Spaces for Health and Recovery

½

The evolution of hospital architecture and how to design hospitals of tomorrow

Spaces for health & recovery

Spaces for health and recovery The health care sector in Denmark is currently undergoing an extensive reform. Within the next ten years, the Danish state and regions will be constructing 38 new hospital projects: five super-hospitals, four regional hospitals, eleven psychiatric hospitals, fifteen local and specialised hospitals as well as three accident and emergency departments.

As the population is ageing, the cost of running hospitals is increasing. At the same time, the demographic development is pointing towards people moving from rural areas to the cities. The capacity of the city hospitals is under increasing pressure, while there is a need to rethink the placement and functions of the hospitals in the rural areas.

This is why in 2007, a parliament majority decided to make a 40 billion DKK investment in optimisation of the Danish health care system. Due to this decision, Danish consultancy companies are now in a situation where new, specialised knowledge is constantly being generated within this specific area. This situation is unique to Denmark. This is why it is only natural for us to share our knowledge and experience with the rest of the world.

Within recent years, Henning Larsen Architects has focused on the development of sustainable hospital architecture that meets the challenges that the health care industry is facing today. Patients and their relatives are vulnerable segments. This is why hospital architecture is particularly about focusing on people.

This can be done in several ways. At Henning Larsen Architects, we are working with two different models for hospital construction of the future. They are presented in further detail in this magazine. They both focus on patients, next-of-kin and staff, striving to make the hospital a pleasant, well-arranged and functional place to be for both shorter and longer periods of time.

Through articles and case studies, this magazine provides insight into our work and presents Henning Larsen Architects' hospital projects. The magazine also provides an introduction to the national, political requisites that are the foundation of our approach.

It is our ambition that this magazine will contribute to enrichening the insights into the complexity of hospital architecture, both as regards construction and society.

Lars Steffensen Architect and Partner at Henning Larsen Architects

Henning Larsen Architects' design proposal for a new University Hospital in Aalborg focusses on human scale and nature.

Editor: Josefine Lykke Jensen text + RESEARCH: Lars Steffensen, farid Fellah, Josefine Lykke Jensen, Dorte Hermann, Ninna Assentoft Rasmussen Layout: Louise Bay Poulsen, Josefine Lykke Jensen, Dorte Hermann TRANSLATION: Mona Engelbrecht, Hannah Cooper FRONT COVER: The Norweigan Radium Hospital - Radiation Therapy PHOTOS: Adam Mørk (front cover, 22-25), Tiberio Frascari, https://www.flickr.com/photos/tango-/ (41), ILLUSTRATIONS: Marie Brodersen (s. 44-45), Henning Larsen Architects (other) COLLABORATORS: Aurora - Odense University Hospital & Faculty of Health Sciences; Friis & Moltke, TKT, Cowi and Rambøll Denmark, SLA, NNE Pharmaplan Cancer Patient Health Centre; B. Nygaard Sørensen, Marianne Levinsen, Lemming & Eriksson Køge Hospital; Friis & Moltke, Lohfert & Lohfert, SINTEF, SLA, Niras, Arup, Brunsgaard & Laursen Neurorehabilitation facility Glostrup Hospital; NNE Pharmaplan, Buro Happold, Lohfert & Lohfert, SINTEF, SLA New Copenhagen University Hospital; Friis & Moltke, NNE Pharmaplan, Sweco Systems New Herlev Hospital; Friis & Moltke, Brunsgaard & Laursen, Orbicon, Norconsult, NNE Pharmaplan, SLA New Hospital North West Jutland; Niras, Friis & Moltke, SLA, SINTEF, Sweco Norway, Orbicon New North Zealand Hospital; NNE Pharmaplan, Friis & Moltke, COBE, Norconsult, SLA, SINTEF New University Hospital Aalborg; Friis & Moltke, Rambøll, Cowi, SLA Norweigan Radium Hospital - Radiation Therapy; AA Arkiteker, Økaw, Rambøll, Multiconsult, Bjørbekk & Lindheim Norweigan Radium Hospital - Research Institute; Rambøll, NNE Pharmaplan, Multiconsult, Mek-Consult Eiendom, Bjørbekk & Lindheim Prince Naif Centre for Health Science Research; NNE Pharmaplan, Buro Happold, Geoffrey Barnett Associates Sølund Retirement Community; BBP Arkitekter, Architect Ole Andersen, Schul Landscape Architects, Henrik Larsen Consulting Engineers, Hundsbæk og Henriksen Consulting Engineers

Contents INTRODUCTION The Hospital of the Future What We Learned From History...

11 12

APPROACH The Hospital as a City Case: Odense University Hospital

17 19

The Hospital in the City Case: Norwegian Radium Hospital

23 25

p. 17

p. 23

SUSTAINABILITY Design With Knowledge Case: New Herlev Hospital

30 35

p. 33

CONDITIONS The Danish Health Care Model The 2020 Hospital Plan The Danish Health Care Model in Figures

40 43 44

ABOUT US About 48 Selected Projects 50

p. 48

History I Evolution I Innovation

Intr

odu

ctionďż˝

X-ray drawing showing the interiors of the New Herlev Hospital.

