About Hussain 3


Hussain Varawalla – Healthcare Architect

Thirty-Five years of experience in the conceptualization and schematic design of medium to large health care facilities / hospitals in India.Healthcare Projects
Hussain (2)

(Completed 28/32 credits towards)Master of Architecture Kent State University, Kent, Ohio, USA

450-Bed Central Accident & Trauma System, New Delhi
Thesis project, Kent State University, Kent, Ohio -1989

Bachelor of Architecture (Hons) Indian Institute of Technology,
Kharagpur, West Bengal, India.

250-Bed Multi-Specialty Hospital at Mahim, Mumbai
Thesis  project, Indian Institute of Technology, Kharagpur-1979

(With COVID-19 Lockdown Hair)(Without…at Breakfast with my Books)






Employment Record

Name of the Firm Position Held Years of Employment
Healthcare Architecture Principal Consultant Six
Hosmac India Private Limited Mentor-Design Services Three
Reliance Health Ventures Ltd. Consultant-Architecture Two
Hosmac India Private Limited,Mumbai Director-Design Ten
Asian Health Services, Bangalore GM Architecture Two
Indian Hospital Corporation, Chennai Mngr.-Architecture Two
HFP/Alan Ambuske, Cleveland, Ohio Architect (USA Trainee) One
Bharat Kothari & Associates, Mumbai Architect Four
Vijay Raheja & Associates, Mumbai Architect Five
Uttam C. Jain-Architect, Mumbai Architect Four
I. M. Kadri – Architect Trainee SixMonths
 
 Dedicated Healthcare Architectural Firms in Red

Did Healthcare work too in these architectural firms

Plans









Scope of Work – Hussain Varawalla
Healthcare Facility Planner

ARCHITECTURAL PROGRAMMING

The architectural space program consists of a list of the number and type of hospital beds proposed, and the different types of hospital departments further broken down into individual rooms with their areas and numbers.

At the end of the list of rooms in each department, there is a conversion factor, varying from 20 to 35 per cent, to account for the horizontal circulation area or area of corridors. This percentage factor is based on the major circulation corridors having a clear width of 2.40 M (8’-0”), the international norm.

At the end of the list of departments, an additional factor is used to estimate the overall size of the hospital, to account for vertical circulation areas (such as staircases and elevators) and sometimes mechanical spaces to be provided on the floor.

It should be noted that these factors do not account for unique design features such as atriums and courtyards. Ultimately, the actual design will determine the final space requirements.

It is important to always define and understand how square feet/square meters are calculated. Misunderstandings among members of the planning team can be disastrous since the gross space requirement is substantially higher than the net space requirement, because of the multiplier factors discussed above.

APPLICABLE BUILDING CODES

From the very onset of design, it is important to determine the applicable building codes, as they can substantially affect the form of the design solution and the overall cost of the project.

The municipal liaison architect should be appointed at the very beginning of the project.

It is good practice to make all hospital buildings handicapped accessible throughout, whether it is required by code or not.

CONCEPTUAL DRAWINGS

Based on discussions with the clients, we will present a series of conceptual plans for the proposed hospital, which will be sufficient to give an idea of the proposed building showing:

block relationships of the departments showing area, shape and location within the building;

• the number of floors, the area per floor and the shape of the building;

• the location of vertical circulation elements such as elevators and staircases and the layout of the horizontal circulation routes (corridors);

• the location of the building on the site and the conceptual site planning showing roads, parking etc.;

SCHEMATIC (PRESENTATION) DRAWINGS

Based upon decisions made in the previous stage, we will prepare and present design sketches of the proposed layout of rooms within each department for the entire hospital. These will be discussed and modified as necessary. The structural system to be used will be discussed. After finalizing the room layouts, we will prepare a final set of schematic (presentation) drawings giving plans of the proposed building, showing furniture and medical equipment layouts where necessary to demonstrate sufficiency of space.

HEALTHCARE ARCHITECTURE ADVISORY SERVICES

If you should so desire, I can work in collaboration with another healthcare architect of your choice. The scope of work can be decided by discussion between the three of us.

I can, if wanted to, suggest appropriate honest and competent healthcare architects who can work in collaboration with me, for you to choose from.

I can also help you to choose an appropriate parcel of land for the site of the proposed hospital by analyzing its suitability to house the requirements of the proposed project. Speaking from experience, this can be a very cost-effective exercise. Many clients have come to me with completely unsuitable sites, sometimes bought at considerable cost, which defeats the very purpose of the whole design exercise right from the beginning. A little thought given to this aspect of the project at the onset can go a long way to making the project financially feasible and operationally efficient.

The land acquisition process, at a minimum, must involve consideration of the following factors:

1. Size of land. Make sure that the land is large enough to meet long-range growth plans – that is, a 10-year to 20-year growth plan.
2. Usable land. Determine the total acreage that can be used. The total size purchased is rarely the same as the total acres available for the actual building.
3. Zoning restrictions. Be aware of the current zoning limitations and allowances for the area.
4. Potential adjacent development. Find out what businesses and developments are planned or permissible in the adjacent spaces. Those potential developments might not be compatible to healthcare delivery.
5. Site access. Determine if the site is accessible through major roads and if it is fairly or highly visible to passers-by.
6. Services to the site. Evaluate the cost effectiveness of bringing service utilities to the site.
7. Preliminary master site plan. Prepare preliminary master site plans for each potential property. This plan ensures that all current planned facilities and their associated parking needs fit the property. Also, the potential property should have extra space for future development.

The key point to remember here is to never let the land drive the design of the facility.

“If you don’t know where you’re going, any path will take you there.”
Sioux Proverb

“Long-range planning does not deal with future decisions, but with the future of present decisions.”
Peter F. Drucker (1974)

“Intelligent people do not make important decisions on matters about which they are ignorant when additional data are easily available.”
John Kay & Mervyn King: “Radical Uncertainty: Decision –making for an unknowable future”

“In a way, I like this phase of a novel better than the actual writing of it. In the beginning, there are so many possibilities. With each detail you choose, with every word you commit yourself to, your options close down.”
John Irving: “A Widow for One Year”

“CDS (Chief of Defence Staff) Chauhan is in regular touch with the three service chiefs to work out solutions to obstacles that they are likely to encounter in implementing this immense paradigm shift. Indeed, the armed force will have to usher in momentous changes in the way operations, logistics and application of force will be handled under theatre commands.‘The start of this journey depends on right first steps being taken towards jointness and integration,’ Gen. Chauhan has said.”

Pradip R. Sagar – Strength In Unity – India Today – August 21, 2023

Well said! The start of any journey (or project) depends on taking the right first step. If you start off in the wrong direction, you will never arrive at the right destination, no matter the amount of effort you put into it. Beginnings are very important.

“The significant problems we face cannot be solved by the same level of thinking that created them.”
Albert Einstein

“A problem well stated is a problem half solved.”
Charles F. Kettering – American inventor

“Our job is to give the client, on time and on cost, not what he wants, but what he never dreamed he wanted; and when he gets it, he recognizes it as something he wanted all the time.”
Denys Lasdun, architect

 

Perhaps it seems arrogant for the architect Denys Lasdun to make the above statement. But I think that we should try to see through the apparent arrogance of the statement, to the underlying truth that clients do want designers to transcend the obvious and the mundane, and to produce proposals that are exciting and stimulating as well as practical. What this means is that designing is not a search for the optimum solution to the given problem, but that it is an exploratory process. The creative designer interprets the design brief not as a specification for a solution, but as a starting point for a journey of exploration; the designer sets off to explore, to discover something new, rather than to reach somewhere already known, or to return with yet another example of the already familiar.

 

THE CHALLENGE OF PREDESIGN PLANNING

The planning and delivery of a major capital project can be divided into six stages, as shown in the figure below:

The first stage of predesign planning – the focus of this note – includes general concepts and ideas in the form of words, numbers and conceptual diagrams. Preliminary space estimates are used to develop a facility master plan and to generate project cost estimates early .Once specific projects are identified and approved, the detailed operational and space programming begins; when this is completed, the design architect can start the schematic design stage. Each subsequent phase brings more knowledge and detail about the project and has its own cast of players. Nearing the final phases, the concepts and ideas are translated into tangible architectural floor plans, drawings of construction details and the eventual reality of the three-dimensional building.

Predesign planning can be defined as the process of determining the following:

Right services consistent with the organizations strategic initiatives, market dynamics, and business plan, at the
Right size based on projected demand, staffing, equipment, technology, and desired amenities, in the
Right location based on access, operational efficiency, and building suitability, with the
Right financial structure – for example, owning leasing or partnering.

Predesign planning is the stage where the healthcare executive has the most influence on the potential success of the final project. His or her opportunity for input decreases as each subsequent stage passes. The opportunity to reduce both the initial capital cost and the ongoing operational costs is also greatest during the predesign planning stage, as shown in the figure below:

With the prospect of a new building project, healthcare executives tend to short-circuit or bypass the predesign stage to rush into the more tangible aspect of design. This is a big mistake. A premature focus on a construction or renovation project, without the rigor of a predesign planning process and the context of an overall capital investment strategy for the organization, often results in in inappropriate and overbuilt facilities and increased operational costs that may not be justified by revenue growth. This is also a mistake, given that you, your organization and your predecessors will have to live with the results of your project for half-century or more. Predesign planning is critical from a short term-term perspective: it is needed to design and construct a building that meets the needs of the first set of occupants. Predesign planning is also critical to the building’s long-range functional life and it’s adaptability to accommodate future changes in medical practice, technology, and patient care.

Predesign planning is the part of the process where non-architects are the most involved. There should be caution against engaging a design consultant prematurely. Architects and engineers are energetic, creative problem solvers who are really good at what they do. But until your institution has worked through some of the steps of predesign, you don’t know if your problem is really a design problem or some other kind of problem. There are architects who tend to see all problems as design problems, even when they’re actually management or organizational problems. A management or organizational problem can often be solved internally by a policy decision thus saving a lot of time and money.

THE INTEGRATED PREDESIGN PLANNING PROCESS

The figure below illustrates the integrated planning process that can be used by healthcare organizations to reconfigure existing facilities and to plan new facilities. The predesign planning activities shown in the diagram are separated into two:

1. Capital investment strategy development and approval: this includes five major activities (replacing the traditional facility master planning process).
2. Implementation: this includes the detailed operational and space programming for designated projects and the establishment of benchmarks to monitor long-range facility needs as the strategy is periodically updated.

Capital Investment Strategy Development and Approval

The predesign process begins with the collection of baseline data and a review of the organizations current situation, including campus access and circulation, bed utilization and configuration, space allocation and layout, and infrastructure issues. Current market dynamics, workload trends, future vision and projected demand are also reviewed and incorporated into the facility planning process, along with the organizations institution-wide and service-line specific operations improvements initiatives. Planned technology investments are currently reviewed and coordinated with the facility planning process.

Existing and future space need is documented and compared with current space allocation. At this point, future facility needs must be determined, priorities must be established, and consensus must be reached on a long-range facility investment strategy. Once the long-range facility investment, or “road map”, is defined, it can be divided or categorized into immediate, short-term and long-range projects, which are assigned corresponding capital requirements that are sequenced over a multi-year period.

Implementation

With the phasing/implementation plan in hand, detailed operational (functional) and space programming can begin for those projects that are identified as immediate priorities, along with short-term projects for which planning needs to begin so that they can be completed in a two-to-five year planning horizon. Benchmarks are established for long-range projects; these benchmarks can be monitored over time and incorporated into the ongoing predesign planning process as the facility investment strategy is updated periodically.

This note on “Predesign Planning” has been adapted from the book “Healthcare Facility Planning: Thinking Strategically” by Cynthia Hayward, and is fully endorsed by me as relevant and necessary.
I encourage you to read this very good book; it is available on Amazon.in.

The Project Launch Phase

The following are key points to remember about the project launch phase:

• Spend sufficient time defining the scope, cost, and the schedule of the project.
• Develop a budget and schedule early.
• Complete the master facility plan and operational and space programming processes before entering the design phase.
• Make smart land-acquisition decisions. Acquire sufficient land to prevent the land from driving the design, to allow for future expansion, and to accommodate future changes in healthcare delivery and technology.
• Evaluate potential joint-venture opportunities and their impact on capital and operating cost.
• Assemble the key members of the project delivery team.

The Project Delivery Team

The following are key points to remember about the selection and organization of the project delivery team.

• Select external team members – project manager, lead architect, specialty consultants, and construction manager – during the launch phase.
• Organize the Facility planning Committee first. This committee should include representatives from the board and medical staff building committees.
• Identify people from the board, from medical staff, and from the community as “project champions” and involve them in the process.
• Select members for the departmental task forces, and then involve them in the development of the master facility plan, the Operational and Space Planning (O & SP) process, and the design phase. These forces should include physicians, staff, and volunteers from various departments.
• Base selection of key external staff members on qualifications, experience with similar projects, and chemistry with internal team members.

This note on “The Project Launch Phase” and “The Project Delivery Team” has been adapted from the book “Launching a Healthcare Capital Project” by John E. Kemper, and is fully endorsed by me as relevant and necessary.

I encourage you to read this very good book; it is available on Amazon.in.

Proposed 250-375 Beds Model Hospital

Download (PDF, 2.44MB)

The Ability to Accommodate Change
Hospitals and large healthcare campuses need to be able to accommodate change. Buildings that cannot change, and especially healthcare buildings, which often remain in operation for 50-100 years or longer, are at risk of premature obsolescence. There are three ways in which buildings and building complexes can transform and accommodate changing needs: through flexibility, adaptability and expandability. Flexibility involves the ability of a given space, department, building or campus to accommodate changing needs with little or no physical reconfiguration. Adaptability involves planning and constructing buildings or building elements with the capability to transform space easily with the least amount of physical, material and economic impact. Expandability involves planning to accommodate growth and change in a coherent and logical way. It requires planning infrastructure and circulation in a way that anticipates future growth.


A change-ready hospital. Source: Heinle, Wischer and Partner
Primary Drivers
The healthcare context is incredibly dynamic and influenced by constant changes in medical science and technology, healthcare policy and regulations, demographic transformations in both populations served and caregivers, and evolving clinical practices and approaches. Collectively not only are these forces increasing in their impact but also the arte and pace of change are accelerating. Healthcare as delivered 50 years was fundamentally different than today. Facilities that were designed and built then and are still in use were not conceived to easily accommodate changing healthcare needs, practices, and technologies. It was simply impossible then to imagine the scope of changes that have occurred over the life of these facilities, and it will be increasingly impossible to imagine healthcare needs over the next 50 years or how healthcare will be delivered. Therefore, healthcare facilities must be able to accommodate not only changes we can anticipate but also changes we cannot even imagine.

Design Considerations
The first principle of accommodating change is to design the overall building for layers of change, as out lined by Stewart Brand (1995) in How Buildings Learn: What Happens After They’re Built. The fundamental principle is that buildings designed to accommodate layers of change have long lives. These layers consist of site, structure, skin, circulation, services, space plan and stuff. The key is to design buildings so that more stable elements (“hard spaces”), such as structure and core infrastructure, support frequent changes to the more flexible elements (“soft spaces”) around them.

Layers of change. Source: Clemson University Architecture + Health Program
A truly open building system is also designed with a clear hierarchy of circulation where the primary pathways are stable even in the event of changing programmatic use. In cities, we rarely change the location of streets to accommodate the needs of individual development. The most stable elements of the city are its streets and movement systems. Healthcare planners and designers need to employ urban design principles when designing large healthcare facilities and campuses, where movement systems and infrastructure are aligned and stable. Medical planning of a campus, the equivalent of a city block, can then constantly change and transform. Within an open building framework designed for layers of change, modularity can be employed to accommodate flexibility, adaptability, and expandability. Modularity can occur at multiple scales, from building components and individual rooms to planning strategies that allow departments and larger areas to transform. A key aspect of modularity is that it allows for prefabrication. Standardized and prefabricated modules can also lead to improved construction quality in controlling manufacturing conditions, lower waste, and improve the speed of construction. Finally, modularity enables the delivery of high-quality healthcare settings when and where it may be difficult if not impossible to build on-site with locally available materials, expertise and labour. Prefabricated modules are becoming commonly produced at multiple scales:
  • Prefabricated and modular casework, headwalls and wall systems
  • Prefabricated mechanical, electrical, and plumbing modules
  • Prefabricated and modular rooms (toilets, patient rooms, and other spaces that are repeated multiple times in the design and construction of healthcare facilities)

Finally, modularity should be considered in the overall planning of departments and functional areas within them. Standardized clinical modules not only support the implementation of prefabricated building elements but can also help standardize care practices with replicated and pretested design elements.

