Design 9 Final Book

KAMUZU CENTRAL HOSPITAL PLANNING FRAMEWORK PERMEABILITY THROUGH THE NEW CIVIC FRONT Danielle Felicione, Will Ferrill, Ben Manarski, Alexandra Noll, Griffin Voigt

Kamuzu Central Hospital Planning Framework Permeability Through a New Civic Front

Danielle Felicione, Will Ferrill, Ben Manarski, Alexandra Noll, Griffin Voigt Project presented to the Faculty of the Department of Architecture College of Architecture and the Built Environment Thomas Jefferson University In partial fulfillment of the requirements for the degree of BACHELOR OF ARCHITECTURE Arch-507 / Design 9: Research and Design Faculty Associate Professor Chris Harnish Philadelphia, Pennsylvania December 2018

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

THESIS STATEMENT

Our conceptual approach to this project revolves around the idea of permeability, the state or quality of a membrane that allows things to pass through it. By controlling the degree of permeability across the site, we encourage organized program and circulation to mitigate the current levels of congestion. To do so, we have established both membranes, which control access, and barriers, which prevent access, in our framework plan.

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

CONTENTS 4- 1 5

01

THESIS: SUPPORTING RESEARCH AND PROCESS

4- 1 5

02

CONCEPTUAL RATIONALE

4- 1 5

03

SITE INVENTORY AND ANALYSIS

4- 1 5

04

METHODOLOGY

4- 1 5

05

DESIGN CONCLUSIONS

4- 1 5

06

ASSESSMENT

5

01

THESIS: SUPPORTING RESEARCH AND PROCESS The campus of Kamuzu Central Hospital in Lilongwe, Malawi is a complex, disorganized collection of decades of development and expansion. The site responds mostly to short-term issues and growth is considered for immediate needs rather than longterm goals, a method of planning that is common and expected given the circumstances of the region and the hospital itself. Strained resources, staff restrictions, and a population with significant rates of medical complications have all become factors in the resultant campus that exists today. Our design criteria was developed through a variety of research inputs such as emergency care, specific user group circulation, and stormwater management. Initial concepts led to a framework proposal for the future development of KCH. Our conceptual approach to this project revolves around the idea of permeability, the state or quality of a membrane that allows things to pass through it.

By controlling the degree of permeability across the site, we encourage organized program and circulation to mitigate the current levels of congestion. To do so, we have established both membranes, which control access, and barriers, which prevent access, in our framework plan.

The new civic front of the hospital, composed of a main entrance and emergency department, serves as a membrane that quickly assesses incoming people and filters them into several groups: outpatients, inpatients, staff, and guardians. They are then directed through the corridor that will best fit their needs, each of which is separated by barriers in the forms of buildings and strategic landscape design.

This method will improve the entry sequence, programmatic organization, and pedestrian and vehicular circulation of the hospital, therefore improving the overall efficiency and experience of the campus.

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Patients enter the hospital in one of three ways: by pedestrian path, by car or bus, or by ambulance.

The civic front is organized to accommodate people entering the hospital through either the main entrance or the emergency department from multiple angles. Terraced parking fits into the natural slope of the landscape inside a loop that stretches to the emergency entrance to accommodate patient dropoff. The edge of the road is marked by a large public stair to control the points at which pedestrians are crossing the street.

Across the civic front, strategic landscaping techniques provide barriers between different spaces. These barriers aim to separate pedestrian and vehicular traffic in order to enhance the visual and auditory experience and ensure the safety of pedestrians. They also help to manage stormwater across the site, especially during times of heavy rainfall which are common in Malawi. Finally, they work to balance out the addition of hardscapes to maintain a suitable habitat for native organisms.

Covered walkways lead patients and guardians toward the building and connect to overhangs of varying depths. The materiality of the overhangs and the ground are consistent throughout the campus and communicate that the space is either for walking or gathering.

Pedestrian circulation is problematic on the hospital campus as overlap between staff and guardians results in a chaotic environment. Therefore, each corridor has been designed specifically for their intended user groups to encourage a higher level of organization. The outpatient corridor is located adjacent to buildings such as radiology and pharmacy to keep short-term patients from wandering further into the hospital. It is designed to keep people moving but allows room for seating for those waiting to be evaluated. The high-risk corridor encourages speed

KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

and efficiency for staff and patients moving between programs such as the ED, surgery, and ICU. This corridor offers no seating to deter guardians from gathering and causing congestion. The staff corridor is located between the ED, surgery, and inpatients wards. The seating, landscaping, and intimate scale are designed to promote privacy and better the mental health of workers on campus. Lastly, the guardian corridor allows for many shaded gathering spaces and immediate access to inpatient, maternity, and pediatric wards, as well as guardian facilities on the far end of the corridor.