The Hospital of the Future "Hospital architecture is a question of balancing a professional environment, efficient workflow, social and environmental sustainability, economy - and most importantly - a respectful setting for human beings…”

Throughout history, the knowledge and experience of doctors has influenced hospital design tremendously.

The earliest European hospitals were traditional building blocks, designed in accordance with the limited treatment possibilities and knowledge about hygiene and spreading of infections. Once it was discovered how infections spread, hospital departments began to be constructed as stand-alone pavilions in elaborate gardens. Later – after modern medical treatments were developed – more coherent structures became the norm again, with the compact and technology-intensive compounds of the latter half of the 1900s representing clearly modernistic examples.

The trends of recent years include, among others, an increased emphasis on preventive measures, monitoring and early diagnosis, as well as close relations between treatment, research and training, an increase in outpatient treatment and decrease in the number of hospitalisations, along with more individualised courses of treatment. For the health care sector as a whole, as well as for certain groups of patients, the focus is changing from “treating illness” to “chronic conditions

with degrees of good health”. Alongside, there is an increasing awareness of rational technology only being a part of a successful course of treatment. Welcoming, warm and respectful physical settings are just some of the qualities that a hospital should hold. This will influence the design of future hospitals, which should not be iconic factories of recovery or symbols of technological knowhow, but rather come across as pleasing, demystified and integrated urban institutions, in coherence with the city's other institutions.

The idea of the patient is also changing within these years. The relationship between practitioner and patient is changing into a collaboration process, in which the patient is accepting responsibility for his or her course of treatment and acts upon this. The patient’s next-ofkin is also, to an increasing degree, involved as an active resource in the treatment process. This is happening in accordance with an increasing wish to maintain an active work and family life to the furthest extent possible.

11 | The Hospital of the Future

- Lars Steffensen, Architect and Partner, Henning Larsen Architects

What We Learned From History The development of the health care sector has, throughout history, had a tremendous impact on hospital design. From the earliest, classical building blocks to the vast complexes of modernism, the knowledge of and approach to illness and health of the time period in question may be understood based on hospital design.

The Aesthetic Hospital (from 1450) The first European hospitals were classic building blocks, designed according to the limited treatment possibilities and knowledge about hygiene and spreading of disease at the time. They were constructed in consideration of aesthetics and composition alone.

The earliest example is Casa Grande (Ospedale Maggiore) in Milan from 1450, which is, today, home to the University of Milan.

Casa Grande, 1450 Care rather than recovery

The Hygienic Hospital (from 1850) When the spreading of bacteria was discovered, hospitals began to be constructed as isolated pavillions in elaborate gardens.

Here, patients were isolated from one another and from the city.

The distance and the spatiality efficiently reduced the danger of infection between patients, although the hospitals were constructed with focus on treatment and the medical science.

Bispebjerg Hospital, 1913 Focus on recovery and the medical sciences

The Recovery Machine (from 1960) Later - after the invention of new, medical treatments - it once again became possible to gather patients in more compact and efficient buildings. In this time period, more coherent constructions became the norm again, with the compact and technology-dense complexes of the latter half of the 1900s as clearly modernistic examples.

The Copenhagen University Hospital, 1970.

Focus on recovery and the medical sciences

The outdoor spaces of New Herlev Hospital are designed to interact in a way that appeals to all senses.

13 | What We Learned From History

The patient's hospital (from 2017) Henning Larsen Architects' current hospital design philosophy is that we wish to create decent surroundings for human beings.

This applies to both the patient, the next-of-kin, staff, as well as bypassers.

It is important to us that hospitals are worthy and inspiring settings that have a positive effect on any course of treatment.

The patient's experience of the hospital should be characterised by a sense of welcoming and safety and be adapted to the needs of the patient. In harmonious hospitals, focus is directed at efficient and rational working processes and towards compassionate safety in treatment in a beneficial architectural setting.

Following an increased urbanisation and emphasis on sustainability, there is reason to break away from previous, monumental hospitals placed in the outskirts of the city.

Hospitals should, both in location and design, be closer to the city in order to achieve the synergy and sustainable advantages that the city offers.

New Herlev Hospital, 2017 "Focus on the patient"

Philosophy I Method I Thinking

App roa

ch�

The individual is in focus in the circular city structure whose ground plan meets the requirements for a highly efficient, future-proof hospital.

The Hospital as a City

Many functional workplace and technological procedures are carried out in a simple and efficient manner in a compact and cohesive building structure with maximum density and minimum physical extension. Conversely, welcoming and decent physical settings find favourable conditions in more divided structures with clearly laidout building volumes and inspiring outdoor spaces. The balance between the hospital complex as a ‘big house’ and as a ‘city’ constitutes the framework for both aspects.

The rational and compact ‘big house’, which is characterised by density and short internal distances, does not necessarily offer inner outdoor spaces of significance. By contrast, the ‘city’ or the ‘built-up area’, which is divided into identifiable sub-elements, naturally embraces a hierarchy of inviting outdoor spaces, thus giving associations to the urban environment. Modernday hospital structure features an organisation of a large number of smaller rooms, along with a spatial contrast to this – the place's ‘cathedrals’ – which are created in the outdoor spaces, indoor open spaces and in the

courtyard and garden areas close-by. The special fragility or vulnerability that characterises the encounter with the hospital institution calls for special consideration. And exactly the clearly laid-out building scale along with highquality outdoor and indoor spaces can support the many different courses of treatment. From the short-term and repeated outpatient visit, which should take place without unnecessary involvement in the large complex, to the long-term stay in a single-bed unit with peace and quiet for both visits and examinations.