This note on “The Ability to Accommodate Change” has been adapted from “Chapter 22 – Epilogue: The Future of an Architecture for Health by David Allison, Eva Henrich, and Edzard Schultz” in the book “Architecture and Health: Guiding Principles for Practice Edited by Dina Battisto and Jacob J. Wilhelm” and is fully endorsed by me as relevant and necessary.


Levels of Care: Primary, Secondary, Tertiary

There are three classes of primary care practitioners, distinguished by increased sophistication in their level and type of training, as well as by their historical emergence (see figure 3.16) at the lowest level there is a staggering number (roughly 1.1 million) of individual practitioners without any staff (and probably without any qualifications) who are owner-operator of their own clinics; such practitioners are labelled “quacks”. Roughly 80 percent of these are rural establishments located in villages.



One of the reasons healthcare in the USA is so expensive is that doctors have to pay high premiums for malpractice insurance, and this cost gets passed on to the patient. Also, unlike India, there are no “quacks”.
Calvin and Hobbes is my favourite comic strip.




This illustration from Boccaccio’s Decameron shows the Roman emperor Galerius being bled by leeches. According to the text, his symptoms included putrefaction and abominable stench.
A handy medical reference text for physicians was the “leechbook”, perhaps so-called because physicians ere nicknamed “leeches”, from the habit of using these worm-like creatures to drain blood for almost any ailment. Most leechbooks contained remedies of the time gathered indiscriminately from a vast array of sources.

A traditional means to segment delivery across countries is primary, secondary, and tertiary care. These levels have been defined in a variety of ways by a variety of organizations:
Primary care is medical care provided by the clinician of first contact for the patient. Typically, the primary care physician is a general practitioner, family practitioner, primary care internist, or primary care paediatrician. Primary care may also be administered by health professionals other than physicians, notably, specially trained nurses (nurse practitioners) and physicians assistants. Thus, it is the nature of the contact (first compared with referred) that determines the care designation rather than the qualifications of the practitioner.
Secondary care is medical care provided to a patient when referred by one health professional to another with more specialized qualifications or interests. Secondary care is usually provided by a broadly skilled specialist such as a general surgeon, general internist or obstetrician.
Tertiary care is provided on referral of a patient to a subspecialist, such as an orthopaedic surgeon, neurologist, or neonatologist. A tertiary care centre is a medical facility that receives referrals from both primary and secondary care levels and usually offers tests, treatment, and procedures that are not available elsewhere. Most tertiary care centres offer a mixture of primary, secondary, and tertiary care services so that it is the specific level of service rendered rather than the facility that determines the designation of care in a given study.

Primary Care

In terms of overall infrastructure capacity, organized primary care sites comprise an estimated 95 percent or more of India’s delivery capacity, with secondary and tertiary care accounting for 3 and 2 percent, respectively.

There are three classes of primary care practitioners, distinguished by increased sophistication in their level and type of training, as well as by their historical emergence (see figure 3.16) at the lowest level there is a staggering number (roughly 1.1 million) of individual practitioners without any staff (and probably without any qualifications) who are owner-operator of their own clinics; such practitioners are labelled “quacks”. Roughly 80 percent of these are rural establishments located in villages.

At an intermediate level are practitioners of the Indian systems of medicine (ISM): ayurveda, unani, siddha, naturopathy and yoga. For centuries, they were the traditional suppliers of primary care. During the nineteenth century, these groups were supplemented by practitioners of homeopathy. Collectively they have been referred to as ISM&H, or the more convenient label AYUSH practitioners. These practitioners are typically concentrated in small towns and rural areas. Roughly 75 percent of the populace utilize their services, given their low cost and accessibility. This traditional form of medicine is very popular because the providers consider personal, social, and cultural dimensions of illness and care.

At the highest level are providers of allopathic medicine, which the Indian government began to favour post-independence. The dividing line between AYUSH and allopathic is codified in law and institutionalized in different medical colleges for both. In practice, things are less clear cut, as some practitioners may practice across these boundaries .Neither allopathic medicine nor AYUSH is closely regulated internally or externally, and neither is standardized in terms of qualifications.

Most allopathic physicians are primary care practitioners in solo practice or in small group practices (called “polyclinics”). Three-quarters of them are located in urban areas, providing perhaps a broader range of services than the preceding practitioners, staffed with employed personnel and one or more trained physicians. Roughly one-quarter of the Indian population uses the modern allopathic medicine practitioners who are located primarily in urban areas and who generate nearly 90 percent of healthcare revenues; three-quarters of the population avail themselves of traditional medicine, which is heavily located in rural areas and which accounts for only 10 percent of healthcare revenues.

Secondary and Tertiary Care

Secondary and tertiary care rendered in hospitals was traditionally offered through public facilities which provide services free of cosy or at subsidized rates to the lower-income populations. Secondary facilities are found at different administrative levels in each state, including district hospitals, sub-divisional hospitals, and CHCs (at the block level).

Since the mid-1070s (and especially after the 1991 market liberalization), the Indian government has provided a host of incentives to expand facilities in the private sector, including land concessions, tax breaks, low-income loans from public banks, transfer of public hospitals to private firms, duty exemptions for imports of medical equipment, rebates in customs tariffs, reimbursement for government employees, and allowances for hospitals to be run as tax-exempt “trusts.”

Not surprisingly, statistics on India’s bed capacity also vary widely. The count seems to depend on whether or not nursing homes are included. Across all facilities, there are 1.2 million to 1.7million beds, if one considers only hospitals with 30 or more beds, the count is 680,000 private hospital beds. Despite the large number of hospitals and beds, world benchmarks suggest that India suffers from a lack of capacity (see Figure 3.17). Compared to OECD and select other nations, India ranks second to last with 0.7 beds per 1000 population (versus the OECD average of 4.9). India ranks unfavourably when compared with the world average of 2.6 beds as well as the capacity found in other emerging markets (2.3 beds in China and 1.8 beds in Brazil).

As in the US, bed statistics can be decomposed into licensed beds and staffed beds; the former represents potential capacity, while the latter reflects what the hospital can actually staff and utilize for patient treatment. Data from TechoPak suggest that 30 percent of private beds and 50 percent of public beds are “non-functional” due to lack of personnel. Using their base of 1.37 million beds, there are 853,000 operable beds in the country (consistent with the OECD bed/population ratio).

Overall, in spite of a majority of the population residing is rural areas, the distribution of hospital bed capacity is noticeably skewed in favour of urban India, where roughly three-quarters of both public- and private-sector beds are located. Nonetheless, even for many in close proximity to urban hospital facilities, “socioeconomic distance” has proven a barrier to healthcare access: basic measures of health for the poorest 40 percent of the urban population remain at par with the substandard levels observed in rural areas.

The above extract, Levels of Care, has been adapted from the book ‘India’s Healthcare Industry: Innovation in Delivery, Financing, and Manufacturing – Chapter 2 – An Overview of the Value Chain’, edited by Lawton Robert Burns. This book has been published in 2014, so the statistics are dated accordingly. It is presented here to put the efforts of Indian healthcare architects in context.

On Strategy for Healthcare: Will Disruptive Innovations Cure Healthcare


A Bit of Context
This article made the competitive threats and opportunities in health care explicit when it was published in 2000. Its messages are now even more compelling, as competition on value rather than brand is increasingly driving the health care marketplace, and as a wired world enhances the feasibility of meeting patients needs in so many new, more convenient, and less expensive ways. If in-office care is a potential disruptor, as portrayed in this articles well-known graph, “Disruptions of Health Care Institutions,” the race is on to develop models that make the office visit a secondary or even more later option in meeting patients’ needs.

The authors’ “disruptive innovation” framework also helps explain why health care leaders must recognize that fighting against the outward trend of health care services is a losing battle, as they shift from the high-cost centers where many were invented, towards lower-cost and more convenient sites of care. The natural sequence goes like this: An academic medical center where expert clinicians and researchers work shoulder to shoulder develops a new test or procedure. Its value is proven in research studies. At first, patients flock to the one or several medical centers that offer it, but once the bugs are worked out, other well-trained clinicians can perform it. Soon, community hospitals offer the test or procedure. Then doctors’ offices. And then, in some cases, other settings, including patients homes

If you are a leader in an academic medical center or any of the other stopping places along this path-but only one stopping place-you naturally don’t want the expertise to migrate outward. You want the patients (and the revenue) to stay with your organization. So you resist, using tactics such as pushing for regulations that make it difficult for the test or procedure to be performed in other settings. In doing so, you are setting yourself up to be a casualty of the disruptive innovation that will inevitably rise-somewhere else.

Instead, recognizing these dynamics at work, many health care organizations are merging vertically, that is, acquiring the downstream lower-cost sites to which they would otherwise inevitably lose business. Moving to own more of the options is a step in the right direction, as it at least reduces the reflexive resistance to movement outward. But, to compete successfully and thrive in today’s marketplaces, more is needed than these opportunistic mergers. Health care leaders should ask how disruptive innovation represents a threat they are at risk for ignoring and an opportunity they should seize as they compete to improve the value of care.

-Thomas H. Lee
—————————————————————————————————————————————

Idea in Practice

Disruptive innovations in other industries offer lessons for transforming health care:

Create a system that matches clinicians’ skill levels to the level of medical difficulty.
Use technology to channel simple problems (e.g., strep throat) to clinicians who can follow predictable rules for diagnosis and treatment. For example, expand nurse practitioners’ role as primary care providers and provide tools that allow them to accurately refer more complicated conditions to more sophisticated diagnostic abilities.
Invest more money in technologies that simplify complex problems, and less in high-end technologies.
Today most R&D dollars go to complex solutions for complex problems. But more venture capital must flow to projects focused on technologies that simplify diagnosis and treatment-especially of common diseases. By launching a series of such disruptive business ventures, major health care companies (Johnson & Johnson, Baxter, Merck) could spur significant growth – with less investment. c • Don’t be afraid to invent the institution that could put you out of business.
We’ll always need some general hospitals for critical care (just as we still need mainframe computers after PCs transformed that industry). But most health care needs can be better met through specialized institutions that provide state-of-the-art care for a single category of disorders, such as cardiac or renal illness.
Overcome the inertia of regulation.
Instead of working to preserve the existing system at all costs, regulators should be asking “How can we enable disruptive innovations to emerge?” Example: An entrepreneur creates a portable X-ray machine for use in medical offices rather than in hospitals – promising significant cost savings. Regulators could support the new technology and address any concerns about possible risks. How? Require that all images interpreted by non-radiologists be transmitted via internet to a second-opinion center. There, skilled radiologists could check or confirm initial diagnoses.

The progress of disruptive innovation
Dominant players in most markets focus on sustaining innovations – on improving their products and services to meet the needs of the profitable high-end customers. Soon, those improvements overshoot the needs of the vast majority of customers. That makes a market ripe for upstart companies seeking to introduce disruptive innovations – cheaper, simpler, more convenient products or services aimed at the lower end of the market. Over time, those products improve to meet the needs of most of the market, a phenomenon that has caused many of history’s best companies to plunge into crisis.
Disruptions of health professions
As specialist physicians continue to concentrate on curing the most incurable of illnesses for the sickest of patients, less skilled practitioners could take on more complex roles than they are currently being allowed to. Already, a host of over-the-counter drugs allow patients to administer care that used to require a doctor’s prescription. Nurse practitioners are capable of treating many ailments that used to require a physician’s care. And new procedures like angioplasty are allowing cardiologists to treat patients that in the past would have needed the services of open-heart surgeons.
Disruptions of health care institutions
Teaching hospitals incur great costs to develop the ability to treat difficult, intractable illnesses at the high end. In the process, they have come to over-serve the needs of the much larger population of patients whose disorders are becoming more and more routine. Most types of patients that occupied hospital beds 20 years ago are now being treated in more-focused care centers and outpatient clinics, doctors’ offices, and even at home.


The above extract is from the book “HBR’s 10 Must Reads – On Strategy for Healthcare” from the article “ Will Disruptive Innovations Cure Health Care” byM. Christensen, Richard Bohmer and John Kenagyand is presented here for my Healthcare Management readers. This very good book is available on Amazon.in at a reasonable price.

Future Healthcare Design: The Five Constants of Healthcare


In The Context of the National Health Service (NHS), UK. The importance of healthcare has long been understood and valued; however, the importance of healthcare design is not well understood and doesn’t appear to be valued. Whenever I visited hospitals – private, state-run and charitable – I became curious of healthcare design. Common patterns began to emerge – and inspiring solutions, too. While other areas of public architecture such as schools, libraries and housing have had a continuous history of design development, and even aesthetics, hospitals have suffered from a stop-start timeline despite advances in technology and medical care. Five themes recurred during my research for this book, not only in the UK but also globally. These are what I have called the five constants:
  • Attachment
  • Money
  • Risks
  • Silos
  • Reorganization


Attachment
There are many forms of healthcare buildings, including GP Surgeries and community healthcare buildings, but it is the hospital building to which we feel most viscerally connected. And for a good reason, too. It is the place where all our insecurities about our biological and psychological lives are played out; it is the theatre where we witness the drama of our own mortality from birth to death; it is where we place our lives and those of our loved ones in the hands of strangers we trust to make everything all right again. It is no wonder that hospitals have provided so much entertainment in the form of films, TV dramas and documentaries. Our attachment to hospitals is also the reason why people donate generously to the cost of their building. This attachment provides a strong engagement with healthcare buildings – a connection that can be useful for creating patient-centered designs using participatory design methodologies. Durability and functionality are two of the three qualities of architecture specified by the Roman architect and engineer Vitruvius (the third is beauty). Henrik Fisker, the car designer who conceived the Aston Martin DB9, said, ‘I believe good design is about finding beauty – an emotional connection with the consumer..’ Attachment through beauty is a strong human emotion, and it can be used to create better designs and a sense of ownership over the building.

Money
Money is the lifeblood of hospitals and it is very limited and precious, even in wealthy countries. When healthcare staff refer to efficiency and sustainability, it is always in the context of money. The NHS suffers from chronic lack of investment in its services and estates. The most recent NHS funding increase of January 2019 remains below the average increases of 3.7 per cent a year since the NHS was founded and is less than the 4 per cent annual increases that are necessary to meet rising demand and maintain standards of care. However, it is worth noting here that despite the calls for greater efficiency, the NHS is actually 10 times more efficient than the UK’s economy. During 2016-17, the NHS delivered 60 per cent more ‘care’ per year than in 2004, including 5.2 million more operations a year and 60 million more patient appointments. Despite not getting funding increases for staff, medicine and repairs, pound for pound the NHS delivered 16.5 per cent more care in 2016/2017 than it did in 2004/2005, while the wider economy grew by just 6.7 per cent. In London’s most dilapidated hospital, ice cream distribution continues in hot weather because the windows don’t open, while beds have to be pushed away from the walls during rain, and an ambulance is used to move patients in parts of the estate to find a lift than works. Ironically, even this hospital delivered London’s best A&E performance in 2017.

Risks
Around the world, most hospitals of all kinds have boards with non-executive directors from the private sector, working alongside the executive directors. While the CEO’s and executive team are people who have worked their way up or may have studied management (apart from the medical and nursing directors), the non-executives come from many different background such as medicine or nursing, social care, the charity sector, banking, surveying and law. The intention is that the private sector brings ideas and challenges to the executive team. In practice, this doesn’t always work because healthcare delivery is risky and money is limited, while healthcare delivery is highly regulated. In particular, medical mistakes are very expensive. The 2017/2018 NHS balance sheet for medical negligence was estimated at UK pounds 77 billion out of its UK pounds 122 billion overall budget. Mistakes also come with reputational risks, and one can understand why NHS boards might be generally risk averse. This means that in the delivery of healthcare buildings, risk taking in the form of new designs which could influence ways of working may not be welcomed. While most staff might want a better working environment, they also dislike the disruption that construction work invariably brings. However, there are risks to working in buildings that do not support today’s IT systems or comply with fire regulations. In procuring healthcare designs, risks are reduced by having various mechanisms via which unfamiliarity is reduced. There’s a tendency to rely on ‘frameworks’ that weed out potentially risky suppliers, including architects. Smaller or internal projects make use of the in-house estates teams for ‘design’ instead of architects. Other ‘safe’ relationships include choosing a company or a person who have been worked with before. However, better managed healthcare trusts take more risks and are more likely to consider innovation. Mistakes can be still made (as can be seen from the long list of NHS enquiries and reports; e.g. the Francis report), but failure can be a positive thing because improvements also come out of a rigorous examination of failures. In 2018, the Good Governance Institute organised a round table about the differences in the appointments of artistic and medical directors. For arts organisations, the artistic director leads the strategy, balancing risk appetite while pushing the brand image, for the medical director (and other executive staff), strategy is driven by finances, risk avoidance and regulatory compliance. Thus, the end results are very different.- one is expansive and the other is restrictive.