Controlling the degree of permeability throughout the hospital campus mitigates the primary issue of congestion on the site above all else, which is crucial because in this context, improvements in design could save lives. Overall, our project aims to maintain the proper balance between the efficiency needed to run a hospital and the experience necessary for staff and guardians to provide adequate care and most importantly, for patients to heal.

The new civic front of the hospital, composed of a main entrance and emergency department, serves as a membrane that quickly assesses incoming people and filters them into several groups: outpatients, inpatients, staff, and guardians.

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02

CONCEPTUAL RATIONALE In designing a new civic front for the hospital, the goals was also to construct a hierarchy that could start to determine further development for the hospital. The following diagrams illustrate our concept and its relation to the rest of the hospital.

OUTPATIENT

PAR

KIN

G

ve

OUTPATIENT

pede

n

guardian

KIN

SU

RGE

PAR

PARKING PEDIATRICS PEDIATRICS INPATIENT INPATIENT INPATIENT

EME

r ula hic ve

staff

G

outpatient staff

PHARMACY LAB RADIOLOGY HDU MORGUE RGERY SURGERY ICU

ENTRAN

stria

SERVICE PARKING

CORRIDORS

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

OUTPATIENT

PROGRAM ADJACENCIES

CHAPEL

M

ATERNITY BAYLOR

MATERNITY

hic

ula r

OUTPATIENT OUTPATIENT

MATERNITY MATERNITY MATERNITY MATERNITY MATERNITY GUARDIAN GUARDIAN GUARDIAN GUARDIAN GUARDIAN

R IE

BARRIER

BARRIER BARRIER

BARRIER

BARRIER

BARRIER

ARRIER BARRIER

BARRIER

BARRIER BARRIER BARRIER BARRIER BARRIER

BARRIER

BARRIER

BARRI 02 ER

BARRIER

R R A B STORMWATER CONCEPT

BARRIER

BARRIER

MEMBR MEMBRA

IER RR BA

BARRIER

B

BARRIER

BARRIER

BARRIER

BARRIER BARRIER BARRIER BARRIER BARRIER

BARRIER BARRIER BARRIER BARRIER BARRIER

MEMBRANES & BARRIERS

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03

SITE INVENTORY AND ANALYSIS Investigations into permeability and membranes required an understanding of existing site conditions and green barriers. The resultant strategy acknowledged existing context and buildings.

Permeability is the state or quality of a material or membrane that permits it to allow things to pass through it. By controlling the degree of permeability across multiple planes throughout the site, we can encourage organized program and circulation to mitigate the current levels of congestion. To do so, we have established both membranes -- that control access -- and barriers -- that prevent access -- in our framework plan.

Membranes Current conditions allow pedestrian and vehicular traffic to move freely throughout the site, creating congestion that hinders both efficiency and experience. Establishing a membrane for people to pass through can organize circulation by user group.

Barriers Barriers currently exist only in the form of physical buildings. In addition, we can use green barriers to separate program while maintaining a positive experiential quality and response to the environment.

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

pede stria n

lar

u hic

ve

outpatients

staff

ar icul h e v

guardians

SITE INVENTORY AND ANALYSIS

03

Program adjacencies were actively considered as circulation was developed.

The final design clusters program types to increase efficiency.

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03

SITE INVENTORY AND ANALYSIS Considerations into emergency and trauma services had to be modeled after accepted methods yet also be contextual. The following diagrams were based on an analysis of a typical emergency room, These diagrams influenced Emergency Department placement and adjacencies within the larger scheme.

A DROP OFF

ASSESSMENT

B

CORRIDOR TRAUMA/RAD.

HIGH RISK

STAFF/ MAIN

AMBULANCE/DISASTER

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

RELIEF/BREAK ADMIN. STAFF

WAIT

INTAKE FAST-TRACK MAIN HIGH-RISK TRAUMA

STAFF

JEFFERSON E.R.

PATIENT

MAIN

ENTER WAITING ELEVATOR

Emergency Breakdown

Fasttrack

Intake consists of an early evaluation system by which physicians quickly determine the needs of the patient, reducing wait times. This functions primarily as a transitional space.

