Teachings of the Orient


Recent visit to Japan to attend the first Forum of Healing Environment Awards, inspired by the emphasis on patient-first design. HD Healthcare Design & Development April 2003

Following the "Recent Healthcare Architecture in Japan" symposium hosted by the Royal Institute for British Architecture in 2001 (see HD November 2001), I was invited by Professor Nagasawa to present a lecture to the Department of Architecture at the University of Tokyo. As an advisor to the newly formed Forum on Healing Environments (FHE) Professor Nagasawa recommended me as an international speaker at the inaugural national FHE Healing Environment Awards.

The FHE awards were designed to coincide with the November 2002 Hospex trade show at the mammoth Big Sight venue in Tokyo Bay. The presentation was based on a patient-first¹ design principle exploring ways to link he patient experience with the natural world. Introducing natural phenomena as a form of sensory stimulation and patient comfort was the trigger for a subsequent study tour where I visited eight premier healthcare facilities, five of which were FHE award winners.

Due to the priority given to clinical function, medical facilities tend to be uncomfortable environments for patients. However, a greater awareness of quality of life has in recent years led to the mphasis of cultivating healing and comfort.¹ The FHE provides a venue for the exchange of information by introducing and awarding the activities of facilities in four areas: hospitals, clinics, nursing care and hospices. The FHE wards focus on whether the activities of medical facilities have improved the overall environment of the facility and created a place that provides Ohealing and comfort.¹ Selection criteria include whether or not the activity is ustained, with no limits on the scope of the arts, paintings, photographs, ikebana, collaborations or performances. Another is that works are not separated into professional and amateur categories.The president of the Sentaku ency, Kazunori Ojiri (founder of the FHE Awards), brought together leading figures in the Japanese medical world including the chairman of St Luke¹s Hospital Shigeaki Hinohara, the executive director of Nippon Medical chool akai Iwasak, and professor of architecture Yasushi Nagasawa as consultants to the forum. The judges for the awards included a 14-strong independent panel of doctors and celebrities including architect Tadao Ando, actress oko Maya, an art director, an opera singer, and a photographer. The award was launched through the Asahi Shinbun, a national newspaper, and due to wide coverage around 265 entries were received. A variety of programmes such s visual arts, musical performances, garden schemes and voluntary projects were entered. With so many entries, in a wide range of contexts, the diverse panel were unable to identify outright award winners, resulting in several nners for each category. The individual winning teams were invited from across Japan to attend the Big Sight ceremony for the special occasion. Improving quality of life in healthcare facilities means serving the wider public and he FHE awards sought a collaborative and complementary approach. Simply leaving hospital developments to professional interest groups alone, whether political, medical, architectural or scientific, has failed to deliver cceptable quality of life or sufficiently valuable experiences. The award winners were selected on the basis of projects that Ocompassionately support the patients and are purposefully incorporating the arts.¹ Competitive ward schemes are by definition contentious, so what is best practice in such circumstances? Quantitatively and qualitatively challenging, the selection process must have been complex. How in such circumstances is a fair and ocussed programme achieved? It is clearly unlikely or worthwhile for the celebrity panel of judges to visit every entry project, so how are satisfactory short lists achieved? The national newspaper coverage created by the awards was mpressive and will do a great deal to raise popular awareness and expectations. No such forum or profile exists in the UK and there are clearly lessons to be learnt from the FHE Awards event. During the study tour that followed the award ceremony I was able to witness the latest innovation in infrastructure and state-of-the-art services. The tour included documentation visits to the following facilities, which included two mainstream hospitals, children¹s health centre and rehabilitation clinic.

Case Studies
Kawasaki Municipal Hospital was originally established in 1936, but later medical developments led to a sprawling general hospital lacking rationality. Full reconstruction while maintaining services on an incremental edevelopment basis would have taken 10 years. A further challenge was to dramatically reduce transportation distances and the hospital footprint to a quarter of the site. In order to reduce disruption a huge T-shaped structure as created containing the whole of the new 700-bed ward specification cantilevered over the existing low-rise accommodation. Finally, the outpatient accommodation, administration and central diagnostic department were ompleted in the spaces under the new elevated wings. The whole redevelopment was completed in five years and was opened in March 2000. Four giant posts support the wards between the seventh and 15th floors, and to revent overturning during earthquakes the structure is jacked on each side and anchored to a concrete reinforcement wall. Made up of four posts the open piers incorporate easy access and removal of the services, and a natural unnel-type ventilation system. Described by the project architect Takeshi Kuwano as a hanging birdcage, the external bracing provides flexible internal spaces that can be completely re-adapted for future configurations. With 100 beds per floor the patient spaces surround the light well at each end of the floor template. A central robotic elevator and delivery system at the core of the staff base allows consumables to be deposited into the cupboard rays of the individual patients. Trolleys are largely redundant relieving circulation and wards from unnecessary clutter and damage. The resulting higher levels of cleanliness and less wear and tear result in reduced maintenance osts and friendlier, less institutional surroundings.