Silos
Effective design solutions require collaboration between healthcare team members – but there are often information silos in hospitals, nursing data is not shared effectively between departments. Architects are used to working in teams and therefore they might find the healthcare working environment very strange. Furthermore, many capital developments are estates led rather than strategy- or service-led, leading to operational problems. Existing pressures on facilities and opportunistic approaches can lead to poor decision-making on long term capital projects and strategic planning. Presently, the NHS estate is scattered across 250 trusts and foundation trusts, NHS Property Services and Community Health Partnerships, which are located within hundreds of areas called Sustainable Transformation Plans (STPs) and Integrated Care Systems (ICSs). However, the organisational set-up of hospitals can also impede the deign process. In the past, trusts were encouraged to compete both internally and externally and this mentality continues. In one trust based in London, such competition led to death, and a 2018 enquiry found that internal scrutiny of the department was ‘inadequate’ and the surgeons were split into two camps exhibiting ‘tribal-like activity’. But this is not new. In 1930 Gordon Friesen, the Canadian hospital planner, said ‘most hospitals today are made up of little kingdoms, all ruled by influential staff members. Now, if you ask each of these people what they need, they will ask for things which perpetuate their kingdoms.’ Design engagement with different teams within the healthcare provider can become difficult due to this attitude.

Reorganisation
Healthcare, particularly as delivered by the NHS, has been restructuring almost since it was formed due to increasing demand and decreasing money. Reorganising is perceived as progress, as in this satirical observation: ‘every time we were beginning to form up into teams, we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralisation.’ Even more capricious have been hospital management systems which affect healthcare estates. The NHS leases estates from local authorities, private companies and PFI providers, while thousands of individual GP Practices own their own premises. Such disparate elements affect the NHS’s strategic capability for capital planning. The pace of policy change far outstrips capital development plans, while timescales for strategic plans and capital developments are rarely aligned. There are very few individual organisations that have appropriately trained board-level estate leads (let alone architects or planners) to be able to engage effectively across the system. Though this constantly changing landscape is difficult to navigate, it may also help to open up areas for future work in healthcare design.

What can architects do for future healthcare design?

Healthcare design presents a strange conundrum. While medical technology and delivery have become smaller, faster and more portable, they are used inside cumbersome buildings that are difficult to adapt and use. But this is exactly why the architects role in healthcare will continue to evolve and become increasingly important, as hospitals seek to find value for money with ever-diminishing capital budgets.
The value of design may not be something that is understood by the staff, who are used to working in the most challenging circumstances. Although admitting that users are heavily influenced by the environment in which they work, a British doctor justifies this situation: ‘We know that fellow professionals can and are achieving wonders in helping patients in the most primitive accommodation and circumstances around the world. I suggest we should not only be grateful that most of us are not trying to practise under conditions of open warfare, flood, fire and famine, but should make the very most of our (for the most part) privileged clinical and professional environments.’ But as the NHS is the largest single employer within the EU, employing 1.5 million people, it is morally unacceptable to make them work in poor environments. Plus, as we will read later, this also makes for poor patient experience and endangers patient safety.
According to a survey of medical professionals in the US in 2014, 85 per cent of them did not receive any information about the impact of buildings upon health, even though they knew that the buildings have an effect on the occupants. The authors of the report concluded simply that architects and designers should continue to connect with clinicians. The NHS used to have a Chief Architect, but the role played by architects in the public sector has diminished. Though in 2019 the Ministry of Housing Communities and Local Government has created a new post of ‘Head of Architecture’, knowledge about architectural services is very poor. In a survey conducted by YouGov in 2012, 15 per cent of Britain’s population did not know what an architect does. Twenty-two per cent did not know that architects prepared detailed construction drawings for building projects, 48 per cent did not know that they prepare building specifications, while 72 per cent didn’t know they applied for planning permission.
Design is not a subject taught in school in the UK. In life, price is usually valued over design, a mindset ingrained daily through habit. Quantity is valued is valued and understood more than quality. This might explain why more accountants and quantity surveyors sit on the boards of NHS trusts, than architects, designers, artists or psychologists.
The general assumption is that design means how something looks – as an NHS executive put it to me, ‘I care about functionality, I don’t care about design.’ Steve Jobs explained the paradox: ‘Design is a funny word. Some people think design means how it looks. But of course, if you dig deeper, it’s really about how it works.’ Within healthcare, beauty is viewed as a frivolous matter – an unnecessary, expensive thing.
If saving money is a big concern, then an increasingly relevant area where architects can contribute is the design of sustainable buildings for healthcare. Hospitals are very energy-intensive buildings, and need air-conditioning, lifts, water purification, incineration of bio-hazards and other services. If healthcare were a country, US healthcare would be the world’s tenth-largest carbon dioxide emitter. Goals can be set towards the best possible energy rating (LEED or BREEAM), whether the building is new, an extension or a retrofit. This is not just for economic reasons but also for the wider social responsibilities of a healthcare building.
Sustainability is embedded in the NHS constitution with an emphasis on ‘the most effective, fair and sustainable use of finite resources’, yet it is responsible for 18 per cent of carbon dioxide emissions of non-domestic buildings in the UK – 30 per cent of all public sector emissions. Twenty-two per cent of these come from building use, 18 per cent from travel and 59 per cent from procurement. It is perfectly possible to cut these emissions particularly those relating to energy-intensive procurement, by sources products and services that are climate friendly and ethical. In fact, the NHS supply chain provides a code of conduct for this, but it doesn’t seem to be used effectively because cost savings are prioritised. However, energy costs are expected to increase at a rate above inflation, demanding an increasing share of NHS budgets. It has been estimated that energy-efficiency measures could cut this bill by up to 20 per cent, saving the NHS UK pounds 150 million each year. So, saving the planet can also save money.
However, this requires capital investment of up to UK pounds 1.5 billion (based on a 10-year payback) – this may significantly add to the existing backlog maintenance. The Department of Health provided only UK pounds 49.3 million in 2015 for over 100 energy efficient projects to 48 NHS organisations in England, so this is a significant shortfall that needs to be made up over the coming years. But it is also possible that a well-designed passive building might not need solar panels or other gadgets.
Clean water is one of the scarcest resources on the planet but vital to modern healthcare, so efficient use of water could yield significant savings for the NHS. An exemplary water-saving programme at Guy’s and St Thomas’ has reduced the trust’s water consumption by nearly 20 per cent, and this saving of UK pounds 120,000 went to the charity WaterAid to provide safe water and sanitation in Nepal. Great Ormond Street hospital has also introduced rainwater and grey water recycling.
As the theory of culture lag suggests, alteration of values is likely to be slow and evolutionary, while changes in material culture are quick and revolutionary. This may explain why the NHS in particular is quick to embrace technological changes (material) but not design advances (value). The challenge for architects is to convince healthcare providers that good design involves the delivery of all the things on their ‘worry list’ – that design is a way of improving health. The authors of a paper titled ‘Architects, Urban Design, Health and the Built Environment’ propose that there are three types of architects: architects (who) desire to be the star of the moment (fashionistas), those who focus on the improvements of functions for humans (life improvers), and those who focus on creating packages that include both a design and the services that accompany it (object-service packagers). They say that the future of healthcare architecture lies in the third role of object-service packagers, i.e. those who focus on bundling objects and services related to improving health. This collective approach should be the goal for governments, clinicians, patients and architects all over the world.

Design as way of solving healthcare problems



The focus of the healthcare facility should be on the patient first, and processes should follow. The human body as a ‘machine’ was described by Descartes in his book Treatise on Man (1662), while Le Corbusier called the house a ‘machine for living in’. In the same vein, hospitals can appear to be like factories. Design processes used by the car industry are often replicated in the NHS to show efficiency and cost savings, but patients are not cars. Furthermore, a healthcare facility is not a sealed environment like a car factory. How can the design process of healthcare buildings become more humanised?
A design tool from the Design Council is the ‘Double Diamond’. Four stages are organised to create a system of designing. The expansive phases of the Diamond represent the divergent thinking that embraces many issues, while the pinch points represent the coming together of those ideas and thinking – the convergence. The Double Diamond indicates that this happens twice – once to define the problem, and then to define the solution. However, this approach imagines the architect being a team leader, like in a traditional contract. Today, most healthcare buildings are procured by D&B, or via a Framework, so this has been adapted to current healthcare procurement.
  • Understand: Understand the specific concerns of the healthcare provider, be it specialist, acute, general or community care. Remember, what underpins good healthcare design is good patient experience.
  • Uncover: This would be the initial survey of design requirements for the healthcare facility. This stage is about revealing the fundamental blocks to making the desing patient-centered and thinking outside the regulatory box.
  • Unite: This is the inch point, where understanding the concerns leads to the formation of a ‘vision’, literally the coming together of the understanding of the project and an aspiration in as simple words as possible, such as ‘A hospital that doesn’t feel like a hospital’. A good vision will unite all users – staff, patients and visitors.
  • Uplift: The role of the architect in a healthcare environment is to provide an uplifting design based on a creative vision for the facility. This may be challenging due to the past constraints and habits, particularly the tendency towards risk avoidance and therefore going for what is safe.
  • Use: The intelligence and evidence gathered so far should provide the design solutions that unite and uplift all users.

In a survey in 2011, Patient Opinion analysed the 537 most critical responses of the 2,537 negative comments it received. The top complaints were about staff attitude and waiting times, regardless of the type of hospital. Can architects help to find design solutions for these two problems? Hospital staff must provide both medical and psychological support patients, sometimes in traumatic situations. Staff working night shifts suffer from sleep deprivation and stress. In addition, many staff suffer from musculoskeletal disorders as a result of lifting and stretching, and from hospital infections. Woking in such conditions can affect staff attitude.

The above extract is from the book “Future Healthcare Design” from the chapters “Introduction” and “The Brief and the Process” by Sumita Singha and is presented here for my Healthcare Architect readers. This very good book is available on Amazon.in at a reasonable price.
     

For Health, You Needn’t Have Wealth

By Dr Devi Shetty
Here’s how govt can ensure very affordable health insurance, including for outpatient care, for hundreds of millions of Indians who are neither poor nor rich
Countries that have managed ‘universal healthcare for free’ through taxation have three things in common. They are invariably small countries with a high tax-to-GDP ratio of more than 30% and spend more than 10% of their GDP On healthcare.

India is the world’s most populous country with a tax-to-GDP ration of 11.7% and spends 3.16% of the GDP on healthcare. The government’s contribution is 1.28% and out-of-pocket health expenditure is 1.52% of GDP. We can’t expect the government to enhance budgetary allocation to healthcare significantly.

Fortunately, the Ayushman Bharat scheme covers the population living below the poverty line. But what about the millions of Indians who are one medical bill away from slipping into poverty?

Although 300 million middle-class Indians cannot afford to pay for the hospitalisation, they can pay for affordable health insurance. So, our national narrative should change from ‘universal healthcare’ to ‘universal health insurance’-which should cover primary, secondary and tertiary care through integrated health insurance.

In the integrated health insurance model, hospitals will become the health insurance providers and work hard to ensure that members don’t fall sick to save money, thereby aligning the interest of the patients and the hospitals. This will also address the patient’s fear of unnecessary procedures.

Why change from current health insurance which pays for hospitalisation to integrated health insurance?
About 14% of the heart surgeries performed in India are done by our group of hospitals-the more people develop heart attacks the better it is for our business. There is absolutely no incentive for us to keep people healthy. In reality, in any business, if the interest of the customer and the service provider is not aligned, there is no trust.
In the integrated health insurance model, hospitals will become the health insurance providers and work hard to ensure that members don’t fall sick to save money, thereby aligning the interest of the patients and the hospitals. This will also address the patient’s fear of unnecessary procedures.
Why is primary care very important?
About 30% of Indians visit primary care physicians at least twice a year. Over 60% of healthcare expenses are due to outpatient care which most health insurances do not cover. Uncontrolled diabetes and blood pressure which lead to heart attacks, brain strokes, and kidney failures can easily be controlled by hospitals online. With early detection, most diseases can be cured.

What is the ideal integrated health insurance model?
By trial and error, the aim should be to achieve an integrated health insurance model with an annual premium at about Rs 8,000-10,000 for a family of parents and all the children less than 21 years. Parents should undergo health check-ups costing about Rs 15,000 by paying a token amount of Rs 1,000. Health screening is very important for early detection.

Apart from unlimited outpatient coverage families should be covered for multiple admissions up to Rs 10 lakh and single admission up to Rs 50 lakh, to cover complex procedures like transplants and artificial hearts.

Health insurance experts will certainly disagree with the amount of premium. That was our experience 17 years ago when we conceptualised “Yeshashwini’ micro insurance in the state of Karnataka. We believed that if every farmer in Karnataka paid Rs 5 per month, they could be covered for any surgery from cataracts to heart surgeries at over 700 hospitals. The state government launched the scheme through cooperative societies and became a reinuser and then the magic happened. At the end of 12 years 1.21 million farmers had surgeries and 1.3 lakh farmers had cardiac procedures just by paying Rs 5/month.

How do we make health insurance premiums affordable to the middle class?
‘Health Savings Account’ is a platform for people to save money to pay for healthcare which is implemented successfully in many countries.
  • In India with over 90% of the workers employed by the unorganised sector, HAS can be implemented by converting ABHA (Ayushman Bharat Health account) into a wallet funded via UPI, so HAS and electronic medical records can be captured digitally in one place.
  • The unorganised employer should contribute Rs 100/month or more to the employers HAS account.
  • Employer, employee or donors’ contribution should be exempted from taxes and the money used only for buying health insurance.
  • A few thousand rupees of contribution to HAS will offer few lakhs of benefits to the deserving family.
  • This will be the first step in shifting unorganised workers to the organised sector.
  • If 18% GST on low-cost health insurance premiums is exempted, then the health insurance providers can arrange interest-free loans for the premiums through NBFCs.
Yes, the magic will happen:
For social upliftment we believe the government should utilise the power of creating a regulatory framework for the private sector to innovate, take risks and deliver rather than spending the money directly. If 100 million middle-class families contribute Rs 10,000 per year as the health insurance premium, Rs 1 lakh crore can be raised which is more than the health budget of the government.

In a short period of time, we have grown from radios to colour TVs with a few hundred channels, from no phones to smart phones, and emerged as the world’s largest online payment provider. With an affordable digital health insurance platform, we can become the first country in the world to disassociate health from wealth in just five years and prove to the world that the wealth of the citizens has nothing to do with quality of healthcare they can enjoy. This is the power of India with 1.4 billion people managed by the government with a vision and belief in technology.

This article taken from the newspaper The Times of India, Monday, January 30, 2023.

The writer is a cardiac surgeon and Chairman and Founder, Narayana Health.




Sustainable Design: Ecodesign: What and Why



As designers we have a divided set of responsibilities. Professionally and contractually, our primary obligation is to our clients, including a mandate to protect public safety. Artistically and financially, we also have certain obligations to ourselves. Beyond these, though, we have a duty to the public in a larger sense than the safety issues that licensing addresses. That ethical responsibility, which considers how our built designs affect the world, is both professional and personal.

One way to view this is to interpret public safety as encompassing environmental issues, for without the support of the Earth’s ecosystems, human life would be threatened. We could not survive without the air, water, and atmospheric protection that our exquisitely tuned planet provides. Our lifestyles, if not our lives, are reliant on the “free” ecological services – oxygen creation, water filtration, nitrogen fixation, etc. – that we too often take for granted. It is by no means a leap, then, to say that a primary

Its become a truism that green design is a valuable and necessary goal. But it’s worth taking a few moments to establish just how important it is, before getting to what it is. Buildings are not only the cause of ecological issues. Blame can be shared with population growth, transportation, industrial agriculture, carnivorous diets, and our sometimes irrational desire for ever more stuff. How important are buildings in this gathering storm?

