Gupha meet in Tokyo

Cancer Hospital Cancer Institute Hospital Ariake Tokyo

Reporting the 5th Gupha Forum at the University of Tokyo. November 2007

The Gupha Forum*1 consisted of many speakers from all parts of the globe addressing both macro and micro forms of health care design from world health provision and massive hospitals in Malaysia to the new Community Facilities in Northern Ireland. Introducing the proceedings Professor George Mann of Texas A&M University *2 outlined the main trends in facility design and described the challenge for the next generation would be the rise in population from a current 6.6 to 10 billion mostly in developing countries. He then proceeded to present the Gupha international student design awards for innovation. For his special lecture based on his considerable achievements and international experience, Professor Yasushi Nagasawa, described the lessons of the two Gs, - Global and Geography

Including design for health in a global context is a complicated issue. The World Health Organisation is now attempting to update its knowledge base and capacity for guidance to meet 21st Century needs and patterns of care requirements. Enlightening the forum on WHO's work on health care infrastructure, facilities and technology Dr Andrei Issakov made an appeal for assistance from Gupha delegates for current guidance. We appear to have arrived at a fragmented stage where central advice is no longer satisfactory and delegates found themselves unable to respond adequately to the invitation. In a culturally diverse world of such inequality in life expectation and access to health care, it is difficult to know where to begin, but the basic principles are straight forward. Consider first the subject, - the sufferer and all the individual citizen of this planet suffer at some time in their life. The aim is the wellbeing of the world's population by aspiring to the public health objectives as defined in the WHO's constitution.(*3) Between the subject and the object are the means (how, where and when) of delivery and availability, for instance the degree of inclusiveness and whether access is based on ability to pay and is affordable at the point of service. To establish a fair health infrastructure is a considerable undertaking with numerous stakeholders, politicians, clinical consultants, nursing carers, financial sponsors, drug companies, contractors and the service users. With an extraordinary commitment and investment each stakeholder believes they have a significant role to play in the health service delivery. At this stage the whole process becomes very muddled as each of the contributors compete for the territory and control over the programme and influence over the end product. In other words the means of the process begin to determine the outcome. The contractor for example believes their building is the subject and the object is to profit from their investment, when in fact it may not be appropriate or even necessary to build a permanent monument. Due to a lack of universal resources there is serious ethical imbalance where the privilege few have access to the specialist teaching hospitals and increasingly cosmetic surgery whilst elsewhere millions still don't have access to clean water, the most common cause of disease and sickness. When it comes to achieving health care benefits across the whole population each independent country with variable ability to govern and regulate has different political, social and financial priorities. Overwhelmed with such dilemma all of this complexity compromises WHO's effectiveness in delivering best practice guidance.

Considering the Geography *4

From the UK Architects for Health colleagues *5 and myself attended and although the majority of the delegates were from Asia, it was the Americans who were most vocal. Under the Chairmanship of Professor Kazuhiko Nishide, we were treated to two days of highly efficient communication support. The chair was assisted by the irrepressible Professor Nagasawa and his extraordinary capability to switch instantly between Japanese and English keeping everyone informed. Translation was simultaneous and even the Japanese volunteers were transforming spoken English directly into Japanese sign language. The only presentation throughout by a speaker from a disabled user's viewpoint, Dr Toshinobu Obata from Honda Motors spoke on behalf of the deaf and appealed for their inclusion in environmental decision making. He informed the international gathering that sign language is by no means universal and that there were differences even between Tokyo and Osaka.

The conference provided a much needed platform and morale support for the various university departments who specialise in design for health care, and there were exchanges on the various educational structures. The conference however offered far more than approaches to curriculum, such as the Development of Guidelines for the Design and Construction of Health Care Facilities presented by Joe Sprague the Director of Health Facilities at HKS Inc.. On one hand there was the USA demand driven model with $43 billion pa worth of business and the mass care systems rapidly appearing in the Asia Tiger Economies. We were shown plans for a 3000 bed hospital in Malaysia by Professor Norwina M Nawawi and mega hospitals in China by architect Dr Huang Xi Qiu whose office has designed over a hundred such hospitals. In the mass orientated Asian countries there was little evidence of an individual patient focused service. (The sight of such mammoth hospitals being rolled out were beginning to make your reporter feel sick with despair, but of course huge swathes of users were likely to benefit from such enormous institutions, so it would be churlish to criticise such ambition!). Architects for Health Chairperson Dr Ann Noble presentation proved when it comes to health provision small is beautiful, and care in the communities of Belfast finished the day on a note of cautious optimism particularly in the aftermath of the troubles.

