David Stoneley, Director of Health Architecture for Australia at global design practice GHD Woodhead, outlines some of challenges in designing healthcare facilities, from an architect’s point of view.

Q: What are the biggest challenges when designing healthcare facilities in general?

The one biggest challenge is that it’s always changing. Facilities, service demand, the expectations of patients and staff, and the way services are delivered, are all continually changing. Technology changes rapidly too. How it was done 10 years ago is very different to how it would be delivered now.

There have been significant changes right across the board. Now, services are far more individualised and personalised, and there is a lot more emphasis on how staff and patients will use the space rather than just on meeting capacity needs. It is important to create comfortable and welcoming healthcare environments and engaging user groups in the design.

Another challenge when planning for a new healthcare facility on an existing site is that hospitals in particular are busy places, and it is important that building work does not disrupt day to day activity on the site. Aside from that, there can be site specific challenges that may affect both the design and the build or installation.

Q: How important is the issue of sustainability in healthcare design, and what are the key considerations?

It is very important, and increasingly so. There are two aspects to sustainability. One is the provision of a sustainable service from a workforce perspective, and being able to deliver services cost effectively to the various communities. A lot of careful planning is needed to make sure service delivery is sustainable and optimised, and this includes considering other alternatives as well – the solution is not always to build something new.

The other is the environmental aspect. Unfortunately, healthcare facilities are tremendous consumers of energy – and producers of waste as well. As 24-hour facilities, activity doesn’t stop and a large amount of goods and services are going in. Aside from the impact on the environment, this is also costly for health providers. There needs to be a lot more emphasis on stretching the dollar further, so that more staff and better facilities can be provided to help care for patients. It is important to design smarter, and look at the longer term operational cost of facilities as well as opportunities to save energy.

Q: You were recently involved in designing a modular solution to provide additional capacity at a hospital site in Brisbane. What were some of the specific considerations and challenges from a design and planning perspective?

The Prince Charles Hospital is a tertiary level metropolitan hospital, and as such is a busy centre with high demand. There was a need for additional capacity to help tackle waiting lists, and a modular endoscopy complex was to be used as an extension of the hospital’s existing endoscopy department for a limited time.

Firstly, the site where the facility would be located was constrained in terms of space, which meant careful planning was needed with regards to its design and also in how the facility would be built. There were some constraints around access too – the modules would need to be craned into a small targeted area within a busy hospital site.

There was also a fair bit of fall across the site. The sloping ground provided a particular challenge, since the facility was to be connected to the existing endoscopy department at a similar level to provide patient and staff access. Patients would wait in the main building and be taken through to the new facility to have their procedure, so the connection needed to be seamless, and a fair bit of detailed work and planning went into making that work both correctly and cost effectively.

To add to this, the area where the unit was to be sited had live services, such as power, water and drainage, running below ground. Even with careful planning and access to relevant records, there was a need to undertake further visual inspections and commission new surveys as a precaution.

Parts of the proposed site had vegetation on it, including mature trees, and these areas were used by staff as informal outdoor breakout space. One of the main challenges was ensuring the site was not disturbed. We wanted any lasting impact on the site to be minimal so that it could easily be returned to its former state.

Q: How were those challenges solved?

To deal with the sloping ground at the site, the whole facility was raised up and placed onto a series of footings. Even at its lowest points, the building was more than half a metre off the ground, while down at the other end of the facility – a span of 20-30 metres – the facility was raised over 2.5 metres off the ground, so it was a fair bit of fall.

One of the challenges with that was setting up the actual support frame. The modules would be craned onto the site and placed onto legs at specific support points. Significant weight would be placed onto the footings at those points.

With regards to the services that ran below ground, there is always some uncertainty over the drawings and service records we get access to – they are rarely kept up to date. So to avoid any unwelcome surprises, it’s best to always challenge them and obtain additional survey information and undertake further inspections.

We tried not to disturb the site as far as possible and managed to keep the green space. The site will eventually be returned back to its former use – a car park and a bit of outdoor space. While we probably had the opportunity to cut the trees down, that was not something we wanted to do. Quite often, people are attached to natural elements and green spaces.

The facility was placed in a very visible location, near several of the hospital’s main entrance points, including the emergency entrance. The modules were already pre-finished to a very high standard – they don’t look like a basic, temporary boxes just plonked on the site, and once inside, you would not realise you were in a modular unit. While the outside of the complex could have been customised, it did not look out of place and there was no need to do so in this instance.

Q: What were the key challenges with utilising a prefabricated but bespoke solution, in a unique configuration to the hospital?

Three main modular units were delivered to site; a main endoscopy unit, a separate ward and a decontamination unit, plus a small toilet facility as well. While they are designed to be easy to physically connect together, we had to create a network of connecting areas to make the three separate units work as one consolidated facility.

The complex also had to fit in with existing flows of patients, staff, goods and waste. Each of the modular units had both a public entrance and exit, for patients and staff, and goods and services access points, and escape pathways too.

Made offsite using modern methods of construction, the prefabricated modules are pre-wired, pre-plumbed and some of the equipment is already on board. Once they arrived on site, they had to be connected up to all the services and utilities, the units had to be placed onto the frames, and the network of covered space and connecting areas around them had to be built.

The timescale was tight to get the complex built once on site. The units were being shipped from overseas, and with Covid-19 restrictions in place, there was a risk of delays.  However, the process was very well managed and everything went smoothly. With a modular solution, the build is far quicker than when using traditional build methods and the time on site is considerably shorter. It did require careful planning, but once the modules arrived the complex was put up very quickly.

Healthcare equipment is often made by global companies and imported, and meeting local standards can therefore present a challenge. While local standards tend to be based on international standards, and often aim for the same outcome, there may be variations or scenarios which previous tests and certificates doesn’t cover. In this case some further testing was required once on site, specifically around fire risk and the potential flammability of the shell of the building, due to the Australian climate.

Q: How has Covid-19 impacted design requirements overall, and do you think it will have a lasting impact?

Although the uncertainty during the pandemic has meant a higher risk of delays, thankfully it has not had a major impact on project timescales.

Since the start of Covid-19, there is certainly more thought going into designing efficient patient pathways and the pandemic has highlighted the need to be able to achieve a separation of pathways and to have sufficient space to isolate patients if need be. Previously, space in waiting rooms might have been down to one chair per square metre, now it might be double that or even more, depending on the space available.

However, many facilities are limited in terms of space, so Covid-19 has had a clear physical impact. There were a lot of rapid changes to some of the front ends. At the same time as space in healthcare buildings is limited, people are still getting sick, and the population is increasing over time. Demand for services is increasing in the longer term, so as well as adding capacity, it’s also important to look at other strategies; how can we move people through the service effectively?

In terms of elective care and diagnostic services, it’s not just about the number of people on the waiting list – we also need to be prepared for the backlog of patients that have been reluctant to or have put off seeking care during the pandemic.

When we went into lockdown initially, urgent care still happened but elective really died off. People were staying away and didn’t go to the doctor unless they were very sick. Now, as places have come out of lockdown there is a real build-up of demand for a lot of those elective services again.

The need to be able to separate urgent and elective pathways and to have dedicated space to isolate patients, wasn’t there before the pandemic. Going forward though, hospitals need to have more flexibility so that they can respond to these kinds of events effectively. Modular facilities give health providers the ability to very rapidly respond to a change in service requirements.