In 2003, Edward Mazria, who was a green architect before such a category existed, looked closely at the statistics of energy consumption in the United States and concluded that the role of buildings was far greater than expected, amounting to 48 percent of U.S. energy consumption and 46 percent of U.S. carbon dioxide production. These statistics convey a significant point: climate change and other environmental issues are not somebody else’s problem: they are ours. They are not issues to be passed off to the worlds of governrnent, though they, too, bear a large part of the responsibility. Buildings are put creation, and with that comes the need not only to make them durable, functional and good-looking but also to ensure that they are good citizens.

Marzia’s numbers were eye-opening for the architecture and design community, sparking renewed concern over the role of buildings in our energy usage and dependence. Shortly thereafter, the film An Inconvenient Truth drew further attention to these issues. In the process, though, other no-less-than- important – such as water pollution and usage, resource consumption, the effects of toxic materials, and social and ethical dilemmas – have sometimes been de-emphasized. While energy conservation and alternative energy development are indeed critical, a more holistic approach to design and construction is needed. The more encompassing objective is to ensure the well-being of our communities and the ecosystems that surround them for current and future generations.

And when we adopt this broader vision, we can begin looking anew at additional questions, asking what the role of a building should be. We tend to view buildings as discrete, individual objects inserted on the planet. A holistic view would see them as systems both unto themselves and inseparably tied to surrounding ecosystems.

Redefining the role of buildings and our relationships to them can take us in new directions artistically (what does an ecobuilding look like?) and beyond if we are modifying the goals of design to change what it is designers do.

The Beginnings of Green Design

What do we actually mean when we talk about green design, sustainable design, or ecodesign? Generally speaking, we can apply these terms interchangeably. While there may be nuanced differences between them, I find it more helpful to think in terms of what we are trying to achieve.

Ecodesign has evolved considerably from its 1960s origins, captured in the phrase “reduce, reuse, recycle.” The catchiness of the now ubiquitous three Rs helped immensely in expanding awareness, but that same simple edict has led some people to conclude that once they’ve recycled their bottles and newspapers and converted a light bulb or two, they’ve done their part.

Similarly, designers who have included three R-type type thinking, which can be thought of as the first level of ecodesign, may feel that their jobs are done. These are the tweaks described earlier, incremental changes that, while positive in general, do not go far enough because their goals are too limited or because they look at issues in isolation instead of holistically.

Cradle to Grave


To get beyond this crucial but narrow starting point, the concept of ecodesign has to be broadened. The first step in achieving this is to look at what is called, somewhat inaccurately, the life cycle of building and materials. Life cycle analysis (LCA), also known as life cycle assessment, has been applied more frequently to products, but the principles also apply to buildings. The life of the product (or building) is examined from cradle to grave; that is, from the origin of its raw materials to the manipulation of these materials during manufacturing, to the consumption of energy and resources during its useful life, to the impact of its eventual end of life.

At each phase of the life cycle, there are material and energy inputs and corresponding environmental impacts. An LCA attempts to quantify all of these inputs and then come up with values to represent their impact. By analyzing the results of an LCA, a designer can evaluate where to improve or modify a creation; is it, for instance, more beneficial to increase energy efficiency, replace toxic materials, or convert to recycled materials?

The cradle-to-grave approach, while more encompassing than the three Rs, still has limitations. The use of the word grave implies that buildings and products have a linear life span. In this sense, life cycle analysis is a bit of a misnomer. Another shortcoming, in the words of ecodesign advocates Bill McDonough and Michael Braungart, is that the cradle-to-grave approach amounts to merely “being less bad.” It enables us to see and reduce the overall impact of what we build, but it does not get us to the goal of sustainability.








Cradle to Cradle


Putting the cycle back into life cycle analysis is the next conceptual leap we must make. This represents an expansion from cradle-to-grave to cradle-to-cradle thinking. Though this idea was popularized by McDonough and Braungart in their book Cradle to Cradle: Remaking the Way We Make Things, it has deeper roots, perhaps originating with Buckminster Fuller’s Operating Manual for Spaceship Earth, in which Fuller compares the Earth to a spaceship starting its journey with a finite amount of resources that cannot be resupplied. This concept was driven home in 1968 by the iconic image from Apollo 8 of our planet isolated in space. With that photograph in mind, pondering how we make things and where the materials come from will quickly lead to a visceral grasp of Fuller’s prescient point. Our materials (iron, coal, oil, agricultural nutrients, etc.) as well as the air and water we require for life, do not get replenished from outside the Earth’s closed system floating through the universe, Everything we have and ever will have is, in one form or another, on the planet now. (Given the tremendous cost and energy of spaceflight, we are unlikely ever to bring back useful quantities of materials from other planets.) Therefore, to be truly sustainable, we must never use up resources faster than the Earth’s ecosystems can replenish them.

However, there is one critical exception. Because solar energy is constantly replenished, falling on the Earth every day, we can use it without fear of running out. This includes energy derived directly from sunlight, as well as related renewable sources, such as wind and biofuels, that would not exist without the presence of the sun and, by loose extension, tidal and geothermal energies.

Prior to humanities presence, the Earth existed with the fundamental constraints for eons and therefore developed ingenious systems in which nothing is ever discarded. If it had not, some resources would have been exhausted over time. But nature is an expert at efficiency and symbiosis and long ago demonstrated a concept that we verbalized only recently: waste = food. This doesn’t refer literally to food that we throw out, but to all kinds of waste – organic, inorganic, industrial, residential – and signifies that everything we think of as garbage must become an input for another use. Landfills, by this measure, are wasted resources, a sign of gross inefficiency, and they represent a failure to follow the instructions in Fuller’s Operating Manual.

McDonough and Braumgart divide everything we might consider waste into two primary categories: biological nutrients and technical nutrients. Biological nutrients are materials that, after we are done with them, can be safely returned to the earth and therefore need to be kept in cycles of usage – they need to be recycled. Petroleum-based plastics are a good example.

There are also materials that are both unrecyclable and unsafe to put back into ecosystems (e.g., nuclear waste and toxic chemicals). Because these are so expensive to deal with and because they have no place in a cradle-to-cradle system, these are to be avoided at all costs. Composites of materials that cannot be separated after use and so cannot become either biological or technical nutrients are also problematic. McDonough and Braumgart call these “monstrous hybrids.”

The Triple Bottom Line


So far, we’ve been looking at green design in terms of environmental impacts. True sustainability, though, requires us to broaden our definitions to include aspects of how we live. How are the people who make things treated? How are their communities affected? How are the economic and social inequities among regions of the world dealt with? How do our buildings affect their occupants and local communities? This can be thought of as the fourth level of ecodesign, building upon the ecological foundations of the three Rs and the cradle-to-grave and cradle-to-cradle approaches.

In conventional business practice, the standard gauge of success is the bottom line: is the company making money? In the world of green business, an alternative gauge has evolved. The triple bottom line concept adds two criteria alongside the financial one: how the planet is treated and how people are treated. The three bottom lines are frequently referred to as “people, planet, and profit” or “ecology, economy and equity.”

Putting numbers to ecology and equity is a very complicated and controversial process, but the concept that good business (and, as a corollary, good design) embraces these aspects of sustainability is not. In practice, this concept can have several interpretations, ranging from not buying products made affordable only because they are produced by people who are not paid “living wages” to adopting social programs and design approaches like those of the Rural studio, the Make It Right Foundation, or Architecture for Humanity, which promote “design for the other 90%.”

This also brings us back to the fundamental question of what sustainable design is and what it’s goals are. The classic definition of sustainable design actually derives from a United Nations committee’s description of sustainable development. Substituting “design” for “development” in their definition, we get “design that meets human needs while preserving the health of planetary life.” A balancing act, in other words. How do we provide for ourselves now without destroying the ecosystems that will enable future generations to survive? What, then, does the goal of sustainability mean? Is it a useful term in communicating the intentions of ecodesign? What are our goals? The most basic of goals is to survive. Chances are that your primary survival needs – food, water, air and sleep – are pretty well fulfilled. Once these are assured, the objective becomes providing the means to continue to survive. The conventional precepts of ecodesign involve setting the stage so that the things we need for survival are not in short- or long-term jeopardy. The loops are closed, and we take no more from the environment than can be returned or renewed.

But we need to question whether sustainability is truly our ultimate goal. If we define sustainability as the means to continue to exist, is that really a sufficient aspiration? Many would argue that our reasons for existence, both as individuals and as a species, go beyond this to fulfilment in interpersonal or community or intellectual or spiritual senses. This state of fulfilment might best be termed flourishing and raises the accompanying question: how does design enable us not merely to sustain but to flourish?

If sustainability is not an adequate goal, what should we call this? What term could describe the attempt to go beyond “being less bad” and beyond “mere” sustainability to get to a point where design is not just minimizing negative effects but is encouraging positive impacts? There’s no consensus on this so far. One way to describe it might be “positive design,” defined as the creation of an object or system that contributes to the fulfilment of real human needs while preserving or complementing the natural world.

This definition is not earth-shatteringly different from the one we started with, but it modifies two things. It refers to “real” human needs in order to differentiate needs from wants (flourishing would be a need; a larger television would be a want). In relation to architecture, this might mean addressing social and equity issues (such as the needs of low-income groups) or, on another level, analyzing the nature of the spaces we create, looking at what they add to or how they detract from our lives.

Regenerative Design

The second modification of our earlier definition of sustainable design adds “complementing the natural world,” as opposed to simply maintaining it. The previous definition stated that the health of the planet should not be compromised but said nothing about repairing the damage that has already occurred.

This leads us to the ultimate level of ecodesign: taking care of all our current ans future needs as well as those of our planet (they are inseparable) and repairing those areas of our ecosystems that have been compromised or destroyed by human endeavours. This is no small goal in light of the demands we put on our ecosystems and the way we continue to view ourselves as separate and independent from the Earth. Examples of regenerative design (which is sometimes called restorative design), therefore, are hard to find. Some candidates include the reclamation of New York City’s former landfill into a park with restored ecosystems and the dumping of (and stripped) subway cars offshore to help rebuild coral reefs.

The Cost Issue


We tend to look at the case for green design in terms of avoiding negative impacts. On the flip side, we can look at the positive impacts instead. The environmental gains are often obvious. Less apparent, though, may be construction and operating cost benefits. The commonly accepted view is that green design and construction are more expensive, often prohibitively so. But more and more studies are showing that green buildings can cost the same or even less than conventional ones, providing some fundamental green design concepts are applied.

In a conventional design process, the architectural work typically occurs first, followed by engineering and then construction. Often, however, this approach results in missed opportunities because of the lack of input from and coordination with all the parties involved in the project. Integrated design is the alternative process of including all primary contributors from the beginning, before design begins. Frequently a collaborative workshop called a charrette is held, and the entire project team – including consultants, owners and contractors – meet to propose and discuss fundamental ideas. This has the dual purpose of making sure all parties are aware of hat everyone is doing and, perhaps more significantly, encouraging brainstorming in which new solutions can arise.

For example, an architect’s decision to specify triple-pane windows, which provide extra insulation but are more expensive than standard windows, will increase the construction cost. However, the specified windows will decrease the heating and cooling loads. If the mechanical engineer is involved in that decision, he or she may downsize the heating, ventilating and air-conditioning (HVAC) systems, offsetting the cost of the windows.

The new high-efficiency windows may also result in future savings in the form of lower utility biils. In many budget decisions, though, only first costs are considered, a short-sighted approach that saves a few dollars upfront while incurring much larger costs later on. Taking the long-term view, though, is especially difficult in cases where the building will be turned over to someone else after completion or when the occupant rather than the developer will be paying the utility bills. But even then, studies have shown that a building with lower operating costs will usually command a higher sale or rental price, justifying the initial costs.

Analyzing long-term costs involves looking at return on investment (ROI), sometimes referred to as the payback period. To give an overly simplified example, if installing a $20,000 solar panel leads to a saving of $2,000 per year in utility bills, the payback period is ten years. A real ROI calculation also takes into account inflation and interest rates and attempts to anticipate fluctuations in the cost of energy. Looking at the hard numbers of an ROI sometimes yields surprising results and tells us where to find the low-hanging fruit. For example, Kendall-Jackson, a winery in Northern California, has been undergoing a business-wide green conversion that examines all aspects of its operations, ranging from lighting to irrigation to pest control. The company found that many of its green programs resulted in very short-term payback periods. Upgrading their lighting to more efficient sources led to a 50 percent reduction in electrical usage and an ROI of less than a year. Better controls on landscape irrigation, combined with planting native and drought-resistant species, yielded an ROI of just two years.

Further Benefits

There are other categories of ongoing potential savings that can more than justify the price of green design. For most businesses, the costs of labor far outweigh the cost of building and operating a facility, and design decisions that result in reduced labor costs can have quite a significant effect. Many studies have shown that incorporating increased day-lighting, improved artificial artificial lighting, or better ventilation and air quality, to cite a few examples, increases productivity, decreases employee sick days, and lowers employee turnover. If the building is residential, making it healthier can create other benefits, both tangible and intangible, such as reduced medical costs and fewer days when children are home sick, keeping parents from work. We’ll look further at this in “indoor air Quality.”

Not to be left off the list of the advantages of green design are the positive effects it can have on its practitioners. It is tempting to see this new part of design as an added burden, requiring additional knowledge, coordination, time, and, if you’ve been practicing conventional architecture for a while, changes to the way you work. The other side is that it can open up unexpected paths: new clinets, fresh design influences, and increased personal satisfaction.

All told, the common perception that ecodesign is more expensive for clients and a burden for designers is more often than not incorrect. Hen ecodesign is incorporated well, e get a in-win situation in which everyone is better off. You don’t have to be a tree hugger or an altruist to incorporate green design. Green design, as it has been suggested, should just be good design.

The other misconception that we need to dispel is that ecodesign is a passing trend. Yes, we ent through this once before in the 1970s. After that energy crisis abated, after the gas lines disappeared and oil prices fell back to “normal”, the interest in conservation waned, too. Now, in the midst of what might be called the second generation of environmentalism, I think it’s fair to say that it’s not a fad this time. Very few people expect energy prices to remain low or to do anything but go up in the long term. And on the regulatory side, more and more municipalities are requiring energy- and water-efficient design. Sometimes this is just for government-owned buildings, but increasingly, codes are being updated to incorporate environmental efficiency for all buildings. Ecodesign is becoming impossible to ignore; not only is it financially wise, but it may also be required.

The above extract is from the book “Sustainable Design: A Critical Guide” from the chapter “Ecodesign: What and Why” by David Bergman and is presented here for my readers who, like me, are interested in Sustainable Design. This very good book is available on Amazon.in

COVID-19:Coverage + Resources

https://www.healthcaredesignmagazine.com/trends/perspectives/covid-19-coverage-and-resources

As the COVID-19 outbreak unfolds across the U.S. and world, the healthcare design community is being called to action. Industry members are now navigating challenges ranging from combating limited resources and ICU/isolation beds to constructing temporary facilities and testing sites, all while maintaining a constant eye on infection control across scenarios.

Healthcare Design will continue to monitor the situation with an eye on design and the built environment, and the role each plays in how the pandemic is managed.

Here, you’ll find an updated list of COVID-19-related articles and news items as we publish them. Additionally, we’ve compiled archived content from Healthcare Design on topics including infection control and prevention as well as biocontainment.

Riverstate Hospital-PortHarcourt-Nigeria:AutoCAD Plans

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SPACEMED-Quick Calculation Template

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SPACEMED-Planning Templates

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SPACEMED-Essentials

https://blog.spacemed.com/

Online Healthcare & Medical Courses –FutureLearn

https://www.futurelearn.com/subjects/healthcare-medicine-courses

 

These are some of my favourite musicians and here they sing about my life and beliefs.

Mountain Jam – Duane Allman
They Call Me the Breeze – J.J. Cale/Eric Clapton
Flying Without Wings – Westlife feat. BoA
Ripple – Dead & Company
Stuck in a Moment You Can’t Get Out Of – U2
Free Bird – Lynyrd Skynyrd – Live
Walk Tall –John Mellencamp
Wasted On The Way – Crosby, Stills and Nash
The Road to Hell – Chris Rea
Shine On You Crazy Diamond – David Gilmour
Lives in the Balance – Jackson Browne
I am a Patriot – Jackson Browne
Just Older-Bon Jovi
Come Undone- Robbie Williams
Child of the Universe – Barclay James Harvest

Hospital Design Guide: How to get started

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The Architecture of Health:Hospital Design and the Construction of Dignity
Michael P. Murphy Jr. with Jeffrey Mansfield and MASS Design Group
Inpatient Floor Plans
The design process for a hospital starts with the layout of the inpatient floor plan (to put it simply; you will need at least a tentative mental picture of the diagnostic, therapeutic, interventional and building services floor plans as well.)

