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UNIVERSITY OF NAIROBI
COLLEGE OF ARCHITECTURE AND
ENGINEERING SCHOOL OF THE BUILT
ENVIRONMENT
DEPARTMENT OF ARCHITECTURE &
BUILDING SCIENCE

THE PLANNING AND DESIGN OF


HOSPITALS:
A comparative analysis of the hospital design
typologies.

A Research Thesis
Bachelor of Architecture
Submitted by: MAINA HARUN WANYEKI
BO2/0310/2009
2014/2015

TUTOR: DR KAMENJU

The Planning & Design of


Hospitals

DECLARATION
This thesis is my original work and to the best of my knowledge has not been presented for a degree
in any other institution. Author: Maina Harun Wanyeki
Signature.

Date

This thesis is submitted in part fulfillment of the examination requirements for the award of the Bachelor of
Architecture degree, Department of Architecture and Building Science, University of Nairobi.

Tutor: Dr. Kamenju


Kimeu

Year Co-ordinator: Arch.Musau

Signature..

Signature

Date

Date

Chairman, Department of Architecture and Building science: Arch


Erastus Abonyo Signature
Date
ii

ACKNOWLEDGEMENTS
To God almighty, for the gift of good health and mental composure that enabled me to write this
thesis with consistency.

. To my loving Parents, Mr. and Mrs. Maina, Thank you for your
continuous devotion to me through prayers, moral and financial support.
To my siblings: Regina Maina, Monica Maina and Hellen Maina, thank you for your moral support throughout
the writing of this thesis. To Dr.Muriithi, thank you for your career guidance and financial support. I would not
have joined the field of Architecture were it not for your career guidance.
To Tabitha Kiarie (department of architecture) thank you for allaying my fears in first year when I
joined the department. Your encouragement has brought me this far.

. To my tutor, Dr.Kamenju, I am greatful for your valued


insight, support and encouragement throughout the writing of this thesis.
th
To Arch.Musau (6 Year Co-ordinator), Prof .Rukwaro (Dean, school of the built Environment) and Arch.Samuel
Kigondu (JKUAT) thank
you for the initial guidance that helped shape this thesis.
To all lecturers, Department of Architecture and building science: Prof.J.Magutu, Prof.Anyamba, Arch.Abonyo,
Arch.Adnan Mwakulomba, Arch.Liku, Arch Bulli ladu, Arch.Oyaro, Arch.Oyugi, Arch.Allan Otieno, Dr.Kakumu,
Arch.Thatthi, Arch.Lorna kiamba, Arch.Kamau Karogi, Dr.Shihembetsa, Arch.Kigara Kamweru, Des.Kahare
Miano, Arch.Norbert Musyoki, Arch.Robert Kariuki, Arch.Yusuf Ebrahim, Arch.Mahinda, Arch.Ogolla and Linda
Nkatha, I owe you for the critiques during the design studios and for broadening my academic horizon through
the theory classes.

. To Mr.Mundia (Administrator Kenyatta National Hospital), Mr.


Githaiga and Mr. Mungai (Kenyatta National Hospital drawings office), thank you for taking time from your busy
schedule to orient me through Kenyatta National Hospital during the fieldwork.

. Special thanks to my friends Jedidah Gitahi, Mr. Matagaro,

Rhoda Kaguo and Patrick Gitonga for their contribution in the data collection during the fieldwork. I wish to
particularly thank Mr.Caleb for undertaking to print this thesis document free of charge.

. To the B.Arch class of 2014/15, it has been a wonderful


experience learning together. Thank you for your positive criticism that helped shape this thesis.

DEDICATION

To
Dr.Muriithi

TABLE OF CONTENTS
Declaration...................................................................................................................................................................................................... ii
Acknowledgement........................................................................................................................................................................................iii
Dedication....................................................................................................................................................................................................... iv
Table of contents............................................................................................................................................................................................v
List of figures.................................................................................................................................................................................................ix
List of tables..................................................................................................................................................................................................xii
Abstract........................................................................................................................................................................................................ 1
Chapter 1: Introduction
1.1...........................................................................................................................................Background of study 2
1.2 Problem statement.......................................................................................................................................................................... 3
1.3 Aims & Objections...........................................................................................................................................4
1.4 Research Questions.........................................................................................................................................4
1.5 Scope & Limitations........................................................................................................................................4
1.6 Justification of Study....................................................................................................................................5
1.7 Significance of Study....................................................................................................................................5
1.8 Definition of Terms..........................................................................................................................................5
1.9 Structure of the Paper..................................................................................................................................6
Chapter 2: Literature Review
2.1 Introduction.....................................................................................................................................................7
2.2 History of hospital planning.............................................................................................................................7
2.2.1 Early times..........................................................................................................................................7
2.2.2 Greece................................................................................................................................................8
2.2.3 Classical antiquity...............................................................................................................................8
2.2.4 Medieval Christian period...................................................................................................................8
2.2.5 Renaissance........................................................................................................................................8
th
th
2.2.6 18 & 19 Century.............................................................................................................................9
th
2.2.7 20 Century........................................................................................................................................9
2.3 The organisation of Health care facilities......................................................................................................10

2.4 Hospital planning and design........................................................................................................................11


2.4.1 Nursing zone.....................................................................................................................................11
2.4.2 Clinical zone......................................................................................................................................12
2.4.3 Support zone.....................................................................................................................................13
2.4.4 Location of the support zone.............................................................................................................13
2.5 Planning Guidelines.......................................................................................................................................14
2.5.1 Site planning and external circulation...............................................................................................14
2.5.2 Provision for growth..........................................................................................................................15
2.5.2.1 The nucleus concept...........................................................................................................................................15
2.5.3 Separation of dissimilar traffic...........................................................................................................16
2.5.4 Anticipate change..............................................................................................................................16
2.5.4 Development of modular spaces......................................................................................................17
2.5.5 Energy conservation and sustainability..............................................................................................17
2.6 Circulation and communication spaces in hospitals............................................................................18
2.6.1 Access...............................................................................................................................................19
2.6.2 Corridors............................................................................................................................................20
2.6.3 Lifts...................................................................................................................................................21
2.6.4 Privacy...............................................................................................................................................21
2.7 Emergency Response facilities in hospitals.......................................................................................22
2.8 Types of hospital planning.................................................................................................................24
2.9 The horizontal hospital......................................................................................................................24
2.9.1 Independent linked slabs hospitals...................................................................................................25
2.9.2 Spine and pavilion hospitals..............................................................................................................26
2.9.3 Extended courtyard hospitals............................................................................................................27
2.9.4 Horizontal monolith hospital..............................................................................................................28
2.9.5 Compact courtyard hospitals.............................................................................................................28
2.10 The Vertical hospital..........................................................................................................................29
2.10.1 Simple tower on podium hospitals...................................................................................................30
2.10.2 Complex tower on podium hospitals................................................................................................31
2.10.3 Radial tower on podium hospitals...................................................................................................32
2.10.4 Articulated slab on podium hospitals...............................................................................................33

2.10.5 Vertical monolith hospitals...............................................................................................................34


Chapter 3: Research Methodology
3.1.........................................................................................................................................................................Intr
oduction...........................................................................................................................................................35
3.2.........................................................................................................................................................................Re
search purpose................................................................................................................................................35
3.3.........................................................................................................................................................................Re
search design and Strategy.............................................................................................................................35
3.3.1.............................................................................................................................................................Ca
se study method......................................................................................................................................................................35
3.4.........................................................................................................................................................................Sel
ection Criteria (sampling method)...................................................................................................................37
3.5.........................................................................................................................................................................Da
ta Collection Methods......................................................................................................................................39
3.5.1.............................................................................................................................................................Pri
mary data.............................................................................................................................................39
3.5.2.............................................................................................................................................................Se
condary data........................................................................................................................................40
3.6.........................................................................................................................................................................Da
ta Collection Tools............................................................................................................................................40
3.7.........................................................................................................................................................................Da
ta Analysis methods.........................................................................................................................................41
3.7.1............................................................................................................................................................Da
ta Analysis Tools...................................................................................................................................43
3.7.2............................................................................................................................................................Da
ta Presentation Modes..........................................................................................................................43
3.8. Time Horizon
..............................................................................................................................................................................
43
Chapter four: data presentation and analysis

4.0........................................................................................................................................................................Intr
oduction..........................................................................................................................................................44
4.1........................................................................................................................................................................Ke
nyatta National Hospital..................................................................................................................................44
4.1.1............................................................................................................................................................Intr
oduction...............................................................................................................................................45
4.1.2............................................................................................................................................................Cur
rent Status............................................................................................................................................46
4.1.3............................................................................................................................................................Ho
spital Services......................................................................................................................................46
4.1.4............................................................................................................................................................Pla
nning....................................................................................................................................................48
4.1.5............................................................................................................................................................Zo
ning......................................................................................................................................................50
4.1.5.1................................................................................................................................................Cli
nical Zone................................................................................................................................................................... 50
4.1.5.2................................................................................................................................................Nur
sing Zone.................................................................................................................................................................... 51
4.1.5.3................................................................................................................................................Su
pport Zone..................................................................................................................................................................51
4.1.6 Circulation...........................................................................................................................................53
4.1.6.1................................................................................................................................................Acc
ess..................................................................................................................................................................................53
4.1.6.2................................................................................................................................................Se
paration of Dissimilar Traffic................................................................................................................................ 55
4.1.6.3................................................................................................................................................Int
ernal circulation........................................................................................................................................................56
4.1.6.4................................................................................................................................................Ea
se of wayfinding....................................................................................................................................................... 56
4.1.6.5................................................................................................................................................Cir
culation spaces......................................................................................................................................................... 57

4.1.6.6

Communication spaces...................................................................................................................................57
4.1.7
Flexibility & growth.............................................................................................................................59
4.1.7.1
The Old Hospital.....................................................................................................................................................59
4.1.7.2
Phase 1......................................................................................................................................................................63
4.1.7.3
Phase II......................................................................................................................................................................65
4.1.7.4
Phase III..................................................................................................................................................................68
4.1.8
A& E wing.............................................................................................................................................67
4.1.9
The nursing tower...............................................................................................................................70
4..1.10 Emergency design features in the nursing tower..........................................................................74
4.1.11........................................................................Comparison of the Horizontal typology models at KNH
77
4.1.12..............................................................plannning & design challenges at Kenyatta national hospital
79
4.2 Nanjing Drum Tower Hospital.............................................................................................................81
4.2.1...........................................................................................................................................Introduction
81
4.2.2......................................................................................Nanjing Drum Tower Hospital South Extension
...........................................................................................................................................................82
4.2.3Sustainable design features in the hospital.....................................................................................83
4.2.4........................................................................The Planning & design of Nanjing Drum Tower hospital
...........................................................................................................................................................85
4.2.4.1............................................................................................................................................Zoning
.....................................................................................................................................................93
4.2.4.2......................................................................................................................................Circulation
.....................................................................................................................................................94
4.2.4.3.........................................................Emergency design features at Nanjing Drum tower hospital
.....................................................................................................................................................96
4.3. Comparison of KNH & Nanjing drum tower hospital....................................................................................97
Chapter five: conclusions and recommendations
5.1.........................................................................................................................................................Introduction
100

5.2........................................................................................................................Conclusions on Literature review.


100
5.3.....................................................................................................................................Conclusions on fieldwork
104
5.4...............................................................................................................................................Recommendations
108
5.5Recommendations for future research on hospital planning and design......................................................108
List of References...............................................................................................................................................110

LIST OF FIGURES

diagram showing expansion and growth in a vertical


hospital.pg15

Chapter 1: Introduction
Figure 1-1: A diagram illustrating the horizontal and vertical
planning strategies in hospital design .pg2
Figure 1-2: vertical planning strategy in hospital
design.pg3 Figure 1-3: Horizontal planning strategy
in hospital design.pg3 Figure 1-4: Rush University
Medical Center, Chicago, and USA.pg4 Figure 1-5:
Aerial view of Mbagathi District hospital.pg4
Figure 1-6: National Cancer Center Tokyo, Japan (361
feet).pg5
Figure 1-7: The southwest hospital surgery tower in
Chongqing, china.pg5 Figure 1-8: Hervey Hospital,
Denmark.pg6
Figure 1-9: Queen Mary Hospital, Hong Kong.pg6

Chapter 2: Literature Review


Figure 2-1: basic human needs. Pg7
Figure 2-2: Maslow hierarchy of needs.pg7
Figure 2-3: The priest medieval consultant of classical
Greece.pg8 Figure 2-4: Greco-Roman Latreia.pg8
Figure 2-5: Romano-Christian xenochichium at Ostia,
Italy.pg9 Figure 2-6: Florence Nightingale ward.pg9
Figure2-7: The Health pyramid.pg10
Figure 2-8: Relationship of the 3 zones in a hospital and their
approximate proportions in a general hospital.pg11
Figure2-9: Diagram showing the distribution of the 3 zones in
a vertical hospital.pg11
Figure2-10: Diagram showing the distribution of hospital zones
in a horizontal hospital.pg11
Figure 2-11: Relationship and zoning diagram for a healthcare
facility.pg12 Figure 2-12: Expanded relationship diagram for a
healthcare facility.pg12 Figure 2-13: support services on a
vertical model.pg13
Figure 2-14: support services on a mixed horizontal-vertical
strategy.pg13 Figure 2-15: support services off site.pg13
Figure 2-16: support services on a horizontal hospital
model.pg13 Figure 2-17: Block schematic plan of
Maidstone general hospital.pg15 Figure 2-18: Stack

xi
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Figure 2-19: Massing diagram showing expansion and


growth in a vertical hospital.pg15
Figure 2-20: space for independent wheelchair &ambulant
person.pg 18 Figure 2-21: Space for wheelchair user and
semi-ambulant user with clutches to pass.pg 18
Figure 2-22: space for two independent wheelchairs
users to pass.pg 18 Figure 2-23: Space for
independent wheelchair user and semi-ambulant
person with walking frame to pass.pg 18
Figure 2-24: space for 2 beds passing.pg19
Figure 2-25: corridor with recess for turning bed
0
through 180 . pg.19 Figure2-26: Lift for bed
movement.pg 20
Figure 2-27: General Service lift.pg20
Fig 2-28: Mattress evacuation down
stairway.pg21 Figure 2-29: Ramp for the
physically challenged.pg22 Figure 2-30:
vertical massing hospital model.pg24
Figure 2-31: horizontal massing hospital
model.pg24 Figure 2-32: Independent
linked slab.pg25

Figure 2-33: Khon Kaen university hospital,


Thailand.pg25 Figure 2-34: spine and
pavilion.pg26
Figure 2-35: Samaritan hospital, Arizona,
USA.pg26 Figure 2-36: Extended
courtyard.pg27
Figure 2-37: Wexham park hospital,
slough, UK.pg27 Figure 2-38: Horizontal
monolith hospitals.pg28 Figure2-39:
compact courtyard hospitals.pg28 Figure
2-40: Vertical hospital.pg29
Figure 2-41: New York Presbyterian
Hospital.pg29 Figure 2-42: simple tower
on podium.pg30
Figure 2-43: Queen Mary Hospital, Hong
Kong.pg30 Figure 2-44: complex tower on
podium.pg31
Figure 2-45: Hervey Hospital, Denmark.pg31
Figure 2-46: Radial tower on podium
hospitals.pg32 Figure 2-47: Rush
University Medical Centre.pg32 Figure 248: Articulated slabs on podium.pg.33
Figure 2-49: The bunting centre.pg33
Figure 2-50: vertical monolith.pg34
Figure 51: Kenyatta national hospital nursing tower block.pg34

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Chapter 3: Research Methodology


Figure 3-1:50m long measuring tape used for data
collection.pg39 Figure 3-2:5m measuring tape used
for data collection.pg39 Figure 3-3: canon digital
camera used for data collection.pg 40
Figure 3-4: black pen used for data collection in interviews,
notes and sketches.pg 40
Figure 3-5: sketch pad used in data collection in form
of notes and sketches.pg40

Chapter 4: Fieldwork Documentation and


Analysis
Figure 4-1: map showing the location of Nairobi in Kenya
within Africa.pg45 Figure 4-2: map showing the location of
KNH within Nairobi.pg45
Figure 4-3: A monument of the nursing tower at
KNH.pg46
Figure 4-4: An Image of Kenyatta National Hospital taken from
Ngong road.pg46
Figure 4-5: An image of the model of Kenyatta National
Hospital.pg47 Figure 4-6: A model of Kenyatta National
hospital complex.pg48 Figure 4-7: Master plan of
Kenyatta National Hospital.pg49
Figure 4-8: 10 storied nursing tower bock home to the entire
nursing zone at KNH.pg50
Figure 4-9: Caption of the single storied clinical zone
at KNH.pg50
Figure 4-10: The support services block at KNH housing the
C.S.S.D, general stores, kitchen and dining.pg51
Figure 4-11: Oxygen plant at KNH.pg51
Figure 4-12: zoning map of Kenyatta national
hospital.pg52 Figure 4-13: main entrance to the
Wards and clinics at KNH. Pg53
Figure 4-14: Pedestrian walkways have been used to avoid
vehicular and pedestrian conflict.pg53
Fig 4-15: Master plan of Kenyatta National
Hospital.pg54
Figure 4-16: The helipad strategically located at the rear of the
A& E unit.pg55 Figure 4-17: Direct vehicular access at the A& E

unit for emergencies.pg55 Figure 4-18: The hospital street as


captured in the physical model of KNH.pg56 Figure 4-19: View of
the lifts lobby from the hospital street.pg57
Figure 4-20: Wall fixed signage plates along the secondary
streets at KNH.pg57 Figure 4-21: Mosaic arts along the
corridors.pg57
Figure 4-22: Internal circulation map at Kenyatta National
hospital.pg58 Figure 4-23: The old hospital block.pg59

