work in such a prestigious building. Staff explained how nice it was to enter the building through the bright elegant main hall instead of the standard back entrance.

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Environmental Tensegrity

The environmental tensegrity in this building is best demonstrated by its accessibility to the city population (bike trails, buses, parking complex) and symbiotic relationship with University hospital and the other medical and technological facilities on site. Shifting demographics demand that we experiment with new clinical models and methodology for geriatric care. This challenge is being met here within an active educational environment where research, development, and dissemination, work hand-in-hand with treatment. The patients and the local community are benefiting from this environment designed around cooperation and the added value of shared resources.

Within the hospital environment the therapeutic benefits of social/community activity are not as well developed as in some of the other European models. This may be a product of the culture, but the design and staff interest hints at a desire to develop this aspect further.

Quotes

�The vision is working ... Very proud ... Lucky to be able to plan this and provide a role in the care chain�

�Space encourages patients to get out of bed�

�Worn out!�

�Distances too long ... too much wasted space, need staff more�

�Technology can fail�

�Sauna wonderful, traditional, loved by Finnish�

�Keeps the spirit alive, everything tells you this is normal�

�To be old is a NEW problem. We don�t have experience with this problem�

�Students are learning through example�

�Colors are like home�

�It�s so clean. One can feel it all over the inside of the hospital!�

�Good location, close� �girls (nurses) are running all the time!�

�Easy to visit�

�Light colors sensitive to patient�s feelings.�

�Medical care is not too visible�

�Not traditional model, more supportive of daily routines, as well as the individual.�

Country Norway

Project Acute Pyschiatric Section, Sykehuset Telemark

Address

Acute Psychiatric Department, Psychiatric Clinic,

Sykehuset Telemark, HF, Ulefossveien 56,

N-3710 Skien

Owner/Operator Helse Sør RHF, Postal address: Postboks 2825, Kjørbekk, 3702 Skien

Type Of Healthcare Building

Acute Psychiatric Department in a Psychiatric Clinic connected to a general hospital.

Size/Capacity 28 beds in 3 sections, (10+10+8).

Catchment population

approximately 150,000

Capital Cost 60 million NOK (2000)

Date Completed August 2000

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Procurement Method

Contact Name In Facility

Head of Clinic, Egil Waldenstrøm, Tel: +4735003500

Details of Design Team

Sivilarkitekt MNAL Tor Arild Danielsen

Asplan Viak Sør AS

PB 393 Sentrum N-3701 Skien Tel: +4735905626

Details of Main Contractor

Reason For Selecting Facility

The facility was termed by the Health Minister (2000) to be a model for a future mental health care building, with its weight on a more homelike environmental quality, replacing the need for visible safety and security measures.

There is a need for closer inspection/evaluation of the model qualities.

Descriptive Key Words

Self-contained, stand alone adult acute mental care inpatient unit.

Patient focus

Physical environmental quality

Innovation/ Characteristics: Organizational

More space than usually planned for.

Two closed atria, plus access to outdoor spaces on all sides of the patient wings.

Special acute reception (3 rooms)

Living rooms and dining rooms open to the corridors.

Wood as the main material both indoors and outdoors.No visible windows locks or visible protection of windows.No belt room.

Innovation/ Characteristics: Design

3 inter-connected L-shaped sections (10,10 and 8 rooms) connected

Innovation/

Characteristics: Impact

Quality in the patient environment was a major consideration, in the treatment of space, in the use of materials, furniture and art.

Value For Money

The new department has attracted more personnel / staff than �competing� units

Flexibility in adaptation to different treatment philosophies/ ways of working

Reduced need for staff during the night.

Less disturbance and agitation in patients. The use of coercive measures, belts and drugs has been substantially reduced in relation to the former unit since moving into the new unit

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Statement of what the building is about official (mission statements) definition of care group and therapeutic model

Acute psychiatric treatment is a core element in the complete treatment supply chain for mental health care. The Acute care section receives patients with the onset of a psychiatric disorder and by relapse of a known sickness.

Definition of case load, acute, long-stay, mixed, (general)

People with acute psychoses, with symptoms or behavioral changes such as:

Withdrawal/ isolation

Socially uncritical behavior

Drug and/ or alcohol abuse

Suicidal or self-destructive behaviour

In addition: People with drug problems who experience a crisis (up to 30% of the inpatient population)

40% of patients are committed (compulsion according to special paragraphs)

Average length of stay

Occupancy rate: 115%.

Single room ratios Single room ratio : 100% (because of overcrowding, see 2+3, some treatment rooms have been taken for patient rooms, one of which has two beds)

Lists of staff (+ ratios)

Staff. Nursing factor 3, 0 in daytime. (Cannot find correct number of staff.)

Volunteer Culture There is no culture for volunteer activity at the hospital.

Management structure

Self-contained section of the Psychiatric Clinic.

Healthcare �community

Healthcare community: The Psychiatric Clinic is part of the general hospital.

Users interviewed 5 Nurses

1 Doctor

1 Psychologist

5 Patients

2 Administration

1 Project manager

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Context

The conceptual basis for the briefing process used at by this hospital was inspired by a public institution planning conference attended by the project manager where a new planning system was demonstrated. They were just beginning project development for Sykehuset Telemark at this time. He was able to experiment with this new model for six weeks, put together a proposal, and go back to the consultants for feedback. Based on this thorough approach and the climate in the Norwegian government at the time, who knew change in psychiatric care was long overdue, they were given 100% funding by the county administration to go ahead with the project which was completed in 2000.

They feel that the inclusive process they undertook with the brief was essential to establishing the building�s success. This involved the participation of a multidisciplinary team in research and development, connecting the architect, project manager, and users (staff, patients, community, and institution). Together they visited projects from other parts of Norway and abroad (Sweden and Denmark) and allowed time for social exchange between the members of the development team to argue and discuss the merits and pitfalls of these projects from their differing perspectives. This bonding exercise had a strong influence on the architect who continued to work hand in hand with the project team all the way through the project development which, surprisingly only took three years from inception to completion.

.

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The master plan or site strategy that contains this building was long established. It sits adjacent to the older psychiatric building on a complex housing four generations of medical buildings. The original plan had been to renovate the older building but mid-project this idea was discarded and a new building designed. An area of the old building has been renovated to house extra administration, doctor�s offices, and a cafe. An enclosed corridor with walls of glass-enclosed paper artwork connects the two. Food, catering, technical services, and most supplies, are all provided by the psychiatric department at the neighboring general hospital of which the Acute section is part.

Themes

Designing within limits is a very prevalent theme in this building. The difficulties of creating a normal environment for the therapeutic benefit of the acute psychiatric patient posed serious challenges: but this factor was also instrumental in generating novel solutions.

Normalization is the dominant philosophy in a space that refuses to articulate problems following the lead of the care model. There is careful design logic behind all of the features in this building. An example: the windows look like normal wooden sash windows found in traditional houses, but the cosmetic wooden frame encases an unbreakable steel interior structure. Though the windows do not open, a narrow (to prevent escape) ventilation grid next to them does, providing a sense of control.