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Building Type Basics For Healthcare Facilities
On The Design Of Inpatient Care Facilities
Michael Bobrow and Julia Thomas

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Reflections on Architectural Design – Drawing: Making Love to the Paper BYT-2BYT-4
The act of drawings seems particularly important to many designers.I actually find it hard to think without a pen in my hand and at least four more inmy pocket. The act of making marks on paper mediates the flow of words. Donald Schon has referred to the architect as ‘having a conversation with his drawing’. This seems to be what Denise Scott Brown, the wife and professional partner of the architect Robert Venturi, means by the ‘eye re-interpreting what the hand has done’. The drawings designers make while thinking are frequently diagrammatic in the sense that they are not attempting to indicate three- or even two- dimensional form. Even organizing the brief is a graphically aided activity for Herman Hertzberger, architect and editor of the highly influential Dutch architectural magazine, Forum. I make notes during meetings in the form of little doodles, an attempt to use even text artistically, often switching between black, red and blue felt pens. With felt pens you can stroke the paper, a feeling akin to touching your mistress when the drawing is going well. Like I said. BYT-2BYT-4
Frequently, drawings are overlaid and mixed together. Two-dimensional plans or sections can be seen with sketches and more diagrammatic marks all on the same piece of paper in what appears to be a confusing jumble. (Remember the ‘juggling’ of issues in the previous article?) Richard MacCormac (him again?) talks of his “thinking pencil”. It is definitely true that designers need to draw in order to think, and perhaps we could conclude that a failure to draw might indicate a gap in thought. The drawings I make while thinking define the problems I find and thus are related to the problems I solve. These are serious drawings, lean and mean, they try to clarify and communicate. They are not drawings as in ‘art’. At least I try not to let them become that. Many times I am have been guilty of being seduced by the drawing to the point of designing the drawings itself rather than the object it represents. Just having fun. My felt pens are almost a part of me, I travel with them, the relationship is close, very natural, such a contrast to my awkwardness with people. I love my felt pens. BYT-2BYT-4Richard MacCormac (I can hear you going: tch!) makes explicit reference to the role of the drawing tool as a way of mediating an appropriate cognitive phase. “These different frames of mind involve different instruments for producing and representing what you are doing.” What this suggests is that somehow the feel of the instrument in the hand and the way it interacts with the paper induces the right mental set. Marshall McLuhan taught us that the “medium is the message”, but for designers it seems that the medium is related to the frame of mind. (I am most at peace and very tranquil when I have a yellow ochre felt pen in my hand.) There is a sense of immediacy about drawing lines on paper that I think only a designer or an artist can feel. I like designing most of all on white A2 paper on a writing table. No backs of envelopes during plane journeys for me, I like to design in comfort and let the drawing breathe. No standing at drafting tables either, had enough of that, I’ve paid my dues. It’s only about having fun from now on, stroking and getting stroked. Hussain Varawalla, Senior Fun-Lover, HOSMAC (India) Private Limited, Mumbai. This is the way I like to do it:Just like that. BYT-4











Reflections on Architectural Design – Speed of Working: ‘Capturing the Violence of the Idea’ BYT-2BYT-4
The French designer and architect, Philippe Starck, has a reputation for working extraordinarily quickly. He claims that while travelling by plane on one occasion he designed a chair during the period the seatbelt signs were on for takeoff. He says working at this speed allows him to ‘capture the violence of the idea’.
In my experience of plane journeys, when the seatbelt signs are on for takeoff, the only thought in my mind is that of the discomfort and boredom of the journey ahead. Mr. Starck must be travelling first class, a design opportunity I have yet to experience. Having said that, I too subscribe to the idea of the design process at its best happening in a creative rush. I recently described the experience to a client (a psychiatrist) as akin to a cocaine trip. I think it made him just a little bit nervous as to who was (or would be) using whose professional services. Also, I get impatient and thus upset with the good people who give me drafting support at times like this, as the process of drawing never seems to keep pace with the sped at which the design pours out. Many times I have to apologize at the end of the day, when the dust has settled down, for any inadvertent offence given (but never taken, I think).
It is commonly held that creative work is characterized by periods of intense activity interspersed with times of quieter, more reflective contemplation. I confirm this as being my experience too. Some architects have described the periods of intense activity as being like juggling. They speak of the need to oscillate very quickly between the many issues with which an architect must be concerned. To take your mental eye off any of these issues is the equivalent of dropping a ball. This kind of concentration is extremely intense and difficult to maintain for long periods. I agree. Every evening I feel the need to contemplate seventies and eighties rock and roll, best seen through the bottom of a glass.
BYT-2BYT-4As Richard MacCormac (of MacCormac, Jamieson and Prichard, Architects, fame) puts it “one couldn’t juggle slowly over a long period”. This analogy, I think, describes the skill perfectly. I have found this to be one of the skills young architects find most difficult to acquire. However, they excel at endlessly debating within themselves a minor facet of the design. Each to their own, as I have always said.
Richard Burton, of the architectural firm Ahrends, Burton and Koralek shares this view. He feels the design process must work very quickly, this follows from his insistence that no one aspect of the problem should dominate. From his teaching and examining experience he identifies a failure to work quickly enough as one of the problems facing students trying to develop their own design process.
Michael Wilford, (previously James Stirling’s partner) refers to the “skill of prioritizing the stages at which certain inputs are valuable as distinct from an impediment to the process”. Creative inputs on design issues when construction documents are being prepared are not always welcome to those preparing the construction documents, and these fine people too are critical to the overall scheme of things, and must be kept happy. It’s not just about juggling, but also about knowing which balls to use, and when!
There is also the need to contrast the intensity of working in the group within the office with quieter periods of solitary contemplation. The need for longer periods of quiet reflection as well as the intense periods explains why the design process cannot be hurried and compressed without considerable loss of quality. Certainly, it has not been my experience that the quickest and cheapest design process will give rise to the most desirable result. Imagine trying to juggle too many eggs too fast. Undesirable results!.
In fact, bearing in mind the small part of the total cost of a building that goes on the design process, this is an entirely fallacious and counter-productive notion!
Dr Santiago Calatrava, one of an extremely rare breed of architect-engineers (he studied architecture at the Escuela Tecnica Superior de Arquitectura de Valencia in the Spanish region of Valencia and then moved to Switzerland to study civil engineering in Zurich), believes that design should have a ‘freshness and spontaneity’. He says this comes from working rapidly and intensively at certain stages of the design process. He talks about the tensions between the intense and relaxed periods of design and the need to fight for the idea and yet allow criticism of it. On the one hand it needs a lot of spontaneity and on the other it needs perseverance.’
Dr Calatrava has been awarded the Gold Medal by the Institute of Civil and Structural engineers. Way to go, Doctor! They need to be shown the light.
BYT-2BYT-4Although Dr Calatrava is undoubtedly a great artist and his work is highly personal he is not frustrated, as might be expected, by a process which necessarily involves so many other people. He thinks the architect should transmit a vision of something. I think it is very much about seeing and showing the Path, the Way, something like Gautama Buddha. Great design is about seeing the Light. And it not like it needs to be approached with the seriousness of a religion. As I have said before, and intend to keep saying, it is all about having fun.
The Boss, Bruce Springsteen, wrote a song called ‘Blinded by the lIght’. Somewhere in the middle it goes like this: “Mama always told me not to look into the sights of the sun…” There is a pregnant pause in the music, and then the next line goes: “Woah but but Mama-a-a, that’s where the fun is…” The refrain goes “Blinded by the light…” Oh well, that’s neither here nor there. It’s just a casual aside, lyrics from a song I heard years back. Our circumstance has changed since then. Do you think half-forgotten rock ‘n roll lyrics can define a vantage point from which to view the world? The first ten appealing answers will get their originators a CD of the Grateful dead titled “American Beauty” (American Reality?) as a prize. So think hard. To get back to mr Calatrava, he too speaks of the idea being not inside but outside him as some sort of distant light which offers a focus for the process. For him the design is largely linear. He does not normally believe in exploring alternatives and seems to arrive at the basic idea of a scheme fairly early on. For him this starting point can be remarkably fundamental. “Sometimes it is just a gesture or an idea about equilibrium, for example.”
I like to think that maybe sometimes it could be a funny thing that happened to him on his way to the office, for example.
BYT-2BYT-4Santiago Calatrava then represents a fusion of the worlds of the civil engineer and the architect. He claims that his imaginative structures do not necessarily cost more to build but admits they might take longer to design. He feels that to design too quickly and to look for the cheapest solution is both short-sighted in that this can destroy important landscapes, and is often not an economical policy in terms of lifecycle costs. Most of his work has been commissioned by public authorities who have been convinced by these arguments.
What I think he is saying is that you can make a good omelet without necessarily breaking (or juggling) a whole lot of eggs, if you do it with care and cook it over a low flame. Present and potential clients please note. Let us designers simmer.





Healthcare Architecture (as seen through) Ian Ritchie’s Eyes
taraIan Ritchie was born in Hove on the south coast of England. He studied architecture at the Polytechnic of Central London where he graduated with distinction in1972. He worked with a number of prominent architects, and in 1981 he formed Ian Ritchie Architects and co-founded the special design engineering firm of Rice Francis Ritchie (RFR) in Paris. Peter Rice is an engineer, and Martin Francis is an industrial designer and naval architect.

Ian Ritchie’s attitude towards the size and organization of his design office sounds very simple. He claims this is about the number of people who can basically communicate well together’. The number five figures strongly in his calculations. He feels groups of up to five work well on a design.To cut short the story, the result is a staff of 20 to 25 people who, as lan says ‘can actually all discuss around a table, especially when someone has a birthday’.

Heading the architectural design section of a healthcare consulting firm as I am, I too feel that smaller groups of people work better and with more intensity. Alienated as I am, there is actually only one person in the firm with whom I can communicate well (or rather excellently). S/he is not even an architect, not the big boss and not even one of my fellow directors. Odd, to put it mildly. Eccentricity is flaunted by many designers, and not only in their designs. My designs are anything but eccentric, models of rationality, rather. It’s more the clothes I wear and the company I keep. Anyway, BYT-2BYT-4 Robbie Williams sings in his song Better Man.

“. ..and I’m doin’…the best I can…to be a better man.” No surprises there. I too am trying to improve the quality of my wardrobe. I bought four long sleeved shirts one of which can be best described as ‘funky cool’, but what the hell, three out of four ain’t bad.

Why are we singing along with Robbie and discussing my laundry? This article is supposed to be about healthcare architecture seen through Ian Ritchie’s eyes. Let’s pay that some lip service, at least.

For Ian the design process begins with an attempt to construct a working relationship with the client. Before even discussing architecture, he tries to lead his client into his process. He says:

“It is very rare for a client to commission a building more than once in his life, except in the commercial sector. There is nobody who ever trains or deal with an architect. The first move is to talk through the brief, understand what has led to it, understand fundamentally what it is about.”

For me the design process begins with trying to find the time to design the damn thing .My clients are usually financiers and/or doctors wanting to build corporate hospitals, and the brief is easy to understand, fundamentally it is about making money through providing healthcare services. Jokes apart, that is more easily said than done. Financial planning has to precede any ideas about buildings. When I look at rows of figures they seem to be dancing to some kind of presumably divine music, so obviously I am only marginally involved in doing this financial planning. Fortunately for our clients there are good people in the firm who do this very well.

BYT-2BYT-4 Technology is an important factor in the financial planning and the architectural design of healthcare facilities. Ritchie, however, does not feel that technology is a design generator for him. He has clearly been asked about this before and describes his relationship with technology thus:

“When people ask me this question I use an analogy. I describe this beautiful parrot sitting on my shoulder — multicolored, very beautiful – called ‘technology’. Very often he leaps off the shoulder onto the paper and shits all over it before we’ve actually started thinking and you have to get hold of him and stick him back up here. He is tame, he does behave himself and he doesn’t always end up in the project at all, but he’s there and wet talk to him all the time.”

All I can say is it’s a good thing he jumps onto the paper to do his thing, otherwise we would be discussing lan Ritchie’s laundry along with mine, and his would not be ‘funky/cool’.

What does healthcare architecture have to do with beautiful parrots doing what they do? I’ll try to tell you. Technology can indeed do what the parrot with the same name does to your best laid plans for your healthcare facility, unless tamed. C T Scans are to be thought of as machines that help diagnose illnesses in much the same way your GP takes your pulse, and not as ravenous monsters that demand to be fed with warm bodies. The architecture, the interior design and the people the patient meets on his way to this monster need to be as reassuring and generate the same warmth and concern as the pulse-taking GP. Ian is right about that, and very well put too, he has a way with words, some people do. It’s an acquired gift.

Ian has a parrot on the other shoulder too:

“There’s a little one on the other shoulder called ’art’ or poetry’, he’s very powerful squeaks a lot but he’s not got the nerve of this one yet and that’s because we are still maturing into that field. It’s only been a few years since we’ve been working hard at it, so it doesn’t feel comfortable yet.“

BYT-2BYT-4That parrot’s also called ‘funky/cool’ and whenever I wear one of the funky/cool selections available in my wardrobe s/he sits on my shoulder too. Doesn’t shit on the paper or create laundry. S/he’s a parrot that is chilled out and we need Robbie’s help again in describing how s/he makes me feel:

“…so high you’ll be flyy..yyy…ing!” From his song titled She’s the One.

For Ian Ritchie it is the technology or function of the building which brings order to the art or poetry. For me it is music that brings order to my life. Living an orderly life then enables me to bring to bring technology, art, function (poetry?…working hard at it…) and above all order to my healthcare facility.

In conclusion, if you’re trying to design a healthcare facility (or, for that matter, any kind of building) attempt to keep bird-shit off your paper. Keep both parrots on your shoulder, where they belong.

And, you know, if either of them has just gotta go, it’s only laundry, after all.



Reflections on Architectural Design: The Central Idea
The ‘Central Idea’: Hang On To It Like Grim Death!
BYT-2BYT-4Good designs often seem to have only a few major dominating ideas which structure the scheme and around which other relatively minor considerations are organized. Sometimes they can even be reduced to one idea known to designers by many names but most often called the ‘concept’ or the ‘parti’. Such ‘central ideas’ inevitably emerge from early design explorations into the project.
In architectural design in general, these dominating ‘central ideas’ usually can be visualized almost immediately in terms of one or more kinds of architectural form(s) or architectural space(s). The ‘central idea’ for a healthcare (especially hospital) project may, however, be of a more complex nature, not so easy to grasp and not so easily visualized in architectural form or space. The ‘concept’, for a hospital building may involve elements of its proposed manner of financing, it may involve a separate ‘central idea’ about a building services framework which the designer, so to speak, can hang his hat on, and, in addition to the usual social and formal concerns will definitely involve an idea of the evolution and change of the building through a long time span.
BYT-2BYT-4In HOSMAC, we approach our projects ‘holistically’. We insist on our clients formulating a ‘statement of intent’ for the project. This forms a reference point for professionals of various disciplines working on the project to make decisions consistent with the project goal. Thus we see that this ‘central idea’ need not restrict itself to the process of architectural design. A.N. Whitehead in his presidential address to the Mathematical Association puts it rather succinctly:
“The art of reasoning consists in getting hold of the subject at the right end, of seizing the few general ideas that illuminate the whole, and of persistently organizing all subsidiary facts around them. Nobody can be a good reasoner unless by constant practice he has realized the importance of getting hold of the big ideas and hanging on to them like grim death.”
Time and again, however, I have been involved in projects where the client has a clouded vision of what it is he or she wishes to achieve, and this fogginess communicates itself to all those who are involved in the project, there is no ‘central idea’, there is no clarity of vision. And of all the various professionals involved I think it is the designers who feel the most frustrated by the aimlessness of the exercise.
BYT-2BYT-4Designers need to feel purpose.
The architect Richard MacCormac of the firm MacCormac, Jamieson & Prichard, referring to the ‘big idea’ keeping designers going through what he recognizes as a very fraught process, says:
“This is not a sensible way of earning a living, it’s completely insane, there has to be this big thing that you’re confident you’re going to find, you don’t know what it is you’re looking for and you hang on.”
Somebody at the top has to communicate to the whole team that yes, there is a pot of gold at the end of this rainbow. This sense of purpose is what sustains the team, the quality of the idea is the sustenance that nourishes and keeps the team going towards this distant light, sometimes maybe hazy but definitely beautiful. BYT-2BYT-4






These are some of my favourite musicians and here they sing about my life and beliefs.