Intake

If the patient can be treated quickly, they are sent to Fast-track where they can easily circulate through the outpatient section of the site and exit the hospital campus efficiently.

If the patient is in need of more serious intervention or a longer hospital stay, they move into the High-risk section of the Emergency department, immediately adjacent to surgery facilities and the inpatient ward.

Highrisk

Outpatient

Surgery

Inpatient

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03

SITE INVENTORY AND ANALYSIS Analysis of the main campus of the hospital revealed severe defficiencies when it came to pedestrain congestion. The main accedd road was essentially a dead end and green spaces were under-utilized.

ED Circulation Outpatient Circulation Guardian Circulation

Grade Allows for Two-Levels Green Space/ Unprogrammed Green Space

Area of Congestion 2+

Program Allows for More than One-Story Programs Not Afftected by Main Circulation Entrances Circulation

Malawi College of Health Sciences

UN

Views to Green Space

CC en ter

Eye Center

EN

2+

TC en te r

UNC Annex

Eye Center

2+

ht

er Ov

g ni

Prothestics & Orthotics Center

Public Bathrooms

Eye Center

Eye Center

Or

2+

th

op

ed

ics

2+

UNC Annex

Outpatient Ward 2/admin

Pharmacy?

2+

Lighthouse Centre

Original reception area

Outpatient Ward 1 Trauma/Emergency Paying Clinic

Skin Clinic

Surgery Laboratory

Dental Clinic?

2+

Radiology

Maternity Inpatient

XRay

2+

Maternity: -1st story: Outpatient -2nd story: Admin

Maternity Paying

Oxygen & Vaccum for HDU/ICU

Mortuary

Maternity: Delivery

Laundry

Inpatient

ICU HDU/Endoscopy

Guardian Waiting

Pediatrics: Outpatient Pediatrics: Inpatient

Facilities

Kamuzu College of Nursing

KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

Baylor

Haematology-Oncology Outpatient Clinic Facilities

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Pastoral Care Chapel Building

Kitchen

Facilities

Guardian Housing

Maternity Inpatient

UNC Housing

SITE INVENTORY AND ANALYSIS

03

Analysis of the site effectively revealed opportunities for a clear organizational strategy. Designs for the Civic Front became iterative of this premise.

CANCER CENTER

ORTHOPEDICS

r

la u c hi

ve

OUTPATIENT OUTPATIENT

pede strian

OUTPATIENT OUTPATIENT

outpatients

OUTPATIENT

LAB

PHARMACY

outpatients MAIN ENTRANCE /ADMIN.

HDU

RADIOLOGY

MORGUE

vehic ul

ar

staff

MATERNITY

EMERGENCY DEPARTMENT

SURGERY

SURGERY

ICU

staff

MATERNITY

INPATIENT

MATERNITY

MATERNITY

MATERNITY

INPATIENT

guardians

GUARDIAN PEDIATRICS

PEDIATRICS

MATERNITY

PEDIATRICS

INPATIENT

GUARDIAN

PEDIATRICS

GUARDIAN

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04

DESIGN CONCLUSIONS The final design for the hospital’s civic front focused on an undulating front pathway. This pathway acts as a continuous membrane along the main axis of the hospital.

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

KAMUZU CENTRAL HOSPITAL 60 ACRE SITE PLAN 0’

100’

300’

500’