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This design methodology has been used throughout the building in the design of showers (all in one stainless steel with no protrusions for attaching rope), mirrors (fully glued to the wall), adjustable thermostats which again provide a sense of control (although they are actually controlled centrally when the signal comes in from the patient), security devices that are not visible, etc. Technological dependence has made it possible to develop many of these features, mobile alarm systems that allows for less staff presence for instance, but in many cases they have found they do not need to use these aids due to a general behavioral change.

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The most mentioned design successes are the two open atriums, one on the theme of rock and mountain, and the other on water and motion. These are central to the building, one backing onto the offices (where workers use there shades to display an �open� or �do not disturb� message), and are open to the sky and escape if one is determined, communicating respect

The actual ability to escape offers choice. This is considered therapeutic in itself. If patients do manage to get away they will eventually be found and the action of escaping will have worked out the aggressive behaviour that created the problem/need. As much as is possible, every aspect of the building generates an air of trust, expressed by the selection of high quality contemporary Norwegian furniture, light fittings, and art. When the building was commissioned it was said that these things would only last for days. In fact virtually nothing has been broken.

Though the patients do not use the kitchen (many patients have hepatitis C), food/food systems and community and routine are present in the communal eating that takes place daily in the alcoves that overlook the atriums.

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The most popular seating is located in a different space, a corner crossroad area that lies between the staff room and the atrium from which most of the activity in the unit can be viewed.

The materials and memory theme was demonstrated very dramatically in this building by the use of wood. The memory it triggered was that of camp and time spent in a wilderness retreat. Many respondents mentioned the characteristics of this material, the warmth and calm it transmitted along with the general ability of the building to absorb problems. The wooden clad gym and seclusion units are probably the best examples of this. Apparently violence has been reduced from one incident a day in the old cement building to hardly any in 4 years.

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The architect has a personal interest in sustainable (environmental) design and his leanings are expressed in the simple construction techniques, use of wood and natural materials. The slightly pitched roof offers a nod to the older buildings on the site and breaks up the block-like monotony of the newer ones. The use of wood and a meticulous approach to planning from the onset meant they were able to achieve very low building costs (18,000 NOK per square meter) within a very short inception to completion time of three years.

Though the building provided many views of the surrounding landscape and profuse natural light, a sense of shelter and safety (also expressed by the materials) has been communicated in the way the wooden ceilings slant down toward the windows creating the sense of being protected by a cave-like environment. Only one person expressed slight unease around the expansive use of dark wood, a doctor, who was, in fact, not Norwegian!

A significant and perhaps somewhat subconscious theme that ran through the length of this project was sustainability. The inclusive design process represents a clear demonstration of truly holistic planning that attends to the four pillars of sustainability, social, environmental, economic, and institutional, in a comprehensive manner.

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It is difficult to know which came first, but it appears that the building is not only a creative solution but also continues to inspire creative development within the organization. New therapeutic methodology is experimented with daily (they were talking about joint report writing with patients while we were there). The compact design provides short distances between office and clinical sections creating the sense of a �community of workers�. Because of this it is possible for administration to develop an intimate understanding of patient needs and influence the patient�s schedule accordingly.

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Simple provision of several adaptable spaces for meetings with patients has meant that there is less need for designated meeting rooms. These rooms have also absorbed the recent patient overflow due to a breakdown in the care chain, providing spare bedrooms in a crush. Since most of the administration staff is multifunctional (have had training in nursing, therapy, or other diverse skills) it has been possible to multitask, creating lean and efficient way of working. Staffing levels are 5-6 per 15 patients (1/2 official Norwegian standards in acute psychiatric units). They are able to stand in and work with the patients when required. These organizational changes have also led to flexible timetabling. It is possible to adapt to suit personal need, prioritize family, and reduce costs in both human and financial terms (respecting the 1/5/200 ratio).

Environmental Tensegrity

The Psychiatric Acute Care Section at Sykehuset Telemark exhibits a pleasing example of care model, place, and built response in an almost equilateral balance, nurtured by a conscientious inclusive planning and design process, and strong therapeutic model and operational culture fit. The building offers environmental choice and organizational flexibility to a notoriously difficult care group, and also to staff. The result is heightened therapeutic performance, the average stay last year was 18 days with 700 patients attending, 60% of these voluntarily. In addition a 30% drop in medication was achieved. This information needs to be backed up with statistical evidence, documented, and promoted.

Architecturally this building is probably the least dramatic of the five case studies in this project proving that successful buildings do not need to be expensive buildings. This simple, uncomplicated, yet thoughtful design illustrates the time in relation to adaptive ability and understanding diagram showing that a higher level of understanding of care model and place at onset produce more sustainability over time.

The aspect or theme least evident here is the one you would expect: community/ routine. Yet this is the area most mentioned in plans for future development. The surrounding landscape (hillside, river, trees), is another area to escape to for the less ill patient for walks and sport, is under ongoing development. The ultimate aim is to integrate this space into the community as a public park and amenity with a football field for the local children alongside more facilities to house activities for the patients (workshop, café, etc.) to offer constructive diversion. The intention is to bring the facility closer to the community, further normalizing the hospital�s care model.

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Quotes

�Difficult (to describe his experience in the building), so much of my heart and soul is here ... proud ... human ... signals dignity and respect.�

�A miracle for both patients and staff ... could be better but that would be difficult.�

�I find the wooden seclusion rooms are a bit dark, but I am not Norwegian!�

�Freedom and choice�

�Sometimes like a community ... special relationships here (with staff)�

�on one level ... communicates with outside, nature, activity, I can see the world is still there�

�I hate the building, it�s too nice. I get aggressive. In the old building I didn�t care about the environment, and felt free to destroy it. This building is too nice ... I can�t take my aggression out on the surroundings!�

�Not different from other buildings ... Feels like Norway (she is not Norwegian), expensive, nice people, clean, bright, working, normal�

�Cozy, but not at all cozy, kind of cozy�

�Soft Atmosphere ... building absorbs noise and bad feelings, old building amplified bad experiences.�

�Many visitors ... People like to come. They like what they see. This is changing attitudes.�

�Design of intimate relationship between spaces encourages closeness to patients and co-workers ... Feeling of both giving and getting back�

�Good intention in the plan�

�Coming home�

�(I like the) wood (paneling) in rooms ... more life to it, camp like ... communicates on a non-verbal level ...

�Inventive atmosphere ... building inspires experimentation with new ways of working ... invites me to do what I need to do, develop human awareness, openness ... brings out a therapeutic feeling.�

Country The Netherlands

Project Ter Reede, Vlissingen

Address Verpleeghuis Ter Reede Koudekerkseweg 81 4382 EJ Vlissingen T. ++31(0)118 448448 F. ++31(0)118 411721

Owner/Operator Stichting werkt voor ouderen, Vlissingen

Type Of Healthcare Building

Nursing Home

Size/Capacity 5.524 m²

15 groups (6 tenants per group)

Catchment population 90 tenants + staff

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Capital Cost �8.5 million (excluding tax)

Date Completed January 2003

Procurement Method This project was financed by a regular contribution from Dutch government according to building criteria of the College Bouw.

