Ros cheong thesis 2013 design optimized

CARE IN PLACE:

A PARADIGM SHIFT OF THE LOCAL HOSPI+AL THESIS DESIGN COMPONENT _pg 174 - 317

Care in Place

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CHAPTER FIVE: DESIGN COMPONENT A CASE STUDY ON NORTH SHORE HOSPITAL , AUCKLAND, NEW ZEALAND

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ESTABLISHMENT OF PLACE: NORTH SHORE HOSPITAL, AUCKLAND 124 Shakespeare Road, by Lake Pupuke, Takapuna, Auckland

+

auckland, new zealand

North Shore Hospital is a large public multiplex hospital that serves the Northern region through the Waitemata District Health Board, serving around 47,000 people a year , through up to 131 surgical beds, 163 general medical treatment beds and 9 operating theatres.

This is on top of many other specialized departments and a series of secondary services enmeshed in peripheral context, including hospices, aged-care, sports facilities and independent health centres.

Previously flagged for staff shortages and overcrowding in previous years, it has since looked towards future-proofing its facilities with the recent addition of more ward space, specialist services (such as a new renal centre in 2010) and is currently undergoing a decadelong strategy to establish a ‘health campus’ for further opportunities in research and education. This parallels the District Health Board’s (DHB) ambition to provide an environment for academic excellence and innovation beyond care and attract a student culture.

The hospital is accessible from the Auckland Waiwera Motorway and bus routes, and conspicuous from right around Lake Pupuke due to its large-scale structure.

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ISOMETRIC PHOTOGRAPH OF PLACE

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FIGURE GROUND OF PLACE surrounding place existing hospital

Carmel College

rented hospital space recreational spaces

lake pupuke

Squash Club Westlake Girls High School St John Ambulance Station

golf course

Metlifecare Retirement Village

Smales Farm Business Park

Telstraclear Building Care in Place

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The hospital site is surrounded by a diverse mix of activities: Its adjacency to the scenic Lake Pupuke, a freshwater lake, wetland and reserve smack in the middle of the suburbs and parkland. The lakefront is popular with wildlife, recreational activities with picnickers and water sports enthusiasts, and is known for its million-dollar views, including that of Rangitoto Island.

• According to the Department of Conservation, Lake Pupuke Maar belongs to the Crown and is classified under Section 6.0: Mixed cultural/natural site of high priority for immediate world heritage listing – 6.1: Auckland Volcanic Field, under (Cones and other geological features of volcanic origin). It is a tuff Ring surrounding a Broad maar Crater – as the wider Auckland landscape is dominated by volcanic cones. This therefore comes with a height restriction for buildings within the region.

• Biodiversity: Some common wetland birds. High black swan (introduced) population, and some ducks and swans. Larger lake habitat includes pied shag nesting colony and four species of shag (SSWI) The lake is enriched but supports a variety of fish and bird life including pied shag, ducks, black swan, pukeko, whitefaced heron, Canadian geese (all of which breed on the lake), tui, fantail, silvereye, and grey warbler.

• The larger Pupuke Lake habitat has a lack of marginal reed zone, and pohutukawa, willow trees and pampas grass around much of lake edge, as well as some tiny Carex secta and raupo patches.

• An education-intensive amalgamation with predominant residential composition, with major highdecile schools within a 2km proximity (including Westlake Girls and Boys High Schools, Carmel College and Takapuna Normal Intermediate) • The 4-5-storey Medlifecare Building on the corner of the site, at the Taharoto-Shakespeare Road intersection for the aged.

• Commercial and retail entities are located southwards of the site across Taharoto road, in the form of the new business park Smales Farm. It includes the large Telstraclear Building, Sovereign House and Air New Zealand building in the site’s immediate periphery.