Figure 4-24: Image of the circulation spine in the old


hospital.pg59
Figure 4-25: The old hospital as it existed before
construction of the main hospital block.pg60
Figure 4-26: detailed layout of the old
hospital.pg61 Figure 4-27: Layout plan of
the old hospital.pg62
Figure 4-28: Typical ward plan of the old hospital before
relocation of the wards in the Nursing tower block.pg62
Figure 4-29: Courtyard used as an organising principle at the
Paediatric unit.pg63
Figure 4-30: Roof lights used to light the single storied deep
planned blocks.pg63
Figure 4-31: Layout of the phase -1 development at Kenyatta
National Hospital.pg64
Figure 4-32: Layout of the phase development at Kenyatta
National Hospital.pg65
Figure 4-33: Layout of the phase-III development at Kenyatta
National hospital.pg66
Figure 4-34: View of the A& E unit from the
parking.pg67 Figure 4-35: Location of the
A&E unit at KNH.pg67

Figure 4-36: Ground floor plan of A&E department


at KNH.pg68 Figure 4-37: First floor plan of A& E
department at KNH.pg69 Figure 4-38: A model of
the KNH Nursing tower block.pg70 Figure 4-39:
hard landscaped tower block courtyard.pg70
Figure 4-40: A typical floor plan of the ward.pg71
Figure 4-41: Aerial view of the nursing tower.pg72
Figure 4-: A detailed analysis of the typical wards in at
Kenyatta National Hospital.pg72
Figure 4-42: Sectional analysis of the tower block at KNH.pg73
Figure 4-43: The four compartments of double wards in a
typical floor of the nursing tower.pg74
Figure 4-44: Sketch of a fire resistant door along the 3000mm
wide corridors in the wards.pg74
Figure 4-45: Analysis of the architectural design emergency
features in a typical floor of the nursing tower.pg75
Figure 4-46: The ramp serving the obstetrics wards in the
first floor and the delivery suite in the Ground floor at
KNH.pg76
Figure 4-47: Fire exit sign at an emergency escape door at
KNH.pg76 Figure 4-48: Location of the paediatric
department at KNH.pg79

Figure 4-49: Make shift waiting area for paediatric outpatient


unit donated by Posta.pg79
Figure 4-50: A child receiving emergency service at KNH
A&E unit.pg80 Figure 4-51: A child looking for play activities
at KNH.pg80
Figure 4-52: location of china within
Asia.pg81 Figure 4-53: Location of
Nanjing within China.pg81
Figure 4-54: The 1892 Drum tower hospital during winter
in1892.pg81
Figure 4-55: The 1892 memorial Hall and Hospital Archives,
Jan 23, 2007.pg81 Figure 4-56: Nanjing Drum Tower south
extension.pg82
Figure 4-57: View of the roof gardens at Nanjing drum tower
hospital.pg82 Figure 4-58: A model of the Nanjing Tower
hospital.pg83
Figure 4-59: Roof garden at Nanjing drum tower
hospital.pg83 Figure 4-60: Faade of the
gardenised architecture.pg84 Figure 4-61: A detail
of the gardenised envelope.pg84
Figure 4-62: The 6 healing Gardens at Nanjing Drum
hospital.pg84
Figure 4-63: section through Nanjing Drum Tower hospital
showing the tower and the podium.pg 85
Figure 4-64: Image of Nanjing drum tower
hospital.pg85 Figure 4-65: site plan of Nanjing
drum tower hospital.pg86
Figure 4-66: Ground Floor plan of Nanjing drum tower hospital
South Extension.pg87
Figure 4-67: Diagrammatic arrangements of
departments at the south extension at Nanjing drum
tower hospital.pg88
Figure 4-68: Section-01 through the south extension of Nanjing
Drum Tower Hospital.pg89
Figure 4-69: First floor plan of the South extension at Nanjing
drum tower hospital.pg90
nd, rd
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Figure 4-70: Typical 2 3 & 4 floor plan of the south
extension at Nanjing
Drum Tower hospital.pg91
th
Figure 4-71: 5 floor plan of Nanjing Drum Tower hospital.pg92

th

th

Figure 4-72: Typical 6 -13 floor of Nanjing Drum Tower


th
th
Hospital.pg92 Figure 4-74: Zoning plan of the typical 6 -13
nursing floors of the Nanjing Drum Tower Hospital.pg93
th
th
Figure 4-75: Activity plan of the typical 6 -11 floors of the
Nanjing Drum Tower Hospital.pg94

Figure 4-76: Circulation flow plan in a typical nursing floor at


Nanjing Drum Tower hospital.pg95
Figure 4-77: Design emergency features in a typical nursing
floor at Nanjing drum tower hospital.pg96

Chapter 5: Conclusions and Recommendations


Figure 5-1: Early cruciform halls hospitals.pg100
th
Figure 5-2: horizontal hospital model established in 19
century.pg100 Figure 5-3: Vertical hospital model
th
established in the 20 century.pg100 Figure 5-4:
Independent linked slab model.pg101
Figure 5-5: Independent spine & pavilion
model.pg101 Figure 5-6: Extended
courtyard model.p101
Figure 5-7: Horizontal monolith
model.pg101 Figure 5-8: Compact
courtyard model.pg101 Figure 5-9:
Simple tower on podium
model.pg102
Figure 5-10: complex tower on podium
model.pg102 Figure 5-11: Radial tower on
podium model.pg102 Figure 5-12:

Articulated tower on podium model.pg102


Figure 5-13: Vertical monolith model.pg102
Figure 5-14: model of Kenyatta national
hospital.pg103 Figure 5-15: model of Nanjing
Drum Tower hospital.pg103 Figure 5-16: Use of
roof lights in deep plans.pg104
Figure 5-17: Use of narrow plans to achieve natural lighting &
ventilation.pg104
Figure 5-18: Compartmentalization of wards for ease of
evacuation.pg105 Figure 5-19: Use of ramps for vertical
movement of the semi-ambulant.pg105 Figure 5-20: Use of
vertical gardens to create places of respite.pg106
Figure 5-21: Use of light wells for lighting interiors.pg106
Figure 5-22: Hybrid typology of vertical and horizontal
models.pg107 Figure 5-23: A hybrid model of spine and
pavilion and extended courtyard models.pg107
Figure 5-24: Use of circulation as the principle organising
element.pg107 Figure 5-25: Use of healing gardens for
therapeutic benefits.pg108
Figure 5-26: Use of interstitial floors in vertical hospitals for
maximum natural ventilation through stack effect.pg108
Figure 5-27: Provision of vertical gardens in vertical
hospitals.pg108

LIST OF TABLES
Table 3-1: Table of study parameters.................................................................................................................................................................... 41
Table 4-1: Comparative analysis table of the horizontal hospital typologies at Kenyatta National Hospital........................77
Table 4-2: Comparative analysis table of Kenyatta National Hospital (Kenya) & Nanjing Drum Tower Hospital (China)......97

The Planning & Design of


Hospitals

ABSTRACT
Hospitals may be thought of as icons of pain, sickness and distress, but they are also icons of healing, life,
family and hope. They are therefore important buildings for any community. The planning and design of
hospitals has a great impact on the stress levels (to staff & visitors) and to the patients recovery period.
The main factor which differentiates hospitals from other buildings is that no other building type presents
such a diverse spectrum
of occupants with varying physical and emotional needs. The hospital is
therefore a complex building type. A deep understanding of the inter-relationship of the parts and their
relationship in-turn to the whole hospital is required to make a meticulous healing environment.
Hospital planning can be grouped into two types; the horizontal hospital and the vertical hospital. The
success of these two types cannot be overstated; however they are characterized by their own unique
challenges. Its precisely because of the limitations exhibited in the two hospital types and their typologies
that a conceptual framework is needed to clearly understand the creation of a proper healing environment.

The Planning & Design of


Hospitals

CHAPTER ONE: INTRODUCTION


1.1 Background of study
There has been quite a number of Bachelors of architecture theses
in the University of Nairobi dealing with hospitals planning and
design:Versus

Shivji, R. (1985).The influence of circulation and services to the


functional planning and design of hospitals
Ochieng, G. (1989) Curative Environment: Stress reduction in
hospitals
Oyaro, E. (1992).Architectural expressions in hospital forms
Momanyi, J. (2003).Hospital design: A search for flexibility in
hospitals
Muriithi , G.(2005).Architecture for spinal injury hospital.
Njuguna, W. (2006).Development of paediatric hospital in Nairobi
Mulanga, M. (2007) Health care design: Creating a healing
environment. Kaseda, E. (2013).Environmental strategies for
hospital design in warm humid climate.
Whereas the precedent theses are rich in aspects pertaining to
hospital design, none has carried out a comparative analysis of
the typologies in hospital planning and design.

Therefore, the author finds a gap of knowledge to fill in the


planning and design of hospitals by analysing and comparing the
typologies in hospital planning and design. This area has not been
Figure 1-1: A diagram illustrating the horizontal and vertical planning strategies in hospital design
studied before; hence it will contribute new knowledge to the bulk
Source: Authors sketch, June 12th 2014
of information available on hospitals planning and design.
2

1.2 Problem statement


Most of human history has seen the vast majority of people living in
rural areas. However the urban population has risen steadily over
the last two centuries. The 1800s started with just a 3% of the
worlds population living in urban areas. By 1900 the urban
population had increased to 14% and then doubled to almost 30%
by 1950.In 2008, for the first time, the worlds population was
evenly split between the urban and rural areas. Urban growth is
projected to continue its increase with expectations that 70% of the
world population will be urban by 2050. Thus, urban growth trend
Figure 1-2: vertical planning strategy in hospital design Source: Author modified sketch, July 2 nd 2014
places a particular emphasis on developing sound planning and
design strategies within urban areas (World health organisation,
2010).

Versus

The hospital being a complex building type needs to respond to the


urban growth trend by developing sound planning and design
strategies. This would help in addressing the problems in the
planning and design of hospitals which range from site limitations
in urban areas, difficulties in achieving growth and flexibility,
challenges in achieving maximum natural lighting and ventilation,
challenges in carrying out evacuation in times of emergencies,
circulation stress and mixing of incompatible traffic which lead to
cross-infections among other problems.
The horizontal hospital by nature utilizes a great deal of land to
fully accommodate its functional requirements compared to the
vertical hospital. The sustainability of the horizontal hospital
especially in urban areas is therefore questionable since land is at
a premium and the footprint is limited. On the other hand, the

vertical hospitals are not without their problems; it is argued that


the usual vertical hospital is inflexible, experiences vertical traffic
stress and heavily relies on lifts which may present challenges in
carrying out evacuation in case of emergencies among other
Problems.

Figure 1-3: Horizontal planning strategy in hospital design


Source: Author modified sketch, July 2nd 2014

Therefore there is need to study and analyse the two hospital


typologies and their models in order to help address the problems
in hospitals planning and design.

1.3 Aims and objectives


1. To investigate the typologies in the planning and design of
hospitals.
2. To investigate the current global trend in the planning
and design of hospitals.
3. To analyse and compare the typologies in the planning
and design of hospitals in order to determine their
levels of efficiency.

1.4 Research questions


Figure 1-4: Rush University Medical Center, Chicago, USA. A 386 bed vertical
urbantypologies
hospital
1. Which
Source: August 4th 2014

exist in the planning and design of hospitals?


2. What is the current global trend in the planning and design of
hospitals?
3. Which are the most efficient typologies in the planning
and design of hospitals?

1.5 Scope and limitations


Hospital planning and design is broad. Due to limitations of time
and resources, the study was limited to the analysis and
comparison of the typologies in the planning and design of
hospitals. The spatial analysis covered the three basic zones in a
hospital and how they have been manipulated to achieve a
hospital organism.
These are the clinical, nursing and support zones.

Figure 1-5: Aerial view of Mbagathi District hospital


A 250 bed urban horizontal hospital Source: Google Earth, August 6 th 2014

The field work was limited to Kenyatta national hospital in Nairobi


as it provided an opportunity to investigate both the horizontal and
vertical strategies in the same context. In addition, Nanjing drum
tower hospital was selected as an international case study to
provide a comparative base with Kenyatta national hospital.

The Planning & Design of


Hospitals

1.6 Justification of study


The impetus of the study arises due to the need to address the
challenges in hospital planning and design especially in urban
areas where there are tight site constraints.

1.7 Significance of study


This study will benefit Architects and developers by providing
guidelines to achieve an appropriate, efficient and sustainable
healing environment. Additionally the study will assist government
institutions by implementing the findings and recommendations in
their projects.
Figure 1-6: National Cancer Center Tokyo, Japan (361 feet)
Source: -September 19th 2014
1.8

Definition of terms

Horizontal hospital- This is a hospital model that utilizes


horizontal planning strategy. The zones are linked together
laterally so that the movement is mainly horizontal. They are
limited to 4 floors
Vertical hospital- This is a hospital model that utilizes
vertical planning strategy. The zones are arranged one
above the other so that the movement pattern is mainly
vertical. They rise above 4 floors
Circulation spaces- These are spaces that provide access
within the hospital departments. They comprise of corridors,
internal lobbies etc. within a department for moving
between rooms/spaces within an individual department.
Communication spaces- They are spaces providing access
between departments. They comprise of hospital streets,
Lifts, Ramps, staircases etc. that provide access between
Figure 1-7: The southwest hospital surgery tower in
departments.
Chongqing, china (394 feet (120 meters) with 2,200 beds Source: -September
19th 2014
Flexibility-Ability of a hospital to accommodate change and
growth without destruction of existing systems.

The Planning & Design of


Hospitals

The Planning & Design of


Hospitals

Hospital Street-The primary circulation corridor from


which all other secondary corridors branch.

1.9 Structure of the research paper


Chapter 1: Introduction

This chapter serves as the introduction of the topic of study. It


highlights the background of the study, problem statement, aims
and objectives, research questions, the scope and limitations,
definition of terms, relevance of the study and the research
methodology used to undertake the investigation.
Chapter2: literature Review
The chapter begins with the history of hospital planning over the
Figure 1-8: Hervey Hospital, Denmark Bed capacity-1,616 beds centuries to give a clear understanding of the trend in hospital
Year Built-1976
planning and design over time. The chapter further explores the
Source: Source: August 3rd 2014
parameters in hospital planning and design and the typologies and
models in hospital planning and design.
Chapter 3: Research Methodology
This chapter outlines the process of selection of the area of study
and the case studies that are a representative of the research by
describing all the methods of data collection, presentation and
analysis. Case study method was selected for this study due to
exploratory nature of the study.
Chapter 4: Field work
This chapter is on case studies, data analysis and presentation and
examines a local and international case study to provide a
comparative base. The two case studies are Kenyatta National
hospital (Kenya) and Nanjing Drum Tower Hospital (China)
Chapter 5
This chapter is on conclusions and recommendations of the
study. It succinctly highlights the salient conclusions deduced

Figure 1-9: Queen Mary Hospital, Hong Kong Bed capacity-1,400 beds
Year Built-1991
Source: Source: , August 3rd 2014

The Planning & Design of


Hospitals

from the findings of the study. This chapter concludes with


recommendations based on the findings of the study.

The Planning & Design of


Hospitals

CHAPTER TWO: LITERATURE REVIEW


2.1 Introduction
The study of man from his beginnings shows that the desire for
health along with food, shelter and clothing ranks high among the
fundamental basic needs. The hospital has developed over the
centuries to serve this basic urge (American institute of hospitals
consultants, 1969).
Peoples expectations from hospitals have changed over the
centuries. In the middle ages they were primarily associated with
death. Some of the finest hospitals were built for pilgrims far from
Figure 2-1: basic human needs Source:en.m.wikipedia.org/ human needs, Sep 2nd 2014
home since they had nowhere to go when they fell sick. They were
offered care in cruciform halls with the nuns nursing station at the
centre and the altar at the end. The aim was to protect the healthy
pilgrims from infection and to prepare the sick for the death. The
idea that hospitals were about life rather than death began to dawn
gradually (James & Tatton-Brown, 1986).

2.2 History of hospital planning


2.2.1

Early Times
In the early 3rd century B.C, medicine and healing were linked to the
gods. Consequently, the hospital forms that existed closely
resembled the forms of the temple. The temples enshrining these
gods became centres of healing, although in a basic manner with
priests as medical consultants (Rosenfield & Rosenfield, 1969).

The Planning & Design of


Hospitals
Figure 2-2: Maslow hierarchy of needs
Source: en.m.wikipedia.org/Maslow, Sep 2nd 2014

The Planning & Design of


Hospitals

2.2.2

Greece
th
By the end of 6 century B.C, medical clinics had developed in
Greece to complement the temples that acted as healing centres.
The Greek physicians who were free citizens held consultations
and treated their private patients. These clinics were eventually
private institutions but the state funded similar institutions to
provide health care to the citizens.