Contact Name In Facility

Directeur Jan de Graaf. Tel: ++ 31 (0)118 44 84 48

Details of Design Team

Architect: Freek Prins and Pauline Heijmans

Project coordination: Ton Luttmer

Constructor: Bouwtechnisch Adviesbureau J. L. Croes bv

Building physics: EGM advisors, Dordrecht

Garden and landscape architect: Braber groenvoorziening

Mechanical engineering advisor: Bravenboer en Scheers, Middelburg

Electro technical advisor: Bravenboer en Scheers, Middelburg

Details of Main Contractor

Construction team Peters/Korteweg (Middelburg/Breda) with a so called �open budget�

Reason For Selecting Facility

Scale and flexible usage

Descriptive Key Words

Small-scale living; group of six tenants; house-principle; flexible usage; rational building system, installations and way of bidding (open budget)

Innovation/ Characteristics: Organizational

All-scale living (group of six) and more personal care and nursing is accomplished in a nursing home with altogether 90 beds. This project shows that small-scale living for tenants is realizable within a larger institution. With certain design principles which significantly reduce the scale, inside as well as outside, this goal was achieved. It is a mix of small-scale living with the organization structure that promotes efficient work.

Innovation/ Characteristics: Design

Each house has its own entrance from the public road and their own kitchen to prepare food; tenants have their own bedrooms, and share a living room with others: a living room has either a sheltered courtyard or a balcony.

All houses are connected to each other by a main corridor which is important for work efficiency.

Various design aspects increase a choice and/or a freedom of movement for tenants. For example, placement of living rooms was an important aspect. They are positioned in such a way that between two living rooms one sheltered courtyard is realized wherein tenants can come on their own without guidance. From living room there is a view on a courtyard as well as on street-life. Due to flexibility in design it is possible to connect two living rooms (two houses) which can especially be beneficial for a night shift where one staff member can monitor two houses at the same time (12 tenants).

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Innovation/ Characteristics: Impact

Even though a building has a capacity of 90 beds, the scale of this building corresponds to the surrounding environment. Patients experience the space as peaceful. It is one of the first projects in the Netherlands where a group of six persons could have been accomplished. In Zeeland this can still be done for group of six, while in the rest of the Netherlands groups of eight and maximum ten persons is cost-effective.

It is worth mentioning that this project is not an isolated nursing home. It is a part of Care Campus where the apartments in various price ranges are/will be realized. The tenants of the apartments can, if necessary, make use of the medical care on the location with the nursing home Ten Reede as a most intensive form of care.

Value For Money More square meters have been built than proposed by regulations due to rationality of the building system, installations and the way of bidding (open budget).

Statement of what the building is about official (mission statements) definition of care group and therapeutic model

The building consists of one two-story building containing fifteen house units for 90 residents with dementia. It provides skilled nursing care and rehabilitation service to people with illnesses, injuries or functional disabilities. The therapeutic model is all about normalization. Every licensed practical nurse has full responsibility for house-keeping, cooking, personal care, etc. They also support residents to assist them with those tasks.

Definition of case load, acute, long-stay, mixed, (general)

Every resident is established on a long-term basis. The house units don�t select residents based on their condition. Every house unit consists of a heterogeneous group of residents.

Average length of stay

The average length of stay for residents is 1.9 years. However, the nursing home exists since January 2003, and the measurement therefore can�t be held valid. The average length of stay in a nursing home in The Netherlands is 2.5 years.

Single room ratios The fifteen house units containing eighty-two single rooms and eight double rooms.

Lists of staff (+ ratios)

! 36 hours department head (nurse)

! 108 hours unit coaches (nurses)

! 1743 hours licensed practical nurses

! 175 hours nurses

! 300 hours nursing assistant

! 36 hours doctor geriatric

! 20 hours physiotherapist

! 12 hours ergo-therapist

! 18 hours social worker

! 12 hours religious worker

! 54 hours occupational therapist

! speech therapist and dietician available on demand

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Volunteer Culture 130 volunteers assisting the staff in the house units and the occupational therapists with collective activities. Some people volunteer for visiting residents and doing individual activities like taking a walk or reading the newspaper.

Management structure

In hierarchical order: 1 director, 1 Management Team (includes 4 location managers, 1 financial manager and 1 head of personnel department), 1 department head nursing home, 3 unit coaches, nurses, licensed practical nurse and nurse assistant. The geriatrician is the head of the paramedical department and gives reports to the director.

Healthcare community

Staff of the nursing home exchange information with residential care staff and with staff of the home care.

Users interviewed 8 Nurses and Carers

1 Doctor

1 Visitor

1 Café manager

1 Project Manager

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Context

Ter Reede is a psycho-geriatric nursing home for ninety individuals. It is part of an overall site strategy, a campus for elderly people (over sixty-five years). When entirely realized in 2006 this campus will also provide independent living apartments of 2 and 3 bedrooms for rent and for sale, assisted living apartments, and, in the heart of the campus, a central service area providing amenities that will also be available to the public, including shops, a chapel, a hairdressers, sports facilities, and a restaurant.

The philosophy behind this campus was developed by Werkt voor Ouderen, the owners of the site and based on research they have conducted on intentional communities for the elderly around the world. The nursing home is one end of a continuum of care, facilities for the over sixty fives that can be accessed progressively, without leaving the site, as health deteriorates with age. The overall vision is to provide client-specific care, catering to the individual.

Ter Reede�s small �home� cluster concept was considered an experiment when built originally but since its inception the government has reassessed its policy for nursing homes moving away from the economically driven rationale behind larger wards toward a more long term view that appreciates the better quality and added value provided by units of no more than ten occupants. In time, the older nursing home, still functioning on the site will be renovated to provide a further seventy rooms along the same style.

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The nursing home consists of one two-story building containing fifteen house units, connected by a central corridor. Each unit is designed to function as an independent �home� for six to seven residents,� providing a living room, kitchen, mostly single bed rooms, and shared bathrooms situated in between every two bedrooms (averaging one bathroom per four patients). There is another �house� unit that is currently being used as offices for doctors and therapists. When the master plan is complete these offices will be shifted into the central service centre and the unit will adapt back into another housing unit.

The exact location for the nursing home on the site was determined by the surrounding context. The small scale, two-story, brick construction, was designed to integrate into and reflect the atmosphere of the brick housing opposite on the adjacent lane. Services for the nursing home are almost 90% self provided. The �Zorgkantoor� (provincial and local governing board) of the Ministry of Public Health, oversee the quality standards of the building.

The project brief was primarily driven by the company director who had conducted a thorough feasibility study and developed a clear diagram of needs. It is a legal requirement that a patient�s representative committee is part of the planning process. In general involvement from other groups, including the community, was conducted through presentations and focus groups.

