Title: Doctors can't design but their knowledge is crucial to hospital planning
Pages: 62 - 65
Author: Denis Melrose
Text: Doctors can't design but their knowledge is crucial to hospital planning
Hospitals are complex organisations. Architects, engineers, psychologists, technicians and many others are involved. The most vital specialist of them all is the medical expert. Somehow, his experience and knowledge have to be exploited to the full. by D. G. Melrose
From earliest times, man has always sought to control his environment: and this, fundamentally, is what design is all about. Paradoxically enough, in the field of medicine - which is so intimately concerned with man and his reactions to his environment- design in its broadest sense is often ignored.
However, the two criteria underlying good design are that it should be functional, and that it should be aesthetically attractive. And the aesthetic aspects of medical equipment design are now, with our present enlightened approach to patient comfort, more important than ever before.
In our field, there is an enormous amount which could be done by closer liaison between the medical man, his technicians and (depending on the project) the specialist in engineering, industrial design, architecture or instrumentation. But liaison of this kind is a difficult problem -which, incidentally, reflects the overall contemporary problem of the 'knowledge explosion'. The medical man is hard put to it to keep abreast of developments in his own speciality; now we are going to ask him to be competent in other fields as well.
It always helps to define the problem, however, so we can analyse it by breaking it down into specific medical considerations; ergonomic considerations; engineering (anres/pub/COID/or design) considerations; financial considerations; and aesthetic considerations. The medical man must regard the last four categories as being as significant as the first one, while of course appreciating that they are all interdependent.
Some possibilities and some drawbacks
It is appropriate here to look briefly at the way in which operating room design policy is formulated at the moment. There is no set official procedure, but what usually happens is that a hospital board of governors convenes a subcommittee-on informal lines - to make proposals for future developments in the hospital. Because of this informality, the composition of the subcommittee varies from hospital to hospital, and (for example) it might possibly consist of just the senior surgeon, the theatre superintendent and the hospital secretary.
The board of governors passes on the recommendations which are made and agreed to the ministry for examination and approval, within the framework of the money available. While the flexibility inherent in this approach is a good thing, proposals formulated in this way do not necessarily give the best result.
However, we ought to look more closely at the financial aspects; there is no point at all in conceiving new designs or techniques if the money for development is not forthcoming. One possible solution is a consortium representing the ministry, the medical profession, the architectural profession (where appropriate) and interested manufacturers. Specific projects could be mutually agreed, and funds contributed by the ministry and by industry for development projects (with a proviso that the interested companies would have to share any marketing potentialities). This sounds very promising, but in practice bristles with difficulties -the manufacturers, who have to survive in the commercial market, would want to be pretty sure that they would see something back for their money; the ministry, hard pressed as it is with competing claims for the money it has available, would almost certainly have similar misgivings. It seems that the medical people would come off best, but at the same time they would be under pressure to find a design approach that would please everybody - which of course it wouldn't.
The hope here - as in all similar situations would be that a suitable compromise could
be reached. Taking this part of the suggestion one stage further, it would be possible theoretically to standardise on basic pieces of equipment or apparatus. This, of course, is an attractive idea from the point of view of cost, and medically there is no reason at all why one could not produce, for example, standard circuitry and mechanical design for an ECG amplifier. But generally - and I think a lot of medical people would agree- I feel that if standardisation were introduced to any extent we should find ourselves confronted with the familiar dichotomy of low cost and ease of production on the one hand, and complete design stagnation on the other.
Another approach which seems to be reasonably successful in other fields is that the ministry decides on a design specification and invites tenders for a development contract. The successful manufacturer then has an option on future production. But whether this method necessarily produces the best design is open to conjecture.
Individual design studies
There is nothing to stop specific groups from carrying out design studies, and two examples where this has been done with great success are Musgrove Park Hospital and the Nuffield Twin Theatre Unit. In addition, the Newcastle Regional Hospital Board has produced an exhaustive memorandum on operating theatre construction and design (see pages 44-49).
We at Hammersmith Hospital also felt it desirable to initiate a design study of
The basic theatre framework, octagonal in plan, was erected on the concrete floor of an industrialised building housing a triple theatre suite. The central overhead lighting assembly is already in position. The extreme mechanical simplicity of the design is very apparent here. 3 The next stage of construction indicates how the wall panels, with their built-in instrumentation, fit straight on to the basic structure. Here, the air-conditioning ducting, which has just been assembled to the roof, is visible. The design conception of the theatre as a self-contained package, mentioned earlier, is evident here too, combining the desirable engineering, instrumentation and architectural features. Opposite page: 4 A typical four plan, demonstrating how this configuration lends itself well to the applications of properly studied work motion patterns - just as important in this field as in industry. 5 This view of a twin theatre suite gives a good overall impression of the pleasant working conditions.
operating rooms, and it is worth mentioning two things: first, medical staffs had been expressing dissatisfaction with the conventional designs for some time without really being able to analyse in detail what was wrong; and second in fairness to them - radical experimentation in this field had been relatively rare because of cost and pressure on time. It was felt, however, that the shortcomings of existing designs were due primarily to the limitations imposed by conventional structural building methods and materials, and by the concomitant restrictions associated with accepted shapes and interior arrangements.