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CONTEXT AROUND PLACE

1: TAHAROTO ROAD

Fringe of Smales Farm Business Park

St John Ambulance Station

3 4

5 2

6

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2: SHEA TERRACE

Mental Health Unit, Hospital

Lake

Misc. Office Buildings

3: HOSPITAL REAR

Carmel College Gym

Hospital Entrance

4: SHAKESPEARE ROAD

Lake

Services Units, back of hospital

Poynton, Medlifecare Retirement Village

Taharoto Road

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5: FROM SQUASH CLUB

Main hospital block

Helipad

184 Care in Place 6: FROM CURRENT HELIPAD

Rangitoto Island

Local Squash Club

Boat pier by lake

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A lack of sense of care in place I chose this particular site because I feel the design is contextually unaware, with conservative attempts to orientate building form with the neighbourhood. The end result is that the building footprints and form are quite intrusive with the visual landscape. The general built form compares with the archetypal podium concept developed in North America, despite wide differences in geographic locations.

The DHB had stated their intentions to“improve health outcomes and reduce disparities by delivering better, sooner, more convenient services…in a way that meets future demand whilst living within our means.” There lies the abundance of opportunities to integrate other supplementary facilities on the site in order for it to re-establish its civic role in the community which the hospital does not seem to be taking advantage of, despite having a very large site.

Each building was conceived as a discrete project to satisfy immediate needs, a dangerous methodology resulting in an incoherent spread of buildings across the hospital sites.

Additionally: Under The Council’s Special Purpose 1 Zone: Health: - The four policies for operations: Use a concept Plan to determine developed and open spaces, providing primary health care and associated activities, hospital support services (workshops and laundries) as Permitted Activities, and allowing limited range of commercial and non-medical facilities. However, as illustrated in the next few pages, there has been more focus on carpark planning and building merely for needs, with a lack of reference to place.

- Height controls: Platform A – 16m/18m, Platform B – 10m/12m (+1m if it produces more attractive rooflines). The current hospital building easily topples this standard height, therefore all new buildings, the height limit reflects low to medium level of development and not considered appropriate having regard to the residential nature of much of the area surrounding. Building platform Area B has marginally lower height limit because it’s at the periphery of the zone and closest to other facilities.

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DeďŹ es height restrictions unnecessarily.

Essentially a replica of the pillar-on-podium typology from the USA.

built mass

L

density strategy: - projected to 2030

5m 10m 15m 20m 30m

internal circulatory routes

wards and offices

L1 - hot floor ground - public entry and ED basement - support services

vertical organization

suburb

DEFIES HEIGHT RESTRICTION UNNECESSARILY

ESSENTIALLY A REPLICA OF THE PILLAR-ON-PODIUM TYPOLOGY FROM THE USA

The hospital is currently the tallest building in its area.

Even with the availability of land, the hospital is built large, cumbersome and tall.

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Current programmatic and zoning strategies do not reference place very well. communal health centre secluded away from sight

future plans to build a mental ward next to carmel college and across residential zone in 2030 sounds contentious! service areas and helipad at the front of the lake and exposed on ground oor

mental unit right at commercial edge and busy road

building forms generally oriented away from urban grain

mental

commercial and retail edge

geriatric

specialist road (rentable spaces)

acute, emergency and ADU

residential edge

community

education edge

education and outpatient retail and commercial (future) wards

emergency centre too far from major road, and on a quiet street

quadrant

community health

women & children’s clinic

mental health

older adults

maternity

stroke unit

elective surgery

wards marae

PUBLIC

education

outpatients

energy centre

parking

current zoning plan

zoning strategy - projected to 2030

Quadrant diagrams

CURRENT PROGRAMMATIC AND ZONING STRATEGIES DO NOT REFERENCE PLACE VERY WELL. Current hospital buildings resist conformity to the urban grain, partially due to how the initial buildings were constructed in the first place.

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LACK OF CARE AND PLACE: A SITE REVIEW Isolated away from the public fringe.