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Themes

Normalization is the dominant therapeutic element of this environment and the design assists the dramatic change expected by this progressive care model. In the past the use of larger wards supported the development of individual tasks and specialization. In these smaller units the nurses are asked to multitask and assume the role of �mother� to the six residents. They have full responsibility for every aspect of the resident�s needs, house-keeping, cooking, to personal care, relationship with family, etc.

Because of this consistent and intense day to day contact, nurses develop an intimate knowledge of the patient�s background. Their job is to bring the patients� �living world� to the fore through the course of every day events, and to gain a deep understanding of their needs, and not just the clinical, but also their physical and emotional preferences. This new way of working creates a situation within which the staff members are always learning, and they encouraged to do so, both inside the unit and outside of building at training courses paid for by the organization.

Other designs in normalization include a door bell which must be rung before entry to every house (creating a sense of ownership and respect) and a mail box outside. Mobile furniture is used to bring the less mobile into the centre of activity (living room, kitchen) and the houses are positioned opposite each other in case a carer needs neighborly assistance. Enclosed atriums with exposure to the sky and fenced in street side terraces are also shared between units.

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Personalizing of all spaces is encouraged by inviting residents to bring photographs, paintings, and small pieces of their own furniture. The carers are asked not to wear uniforms, and private offices for report writing are not available in the units. This is intentional because office work would take time away from clients. The café menu is also limited to discourage staff from eating outside of �home�.

When given a choice the patients seem to prefer walking in the corridor where they can view the other houses, community activity, and meet other residents. The units at the end of the corridors have a different shape and orientation. The living rooms are on a corner and view local street life, the older hospital building, and a bus stop. These units are preferred and the living rooms are used more for relaxing as well as eating. Upstairs there is less ability to get outside, no access to the atriums or terraces, only balconies. It is noticed that more socializing takes place in these units. There are no handrails to encourage independent mobility (fewer lifting devices are necessary as a result) but (similar to views at St. Joseph�s) the residents find the edgy, upper floor glass-walled corridor unsettling both during the day (cliff-like), and at night (large areas of unfathomable darkness outside).

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One of the big successes of this building is its focus on the most basic of physical and social needs, food and food systems. There is an open kitchen, where kitchen implements (including knives) and equipment (the stove is lockable) are accessible to the residents (under the supervision of the carer). Initially this was assumed dangerous and was resented by anxious relatives, but there have been no problems in two years.

The benefits have been dramatic. Rather than creating nutritional problems, as predicted, patients find the smell of food cooking exciting, anticipate their meals, and have gained weight.

The activity created by the daily routine of selecting the menu, peeling the potatoes, setting the table, clearing the dishes, doing the shopping, has given their lives purpose. The Housekeeping budget can be spent inside the building or outside in town and the carer tries to bring one resident with her each day. This outing is a high point and the cramped temporary shop in the building (due to shift to the service area when complete) is a busy hive of social exchange.

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Making the environmental experience normal for this care group has led to technological dependence. At night the staff levels are stripped down to one nurse and one carer for the ninety occupants. To maintain vigilance over the length of the building it is essential that all nurses have in house mobile phones. Electronic sensors detect movement in the rooms and corridors. All medication is administered by computer, and automatically sealed into daily dosage amounts to avoid mismanagement. Individual environmental controls are provided in each unit to allow for individual preferences. Despite this the building is often thought to be too hot due to the considerable amount of glass. This is a particular problem in the glass walled corridor upstairs and in the units that front onto the main road where windows cannot be opened (pollution legislation).

An example of �no meaning yes!� expressed in this building was related to services to patients versus patients to service. The doctors and ergo therapist have no clinic and must do their work on a �house call� basis in the units. This is awkward for them, but, they argue, better for the patient because they can both work with the patients while instructing the carers about the regime at the same time. Viewing the patient in situ also provides useful hints about influential social or environmental factors that may contribute to the problem. They also like the social aspect of these visits, find them enriching, adding a new dimension to their work experience and job satisfaction.

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Community/routine, are highly prioritized. There are two �milieu� specialists who create a daily schedule of activities to stimulate the residents. A children�s playgroup comes twice week, and there is an abundance of voluntary activity (one hundred and forty volunteers for this building alone), so much so that the organization has to hire a fulltime member of staff to schedule the extra activities, which include crafts, gardening, walking dogs, cycling, trips to the boulevard. In return the organization provides a training party for all the volunteers once a year.

Culture, materials and memory, on the other hand, posed a problem in the interior of the building where Italian faux wood (plastic?) paneling was extensively used. The milieu therapists found the building atmosphere and materials cold and resistant to their attempts to conduct �reminiscence� therapy. The ergo therapist spoke of a similar mismatch with regard to the contemporary furniture (Ikea), which suited the style of the building, but not to the comfort and postural requirements of this �cup and saucer� generation.

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Environmental Tensegrity

In this example the carefully considered care model locked into a thorough site strategy provides a sound foundation for the built response. The top down application of therapeutic model and operational culture fit is also very tight, so tight that it was often difficult to separate the organizational aspects from the built response. Though no scientific study has been done to document the results of this strategy, they intend to do one soon. Signs indicate that their normalization methodology is highly effective.

Almost universally the level of job satisfaction was extremely high in this building. A lean work force and multitasking made it possible to provide each unit with a consistent team of carers. Though a demanding way of working, the system nurtures intimate relationships. This was very rewarding for both staff and patients, but also impressed and influenced visitors who quickly became engaged with the care process by sharing responsibility, not only for their own relative, but for the other five members of the family. A telling demonstration of the benefits of therapeutic model and operational culture fit.

As with St Josephs, many of the stresses in the building could be put down to compensatory measures in lieu of the completed master plan. The therapeutic gardens and animals maintained in the previous premises, loved and missed for their sensual stimulation are currently in temporary homes. It hoped they will be restored here in the park area that is promised. A chapel, also wished for, is planned for inclusion in the central services pod

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The generational preferences of the care group seemed less well coordinated with individual qualities of the environment, as mentioned previously regarding the use of materials. This was also true of the building design in some cases, particularly the long corridors that looked the same in both directions and were felt to be confusing (for the staff let alone patients suffering from dementia) and largely featureless, offering little incentive or goals to aim for when walking (an attempt has been made to counteract this with large images on each mailbox giving each unity an identity but this is has not helped).

Nevertheless, despite some alienation at the onset, the occupants feel the building is �warming up�. This character development demonstrates how a strong organizational culture within the building will help people adapt it to purpose over time

.

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Quotes

�The building stands well in the area. This road is called a �lane� and has associations with the country. In the summer the trees create shadows along the path, multicolored, mixed light and shade, which are reflected in the patterns of the building, colors in the brickwork, the curtains, etc.�

�Help is nearby ... people meet often, at the shop, music events, activities�

�Furniture could be older in style, more in tune with residents�

�Come back when the Master Plan is finished!�

�Visitors can help (peel the potatoes)!�

�The sleepy lady who came two months ago in a bedridden underweight state is now walking and talking and has gained three kilos!�

�My grandfather came here one month ago from a nursing home with large wards. He had lost the ability to recognize relatives. Since moving here he has undergone a big change. He is peeling potatoes, playing games, reading the paper, and recognizes his family again!

