Publication history, Reflections & comments
Hospitals have two main kinds of problems: sick people, poor organization.
In 1981 the South Australian Health Commission spent $A28 million on rebuilding the Whyalla Hospital. It then had 200 beds which have now been reduced to 145. There were many improvements over the old building, which had a tiny Casualty department, small operating theatres and a small intensive care unit. However mistakes in design became obvious over the next ten years. Legally the builders were not responsible for defects which appeared more than one year after their task was finished, though new laws may have changed this.
Daily observation as a surgeon over 10 years, and discussions with other staff revealed a wide range of mistakes made by the architects.
Public access areas : There was insufficient car parking, poor traffic flow and signage, new entrances causing security problems and confusion to newcomers. There was no longer an obvious main entrance. Carpets in public areas were impossible to keep clean because of poor quality, discarded wrappers and spilt food. The cleaning staff became discouraged but only after 9 years were the carpets scrapped and replaced with linoleum. On windy days, leaves and other rubbish blow into the hospital through automatic doors. It is interesting to contrast this problem of air flow with the self cleaning design of the rear lights on a Mercedes motor car.
Accident and emergency department: This was designed for the care of 8 critical cases at one time. This is a rare occurrence and can be managed in an open area nearly. It was not designed for the usual 80 or 100 walking outpatients treated on a holiday or weekends. There are curtains but no acoustic privacy. At first there was no writing bench, or seats for patient, relatives, or doctor. The fitted spotlights have a limited range and wander from their set position, making clinical examination more difficult than it should be. The central office position in the large open area has no convenient site for a computer terminal One was tried there but abandoned after a few weeks.
Storage for frequently used material is a long walk away, and so are the reception desk, and staff tea room with no direct lines of sight, causing delays and increasing the workload. Within weeks of moving in, extra staff had to be provided after threats of industrial action.
Hospital switchboard: A screen prevents the operator seeing passers by except by stretching up hard. There is no room for an electric jug or coffee cups by the switchboard, so there are delays answering calls when operators take breaks in a separate tea room. Space for phone directories and other information needed both routinely and in the event of a sudden mobilization for disaster is inadequate. Walking access to the switchboard from the reception area is by the longest possible route, so at quieter times when one person does two jobs, there are further delays in answering the phone. Some operators wanted extra staff to solve this problem.
Ward design: In two new wards columns block the line of sight from the desk to heads of beds. Within two days of moving into the new children's ward, one small child suffered brain damage, fortunately temporary, after choking unobserved between the mattress and a cot side.
Large new "Seminar" rooms on each floor became smoking rooms and then tea rooms, where nurses were hidden from patients and from medical staff, but not used for teaching or opportunities for work related discussions such as quality circles.
About six years after the rebuilding, a visiting Health Commission architect urged motel style accommodation for all patients, as their entitlement. He felt every patient deserved to have a separate room with its own toilet facilities, oblivious to the cost of building and running costs, especially wages for extra nurses and cleaners.
Other problems: The X-ray department had a classic blunder repeated in many hospitals. The doorway, wide enough for a patient trolley, was too narrow for beds on which sicker patients were brought from the wards or intensive care unit. It had to be knocked down and rebuilt.
Practically every area in the hospital had problems resulting from poor design, such as glass windows quickly covered by obsolete notices in order to give visual privacy. Theatres lacked an adequate well lit area for cleaning and checking of delicate surgical instruments.
Fixtures and furniture were poorly designed and chosen. The bolts on double doors had little knobs for handles suitable for steel fingered pixies rather than normal human beings, and sticking of bolts led to them breaking from rough handling
In the recovery room where nurses sat to observe patients after anaesthesia, the desk and seats provided were ideal for someone with no legs, but provided no leg room for normal people. There were 72 surgical stools bought for $120 each, with unpadded steel seats. None were used, and most have disappeared.
Following the early part of this study, a new design of office was installed in four wards at the Whyalla Hospital. The aim was to improve work partly through standardizing the clerical procedures and materials. Each one was enlarged by removing one patient bed, with the hope that increased efficiency would compensate for this. An L shape of office was installed without a mirror image to make work less confusing. Task analysis and staff consultation were planned but not carried out because of administrative decisions and lack of resources.
This superficial study revealed many errors in a hospital design and suggested that many more would have emerged through a systematic study of each department. It did not discuss flexible design for future changes, or structural faults such as cracking walls from faulty foundations. Problems occurred at many different levels, and remedies seemed painfully obvious.
The underlying problems were:
1. Architects don't understand hospital work or the needs of users.
2. Communication about problems at work is poor within and between hospital departments.
3. Smaller items are chosen poorly.
4. Success of architecture can not be separated from management competence and personal commitment by workers.
5. Post occupancy evaluation had not been carried out earlier.
6. Architects' drawings were confusing.
Simple physical models on a scale of 1: 10 have been found useful elsewhere (Patkin 1990), where Computer Aided Design would intimidate many people, including cleaners, carpenters, and others using the work area daily. However such models are expensive and time consuming to make.
These are now being replaced by a trial of 1: 10 scale drawings simplified to bare essentials, and with models of movable items such as trolleys and wheel chairs to check for access.
Such large scale drawings are useful for showing access and lines of sight, but can not represent problems of noise, temperature, smell, or the overall "feel' of a new working environment. However they would avoid the common problem of entrances which are made too narrow and have to be torn down and rebuilt.
Ergonomists in Australia and in other parts of the world have been preoccupied with problems of physical strains in office work and their medical and political aspects. It is a shame that they have neglected other areas such as hospital design, with a view to improving productivity and quality of work as well as the satisfaction of those who work there.
Hospital design represents an important but unmet challenge for ergonomists. It requires task analysis, better communication with architects, and the use of models for all users to be able to contribute ideas based on everyday experience.
Patkin, M. 1990, Sic [sic] architecture POE and PPOE: The argument for pre- and post occupancy evaluation. Proceedings of the 26th Annual Conference, Ergonomics Society of Australia, Adelaide, 189 194.
The ward office project
Published in Hospital Ergonomics: International symposium, Paris, July 1981, Octares editions, Toulouse, France.
formerly Whyalla Hospital, South Australia.
Communication Research Institute of Australia, Canberra.
PO Box 312, North Adelaide SA 5600, Australia
This paper was presented at the world's first international meeting on ergonomics in hospitals, held in conjunction with the 3rd trienniel congress of the International Ergonomics Society.
It was a landmark occasion, or should have been. However i found the papers and content disappointing, and nothing of a similar scope has been attempted since, to my knowledge.
Perhaps i was peeved because my own pet hobbyhorse of ergonomics applied to haspital design has not been attempted since (but see my papers on design of operating rooms elsewhere on this website).