In the encounter with the hospital, many patients experience that control and responsibility is handed over to the institution. One of the few elements of control that can be retained is quite simply the awareness of where in the large hospital structure a person finds himself. Thus, a spatial division of the large structure into clear and identifiable buildings and outdoor spaces is an important element when it comes to achieving dignified physical settings – as in a functional city, where the logic is evident, and the overall size and scope is played down.

17 | The Hospital as a City

We are, as human beings, used to navigate the structure of the city. We allow for city squares and landmark buildings to guide us. This is why it makes sense to think and design the hospital as a city, especially when constructing hospitals in areas with low population density.

PROJECT FACTS Location: Odense, Danmark Gross floor area: 234.000 m2 Year of design: 2011 (Finalist)

When approaching Aurora, you are met by an inviting and recognisable urban scale, where the complex is divided into varied units with each their clear entrance and reception area.

When approaching Aurora, you are met by an inviting and recognisable urban scale, where the complex is divided into varied units with each their clear entrance and reception area.

When approaching the hospital, you are met by an inviting and recognisable urban area, where the complex is divided into varied units.

Case: Odense University Hospital

The new Odense University Hospital (OUH) embodies an innovative building of high architectural quality, designed to meet the requirements and challenges of tomorrow. The hospital finds renewal in the transition between old and new – and the conversion from tradition to modernity. The human level supports the idea of the hospital as ”the good host” and a place where patients and visitors can easily navigate and feel at home.

The individual is in focus in the circular city structure whose ground plan meets the requirements for a highly efficient, flexible and future-proof hospital and, at the same time, meets the employees, patients and other users on their own terms and with a high degree of respect. The New Odense University Hospital and Faculty of Health Sciences connects ”the Big House” with ”the City Quarters”. “The Big House” constitutes a continuous building complex with short distances, and ”the City Quarters” are made up of distinctive building units and intimate outdoor spaces. Diagnostic and treatment functions are placed on the lower, continuous

floors constituting ”the Big House”, while the wards and outpatient clinics are located in the upper, detached building volumes.

Sustainability OUH is based on the holistic objective of creating simple, uncomplicated connections between buildings, people and nature. The project has focus on achieving a sustainable balance between people, nature and economy and is thus a durable platform for further development.

The highest possible value is generated through the application of synergy-creating tools. The project is based on a sustainable bottom line consisting of three parts: social, economic and environmental sustainability.

It takes social responsibility for the area in which it is built by applying local resources and having focus on the recreational opportunities of both users and neighbours.

Economically, OUH builds on a generic construction principle with emphasis on minimising waste in

19 | Case: Odense University Hospital

The proposal for Odense University Hospital is a circular city structure. It accomodates the requirements for a highly efficient, flexible and future-oriented hospital compound, while at the same time ensuring that the individual employee, patient and relative is met on their own terms.

20 | Spaces for health & recovery

Rainwater from the roofs and impermeable areas is used locally to create new natural experiences and added value in the hospital.

"The human scale supports the conception of the hospital as ‘the good host’ – a place where patients and visitors can easily find their way and feel at home."

- Lars Steffensen, Architect and Partner, Henning Larsen Architects

production as well as utility maximisation in the overall investment by means of a value-generating physical framework, growth and new cross-disciplinary synergies.

Not least, OUH will become a textbook example in the field of environmental sustainability as regards an environmentally responsible selection of materials, rainwater and waste treatment, transport and logistics, room acoustics and the integration of recreational areas and existing landscape resources.

Hospital and landscape The New OUH and Faculty of Health Sciences is placed on a very special location in Odense - close to the city centre but, at the same time, in a scenic landscape with dense old forests, extensive fields, hedges, ponds and channels. In this setting, the hospital constitutes a compact building complex with efficient logistics and a high level of flexibility as regards future extensions. The western part of the landscape will remain undeveloped to maintain and enhance the experience of the impressive Funen countryside. The densely built-up area provides a

large open space with great recreational potential.

Three overall elements have been in focus in the landscape design process, all of which offer their own individual landscape and composition of plants: the wet meadows, the apple grove and the adjacent outdoor spaces are made up of small, but extremely varied areas.

The landscape contains elements that are considered important cultural historical heritage. One path is already preserved.

Sustainability Certification OUH was designed to be certified according to the leading certification system worldwide, DNGB. The system covers a broad range of criteria ranging from indoor climate through process management to the environmental impact of materials, from production to decomposition. DGNB ensures a vast overview of the resource consumption of the entire area.

With its existing classic pavilions and its location in the centre of Milan, Ospedale Milano is a significant part of the city.

The Hospital in the City

Today, hospitals should be placed in the urban context, by the train station, in immediate connection with collective means of transportation. Transportation has become a central issue. First of all because the costs are constantly on the increase, as is population density in the cities.