�Building all looks the same, even after a year its still confusing!�

�Busy! Time goes fast!�

�Doesn�t look like a nursing home, inside feels like outside.�

�More time for patients and myself ... Feels like home, a family ... allows for adaptation ... visitors become more involved in the care.�

�These residents are of the �tablecloth, cup and saucer� generation (60�102 years old), this environment is cool and alien to them, few memories, disorienting ... must be in Vlissingen, but where? Relationship with the �outside� needs to be negotiated.�

�More difficult way to work, but better for the patients ... working �in house,� training staff and assisting residents at the same time is efficient.�

�Not many soft materials.�

�There is a bit of an �Ivory Tower� feel with the doctors and nurses offices so distant from the units. I would be happier if I was closer, socializing and drinking coffee in the unit. They will be moving the offices to the new building, then distances will be longer!�

�Would you like a cup of coffee?�

Country Northern Ireland

Project

Mater Hospital

Phase One Development

The McAuley Building

Address

45-51 Crumlin Road

Belfast

Co Antrim

BT14 6AB Northern Ireland

Owner/Operator Mater Hospital Trust

Type Of Healthcare Building

Acute Hospital

Size/Capacity

Catchment population

500,000

Capital Cost £17 million

Date Completed December 2001

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Procurement Method Traditional

Contact Name In Facility

Bernie McQuillan, Director of Development

Details of Design Team

Watkins Grey International/Todd Architects

Details of Main Contractor

Karl Construction

Reason For Selecting Facility

Visual impact, design quality, concept and functional layout

Descriptive Key Words

Innovation, integration, design quality

Innovation/ Characteristics: Organisational

Integration/interface between client/user and design team

Innovation/ Characteristics: Design

Integration of new build with old existing building, flair and vision within design, incorporation of artwork

Innovation/ Characteristics: Impact

Excellent working environment for staff, healing and therapeutic effect on patients

Value For Money Post project evaluation is ongoing.

Statement of what the building is about official (mission statements) definition of care group and therapeutic model

� ... to provide a range of high quality Acute Hospital and Mental Health Services in a caring and professional manner, to improve the health and well being of the community ... [and to] ... deliver services in a safe environment, where everyone is treated as an individual.�

Definition of case load, acute, long-stay, mixed, (general)

Acute and psychiatric services

Average length of stay

Single room ratios Mix of 6 bed bays and single rooms

Lists of staff (+ ratios)

Volunteer Culture Very highly developed; many staff participate in community ventures; patients and public encouraged to view the hospital as a resource beyond immediate health care needs.

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Management structure

Trust Board sets strategic vision. Governance Committee reports to the Trust Board; consists of a Corporate Governance Committee and a Clinical and Social Care Governance Committee.

Healthcare community

Strong links with GP practices and partnerships with other Trusts and other organisations (e.g. Health and Wellbeing Centres). High value placed on input from nursing staff.

Users interviewed 5 Nurses

2 Patients

2 Visitors

1 Facilities Manager

1 CEO

1 Therapist

3 Administration

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Context

The original vision for the McAuley building at the Mater was to provide proper up-to-date wards to replace the Nightingale wards still functioning in the Victorian (Dorian) building originally built by the Sisters of Mercy in the 1900s.

The driving force behind the brief was the unprecedented coming together of the Catholic and Protestant neighbourhoods in this notoriously volatile community when the acute status of their hospital was under threat.

In collaboration with this local body, the brief was developed by a female team: the Chief Executive of the hospital, The Director of Nursing, and a female project manager. Many feel this feminine influence present in the McAuley stands in stark contrast with the previous extension on the site, the Dempsey, a modernist glass cube, conceived by a male doctor only fifteen years ago, demonstrating how rapidly design thinking can change.

The site contains a complex of older buildings: two original Victorian buildings joined by the glass cube, where Accident and Emergency is housed, with another Victorian building containing the psychiatric unit adjacent. The McAuley has now absorbed all the elective services and day procedures previously housed in the older Victorian buildings.

What originally began as a new wing of the existing complex is now being re-conceptualised into a comprehensive site strategy for redevelopment driven by the Mater�s new Chief Executive. The McAuley building provides a standard and marker for the future in this ambitious master plan. Phase 1 is now complete, and some renovations of the older Victorian buildings and the Dempsey building have taken place. A further sixty million pound phase two is currently under negotiation.

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There was no choice regarding a location for this building, in fact the Sisters of Mercy convent had to be torn down to create the space. This area has been devastated by a long difficult history. It is situated in a political hotbed within a divided community, sandwiched between several historically significant buildings (a Jail, a courthouse, a school) bordering both Catholic and Protestant neighbourhoods. Depressing by day and dangerous at night, the community is saturated with memories of �the troubles� and has learned diplomacy the hard way.

The economic background to this building is significant. The Young Philanthropists, a local charitable organization set up the �YP Pools,� a lottery, to fund the Sisters of Mercy in their cross community endeavours. Both sides of the community contributed over the years. The funds collected were invested wisely. When the community united for the first time in order to save the hospital this organization was determined to make it happen and paid the entire cost. This amounted to approximately twenty million pounds sterling.

The foundation still exists and will continue to support the hospital. It is anticipated that the NHS will match their investment (as previously agreed many years ago) plus match any further investment by the Young Philanthropists in the second phase.

The high quality results realized by this collaborative effort raised local self esteem and instilled new confidence. This has inspired the community to continue to work actively alongside the Mater Trust in the redevelopment of the �prison� into a multifaceted development of various community amenities.

Another aspect of the site strategy is the shared exchange of services between the new and older buildings on site. The buildings are approximately ninety percent self-sufficient as a result. This is cost effective but the patchy development of the complex over the years has culminated in a confusing network of passages and connecting glass corridors that can be very disorienting.

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The side street entrance to the McAuley building, hidden from the main road, and the inadequate design of new reception desk (which obscures the receptionist when seated and makes her stretch to make eye contact with visitors when standing) has not helped this dilemma. In contrast seating patterns in the renovated accident and emergency area were very thoughtfully considered to avoid confrontations between community factions. No one sits facing anyone else to avoid (�who are you looking at?�) provocation.

Themes

Because of the high level of user involvement in the briefing process little adaptation from the original plan was necessary. The local architectural team was very responsive, and any changes that did become necessary were handled early. The main objective was to make the building accessible to the varied clinical and social needs of the community while maintaining a strong connection with local history. The culture of the Sisters of Mercy and their cross community caring ethos has been very effectively communicated though the integration of old with new.

The decorative arched doorway with stained glass panels, which was a feature of the now dismantled convent, is a main feature in the main atrium space - which is actively used for a wide variety of community functions. The convent courtyard dimensions were maintained in the development of the central therapeutic courtyard garden adjacent. The Chapel in the Dorian building has been restored and is used for interdenominational services.