Designed around automobiles rather than community existing - ground existing - multilevel future - ground future - multi future - underground

U D

L

AA

Taharoto Road and Shea Terrace intersection

Q

W C

EZ-4

O

EZ-1 PUBLIC

Taharoto Road

B

F

E

EZ-5 EZ-3

B-03

EZ-2

Shakespeare Road

carparking

ISOLATION AWAY FROM THE PUBLIC FRINGE

DESIGNED AROUND AUTOMOBILES RATHER THAN COMMUNITY

What was noticeable during my site visits was that not only were the hospital boundaries shrouded and overshadowed with huge trees which made the site feel closed off from public routes, that there was a lack of public presence onsite.

An investigation into the 2030 strategy for the hospital reveals an enormous emphasis on the planning for future carparking - far more than the mention of the community.

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Little reference to place

main hospital blocks lake view. in general, the buildings are not really designed to landscape, not do their feature it.

unattractive entryways into building

visual clutter

huge carpark that overtowers surrounding space

infrastructure and services next to the lake

GENERAL LACK OF REFERENCE TO PLACE, AND HAS AN ATMOSPHERE THAT IS UNINSPIRING AND UNINVITING, Existing built form appears to be built solely for need but with little regard to context or the aesthetic impact to the rest of the site. An emergent issue that emerges is the complexity and redundancy of spaces being created in-between, that often gets turned into a road or a green patch; another is the inhibition of the spectacular views of the lake, that can only be seen Care in Place

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Diagrams from theory

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Design proposal / strategy Patients are confronted first with themselves, and afterwards with people who take care of them.

The nature of patients also makes them exceptionally sensitive to their surroundings. In this case, the hospital facilitates the environment for medical processes to take place. It is identified as a tool and healer that cares for both people and the city and exists as part of the built ecosystem.

The thesis proposes three key ideas: - An alignment to context and the culturally relevant concepts of care and place.

- Infuse in the masterplan a series of quality spaces that shifts away from the conventional hospital typology - Create an aesthetically humanizing environment.

Notes: Key assumptions made for the hospital while not explicitly mentioned: - Reference material for the site analysis, demographics and number-crunching comes from Jasmax, Waitemata DHB, NZ Health Strategies and statistics, the previous NSH, and consultations with various people.

- Where space-making of facilities in hospitals follows stringent building codes, the establishment of this project had started with the dimensioning of spaces, which is loosely approximated and referenced from both Australasian and European building guidelines. The aims of the project shares those from precedent journals and reports. It has helped to steer the project by providing a pragmatic foundation.

- This also follows in line with 2030 benchmarks, including the ongoing decanting with Waitakere Hospital within the Waitemata Region.

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A PROPOSED SENSE OF PLACE: ISOMETRIC OVERVIEW

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place: A masterplanning exercise study Getting back into Place: main arterial route, 30% traffic

Development of a site as large as the hospital’s can be treated like a masterplan. Bringing the hospital back into place means the imperative for the proposal to bring the hospital back into the city, A priority includes a need for a clarity of circulation and orientation for both patients and visitors, for this sews the site back into context. One of the first places to investigate is the road infrastructure to determine accessibility into place.

motorway 9

9

9

9

ambulatory access 175 169

SMALES FARM See Appendix 9 for clarification of Busway Designations

SMALES QUARRY

110

quiet road secondary road

main arterial route from highway, 30% traffic

major artery + transport hub cycle ways (dotted = proposed)

8

taharoto road, 30% traffic

main pedestrian route (dotted = proposed) main vehicular access Care in Place

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Strengthening the grid: align proposed buildings to place CURRENT PAGE: The combined investigation into the urban grain and road infrastructure resullts in an extrapolation of the urban grain and grid in the hospital’s process of emulating the suburb.

steep land gradients - building g form ut iint follow landscape and ow ou out into a ke recreational area facing la lake

OPPOSITE PAGE: The accumulation of contextual research and its existing programs are conceived within a zoning strategy that is used as a tool to determine where hospital programs (and related programs) would be located. Existing planning boundaries (from Auckland City Council) are also taken into account in the massing process,

main road intersections

proposed gridlines parcel and road boundaries private healthcare services 196

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30m lake yard and reparian buffer

aligning future building forms with residential parcels and roads

The pink lines and arrows represent the steepest contours on the site towards the lake, which also acts as a guide for future built forms to contour themselves around to preserve its topographical nature.