At the same time, development clearly points towards fewer long-term hospitalisations, while the number of outpatient treatments is growing explosively. This means that an increasing number of people travel to and from a large hospital during the day – thousands of outpatients in the daytime and thousands of employees at the beginning/end of every shift. In this connection, by far the most eco-friendly position is in the city.

Secondly, the health care sector as a whole, from prevention and monitoring to actual diagnostics and treatment, is a far more integrated part of many people's everyday life. The boundaries between ‘ill’ and ‘well’ are being revised, and many will experience different degrees of health in the course of their lives.

To patients and relatives, the close integration into the city makes it a far more gentle and comfortable event to have to visit a hospital. Not only the physical, but also the psychological distance to the hospital as an institution and authority is reduced. Patients who are hospitalised for a prolonged period of time can maintain contact with and feel that they are still a part of their normal urban life. Employees can benefit from the city's plethora of offers, extensive means of public transportation, and generally shorter distances.

Flexibility and urban development potential for the area as a whole is crucial. Apart from embracing the good physical settings for treatment, the situation also contains potentials for attractive and inspiring environments for research, studies and learning, including a development of collaboration between, for instance, universities and businesses in the hospital's local area.

23 | The Hospital in the City

The need for and logic behind placing hospitals in the cities will be strengthened as the population density in the major cities remains on the increase. The most sustainable location of the hospital will, by far, be in the city.

PROJECT FACTS Location: Oslo, Norway Year of construction: 2003-2006 Gross floor area: 8,500 m2

The flora and stream of the surrounding woods is visible through the large west-facing windows in the resting area of the foyer.

Case: DNR Radiation Therapy

The Norwegian Radium Hospital serves people from the entire country. The Radiation Treatment Department is located on the highest and most hilly part of the area - an area to which Henning Larsen Architects also designed the development plan for the hospital as a whole.

The radiation therapy comprises five new radiotherapy facilities, examination functions partly below terrain as well as laboratory, teaching and office facilities above terrain. The oldest buildings of the hospital, the new extension and the tall trees of the nearby woods provide the framework of a new local arrival’s area, from where patients have direct access to the facilities of the building.

Next to meeting all the complex technical and logistic requirements, the most important objective for the design of the new radiation therapy building at the Norwegian Hospital was to develop a building that has a positive influence on both staff and patients.

Light and glass create a peaceful environment A tall, south-facing glass facade ensures a rich inflow of daylight into all building functions. The flora and stream of the Mærradal are visible through the large west-facing windows in the resting area of the foyer and from the examination and conversation rooms of the lower west wing.

The light, timbered walls and sloping ceilings of the entrance areas and treatment rooms reflect the daylight far into the rooms, improving their wellbeing and comfort.

The angled shape of the entryway to the radiotherapy facilities ensures privacy and makes it possible to avoid typical heavy metal doors. Instead, tall glass doors and private, intimate spaces help ease the patients’ wellbeing during their radiation therapy.

Organisation The new radiation therapy building is divided into two main functions: Levels 1 and 2 comprise the treatment

25 | Case: DNR Radiation Therapy

The Norwegian Radium Hospital is the nation’s main cancer research and treatment facility. The Radiation Therapy adds a 8,500 m2 extension to the existing hospital, which is located in a hilly and densely populated area in Oslo.

26 | Spaces for health & recovery

A pleasant atmosphere and a functional working environment is crucial to the nurses who spend more time in the treatment facilities than the patients.

"When you walk from the old building into the new one, it opens up to you. The new facilities are so much brighter and better ventilated, which makes us more efficient at our work.�

- Siri Lise Vendshol Chief Radiation Therapist, The Norweigan Radium Hospital

facilities and levels 3 and 4 house offices and laboratories.

The treatment facilities on levels 1 and 2 are situated under arrival level.

The organisation of the radiation therapy building ensures optimal logistics - a decisive parameter for a rational operation. All functions in the main wing are organised around a central, bright atrium - also referred to as the ‘light hall’ - rising from the first to the fourth floor. The atrium provides access to five radiation bunkers with adjacent control rooms and waiting areas on the first floor. A large window lets in the daylight and ensures a bright, welcoming space - despite its location under arrival level.

Despite the many complicated functions comprised in the building, the design should be clear and easily comprehensible, just as the materials selection should provide a worthy framework for the various functions.

The vision has been to establish a physical setting that promotes collaboration and professional development, rational operation and, not least, high quality in treatment and research in a modern working environment.

Bunkers In collaboration with the users, the design team chose to design the bunker facility based on a similar facility in another Norwegian city.

The design provides an optimal treatment environment with sufficient light and space.

The entrance to the bunkers is oriented towards the daylight, which ensures that daylight is let into the far corners of the bunkers. The labyrinthine design of the bunker facility makes sure that the radiation is absorbed before reaching the entrance. This has made it possible to choose glass doors for the entrance to the bunkers - and avoid heavy steel doors.

Daylight I Energy I Health

Sus

taina bilityďż˝

At the Henning Larsen Architects Department for Sustainability and Innovation, architects and engineers work closely together to create a sustainable design.

Design With Knowledge A sustainable hospital is much more than just an energy-efficient hospital. Sustainable hospital architecture requires healthy buildings with a good indoor climate. A prerequisite is plenty of daylight for patients and employees alike.