2.2.3

Classical Antiquity
According to Rosenfield & Rosenfield (1969), Later in Classical
antiquity, the rational processes of thought were reflected in the
plan form which gradually achieved a character of its own. The
Figure 2-3: The priest medieval consultant of classical Greeceorder and clarity became evident, Clear patterns of circulation
Source: Rosenfield. (1969) Hospital architecture and beyond,
were delineated and attention paid to functional groupings.
July 5th 2014
2.2.4

Medieval Christian Period


The clarity in the classical antiquity was lost during the medieval
Christian period. Hospital buildings again became
undistinguishable from general medieval architectural forms.
Concepts of rational planning and logical sequences of function
disappeared (Rosenfield & Rosenfield, 1971).

2.2.5

Renaissance
In Italy, Renaissance brought back a certain rational clarity to the
plan form. Orderliness and careful attention to circulation was
demonstrated but the Alter was still the focal point.

Figure 2-4: Greco-Roman Latreia


Source: Rosenfield. (1969) Hospital architecture and beyond,
July 5th 2014

The Planning & Design of


Hospitals

The Planning & Design of


Hospitals

2.2.6

th

18th &19 Century


Hospital planning took the functional and scientific dimension in
th

th

the late 18 and 19 centuries forerun by Florence Nightingale.


The pavilion type which segregated patients into small groups and
ensured there was natural light and ventilation evolved. There was
orderliness and clarity; patterns of circulation were delineated,
functional groupings were assembled and a greator respect was
shown to human dignity (Cox & Groves, 1990).
1846- The discovery of anaesthetics. The use of anaesthetics
permitted carefully planned deliberate procedures .An operating
theatre became a part of every hospital, and more beds had to be
provided to accommodate an increasing number of survivors.
1866-9 Listers use of carbolic sprays for antiseptic surgery
which reduced the number of post-operative fatalities. This
increased the range of surgery and surgical theatres
1886Introduction
of aseptic
techniques,
the
sterilizing
Figure 2-5: Romano-Christian xenochichium at Ostia, Italy Source: Rosen
field.
(1969) Hospital
architecture
and beyond,
July
12th 2014 of
equipment. This extended the area of ancillary accommodation
1895- Roentgen used x-rays as an aid to diagnosis hence the
need for x-ray rooms arose.
Laboratories similarly added a new dimension to medicine and
extended the use of pharmaceuticals.
The primary function of hospitals turned slowly from custodial care
to active intervention. They became places to save and improve
the quality of life (James & Tatton-Brown, 1986).
2.2.7

Figure 2-6: Florence Nightingale ward


Source: Fletcher, B (1975).History of Architecture,
July 12th 2014

th

20 Century
As from the 20th century to the present day, the architectural
form of the hospital has changed from the low horizontal pavilions
to a vertical hospital. The vertical

The Planning & Design of


Hospitals

hospital superseded the pavilion plan and became the accepted


architectural form for hospitals during the twenties (Hudenberg,
1969).

2.3 THE ORGANIZATION OF HEALTH CARE


FACILITIES
All systems of healthcare delivery comprise of a range of
institutions which are graded according to their degree of
sophistication and specialization as well as the level of care they
can provide (Ministry of health, 2010).
Classification of health facilities in Kenya is based on the following
criteria:
a) Services offered e.g. inpatient, outpatient, specialised
treatment.
b) Physical facilities e.g. number of beds, rooms, treatment
and diagnostic facilities.
c) Catchment population- the potential population served
by the health facility.
d) Staff-both in numbers and fields of specialization.

Figure2-7: The Health pyramid Source: ministry of health, 2010

Based on this criterion, the health facilities are then classified


into 6 distinctive levels. The Community hospitals like the
village health centres are classified as level-1. Dispensaries
and health centres are classified as level 2 and level 3
respectively.
Level 4 comprise of the sub-county hospitals in the new
constitution formerly known as district and sub-district hospitals.
County hospitals, formerly provincial hospitals are classified as

The Planning & Design of


Hospitals

level-5 hospitals. The national referral hospitals are classified as


level 6 hospitals.

10

The Planning & Design of


Hospitals

The central government through the relevant ministry used this


classification to come up with standard model architectural
drawings upon which the design of any public health facility within
the country by the government was based. The new constitution
2010 has since devolved health services to the county
governments.

2.4 HOSPITAL PLANNING AND DESIGN


It has been argued that a study of traffic requirements suggests a
number of villages than a single
organism. Hospitals should be assembled in a way that it will be
more than a mere collection of functions and departments needed
in the practice of medicine. The avenues of circulation should be
organised to create order in the movement of persons, supplies
and services. Everyone should be able to arrive at, move around
and leave the hospital building without unnecessary effort, anxiety,
embarrassment or confusion (Rosenfield & Rosenfield, 1969).

Figure 2-8: Relationship of the 3 zones in a hospital and


operating
a
their approximate proportions in a general hospital. Source: Source:hospital
Author modified
sketch,more
July 10like
th 2014

Activities within the hospital building are grouped into three


distinct zones. These are:

Figure2-9: Diagram showing the distribution of


the 3 zones in a vertical hospital
1.
Source: Author modified sketch, July 10th 2014

Clinical zone
2. Nursing zone
3. Support zone

The key to hospital planning is the manipulation of these zones


and their relationships to produce a fully functional, integrated
hospital (James & Tatton- Brown, 1986).
Figure2-10: Diagram showing2.4.1
the distribution ofNursing
hospital zones in a horizontal hospital
Source: Author modified sketch, July 10th 2014

zone
11

The Planning & Design of


Hospitals

The nursing zone can generally be referred to as the patient wards.


Its purpose is to foster patients throughout their stay in hospital.
James and Tatton-Brown (1986) assert that:

Figure 2-11: Relationship and zoning diagram for a healthcare facility

Source: Metric handbook planning and design

2.4.2

Maternity beds should be sufficiently separated from the rest


of the hospital to avoid contamination, but still be part of the
hospital with reasonably ready access to the clinical and
support zones. The beds of the mothers should conjoin the
delivery suite.
Recovery beds should be adjacent to the operating suite
since the patients are under constant supervision.
Intensive care beds should be adjacent to the recovery beds
since acutely ill patients require the same kind of expert
nursing as recovery patients
Paediatric beds may be part of an intermediate care nursing
unit in a very small hospital or occupy the space of a full
typical intermediate nursing unit with pertinent modifications
or comprise a separate building conjoined with clinical
division.

Clinical zone
This is the working area for medical treatment and observation.
The clinical zone should be located on the most accessible floor
from the street or road, from the inpatients quarters and from the
outpatient clinics. It comprises of various departments needed for
medical treatment and observation. Of importance to note in the
clinical zone is:

Laboratories serve both inpatients and outpatients. Its


therefore preferable that this department be so
situated that it is accessible to both. The labs should
also be accessible by radiotherapy and the surgical
theatres.

Figure 2-12: Expanded relationship diagram for a healthcare facility


Source: metric handbook planning design

The Planning & Design of


Hospitals

12

The Planning & Design of


Hospitals

Radiation services serve both inpatients and


outpatients. In modern medicine, there are situations
in which the work of the departments of labs and
radiation intermingle.
Surgical theatres should be contiguous to labs and
reontology. This is due to the necessity of consultation
between surgeons and lab scientists which is often
done July
when
patient is on the operation table. Most
Figure 2-13: support services on a vertical model Source: Author modified sketch,
14 ththe
2014
surgery operations are done on inpatients rather than
outpatients.
Emergency service should be accessible from the main
road with a separate entrance shielded from sight of
the main hospital entrance. Emergency patients may
need immediate laboratory tests, x-rays and even
surgical intervention. Following emergency treatment, a
patient may need intensive care, thus intensive care
unit and surgical theatres, and recovery beds should be
provided in the accident and emergency department.

Figure 2-14: support services on a mixed horizontal- 2.4.3


vertical strategy
Support
Source: Author modified sketch, July 14th 2014

Figure 2-15: support services off site


Source: Author modified sketch, July 14th 2014

The support zone is the third main section of the hospital. Its
purpose is to satisfy all the physical and material needs of the
nursing and clinical zones. Such needs include: food, energy,
goods and services. It has to provide for the reception, handling,
distribution, storage and disposal of everything that comes into
and goes out of the hospital (Wheeler, 1964).

2.4.4

Figure 2-16: support services on a horizontal


hospital model
Source: Author modified sketch, July 14th 2014

zone

Location of the support zone

Until recently, most buildings have been planned with


comprehensive support zones within the building, either in the
basement (vertical scheme) or in a separate block (horizontal
scheme).Today, due to mainly technological

The Planning & Design of


Hospitals

13

The Planning & Design of


Hospitals

developments in catering, sterilizing and laundry equipment, it is


more efficient to provide these services on an area or regional
basis. This, with the increasing use of commercially supplied
disposals, has resulted in the reduction of the support zone
within the hospital.

2.5 PLANNING GUIDELINES


In his book, Hospital planning handbook, Rex Whitaker (1976)
outlines the general principles of planning that may apply to any
complex building and particularly medical facilities. The
principles provide some guidance to architects interested in
hospital design .They are outlined as follows:

2.5.1Site Planning/External Circulation


Careful consideration must be given to site access for the public
and staff and for the service and emergency vehicles. It is
desirable to screen ambulance and service entrances (including
morgue) from patient areas. Ambulances shouldnt pass through
parking areas where they may be subject to delay.
The location of parking places can have a great impact on
internal hospital circulation. People always seek way out of the
shorter route, and no number of signs indicating where the
outpatient entry is will force people to use that entry if there is
an entry close to where they left their cars. Obstetric patients
should be provided with drive-up and parking space close to the
entrance. Healthy staff members and visitors can be asked to
walk some distance from their cars.

The Planning & Design of


Hospitals

Physicians should be assured space by designating a specific


area. It seems self- evident but it is sometimes forgotten that
patients to clinics and emergency
14

The Planning & Design of


Hospitals

rooms are often old and infirm, that they may require assistance
in walking and that parking spaces for these people should be as
close as possible to the entrance.

2.5.2

PROVISION FOR GROWTH


2.5.2.1 The nucleus
concept
The rate of increase both in complexity and
the size of hospital is unprecedented. The
nucleus concept arose due to the need for
flexibility. It aims to build a hospital in phases.
It is a highly versatile and economical answer
to the problem of growth and change.
The size of the nucleus is designed to be fully
operational

Figure 2-17: Block schematic plan of Maidstone general


hospital
th
Source: Author modified sketch, July 19 2014

in
its
own
right
.

The Planning & Design of


Hospitals

Figure 2-18: Stack diagram showing expansion and growth in a


vertical hospital
Source: Authors sketch

Figure 2-19: Massing diagram showing expansion and growth in a


vertical hospital
Source: Authors sketch-September 2014

2.5.3Separation of dissimilar traffic


The five classes of people who create hospital traffic are:
Inpatients, outpatients, hospital employees, staff physicians and
visitors. In the horizontal hospital, there are three avenues of
horizontal traffic; one for supplies, one for staff and patients and
another for visitors.
To reduce the mixing of incompatible kinds of traffic which the
vertical hospital implies, one set of elevators should be provided
for ancillary and professional transactions and another for
transporting visitors. However this system is inflexible .To relive
the elevators of the ancillary load and also to obtain quick
unscheduled deliveries, various conveyors and dumbwaiters are
employed. An average vertical hospital should have three
Systems; dumbwaiters and conveyors for ancillary services,
service lifts for staff and patients and finally visitors elevators.
Whether the hospital is vertical, horizontal or a combination of
both, its not possible to route these three avenues separately
into every part of the hospital. Nevertheless, keeping categories
of traffic separated should be followed as far as possible. The
more separation is achieved, the less chance of infecting the
patients. Separation also cuts down exposure of those patients
whose condition and appearance might upset passerby and who
would in turn prefer not to be seen by passerby.

2.5.4Anticipate change

1
6

Hospitals are subject to the demands of new developments in


function and technology. Its reasonable to eliminate as many
fixed vertical elements as possible. This would mean reducing
the number of columns, consolidating mechanical shafts and
keeping elevator shafts, stairs and other vertical circulation from
dividing floor space into small compartments.
All of these elements are practically impossible to move once
built and therefore inhibit change.

2.5.5Development of modular spaces


Modular spaces provide flexibility. Room sizes are seldom critical
that a variation of 10%-20% will not make any difference in their
usefulness. If a module can be developed that is acceptable for a
variety of occupancies, change in use will require minimum
alteration

2.5.6Energy conservation/sustainability
Studies have concluded that a natural environment is essential
to creating a genuine state of the art-healing environment
(AECOM, 2012). Spending time in outdoor places of respite has
been shown to reduce stress (important for staff and visitors)
and views to nature have been credited with reduced pain
levels and a shorter stay in hospitals. This would entail:

Buildings orientation-The hospital blocks


should be designed such that the long
axis is along the East-West axis.

Narrow plan-This helps to achieve


maximum natural lighting penetration and
cross-ventilation into the wards.

Sun shading all glazed areas-This should be


realized by use of vertical and horizontal
sun-shading elements, deep roof
overhangs, balconies etc.
Use of High thermal mass on walls (thick
walls)-all external walls should be at least
200mm thick.

The Planning & Design of


Hospitals

Placing window openings on the North and South facing


walls.
Landscaping use of well-chosen native trees in the
courtyards and roof gardens within the hospital to create
spaces of respite.

2.6 circulation and communication spaces in


hospitals

The form of a hospital building is strongly influenced by the


choice of access and circulation routes. Circulation systems once
designed remain as fixed elements from which the hospital can
change or grow for expansion to meet future needs. The
circulation systems are difficult to modify once in place and
difficult to insert where they do not exist. Its essential to
understand the nature of circulation in a hospital before
attempting to devise concepts relating to it. However, this
Figure
2-21:
for wheelchair
user and
semi-ambulant
user
clutches
pass
Figure 2-20:
space
forSpace
independent
wheelchair
&ambulant
person
towith
pass
Source:
hospital
notes,
2013think of circulation first
doesnt
meantothat
an building
architect
should
Source: hospital building notes, 2013
and then about other aspects of planning. The architect has to
consider all pertinent issues simultaneously. Nevertheless, in the
process of synthesing the numerous factors and considerations
involved in planning, the very first glimmer of a concept has to
include the pattern of circulation (Rosenfield & Rosenfield, 1969).
Circulation and communication spaces allow for movement of
ambulant and semi-ambulant people (including those using
crutches, sticks and walking frames and wheelchair users). They
should also allow for bed and trolley movement.
Circulation spaces provide access within the hospital
departments. They comprise of corridors, internal lobbies etc.
within a department for moving between rooms/spaces within a
department. On the other hand, communication spaces provide

The Planning & Design of


Hospitals

access between departments. They comprise of hospital streets,


lifts, ramps, and staircases etc. that provide access between
departments.
Figure 2-23:
2-22: Space
space for
for two
independent
independent
wheelchair
wheelchairs
user and
users
semi-ambulant
to pass
person with walking frame to pass Source: Hospital building notes, 2013
Source: Hospital building notes, 2013

18

The Planning & Design of


Hospitals

The entrance to the hospital buildings and the circulation within


it should be designed with due consideration for wheelchair
users, people with visual, ambulatory disabilities and the
physically frail who constitute a large proportion of the hospital
users.
Circulation in hospitals should flow seamlessly to avoid confusion
and loss of time which could be a matter of life and death to
patients in critical conditions. The pattern of circulation should
be obvious to the visitors and the patients.
Circulation in hospitals can be classified into two categories; the
external circulation and the internal circulation. The external
circulation influences the functional organisation of the
interdepartmental relations whereas the internal circulation
influences the functional organisation of intradepartmental
relations within the hospital.

2.6.1
Figure 2-24: space for
2 bed
s passing
Source: hospital
es, 2013
building not

Access

One of the primary success factors for proper healthcare


design is convenient and easy access to and from the facility.
This includes simple way finding, safe and weather protected
vehicular drop-offs and convenient access to parking. The
external access points have their location around the hospital
street. A modern healthcare facility requires multiple
entrances:
Main patient entrance for inpatients and visitors.
Emergency department entrance for emergency cases and
Ambulances.
Outpatient Entrance.
Service Entrance usually at the rear of the site.
All traffic, including outpatient, admission, staff and visitors
should enter through a common main entrance which becomes

one of the hubs


of hospital

The Planning & Design of


Hospitals

activities and may contain other facilities such as shops, banks,


cafeteria etc. The
19

Figure 2-25: corridor with recess for turning bed through 180
Source: hospital building notes, 2013

The Planning & Design of


Hospitals

main entrance, probably leading directly to the outpatient


department should have an easy access from the public highway
and some parking for cars. (Nuffield Provincial Hospitals Trust,
1955).
Internal traffic is the most important single determinant of the
location of departments within a hospital. Traffic between
hospital departments consists of inpatient, outpatients, hospital
employees, staff physicians and visitors. The smooth running of
the hospital requires that traffic be allowed to move as directly
and conveniently between origin and destination. The location of
outpatient rooms is of particular importance .separation of routes
taken by outpatient, emergencies and inpatient should be given
consideration early in the planning process. Patient travel
distances should be reduced to a minimum. The simplest way of
reducing interdepartmental distances is by linking the ends of
the corridors to form a ring to achieve growth
Figure2-26: Lift for bed movement

Source: Hospital building notes, 2013

Figure 2-27: General Service lift


Source: Hospital building notes,

The accident and Emergency (A&E) department will need its own
entrance because It is open 24hours and since there are clinical
and aesthetics reasons for not allowing accident traffic to mix
with outpatient and visitors. The entrance to the emergency
service should be shielded from sight of the main hospital
entrance. It should have space for unloading about 3 vehicles
simultaneously and there should be parking space where waiting
cars can be parked without obstructing access and
maneuverability in front of the entrance. The door opening to the
Accident and Emergency department should be wide enough
(1800 min) to permit a stretcher with attendants and even
transfusion apparatus to pass through with ease and dispatch.
Provision space for wheelchairs and wheel stretchers should be
made at the entrance.