Story Of My Life – Bon Jovi
Welcome To Wherever You Are-Bon Jovi
Last Man Standing – Bon Jovi
Peaceful Easy Feeling – Glenn Frey
Human Touch – Bruce Springsteen
Sad Café – Eagles with David Sanborn
Money Talks – AC/DC
Radio Nowhere – Bruce Springsteen
Better Days – Bruce Springsteen
Forever Young – The Band Bob Dylan
Further On Up The Road – The Band Eric Clapton
Stairway To Heaven – Led Zeppelin
Shadow Captain – Crosby, Stills & Nash
November Rain – Guns N’ Roses
Comfortably Numb – David Gilmour
   

Proposed Cumballa Hill Hospital at Mumbai for Dr Shetty

 

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150-Bed Hospital at Gelephu, Bhutan.

 

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My 99 Sq. Ft. Bedroom in Thane, Mumbai Metropolitan Region

       

“These are some of my favourite musicians and here they sing about my life and beliefs.”

Shine On You Crazy Diamond – David Gilmour
Stairway To Heaven – Led Zeppelin
We Weren’t Born To Follow – Bon Jovi
Dream On – Aerosmith
Silver and Gold – U2
No One Said It Would Be Easy – Sheryl Crow
Steve McQueen – Sheryl Crow
Boulevard – Jackson Browne
Unwell – Matchbox 20
Doctor My Eyes – Jackson Browne
Van Diemens Land – U2
I Have a Dream – Westlife
U2 – Love And Peace Or Else
U2 – Yahweh
Lynyrd Skynyrd – The Ballad Of Curtis Loew

Work Done While At Hosmac India Pvt. Ltd. As Director-Design Services

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I am in solidarity with the outstanding students and activists of India, my country, it’s all I know.

I am a Patriot – Jackson Browne

Green Design: Environmentally Effective Design Principles

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HEATING, COOLING, LIGHTING

Sustainable Design Methods For Architects

Norbert Lechner

Fourth Edition – Copyright 2015 by John Wiley & Sons, Inc.

“One of the most useful and important books on building design in years…Nowhere else have we seen such clear explanations of energy flow mechanisms that occur in buildings. Take our word for it, this book is a must have for any design firm.”

Environmental Building News

A leading guide and reference on the design of a building’s environmental controls, Heating, Cooling, Lighting Fourth edition supplies architects and students with the strategies they need for making initial design decisions when creating energy sustainable buildings. Based on a three-tier approach, – load avoidance, optimum use of natural energies, and the selection of appropriate mechanical equipment – this bestselling guide gives designers the information they need when considering a buildings thermal and lighting needs in order to create aesthetic, low energy sustainable buildings.

New to this edition:


– Useful content for the “integrated design” studio, explores how strategies interact to create an integrated
building system
– Information on Tropical Architecture explains how that climate differs from design in temperate regions
– The latest practices for low energy building design
– Filled with the most recent developments, codes, standards, and rating systems for energy efficiency
– A checklist to help design low energy buildings

Well organized and clearly written, without overly technical language or mathematics, Heating, Cooling, Lighting, Fourth Edition is an essential resource for today’s architects and architecture students.

NORBERT LECHNER is Professor Emeritus in the College of Architecture, Design and Construction at Auburn University and an architect. His articles have appeared in Architectural Lighting and Solar Today, and he is invited to give lectures and workshops throughout the world. He is author of the companion book Plumbing, Electricity, Acoustics, published by Wiley.

CHAPTER 1

Heating, Cooling and Lighting as Form-Givers in Architecture

I urge you to buy and read with attention this excellent book. It is value for money and a necessary read in these days of climate crisis. It focuses on the reduction of our dependence on the use of fossil fuels. 

Download (PDF, 5.44MB)

Chapter 2: Sustainable Design and Energy Sources

Chapter 17: Tropical Architecture

Chapter 19: Checklist for Designing Integrated Sustainable Buildings

I urge you to buy and read with attention this excellent book. It is value for money and a necessary read in these days of climate crisis. It focuses on the reduction of our dependence on the use of fossil fuels. 

Download (PDF, 8.04MB)

A Project Planning Guide For Healthcare Facility Owners

By

Brian Walrath & Godfried Augenbroe

Purpose

According to a recent study, about 30 percent of US real estate projects are cancelled midstream, while more than half run up to 190 percent over budget and 220 percent over their initial time estimates. The reasons for this are manifold but poor decisions during the initiation and early planning of the project can be pointed to as one of the main causes. Most poor decision-making stems from lack of information, bad judgement, or lack of communication and transparency between what the client expects and what the project team can deliver. Proper project planning procedures and methods will lead to proper contingency planning, management of partner relationships and contracts, management of dynamic unforeseen changes and associated risks that can, and most probably will, occur in the course of the project. The role of the owner cannot be overstated in all of these targets.

As a general rule, healthcare executive leaders may have only one opportunity in their career to participate in the design and construction of a hospital replacement or major hospital expansion project. The interaction with planners, public bodies, architects, engineers and other stakeholders is a daunting prospect for which an owner organization will seek help from specialized firms that can represent the owner. This guide should allow the owner to better navigate the process. Additionally, while this guide has no intention of replacing the deep and specialized knowledge of or need for advisors (internal or external), it will prepare owners to recognize the major tasks and decision steps throughout the process, while keeping the focus on the desired outcome. Any owner should recognize that the slogan “ if you don’t know or cannot express what you want, you will not get what you need” is as true today as it ever was. 

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Guiding Principles for the Development of the Hospital of the Future

The Joint Commission

Introduction

Human lives weigh in the balance every day in hospitals. For hospital patients and their families, the hospital experience is often a central point in their life – where their child was born, where their beloved died, where they received life-saving treatment, rejuvenating therapy or care to overcome an episode of illness. The hospital is the setting of oft-told tales among friends and family throughout the generations. It is no wonder that hospitals are often used to depict human drama – and even comedy – for popular consumption across the panorama of entertainment media.

In reality, hospitals are the setting where cutting-edge medical advances relieve suffering, and bring healing and new life for those whom, even a few short years ago, there would be little hope. Featherweight babies, born eight weeks prematurely can now survive and even thrive. Minimally invasive surgeries allow patients to heal quickly with less risk of complication. The evolving science of organ transplantation brings a second shot at life for an increasing number of people whose lives would otherwise be foreshortened.

In addition to their impact on human life, hospitals are a major driver of the US economy. The hospital industry is the second largest private-sector employer in the US and contributes nearly $2 trillion of economic activity. In any small communities across the country, the local hospital is the largest employer and most valuable economic asset.

Consumer attitude towards hospitals waxes and wanes, seemingly with some dependence on hospital news that makes headlines, such as traumatic medical errors, rampant hospital-acquired infection, and unscrupulous billing practices. There is no doubt that hospitals face greater scrutiny over the issues that can erode public trust. In order to secure the public’s trust, hospitals will need to become highly reliable – ensuring patients’ safety, providing clinically effective care, and embodying the ethical ideal that has long been the expectation of the public.

Hospitals will have to meet the high expectations of the public and all stakeholders in an increasingly challenging environment. There are many issues with which hospitals must now contend. These include escalating healthcare costs that are no longer publicly – or politically – tenable, changing demands in reimbursement for services, demands for transparency of cost and quality data, and workforce shortages. At the same time, the conditions and care needs of hospitalized patients are more complex. The rise in patients with chronic illness, older age adults, and medical interventions and therapies, are already influencing hospitals today and that influence will deepen well into the future.

The importance of hospital-based care will not diminish in the future. However, changes in the social and economic environments in which hospitals operate, as well as medical and technological progress require hospitals to be equally transformative as the future unfolds.

There has been a hospital building boom underway – fuelled by both increasing demand for health care services, and increasingly obsolete hospital plants. Though economic conditions are expected to slow its place, the continuing investment in hospital construction offers the opportunity to remake the hospital – its design, culture and practices – to better meet the needs of patients and families and the aspirations of those that provide their care. But, unless there are principles to guide the development of the hospital of the future, hospitals may simply freeze into place the status quo of today.

In order to identify these principles, the Joint Commission appointed an expert Roundtable panel comprising hospital administrative and clinical leaders, as well as experts in technology, healthcare economics, hospital design and patient safety. The Roundtable was charged to evaluate the current health care environment and identify the elements of the future hospital that will position it to play an appropriate role or roles in meeting the needs of patients and public. Among specific issues that were addressed by the Roundtable were socio-economic trends, technology, the physical environment of care, patient-centered care values, ongoing staffing challenges, and the global confluence of these issues and their impact on the hospital of the future.

This white paper represents the culmination of the Roundtables discussions. The proposed principles for guiding future hospital development are summarized below:

Principles to Support Economic Viability:

    1. • Encourage the alignment of hospital measurement and payment systems to meet quality and efficiency-related goals
    1. • Apply process improvement tools to improve efficiency and reduce costs
    1. • Pursue coverage options to ensure patient access to, and affordability of, healthcare services
    1. • Address the disequilibrium between the burdens of general acute hospitals and speciality hospitals in fulfilling the social
    mission for healthcare delivery

Principles to Guide Technology Adoption:

    1. • Establish the business case and sustainable funding sources to support the widespread adoption of health information technology
    1. • Redesign business and care processes in tandem with health information technology to ensure benefit accrual
    1. • Use digital technology to support patient-centered hospital care and extend that care beyond the hospital walls
    1. • Establish reliable authorities to provide technology assessment and investment guidance for hospitals
    • Adopt technologies that are labor-saving and integrative across the hospital.

Principles to Guide Achievement of Patient Centered Care:

    1. • Make adoption of patient-centered care values a priority for improving patient safety and patient and staff satisfaction
    1. • Incorporate patient-centered care principles into the activities of hospital oversight bodies and transparency initiatives
    1. • Address barriers to patient and family engagement, such as low health literacy and personal and cultural preferences
    1. • Eliminate disparities in the quality of care for minorities, the poor, the aged and the mentally ill
    • Improve the quality of care for the chronically ill through adoption of care models that encourage coordinated, multi-disciplinary care

Principles to Address the Staffing Challenge:

    1. • Address the maldistribution of health care workers across the globe by instilling fair migration and compensation policies for affected countries
    1. • Expand health professional education and training capacity to accommodate the growing demand for health care workers
    1. • Create work place cultures that can attract and retain health care workers
    1. • Support the development of health professional knowledge and skills required to care for patients in an increasingly complex environment
    1. • Educate health professionals to deliver team-based care and promote teamwork in the hospital environment
    • Develop the competence of health professionals to acre for geriatric patients

Principles to Guide Design:

    1. • Incorporate evidence-based design principles that improve patient safety, including single rooms, decentralized nurse stations and noise reducing materials, in hospital construction
    1. • Address high-level priorities, such as infection control and emergency preparedness in hospital design and construction
    1. • Include clinicians, other staff, patients and families in the design process to maximize opportunities to improve staff work flow and patient safety, and create patient-centered environments
    1. • Design flexibility into the building to allow for better adaptation to the rapid cycle of innovation in medicine and technology
    • Incorporate “green” principles in hospital design and construction

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Planning, Design, and Construction of Health Care Facilities,Third Edition

By

The Joint Commission

About This Book
A health care facilities new or improved design establishes the basis for safe and effective care within that structure. Designing and executing a construction or renovation project requires resources, education, communication and collaboration throughout the process. When patient and worker safety are at risk, the stakes for a successful project are even higher.
This third edition of Planning, Design and Construction of Health Care Facilities – developed in conjunction with the American Institute of Architects Academy of Architecture for Health (AIA-AAH) – presents a comprehensive guide for health care organizations around the world looking to build new facilities or update current structures. This revised edition offers the following:

    • New and expanded information on the topics of process improvement, risk assessment, healthcarecommissioning,
    designing for safety and reliability, alternate facility delivery models, and much more
    • Case studies that highlight the application of key strategies

Health care organization leaders, their facilities managers, and the architects, designers and construction firms they work with will all benefit from Planning, Design, and Construction of Health Care Facilities, Third Edition. In fact, the AIA-AAH recommends this book as preparation for becoming a certificate holder in the American College of Health Care architects (ACHA). A board certified health care architect with ACHA credentials is the only specialized certification recognized by the AIA.

About Joint Commission Resources
The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services.

About American Institute of Architects Academy of Architecture for Health
The mission of the American Institute of Architects Academy of Architecture for Health (AIA-AAH) is to improve both the quality of health care design and the design of healthy communities by developing, documenting and disseminating knowledge; educating design practitioners and other related constituencies; advancing the practice of architecture; and affiliating and advocating with others that share these priorities.

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The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity

By

Roger Ulrich & Craig Zimring

A visit to a U.S. hospital is dangerous and stressful for patients, families and staff members. Medical errors and hospital acquired infections are among the leading causes of death in the United States, each killing more Americans than AIDS, breast cancer, or automobile accidents (Institute of Medicine, 2000; 2001). According to the Institute of Medicine in its landmark Quality Chasm report: “The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits” (IOM, 2001). Problems with U.S. healthcare not only influence patients; they impact staff. Registered nurses have a turnover rate averaging 20 percent (Joint Commission on Accreditation of Healthcare organizations, 2002).

At the same time, the United States is facing one of the largest hospital building in US history. As a result of a confluence of the need to replace aging 1970’s hospitals, population shifts in the United States, the greying of the baby boom generation, and the introduction of new technologies, the United States will spend more than $16 billion for hospital construction in 2004, and this will rise to more than $20 billion per year by the end of the decade (Babwin, 2002). These hospitals will remain in place for decades.

This once-in-a lifetime construction program provides an opportunity to rethink hospital design, and especially to consider how improved hospital design can help reduce staff stress and fatigue and increase effectiveness in delivering care, improve patient safety, reduce patient and family stress and improve outcomes and improve overall quality.

Just as medicine has increasingly moved toward “evidence-based medicine,” where clinical choices are informed by research, healthcare design is increasingly guided by rigorous research linking the physical environment of hospitals to patients and staff outcomes and is moving towards “evidence-based design” (Hamilton, 2003). This report assesses the state of the science that links characteristics of the physical setting to patient and staff outcomes.

    • What can research tell us about “good” and “bad” hospital design?
    • Is there compelling scientifically credible evidence that design genuinely impacts staff and clinical outcomes?
    • Can improved design make hospitals less risky and stressful for patients, their families, and staff?

In this project, research teams from Texas A&M University and Georgia Tech combed through several thousand scientific articles and identified more than 600 studies – most in top peer-reviewed journals – that establish how hospital design can impact clinical outcomes. The team found scientific studies that document the impact of a range of design characteristics, such as single-rooms versus multi-bed rooms, reduced noise, improved lighting, better ventilation, better ergonomic design, supportive workplaces and improved layout that can help reduce error, reduce stress, improve sleep, reduce pain and drugs, and improve their outcomes. The team discovered that, not only is there a very large body of evidence to guide hospital design, but a very strong one. A growing scientific literature is confirming that the conventional ways that hospitals are designed contributes to stress and danger, or more positively, that this level of risk and stress is unnecessary: improved physical settings can be an important tool in making hospitals safer, more healing, and better places to work.

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To Err Is Human: Building A Safer Health System

By

Institute Of Medicine

Preface
To Err Is Human: Building A Safer Health System. The title of this report encapsulates its purpose. Human beings, in all lines of work, make errors. Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing. Cars are designed so that drivers cannot start them while in reverse because that prevents accidents. Work schedules for pilots are designed so they don’t fly too many consecutive hours without rest because alertness and performance are compromised.

In health care, building a safer system means designing processes of care to ensure that patients are safe from accidental injury. When agreement has been reached to pursue a course of medical treatment, patients should have the assurance that it will proceed correctly and safely so they have the best chance possible of achieving the desired outcome.