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The theme of community and routine is the substance of the thinking throughout. Their redesign of the Nightingale ward (a recent memory) is perhaps the best example of this. The twelve-bed ward has been divided into two six-bed rooms with a glass nurses sub station fronting the corridor end of both. This arrangement is very cost effective, assists the ability to observe patients (still intrinsic to the care model here), and is preferred to single rooms by the staff as well as the patients who predominantly like the presence of neighbours and family. Several single rooms are also available and useful for quiet during recovery, or for younger patients, but they are always situated opposite the nursing station for easy access.

Hospital acquired infection is dealt with through the application of a diligent hygiene strategy overseen by a dedicated Quality and Infection Control Nurse. She leads quarterly audits of the buildings with a Patient Environment Action Team (PEAT) made up of internal members of the hospital staff (including the CEO), patients, and community groups. Areas that the audit covers include: Environment (hygiene), food, signage, and car parking. They recently won an award for hospital catering and have been recognized by the government for their hygiene standards.

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Great attention has been paid to materials and memory in the design to communicate respect and maintain the caring ethos and history of the Sisters of Mercy. Pieces of the old building, stonework, brick, and stained glass remain, sensitively integrated in the contemporary design strategy. Decorative themes from original features, the meaning of �mater� (mother) as a concept, and photography and portraits of local people, have been used as source material for the integrated art schemes commissioned for the new building, providing great interest and reassurance to the public.

Normalization was present in the redesign of domestic components to meet stringent hygiene controls (e.g. delicate window blinds enclosed between two layers of glass for dust free shading). Natural light and ventilation are maximized and the artificial lighting has day and night levels that are used to assist quiet times between visiting hours.

The courtyard garden, atrium, and outdoor furniture, surrounding the building, have been carefully design to eliminate vandalism (e.g. pebbled areas imbedded into a surface to avoid stone throwing). The public toilets of marble and stainless steel resemble those found in an upmarket hotel. Cash points and public phones (surprisingly lacking in all the other buildings viewed) are provided in the atrium space. As seen at Sykehuset Telemark, the whole building communicates quality and respect to a deprived community and this trust has been reciprocated.

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Once again the delivery of services to the patients has been very successful. A small physiotherapy unit has been put into the stroke rehabilitation ward next to an outdoor terrace with raised gardens for therapeutic use. Space provision is ample enough to facilitate most of the therapy being conducted at the bedside while instruction is also given to the carers.

The physiotherapy staff members were involved in the choice of suitably supportive furniture for the patient rooms, but were disappointed that they weren�t consulted about the design of the shower rooms in the new wards which are too confined to use with aids affecting levels of dignity and independence.

Part of achieving normalization is displayed by the way and food systems are given priority (as mentioned previously). Meals are served in the ward by a chief using a heated buffet cart. There are always two choices and the patients are asked to decide on size of portion. The café just inside the main entrance is open to everyone and is constantly buzzing, the busiest of any café in this study. This may be due to the way it is positioned, or to its size, which is not large, making it easy to fill and always an enticing hive of social activity. Everyone (the chief executive, nurses, cleaning staff, and visitors) can be found there.

Social sustainability is highly active in the building making it impossible to estimate how many people visit the building during a day. The complex provides a venue for many adult-education programs and self-help classes, attended by the public, as well as voluntary and community groups who assist the hospital and use the building for meetings and events.

These include: the clergy, the literacy training group, the learning disability group, the local community centre, youth groups, the mental health group, patient support groups, and the �Heart of the Mater� (a support group from the Mater itself).

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As mentioned earlier the integrated art program is a community based group that uses the hospital as a base. It has embedded its presence in every corner of the hospital. Their collaborative art projects, directed by resident artists using patients and members of the community, and rooted in local history, were often mentioned by staff, patients, and visitors in the interviews. In particular, the non-challenging nature of these pieces was felt to be contributory to their therapeutic resonance.

The Sisters of Mercy stood by their open policy and established the Mater as the best teaching hospital in the country. Their ethos has been protected over time and carefully transferred into the design and the use of this new facility. It will be interesting to see if this continues over time as the hospital develops into phase two.

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Environmental Tensegrity

The integration of place and care model that forms the foundation for this building was laid by the Sisters of Mercy and the years of commitment to cross denominational community work. Taking full advantage of this, the development team have managed to sensitively guide local needs into the briefing, development, and day-to-day running of the McAuley building. This process displays an acute awareness of the mechanics of diplomacy. Perhaps this is intrinsic to survival in this difficult location. As a result the McCauley building has become far more than the sum of its parts.

Its seamless integration into the existing buildings on site is so effective that its development has raised the standard of the whole complex and extends beyond building morale in the surrounding community where most of its employees live. This win-win situation easily overshadowed the persistent difficulties of way finding as staff members take pleasure in personally directing people around the building while sharing anecdotal titbits of information and history triggered by the environment. It is clearly evident that the community owns every brick of this building.

The overwhelming preference for wards (observation, activity, gossip) over single rooms, though both are available, offers a fascinating contrast to the Nordic countries where choice leaned in favour of privacy during illness. Additionally, the development of a prize winning hygiene strategy as a knock-on effect was an exciting example of unexpected value.

One thing that may be missing could also stem from the original care model (nuns thinking of others before themselves). The emphasis on fulfilling public needs has left staff less well catered for. Most of the administration offices are still housed in semi condemned accommodation across the road. This, of course, is about to change as the master plan spontaneously develops.

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Quotes

�This is a deprived area that has been through the worst, it deserves the best ... predictions from the outside were that this quality would be destroyed ... They have been proved wrong.�

�This building has showed what is possible, quantum change ... kick starting new perspectives, a cutting edge view of healthcare, and a new way to engage with the health service ... a sense of pride is reflected in people�s faces.�

�Because of the easy accessibility of the building, accident and emergency is sometimes overused for casual problems rather than a GP.�

�Most babies in Belfast have been born here (in the older building). This project had strong support from both sides of the divide. The whole community (teenagers as well as pensioners) fought to maintain the hospital�s acute status. The two sides of the community work together in this building, their problems are the same.�

�The atrium originally seemed like a waste of space but it is used in many special ways for public functions.�

�Convent door retains the physical memory of the Sisters of Mercy.�

�Crumlin Road is a dark, grim, area scarred by violence and graffiti ... The design was influenced by staff, management, and the community. They were able to hold their ground and develop a very personal community driven care model, representative of the people who use the building.�

�Every stone was bought by the community ... recruitment and staff retention has been improved by between five and twenty five percent.�

�I enjoy taking �lost� people to their destination and giving them a potted history as I direct them.�

�The scenic paintings in this ward where chosen by the staff not to be too confusing or abstract. They have a good influence.�

�Art provides focusing points and are valuable goals for patient remobilising.�

�There is no environmental policy here ... Not good enough!�

�Tight relationship between the building complex (old and new sections) and the community ... Design respects the history of the site ... it�s like putting on an old pair of slippers.�

�A calm oasis ... I like the art, particularly �100 Words for Mother� (a commissioned series of collages), and the textile pieces ... colourful ... My father helped build the hospital ... Nobody wants to be here. This has been a shock (visiting mother after stroke. No family member has been hospitalised before), but our experience has been pleasant despite this.�

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Outcome

Response from participating organizations

Feel Good Factor

We consistently met with an atmosphere of good will throughout the process of this study. It is an established opinion that most organizations, and, in particular, the architects who design buildings, are not interested in post occupancy evaluation. In our study this simply was not the case. Every level of user cooperated in the interviews and expressed pleasure in being asked how they �felt� in the building.