Within the health sector Henning Larsen Architects considers social factors the area in which the most significant, sustainable benefits may be found. Data from the Danish somatic hospitals indicate that the expenses for pay constitute approximately 50%, while energy and environment only takes up 5% of the total budget. This emphasises the importance of working with social sustainability, where procedure improvements and productivity will be of increased significance to the total cost of operations than similar savings on energy.

To accommodate this, the Sustainability Department at Henning Larsen Architects has developed an objective and scientific method of prioritising sustainability in each individual project. “It is about including sustainability where it makes sense to do so. When constructing hospitals, health must not be compromised. It is important that the architecture supports the treatment and creates healthy environments for patients and employees”, says Signe Kongebro, partner and head of the Sustainability Department at Henning Larsen Architects. All the tools applied should be focused on health.

Healthy buildings “Energy optimisation is not relevant when it comes to hospitals, considering that an MR scanner uses as much energy as a suburban neighbourhood. This means that what might be saved through energy optimisation is at a minimum, taking into account the enormous energy consumption of a hospital”, Signe Kongebro says. This is why the sustainability efforts entail the making of healthy buildings with good indoor and outdoor climates.

Henning Larsen Architects is working with detailed analyses of, among other things, indoor climate and user behaviour related to energy consumption. These are strategies in which daylight and artificial lighting are combined to allow for both functional operating wards and comforting bed sections.

Daylight Daylight affects our senses and retains focus on the here and now. The light supports the beholder’s experience of being present in the moment. In this way, the building becomes an instrument that constitutes the backdrop for daylight, allowing the architecture to frame the lives

Reduce, optimise, produce When it comes to energy consumption, our sustainability work methodology can be described by means of a pyramid structure where the different agents are divided into reducing, optimising and producing measures. The objective of this method is to eliminate the need for energy by means of an iterative process where technical specialist knowledge brings about the creative process, while aesthetics and space are the means of achieving significant energy reductions.

REFERENCE:

PRODUCE Local energy

OPTIMISE Components and installations

REDUCE Context, geometry, daylight, functions and systems

48.6 kWh/m2/year The project is based on the standards for traditional building as provided for in the Danish building regulations BR10. This corresponds to an energy consumption of 48.6 kWh/m2/year when using the calculation scheme of Building Class 2020.

The objective for the project is to meet the energy requirements of Building Class 2020, corresponding to approx. 25 kWh/m2/year.

48.6 kWh/m2/year

44.2 kWh/m2/year

Daylight The many open atriums ensure optimal daylight utilisation. The buildings are lit up by a homogenous light.

Placement of functions The placement of the various functions has been determined according to daylight and the thermic mass of the building. There is, for instance, an increased temperature stability close to dense floors and pillars.

Facade design The facade has been optimised through an increased air density in the building's construction and through reduction of cold conductors.

Materials Light colours reduce the heat absorption and reflect daylight into the inner atriums. The materias have been chosen based on Life Cycle Analyses (LCA).

31 | Design With Knowledge

REDUCE :

OPTIMISE :

44.2 kWh/m2/year

35.0 kWh/m2/year

Lighting The indoor lighting is regulated automatically according to the level of daylight. The technology behind is Digital Addressable Lighting Interface (DALI).

32 | Spaces for health & recovery

Glass type The choice of glass with a low iron content for the windows allows for more sunlight and passive solar heating. At the same time, glass with a low content of iron allows the natural shades of daylight to enter the building.

Mechanical ventilation The entire building is ventilated by a highly efficient, mechanical ventilation system. Wide ventilation shafts and energy efficient ventilation engines ensure a low pressure and, consequently, a low air circulation energy consumption. Natural bed ward ventilation is possible when necessary.

Green roofs and local rainwater drainage Green roofs slow rainwater seeping on the premises. Projected catchwater drains and wetlands in the outside areas are used for local drainage of rainwater (LAR), which takes pressure off the sewage system.

PRODUCE :

35.0 kWh/m2/year

24.6 kWh/m2/year

Groundwater cooling (anticipated) It is anticipated that the groundwater below the hospital can be used for direct cooling of the building.

Solar power cells 1280 m2 of solar power cells are installed on the roof. In size, this equals five tennis courts. The solar power cells supply 30% of the total energy consumption of the operations of the hospital (lighting, ventilation, etc.).

New Herlev Hospital is being tested in a wind tunnel. The purpose is to ensure that the planting in front of the hospital provides sufficient shelter.

- Signe Kongebro Architect and Partner, Henning Larsen Architects

of human beings. Daylight is the strongest instrument when it comes to creating an architectonic experience of a room. At the same time, it may be used to create a healthy indoor climate and optimum daylight conditions in a building. The key to beautiful, comfortable and energy efficient buildings is found in the interplay between architecture and technology.

Design with knowledge Studies indicate that daylight and nature have a direct effect on health. It is documented that individuals with limited access to daylight have a higher risk of developing diabetes, just as nurses working night shifts have a higher risk of miscarriage. A recent 2013 study that compares the duration of hospitalisations with the level of daylight, measured above the head of the patient, concludes that a patient’s hospitalisation time is reduced by 7.3 hours every time the level of daylight is increased by 100 lux. These studies indicate that daylight has a significant impact on our health and well-being. This is why it is important that the work with hospital design includes a high level of awareness of daylight.