This report describes a serious concern in health care that, if discussed at all, is discussed only behind closed doors. As health care and the system that delivers it become more complex, the opportunities for errors abound. Correcting this will require a concerted effort by the professions, health care organizations, purchasers, consumers, regulators and policy-makers. Traditional clinical boundaries and a culture of blame must be broken down. But most importantly, we must systematically design safety into processes of care.

This report is part of a larger project examining the quality of health care in America and how to achieve a threshold change in quality. The committee has focused its initial attention on quality concerns that fall into the category of medical errors. There are several reasons for this. First, errors are responsible for an immense burden of patient injury, suffering and death. Second, errors in the provision of health services, whether they result in injury or expose the patient to the risk of injury, are events that everyone agrees just shouldn’t happen. Third, errors are readily understandable to the American public. Fourth, there is a sizeable body of knowledge and very successful experiences in other industries to draw upon in tackling the safety problems of the health care industry. Fifth, the health care delivery system is rapidly evolving and undergoing substantial redesign, which may introduce improvements, but also new hazards. Over the next year, the committee will be examining other quality issues, such as problems of overuse and underuse.

At some point in our lives, each of us will probably be a patient in the health care system. It is hoped that this report can serve as a call to action that will illuminate a problem to which we are all vulnerable.

Foreword
This report is the first in a series of reports to be produced by the Quality of Health Care in America project. The Quality of Health Care in America project was initiated by the Institute of Medicine in June 1998 with the charge of developing a strategy that will result in a threshold improvement in quality over the next ten years.

Under the direction of Chairman William C. Richardson, the Quality of Health Care in America Committee is directed to:

    • Review and synthesize findings in the literature pertaining to the quality of care provided in the health care system.
    • Develop a communications strategy for raising the awareness of the general public and key stakeholders of quality care concerns and opportunities for improvement.
    • Articulate a policy framework that will provide positive incentives to improve quality and foster accountability.
    • Identify characteristics and factors that enable or encourage providers, health care organizations, health plans and communities to continuously improve the quality of care.
    • Develop a research agenda in areas of continued uncertainty.

  This first report on patient safety addresses a serious issue affecting the quality of health care. Further reports in this series will address other quality-related issues and cover areas such as re-designing the health care delivery system for the 21st century, aligning financial incentives to reward quality care and the critical role of information technology as a tool for measuring and understanding quality. Additional reports will be produced throughout the coming years.

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Concepts in Flexibility in Healthcare Facility Planning, Design and Construction

Tannis Chefurka and Faith Nesdoly, Partners, RPG-Resource Planning Group Inc. and John Christie, Director, Parkin Architects

This is an excellent and well thought-out document, if a bit dated, but for Western applications. It is still very relevant to us in India. If you find it difficult to read, kindly try to read and understand only the text highlighted in blue and the comments in red. Even an architect would find the going difficult.

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2010 ADA Standards For Accessible Design

(ADA: Americans with Disabilities Act)

Prepared By

The Department of Justice, USA.


Overview
The Department of Justice published revised regulations for Titles II and III of the Americans with Disabilities Act of 1990 “ADA” in the Federal Register on September 15, 2010. These regulations adopted revised, enforceable accessibility standards called the 2010 ADA Standards for Accessible Design “2010 standards” or “Standards”. The 2010 Standards set minimum requirements-both scoping and technical-for newly designed and constructed or altered State and local government facilities, public accommodations, and commercial facilities to be readily accessible to and usabale by individuals with disabilities. Adoption of the 2010 Standards also establishes a revised reference point for Title II entities that choose to make structural changes to existing facilities to meet their program accessibility requirements; and it establishes a similar reference for Title III entities undertaking readily achievable barrier removal. The Department is providing this document with the official 2010 Standards in one publication. The document includes:
  • The 2010 Standards for State and local governments, which consist of the Title II regulations at 28 CFR 35.151 and the 2004 ADAAG at 36 CFR part 1191, appendices B and D.
  • The 2010 Standards for public accommodations and commercial facilities which consist of the Title III regulations at 28 CFR part 36, subpart D, and the 2004 ADAAG at 36 CFR Part 1191, appendices B and D.
The Department has assembled into a separate publication the revised regulation guidance in its revised ADA regulations published on September 15, 2010. This guidance provides detailed information about the Departments adoption of the 2010 Standards including changes to the Standards, the reasoning behind those changes, and responses to public comments received on these topics, The document, Guidance on the 2010 ADA Standards for Accessible Design, can be downloaded from www.ADA.gov. For more information about the ADA, including the 2010 ADA regulations, please visit the Departments websitewww.ADA.gov.; or, for answers to specific questions, call the toll-free ADA Information Line 800-514-0301 (Voice) or 800-514-0383 (TTY).
Legalese aside, (which I have provided above as a matter of form), I think a society that cares for its disabled members is a civilized, humane and mature society. Being mentally challenged, I keenly feel the need for legislation to provide for the needs of differently-abled people. I encourage all designers of the built environment to champion this noble and just cause. In India, healthcare architects can make a start by designing healthcare facilities that are handicapped accessible throughout. I hope these standards will be of help.

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Planning Hospitals of the Future

By

Richard Sprow, AIA

Over the last 60 years, there have been recurring trends in thinking about the planning and design of hospital facilities, which seem to go through cycles. Specialty hospitals, new standards for patient rooms, ideas for efficient nursing unit planning, and design for healing environments; all have been the subject of architectural thinking in the past and then interest has subsided – but all will certainly be back again. As planners in one of the world’s largest healthcare design practices, we spend every day talking with hospital managers about future planning issues, which are often linked to market responsiveness, new technologies, and changing expectations about healthcare delivery.

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Regenerative – Adaptive Design for Sustainable Environment

A Pattern Language Approach

Phillip B. Roos

New Patterns for a Healthy Planet

I discovered Christopher Alexander’s important idea of a Pattern Language more than 40 ago, when I was a young graduate student at the University of Oregon. It was a chance discovery as I was working part-time for a local planning consultant under contract to prepare a series of housing studies for the Warm Spring Consolidated Tribe, a Native American community located in the eastern part of the state. I had been tasked to prepare a housing options report and in the process of research found Alexander’s books. Multiple volumes, beginning with The Timeless Way of Building and A Pattern Language, were like none I had ever read – more like sacred design scriptures, it seemed, than a typical book. The third volume in this remarkable sequence was one specifically applying these ideas to the University of Oregon (called The Oregon Experiment), where I was studying, and so to me it made the idea of patterns even more relevant and impactful (this document is apparently still the official master plan for the campus). To me the notion of timeless and ancient building and townscape patterns made considerable sense. Surely, we had learned much as a species over the several hundred thousand years of our evolutionary life (and out of 10,000 years of living in place in villages and settlements) about what we needed to build and about the physical and social relationships needed to flourish. Why reinvent what ancient builders and planners had known for millennia? The essential insight was an epiphany – that there were tested and timeless place-building patterns that could be tapped to guide our future design and planning work.

In the last few years there seems to have been an encouraging renaissance and rediscovery of the power of Alexander’s pattern language idea and belief in the need to refresh and expand the repertoire of patterns. These efforts have included the 14 Patterns of Biophilic Design, written by Bill Browning and his colleagues at Terrapin Bright Green; Michael Mehaffy’s A New Pattern Language for Growing Regions: Places, Networks, Processes; and Phillip Tabb’s work on biophilic patterns derived from the inspiring biophilic community of Serenbe, among others.

Peter Kahn has argued for the need to collect and re-invigorate new patterns of nature experiences. He believes – and rightly so, I think – that we have forgotten many of the ways we as a species have historically utilised, enjoyed, celebrated and closely experienced nature in our lives. We have even forgotten what we have lost: Kahn believes we suffer from a pernicious form of “shifting baselines,” as fewer and fewer of us remember the many wondrous and life-affirming ways we tended to interact with nature in the past.

Against this backdrop of climate crisis, global biodiversity loss, and an unravelling of our planetary ecosystems, Roös’s book adds immeasurably to a sense of what is possible and needed. Urban design patterns – regenerative and biophilic – are more important than ever, and we need an even more ambitious system of new patterns, commensurate with the extraordinary challenges we face. The need to move beyond modest adjustments and small design tinkering is undeniable, and Roös’s new patterns for regenerative-adaptive design are essential. They build on the new-found power of patterns but extend and expand their scope and ambition to fit the dire circumstances we are facing today. As this book shows, everything we build and design must be deeply biophilic; it must work in significant ways to repair and restore these lost connections, at the same time that species, landscapes and ecosystems are restored and regenerated.

What is evident here is a growing sense that our patterns of living and building must acknowledge the deep interconnectedness of our world. Modern cities source much of their food, materials, water and energy from distant hinterlands with little concern for, or transparency about, the long- term impacts, while externalising the waste and pollutants generated there. We don’t care where the outputs go, as long as they go away. The good news is there is a growing movement which understands that we must make room for nature where we live and work and that we need and want nature around us – an especially important (finally) recognition that being truly healthy, happy, and human requires close contact with nature. Many of the patterns described in this book aim directly at bringing about these closer urban- nature connections. And there is also a growing sense that designing just to be a little less damaging or consumptive of resources and energy can’t be enough – we need projects, neighbourhoods, and cities that are regenerative and adaptive, and that help to restore and repair a planet that is already heavily damaged.

We will want to take Roös’s regenerative-adaptive patterns and find ways to amplify and accelerate their application. Part of this task will require us to re-think the design fields and what we are teaching in schools of architecture and design. How can the owners, occupants, users of buildings and spaces in our cities care about their regenerative qualities when architects and designers who work to create them don’t have the passion, commitment and tools to aspire to higher goals themselves? I have been discouraged to see what we teach, or more importantly what we don’t teach, in schools of architecture. There is not much about sharing space with other life, about building and living modestly, about the need to design spaces and places that restore and repair rather than destroy and deplete.

As we tell this story of profound interconnectedness we will need better and more effective methods of storytelling in an era of text messaging and short attention spans. The mystery and magic of Nature will need to be part of the answer. I recently participated in a medicine walk in the forests of High Park in downtown Toronto that offers some hope. Led by Irish-Canadian forest ecologist and medical botanist Diana Beresford-Kroeger, it was a vivid and visceral demonstration of this principle of interconnection, but delivered with fun, beauty, and wonder. She explained how essential trees and forests were to human health and the source of a majority of our drugs. She spoke of even deeper connections, telling the group of rapt fellow walkers how terrestrial trees and forests sustained marine ecosystems, fallen leaves providing iron to support microorganisms at the bottom of the marine food chain.

Beresford-Kroeger’s work (and she is not alone) reflects the critical power of awe and importance of love. At several points during the walk that day she lovingly embraced the trees she was discussing. The regenerative design responses we need and that are advocated in this book will require a merging of a deep understanding of interconnection with an even deeper sense of love and kinship with all other forms of life.

An appreciation for the value of this kind of ancient knowledge is gaining ground, which is encouraging and reflected strongly in Roös’s work here. My brief experience in Oregon also reminds me of the essential role that native cultures can play in helping all of us renew our relationships to nature. They have, after all, managed to live wisely and sustainably for millennia and offer hopeful direction out of the climate and ecological disaster Western societies and economies have precipitated in.

I am especially excited to see in this book an attempt to learn from Indigenous cultures. Australian Aboriginals have lived sustainably on the land for more than 60,000 years, an astounding length oftime. Some research conveyed the idea that this culture was mostly nomadic, with few efforts or innovations at creating settlements or actively managing their environments. New research and new books have shown this to be false. There are few silver linings to the horrific bushfires of the Australian summer, but in the emptiness of the devastation they did in many places show the lines and evidence of long-standing and ancient improvements on the land. Extensive and continuous land management, something careful scholars have known, was made evident in the aftermath of the bushfires when an ancient and elaborate system of aquaculture was discovered.

Hopeful as well are the ways that Indigenous cultures are merging ancient wisdom and modern legal tools, such as the efforts to attach legal and legally defensible rights to nature and natural systems. Ironically an idea expressed in the 1970sbyanother Christopher (Stone, not Alexander) in the important book Should Trees Have Standing?, it was the Maori of New Zealand who applied and tested this idea, notably through the Te Urewera Act of 2014, declaring this large ancient forest a legal person and as such entitled to rights of protection and the ability (through a special governance board) when threatened to sue in the courts. More recently the idea is gaining hold and being applied in a variety of settings, including in ecosystems near cities (such as in the city of Toledo, Ohio, through the Lake Erie Bill of Rights ). The lessons may also include the need to shift our Western thinking more in the direction the Maori call “Mauri,” or the spirit or life force that can be found in every element in nature, from fish to trees to rocks. This moves us closer to the notion of their inherent moral worth, and also to a sense of their pervasive and all-encompassing nature – it is all around us, even in cities, calling for acknowledgement and respect.

Several years ago I had the chance to participate in filming the story of how a group of citizens of Perth, Western Australia, organised to defeat a proposed highway expansion (the Row 8 highway) that was slated to destroy an ancient banksia forest and rare wetland. These areas are highly sacred to the Noongar people, and during one on-camera interview with Noongar Elder Noel Nannup, I learned more about how deeply embedded in nature these ancient Aboriginal societies saw themselves. The larger non-Indigenous world is not likely to embrace this worldview completely, but there are clear lessons to be learned and patterns (some contained here in this book) that can be followed. Most impressively, Nannup talked about the sense of unity between Aboriginals and nature, a totemic culture. Nannup described how at a young age every child is assigned one (or more) totems in the natural world. His was the Bronzewing Pigeon. He spoke eloquently and with remarkable detail about this bird and its biology. It was a creature that he was both clearly fascinated by and that he loved deeply. It was his totem and as such he always carried with him the duty to stand up for the pigeon.

This is just one example of the wonderful traditions that offer compelling lessons for how we cultivate the love, respect and active care for nature we need today. It is easy to succumb to despair, as official reports and projections come piling in and images of burning forests and the deadening of nature bombard us daily. The book before you is one positive response to the challenge of ecological grief experienced by many of us today. It is hard not to fall into a morass of hopelessness and despair, especially when contemplating the diminished world we are leaving the young. But books like this one offer a dose of hope that we might develop the tools and methods and framework to address these challenges and to find (hopefully) a more restorative path and future.

Philosophers sometimes challenge us to consider the ultimate meaning of life: is it primarily about seeking pleasure or happiness, or is it also (or primarily) about purpose and meaning? The rekindling of connections with nature and the natural world provides, I believe, at least some of what makes up meaning and purpose, and some of the antidote to rising levels of anxiety and depression. Perhaps even more essential to purpose and meaning is the renewed commitment at personal and collective levels to begin to tackle the daunting challenges we face. That may be the most important role of the book to follow: as a reservoir of compelling, inspiring and immensely usable patterns that we must all begin to advocate and apply in our work. To follow are at least some of the seeds of hope and the antidotes to despair.



University of Virginia
Timothy Beatley
Charlottesville, VA, USA


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The Intergalactic Design Guide – Harnessing the Creative Potential of Social Design

By

Cheryl Heller


Social Design is a new kind of leadership. It offers innovative approaches for increasing creativity, strengthening relationships, and developing our capacity to collaborate – with the potential to transform everything from corporate culture to cities. It pushes us to become comfortable with uncertainty, to design ourselves for change. In The Intergalactic Design Guide, business strategist and designer Cheryl Heller explains eleven common principles, a step-by-step process, and essential skills for successful social design. She uses in-depth examples – from the CEO of a multi-national carpet manufacturer to a young entrepreneur with a passion for reducing food waste – to illustrate how applying the social design process brings together innovative elements of business and design. While changemakers like Paul Farmer and Oprah Winfrey have instinctively practiced social design for decades, Heller organizes concepts applied by leaders in diverse fields so that they become accessible to all of us, no matter the focus of our work. From start-ups to global NGO”s. the Intergalactic design guide provides both inspiration and practical steps for designing a more resilient and fulfilling future. Thought leader David Orr wrote, “If our industrial civilization was entered into an intergalactic design competition, it would be tossed out in the qualifying round.” This book points the way for us to change how we relate to our world, and to each other.