steep contours

overland ow

^

Responding to surrounding place hospital

diagnosis

great potential to create an education hub and conference venue to share with surrounding secondary schools

rehab

screening

public space

prevention

home

treatment management surveillance

y an nd sm mall preserve residential boundary and small posittio to o urban grain. note juxtaposition nd aged a ed d ca cilities independent clinics an and care faci facilities

patient experience as a care landscape

10m 5m

carmel college

lake pupuke

30m

10m

10m 5m

commercial and retail edge office road (rentable spaces) domestic edge education and community edge Care in Place

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Accessibility into place Iterations for possible routes on site is made, while conforming to the grid template as much as possible and bearing in mind uttess potential secondary or minor routes

keep entrances here good e = go oo aaccess ccce ccess from opposite road d and a shakespeare hakes ke pea ear eare

direct entry from taharoto h road = great accessibility

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Accessibility into place (after consultation) Having talked to Jasmax - the firm who compiled the original masterplan - they made a few key revisions on the access diagram.

keep entrances he here re = good ood aacce access ess e from opposite rro road shakespeare ad and nd sh sp peaare

route too exposed to public! needs a ‘bufferr zone’ - ie. here

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Proposed zoning strategy (iteration) The combination of previous templates , and the knowledge of hospital programs accumulates into a zoning strategy.

At this stage, programs at this stage is divided into three categories: non-urgent / primary and preventive health care; inpatient care; and services + general hospital care for more urgent cases.

carmel college

Two theories are given about hierarchy: either the core could be the emergency department, or the social space.

Here, the emergency department takes utmost priority with other programs designed around it.

medlifecare st john

outpatient, elective, ambulatory care research, education and admin

geriatric care psychiatric / mental health centres inpatient care

assessment & diagnosis units, radiology service spaces accidental and emergency 200

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telstraclear building

Proposed zoning strategy (ďŹ nal) Programs that are more community-oriented are sited in the middle, or the ‘heart’ of the site. While acute care is obviously more important and urgent than non-acute care, thinking of the core as a social space (rather than the actual general hospital) would facilitate better community care than the other.

carmel college

medlifecare st john

outpatient, elective, ambulatory care research, education and admin

geriatric care psychiatric / mental health centres inpatient care

assessment & diagnosis units, radiology service spaces

telstraclear building

accidental and emergency Care in Place

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202

Care in Place

A low-rise design to conform to neighbouring place: From vertical to horizontal strategy 65210.00

52875.00

NSH Level 8

49000.00

NSH Level 7

45120.00

Offices Refurbished Ward Refurbished Ward Refurbished Ward Refurbished Ward Refurbished Ward Offices Refurbished Ward Maternity Ward Theatres

Service Corridor

NSH Level 6

41235.00

NSH Level 5

37360.00

NSH Level 4

33495.00

NSH Level 3

29595.00

NSH Level 2

25720.00

NSH Level 1

21150.00

SSOA

NSH Ground Level

16580.00

SSOA

NSH Basement

12015.00

Gastro

Offices Courtyard

Allied Health

SSOA Pathology

Courtyard

Biomed

Radiology Plant

Mortuary

Ward Ward Ward Maternity Ward Cathlabs

Circulation

56750.00

NSH Level 9

Circulation

60625.00

NSH Level 10

Circulation

NSH Level 11

Circulation

NSH Level 12

Lakeview Lakeview

ED Plant

Service Road

Road

current hospital model

telstraclear building

Shea Terrace

Taharoto Road

Shakespeare Road

medlifecare

Taharoto Road

Horizontal and decentralised massing over vertical typology creates forms that connect to place.

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Massing into Place: Reduction of the Urban Grain Breaking away from the conventional hospital form to In the process of getting back into place, the current centralized podium form of the develop one that is appropriate for current place. the main building is to be replaced with a campus / pavilion-like methodology is because current centralised podium form of the main building is we are in the suburbs. This is determined by the existing urban grain and road replaced with a campus one. infrastructure, which leads to more appropriate urban grain.