17

04

DESIGN CONCLUSIONS

70

60

50

70 40

60 30

50 20

40 10

PEDIATRICS

CHAPEL

PEDIATRICS

MATERNITY HDU

30

LAB

0

20

GUARDIAN CORRIDOR

-10

10 -20

PEDIATRICS 0

20

40

60

PEDIATRICS120

80

100

OUTPATI

STAFF CORRIDOR CHAPEL

140

160

180

200

220

240

HIGH RISK CORRIDOR

MATERNITY 260

280

300

320

340

360

380

400

420

440

460

480

500

520

HDU

540

560

580

600

620

640

680

700

720

740

760

780

800

820

860

840

LAB

0

GUARDIAN CORRIDOR

-10

-20

660

EAST SECTION MAIN CORRIDORS 0

20

40

60

80

100

120

140

160

180

200

STAFF CORRIDOR 220

240

260

280

300

320

340

MAIN/OUTPATIENT CORRIDOR

HIGH RISK CORRIDOR

360

380

400

420

440

460

480

OUTPATIENT CORRIDOR

500

520

540

560

580

600

620

640

660

680

700

720

OUTPAT

740

760

780

800

820

840

860

OUTPATIENT CORRIDOR

MAIN/OUTPATIENT CORRIDOR

70

60

50

70 40

60 30

INPATIENT

50 20

SURGERY RADIOLOGY

40 10

PEDIATRICS

PHARMACY 30

PEDIATRICS

INPATIENT

0

20

MAIN CORRIDOR

OUTPATIENT CORRIDOR

-10

10 -20 0

20

40

60

80

100

120

140

160

180

200

HIGH RISK CORRIDOR

RADIOLOGY

PHARMACY 220

240

260

280

300

320

340

360

380

400

420

STAFF CORRIDOR

SURGERY

440

460

480

500

520

540

560

580

GUARDIAN CORRIDOR 600

620

640

660

680

700

720

PEDIATRICS 740

760

PEDIATRICS 780

800

820

840

860

0

-20 0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

WEST SECTION MAIN CORRIDORS

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HIGH RISK CORRIDOR

MAIN CORRIDOR

OUTPATIENT CORRIDOR

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

STAFF CORRIDOR

340

360

380

400

420

440

460

480

500

520

540

560

580

GUARDIAN CORRIDOR 600

620

640

660

680

700

720

740

760

780

800

820

840

860

70

70 60

60 50

50 40

40 30

30

Kamuzu Central Hospital

20

Kamuzu Central Hospital

20 10

SERVICES/MORGUE 10

SERVICES/MORGUE

0

0 -10

EMERGENCY DEPERTMENT ENTRANCE EMERGENCY DEPERTMENT

-10 -20 0

20

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

360

340

380

400

420

440

480

460

-20 40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

360

340

380

400

420

440

500

ENTRANCE 480

460

520

500

GUARDIAN CORRIDOR

GUARDIAN CORRIDOR 540

520

560

540

600

580

560

620

600

580

640

620

660

640

680

660

700

680

720

700

740

720

760

740

780

760

800

780

820

800

860

840

820

880

860

840

880

MAIN ENTRANCE

MAIN ENTRANCE

WEST SECTION CIVIC FRONT

70

70 60

50 60

50 40

INPATIENT

30 40

CHAPEL

INPATIENT

INPATIENT

INPATIENT EXPANSION

30 20

CHAPEL

INPATIENT

INPATIENT EXPANSION

10 20

CENTRAL CORRIDOR CENTRAL CORRIDOR

10 0

CIVIC FRONT

PARKING

-10 0

-20 -10 0

20

0

20

40

60

80

PARKING 100

CIVIC FRONT 120

140

160

180

200

220

240

260

280

300

320

360

340

380

400

420

440

480

460

500

520

540

560

600

580

620

640

660

680

700

720

740

760

780

800

820

860

840

880

-20

SOUTH SECTION CIVIC FRONT

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

340

360

380

400

420

440

460

480

500

520

540

560

580

600

620

640

660

680

700

720

740

760

780

800

820

840

860

880

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04

DESIGN CONCLUSIONS Aside from efficiency concerns and circulation, experiential factors were also considered. Corridors were designed to comfort patients, staff, and family. All interventions were meant to be performative and appealing.

GREEN BUFFER GREEN BUFFER

GREEN BUFFER

STORM WATER MANAGEMENT

MAIN PEDESTRIAN WALKWAY

PERSPECTIVE OF MAIN PEDESTRIAN PATHWAY

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

STORM WATER MANAGEMENT

PERSPECTIVE OF EMERGENCY DEPARTMENT DRIVE

SERVICES BUILDING

VEHICULAR RAMP TO EMERGENCY ENTRANCE

PARKING

ELEVATED PEDESTRIAN WALKWAY

PARKING

PERSPECTIVE OF PATHWAY THROUGH PARKING LOT

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04

DESIGN CONCLUSIONS

HIGH RISK CORRIDOR

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

DESIGN CONCLUSIONS

05

GUARDIAN CORRIDOR

23

04

DESIGN CONCLUSIONS

STAFF REST AREA

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

DESIGN CONCLUSIONS

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CORRUGATED METAL ROOF

WOOD SHADING / PRIVACY

CONCRETE PLANTER WOOD BENCH

GRAVEL OVERFLOW FOR STORMWATER CONTROL PERMEABLE BRICK PAVERS BEDDING LAYER BASE COURSE GROUND

GATHERING SPACE ON CIVIC FRONT

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04

DESIGN CONCLUSIONS Landscape design was based on making minimal changes to the existing environment, while still promoting storm water management and clear site access. Green space in corridors was based on their function and congestion

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

DESIGN CONCLUSIONS

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CONCEPTUAL GRADING PLAN OF CIVIC FRONT

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DESIGN CONCLUSIONS

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Signs hang from the roof of the covered walkways to direct patients to nearby programs.