2.6.2

Corridors

The Planning & Design of


Hospitals

20

Corridors should be designed for the maximum expected


circulation flow to cater for trolleys, wheelchairs and
wheeled-beds. The circulation and communication spaces
should be unobstructed; any projections should be avoided,
for example by recessing radiators and fire extinguishers.
Corridors connect spaces and in emergencies form part of
escape routes. They must be simple and safe to negotiate, and
aid navigation around the building. They should be designed for
maximum expected circulation flow which includes the trolleys,
wheelchairs, wheel stretchers

2.6.3

Lifts

All lifts in healthcare buildings should have minimum internal


dimensions of 1100mm wide x 1400mmm deep that is capable
of accommodating a minimum of 8 people 630 kg. At least one
wheelchair-accessible lift should be in operation between each
Fig 2-28: Mattress evacuation down stairway Source: hospital building notes, 2013
floor of a healthcare facility. Each lift should open onto a landing
of adequate depth, in order not to restrict traffic flow in front of
the lift entrance, or onto a protected lobby. Lifts should not open
directly onto corridors.

2.6.4

Privacy

Privacy and confidentiality are important aspects of the


relationship between a patient and staff members. Two places
where these aspects suffer from poor design are:
The reception desk, where one side of a telephone call can
be overheard by people waiting.

Figure 2-29: Ramp for the physically challenged. Source: Metric planning handbook

2
1

Clinical rooms during consultations and treatments,


where personal topics must be discussed freely and in
confidence without fear of being

2
2

seen or overheard; there should be no waiting outside


doors or along corridors.

2.7 EMERGENCY DESIGN FEATURES IN


HOSPITALS
Hospitals are not exempt from devastation of a disaster. In
hospitals, patients have differing physical abilities and a range of
psychological characteristics which all impact on the degree of
assistance that they will require to evacuate from a building
safely. In the case of fire for instance, a bed-ridden patient
though noticing fire would not be in a position to escape unless
otherwise assisted.
Adequate facilities for safe evacuation of patients and even for
combating the hazard should therefore be in place. Certain
architectural design emergency features should be considered in
hospitals to aid in evacuation. These include:
1. Exit signs. They should be provided and set to flash(less
than 5 hertz) when a fire alarm sounds. These signs should
be connected to the emergency power systems. The
colour of the exit door should contrast with the
surrounding surface so as to make it distinguishable by the
people with sight problems (Neufert, 2003). These exit
signs should be visible and should be placed on the
doorframes and not on the doorleaves.This will enable an
individual to identify an escape route at all times even
when the door is open. The exit signs should have

contrasting colours that are conspicuous to the visually


impaired.
2. Doors-An accessible door should have the following
features: A sign, door handle, glazing and a kicking plate.
These make the building more accessible to wheel chair
confined persons. Revolving doors are not suitable for use
by patients and people with prams. The emergency doors

should be fire resistant and are normally located in


stairwells, corridors and other areas as required by fire
codes.
3. Exit/Escape routes-A minimum of two accessible exits, or
horizontal exits for all accessible areas of the building
should be provided (Dawson, 1999).Incase of fire, one exit
can be used as an escape route.
4. Ramps They are used for ease of movement for the
mobility impaired, where there is a level difference and
ease of manouvre for semi- ambulant is required. The
ramps are particularly helpful in evacuating semiambulant persons with ease and speed from floor to
floor.
5. Emergency staircases Every multileveled building should
have a set of emergency staircases to aid in evacuation of
ambulant people. In hospitals, the emergency staircases
should be wide enough to allow for mattress evacuation
(min 1500).The emergency stairs should neither have
open risers nor protruding nosing. The emergency
staircases should preferably open to the courtyard and not
within the hospital building.
Whereas emergency evacuation in horizontal hospitals is fairly
achievable due to horizontal contiguity, evacuation is vertical
hospitals is challenging due to vertical contiguity. Vertical
hospitals heavily rely on lifts which are unsafe to use in case of
emergencies such as fire. This requires additional genius design
features by the architect to ease in evacuation such as:

1. Helipad- A helipad is a typical designated helicopter


landing and take-off area. Its useful for high-rise buildings
and it forms a good area for attending evacuees.
2. Roof gardens- The roof-garden itself is a key sustainable
design element in that it minimizes the buildings heat
island effect, reduces demand on storm water systems,
improves surrounding air quality and reduces noise

The Planning & Design of


Hospitals

pollution. As such, it not only provides an amenity for the


buildings occupants, but and it forms a good area for
attending evacuees.

2.8 TYPES OF HOSPITAL PLANNING


th

Since the beginning of 19 century various strategies have been


devised in the planning of the modern hospital. The hospital
planning can be grouped into two primary types:
1. Horizontal hospitals
2. Vertical hospitals.
In the vertical planning strategy, the zones are arranged one
above the other such that the movement pattern is mainly
vertical.
In the horizontal planning strategy, the zones are linked together

Figure 2-30: vertical massing hospital model Source: Author modifiedlaterally


sketch, July
2014
so20th
that
the movement is mainly horizontal (James &

Tatton-Brown, 1986).
Versus

2.9 The horizontal hospital


Horizontal hospitals planning go as far as the Greek civilization
period. The horizontal hospital can be broken down into several
categories. These are:
a) Independent linked slabs hospitals
b) Spine and Pavilion hospitals.
c) Extended courtyard hospitals
Horizontal monolith hospitals
e) Compact courtyard hospitals
d)

Figure 2-31: horizontal massing hospital model Source: Author modified


sketch-July
20 th planning
2014
Horizontal
hospital

requires large sites to fully


accommodate their functional requirements.

The Planning & Design of


Hospitals

24

2.9.1

Independent linked slabs hospitals

In this type of hospital planning, allocation is done for three basic


zones; nursing, clinical and ancillary. The three zones are linked
horizontally, usually at ground level by means of a wide corridor.
They are usually low rise.
Figure 2-32: Independent linked slab
st
Source: Author modified sketch, July 21 2014

Figure 2-33: Khon Kaen university hospital, Thailand Source: Author modified sketch,
st
July 21 2014.

2
5

Example: Khon Kaen


university hospital,
Thailand

It utilizes Independent parallel linked slabs with varying storey heights.


This type

2
6

of planning strategy requires large site to allow


independent expansion of buildings (James & Tatton-Brown,
1986).

2.9.2 Spine and pavilion hospitals


These hospitals have a strong central spine usually with
clinical and support zones to one side of the spine and the
nursing zone to the other side of the spine. The nursing unit
is high-rise usually up to four levels.
Example: Samaritan hospital, Arizona USA
Figure 2-34: spine and pavilion
Source: Author modified sketch, July 21st 2014

Figure 2-35: Samaritan hospital, Arizona, USA.


Source: Author modified sketch, July 21st 2014

Phase-1 of Samaritan Hospital, Arizona, USA completed in


1977.It has a capacity for 275beds and provides for expansion
of up to 1100beds.It uses the spine and pavilion strategy to
provide for open ended incremental growth.

The simple spine corridor/street, allows for unlimited growth at


almost any point, either of the street itself or of individual
departments. On the other hand,

The Planning & Design of


Hospitals

such streets can be up to 400 m long in a completed


development creating boredom (Hudenberg, 1969).

2.9.3

Extended courtyard hospitals

This type of a hospital is planned around open courtyards. The


zones are linked horizontally at upper levels as well as the
ground floor via a central spine corridor system which affords
easy access for patients, visitors and goods to all departments.
Height is usually limited to four storeys but never usually
exceeds two stories (Oyaro, 1992).
Figure 2-36: Extended courtyard
Source: Author modified sketch, July 21st 2014

Example: Wexham park hospital, slough, UK.


The hospital is a single storey layout utilizing the extended
courtyard strategy. It is a 300 bed general hospital completed in
1966. It fully exploits advantages presented by the extended
courtyard strategy:

-Natural light

-Ventilation from roof lights

-Landscaped courtyards

-Domestic scale
of evacuation in case of fire
-Ease

-Provision
for future extension

-Simple
load bearing structure

Figure 2-37: Wexham park hospital, slough, UK


Source: Author modified sketch, July 21st 2014

The Planning & Design of


Hospitals

27

The Planning & Design of


Hospitals

2.9.4 Horizontal monolith hospitals


These kind of hospitals were and are built in the USA and UK
mostly during the period of 1965-75.They incorporate interstitial
floors which permit easy installation of engineering services and
equipment.The hospitals were mainly experimental and are
limited to science research centres (Oyaro, 1992).
The advantages presented by this type of a hospital include

Natural lighting
Landscaped courtyard providing places of rest and natural
ventilation
Figure 2-38: Horizontal monolith hospitals. Source: Author modified sketch,
Julyof21st
2014
Ease
evacuation
in case of emergency
Simple load bearing
However this hospital type is inflexible to future extension and
growth

2.9.5 Compact courtyard hospitals


These kinds of hospitals were first built in the UK in the mid
1960s.The main aim was to reduce the content,size and cost of
hospitals in the UK.The resulting design concept was called
Best-Buy.In this strategy,planning is centralised around a
courtyard/s and nursing zones occupy the periphery and usually
rise up to four levels.The greatest limitation of this hospital is
expansion when completed (Oyaro, 1992).
However this hospital type presents several advantages which
include: Economic utilization of the site, landscaped courtyard
places
Figure2-39: compact courtyard hospitals Source: Author modifiedproviding
sketch, July 21st
2014 of rest and natural ventilation, ease of

The Planning & Design of


Hospitals

evacuation in case of emergency, they are of domestic scale,


ventilation from roof lights and natural lighting.
28

The Planning & Design of


Hospitals

2.10

Figure 2-40: Vertical hospital


Source: Authors sketch, July 22nd 2014

THE VERTICAL HOSPITAL

Towards the end of the19th century, technology was improving;


Industrial methods of transportation and handling of supplies
were successfully adapted to hospital needs. The vertical hospital
emerged and with a rare dissent became the accepted form of
the hospital. In the vertical planning strategy the hospital zones
are arranged one above the other such that the movement
pattern is mainly vertical. The steel skeleton frame and the
elevator made it possible to fit the scattered elements in the
horizontal hospital to a single mass (Oyaro, 1992).
In the vertical planning strategy, the clinical zone is placed in the
podium at street level with the supporting zone in the basement
and the nursing zone in the tower. The vertical hospital achieves
economy in use of land since it occupies relatively little space on
site and lends itself well to the vertical stacking of
communications and services. The vertical hospital may be the
only practicable solution where the ground space is at a
premium. It unifies circulation patterns through the use of
vertical communication by elevators. The ward may be naturally
ventilated if it is narrow enough as may be the podium if it
spreads widely around courtyards James & Tatton-Brown, 1986).
The vertical hospital has three systems of services:
1. dumbwaiters and conveyors for ancillary services
2. Visitors elevators.
3. Service lifts for staff and patients
The vertical hospital can be broken down into several categories.
These are:
1. Simple tower on podium hospitals
2. complex tower on podium hospitals

Figure 2-41: New York Presbyterian Hospital. The neo-gothic structure stands 376 feet (114.6 meters) high
Source , July 21st 2014

The Planning & Design of


Hospitals

3. Radial tower on podium hospitals

29

The Planning & Design of


Hospitals

4. articulated slab on podium hospitals


5. vertical monolith hospital type

2.10.1 Simple tower on podium hospitals


This is the simplest high-rise hospital strategy. It consists of a
tower on a podium. The nursing zone is contained in the tower
while the clinical and support zone are contained in the podium.
The tower-on podium design enables a precisely defined
programme to be realized in one complete building operation on
a restricted site. However it is argued that this can result in
buildings which do not readily respond to the need for growth
and change during their lifespan (Oyaro, 1992).

Figure 2-42: simple tower on podium


Source: Author modified sketch, July 21st 2014

Figure 2-43: Queen Mary Hospital, Hong Kong


Source: Source: July 21st 2014

Example: Queen Mary


hospital
Bed capacity-1,400
beds Year Built1991
Queen Mary hospital is situated in Pok Fu Lam on Hong Kong
Island. It is 449 feet (137 meters) tall and was completed in
1991.The facility provides surgical, general medical and
emergency services to Hong Kong and the surrounding region.
The hospital has 1,400 beds and is also a teaching hospital for
the University of Hong Kongs medical and dentistry faculties.

The Planning & Design of


Hospitals

30

The Planning & Design of


Hospitals

2.10.2

Complex tower on podium hospitals

These types of hospitals are similar in many aspects to the


simple tower on podium type but the tower faade are
protruded or recessed to create aesthetic interest, variety and
environmental response. Just like the simple tower-on podium,
the nursing zone is contained in the tower while the clinical and
support zones occupy the podium.
Example: Hervey hospital
Bed capacity-1,616 beds

Figure 2-44: complex tower on podium Source: Author modified sketch, July 24 th 2014

Hervey hospital is located in Herlev, Copenhagen in Denmark. It


was built in 1976 and it stands at 394 feet (120 meters) high.
Hervey hospital is also a teaching hospital for the University of
Copenhagen. It serves 82,000 patients every year with a bed
capacity of 1,616.

Figure 2-45: Hervey Hospital, Denmark


Source: Source: July 24th 2014

31

The Planning & Design of


Hospitals

2.10.3 Radial tower on podium hospitals


This type of hospital has a podium with a circular tower. The
nursing zone is contained in the tower whereas the clinical and
support zone are in the podium. Circulation is usually vertical and
central.

Example: Rush university


medical centre Architects:
Perkins + Will
Figure 2-46: Radial tower on podium hospitals Source: Author modified sketch , July 25th 2014
Location: Rush University Medical Center, 1653 West Congress
Parkway, Chicago, IL 60612, USA
2
Area: 830000 ft
Bed capacity:
386 beds
Year built: 2012
The organizational concept at Rush University medical centre
consists of a rectangular seven-story base, containing diagnostic
and treatment facilities, topped by a five- story curvilinear
nursing tower (ArchDaily, 2013). The podium connects to existing
diagnostic treatment facilities to create a new continuous
interventional platform. Part of the ground level of this base
contains an emergency department, which has been designed to
be an advanced emergency response centre. The geometry of
the bed tower maximizes views and natural light for patient
rooms while also creating an environment for efficient and safe
health care.

The Planning & Design of


Hospitals
Figure 2-47: Rush University Medical Centre
Source: Source: July 25th 2014

32

The Planning & Design of


Hospitals

2.10.4

Articulated slab on podium hospitals

This type of hospital has more than one tower rising from the
podium but these towers are linked and share one central
vertical circulation. Each tower houses one particular zone of
activity, either nursing or clinical only; usually the nursing tower
rises highest.
Example: The
bunting centre
Architects: AECOM

Figure 2-48: Articulated slabs on podium Source: Author modified sketch , July 25th 2014

Location: Baltimore, United


States. Bed capacity-260
beds
Site area-1.5 acres (parking
2
offsite) Building area-700,000 ft
Year built-2010
The bunting centre is primarily an inpatient hospital consisting of
nursing units and diagnostic and treatment spaces. Within the
surrounding blocks are existing related facilities, namely an
outpatient clinic, the original hospital (currently being
regenerated into outpatient and administrative functions), as
well as associated parking structures (AECOM, 2012).

The Planning & Design of


Hospitals
Figure 2-49: The bunting centre
Source: Source: July 25th 2014

33

2.10.5 Vertical monolith hospital


These are usually small hospitals put up at restricted areas for
example in town. Most of such hospitals are special hospitals.
One set of elevators is used for ancillary and professional
transactions and another for transporting visitors. However this
system is inflexible .To relive the elevators of the ancillary load
and also to obtain quick unscheduled deliveries, various
conveyors and dumbwaiters are employed. An average vertical
hospital

Figure 2-50: vertical monolith Source: Author modified sketch

Example: Kenyatta national hospital nursing


tower block
The 10-storey nursing tower block houses all the wards and
theatres in the hospital. Currently, the hospital has 50 wards, 20
outpatient clinics, 24 theatres (16 specialised).

Figure 51: Kenyatta national hospital nursing tower block Source: Author, 22nd August 2014

3
4

CHAPTER THREE: RESEARCH METHODOLOGY


3.1. Introduction.
This chapter seeks to outline the various means through which
the author will undertake to achieve the aims and objectives of
the research outlined in chapter one. To understand the research
problem, detailed case study research will be used to investigate
selected local hospitals in Nairobi as well as international case
studies.

3.2. Research purpose.


The study is an exploratory research. The purpose of this
research is to compare the planning and design of the horizontal
and the vertical urban hospitals. This is due to the urban growth
trend and the resultant limited footprint available for
development in urban areas. This places a particular emphasis
on developing sound planning and design strategies within the
urban areas to achieve a sustainable and efficient hospital
organism.

3.3. Research design and Strategy.


The main research objectives outlined in chapter one were:
1. To investigate the typologies in the planning and design of
hospitals.
2. To investigate the current global trend in hospital planning
and design.
3. To compare and contrast the horizontal and the vertical
hospital models.