1. Designing to accessibility - I start off with the maximum amount of land available for building on, and basic roads in place determined by existing roads and gridlines.

2. Futher cutting into mass, with Riparian corridor and the need for shared spaces taken into account.

3. Basic path for secondary access (for human traffic) is created.

1

2

3

4. The development of built form parallels the process of access development.

4

204

5

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6

5 & 6. Taking into account location of open spaces between and within buildings, mass is further ‘eroded’ to create built forms that are narrower, streamlined, keep in line with urban grain, and maximize access to light and air.

Decentralization: A group of buildings Seven buildings are produced in the exercise to create smaller urban grain. Each of them take on their own form and identities which referencing each other in the infrastructural network.

basic form

ďŹ nal mass

internal access

programs

commercial and retail

hospital core

community health

education

inpatient wards

geriatric wards

mental health wards Care in Place

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From zoning in place to massing in place

Carmel College

Metlifecare Me etl et

St Jo JJohn

Telstraclear

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outpatient, elective, ambulatory care research, education and admin

geriatric care psychiatric / mental health centres general inpatient care

Education

assessment & diagnosis units, radiology

LAKE

service spaces

MASSING BY INDIVIDUAL PROGRAMS AND ROOM SIZES:

accidental and emergency

Green space

Suburbia and independent clinics

Offices

+ Smaller facilities towards the lakeside and Shakespeare Road suburbia, larger facilities towards Taharoto Road and the Smales Farm business park. + Smaller facilities include accommodation for inpatients, geriatric and mental wards. They constitute more private and intimate spaces. + Larger facilities include offices, commercial spaces, services, and the hospital core. They are intended to be easily accessed by the public.

All programs are generally consistent with the proposed zoning strategy and programmatics criteria.

Smales Business Park

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Comparing Figure-ground between current and proposed mass

CURRENT 208

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PROPOSED P RO PR RO OPO POS PO SE ED

FINAL FIGURE-GROUND PLAN: also taking into account the use of light-wells and open spaces within buildings.

D Care in Place

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telstraclear building

ACCESS IN PLACE: FROM SHEA TERRACE

st john

1.

SHEA TERRACE

main hospital road

SHAKESPEARE ROAD

Elevation cuts

2.

MARY POYNTON TERRACE (perpendicular to Shea Terrace)

1.

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Permeability and order of hospital spaces on site via the design and placement of clear and unobstructed access routes are shown in the following elevations around place. It also shows how the final masterplan is not only oriented to urban grain, but the view of the masterplan is ‘framed’ and in proportion with neighbouring buildings from locations opposite the site.

A&E

services entry

road entry to mental unit

LAKE

telstraclear building

FROM ACROSS SHEA TERRACE

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SHEA TERRACE

ACCESS IN PLACE: FROM SHAKESPEARE ROAD

LAKE

greenspace

2.

SHAKESPEARE ROAD

212

Care in Place

telstraclear building

TAHATORO ROAD pedestrian point of entry

pedestrian point of entry

main hospital road

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telstraclear building IN PLACE:

medlifecare

FROM TAHAROTO ROAD

SHAKESPEARE ROAD

3.

SHEA TERRACE

SHAKESPEARE ROAD

PEDESTRIAN ENTRYWAY INTO THE HEART OF THE HOSPITAL., from Taharoto Road

Elevation cuts

3.