Signs with coordinated colors are placed by the entrances to each building so patients can identify that they have arrived at the correct location. The signs are written in several languages and include universal healthcare symbols.

KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

WAYFINDING 03

WAYFINDING 02

WAYFINDING 01

04

Signs on the ground adjacent to roads inform patients arriving by car of the general layout of the hospital, providing a map to help them orient themselves.

DESIGN CONCLUSIONS

05

PERSPECTIVE OF MAIN PEDESTRIAN ENTRANCE APPROACHING CIVIC FRONT

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04

DESIGN ASSESSMENT

Our main intentions in this project were to encourage organized program and circulation to mitigate the current levels of congestion through a series of membranes and barriers. We felt that focusing on the civic front as a threshold to the rest of the site would create a trickle-down effect across the rest of the hospital behind it. Overall, our scheme of four corridors (outpatient, high-risk, private staff, and guardian) was successful in the way that it organized critical program adjacencies and allowed specific user groups to travel closest to the buildings that they need to access.

If we were to develop our scheme further, there are a few points that we would address based on our feedback. Firstly, while our four corridors were clearly organized, the North-South corridor that cuts through the center of the main campus could use some more development. Moving forward we would consider ways to ensure that people navigating through that corridor would not stray into the wrong path by accident through methods such as green barriers.

In addition, we have some alterations and additions that we would consider making to the civic front. One critique of our scheme is that the procession to the emergency department makes it appear as though that is the main entrance to the hospital and that some patients or guardians may gather on the stair leading up to it. We could mitigate these problems by drawing more attention to the main entrance from

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the perspective of the parking lot and continuing our designs of the seating elements adjacent to it. Finally, if we continued our progress we would extend the concept of permeability to the architecture itself. This could be achieved through the application of building materials of different transparencies to communicate whether the area welcomes people to pass through or blocks their movement. While we know there are aspects of our project that could be improved with more time, our group is generally satisfied with the point we reached with our scheme this semester and the feedback we received.

KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

We felt that focusing on the civic front as a threshold to the rest of the site would create a trickle-down effect across the rest of the hospital behind it.

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BIBLIOGRAPHY

Dickinson, Garth. “Emergency Department Design and Patient Flow.” Annals of Emergency Medicine, vol. 17, no.

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Elamir, Hossam. “Improving Patient Flow through Applying Lean Concepts to Emergency Department.” Leadership in Health Services, vol. 31, no. 3, Feb. 2018, pp. 293–309., doi:10.1108/lhs-02-2018-0014.

Martin, Niels, et al. “Developing an Emergency Department Crowding Dashboard: A Design Science Approach.”

International Emergency Nursing, vol. 39, 2018, pp. 68–76., doi:10.1016/j.ienj.2017.08.001.

Young, Sven, et al. “The Impact of the Increasing Burden of Trauma in Malawi on Orthopedic Trauma Service Priorities at Kamuzu Central Hospital.” Acta Orthopaedica, vol. 87, no. 6, 2016, pp. 632–636., doi:10.1080/17453674.2016.1228413.

Kazeze, Z. (2008). Social protection and ageing in Malawi.

Rome: Economic and Social Department, Food and Agricultural Organization *All photographs of Kamuzu Central Hospital Courtesy of Christopher Harnish

Rosso, Caroline Brum, and Tarcisio Abreu Saurin. “TheJoint Use of Resilience Engineering and Lean Production for Work System Design: A Study in Healthcare.”

Applied Ergonomics, vol. 71, 2018, pp. 45–56., doi:10.1016/j. apergo.2018.04.004.

“The United Nations Assistance Framework Malawi 2019- 2023.” The United Nations Assistance Framework: 1-69.

Accessed October 8, 2018. https://www.unicef.org/about/ execboard/files/Malawi-UNDAF-2019-2023-17May2018.pdf.

World Bank, Bulletin Board on Statistical Capacity bbsc. worldbank.org.

Mpoola, Dalitso. “Malawi: Lilongwe Urban Profile.” United Nations Habitat: Regional and Technical Cooperation Division, 2011.

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KAMUZU CENTRAL HOSPITAL: PERMEABILITY THROUGH THE NEW CIVIC FRONT DECEMBER 2018

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