3.3.1Case study method


The case study method was chosen for this study since it is a
qualitative analysis where careful and complete observation
of an individual/a situation/an institution is done. Efforts are
made to study each and every

aspect of the concerning unit in minute details and then


from case data generalizations inferences are drawn
(Kothari, 2004).
Groat & Wang (2002) identify several characteristics in
the case study method should be outlined in order to
answer the research questions appropriately. These
characteristics are:
1) Focus on the cases in their context-Phenomena should
be studied in their context especially when the
boundaries between context and phenomena are not
clearly defined. In this case the hospitals were studied
in their planning and design context as this
determines whether a hospital will be horizontal or
vertical.
1) The capacity to explain casual links-Case studies can
either be descriptive or exploratory in purpose (Yin,
1994).The selection of hospitals to be analysed for the
case study was important in explaining the subject
matter of the thesis by analysing the planning and
design of the vertical and the horizontal hospital.
2) The role of theory development-This is guided by
theoretical development whether the case studys
purpose is to develop or to test theory. It should be a
sufficient blueprint for the study that will suggest what
data must be collected and what criteria should be used
for analysing it. An important part of the research was
through theoretical analysis of the planning and design
of both the vertical and the horizontal hospitals. It was
possible to carry out the study with clear goals in mind.

3) Use of multiple sources of evidence-The strength of the


case study method is incorporation of data from
multiple sources. There was sourcing of secondary
data from several authors in literature review.
Similarly, several methods of data collection were used
to ensure all

relevant data was collected. These were observation,


interviews, surveys and use of instruments.

3.4. Selection Criteria (sampling method)


A sample design is a definite plan for obtaining a sample from a
given population. It refers to the technique or the procedure the
researcher would adopt in selecting items for sample. According
to Kothari (2004), the researcher must consider the following
points while developing sampling design.
Type of universe-This is the set of object to be studied and they
should be clearly defined. They can be finite or infinite. In this
study, the type of universe is the horizontal and the vertical
hospitals.
Sampling unit-The sampling unit should be decided before
selecting a sample it may be a geographical one such as a town,
a city or a village. In this study, Nairobi was selected because of
its diverse composition of hospitals of all levels.
Sampling frame- This is where the samples shall be drawn
from. It contains the names of all items of a universe (in this
case of finite universe only).It shall be comprehensive, correct
reliable, appropriate and as a representative of the population
as possible. Based on the literature review, horizontal hospitals
are limited to four floors. This implies that any hospital above
five floors shall be considered vertical.
Size of sample-This refers to the number of items to be selected
from the universe to constitute a sample. It should be optimum,
not too large and not too small. The parameters of interest in a

research study must be kept in view, while deciding the size of


the sample. Theres only one level 6 hospital in Nairobi which has
applied both the horizontal and vertical planning strategy and
therefore qualifies as a case study to fulfill the research
objectives.

Parameters of interest-In determining the sample design, one


must consider the question of the specific population
parameters which are of interest. As mentioned earlier, the
study is a comparison of the planning and design of the vertical
versus the horizontal hospital model. This will be analysed
against the findings in the literature review.
Budgetary constraint-Cost considerations have a major impact
upon decisions relating to not only the size of the sample but
also the type of sample. This fact can even lead to use of nonprobability sample. This study was restricted to Nairobi and its
immediate environs due to budgetary constraints.
Sampling procedure-The technique to be used in selecting the
items for the sample must be decided upon. This technique or
procedure stands for the sample design itself and there are
several to choose from. There are basically two types of sample
designs:
Probability sampling (random sampling)-Every item of the
universe has an equal chance of inclusion in the sample.
Non-probability (purposive sampling)-Items for the sample are
selected deliberately by the researcher and his choice
concerning the items remains supreme. For this study, purposive
sampling was used to select the case studies and this is how it
was done:
Area selection- Nairobi will be used as the case study area.
Nairobi provides a mix of public and private hospitals in large

numbers. The area is also at close proximity to the University of


Nairobi which shall be used as the centre for data analysis.

Case study selection- The investigation shall be limited to one


selected local case study in Nairobi. This shall be Kenyatta
National Hospital
The hospital was selected as both the horizontal and the vertical
models are available concurrently for study in the old and the
main hospital complex respectively. Kenyatta national hospital is
the biggest referral hospital in Kenya hence presenting a good
opportunity to study the complexity and simplicity of a national
hospital. The hospital has transformed from a horizontal hospital
to a vertical hospital over time. The old hospital was designed
using the horizontal planning strategy whereas the main
hospital complex has predominantly employed the vertical
planning strategy in its nursing tower.

Figure 3-1:50m long measuring tape used for data collection


Source: wwwmaplin.co.uk
3.5.
Data

Collection Methods

The methods used to collect primary data were:

3.5.1

Primary data

1. Observation (structured)
The authors interest shall be to observe the planning, functional
organisation, zoning, and space utilization in the Hospitals under
investigation. This shall be done by recording observation in
writing, using annotated diagrams, sketches and through
photographic recording.
2. Interviews (non-structured)
Figure 3-2:5m measuring tape used for data
collection
Source:

The author shall seek to interview various categories of hospital


users to get their reaction on the functioning and organisation of
the hospitals under investigation. The respondents shall
comprise of the hospital management, staff and visitors

3.

Physical measurements
The author shall use physical measurements to determine certain
measurable aspects such as corridor sizes, inter-departmental
distances and ward sizes. This shall be done using 5M and 50 M
measuring tapes.

3.5.2 Secondary data


Figure 3-3: canon digital camera used for data collection
1. Architectural drawings
Source:

Existing master plans and architectural drawings of the


hospitals under investigation shall be collected from the
relevant authorities to aid in data collection and analysis.

Figure 3-4: black pen used for data collection in


interviews, notes and sketches Source: Author

3.6.

2. Background information
Background Information such as the establishment, catchment
population, bed capacity and bed occupancy levels shall be
collected from the hospital administration. This shall help in
analysing and determining whether the facilities are
overstretched, underutilized or optimized.

Data Collection Tools.


The following tools shall be used to collect data:

Figure 3-5: sketch pad used in data collection


in form of notes and sketches Source: Author

a)
b)
c)
d)
e)

50 metres long measuring tape


5 metres long measuring tapes.
12.1 megapixels Canon digital camera
Notebook
sketch pad
4
0

f) Black Pen.

4
0

3.7 Data Analysis methods.


The research focused on the planning and design of
hospitals with a view of comparing the vertical versus the
horizontal hospital models.

Study parameter

Representation

Size of site

Master plan, Google maps

Size of developed &


undeveloped Land
Typology

Master plan, site plan

Zoning

Master plan, site plan

Horizontal planning strategy

Site plan ,sectional drawings

Vertical planning strategy

Site plan ,sectional drawings

Ease of evacuation

Master plan, images

floor plans ,sectional drawings

Flexibility and growth


Ease of way finding

Master plan ,floor plans ,sections


Site plan ,floor plans

Separation of traffic

Master plan ,floor plans ,sections

Analy
Availability
sis of land

Availability of Land bank for


future growth, projection for
vertical/horizontal future
expansion
Vertical typology,
horizontal
Clinical zone, nursing zone,
support zone, manipulation of
the zones to form a fully
integrated hospital and their
relationship
with each
other
Horizontal
planning
strategy
,Lateral linking of zones,
horizontal movement of
activities
Vertical planning
strategy
,vertical linking of zones, vertical
movement
of activities
Exit
signs, Fire
resistant doors,
Ramps, Exit/Escape routes,
Emergency staircases, Helipad,
Roof gardens
Phasing,
proposed developments
Signage, pattern of movements,
clearly defined circulation paths,
articulation of entry points
Walkways, driveways, service
lifts, patients /staff lifts, visitors
lift
4
1

Patient admission travel

Site plan, floor plans

Track patient admission travel


from entry to exit.

4
1

Occupancy levels in wards

floor plans

Scale

sections ,Images

Access

site plan ,sections, Images

Drop-offs & parking

Site plan ,Images

Communication spaces

Site plan, floor plans ,sections,


Images

Circulation spaces

floor plans ,sections, Images

Sensitivity to semi-ambulant
needs
Services
Landscaping

floor plans ,sections, Images


Site plan, floor plans ,sections,
Master planImages,
,sections, Images

Ventilation/air flow

floor plans ,sections, Images

Lighting

floor plans ,sections, Images

Places of rest

site plan ,sections, Images

Neighbourhood
Catchment population

Google maps, Master plan


,sections,
Hospital records
Images

Materials

Floor plans, Elevations, sections,


Images
Table 3-1: Table of study parameters Source: Author

Number of beds per wards, check


for bed utilization levels, total
bed capacity of all wards
Dominance levels, size of
buildings
in
relation
to
surrounding
environment,
hospital level (LEVEL1-LEVEL
Different access routes for
outpatient, inpatient, support
facilities, accident and
emergency
Designated unit,
drop-off
points for
matatus/Buses,
taxis,Staircases,
Hospital
street, Lifts
Ramps, main lobbies, Atriums,
Courtyards, covered walkways
Internal corridors, internal
lobbies, waiting areas,
Airlocks lifts for the disabled
Ramps,
Wet areas, stores
Garden seats, planting material,
places of rest
Stack effect, cross ventilation,
window sizes and their location
Depth of wards, location of
windows, size of windows
Roof gardens, landscaped
courtyards, shaded garden
seats,
play
areas
Type ofchildren
activities
in the
neighbourhood
Estimated
number of patients
per day, outstretched
departments
Building materials, colours,
texture
42

3.7.1Data Analysis Tools.


Due to the explorative nature of this study, comprehensive
analysis of the selected hospitals will involve analysis software
shown in figure3-8.These are:
1. Graphisoft Archicad version 16(Educational version)-This is
both a 2D and 3D drafting software for drafting and
drawing models.
2. Google sketch up version 8-This is purely a 3D tool that is
useful in quick modeling of building.

3.7.2Data Presentation Modes


Research findings were represented using:
1) Tables-These are used to convey columns of texts for ease of
comparison of the findings. Tables have been used to carry
the comparison of the vertical versus the horizontal models.
2) Figures-These are divided into two as follows:
Photography-Image representations of hospitals are
used to illustrate existing conditions of different
components in hospitals.
Illustrations-These are the most essential in this research
to compare and analyse the planning and design of
hospitals with the aim of comparing the vertical and the
horizontal hospital models.

3.8. Time Horizon


4
3

The time horizon shall be cross-sectional as it studies a certain


phenomenon at a particular given time.
th
The research shall be carried out in 4weeks as from 4 August
th
-30 August 2014

4
4

CHAPTER
FOUR:
ANALYSIS
4.0. Introduction

DATA

PRESENTATION

AND

The main aim of this research is to compare the planning and


design of hospitals with an emphasis on typologies .This will help
in addressing the challenges in hospital planning and design
which range from site limitations in urban areas, provision for
growth and flexibility, challenges in achieving natural lighting
and ventilation, ease of evacuation, separation of incompatible
traffic among other challenges.
The research is exploratory in nature, and therefore the case
study approach has been identified as the main research
strategy. The case study approach provides the best opportunity
for analysing and comparing the models and their typologies in
the selected case studies.
The selected case
hospitals are:
1) Kenyatta National Hospital-both horizontal and vertical
planning strategies
2) Nanjing Drum Tower hospital-china-Vertical planning strategy

4.1 KENYATTA NATIONAL HOSPITAL


4.1.1
Background

Figure 4-1: map showing the location of Nairobi in


Kenya within Africa
Source: www.unep.com; 07/11/2014

Kenyatta National Hospital is located along Hospital Road, off


Ngong Road, in Nairobi, Kenya.
Kenyatta National Hospital was established in 1901, as the
Native Civil Hospital with a bed capacity of 40 beds. During that
period the Hospital was handing about 712 in inpatients and
6,425 outpatients annually. In 1964 it was renamed Kenyatta
National Hospital in honour of the first President of Kenya, Mzee
Jomo Kenyatta. The hospital has expanded through three major
phases under the funding of the British Government. In 1971,
phase I comprising of outpatient clinics, Casualty, Central Sterile
Supplies Department (CSSD), Intensive Care Unit (ICU),
radiology, Medical Wards, and Medical school teaching blocks,
hostels, and maintenance department was completed. Phase II
comprising of Sterile Processing Unit (SPU), Pharmacy No.40,
Catering facilities, stores and mortuary was completed in1972.
Phase III was completed in 1981 which included the 10 storey
Tower Block. Under the Health Rehabilitation programme (1992
1998) funded by the World Bank, The Doctors Plaza, private
wing facilities, new mortuary and an oxygen plant were
established.

The Hospital operated as Department of the Ministry of Health up


to 1987 when it became a State Corporation Vide a legal Notice
No.109 with a Board of Management aiming to improve the
management of the institution. It covers an area of 45.7 Hectares
and within the KNH complex is the college of Health Sciences
Figure 4-2: map showing the location of KNH within Nairobi
(University of Nairobi), Kenya Medical Research Institute, National
Source: goggle maps: 07/11/2014

laboratory, Government Chemist (MO and the Kenya Medical


Training College.

4.1.2

Current status

Currently the hospital has 50 wards, 20 outpatient clinics, 24


theatres (16 specialised) and an accident and emergency
department. Out of the total bed capacity of 1800,225 beds are
for the Private Wing. Data from the hospitals records reveal that
the annual average bed occupancy rate is 115% but goes up to
210 % in medical, orthopaedic and paediatric wards. In addition,
on any given day the hospital hosts in its wards between 2500
and 3000 patients. On average the hospital caters for over
80,000 in-patients and over 500,000 outpatients annually.

Figure 4-3: A monument of the nursing tower at KNH Source: Author (14 th August 2014)

4.1.3

Hospital Services

The hospital is the biggest referral facility in the region offering a


wide range of specialised services including diagnostic services
such as
laboratories, radiological interventions/imaging,
endoscopy and radiation/oncology.
In addition the hospital receives referral cases from provincial
hospitals in the country and within the Eastern, Central and
Southern Africa region. The hospital offers primary and
secondary healthcare services to Nairobi and its environs. It
provides facilities and resources for training, teaching and
research to the college of Health Science (University of Nairobi),
Kenya Medical Training College and other training institutions
both local and international. Specialised surgical services offered
include open-heart surgery, kidney transplants, neurosurgery,
orthopaedics, laparoscopy and endoscopy.

Figure 4-4: An Image of Kenyatta National Hospital taken from Ngong road Source: Author (14 th August 2014)

The Planning & Design of


Hospitals

OLD HOSPITAL
HOSPITAL

MAIN

KITCHE
N

NURSING TOWER

MORTUARY

SERVICE
ROAD

ADMI
N
BLOC
K

DELIVERY
SUITE

HELIPAD
A& E

OUTPATIE
NT
CLINICS

LANDSCAP
ED
GARDEN

The Planning & Design of


Hospitals

ENTRANCE -A
OUTPATIE
NT
PARKING
Figure 4-5: An image of the model of Kenyatta
th
National Hospital Source: Author (15 August
2014)

BUS
STOP

MAIN
PARKING

ENTRANCEB TO A& E
ONLY
47

4.1.4

Planning of Kenyatta National Hospital

Kenyatta national hospital has adopted both the vertical and


horizontal planning strategies in its master plan. This is clearly
evident from the construction phases through which the hospital
has undergone through to its current state.
The old hospital and the clinical areas have purely utilized
horizontal planning strategy whereas the nursing areas have
adopted vertical planning strategy in the 10-storey nursing
tower.
On its entirety, Kenyatta national hospital reads as a simple
tower on podium hospital. However, it cannot be classified as
such since the nursing tower doesnt have a podium.
Consequently, the nursing tower can only be classified as a
vertical monolith typology with the clinical areas reading as a
distinct extended courtyard horizontal typology model.
The combination of the vertical and horizontal hospital
typologies has helped in achieving economic utilization of the
land since the site is in a prime location.
Kenyatta National hospital lies on a site of 45.7 ha (113
acres).However the main hospital complex which is the primary
area of study in this research utilizes approximately 18% of the
site (20acres).60% of the site (68 acres) has been utilized by the
staff housing, Mary Griffin Hostels, University of Nairobi medical
school, Students hostels, Kenya Medical Training College
(K.M.T.C), Adult teaching centre and Government laboratories.
22% (25 acres) of the site is available for future expansion of the
hospital. Among the proposed developments in this land are: The
proposed Paediatric emergency centre (P.E.C) that will provide
exclusive healthcare services to children in a child friendly
4
8

environment away from the mix with adult patients, the


proposed burns unit, the proposed construction of a bunker and
Figure 4-6: A model of Kenyatta National hospital complex Source:
author
(15 th August
equipment
of cancer
unit 2014)
and the envisaged expansion of the
nursing tower to cater for the rapidly increasing need for medical
services.

4
9

Figure 4-7: Master plan of Kenyatta


th
National Hospital Source: Author (17
August 2014)

4.1.5

Zoning

Kenyatta national hospital has been zoned into three


distinct zones. These zones are:
1. Clinical zone
2. Nursing zone
3. Support zone.