Daylight: Daylight is a precondition. Architecture is the balance between space and light, and daylight is the strongest instrument when it comes to creating value for architecture. It is of great importance to our health and wellbeing – and to the consumption of energy.

Materials: Buildings breathe, just as human beings do. This is why the choice of materials is part of the definition of our indoor climate and comfort. However, the materials also extend beyond the lifespan of the building, and are of social, economic and environmental significance.

Energy reductions: At Henning Larsen Architects, we have made sustainability tangible by focusing on energy reduction as the primary strategy. This is due to a belief that focus on energy will cause quality all around.

Certifications: Sustainability certifications are becoming an increasing part of quality ensuring process tools. Henning Larsen Architects holds broad experience with international certifications such as LEED, BREEAM and DGNB. Wind and microclimate: The comfort of the urban open spaces has a very direct influence on the direction in which a city develops.

Wind, sun, shade and daylight are the markers that outline the urban space’s potential as the center of the life that is being led.

33 | Design With Knowledge

"Sustainability is an opportunity for all architects to bring more meaningfulness and value to our lives and society."

PROJECT FACTS Location: Herlev, Denmark Gross floor area: 42,000 m2 Year of construction: 2014-2017

The new hospital structure, which consists of a number of smaller units, is structured as a city within the city.

Case: The New Herlev Hospital

The 52,000 m2 extension of Herlev Hospital will, among others, comprise a new accident and emergency department and a maternity services centre, including a pediatrics unit and a maternity ward. The sustainability profile is clear-cut and ambitious. This focus has helped create a hospital that works in practice and offers a great environment.

are spatially contrasted by the proximity of the outdoor environment, inner gardens and courtyards.

A number of separate buildings with contrasting geometries form an inspiring contrast to the existing structuralist building and contribute to considerately adapting the area as a whole to the nature of the surroundings.

Structure The extention of Herlev Hospital consists of three circular buildings placed on rectangular bases – which are displaced from each other creating a number of inviting outdoor spaces. The new extension thus constitutes a down-scaled and compressed contrast to the 120 metre rectangular geometry of the existing hospital.

The building complex as a whole will go from being a very ”large house” situated on a plot without outdoor spaces to becoming a ”built-up area” offering a variety of distinctive elements and eventful outdoor spaces.

A hospital structure constitutes an organisation of a large number of small spaces which – in this project –

Daylight and façades The façades of the New Herlev Hospital have been analysed carefully and designed according to the climate conditions and especially in connection to daylight. One of the characteristics of daylight is its dynamic variation.

It varies during both the day and the year and is therefore a major challenge for both architects and engineers. At Herlev Hospital, this challenging task is solved by means of the façades. The curved surfaces of the round volumes of the buildings give the wards a view to a section of the sky and thereby a better daylight environment. The size of the windows and the quality of the glass will also be thoroughly prepared at the new Herlev Hospital.

35 | Case: New Herlev Hospital

The expansion of Herlev Hospital will give the Capital Region of Denmark a unique opportunity to carry out and showcase a sustainable construction that will reach a very broad target group of patients, staff, and other users.

36 | Spaces for health & recovery

The boundaries between inside and outside are blurred. Large glass panels invite the nature into the hallways and bed wards, allowing both patients and staff to witness the changing of the seasons.

"The vision of the competition team has been to create a symbiosis between the hospital and its surroundings. A symbiosis that will position Herlev Hospital as an exemplary and innovative spearhead in healthcare.�

- The competition jury

Creating good daylight conditions is not only a question of the amount of daylight. The quality of daylight is also significant for the indoor climate created for patients and employees. The quality of the glass and its ability to represent colours play a big role. Using green layers would make it seem as though one is looking at the world through sunglasses. This distorted colour representation means that the patients would see their reflexions with a greenly tinge, which would make them neither look nor feel healhty. Furthermore, this would deceive the doctors when trying to diagnose a patient from his or her complexion. That would maintain patients in the course of their illness.

As opposed to the current Herlev Hospital, the new buildings have been adapted to a human-sized scale with intimate outdoor areas between the many small buildings.

The daylight design at Herlev Hospital is based on a minute examination and optimisation of each window.

The task is to create a building, where recovery is not just a question of medicine but also of well-being. The key is a façade that relates to its surroundings both aesthetically and technically.

The future Herlev Hospital will provide the basis for consistent patient care. The first phase of the extension offers a new accident and emergency department and maternity services centre, among others. These buildings are expected to be completed in 2017.

Small gardens between the buildings invite patients and relatives to go for a walk. The outdoor spaces have a home-like character that the patients might identify with.

With its 4,500 employees and 22 medical wards, Herlev Hospital is one of the largest hospitals in Denmark. The Hospital is one of the four local hospitals of the Capital Region of Denmark, offering acute treatment as well as an accident and emergency department, which is open around the clock. It services 425,000 citizens from the municipalities of Ballerup, Gladsaxe, Herlev, Egedal, Rødovre, Furesø, Gentofte, Lyngby-Taarbæk and Rudersdal. In addition, the hospital services 700,000 citizens from the entire Capital Region within certain specialised fields, as well as citizens from outside the region in the area of cancer treatment.