4a, b 214

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SHEA TERRACE

pedestrian point of entry

4a. ELEVATION TOWARDS LAKE

4b. ELEVATION TOWARDS TAHAROTO ROAD

main pedestrian corridor

TAHAROTO ROAD

ENTRY INTO HOSPITAL

ENTRY INTO HOSPITAL

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telstraclear building IN PLACE:

MAIN PEDESTRIAN CORRIDOR RUNNING THROUGH HOSPITAL

carmel college

mental health

LAKE

5a. ELEVATION TOWARDS LAKE

SHEA TERRACE

community health

5b. ELEVATION TOWARDS SHAKESPEARE ROAD

hospital road

SHAKESPEARE ROAD

Elevation cuts

5a, b

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education

telstra inpatients

core

commercial

hospital road

PEDESTRIAN CORRIDOR

aged care

LAKE

VIEW FROM THE COMMUNITY BUILDING

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COMPREHENSIVE CARE An investigation into the current programs in the hospital to establish an idea of healthcare and the connectivity between each program. getriatric care

OPPOSITE PAGE: Current vs. proposed program

specialist departments and clinics

assessment and diagnosis

outpatient

emergency department

Student area (120 Sha kespeare Road) Dialysis Cen tre

Ward 15 OAHS

general ward

Ward 14 OAHS Maori Hea lth Serv r ices

Chapel

(OAHS)

Outpatien ts Physiothe raphy

ORL Reg istras

Gynaecolo gyy Outpatients t

mental health Radiology

Ort r hopaedic

ADU

2

Outpatien ts Clinic

Outpatien ts Day Clinic

Mammography

Telephonists

3

Stairrs ADU Tower Lifts

4

Cardiolog y Procedur es

Pool

Allied Hea lth

Stairrrss

Liftss tto o Ward a (OAHS) Ward 11 General Med ical

MRI

Lifts L

1&2 21&22

Meeting Rms

Meeting Rms

Stairrrss

Allied Hea lth

Allied Hea lth

Allied Health Gym

Ward 12 OAHS (Kingsley Mort r imer Unit)

ADU Diag nostic

ADU

Lift Lifts Lift

ED/ADU Receptio on

2 Reception Foyer

1

Triag ria e

MAIN HOS PITAL ENT R NCE RA

Pharmacy ED ENT TRA R NCE Cafe f

AMBULA NCE ENTR RANCE

sspecialist clinics: outside main building Emergen cy Depart r ment

DISSECTION OF PROGRAMS

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Comprehensive Care

hospital core recreation primary health private health aged care / hospices

CURRENT

PROPOSED Care in Place

219

INPATIENT BEDS

CLINICAL SUPPORT (assessment diagnostic units)

GENERAL SUPPORT

OTHERS

220

Care in Place

adult medical

main entry public amenities

renal / dialysis (chairs)

community health

stroke unit: acute medical and rehab

education and seminars

adult surgical

pharmacy

ICU/HCU

public staff cafeteria

elective surgery beds

general administration

womens services - 2376

medical records and archives

paediatrics

day-area - allied health incl. SSOA day areas

special care baby unit

elective surgery theatres

mental

elective surgery beds

geriatric (AT & R and MHSOA)

renal / dialysis (chairs)

general xray

general xray

orthopaedic xray CT

orthopaedic xray CT

MRI ultrasound core / emergency: acute theatres

MRI ultrasound cath labs

elective surgery theatres

geriatric (AT & R and MHSOA)

cath labs

mental

biomed engineering

adult medical

engineering

adult surgical

environmental services

womens services - 2376

linen services

paediatrics

supply / materials management

special care baby unit

waste management / loading docks

ICU/HCU

information technology

core / emergency: acute theatres

archives

stroke unit: acute medical and rehab

public staff cafeteria

security

main entry public amenities

mortuary

pharmacy

pathology

pathology

archives

general administration

biomed engineering

medical records and archives

engineering

mortuary

environmental services

security

linen services

day-area - allied health incl. SSOA day areas

supply / materials management

education and seminars

waste management / loading docks

community health

information technology

COMMUNITY CARE AND PLACE

UTILITARIAN CARE

INFRASTRUCTURE

primary health, private clinics

social inpatient

secondary care and outpatients hospital core for acute treatment supporting services

core services

The placement of programs and departments, and the establishment of a gradient between the degrees of care.