4.1.5.1

Clinical zone

The clinical zone is the working area for administration,


medical treatment and observation. The zone has been located
on the most accessible areas from the access routes and
Hospital Street. It comprises of:
Figure 4-8: 10 storied nursing tower bock home to the entire
nursing zone at KNH
The administration block
Source: Author

The old hospital


Accident & Emergency wing/casualty
The old & the new mortuary
The doctors plaza
Observation
Outpatient clinics
Medical records
Main pharmacy
Emergency lab
Medical clinic
Paediatrics unit
Surgical unit
Gynecology unit
Figure 4-9: Caption of the single storied clinical zone at KNH.
The
hospital
runs through it to the nursing tower block creating horizontal contigui
X-ray
department
Source: Author

5
0

4.1.5.2

Nursing zone

The nursing zone is the patient quarters/wards. It fosters


patients throughout their stay in hospital. It comprises of:
The nursing tower block
Obstetrics wards

4.1.5.3

Support zone

The support zone satisfies all the physical and material needs of
the nursing and clinical zones. It comprises of:
Kitchen & dining
Oxygen plant
General stores
Boiler house
Drug stores
Incinerator
Figure 4-10: The support services block at KNH housing
theCentral Sterile and
Maintenance department
C.S.S.D, general stores, kitchen and dining Source: Author Supplies
laundry
Department(C.S.S.D)
Theatre Sterile
Supplies Unit(T.S.S.U)
The three zones have been intrinsically tied together to act as
one homogenous unit. Varying typologies have been used to
assemble the three basic hospital zones. The nursing zone has
adopted the vertical model and it is the most outstanding and
dominating element in the Kenyatta national hospital complex.
The clinical zone has adopted single storied horizontal planning
strategy except the Accident and emergency /casualty wing
which is double storied. However, the ground floor is used by
patients whereas the first floor is office space for the hospital
management. The support zone adopts the horizontal planning.
nd
Interestingly, the kitchen is located in the 2 floor of the
support zone and

rd

th

directly links to the wards located in the 3 to 10 floors. The


oxygen plant is purely an engineering adventure
Figure 4-11: Oxygen plant at KNH Source: Author

The Planning & Design of


Hospitals

The Planning & Design of


Hospitals

Figure 4-12: zoning map of Kenyatta national hospital


Source: Author

52

The Planning & Design of


Hospitals

4.1.6 CIRCULATION
The external circulation has greatly influenced the functional
organisation of the interdepartmental relations at Kenyatta
National Hospital.

4.1.6.1

Access

The main vehicular and pedestrian entrance to the hospital is


from the hospital road .The Bus drop-off point is also located
along the hospital road which links to Ngong road. Ngong road is
used to
access
Mortuary,
Figure 4-13: main entrance to the Wards and clinics at KNH.majorly
This entrance
forms
the the
Hospital
Street.academic institutions within
Source: Author
the hospital as well as servicing the hospital.
The external circulation is a primary success factor in the
planning and design of Kenyatta National Hospital. It provides a
convenient and easy access to and from the facility. This has
been achieved through; simple way finding, safe public vehicular
drop-offs, convenient access to parking and separation of
vehicular and pedestrian traffic.
Careful consideration has been given to site access for the
public, staff, servicing and emergency vehicles. The accident
and Emergency (A&E) department has its own entrance (Gate-B)
which is specifically designated for emergency cases.
The location of parking places has desirably influenced the
location of the hospital street (labeled no.37 in the circulation
diagram)

Figure 4-14: Pedestrian walkways have been used to avoid vehicular and pedestrian conflict.
Source: Author

The Planning & Design of


Hospitals

53

The Planning & Design of


Hospitals

The Planning & Design of


Hospitals
Fig 4-15: Master plan of Kenyatta National Hospital
Source: Author

54

4.1.6.2

Separation of dissimilar traffic

At planning level, Kenyatta National Hospital has achieved to


separate dissimilar traffic through provision of multiple
entrances to the hospital. These include:
Main entrance for inpatients and visitors (Gate A)
A&E entrance for emergency cases and Ambulances(Gate-B)
Pedestrian entrance at the bus drop-off point
Service Entrance at the rear of the site
Convenient location of the Helipad at the rear of A& E
Figure 4-16: The helipad strategically located at the rear of theA&
E unit to avoid
conflict ofwalkways
air and road traffic during emergencies.
Designated
pedestrian
Source: Author

The separation of dissimilar traffic has helped in minimizing the


pedestrian and vehicular traffic as well as minimizing collision
of dissimilar vehicular traffic e.g. ambulances and visitors
vehicles. It has also helped in avoiding collision of Air and road
traffic during emergencies at the Accident and Emergency unit.
The separation of the academic institutions from the main
hospital has greatly helped in controlling and managing the
human traffic within the hospital. The academic institutions
occupy a designated zone within the site. Despite the
separation, they are still able to link seamlessly with the main
hospital while still maintaining the privacy of the patients and
the visitors. These institutions are: The University of Nairobi
(U.o.N) medical school which links with the Mortuary, Kenya
Medical Training College (K.M.T.C), Adult teaching centre, U.o.N
students hostels and, Mary Griffin hostels.
The academic institutions are accessed via the service road (Old
Mbagathi road) which branches from Ngong Road. This helps in

5
5

Figure 4-17: Direct vehicular access at the A& E unit


for emergencies
Source: Author.

separating the traffic from the hospital and the academic zone
while the two still acting as one homogenous unit.

5
6

Hospital Street

4.1.6.3

Internal Circulation

The internal circulation has contributed majorly to the functional


organisation of intradepartmental relations within Kenyatta
National hospital.
The hospital street which is the primary circulation spine in the
hospital runs through the hospital from the parking lots through
the nursing Tower block to the service road which branches
from Ngong road.

Figure 4-18: The hospital street as captured in the


physical model of KNH
Source: Author

The strategic location of the hospital street enables patients and


visitors to access the hospital both from the Ngong road and
from Hospital road with ease. These two roads are the major
matatus drop-off points for users of public transport. The hospital
street (labeled 37) has the most human traffic since its the
principal internal circulation channel in the hospital. There is
conflict of dissimilar traffic such as the patients, visitors, trolley
bays, wheeled beds and staff since they all converge at the
hospital street.
Secondary circulation streets branch from the hospital street
to the various departments hence tying the various
components of the hospital together.

4.1.6.4

Ease of way finding

Way finding at Kenyatta National hospital is convenient and easy.


Figure 4-19: View of the lifts lobby from the hospital Signage has been used as the major tool to direct the patients and
street
Source: Author

visitors to and from the hospital.

4.1.6.5

Circulation spaces

The circulation spaces at Kenyatta National Hospital comprise of


the tertiary corridors, internal lobbies, internal staircases and the
internal ramp at the A& E department. The circulation spaces
have been used to facilitate movement between rooms/spaces
within the individual departments. The internal corridors range
from 1.8m wide to 3m wide depending on their location within
the departments.

4.1.6.6

Figure 4-20: Wall fixed signage plates along the


secondary streets at KNH Source: Author

Figure 4-21: Mosaic arts along the corridors


Source: Author

Communication spaces

The communication spaces at Kenyatta National hospital


comprise of the hospital street, the secondary streets, a set of
10 lifts in the nursing tower,2 service lifts,1-public staircase in
the nursing tower ,4- Emergency staircases in the nursing
tower, a ramp from the delivery suite to obstetric wards in the
st

1 floor and Series of courtyards. These circulation spaces


have been used to provide access between departments at
Kenyatta National hospital.
The hospital street which is the primary circulation route in the
hospital is approximately 6m wide. It has been designed for the
maximum expected circulation flow to cater for trolleys,
wheelchairs, wheeled-beds, patients and the traffic from visitors.
During the visiting hours, there is heavy traffic and long queues
since the 10 lifts are not adequate to serve the patients, visitors,
staff and food items. The only available alternative is the public
staircase at the lift lobby. This staircase is inadequate given the
high traffic of visitors accessing the wards in the nursing tower
block.

The widths of the secondary streets vary from 2.4m to 3.0 m


depending on their location within the hospital.

The Planning & Design of


Hospitals

Figure 4-22: Internal circulation map at Kenyatta National hospital Source: Author

58

The Planning & Design of


Hospitals

4.1.7

FLEXIBILITY & GROWTH

Flexibility and growth at Kenyatta National Hospital is


exhibited through the development of the hospital in phases.
These are:
4.1.7.1
The old

hospital Model:

Figure 4-23: The old hospital block Source: Author

Horizontal hospital model.


Typology: Spine and
Pavilion
The old hospital is a 3-storied spine and pavilion typology. It
has a strong spine with clinical and nursing zones on either
sides of the spine. In this typology, the circulation has been
used as the principle organising element.
Advantages
Along the central spine are emergency fire escape doors
that open to the landscaped courtyards. This is convenient
for emergency evacuation.
The narrow plan characteristic of this typology maximizes
on natural lighting and ventilation in the building. This is
a sustainable approach to hospital design as it alleviates
the need for artificial lighting
The narrow plan maximizes on natural ventilation.
Patients have views to the landscaped gardens hence
offering therapeutic benefits which create a conducive
healing environment.
The simple spine corridor /street allows for unlimited
growth at almost any point, either of the street itself or of
individual departments. This is clearly evident at the
node where the old hospital intersects with the main
hospital to forming a unified composition

The Planning & Design of


Hospitals

Disadvant
ages
The central corridor is too long and monotonous. This
creates boredom and increases the intra-departmental
distances.
This typology requires a big piece of land to develop hence
Figure 4-24: Image of the circulation spine in the old hospital Source:
not Author
suitable in small and congested sites
59

The Planning & Design of


Hospitals

Figure 4-25: The old hospital as it existed before construction of the main hospital block Source: Author
60

The Planning & Design of


Hospitals

1.5 metres wide


Windows lighting the
central spine

3.6 metres
wide central
spine

Staircase to upper floors

The node linking the old


hospital with the main
hospital complex
Emergency fire escape door

Figure 4-26: detailed layout of the old hospital Source: Author

The Planning & Design of


Hospitals

61

The Planning & Design of


Hospitals

The narrow plan allows for natural ventilation and lighting to


the wards.
The pocket landscaped courtyards offer therapeutic benefits to
the patients in the wards
The central aisle allows for emergency evacuation to the
pocket courtyards through doors located along the circulation
spine.
Lighting to the central aisle is achieved through windows
located strategically along the spine

Figure 4-27: Layout plan of the old hospital Source: Author

The Planning & Design of


Hospitals

62

Figure 4-28: Typical ward plan of the old hospital before relocation of the wards in the Nursing tower block Source: Author

The Planning & Design of


Hospitals

4.1.7.2

Phase 1

Model: Horizontal hospital


model.
Typology: Extended
courtyard.

Figure 4-29: Courtyard used as an organising principle at


the Paediatric unit Source: Author

The hospital has expanded through3 major phases under the


funding of the British Government.Phase-1 comprising of
outpatient clinics, casualty, central sterile and supplies
department (C.S.S.D), intensive care unit (ICU), radiology,
medical wards, medical school teaching blocks, hostels and
maintenance department were completed in1972.
Phase 1 development employs the use of the extended
courtyards typology. In this typology, pockets of courtyards are
used as the principle organising elements. This typology
presents several advantages

Figure 4-30: Roof lights used to light the single storied


deep planned blocks Source: Author

maximum utilization of natural light


Ventilation from roof lights
Landscaped courtyards
Domestic scale
Ease of evacuation in case of fire
Provision for future extension
Simple load bearing structure

However the typology still has its own limitations e.g. In areas
where deep plans have been used, it becomes hard to achieve
natural lighting and ventilation. This necessitates the use of roof
lights which are only functional in single storied buildings unless
an atrium has been provided

The Planning & Design of


Hospitals

63

The Planning & Design of


Hospitals

The Planning & Design of


Hospitals

Figure 4-31: Layout of the phase -1 development at Kenyatta National Hospital


Source: Author

64

The Planning & Design of


Hospitals

4.1 7.3 Phase II


Phase II comprising of Sterile Processing Unit (SPU), Pharmacy
No.40, Catering facilities, stores and mortuary was completed

in1972.

Figure 4-32: Layout of the phase development at Kenyatta National Hospital Source: Author

65

The Planning & Design of


Hospitals

4.1.7.4

Phase III

Phase III was completed in 1981.This included the 10


storey Tower Block. Under the Health Rehabilitation
programme (1992 - 1998) funded by the World Bank, The
Doctor Plaza, and private wing facilities, new mortuary and
an oxygen plant were established.

Figure 4-33: Layout of the phase-III development at Kenyatta National hospital. Source: Author

66

The Planning & Design of


Hospitals

4.1.8

A&E Wing

Model: Horizontal hospital


model.
Typology: Extended courtyard
The A&E wing adopts the extended courtyard typology in
its planning and design. This brings several advantages
that are crucial in an accident and emergency wing. These
are:

Figure 4-34: View of the A& E unit from the parking


Source: Author

Reduction of intradepartmental distances


Creation of landscaped courtyard that is being used as a
resting place
Ease of circulation and way finding
Ease of evacuation in case of fire
Provision for future growth

The department is strategically located within the Kenyatta


National Hospital master plan and is easily serviced by vehicles,
pedestrian and choppers. The department is at close proximity to
the helipad which makes it efficient to attend emergency cases
via air transport. Vehicular access to the department is via a
dedicated emergency entrance (Gate-B). This aids in avoiding the
mixing of incompatible traffic which may cause delay while
accessing the emergency department.
The department has a deep plan which creates challenges in
achieving natural lighting throughout the building. This problem
is mainly due to the double storied nature of the building which
makes it hard to light the ground floor using roof lights. The lack

The Planning & Design of


Hospitals

of adequate atriums makes it hard to light the interiors of the


building using natural light.
Figure 4-35: Location of the A&E unit at KNH Source: Author
67

The Planning & Design of


Hospitals

LEGE

ND
Figure 4-36: Ground floor plan of A&E department at KNH
Source: Author

68

The Planning & Design of


Hospitals

LEGE
ND

The Planning & Design of


Hospitals

Figure 4-37: First floor plan of A& E department at KNH


Source: Author

69

The Planning & Design of


Hospitals

Interstitial floor

4.1.9

The nursing tower

Model: Vertical hospital model.


Typology: Vertical monolith
The 10-storey nursing tower block houses all the wards and
theatres in the hospital. Currently, the hospital has 50 wards, 20
outpatient clinics, 24 theatres (16 specialised).
Out of the total bed capacity of 1800,225 beds are for the Private
Wing.
The annual average bed occupancy rate is 115% but goes up to
210 % in medical, orthopaedic and paediatric wards. Based on
the hospital records, on any given day the hospital hosts in its
wards between 2500 and 3000 patients.
On average the hospital caters for over 80,000 in-patients and
Figure 4-38: A model of the KNH Nursing tower block
Source: Author
over 500,000 outpatients annually. Each of the typical floors in
the tower block has 8 wards. A set of 2 wards;1 male and 1
female. A set of 2 wards share facilities such as the service lift,
nurses station, emergency fire escape and the reception.
The Wards are grouped into clusters of 10 beds each.
The tower block is serviced by a set of 10 lifts and one public
staircase. However due to the high number of patients accessing
the wards during visiting hours, one can barely get a lift ride.
This results to long queuing lines and many visitors opt to use
the only staircase available. The lifts are for use by all classes of
people ranging from staff, patients, and visitors. This results to
mixing of incompatible traffic in the vertical circulation.
Based on the authors observation, the vertical circulation is the
biggest challenge being faced by the hospital. At some instances,
the hospital has reported suicide cases whereby patients jump
Figure 4-39: hard landscaped tower block courtyard Source: Author
from the 1200mm high balcony rails to the hard landscaped
courtyard. According to the hospital Engineer, the challenge is
how to balance safety and security of patients in the wards.

The Planning & Design of


Hospitals

70

The Planning & Design of


Hospitals

The Planning & Design of


Hospitals

Figure 4-40: A typical floor plan of the ward Source: Author

71

The Planning & Design of


Hospitals

Figure 4-41: Aerial view of the nursing


tower Source: Author

The Planning & Design of


Hospitals

Figure 4-: A detailed analysis of the typical wards in at Kenyatta National Hospital
Source: Author

72

The Planning & Design of


Hospitals

The Planning & Design of


Hospitals

Figure 4-42: Sectional analysis of the tower block at KNH


Source: Author

73

The Planning & Design of


Hospitals

4.1.10 Emergency design features in the


nursing tower.
Patients have differing physical abilities and a range of
psychological characteristics which all impact on the degree of
assistance that they will require to evacuate from a building
safely. Kenyatta National Hospital has incorporated architectural
design emergency features for safe evacuation of patients in
case of disasters like fire. These include:

Figure 4-43: The four compartments of double


wards in a typical floor of the nursing tower
Source: Author

1) Emergency staircases The 10 storied nursing tower has a


set of 4 emergency staircases to aid in evacuation of
ambulant people. The emergency stairs are approximately
1500mm wide. This width is good enough to allow for
mattress evacuation. The emergency stairs are accessed
via fire escape doors. However, the emergency stairs open
within the hospital in the Ground floor. Whereas it is
preferable for the emergency stair to open to a courtyard
and not within the hospital building, the emergency stairs
open to the latter due to security reasons.
2) Fire Doors-The typical floor of the nursing tower is divided
into 4 sets of double wards. Each of these sets is accessed
via a fire resistant door that has the following features: an
exit sign, door handle, glazing, a kicking plate. This
makes the building more accessible to all including the
wheel chair confined persons.
3) Compartmentalization of wards- The typical floor of the
nursing tower is divided into 4 compartments accessed by
fire scape doors from either side. This division can be
helpful in containing the spread of fire since it would allow
for evacuation of patients from one ward to the other in
the same floor. The fire resistant doors would also help in

combating the spread of fire to the


other wards in the same floor.

