ENVIROMEDICAL : sustainability initiatives complimentary to the medical built environment.
Author ADRIAN CHARLES JUST
BScHonGU BArchHonUQ AIA
Archicology Architects have previously worked on a wide range of commercial projects, including on specialist Health facilities, and have won commercial environmental design awards. We have found our knowledge and expertise of environmental building issues and occupant wellness related space issues, are entirely complimentary to the built environment needs of the health industry.
Hospitals and indeed many medical clinics of all sizes, are often closed, sterile utilitarian boxes that get their medical deeds done. These perfunctory spaces can be intimidating and distasteful for the clients and staff. This does not promote the medical relationship that gets the client back, or promotes client word-of-mouth referrals. This is also definitely not the approach for the emerging Sunshine Coast medical precinct, which is clearly gearing up as a health precinct but also a well being sector. This mirrors the lifestyle choices and architecture of the Sunshine Coast which is responsive to the climate and lifestyle. In this article we explain we make our medical architecture also suit our ideals of a healthy lifestyle.
So, how does environmental expertise cross over with medical space requirements? To explain this I break down the issues to make healthy, vibrant and safe spaces for clients and workers in the health industry. Some detail and examples are provided in the following areas….
- Toxic materials
- Smell and odour
- Colour and hue
- Energy use and air quality
- Cleanliness and maintenance
- Universal access and PWD
- People oriented design
- Statement from architect
Good signage is a mark of efficiency and courtesy for your customers, who are probably already sick and easily annoyed or confused. They are going to see a medical professional and they will expect a professional experience from the start to the finish, which begins with the signage. It’s best not to annoy your customers before they get to you just because of poor signage.
At the least, avoid spelling mistakes, ineffective colour contrast, small print or a bombardment of information, and maps that are not in the correct orientation when you are looking at them can be very confusing for many people. Plan signage to be in a location that will be seen and understood, or a continuance of signage to get clients there and get them out again. You may not remember all of the information on a sign, but you will remember a distinctive sign and its location. Some sign writers are little more than painters so work with them to ensure the design and location of this information is effective. Particularly important in hospital complexes, or large medical precincts with many clinics.
Obviously critical to people with allergies or hyper toxicity, particularly with the very young or very old persons. These reactions can be set off by touch, smell, or inhalation. Also small amounts of chemical in confined spaces can be detrimental to staff over longer periods.
Off gassing in particular or VOCs (volatile organic carbons) can be found in paints, carpets, cabinetry and construction glues, silicon sealants and rubber compounds, vinyls, timber finishes, and even some peripherals in printers and other machines. Some older materials can be particularly toxic with asbestos, sulphur, lead, PCBs (polychlorinated bi phenols), and other nasty chemicals. These days there are alternatives for almost all of these items, but you may need to go to the technical specification sheets or consult the suppliers for details.
This started as an issue in habitable environments but it is now recognised that we spend so much time in our workplaces that it has become a critical factor for workers and can lead to workplace claims. When designing spaces the architect should be briefed on the level of toxicity which is acceptable, and this is likely to be nil for dermatologists, paediatrics and oncology.
Smell and odour
These are included to emphasise these are partly related to the off gassing of many new materials. Odour can also be associated with cleaning chemicals or some common lab materials such as formaldehyde or chlorine, so task specific extraction systems could be required.
If you have a head cold you often lose your sense of smell, but many patients and women in pregnancy for example become hyper sensitive to smell. In this circumstance, other than eliminating any constant sources of odour, providing some area of escape could be useful such as a courtyard or balcony. Better still if these areas can be enhanced with plants like lavender then they can have a pleasing or calming influence.
Avoid those automatic air fresheners and particularly the bug killing brands, and obviously, smoking is not allowed. If you are on a busy road then consider an airlock of sorts, which will help with air quality and noise, or at least an air waterfall at the entrance.
Colour and hue
Areas of access such as stairs, ramps, doorways and amenities are already required by legislation to provide colour contrasts of up to 30% or more, but in many circumstances these principles should be extended throughout the whole premises. Many people do not appreciate that colours and subtle materials like glass can read differently between people.
Some gross colours such as greens and custards can stimulate nauseous feelings for some patients, violent reds can trigger emotional responses, or dark colours can trigger disorientation for the sight impaired. Lots of different colours, or highly patterned areas can be disturbing for people on the autism spectrum. Alternately, carefully chosen colours can be calming, warming, and inviting and should compliment other items and pathways in the rooms. Colours which are not always appealing are probably going to date very quickly in our conscious and the safest selections are colours that we often see in nature.