About The Author

CHERYL HELLER has a history of building new capacities within organizations that expand their reach and make them more resilient. She is the Founding Chair of the first MFA program in Design for Social Innovation at SVA, with alums now working as change leaders in industry, government and the social sector. She is the founder of the design consultancy CommonWise and of the MeasuredLab, which she created in 2017 to investigate the impact of social design on human health. She founded the first design department in a major advertising agency and as a strategist, has helped grow businesses divisions and products, reinvigorated moribund cultures, and designed strategies for hundreds of successful entrepreneurs. She has taught creativity to leaders and organizations around the world. Heller is a recipient of the prestigious AIGA Medal for her contribution to the field of design and was recently recognized by the Rockefeller Foundation with a Bellagio Fellowship. Her clients have included Ford Motor Company, American Express, Reebok, Marriot International, MeadWestIvaco, StoraEnso, the Arnhold Institute for Global Health, Medtronic, Mars Corporation, Discovery Networks International, Heman Miller, Bayer Corporation, Seventh Generation, L’Oreal, Elle Magazine, Harper’s Bazaar, The World Wildlife Fund, Ford Foundation, Lumina Foundation, The Graduate Network and the Girl Scouts of America. Heller is the former Board Chair of PopTech, and a Senior Fellow at the Babson Social Innovation Lab. She created the Ideas that Matter program for Sappi in 1999, which has since given over $14 million to designers working for the public good, and partnered with Paul Polak and the Cooper Hewitt National design Museum to create the exhibit, “Design for the Other 90%”. She is currently working on a Ph.D. at RMIT University in Melbourne.


The Intergalactic Design Guide – Harnessing the Creative Potential of Social Design by Cheryl Heller is an excellent book, timely and relevant, and a must read for anyone concerned about the issues that face us globally today.

I urge you to buy this book and read it with attention. It is available on Amazon.in at the following link: https://www.amazon.in/Intergalactic-Design-Guide-Harnessing-Potential/dp/1610918819/ref=sr_1_1?crid=3HSXB90CL84A&dchild=1&keywords=the+intergalactic+design+guide+cheryl+heller&qid=1635635991&qsid=259-3332233-5117125&s=books&sprefix=the+intergalactic+design+guide+cheryl+heller%2Cstripbooks%2C212&sr=1-1&sres=1610918819&srpt=ABIS_BOOK

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Health Benefits of Gardens in Hospitals

Roger S. Ulrich, Ph.D.

Findings from several studies have converged in indicating that simply viewing certain types of nature and garden scenes significantly ameliorates stress within only five minutes or less. Further, a limited amount of research has found that viewing nature for longer periods not only helps to calm patients, but can also foster improvement in clinical outcomes — such as reducing pain medication intake and shortening hospital stays.

Well-designed hospital gardens not only provide restorative and pleasant nature views, but also can reduce stress and improve clinical outcomes through other mechanisms such as increasing access to social support, and providing opportunities for positive escape from stressful clinical settings.

As well, evidence from studies of a number of hospitals strongly suggests that gardens and other nature helps to heighten patient and family satisfaction with the healthcare provider and the overall quality of care. Research has begun to appear suggesting that hospital gardens also increase staff satisfaction with the workplace, and can be advantageous in hiring and retaining qualified personnel. The potential for hospital gardens to improve medical outcomes, satisfaction, and economic outcomes is notably increasing the attention and priority accorded to gardens, as administrators and providers everywhere face strong pressures to increase quality, become more consumer/patient oriented, control costs, and in some locations establish a positive market identify in the face of strong competition from other providers

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National Accreditation Board for Hospitals and Healthcare Providers

Accreditation Standards for Hospitals (5th Edition) April 2020 – India
Foreword
It is my pleasure and pride to release the 5th Edition of Hospital Accreditation Standard of National accreditation Board for Hospitals and Healthcare Providers. Over the years, successive NABH standards have brought about a significant change in the approach taken by the healthcare units in managing and delivering the healthcare services to the patients. NABH standards are accredited by International Society for Quality in Health Care (ISQU). NABH standards focus on patient safety and quality of the delivery of services by the hospitals in the changing healthcare environment. Without being prescriptive, the objective elements remain informative and guide the organization in conducting its operations with focus on patient safety.
This edition has some changes that were incorporated the suggestions made by various stakeholders. For the first time, there are core objective elements related to Patient safety Goals that have to be complied mandatorily irrespective of the compliance to other elements. There are a total of 651 Objective Elements out of which 102 are in the core category which will be mandatorily assessed during each assessment and 30 are in the excellence category which will be assessed during reaccreditation. This will help the healthcare organization in step wise progression to quality system covering the full accreditation cycle. The scoring methodology is changed to a graded system to help recognising even progressive efforts by the organization in implementing the standards. The chapter on Continuous Quality Improvement is now replaced with Patient Safety and Quality to increase the focus on this aspect of healthcare. Each chapter has a bibliography for reference and this will provide organizations a resource for taking quality beyond the requirements of the objective elements.
In view of these, I expect that the healthcare organizations will indeed benefit by the efforts of the technical committee which developed this standard for National accreditation Board for Hospitals and Healthcare Providers.
Dr Atul Mohan Kochhar
CEO, NABH


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The Vanishing Face of Gaia:A Final Warning

By James Lovelock

About The Book

James Lovelock’s Gaia theory, the idea that our planet is a living, self-regulating system, has transformed the way we see the world and what is now happening to it.

  In this book he distils a lifetime’s wisdom and observation of the Earth to reveal the rate at which our climate is altering, how conventional ‘green’ measures are not working, and how life as we know it is going to change forever.

  Only Gaia, he shows, can help us fully understand this, and prepare us for the future.


About The Author

James Lovelock is the author of more than 200 scientific papers and the originator of the Gaia Hypothesis (now Gaia Theory). He has written three books on the subject: Gaia: A New Look at Life on Earth, The Ages of Gaia and Gaia: The Practical Science of Planetary Medicine, as well as an autobiography, Homage to Gaia. In 2003 he was made a companion of Honour by Her Majesty the Queen, and in September 2005 Prospect magazine named him as one of the world’s top 100 global public intellectuals. In April 2006 he was awarded the Edinburgh Medal at the Edinburgh International Science Festival.

Praise for the Book

‘A prophet who deserves every honour the human race can bestow…Lovelock speaks with a unique authority.”
Guardian

‘The most influential scientist and writer since Charles Darwin’
Irish Times

‘The Earth guru’
Sunday Times

‘Supremely life-affirming…The definitive statement of the Gaia theory and its implications for the future’
John Gray, Literary Review

‘Exhilarating…Lovelock is the closest thing we have to an Old Testament prophet’
John Carey, Sunday Times

‘Gripping, convincing and indeed terrifying’
Michael McCarthy, Independent

‘Lovelock’s writing has enormous warmth and vitality… we need scientists such as him’
Fiona Harvey, Financial Times

Foreword by Martin Rees

A little more than forty years ago, the Apollo 8 astronauts, while orbiting the Moon, photographed the whole Earth – its biosphere contrasting with the sterile moonscape where the astronauts left their footprints. The Apollo images raised global awareness that “Spaceship Earth’ was vulnerable, and that sustaining it was an ecological imperative. But there was a second important influence with similar global resonance – not an image, but an arresting and romantically titled new concept. This was Gaia – the idea that the Earth’s biosphere behaves as though it were a single organism.
Gaia was the insight of a man who is undoubtedly one of the most original and influential living scientists: James Lovelock. He believes that our species is now putting the Earth under unprecedented stress, and that climate change could lead to a world with much impoverished ecology that is barely habitable by humans. More scarily (and more controversially) he claims that the ‘point of no return’ may already have been passed.
Our planet is nearly 4.5 billion years old. If some aliens had been watching it from afar ever since its birth, what would they have seen? Over nearly all that immense time changes were incessant, but generally gradual. The continents drifted; the ice cover waxed and waned; global temperatures rose and fell; species emerged, evolved and became extinct.
But in just a tiny sliver of the Earth’s history – the last one millionth part, a few thousand years – the pattern of vegetation altered much faster than before. This signalled the start of agriculture. The pace of change accelerated as human populations rose and engaged in urban and industrial activity. Consumption of fossil fuels caused an anomalously fast build-up of carbon dioxide in the atmosphere, the climate changed, and the world started to heat up.
If they understood astrophysics, the aliens watching our planet could confidently predict that the biosphere would face doom when the Sun brightens, and eventually flares up into a ‘red giant’ star. But could they have foreseen this unprecedented sudden ‘fever’ less than half way through the Earth’s life – these human-induced changes, seemingly occurring with runaway speed?
And what might these hypothetical aliens witness in the next hundred years? Will spasms be followed by stability? If so, will our Erath settle into a state that still offers a habitat for humans? Or have our unplanned interventions irrevocably tipped the planet into a new and far hotter climatic state? If so, how many species of animals and plants will survive?
These issues – climate change and loss of biodiversity – have risen high on the international agenda. James Lovelock is helping to keep them there. He is a hero to many scientists – certainly to me. His individualistic career is a welcome counterpoint to the specialized, quasi-industrial style in which most research is conducted. In the 1960s he designed an instrument that was so sensitive at detecting minute traces of atmospheric pollutants that many colleagues refused to believe his claims. He is beholden to no institution. He ranges freely across the disciplinary boundaries that too often constrain ‘institutional’ thinkers.
The flavour of James Lovelock’s mind and personality shine through in this important and highly readable book. He writes clearly – even entertainingly – with many apt analogies. But he writes also with passion; and his thoughts are grounded in a lifetime of distinguished work. He is both a fine scientist and an eloquent advocate of action.
Many of us still hope that our civilization can segue towards a low-carbon future and a lower population – and achieve this transition without trauma and disaster. But that benign outcome demands determined action by governments, urgently implemented; and such urgency won’t be achieved unless sustained campaigning can transform public attitudes and lifestyles. Programmes to develop ‘clean energy’ must be accorded, worldwide, the urgency that the US dave to the Apollo programme in the 1960s.
Those of us who are scientists should aspire to emulate James Lovelock’s inventiveness; all citizens should be inspired by his commitment and altruism. It is no exaggeration to say that our civilization’s long term future depends on whether the ‘call to arms’ in this riveting book is widely heeded.
Martin Rees
Trinity College, Cambridge
January 2009


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Neuferts Architects Data – Health


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No Is Not Enough: Defeating The New Shock Politics

by

Naomi Klein

About The Author

Naomi Klein is an award-winning journalist, syndicated columnist and author of the international bestsellers No Logo, The Shock Doctrine and most recently This Changes Everything: Capitalism vs the Climate. In 2017 she joined The Intercept as Senior Correspondent. Recent articles have also appeared in the Guardian, The Nation, The New York Times, the New Yorker and Le Monde. In November 2016 she was awarded the Sydney Peace Prize in Australia.











Praise for No Is Not Enough

‘Urgent, timely and necessary’
Noam Chomsky

‘The right book at the right time. It is a guide to resistance in the age of Trump. It is brilliant…Klein is as close to being a rock star as you can get on the radical left…her most urgent work to date…manages to be that rare thing: both rousing and profoundly sensible’
Laurie Penny, New Statesman

‘Naomi Klein constructs a common story that allows us to sustain the effects of being shocked. We can act upon that, with intelligence and happiness, to recover our world’
Gael Garcia Bernal

‘Essential and gripping…This is the book to read – not just the first word on Trump, but in powerful ways the last word as well’ Bill McKibben, Author, Oil and Honey: The Education of an Unlikely Activist


‘A clear and reliable guide to action’
Paul Mason

‘Klein moves beyond mere outrage and hand-wringing, to offer a practical manifesto for opposition…She makes a powerful and important point: that you cannot understand Trump without looking at how he reflects bigger cultural and social dynamics’
Gillian Tett, Financial Times

‘One of the most influential left wing writers in the world’
Rob Hastings, i news

‘A book abounding in insight…Without lapsing into corny cheeriness or the puffed-up cant of centrist political cliché (“Love Trumps Hate”), Naomi Klein holds out a cautious hope for the despairing age: an honest, prescriptive belief that people can unite in their opposition to Trumpism to build a better world”
John Semly, Globe and Mail

‘A genuine page-turner’
Michael Alexander, author of The New Jim Crow

‘Bold, compelling, electrifying’
Nature

‘Saying No to their shock doctrine is essential but insufficient. Naomi Klein’s new book incites us brilliantly to stiffen our lip, to overcome quickly their calculated shocks, and to interweave our No with a programmatic Yes. It is a manual for emancipation by means of the only weapon against orchestrated misanthropy; constructive disobedience’
Yanis Varoufakis

‘As accessible as it is brilliant. No Is Not Enough is an essential blueprint for a worldwide counterattack’
Owen Jones

‘An essential handbook for all people, especially young people, who want to understand the economic, social and political forces that produced the current crisis we are facing – and how we can effectively organize to win a better world’
Danny Glover, actor

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Health Building Note 00-01 – General design guidance for healthcare buildings

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Healthcare Architecture Lecture Series 1:

The Planning Grid: Creating A Framework For Design
Circulation: A Critical Issue – Conceptual Clarity, Ease Of Wayfinding & Disability Needs
Designing For Flexibility: Building In Order And Direction For Growth And Change

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Healthcare Architecture Lecture Series 2:

Design Concepts: Should Form Always Follow Function?
Green Design: Environmentally Effective Design Principles
Alternative Building Forms and Massing: Pros & Cons – Horizontal or Vertical

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Healthcare Architecture Lecture Series 3:

The Architecture of Imaging: The Design of the Radiology & Imaging Sciences Department
Future Perfect: Trends Shaping Healthcare Architecture
Equipment Planning: Its Impact on Architectural Design

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Plumbing Design for Healthcare Facilities

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A Paradigm Shift To Combat Indoor Respiratory Infection
Roadmap To Improve And Ensure Good Indoor Ventilation In The Context Of Covid-19
HVAC Design Manual For Hospitals And Clinics-Second Edition

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Planning and Designing for State of Art Healthcare Facilities:Brief Overview and Suggested Framework

by Ar Jit Kumar Gupta

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Health Facility And Equipment Planning And Management

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14 Patterns of Biophilic Design
Improving Health & Well-Being in the Built Environment

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Whole Building Design Guide

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Arup in Healthcare

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Arup – Future of Healthcare Ecosystems

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Natural Capitalism – Creating the Next Industrial Revolution

Chapter 5 – Building Blocks

A bank whose workers don’t want to go home – A creek that runs through it – green buildings and bright workers – Just rewards and perverse incentives – Windows, light and air – Every building a forecast – Harvesting bananas in the Rockies – Urban forests – Walkable cities

By: Paul Hawken, Amory Lovins, L. Hunter Lovins.
The world of business is changing – fast. The prevailing model for creating wealth – a model that has its roots in the industrial revolution and that dominated the last century no longer applies. Natural Capitalism introduces an alternative, a new paradigm. Praised by business and political leaders as well as economists and environmentalists around the globe, this ground-breaking book reveals tomorrows most successful global businesses will draw profit from their own environmental responsibility.

“If Adam Smith’s The Wealth of Nations was the bible for the first industrial revolution, then natural capitalism may well prove to be it for the next.”

Peter Senge, author of The Fifth Discipline

“Natural Capitalism is so informative and provocative – and so unfashionably optimistic about the future of the planet – that I wonder why everyone in public life is not reading it and arguing over the implications.”

William Greider, The Nation

“Brimming with examples and anecdotes, Natural Capitalism will exasperate some and excite others – but leave every reader with the hope that the old battle between business and the environment can reach a peaceful and constructive conclusion.”

Frances Cairncross, The Economist

Natural Capitalism basically proves beyond any argument that there are presently available technologies, and those just on the horizon, which will permit us to get richer by cleaning, not by spoiling, the environment.”

President Bill Clinton

“The message is both huge and simple: The Industrial revolution is over…Natural Capitalism for the most part hangs out a big welcome sign, inviting the reader to step inside and enjoy a cheaper, easier, less-polluting and more energy efficient way to live.”

Christine Colasurdo, San Francisco Chronicle

Paul Hawken, founder of the highly successful gardening supply store Smith & Hawken, recorded his entrepreneurial experiences in the popular book and PBS TV series Growing a Business. He is also the author of The Ecology of Commerce.

Amory and L. Hunter Lovins are the founders of Rocky Mountain Institute, a non-profit resource policy centre. Their efficiency innovations have won major awards around the world.
——————————————————————————————————

The below extract is from the book “Natural Capitalism: Creating the Next Industrial Revolution” and is Chapter 5 “Building Blocks” by Paul Hawken, Amory Lovins and L. Hunter Lovins and is presented here for my architect readers. This very good book is available on Amazon.in at a reasonable price.

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Architectural Design and Ethics: Tools for Survival
By Thomas Fisher: Chapter 3 – Why having less is more

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