We decided, therefore, that our study of the design should start from basic principles, that it should be exhaustive, and that- most important - the most extensive collaboration should be sought between all interests, skills, and techniques.
The first stage was to set up a panel of specialists to include not only medical staff, but also people interested in the architectural and engineering aspects of theatre design, construction and instrumentation. The underlying philosophy was initially to encourage as wide a discussion as possible, starting with the fundamental work pattern of a typical operating theatre. There can be certain problems with this approach - the classic remark that a camel is a horse which has been designed by a committee sums this up very well - but the idea was first to produce a basic set of design requirements which satisfied all our criteria, before becoming too specific. This area, where one is looking a/fundamentals, is one in which the industrial design consultant could well contribute much of value, for it involves, basically, a problem-solving activity.
It is interesting to note that when two years later, in 1962, MPs discussed the White Paper on hospital plans for England, Wales and Scotland, the then Secretary of State for Scotland said, "It is most important that these new hospitals should not be buildings modelled on past experience, buildings which are no more than modern reproductions of nineteenth century hospitals designed for working conditions which are already out of date. The new hospitals should be so designed that they will be able to cope with needs which even now can only be forecast from a distance. We are trying, therefore, to see that the various departments are designed not only for today, but that they will also take into account the possibility of change". The Opposition spokesman favoured this view, and also stressed that flexibility was wanted by which he meant adaptability to changing needs. He was glad that the hospital architects were at last addressing themselves to this problem.
In our study, the theatre design fundamentals were established in general terms as follows: 1 Adequate space should be provided both for the theatre staff and for equipment which must be at or near the operating table. For reasons of sterility and convenience, all other equipment should be either wall mounted or outside the theatre altogether. 2 The theatre should be designed for the maximum ease of movement for staff and patient. Movement paths should be separated for reasons of convenience as well as sterility. 3 It should be easy and quick to clean and keep clean, in the full medical sense. As far as possible, all surfaces should be smooth
and flush. 4 It should be air conditioned, or at least ventilated in some way which would prevent infective material reaching the patient. 5 The structure should achieve full acoustical and thermal insulation, and complete electrical screening. 6 The materials used in the construction should require little or no maintenance, redecoration or repairs. It is important here that predictable performance can be guaranteed, and this could only be accomplished by modular construction. 7 Instrumentation and equipment should be accessible from outside the sterile area. 8 The lighting both for general background illumination and for local lighting for the operative site - should be adaptable for changing requirements. It should also be chosen to fall within the range which highlights the natural colour of the skin; this is quite easy to accomplish - an example of how, in practice, surgical requirements can coincide admirably with engineering and architectural requirements. 9 The size of the theatre and available working space should be adequate (see point 1), but not greater than is necessary for the purpose. This simplifies almost all of the problems of lighting, ventilation, maintenance and cleaning. 10 The necessity for change in layout should be accepted and planned for from the outset; the means of construction should therefore allow for built-in flexibility. 11 The final design should encompass all the above requirements, and combine with them a general working environment which provides a comfortable, aesthetically pleasing and relaxed atmosphere.
These fundamentals were accepted without reservation by everyone involved, and three interesting facts emerge: (a) these conclusions could not have been reached without full collaboration between the medical staff and the other specialists; (b) as well as producing the best solution from a medical point of view, they seem to satisfy the other requirements as well; and (c) the only method of accomplishing this solution in practice is to engineer the theatre as a separate self-contained package.
Producing the prototype
Accordingly, the commercial manufacturing organisation which had been represented at the talks, and which has considerable instrumentation and engineering design experience in the medical field, decided to go ahead and produce a prototype in conjunction with the hospital.
My illustrations show how the theoretical design conception was translated into reality; in practice - although of course minor snags were encountered - the design more than justified the thought which had gone into it. As far as costs go, it is sufficient to say that the cost of such installations is no greater than that of conventional structures, but the time taken to completion is appreciably reduced itis usually half that accepted as being reasonable. And this is, of course, a tremendous advantage.
In conclusion, it is worth pointing out that similar problems to those we have been considering exist in areas of the hospital other than the operating theatre. For the solutions we have found have equal application in the construction of diagnostic laboratories, intensive care wards - or any similar environment where design poses a difficult problem.
Acknowledgement The author wishes to acknowledge the help given to him in the preparation of this article by members of the medical division of Honeywell Controls Ltd.
Denis Melrose is reader in clinical rheology at the post-graduate medical school of, and consultant in clinical physiology to,Hammersmith Hospital. He is identified with the heart-lung machine which bears his name, and has been closely involved with the development of heart surgery in Britain.