37 | Case: New Herlev Hospital

Existing Herlev The existing Herlev Hospital was constructed by the Copenhagen County from 1966 to 1976. The original hospital consists of a 26-storey building connected to an auditorium building designed as an elegant, fan-shaped concrete structure, as well as to a four-storey building housing examination and treatment wards.

Welfare I Politics I Economy

Con di

tionsďż˝

40 | Spaces for health & recovery

The Danish Health Care Model A comprehensive extension of the hospital system was introduced in the 1970s, but since then the construction of new hospital buildings has been limited in Denmark. This is why a quality reform, based on the vision of creating a hospital system that is future-proof, was passed in 2007.

Denmark is a country of 5.6 mio. inhabitants, and each year, approximately 90% of all Danes are in contact with the public hospital system either through hospitals, general practioners or medical specialists.

Public health insurance gives all citizens who are residing in the country the right to receive free health services from a general practitioner, a specialised practitioner, or at hospitals. Some choose to supplement with private health insurance which gives the opportunity to freely choose both general practitioners and medical specialists against a minor additional costs.

Private hospitals, clinics and practices where medical treatment of patients is conducted must be registered with the National Board of Health, which monitors the treatment facilities. In 2012, 2% of the total cost of the Danish health care system went to private hospitals.

Quality reform of the health care system Massive hospital extensions were carried out in the mid-1970s, but since then, the amount of new hospital construction in Denmark has been limited. The existing building stock is therefore outdated in terms of operating a modern health care sector, and it is inefficient compared to the concentration of the Danish population, which is moving from the rural districts to the larger cities on the east coast of Jutland and the capital region on Zealand.

Copenhagen alone has approximately 1000 newcomers to the city every month.

The reform of the health care sector to improve the quality and efficiency in general was passed simultaneously with an administrative structural reform on 1 January 2007. The administrative structural reform introduced 5 regions instead of 14 counties, and reduced the amount of municipalities from 273 to 98. The regions have the responsibility for all treatments in the public health care sector. The regions are also responsible for operating the public hospitals and for ensuring that the practice sector is functioning.

With a point of departue in better and more coherent patient care, increased safety for patients, optimisation, and better quality, the quality reform sets up a number of goals for the health sector in 2020: • • • • •

Quality before proximity Better coordination of treatment Better quality of the physical surroundings Reduction of amount of transportation of patients and employees between hospitals Better utilisation of equipment for diagnostic imaging, treatments, laboratories, and so on.

In order to achieve these goals, a number of initiatives have been initiated, where various functions are gathered in fewer locations, competencies are concentrated and the multi-disciplinary cooperation is strengthened.

Greenfield construction Reconstruction and extension

Aalborg

Viborg

Gødstrup

Aarhus Nordsjælland

Roskilde Slagelse

Kolding Odense

Åbenrå

Køge

Rigshospitalet Hvidovre Herlev Bispebjerg

Henning Larsen Architects' proposal for an extension of the Unversity Hospital in Copenhagen focuses on the interaction between hospital, city and landscape.

The 2020 Hospital Plan

In its present form, the 2020 Hospital Plan comprises one to five national and highly specialised hospitals, two to three regional university hospitals, a number of larger local hospitals with emergency functions as well as community hospitals. In total, 21 hospitals will have an emergency department according to the new plan.

In the most sparsely populated areas, the coverage will be 200,000 people, and 400,000 in urban areas. On a national level, the number of somatic hospitals will be reduced by 50%.

The transportation goal in the emergency contingency plan is a maximum of fifteen minutes for the citizens living furthest away. Furthermore, it is the goal to avoid transferring patients between local hospitals and the large regional hospitals with the necessary competencies.

Central regional units for sterile products, pharmacies, blood banks, central warehouses, and catering centres will be worked into the hospital plan.

Area standards for several functional areas as well as general gross/net factors of respectively 2.0 for somatic

hospitals and 1.8 for psychiatric institutions are leading for all of the new projects.

All of the new hospitals will be equipped with single bed wards with separate bathrooms with a standard net area of 35 m2, of which the patient ward itself makes up 17 m2, the bathroom takes up 7 m2 and support functions and secondary rooms make up 11 m2. The philosophy behind the single bed wards is to ensure optimal hygiene and limit infections as well as provide optimal quiet and rest for the seriously ill, providing the option of having relatives spend the night. Most examinations and conversations are expected to be carried out in the ward, reducing the need for examination rooms.

Finally, the ambition is to create highly standardised wards that can contain different types of patients yet at the same time ensure flexibility at department level, which in time can be transformed into facilities for ambulatory treatments.

43 | The Hospital Plan 2020

A new hospital plan was introduced with the structural reform in 2007. This new plan means that from 2020, a map of Denmark will look as presented here. Henning Larsen Architects has participated in the development of a variety of the projects, which are wide-ranging - from state-of-theart university hospitals to specialised hospitals, emergency departments and psychiatric wards.