Colour selection can be very subtle and is easy to get sort of OK, but much more difficult to get their combinations just right. Particular care should be taken for optometrists, paediatricians, dietitians, and physiotherapists. For emergency wards you might think of ambulance red because this triggers reactions of alarm, but this won’t necessarily calm down already distressed patients.
Without going into the full spectral analysis of lighting let’s just say that the human eye is incredibly perceptive and can instinctively delineate between natural and artificial light. A fully enclosed and lit space can be claustrophobic for some people, or uncomfortable for some staff for long periods in these spaces.
Artificial lighting comes in many forms, colours, and brightness and these automatically trigger associations about the activities in those areas. Another immediate distinction is between areas that require certain lux levels for workplace health and safety requirements as opposed to generally lit areas like corridors. For example, receptions are brightly lit with white light, partly to get your attention and partly because there is a lot of reading going on. Waiting areas might be darker and subdued to relax people and the physician’s studio might be dominated by task lighting.
Glare can easily be confusing and damaging to eyesight leading to disorientation, so lighting should compliment the effect of surface materials. Computer screens are generally faced away from windows. The imperceptible flicker of fluorescent lights can trigger fits of epilepsy so this is generally limited or specialised with filters.
Lighting choice also has implications for running costs and maintenance. The old light globes burn most of their power in unwanted heat and poorly directed light. LED lighting is now commonplace, cheap to run, cool, and has a range of light, but many people don’t realise that, unlike the old bulbs that suddenly stop, LEDs slowly dim out over a long period so a maintenance regime should be established to change these. In some circumstances feature pendant lights can be spectacular but their actual light is often diffuse and mottled so they act more like a piece of sculpture.
Designers will often plan lighting in conjunction with lighting specialists to achieve a balance between functional requirements and purely lighting aesthetics. The hardware of lighting in medical facilities generally as a minimum should not flicker or cast shadows, catch dust, be difficult to maintain, go rusty, be accessible by the public (either the light or the switches), throw glare or excessive heat, swing in the wind if outside, house fauna such as geckos or birds nests, or shine directly into people’s line of sight, for example in corridors.
Sounds and Noise
How do you think a child is going to react if he hears a dentist drill and a scream? Well anyone for that matter.
Some sounds such as a growling dog, an angry voice, a bang like a gunshot, or the drowning gurgle of a sink, can also trigger a type of emotional panic.
Noise is slightly different in that some pitches are only heard by some people and unfortunately it is often the high whine of a dry air conditioner bearing that can send people crazy. Unfortunate, because it’s more common than you might think.
Any person that has undergone a disturbing medical procedure is likely to be over sensitive to noise, even after some routine procedures such as an MRI. When you’re sick you are often overly sensitive to noise so the size and layout of waiting areas is critical if say young children will be present. Sometimes a separate children’s play area can help control this potential noise, to everyone’s relief.
Noise is also intimately associated with privacy which is paramount in all medical circumstances, so the delineation of public and private areas, and semi private areas such as reception staff, is important. The difficulty with this is that noise can bend and bounce and go round corners and reverberate. A whisper can be just as perceptible at the other end of a corridor.
Quite often noise does not need a massive block wall to temper it, rather than a good seal around openings such as doors. It is not just attenuated with a bit of insulation in the walls. Floor and ceiling materials matter, as do soft furnishings. The really specialist areas of noise control are of course clinics for Audiologists, Speech Pathologists, and Otolaryngologists (Ear nose and throat specialists).
Energy use and air quality
Medical facilities are generally controlled environments so the costs of clean air supply, cooling and warming, lighting, and other equipment can add up. This can be quickly exacerbated i.e. keep doubling those electricity bills, if the energy supply must be continuous, or without surge, or on 24-7. What’s more, many medical situations don’t really offer an offset with local solar.
Air conditioning is a big one and it is the tolerances and parameters of air control that initially benchmark the capital costs. A consultant might ask if you want all spaces (think the top corners of the room) at a constant controlled temperature of + or – 2 degrees, which is akin to a grade one art gallery or an archive. This might cost say $120,000 as opposed to a usually accepted level of comfort control which might cost $30,000. Alternately, if you choose the cheapest quote your patrons will be uncomfortably hot or cold and the system might cost you five fold to run on a daily basis. It’s a delicate decision for the uninitiated and the consequences for the next 10 years can be catastrophic for a small business.
Worse still, if ducting and sealing are poorly manufactured and installed, which they generally are in at least 50 % of cases, then your air conditioning condenser i.e. the motorised work horse, can be operating at full capacity all of the time to air condition your ceiling spaces instead of a mere fraction of effort to cool your working areas. While you think that your full daily schedules are reaping you profits, up to 10 percent of these are instantly being siphoned by energy companies.