As a non-academy based delegate the Singapore and Single Room study were the most informative. Considering hospitals within the urban and cultural context we learnt about the phenomena of the edge and the importance of boundaries. In her presentation On the Edge Zone between Urban and Hospital Domain Dr Ruzica Bozovic Stamenovic presented a range of border conditions and how such segregation encourages stigma. Temporary Triage Tents systems erected on the perimeter during the recent SARS scare reinforced fear and did little to encourage confidence. Such separation of clinical services from the population was described as an anathema to the spirit of hospitals as healing environments.

Patient Room Prototypes

For a more specific scheme Professor David Allison presented the single room research, the joint Clemsom University and Carleton University Patient Room Prototype Project. a virtual interdisciplinary R&D collaboration with the Spartanburg Regional Health Care System. An elegant functional scheme offering essential nursing sight lines from the ward circulation the forum was able to get their teeth into the detail of this project. Your reporter questioned access to the wc, and it was suggested there were no mandate to provide double loaded disabled access. Although the twin mirrored single room arrangement did offer the disabled a choice, US regulations unfortunately seem to favour a single handed room orientation. Currently there is a directive in the USA towards all single rooms in new facilities, but a Berlin based delegate pointed out that Germany was now moving away from single rooms. It appears single bed rooms are too expensive and there simply wasn't a demand due to insurance companies reluctance to underwrite the tariffs on such services. Within the prototype rooms it was noted the window elevations were least resolved, and it is unclear whether the outer walls were within the designer's brief. This seemed a surprising omission as a permeable perimeter would connect the patient to the geography and natural phenomena which provides daylight and encourages the healing process.

To see the Tokyo Presentation Powerpoints visit


World Leader in Cancer Care.

Following the forum Gupha delegates visited the leading Japanese Foundation for Cancer Research. An historic privately financed and non profit organisation founded in 1908 it recently transferred to the Tokyo Bay Area opening in March 2005. Commencing sixty years ago with 29 beds it was the first hospital in Japan to specialise in cancer. It is now a state of the art 700 bed hospital with the latest advanced diagnostic and treatment technologies combined with a cancer research foundation and teaching establishment located on a single site. As well as the twelve floor institute hospital the facilities boast a screening and chemotherapy centre and the Nozomi Nursing School. As well specialising in cancer care it also operates as a general hospital for a growing local population and offers back up medical functions for use in times of a major disaster.

Welcoming the study tour the Director Tetsuichiro Muto emphasised the new hospital was planned along the principles of the patients care and comfort from the outset. The Hospital Ethos is to improve the well-being of users by delivering better cancer control and to achieve this, its core values are creativity, quality, sincerity and cooperation. The policy is to foster a strong sense of humanity by encouraging the staff to be gentle with the patient paying special attention to the patient's Quality of Life. Instrumental in the whole operation Dr Muto outlined the development process and how he instructed the architects from Kenzo Tange's office to concentrate on an appealing building focusing on functional competence in preference to the spectacular. To achieve "an ideal hospital as a torch bearer for the future" the director estimated there were about 3000 meetings between his team and the contractors. The medical aspiration was for innovative treatment for the patient and to perform multi-disciplinary tasks based on individual needs and organ specific diagnosis. Benefiting from years of experience the 11,000 new patients per year will attend one of four centres, the Thoracic and Gastroenterology Center, The Prostrate Disease and Ladies Center. Decisions on the individual's treatment are made between the surgical, medical and radiation oncologists, the nurses, pharmacists and nutritionists, in accordance with individual cancer characteristics, the patient's condition and point of view. Accessible to all, experienced doctors supervise and are responsible for Diagnosis and Treatment, taking care to the end. Nurses are expected to be attentive and kind, and high levels of staff loyalty ensure patient's are treated consistently by the same personnel.

As a result of considering the patient's emotional comfort all the clinical and administrative paraphernalia is removed from the visitors perceptions as much as possible. Entering the hospital is equivalent and even superior to entering the lobby of an international quality hotel. The spacious open planned hall with a distinct lack of institutional clutter provides a calm, confident and welcoming atmosphere. There is a hidden order where all clinical equipment and transportation operates in its own parallel domain, so visitors don't experience the chaos normally associated with medical environments. At the rear of the ground floor hall flooded with natural daylight is the comfortable local hospital service. Once enrolled patients enter the hall and proceed to the "automatic receipt machines" and obtain their registration pass and an individual "PHS" pager. This miniature device allows patients to roam freely until it is their turn for counselling. The system helps alleviate undue stress caused by worrying waits prior to consultation and examination. The hospital is also a forerunner in the adoption of a total clinical information technology, a service developed with Fujitsu which includes full electronic medical records. All test results and treatment details are all recorded in the patient's medical charts. The digital system will prevent accidents, for example the nurse scans the barcodes on the patient's wrist band and on the medicine packaging to ensure the correct medication. To access laptops fitted to specially designed trolleys each nurse also has an individual ID barcode.