The Danish Health Care Model in Figures General and specialised practitioners

3,646 GENERAL PRACTITIONERS

41

working from private practices

Million, annual visits

1,098

5

SPECIALISED PRACTITIONERS working from private practices

41

Both general as well as specialised practitioners are private business owners offering treatments according to a collective agreement with the state. The general practitioner will evaluate whether a patient is in need of further examination and treatment in other parts of the Danish health care system, including by specialised practitioners.

Costs THE ANNUAL OPERATING COSTS

14,000,000,000 € EQUALLING

2,400 € PER CITIZEN

HO

1 2 Million € 10.5

PR

RE OF

The hospital system

16,400

53

BEDS

PUBLIC SECTOR SOMATIC AND PSYCHIATRIC HOSPITALS

104,000

2.5 MILLION

EMPLOYEES

DANES ARE TREATED ANNUALLY

1.37

PSYCHIATRIC

MILLION HOSPITALISATIONS

OSPITAL SECTOR

RACTITIONERS

EIMBURSEMENT F MEDICINE COST

THE AVERAGE HOSPITALISATION DURATION IS DECREASING, CURRENTLY:

7.9

MILLION ANNUAL OUTPATIENT TREATMENTS

3.5 DAYS

11%

PSYCHIATRIC

ANNUAL SURGERIES:

3 MILLION

THE TOTAL INVESTMENT UNTIL 2012 AMOUNTS TO

5,500,000,000 € THE CONSTRUCTION ECONOMY OF THE PROJECTS (INCL. MEDICAL EQUIPMENT): UNIVERSITY HOSPITALS

3,900 € /m2

EMERGENCY ROOMS

3,600 €/m2

45 | The Danish Model in Figures

4%

Projects I Culture I Contacts

Ab

out

us�

48 | Spaces for health & recovery

About Henning Larsen Architects is an international architecture company with Scandinavian roots.

Founded by Henning Larsen in 1959, the company today has offices in Copenhagen, Oslo, Munich, Istanbul, Riyadh, the Faroe Islands and, most recently, in Hong Kong.

Architecture is the focal point of Henning Larsen Architects. The projects are created on the basis of high ambition, curiosity and a wish to contribute positively to a world in change.

We are inspired by our colleagues, partners, the site and location, society, science, nature and the company’s own history. This is the background of Henning Larsen Architects being able to hold a leading position in the field of architecture, while at the same time maintaining its openness and curiosity in the collaboration with others.

Our designs emanate from a variety of different themes.

The themes have manifested themselves in various ways from project to project. Our architectural visions and ideas are continuously developed in accordance with our broad spectrum of assignments ranging in size from single-family houses to concert halls, hospitals and masterplans.

Henning Larsen Architects has worked extensively on the development of hospital buildings for a number of years.

Inspiring and well-defined spaces, ample daylight and a clear, well-arranged layout are of significant importance for patients’ well-being and are essential factors in the treatment process.

The department for Healthcare and Research Facilities is placed in Copenhagen and run by Partner and Architect Lars Steffensen. Together with his team, Lars Steffensen has played a major role in the development of the Hospital Plan 2020 - especially with the construction of New Herlev Hospital.

Contacts Copenhagen Lars Steffensen ls@henninglarsen.com Tel: +45 8233 3018 Oslo Kasper Kyndesen kkyn@henninglarsen.com Tel: +47 4663 3960

Riyadh Niels Fuglsang nf@henninglarsen.com Tel: +966 553 8515 88 Istanbul Anne Marie Galmstrup amg@henninglarsen.com Tel: +90 535 391 8991 Faroe Islands Ósbjørn Jacobsen oj@henninglarsen.com Tel: +45 8233 3070 Hong Kong Elva Tang et@henninglarsen.com Tel: +852 5313 8285

49 | Contacts

Munich Werner Frosch wf@henninglarsen.com Tel: +49(0)89 856 33 38 - 110

Selected Projects Henning Larsen Architects works with sustainable hospital construction in all sizes. The interplay between multiple dimensions, both architectonically, but especially as regards function, ensures sturdiness and flexibility in the construction. This is important to the total experience of the hospital and its identity.

Sølund Retirement Community, Copenhagen 38,500 m2

New University Hospital Aalborg 135,000 m2

Ospedale Milano 70,000 m2

Cancer Patient Health Center, Copenhagen 1,800 m2

New Hospital Northern Zealand 120,000 m2

New Hospital Western Jutland 150,000 m2

Hospice Søndergård 1,800 m2

Karolinska University Hospital, Stockholm 270,000 m2

New University Hospital Copenhagen 75,000 m2

New Herlev Hospital, Copenhagen 52,000 m2

C

C

Follo Sykehus, Oslo 67,000 m2

r d e io n Un uct tr ons

The Norwegian Radium Hospital - Research Institute Oslo, 17,500 m2

The Norwegian Radium Hospital - Radiation Therapy Oslo, 8,500 m2

Odense University Hospital 234,000 m2

Neurorehabilitation house Glostrup 21,000 m2

51 | Selected Projects

Prince Naif Centre for Health Science Research Riyadh, 24,000 m2

r d e io n Un uct tr ons

7 230 32

OFFICES

EMPLOYEES

NATIONALITIES

PROJECTS IN MORE THAN

20

COUNTRIES

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Copenhagen – Oslo – Munich – Istanbul – Riyadh – Faroe Islands – Hong Kong