This applies to any enclosed space, which is almost all medical, and can be easily remedied at the construction phase, but very difficult to fix after your first power bill.
The next trap here is the actual amount of air circulation versus air renewal. Recycling air is easy and cheap to install but if the facility is dealing with communicable diseases then this is a major trap for clientele and a wide open possibility for bad word-of-mouth referral, and, it is plain unhealthy. Air renewal, or the percentage of fresh air coming into the building, might be partly dependent upon your position within a large building, or the position of the air intake, think main road exhausts. Having a skilled designer review and work with the air consultants will simply get them to think again about the adequacy of the system they are designing.
In North America the greatest number of medical litigants from the built environment is concerned with fungus and toxic moulds that cause skin and breathing ailments for occupants. In our climates it has been more common to have cases of legionnaires disease being dispersed from air conditioning systems and this is also related to moisture.
Once these micro flora and bacteria start forming inside walls and ducts they can be almost impossible to remove, with the consequence that whole buildings are sometimes slated for demolition. This can be caused by poor air conditioning systems or, in our climate when you have high humidity and you get cooler interiors and hot exteriors this will inevitable cause condensation and internal roof spaces can literally run with water. If the initial roof space, insulation and connection to wall cavities is not carefully managed at construction then problems can occur immediately.
Moisture in buildings is obviously not just limited to air, but can easily be walked in on rainy days so the choice of floor coverings and in particular slip ratings for tiles is critical. This also applies to wet areas or around clinic sinks, kitchens and amenities. The highest number of accidents in domestic environments are caused by trip hazards in wet areas, which is a combination of poor design, think shower hobs and lack of grab rails, and wet surfaces. The same applies in medical facilities except the users may already be more prone to accident.
Moisture can be an issue in any building but can be critical for the operation of pathology labs or areas which store medicines out of refrigeration.
Cleanliness and maintenance
Cleanliness is paramount in medical facilities but ironically it can also clash with the quality of the space you are creating. Non slip tiles can be so effective that they also catch dirt so well they are near impossible to clean. This is a repeated mistake in both shopping centres and medical facilities. Some cleaning products are so odorous they can make a confined space non-habitable. In fact it is not untoward to think ahead to the actual cleaning regimes as the spaces are being designed.
The initial choice of materials can influence a lifetime of cleaning by an order of double or half depending on the circumstance. The associated costs of cleaners, or down time for staff, can be significant.
It goes without saying that maintenance is in itself a form of cleaning in that it restores the space or surface to its intended quality. Timber is a good example as it is appealing but it is also porous and should be used judiciously and sealed correctly. Better still there are fantastic look alike alternatives that are non toxic, not porous, clean easily, and are very scratch resistant. Any surface that scratches can of course harbour germs and should be avoided.
Air quality is always an issue and a consistent maintenance regime for air conditioners is important. Who is paying for this and its adequacy for the system, should always be determined when the system is installed, or before lease arrangements are finalised. Also be aware that any sort of air control, be it air conditioning of large spaces, or refrigeration of small spaces, generally causes condensation so the capture and control of this moisture is critical. Ideally this should be planned at the initial building stage and will probably determine to some extent the type of systems installed.
The motion or weight needed to operate doors, especially for universal access, will initially be specified within a range that for example an elderly person or a person in a wheelchair can successfully operate. Maintenance of these can be critical and if they don’t perform then you are essentially broaching workplace ,health and safety requirements. This duty of care also applies to the continuing performance of essential fire equipment including drop handles on doors, fire canister use by dates, smoke alarms, exit lighting, and please don’t store equipment in fire exit hallways and stair wells. This can all be audited by fire officers at any time, but generally if they are advised by disgruntled staff or clientele.
Without tediously going on about general building maintenance it just has to be accepted that eventually paint will peel (especially if it was not applied properly in the first place), ceilings will sag, lighting will dim (especially LEDs), carpets will wear out, entry mats will shed dirt, doors will stiffen, fridges taps and toilets will leak etc and someone will be required to fix these items and pay for it. It goes without saying that the quality and choices at the initial build, or the age of the leased building, will fundamentally affect maintenance thereafter.
Universal access and PWD
Ever noticed that medical facilities are almost always (except in hospitals) at ground level. Obviously this is to cater for ‘people with disabilities’ PWD.