To accommodate increasing nursing duties within a limited floor area most wards in Japan have four bed units. St Luke¹s International Hospital, which was completed 10 year ago (see HD January 1995), attracted attention at the time as it only had single rooms. Nowadays most new facilities have started developing private-style¹ multi-bed accommodation. They still have four beds each, but easures are incorporated to raise the level of personal privacy and for each bed to have a bedside window. In line with site constraints a wide range of echelon formats are now being employed, for example using contoured utsidewalls and arranging beds in a fan shape to give all patients similar views, air and light, together with individual private space. Echelon bed formations such as these were first introduced into Japan at the Nishi Kobe Hospital, and similar echelon layered bed spaces were later seen at the National Children¹s Hospital in Setagaya, The Japanese Red Cross Society operates over 90 public hospitals including the Red Cross Hospital in Akita founded in 1914. The new Akita Red Cross Hospital is a rather ypical modern eight-story development with 496 beds, which opened in July 1998. It contains 77 fan-shaped four-bed units so each patient has their own defined space and unobstructed window view to the surroundings paddy field landscape. The latest plan is a four-bed development of the single bed configuration at St Luke¹s, Tokyo. A refined radial development of the four-bed fan shaped plan layout is now on the drawing board for a new ajor hospital development. Introducing art into the personal space of the patient has to be approached with considerable sensitivity, otherwise the imposition maybe counterproductive and detrimental to the project originators¹ ntentions. At Akita each inpatient is presented with their own individual artwork located on the wall adjacent to their bed. If a patient is dissatisfied with the picture they are allocated they may request an alternative from the art cart.¹

Founded in 1965 the original National Children¹s Hospital in Setagaya has grown into the National Centre for Child Health and Development (NCCHD). The NCCHD is a dedicated paediatric and maternal healthcare facility funded directly by the Japanese Ministry of Health, Labour and Welfare. Briefly introduced to UK audiences at the 1999 CHARTS conference in Manchester by its designer Yoshitaka Tsuji, the project was opened in March 2002. Formerly known as the Okura Hospital, the NCCHD has an imposing 13-story presence in the fashionable western suburb of Tokyo. With a total of 500 beds the centre strives for outstanding patient care, sensitive to the holistic needs of the child and family. It is an international centre offering women¹s reproductive health, maternal foetal medicine, gene therapy and stem cell research. To promote quality, accuracy and safety the centre has implemented a fully computerised, paperless and film-free records and medical ordering service. Once inside the spacious atrium the visitor is aware of entering a new millennium health facility. The naturally lit multi-layered and sunken public spaces are punctuated with an arrangement of colourful play objects and furniture. A selection of interactive arts and crafts, computer graphics and light features with sensitively chosen bright colour schemes and flooring, were assembled and installed in an integrated way. A calm atmosphere is encouraged from the generous open public galleries and the outpatient waiting spaces largely free of staff interference and service vehicles. Within the hospital the movements of staff and their paraphernalia are discreetly offset from the visitors¹ view by means of perimeter circulation and service spaces located between the rows of examination suites. Attention to etailing in Japanese healthcare construction and finishes is of the highest order. As part of thoroughly considered infection control policy on the wards, the floors and wall skirting is unified and to ease access for cleaning, fixtures rarely meet the floor. To reduce germ deposits, basins without overflow drainage are fitted with all washroom plumbing cantilevered from the walls.

The highlight of the study tour was the brief excursion to Amakusa island off Kyushu to visit a remarkable new Spa Rehabilitation Clinic. With a delightful riverside location in Hondo City this recent annexe to the private hospital offers a new formal response and demonstrates what can be achieved in care facilities. According to the president of the medical corporation Eijukai the philosophy is to harmonise the body and soul with the universe, o re-engage the five basic senses of human beings with nature. With its terraced elevations, built for observation purposes, the ferry-boat¹ profile incorporates a distinctive truncated funnel-shaped bridge. Once within, the clinic egins to reveal an extraordinary capacity to incorporate the surrounding scenery, enhanced as it is by excellent gardens. The client has clearly attempted to make the most of the setting and to immerse the users in the natural context from the outset. On the ground floor the elderly day patients attending their Saturday morning life-long learning activities group dine in the spacious glazed quadrant overlooking the traditional rear garden. The onsen¹ ot pring rehabilitation spaces must be among the finest of such healthcare spa settings in Japan. Against the backdrop of an exotic rock garden and Koi-laden pool, disabled and frail elderly bathers are treated with the latest arrier-free hydrotherapy equipment. Adding a further layer of ambient experience, every half hour a spectacular cascade of water flows down the floor-to-ceiling fenestration re-invigorating the tranquillity within. The upper decks contain a fully equipped exercise suite with occupational and physiotherapy gymnasia. The third floor provides a bright short stay 19-bed ward, and the restaurant offers a diet advisory service. For sound and leisure herapy a spectacular fully glazed circular parlour has a piano, deep sofas and wall to wall sunshine. The rotunda observation tower provides unobstructed panoramic views from which to admire the sea, mountains and the stars.


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