Cross Study Networking

All the participating organizations have expressed interest in learning from each other once the report has been produced. In every instance there are aspects of one project (briefing technique, operational methodology, component design, hygiene strategy, etc.) that would benefit another if not several of the other participating organizations. It has been suggested that networking between projects could be prompted into action by a hosted event devoted to a presentation of the project and a facilitated exchange between representatives of each of the case study organizations.

On Site Project Feedback

In all cases the participating organizations were interested in feedback. It was not anticipated that this would be available until the completion of the study when each of the organizations would obtain a copy of the report, but in some instances, immediate feedback was sought from the researchers on the last day. Though this was done informally, with little preparation, these fresh observations based on objective �outsider� impressions confirmed things they knew well but had little opportunity to share. This offered them insight as well as a welcome sense of accomplishment.

Collaboration with MARU

A knock-on effect of the early brainstorming session on methodology with experts in post occupancy evaluation was the assistance provided by MARU, the Medical Architecture Research Unit at South Bank University, London. MARU have a long track record in post occupancy in healthcare post occupancy assessment. They are also in the process of developing a community needs assessment tool that is tackling brief development from a community perspective. Their assistance in the preparatory work and analysis was invaluable.

Client Focus

Time, adaptability, added value

TIME

Adaptive ability

Understanding

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Good buildings are not necessarily expensive buildings; they are dynamic buildings that understand their purpose and users, connect with �outside,� and continue to learn.

Flexibility is probably the most mentioned criteria in healthcare design today, yet the majority of unanticipated and costly changes that take place, during and post construction are due to badly diagnosed client requirements.

The accelerated dependence on technology (internet based communication technologies and software, digital radiology, broadband video, etc.) documented in this report indicates that the choice of geographic location for future healthcare facilities may not be tied to a specific catchment, but developed in relation to local resources. These could be environmental, economic, social, or institutional (e.g., entrepreneurial availability in the locality, an exceptionally therapeutic climate/landscape, a high a level of technical, academic, or medical knowledge base in a specific population/community, etc.).

As value for money becomes increasingly important to healthcare authorities due to many factors, including changes in population demographics and the increasing levels of elderly population, taking advantage of local resources, facilities, characteristics, and the healing potential of familiar environments, home and community, will become an essential ingredient in the drive to make the provision of healthcare systems and property more cost effective.

In this study the buildings speak for themselves. With as many different examples as there are buildings, they explain how design in relation to community, if managed well, promises a higher level of adaptability over time, can accelerate the procurement of unique �site specific� therapeutic models, and as a knock on benefit, inspire creative funding initiatives. These are all essential characteristics of sustainability.

What Tools are necessary to get local community involved?

• Strong leadership and commitment • A focused vision and clearly communicated therapeutic model • A multidisciplinary development team inclusive of all user levels • Feasibility studies with research trips to visit other working models with full

participation of the complete development team (important to allow time for social exchange immediately following).

• A Participatory Community needs assessment linked to a role in project development and management

• Ongoing participatory re-evaluation and modification, before, during, and after construction

What are the Benefits? Added Value

• Local ownership of the project, shared responsibility • Exchanged services and other symbiotic relationships • Social and cultural stimulation and exchange • Volunteer culture • Increased therapeutic performance • Reduction in energy use

What are the Risks?

Additional time and expense will be invested in the early stages of the project, but this study argues that this investment will be recouped as the project develops.

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Are there Shared Benefits/Risks?

This new way of working will place new limits on the design process, but, as discussed previously, these limits will provide important guidance and promote the development of creative solutions. The formula for success will differ from one project to the next. How carefully the expressed needs are translated will be crucial, reinforcing the advantages of local knowledge.

How can this report be used productively?

• As a web based document to allow full accessibility • A presentation to a representative body of the participants for feedback and exchange • Phase two, building on the work done in Phase one and developing it into a cyclical

design system

Suggested Growth Areas

New service models that link healthcare to the community though:

• Food and food systems • Energy efficiency • Services to the patient • Normalization

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Final Review

Revisiting the Original Incentive for the Project

As stated in the introduction the incentive for the development for this study was rooted in the findings of the European Comparative Study on the Design of Health Care Buildings, carried out by the European Health Property Network in 2002. The final recommendation of this study put forward the following recommendation:

�Finally, the study has progressed the issues about the definition of design quality further, and has sought to develop an understanding from a European perspective. It has shown the need for further linking of the theoretical ideas with assessment and evaluation systems to the development of practical projects.�

A considerable amount of the early work of the Design Impact Study was devoted to redefining the original brief to meet the need defined by the 2002 study and to fine tune the four aims of the study to feed back into the study question:

�What is the relationship between design and context and how does this impact on performance in healthcare environments?�

Since the task of meeting these four aims could not be managed by the existing toolset we developed a study specific methodology. It was hoped that additional value would be found in the development of this tool through practical application in case studies. This has been the case.

Meeting the Study Aims

The following offers a brief synopsis of how the methodology worked to achieve the four aims and answer the main study question:

Record how the original intention of the design brief ultimately influenced design impact

The Pre-Visit Questionnaire and walk-through interviews did a thorough job of documenting the history of each project, its brief, the management of the development, and how the original aims of the design had influenced their ability to reach exemplar status.

Uncovering �unexpected� value

The Multi-User Questionnaire picked up on �unexpected� value through the users. This raw analysis pointed out the advantage of the qualitative approach. The instances of �no meaning yes� were the most striking example of this. It is significant to note that interpretation of these �signals,� supported by mixed discipline user interviews, and a acute knowledge of the contextual background will provide a richer picture of what drives preference than a standard questionnaire. This is an area that needs further development.

Enabling us to analyze how interaction between a healthcare facility and the local community (environmental and cultural) works to enhance a �person � environment fit� and influence recovery.

Another �unexpected� value was found in the advantage this project had of working across cultures and across care models. This opportunity was further enhanced by the availability of local EuHPN architects, who had an intimate understanding of the community in which the project was based, to help translate the signals. In this way �person � environment fit� was very effectively brought to the fore.

Though the participating projects are too new to have documented the influence of their building on performance (such as: diminished recovery time, dependency on physical aids,

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drug therapy, violent episodes) with scientific data, impact clearly does exist. This leads to the need for a further analysis to methodically document and publish these outcomes.