The throughput figures are high with a total of 333,000 outpatient appointments plus 152000 inpatients per year. The average inpatient occupancy is 474 per day and the average length of stay is (21?) days. To accommodate this many visitors the main building consists of a familiar seven floor ward slab perched above a podium of main surgical services and the ambulatory care area. The entrance hall is contained within a double height ceiling and the receptions to the four main care centres are found on the 2nd floor mezzanine easily accessed from the central escalator. Simplified by friendly graphics and elegant signs finding the way is intuitive and upon arrival the waiting areas are spacious, comfortable and quiet. A reason for the civilised quality of these spaces is because the patient's journey is essentially through the core of the building whilst the staff circulation and service provision is confined to the perimeter. Largely out of sight it possible the only clinical personnel the patient's may see despite the many visitors are the familiar kind faces and reassurances of the dedicated personal carers. Focusing attention on the dignity and emotions, the individual user will benefit from a sense of being unique and special.

Four stories above with splendid views of the surrounding Bay Area, a typical ward contains sixteen single and seventeen four bed spaces configured around a racetrack arrangement favoured by designers of Japanese Hospitals. Here the essential staff areas are organised within and the invisible order is maintained by a central support corridor along the operations spine of the template. The staff and clinical zones are linked by dedicated elevators independent of the visitor's routes which are kept spotlessly neat and tidy. In these such areas despite high volumes of traffic the floors are kept thoroughly clean throughout by a particularly dependable and diligent cleaner. Such sense of pride and attention to detail in the bed spaces more than met high expectations of the quality control found in contemporary Japanese medical interiors. From the areas visited the main concern was the lack of natural daylight found in the staff bases. It is a warning that perhaps even within amenity designed from a patient's perspective the staff's work space and comfort must not be overlooked. In Japan such bases always seem to be a hive of activity, leaving visitors to wonder whether nurses would be better occupied elsewhere on the wards attending more directly to the patient's needs. Accompanied by their new laptop trolleys the nurses mobility here will be enhanced considerably allowing them to circulate more independently from the base. Apart from such a relatively minor observation this particular delegate left feeling optimistic that maybe after all it is genuinely possible to create a high quality patient centred care environment. It was privilege to have been escorted around this impressive world class facility and a very inspirational way to conclude the Gupha Forum in Tokyo.

Graham Cooper November 2007

Author Art and Nature: Healing

1 Gupha is short for Global Universities Programmes in Healthcare Architecture.

2 Texas A&M University is short hand for the Texas Agriculture and Mechanics University.

3 WHO Definition: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The definition has not been amended since 1948.

4 Geography is a reference to The Geography of the Hospital, (a planning principle identified by the late John Weeks).

5 AfH Colleagues included Ann and Paul Noble, Junko Iwaya, Rosemary Glanville and Giovana Romero from maru.


The 5th GUPHA Forum Schedule

Opening Remarks and Presentation Prof. George Mann Prof. Texas A&M University

Clemson/Carleton Patient Room Prototype Projects Prof. David Allison Clemson University

Can We Rely on Robots to Guide Users in Hospitals? Healthcare Facilities Wayfinding Studies Akikazu Kato Mie University

Development of Guidelines for the Design and Construction of Health Care Facilities Mr. Joseph G. Sprague HKS, INC.

The Best Communicating Environment for Inclusive Education (to Get over the Handicap of Hearing.)~ Dr. Toshinobu Obata Honda Motor Co., Ltd

Update on the WHO's Work on Healthcare Infrastructure, Facilities and Technology Dr. Andrei Issakov World Health Organization

Current Development of Healthcare Architecture in China Dr. Huang Xi Qiu Institute of Project Planning and Research

A Master in Architecture Course with Specialization in Architecture for Health in the University of the Philippines Prof. Prosperidad C. Luis and Associates

Recent Development of Healthcare Architecture in Malaysia - Reflecting the 50th Year of Independence Prof. Norwina M Nawawi International Islamic University Malaysia

National Development Program of Hospital Premises in Finland Prof. Kari Reijula Finnish Institute of Occupational Health

On the Edge - Zone between Urban and Hospital Domain Prof. Ruzica Bozovic-Stamenovic National University of Singapore

What Do Clients Mean When They Ask for: Flexibility, Sustainability And Whole Life Costings Dr. Ann Noble Ann Noble Architects

Special Lecture Prof. Yasushi Nagasawa Kogakuin University

Proposed Center for Health Facilities Design and Testing Prof. David Allison Clemson University

A Holistic Approach to the Perception of Healthcare Environments Dr. Sanja Durmisevic Delft University of Technology

Healthcare in Sri Lanka after the Tsunami Ms. Junko Iwaya Nightingale Associates


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