The Planning & Design of


Hospitals

Figure 4-44: Sketch of a fire resistant door along the 3000mm wide corridors in the wards.
Source: Author

74

The Planning & Design of


Hospitals

Figure 4-45: Analysis of the architectural design emergency features in a typical floor of the nursing tower Source: Author

75

The Planning & Design of


Hospitals

4) Exit/Escape routes-Each set of the double wards in the typical floor plan of the nursing tower has 2
accessible exits for horizontal evacuation/escape route and an internal emergency escape staircase
for vertical evacuation.
5) Exit signs-All doors along the corridors in the nursing tower and emergency staircases have visible
exit signs fixed on door frames. This enables an individual to identify the escape routes at all times
even when the door is open.
6) Ramps The Obstetrics wards in the first floor of the nursing tower have access to a ramp that .This
ramp creates ease of movement for the patients, from the wards to the delivery suite in the ground.
The ramp can be particularly helpful in evacuating semi-ambulant persons with ease and speed from
the first floor to the courtyard in the ground floor. However this ramp is only limited to the first floor.
Figure 4-46: The
ramp
serving
the obstetrics
wards
in the first
floor and
the lifts
delivery
suite
in the Ground floor
at KNH.
Source:
7) Wide
corridors
The main
circulation
corridor
at the
lobby
is approximately
6metres
wide.
The Author
interior circulation aisle in the wards is approximately 3 metres wide. The wide corridors can be
particularly helpful in emergency evacuation. Patients and visitors can be evacuated into the 6metres
wide corridor as they await transfer to safer areas.

Figure 4-47: Fire exit sign at an emergency escape door at KNH Source: Author

7
6

4.1.11 Comparison of the Horizontal


typology models at KNH
PARAMETER

EXTENDED COURTYARD
MODEL

SPINE & PAVILLION


MODEL

Deep plan

Narrow plan

LAYOUT

IMAGE

PLAN

TYPOLOGY
SIZE OF SITE

Horizontal hospital model- mixture


of single, double and 3storied
blocks.smaller site
Requires
a relatively
compared to the spine and pavilion
type.

Horizontal hospital model- 3


storied building.
Requires a relatively larger site
compared to the extended
courtyard.

EASE OF
EVACUATION

Patients can easily be evacuated


directly from the building blocks
into the landscaped courtyards.

Patients can be evacuated out


of the building through the fire
escape doors situated along
the central circulation corridor.

FLEXIBILITY AND
GROWTH
SEPARATION OF
DISSIMILAR
TRAFFIC
PATIENT ADMISSION
TRAVEL/DEPARTMEN
TAL DISTANCES
SCALE

NATURAL
VENTILATION

NATURAL LIGHTING

The typology allows for both


vertical and horizontal growth
with ease. Flat roofs can be
particularly helpful in attaining
vertical
growth.streets
The multiple
secondary
allows for separation of
dissimilar traffic.
The arrangement of departments
around courtyards reduces the
departmental distances since
closely related departments can
be
arranged
around
courtyard.of
Domestic
scale.
Has aamaximum
3 floors in the kitchen and
dining block.
The typology
has deep plans. This
makes it difficult to achieve
maximum natural air ventilation
through cross ventilation via the
courtyards. The roof vents have
been used to provide natural air
ventilation in the single storied
blocks .However they are
ineffective in double storied
The deep plans make it
challenging to achieve maximum
naturally to all spaces in the
building. The roof lights have been
used to provide natural lighting but
this is ineffective in double storied

The typology allows for unlimited


growth at almost any point, either
of the street itself or of individual
departments.
Its difficult to separate
dissimilar traffic since theres
only one central circulation
spine.
The departments
are arranged
laterally along the central spine.
This result to longer departmental
distances compared to the
extended
courtyard
Domestic scale.
Has typology.
a maximum of
3 floors in the old wards.
The typology has a narrow plan
throughout. This is particularly
helpful in achieving maximum
natural air ventilation through
cross-ventilation.

The narrow plans helps in achieving


maximum natural lighting to all
spaces in the building as well as
providing therapeutic views to the
landscape from the wards

Table 4-1: Comparative analysis of the horizontal models at Kenyatta National Hospital Source: Author

4.1.12 plannning & design challenges at


Kenyatta national hospital
To a great extent Kenyatta national hospital is successful in its
planning and design. However, the author was able to identify a
few challenges through observation and interviews from the
hospital administrators. These are:

1) There is high vertical circulation stress in the nursing tower


block due to overdependence on lifts and lack of adequate
public staircases to complement the lifts. Currently there is
only one public staircase in the lifts lobby.
2) The quality of healing environment for children at the
Figure 4-48: Location of the paediatric department at KNH Source: Author,
24th August
2014
paediatric
department
is compromised. The following
limitations were identified in the paediatric section
a) Their location is compromising the accessibility of
emergency services for children since they are in the
adult environment.
b) Inappropriate location: the current location of the
paediatric section is hidden into the other facilities and
is not easily accessible to customers in time of
emergencies.
c) The space for the paediatric emergency unit is
quite small hence limiting the provision of essential
emergency services.
d) The paediatric emergency units are always congested,
crowded and the ventilation is lacking for children and
their parents.
e) The clinics are in the mix-up of environment with adult
Figure 4-49: Make shift waiting area for paediatric outpatient unit donated by
Posta.
clinics.

Source: Author, 19th August 2014

f) Space limitation prohibits the running of specialized


clinics on daily basis, hence limiting the efficacy of
the children care.
g) The waiting areas are too small hence
compromising the children environment in health
facilities.

h) The clinics do not include other support services


e.g. children play areas, laboratories and X-rays
which are required for appropriate paediatric
care, hence children mix a lot with adults as they
move searching for such services.
i) Lack of sufficient space to run all specialized clinics
such as ENT, surgery, Eye and Orthopaedic leaves
similar predicament for children to be mixed with
other adults in these respective clinics.
j) Paediatric department does not have specialised
services such as minor theatre, dental, cardiology,
surgery, orthopaedic services at one stop which are
crucial in the provision of quality paediatric health
care.
current
Figure 4-50: A child receiving emergency service at KNH A&E unit Source: Author,
21 stThe
August
2014 Paediatric outpatient clinic and
Paediatric Emergency Unit lacks space to house or
run these services and make the patients move
where they are provided. The department is
allocated one day for theatre cases excluding
emergencies. This has led to increased congestion
and overcrowding of children in the wards. In
addition, it is the only department without a minor
theatre in the hospital, making it impossible to
decongest wards and clinics. This mix up of children
who require minor and major surgery has a negative
multiplier effect of the increased cross-infections and
eventually leads to higher mortality rates.

8
0

Figure 4-51: A child looking for play activities at KNH


Source: Author, 21st August 2014.

8
0

The Planning & Design of


Hospitals

4.2 NANJING DRUM TOWER HOSPITAL


4.2.1 Introduction

Nanjing Drum Tower Hospital is affiliated with the Nanjing


University Medical School. The hospital serves as a major
medical, academic and research center in China. The hospital is
one of the earliest western medical hospitals in China. It was
founded in 1892 by Dr. William Edward Macklin from Canada on
his mission to China under the auspices of the American
Presbyterian and the American Methodist mission groups.
Originally, the hospital was named Nanjing Christian Hospital,
but was widely known as Ma Lin Hospital, after the Chinese
name
Figure 4-52: location of china within Asia. Source: (Nov 20 th
2014)of the founder. In 1902, the hospital was renamed Drum
Tower Hospital. The original hospital was a four- story 1892
horizontal hospital.
The old hospital building was fully renovated in 2006, and, on
January 23, 2007 the historic building was formally re-dedicated
as The 1892 Memorial Hall and Hospital Archives. The 1892
Memorial Hall includes a series of memorial galleries, a
dedicated archives center, and a spacious conference hall.

8
1

The Planning & Design of


Hospitals

Figure 4-54: The 1892 Drum tower


hospital
during winter in1892
th
Source: www.njglyy.com (Nov 20
2014)

Figure 4-55: The 1892 memorial Hall


and
Hospital Archives, Jan 23, 2007
th
Source: www.njglly.com (Nov 20 2014)

Figure 4-53: Location of Nanjing within China


Source: (Nov 20th 2014)

8
2

The Planning & Design of


Hospitals

4.2.2

Nanjing Drum Tower Hospital South Extension

Nanjing Drum Tower Hospital South Extension is a general


hospital extension project. It combines inpatient, outpatient
departments, emergency unit, medtech and medical academic
exchange departments altogether.
Architects: Lemanarc SA.
Location: Zhongshan North Road, Nanjing, Jiangsu, China.
Architect in Charge: Vincent Zhengmao Zhang.
2
Figure 4-56: Nanjing Drum Tower south extension Area: 260,000 m .
Source: (20th Nov 2014)
Year of completion: 2012.
Typology: Vertical hospital typology; 13 floors.
Model: Simple tower on podium.
Bed capacity: 2,800 beds.
Site: 9.4 acres.
Nanjing Drum Tower Hospital South Extension was designed in
2003 and completed in 2012.It sits on a 9.4 acres site between
Zhongshan road and Tianjin road in Nanjing municipality, china.
According to the architect; Vincent Zhengmao Zhang, the earlier
expansion of the hospital i.e. the outpatient tower was driven by
the need of development of modern medical technology as well
as the increasing municipal population.
Despite the remarkable scales, most of these early expansions
Figure 4-57: View of the roof gardens at Nanjing drumare hardly more than simple and urgent addition and extension
tower hospital Source: (20th Nov 2014)
of existing function to meet the rapidly increasing need for
medical service. As a result, the functional layouts of many

The Planning & Design of


Hospitals and streamlined
organized

floors are not well


for the operation
of the hospital as a whole. For instance, the existing outpatient
department is on the

The Planning & Design of Hospitals

Renovated 1892
old hospital
South
extension

Outpatient
Department

east side of Zhongshan road, connected with the main buildings


of the hospital, which is on the west side, only through a narrow
underground passageway. This creates extra inconvenience to
both patients and staff.
The Nanjing Drum tower hospital has a total of 2800 beds, of
which 1600 beds are in the new south expansion wing. The
2

overall gross floor area of the hospital is 260,000 m .Contrary to


the general expectation of a high rise hospital building in China,
the architect made a seemingly surprising choice: instead of
stacking floors one upon another and resulting in a high floor
area ratio, the design team decided to lay it down to create a
series of gardens at the floor area ratio of 5:2.
Such preference for low rise building went squarely against the
design trend, which is dominated by the frenzy for skyscrapers.
The low rise plan not only reduced the stress on vertical traffic
is a2014)
constant trouble for large general hospitals, but also
Figure 4-58: A model of the Nanjing Tower hospital Source: which
(20 th Nov
creates large areas of urban space with human scales.
However, by choosing a more scattered, low rise plan, the
architects were facing various challenges: from organizing the
arrangement for the newly built areas, understanding and
analyzing the operation and rules of the hospital, to the planning
of ideal operating model for the new hospital.

4.2.3

Sustainable design features in the hospital

The Nanjing Drum hospital tower won the 2013 healthcare WAN
award for its healing gardens. Interestingly, the English word
hospital originates from Latin, meaning Gathering Guests,

but in Chinese, the term Hospital (Yi Yuan) translates directly


as the Healing Gardens. Inspired by such difference of intercultural interpretation, the design aims to achieve home-like
experience within the hospital by combining the function of
healing with that of garden or courtyard. (World Architecture
Awards, 2013)

Figure 4-59: Roof garden at Nanjing drum tower hospital


Source: Source: (20th Nov 2014)

The Planning & Design of


Hospitals

The idea of gardenised architecture is the core of the design for


the project. More specifically, the attention was to create an
ubiquitously accessible system of gardens within the hospital by
variation of means from master plan arrangement to the smallest
details of facades and envelopes.

In the traditional Chinese Culture, a garden is the border


between home and the outside world. Walking into the garden
means you can block all external interference, and achieve true
relaxation in both body and mind. To gardenise the hospital is not
only to achieve the sensory beauty, but more importantly also to
bring spiritual comfort to people. (Vincent Zhengmao ZhangArchitect south extension) The huge rainless hospital is
composed of 6 large courtyards, more than 30 light wells and
micro-gardens woven on the buildings envelopes.
Figure 4-60: Faade of the gardenised architecture Source: innumerable
(20 th Nov 2014)
Equipped with the external sun shades and the lateral natural
ventilation system that help significantly reduce the air-condition
energy consumption; Drum Tower Hospital is a truly energysaving green hospital.

Figure 4-61: A detail of the gardenised envelope Source: (20 th Nov 2014)

The Planning & Design of


Hospitals

Figure 4-62: The 6 healing Gardens at Nanjing Drum hospital Source: (20 th Nov

The Planning & design of Nanjing Drum


Tower hospital The Nanjing drum tower hospital has

4.2.4

fully exploited the vertical planning strategy both in its


earlier expansion and in the South extension.
The hospital can generally be classified as a simple tower on
podium model since it consists of a tower on a 4 storey podium.
This model has presented several advantages in the planning
Figure 4-63: section through Nanjing Drum Tower hospital showing the tower and the podium.
and design of the hospital. These are:
Source: (20th Nov 2014)

The vertical arrangement of departments has helped in


achieving practicable solution in economic utilization of
land in a prime location. The hospital occupies relatively
little space in an urban area and lends itself well to the
vertical stacking of communications and services.
The provision of basement parking has been
particularly helpful in reducing the vehicular and
pedestrian conflict within the site.
There is increasing vertical privacy gradient. The public
and semi-public zones i.e. the support and clinical zones
are located in the basement and the podium. The private
zone i.e. the nursing wards is located in the tower.
The vertical circulation channels comprising of lifts and
staircases are centrally located. This makes it possible to
link all the zones vertically. It also helps in reducing the
departmental distances within the hospital.
The simple tower on podium helps in achieving a low rise
plan by having the clinical zone located in the podium at
street level with the supporting zone in the basement and
the nursing zone in the tower. This helps in reducing the

vertical traffic stress which is a constant trouble in vertical


hospitals.
However, the model doesnt readily respond to the need for
future growth and expansion.
Figure 4-64: Image of Nanjing drum tower hospital Source: (20 th Nov 2014)

th
Figure
4-65:
site Author
plan of modified
Nanjing drum
hospital
Source:
(20 tower
Nov 2014)

Figure 4-66: Ground Floor plan of Nanjing drum tower hospital South Extension Source: Author modified (Nov 20 th 2014)

Figure 4-67: Diagrammatic arrangements of departments at the south extension at Nanjing drum tower hospital Source:

The Planning & Design of


Hospitals

Figure 4-68: Section-01 through the south extension of Nanjing Drum


th
Tower Hospital Source: Author modified (Nov 20 2014)

89

The Planning & Design of


Hospitals

floor
plan
has utilized a deep plan with double banked
Figure 4-69: First floor plan of the South extension at NanjingThe
drum
tower
hospital
Source: Author modified (Nov 21st 2014)
spaces. The second floor houses the imaging suite, inpatient,
coffee bar, outpatient surgery, clinic surgery and lithiasis
centre
9
0

The second, third and fourth floors are clinical zones. The floors
Figure 4-70: Typical 2nd, 3rd & 4th floor plan of the south
have a deep
plan
with double banked spaces which makes it
extension at Nanjing Drum Tower hospital Source: Author modified
(Nov 21
st 2014)
challenging to achieve maximum natural lighting and ventilation.
This has resulted in extensive use of air conditioners in the
hospital.

Figure 4-71: 5th floor plan of Nanjing Drum Tower hospital Source: Author modified (Nov 21 st 2014)

th

The 5 floor is purely dedicated for hospital equipments and air


conditioners.
th
th
The 6 -11 floors are dedicated as the nursing zone. They
contain a total of 1,600 beds, nursing stations and offices for the
doctors.
Figure 4-72: Typical 6 -13 floor of Nanjing Drum Tower Hospital Source: Source: (20 th Nov 2014)

The Planning & Design of


Hospitals

4.2.4.1 Zoning

93
Figure 4-74: Zoning plan of the typical 6th-13th nursing floors of the Nanjing Drum Tower Hospital Source: Author modified (27 th Nov 2014)

The Planning & Design of


Hospitals

4.2.4.2 Circulation

The Planning & Design of


Hospitals

Figure 4-75: Activity plan of the


typical 6

th

floors of the Nanjing Drum Tower Hospital

th

11
Source: Author modified (27 Nov 2014)
th

94

The Planning & Design of


Hospitals

The internal circulation at


Nanjing Drum Tower hospital
is composed of lifts and
staircases
for
vertical
movement and contiguity.
To reduce the mixing of
incompatible kinds of traffic
which the vertical hospital
implies, the architect has
provided a set of 2 service
lobbies comprising of 2
service lifts and a staircase
and another set of 2 central
lobbies with 4 lifts and a
staircase. The service lobby
is used by patients,
ancillary and professional
transactions. The central
lobby is mainly used by
visitors.