The statistics show that across a typical lifetime of the Australian population between 18 and 25 % of all people will have some sort of disability, whether they are in a wheelchair or wearing glasses. In recent history under the Rudd government, policy papers were released that had an aspiration that 25% of new housing would be constructed under the principles of universal access. This was partly to match the statistics, and partly a realisation that it was far more expensive to refit homes than build these initiatives into them to begin with. Thankfully then, commercial property started incorporating these principles into their designs a long time ago.
The actual design considerations are not onerous and include features such as low profile sills on doorways, ramps, colour contrasting, wider corridors, particular handle types, bigger showers, lower sections of bench, etc. Most people would hardly realise these elements have been built in, or would still welcome them whether disabled or not.
Standards change and some regulators would say change the premises at any cost, while others will use the ‘existing condition’ clause. I was once told to widen a long hallway by 25mm in an older dwelling, even though it was a major structural feature of the building. In a government renovation we once had to cap an existing 8 meter solid balustrade because it was deemed to be 2mm under the required height, even though the floor was carpeted. So yes, be serious about it, and make sure your designer has experience in this area or get an access consultant.
I must make special mention of PWD facilities because they have changed considerably in the last few years. A commercial premises will require these and you should not under estimate the sheer space it takes to supply a PWD toilet (5m2 or with a shower 6.5m2), and a PWD car space (26m2), and, these have to be accessible. That means the car space should be as close as possible to the universal access entry, and the doorway to the PWD amenity will need to meet a complex set of entry and exit guidelines. For new builds no certifier will relax any of these measurements for any reason, even by mm.
This has immediate implications for small clinics and it makes sense to group these in a complex of like medical services and share these facilities. In a business and collegiate sense this might then extend to shared receptions, storage , lunch and locker rooms or even security, computer and communications systems. The complex can also then offset some of its costs, say for night lighting in carparks, by the use of solar energy credits.
People oriented design
Architecture is not fundamentally about buildings but about people, and medical facilities have particular clientele and uses. Intimate and technical considerations must be made about workplace spaces, many of which intermix specialist workers and the public. The subtle differentiation and thresholds between these spaces are critical.
Receptionists become gatekeepers, communication systems become immediate, storage and access to medications or chemicals can have legal implications, the experience for the sick person can be fundamentally altered before they meet the doctor, medical workers opportunity for respite and solitude from patients can be paramount to keeping good staff. The issues are seemingly endless except that they are not, they are pointedly specific for each use in each space and yes it is a complex of many competing needs but skilled designers are trained to prioritise and deal with these issues and make spaces that work.
There are many facets to designing spaces that help to make them intuitively functional and to guide people’s actions without their realising. Most people will instantly recognise a reception desk without a sign saying ‘talk to this person who is a receptionist’, or they may be loathe to venture into private areas without big signs saying ‘don’t go here’. They will automatically appreciate that they can sit away from the snuffling nose, or be left alone for a while in a quiet private place before surgery. The varying thresholds of access, the private periods of waiting, the clinical areas of the physician, the support staff, all exhibit functional and aesthetic cues which are not necessarily conscious but give some confidence of use.
Two new hospitals are being constructed on the Sunshine Coast. It might surprise many people that the net cost of supplying a serviced bed in those hospitals is over a million dollars each, but it would also surprise many people to learn about the many varied support spaces that these require, from kitchens to nursing stations to operating theatres. Every aspect of every one of these spaces is carefully analysed and designed. It is no different with any small practice.
Statement from Architect
I am hoping with this article to be able to encourage medically oriented businesses to be specific about their built environment needs, to design it right to start with, and enjoy their premises for many healthy business years to come.
You might think that not all of the above are sustainability issues, but the most fundamental sustainability principle is to be able to build a well functioning facility to start with, and not have to retrofit or change it later. Better still the reuse of existing buildings can be surprisingly cost effective in some cases and this will invariably save almost all of the embedded energy in the structural materials of the building. Also be aware that in the life time costs of a commercial building the initial capital cost is only about 16%, so efficiency is paramount and this is exacerbated in fully controlled internal environments.
It is partly ironic that in gaining expertise to achieve more sustainable and ecosystem friendly environments in other buildings, that this same expertise can transfer to, and enhance the quality of, spaces in the often closed worlds of the medical profession. We are proud that our profession and our practice have the multi-disciplinary skills to achieve these goals and make the medical experience better for everyone.
Written by Adrian Just who is director and principal architect at Archicology pty Ltd and is currently Chair of the Sunshine Coast region of the Australian Institute of Architects. His firm trades under www.archicology.com.au and www.acgcommmercial.com.au. Adrian has a prior professional history in environmental management and is past president of the Cleantech Industries Association. Adrian has a blog at architecture about people.wordpress.com