Suggesting how the study data could ultimately be fed back into future design.

As developed in the previous section on Environmental Tensegrity, we discovered the following:

�Exemplar building can only be achieved when the design is developed in tight relationship with therapeutic model and place (community in its broadest sense) around a realistic knowledge of the care group, with respect for the individual and his/her clinical, cultural, and generational needs. This triangular relationship is held in tension by the operational culture that maintains the functionality of the building.�

The universality of this simple triangular model points toward the need to further develop the methodology used in this study into a linked post evaluation and pre briefing tool. This development would also satisfy the recommendations set by the EuHPN 2002 study: �linking the theoretical ideas with assessment and evaluation systems to the development of practical projects.�

The case studies documented in this report could be used as a feasibility studies in phase two: the development of a design �system� to inform and guide developers, in balancing the related needs of a specific community in relation to the established therapeutic model, and setting the project determinants.

Phase Two

The signals coming out of this report are clear, healthcare design is in transition. Therapeutic models are shifting toward normalization and care is moving toward more sustainable models built in close alliance with community. These changes demand a new way of working. If this project is to accomplish its ambitious aim, to influence future design on a pan-European level, the data and resources (contacts, case study findings, tools) collected by this study must be applied to a second phase.

With rationalization and sustainable development universally pressing subjects throughout Europe, the time for this project could not be more opportune. For example the system could be put to immediate use developing the awareness and information necessary to comply with the EU energy rating certificate scheme due to come into effect in the EU in 2006. The system would also be useful in sourcing information necessary to the development of new service models as mentioned in �growth areas� above.

The first step in this process would bring together the current strands of post occupancy evaluation, which each have their own specialization: Energy, Functionality, User perception, Design quality. Using the triangular model developed by this study as a guide, post occupancy evaluation could be incorporated into a design assessment, briefing, and reviewing, �system� uniting the social, environmental, economic, and institutional, aspects together into an integrated design strategy in this second phase of development

Additional resources, educational value, and dissemination, would be gained by doing this as a collaborative venture with European Universities. The Medical and Architectural Research Unit at South Bank University, London, and the Technical University of Eindhoven, The Netherlands would be obvious candidates.

The following are components that this study suggests should be part of a comprehensive system to support future design processes:

• Community needs assessment tool • Multidisciplinary project team development • Collaborative briefing process: development of the TRIANGLE • Participative project development and monitoring

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• Therapeutic model and operational culture matching • Integrated post occupancy evaluation: development of the Pre-Visit and Multi-User

Questionnaires • Feedback processing system

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Conclusion

The Triangle

In the early stages of this research the members of the peer group were asked to provide a list of criteria against which to measure design �impact�. Surprisingly, each member provided an intrinsically different set. One was a list of design quality indicators derived from exemplar buildings, another a list of five people groups that needed to be satisfied to achieve design excellence, yet another was a list of philosophical guidelines with which to steer a successful design process.

This phenomenon pointed back to the 2002 study where �Focus on design issues differed dramatically from country to country,� and so our task became a global one, again linking us to the 2002 study when it asked �What drives these issues in each country?� and suggested the need to arrive at a �robust EU framework.�

From this point on the intention of the study was to uncover the essential relationship at the source of design Quality as linked to socio-cultural context, rather than develop taxonomy of generic design Qualities. The fact that all five of the necessary people groups were based in the local community locked us into a study of the contextual landscape of each project.

The value of the philosophical approach was confirmed as the study progressed and we discovered that the formula for success was never the same from one building to the next, that good design was not, in fact, a product, but a dynamic process established when the design, in response to the local context, established integral connections between the essential elements of the therapeutic environment to facilitate the role of operational culture.

The findings of this study have been distilled into a simple tool, the triangle. This diagram clarifies the relationship between care model/care group and place as the intrinsic foundation for built response. This basic knowledge can easily be applied as a framework for any project around the world. The details of relationship have been retrospectively explored here using the study specific pre-visit and the multi-user questionnaires. However, it is important not to focus on these themes as a universal set of criteria. Since the relationships explained by the triangle are dynamic, the themes will most certainly adapt to meet the needs of a changing therapeutic and socio-cultural climate.

The beauty of the triangular approach is that it is open, setting the stage for the emergence of new site-specific information important to the development of future briefs.

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Acknowledgements

The Project Manager would like to express sincere appreciation to the following individuals for their generous contribution to this study:

The EuHPN Design Impact Study Team Barrie Dowdeswell, EuHPN Executive Director Jonathan Erskine � EuHPN Research Associate Professor P. Degeling � Centre for Clinical Management Development, Durham

University, England � Research Advisor

The EuHPN Design Study Architectural Peer group who lead the case studies in their own countries and participated in the peer review

Professor Bas Molenaar � EGM Architecten Bv, Head of Design for Healthcare: Technical University of Eindhoven, The Netherlands

Knut Bergsland - Senior Advisor, SINTEF Health Research, Norway Helina Kotilainen - Research Architect, SAFA Stakes, Finland Mike Spence, Chief Architect, Health Estates Agency - Northern Ireland Luub Wessels � Netherlands Board for Hospital Facilities, The Netherlands

The EuHPN other Design Reference Group who offered ongoing feedback and support Susan Francis - Architectural Advisor, NHS Confederation, England John Cole, Director, Health Estates Agency - Northern Ireland Karin Imoberdorf (formerly Baumgartner) - Architect, Itten+Brechbühl AG, Switzerland

Participating healthcare organizations, their Directors, and administration Oulu Main City Hospital, Oulu, Finland Particular thanks to Irma Toivanen, Director of Nursing, and all the staff Ter Reede, Vlissingen, The Netherlands, Particular thanks to Peter Beoie, Facilities Manager, and all the staff The Mater Hospital, McAuley building, Belfast, Northern Ireland Particular thanks to Mary Hinds, Director of Nursing, and all the staff Acute Psychiatric Section, Sykehuset Telemark, Skien, Norway Particular thanks to Egil Waldenstrøm, head of the psychiatric clinic, May Elin

Nilsen, and all the staff St. Joseph�s at Mount Desert Particular thanks to Mimi Cosgrave, Director of Nursing, and all the staff

Architects who participated in the study EGM Architecten Bv, The Netherlands Tor Arild Danielsen, Architect Asplan Viak SØr AS, Skien, Norway Benedict D. Zucchi, Architect, Building Design Partnership, London, England

The Medical and Architectural Research Unit at South Bank University who offered ongoing support and guidance during all the phases of the project

With special appreciation to: Rosemary Glanville, Director, Maru, South Bank University, London, England

Phil Astley, Senior Research Architect, Maru, South Bank University, London, England

Outside experts who contributed to the methodology development and project overview Chris Shaw, Architect, Maap architects, London England Nick Baker, The Martin Centre, Cambridge England Bill Bordass, Usable Buildings Trust, London, England Adrian Leaman, Usable Buildings Trust, London, England Valerie O�Brien, Lecturer in Social Policy and Social Work, University College Dublin,

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