The Planning & Design of


Hospitals

Figure 4-76: Circulation flow plan in a typical nursing floor at Nanjing Drum Tower hospital Source: Author modified (27 th Nov 2014)
95

The Planning & Design of


Hospitals

4.2.4.3
Emergency design features at Nanjing Drum
tower hospital.
Nanjing Drum tower Hospital has incorporated architectural
emergency design features for safe evacuation of patients in
case of disasters like fire. These include:
1) Emergency staircases The 14 storied building
with 3 basement floors has a set of 4
emergency staircases to aid in evacuation of
ambulant people. The emergency stairs are
approximately 1800mm wide to aid in mattress
evacuation
2) Compartmentalization of wards- The typical
th

th

floor of the nursing floor i.e. 6 to 13 is divided


into 4 compartments .This division can be
helpful in containing the spread of fire since it
would allow for evacuation of patients to safety
from one ward to another.
3) Fire Doors- Each of the 4 wards compartments
is accessed via a fire resistant door. The fire
resistant doors would also help in combating
the spread of fire to the other wards in case of
fire.
4) Exit/Escape routes- Each of the 4 wards
compartments has 3 accessible exits for
horizontal evacuation/escape route and an
internal emergency escape staircase for vertical
evacuation.
5) Provision of staircases in the central lobby-Each
of the 2 central lobbies has a 2100mm wide
staircase that can be used to evacuate patients

The Planning & Design of


Hospitals

and visitors in emergencies like fire that would


render the lifts non-functional.
Figure 4-77: Design emergency features in a typical nursing floor at Nanjing drum tower hospital
th
Source: Author modified (27 Nov 2014)

96

4.3. Comparison of KNH & Nanjing drum tower


hospital
PARAMETE
R

Kenyatta National
Hospital
(Kenya)

Nanjing Drum tower


hospital
(China)

-11 floors with no basement and podium


-Interstitial floor for stack
ventilation

-16 floors including 3 basement parking


and podium
-It doesnt have an interstitial floor for
stack effect

LAYOUT

IMAGE

SECTION

9
7

TYPICAL
WARD
PLAN

Narrow plan
Sufficient natural ventilation through
cross ventilation & stack effect-no air
conditioners.

TYPOLOGY

Deep plan-triple banked rooms


depends on mechanical ventilation - high
presence of air conditioners

Its a purely vertical


hospital typology

+
+
MODEL

SIZE OF SITE

FLEXIBILITY
AND
GROWTH

Combines both vertical and


Spine and pavilion + extended
courtyard + Vertical monolith models
Occupies approximately 20 acres in a
113 acres urban site
The horizontal typologies used allow for
both vertical and horizontal growth
with ease. The use of flat roof is
particularly helpful in achieving vertical
growth.typologies, the
In the horizontal
patients can be easily evacuated into
the
landscaped
courtyards.
The
compartmentalization of the wards in

Simple tower on podium model


Occupies approximately 9.4 acres of an
urban site
The model doesnt readily respond to
the need for future growth and
expansion
Evacuation of patients is achieved through
the compartmentalization of the wards in
the typical nursing floors coupled with the
fire escape doors. This

EASE OF
EVACUATI
ON

SEPARATION
OF
DISSIMILAR
TRAFFIC

CIRCULATIO
N

NATURAL
VENTILATI
ON
NATURAL
LIGHTING

nursing tower and use of fire escape


doors can facilitate evacuation of
patients to safety from one
compartment to the other in the same
floor.
The ramp in the first floor can also be
useful in evacuation of semi-ambulant
Multiple entrances to the site is
particularly helpful in separation of
dissimilar traffic at planning level.

There is inadequate lifts in the nursing


tower with only one available public
staircase. This creates long waiting lines
during visiting hours.
There is minimal vehicular and
pedestrian traffic since parking is
controlled
to model
a dedicated
section
of the
The vertical
has narrow
double
banked plan. The provision of an
interstitial floor in the second floor
coupled with a central light well is
particularly helpful in achieving
maximum natural ventilation through
stack
effect wards
and cross
The narrow
planventilation.
helps in
achieving maximum natural
ventilation

can facilitate evacuation of patients to


safety from one compartment to the
other in the same floor. However due to
its height and lack of ramps, evacuation
is not as efficient as at Kenyatta National
hospital
The provision of multiple entrances helps in
achieving separation of dissimilar traffic at
planning level.
The provision of adequate service and
central lobbies in the nursing floors also
in separating
patients,
staff and
Thehelps
provision
of adequate
lifts and
staircases in both the service and the
central lobbies ensures smooth flow of
traffic
Further the provision of basement parking
greatly reduces pedestrian and vehicular
traffic
The model has deep triple banked spaces
that necessitate the need for air
conditioners to achieve mechanical
ventilation.
The lack of an interstitial floor worsens the
situation.
The deep triple-banked ward plan
necessitates the need for artificial lighting
to light some areas

Table 4-2: Comparative analysis of Kenyatta National Hospital & Nanjing Drum Tower Hospital Source: Author

CHAPTER FIVE: CONCLUSIONS AND


RECOMMENDATIONS
5.1

Figure 5-1: Early cruciform halls hospitals


Source: Rosen field. (1969) Hospital architecture and
beyond, July 12th 2014

Introduction

Having undertaken a comparative analysis of the typologies in


hospital planning and design, principle conclusions and
recommendations have been drawn. These are based on the
application of the findings of the literature review to the selected
local and international case studies. The literature review
established variables that were used to carry out a comparative
analysis of the design typologies at Kenyatta national hospital
(Kenya) and Nanjing drum tower hospital (China).

5.2

Conclusions on Literature review.

The author established that the hospital has developed over


centuries from the
B.C. where medicine and healing

th

cruciform hall temples in the early 6 century

were linked
theJune
gods
to
Figure 5-2: horizontal hospital model established in 19th century Source:
Author,to
12th
2014

the functional and scientific approach


led by Florence
th
th
Nightingale in the 19 century. Towards the 20 century, the
architectural form of the hospital evolved from the low horizontal
pavilions to the vertical planning strategy. Thus, the vertical
hospital is seen to be the current global trend in hospital
planning and design as evident from the literature review and
case studies.

The author further established that the hospital planning is


grouped into 2 typologies. These are the horizontal and the
typologies. The horizontal typology is limited to 4 floors
Figure 5-3: Vertical hospital model established vertical
in the 20th
century
Source: Author, 12th June 2014

10
0

whereas the vertical typology rises above 4 floors. In the


vertical planning strategy, the author established that the zones
are arranged one above the other so that the movement
pattern is mainly vertical.

10
0

However, in the horizontal planning strategy, the author


established that the zones are linked together laterally so that
the movement is mainly horizontal. It is the conclusion of the
author from the literature review that both the horizontal and the
Figure 5-4: Independent linked slab model Source: Author modified 15th June 2014
vertical typologies have 5 models each. These are:
Horizontal typology
models
a) Independent linked slabs model.
b) Spine and Pavilion model.
c) Extended courtyard model.
Figure 5-5: Independent spine & pavilion model
d) Horizontal monolith model.
Source: Author modified 15th June 2014
e) Compact courtyard model.
Vertical typology
models
a) Simple tower on podium model.
b) Complex tower on podium model.
Figure 5-6: Extended courtyard model
c) Radial tower on podium model.
Source: Author modified 15th June 2014
d) Articulated slab on podium model.
e) Vertical monolith model.
The activities within a hospital are grouped into three distinct
zones as deduced from the literature review. These are: the
clinical, the nursing and the support zones. The author
Figure 5-7: Horizontal monolith model
established that it is the manipulation of these zones and their
Source: Author modified 15th June 2014
relationships to each other that determine the hospital typology
and model.

Figure 5-8: Compact courtyard model


Source: Author modified 15th June 2014

The main objective of this research was to carry out a


comparative analysis of the hospital typologies and models
based on a set of variables. This was meant to determine the
most efficient hospital models in hospital planning and design.
The research was further meant to address the challenges in

10
1

hospital planning and design. Therefore, the author considered


the comparative analysis as the best strategy to provide
solutions to the various challenges in hospital planning and
design by analysing and comparing their mode of application in
the different

10
2

typologies and models. As such the author took to deduce the


parameters that underpin efficacy in hospital planning and
design. These parameters were summarized as:
Figure 5-9: Simple tower on podium model
Source: Author modified 17th June 2014

Figure 5-10: complex tower on podium model


Source: Author modified 17th June 2014

Site planning.
Circulation.
Departmental distances.
Provision for future growth and extension.
Energy conservation and sustainability.
Ease of evacuation in cases of emergency.
Natural ventilation.
Natural lighting.

The author established that the size and value of the site greatly
influences the typology to be adopted in the planning and design
of the hospital. Circulation was established to be a major
Figure 5-11: Radial tower on podium model
influence in the planning and design of hospitals since once the
Source: Author modified 17th June 2014
circulation systems are designed, they remain as fixed elements
from which the hospital can change or grow for expansion to
meet future needs. External circulation influences the functional
organisation of the interdepartmental relations whereas the
Figure 5-12: Articulated tower on podium model internal circulation influences the functional organisation of
Source: Author modified 17th June 2014
intradepartmental relations within a hospital.

Figure 5-13: Vertical monolith model


Source: Author modified 17th June 2014

The author further established that a natural environment is


essential to creating a genuine state of the art-healing
environment. Spending time in outdoor places of respite has been
shown to reduce stress levels in hospitals. Views of nature have
been credited with reduced pain levels and a shorter stay in
hospitals since they provide therapeutic effect to patients. This is

provided by incorporating landscaped courtyards within the


hospital.

5.3

Conclusions on fieldwork

Due to limitations of time and resources, this research thesis only


covered 2 horizontal hospital models and 2 vertical hospital
models in the fieldwork. These are:
Horizontal
typology
1. Spine and Pavilion model
2. Extended courtyard model
Vertical typology
1. Simple tower on podium model
2. Vertical monolith model
Horizontal
typology
Through the comparative analysis of the two horizontal models
Figure 5-14: model of Kenyatta national hospital Source: Author 15th Aug 2014
covered in the fieldwork i.e. the spine and pavilion model and
the extended courtyard model, the author established that:
The spine and pavilion model utilizes the circulation as the
principle organising element. This model presents several
advantages .These are:
Ease of evacuation in times of emergencies by having
emergency fire escape doors along the central spine.
The narrow plan characteristic of this typology
maximizes on natural lighting and ventilation.
The narrow plan aids in offering views of nature to all
patients from the landscaped gardens hence creating
therapeutic benefits to patients

The simple central spine allows for unlimited growth at


almost any point, either of the street itself or of individual
departments.
However the model has its own limitations, for instance, the
central corridor can be too long and monotonous. This
Figure 5-15: model of Nanjing Drum Tower hospital Source: (20th Nov 2014)
creates boredom and increases the

intra-departmental distances. The model also requires a big


piece of land to develop due to its longitudinal alignment
hence not suitable in small and congested sites
In the case of the extended courtyard model the author
established that courtyards are used as the principle
organising elements. This model presents several advantages
which include:
Provision for natural light through the pocket courtyards.
Ventilation from roof lights
The multiple landscaped courtyards offer therapeutic effects
Figure 5-16: Use of roof lights in deep plans Source: Author 14 th Aug 2014
to patients.
It is of domestic scale hence creates a home like
environment
Ease of evacuation to the multiple courtyards in case of fire.
Provision for future through lateral extension.
Simple load bearing structure.
However the model still has its own limitations e.g. In areas
where deep plans are used, it becomes hard to achieve natural
lighting and ventilation.
Vertical
typology
Through the comparative analysis of the two vertical models
covered in the fieldwork i.e. the vertical monolith (KNH
nursing tower block-Kenya) and the simple tower on podium
(Nanjing Drum tower hospital-China), the author deduced the
following conclusions:
A hybrid of the horizontal and the vertical typologies can
be particularly helpful in reducing the vertical traffic stress
which is a constant trouble in vertical hospitals. This

strategy has been used at Kenyatta national hospital


whereby the nursing zone is located exclusively in a 10
story nursing block whereas all the support and clinical
Figure 5-17: Use of narrow plans to achieve natural lighting & ventilationzones are located in horizontal typology models.
Source: Author 14th Sep 2014

The use of interstitial floor in vertical hospitals helps in


achieving maximum natural ventilation through stack
effect. This significantly reduces the air-condition
energy consumption. This conclusion was drawn from
the case study carried out at Kenyatta National
Hospital nursing tower block.
Compartmentalization of wards in the vertical tower can
be greatly helpful in carrying out emergency evacuation
from one ward to another in the same floor through the
Figure 5-18: Compartmentalization of wards for ease of evacuation fire escape doors. This emergency design strategy has
Source: Author 24th Sep 2014
been employed both at Nanjing Drum Tower hospital and
at the nursing tower block at Kenyatta National hospital.
The vertical planning is convenient in urban areas where
land is at a premium. However, the height should be
controlled in order to reduce the stress on vertical traffic.
This was concluded from Nanjing Drum Tower hospital
whereby the architect made a seemingly surprising
choice: instead of stacking floors one upon another and
resulting in a high floor area ratio, the design team
decided to lay it down. Such preference for low rise
building went squarely against the design trend, which is
dominated by the frenzy for skyscrapers. It went contrary
to the general expectation of a high rise hospital building
in China The low rise plan not only reduced the stress on
vertical traffic which is a constant trouble for large general
hospitals, but also creates large areas of urban space with
human scales.
The circulation in vertical hospitals should not entirely
depend on lifts. The high stress on vertical traffic at
Figure 5-19: Use of ramps for vertical movement of the semi-ambulant
Source: Author 13th Sep 2014

Kenyatta national hospital nursing tower block is


attributed to lack of adequate public staircases. The only
single public staircase available is overly congested
during visiting hours.

Figure 5-20: Use of vertical gardens to create places of respite


Source: July 25th 2014

Figure 5-21: Use of light wells for lighting interiors


Source: (20th Nov 2014)

This results to high traffic and slow movement of visitors in


the 8 working lifts servicing the 10 floors.
The simple tower on podium is convenient in small urban
sites since it provides an opportunity to locate the public
and semi-private areas in the podium and basement while
as the private spaces are located in the tower. This creates
an increasing vertical privacy gradient. This conclusion was
drawn from Nanjing Drum tower hospital.
The provision of healing gardens within the hospital
creates a home-like experience within the hospital by
combining the function of healing with that of garden or
courtyard as it is the case at Nanjing Drum tower hospital.
Incorporation of large courtyards, light wells and
innumerable micro gardens woven on the buildings
envelopes as is the case with Nanjing Drum Tower hospital
helps in achieving maximum natural lighting and
ventilation as well as achieving gardenised architecture in
a hospital. This brings therapeutic benefits to the patients.

The Planning & Design of


Hospitals

5.4

Recommendations

From the findings obtained following the study on comparative


analysis of hospital design typologies, it is evident that there
needs to be interventions in the planning and design of
hospitals.
Figure 5-22: Hybrid typology of vertical and
horizontal models
Source: Author, 16th Dec 2014

The author draws a few recommendations which can be adopted


in the planning and design of hospital towards enhancing healing
environments in hospitals.
These
are:

1) A hybrid system: The author recommends a hybrid of


two models in order to benefit from the strengths
associated with each model while alleviating the
weaknesses prevalent in a given model. For example; a
hybrid of a vertical and a horizontal typology would be
Figure 5-23: A hybrid model of spine and pavilion and
particularly helpful in reducing the number of floors in
extended courtyard models Source: Author, 16th Dec 2014
the vertical hospitals hence reducing the stress on
vertical circulation that is a constant trouble in vertical
hospitals. Similarly a hybrid of the spine and pavilion
and extended courtyard would be rich since it would
incorporate the circulation as the principle organising
element and simultaneously benefit from the courtyards
associated with the extended courtyard model
2) Adoption of circulation as the principle organising
element in the planning and design of hospitals. This is
majorly because circulation remains as fixed elements
once designed hence difficult to change or alter them
once in place.
Figure 5-24: Use of circulation as the principle organising element Source:
www.world
design.com
(20
th Nov 2014)
3) Provision
of health
opportunities
for
future
growth and
expansion, either vertical, horizontal; or a mixture of

The Planning & Design of


Hospitals

both in the initial design stage. This would allow for


flexibility in hospital architecture.
107

4) Incorporation of healing gardens within the planning


and design of hospitals in order to create therapeutic
benefits to patients.
5) Provision of interstitial floors in all vertical hospitals to
maximize on natural ventilation through stack effect.
6) Provision of ramps, adequate public staircases to
complement the lifts in the vertical hospitals hence
Figure 5-25: Use of healing gardens for therapeutic benefits
reducing the stress on vertical circulation.
Source: (20th Nov 2014)
7) Provision of vertical gardens in the vertical hospitals to
order to increase the green cover as well as culminating
as areas for attending evacuees during emergency
evacuation
8) Separation of the paediatric wing from the main
hospital complex in order to provide an exclusive
child-friendly healing environment for children away
from the mix with adult environment.

5.5

Recommendations for future research

The author recommends further investigation on the models


that were not covered in the fieldwork due to limitations of
Figure 5-26: Use of interstitial floors in vertical hospitals
time and money. This would be particularly helpful in forming
for maximum natural ventilation through stack effect Source: Author 13 th Sep 2014
a comprehensive comparative analysis of all typologies and
models in hospital planning and design. The recommended
models for further investigation are:
Horizontal typology
models
1) Independent linked slabs model.
2) Horizontal monolith model.
3) Compact courtyard model.
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Figure 5-27: Provision of vertical gardens in vertical hospitals
Source: Author 13th Sep 2014

Vertical typology models


1) Complex tower on podium model.
2) Radial tower on podium model.
3) Articulated slab on podium model.

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