For example, primary health care services are located towards the suburbs and adjacent to the pedestrian corridor. (Programmatics data provided by Jasmax masterplanning)

current layout Care in Place

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THE CONTINUUM OF CARE: Case study in the general hospital electives

womens + maternity

paediatrics

general inpatients

A close up on the hospital core and how departments are arranged , shown through a series of sections. core

public stairs

main entran nce entrance

outpatients

Outpatients private stairs (community)

community related

hotel lobby to wards

services

vertical exploded axo

AN RI R T S DE IDO PE RR CO

Services and infrastructural units on the ground floor, with entry way from Shea Terrace.

sterilizing retail pharmacy

mortuary

helpdesk inpatient pharmacy linen supply/materials management loading and waste

222

Care in Place

SE

R

C VI

E

RO

E UT

VI

A

E SH

A

T

R ER

AC

E

COMMUNITY CENTRE

womens + maternity

electives outpatients

therapy community clinic retail and food

P

core

services/ offices community related

horizontal exploded axo

ED

T ES

RI

electives elecctives diagnosis diag gnosis pharmacy phaarmacy

AN

CO

I RR

DO

R

PR

IV

AT

E

co al lounge lo communal

CO

inpatient wards

RR

ID

ICU IC / HCU

OR

open spaces / lightwells

maternity mat ternity operating ti theatres t services

Inpatient wards are sited on the upper floors, with a massing gradient towards the lake to increase privacy.

Electives, diagnostics and pharmac are located together in section to share the community / pedestrian corridor, adjacent to outpatient units.

maternity labs services Diagrammatic section of the community health building and hospital core

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at the back: inpatient wards

at the back: education cen entr tre

TOWA TO WARD RDS S GA GARD R EN RD E SPA ACE CES S AN ND SH SHAK AK KES E PE PEAR A E RO AR OAD A

A CONTINUUM OF CARE SPACES IN PLACE: SECTION THROUGH COMMUNITY HEALTH BUILDING, AND HOSPITAL CORE

comm co mmun unitty he heal alth th cen entr t e:

double-hei do e ght hosp spit i al corre entran nce and n gre r en nwa alls:

Upperr flo Uppe floor ors: s: Clini nics cs for o com mmu m nity ty hea altth an nd fo for women and children en Lowe Lo wer flo floor ors: s: boo ooks ksto tore re, su sush s i

Uppe Up per flo oor ors: s End dos osco cope pe (part rt of diag agno n st stic i s) s),, and ele ectiv ve surg rgey y clilinics.

C MM CO MMUN U IT TY + PE PEDE DEST STRIAN A COR ORRI RIDO OR

Ze en-in nsp s irred gar a de d n

DIIAG A NO NOST TIC CS

in ope pen co cour urty tyarrd-- a pla lace c for o light ht and conte emp mplation on

Upperr flo Uppe floors: Mat a er erni n ty war ards ds (co onn n ec ecte ted to o pae a di diat attri r cs an nd d birrth t ing g un nitts)) 1stt flo floor or: Me Medi d ca call lilibr brar a y fo for re reco ord rd, d co onn nnec eccte ted to t pattho h lo l gy y lab a and n offic ffi es. ess Grou Gr ound nd floo or: Eme merg rgen gency cy ope era rati t ng n the heat atre tre res es w wiith h wai aiti ting ng g roo o m fo or th t os o e to t wait aiit fo forr th t ei eirr lo ove ved d on ones es,, + A & E en entrran ance ce.

IMME IM MEDI DIAT ATE E CA ARE

Path Pa thol olog ogy y an and d st staff aff offic fficess.

SE SERV ERVIC ICES ES

SHEA SH EA A TER E RA RACE CE

telstraclear building

SHEA TERRACE

a.

VIEW TOWARDS THE HOSPITAL CORE FROM THE HOSPITAL ROAD.

SHAKESPEARE ROAD

b a

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B.

VIEW INTO THE HOSPITAL CORE, FEATURING ZEN GARDENS AND CLEAR WAYFINDING SYSTEMS AROUND A LIGHTWELL.

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FIGURE-GROUND OF PLACE: A COMBINATION OF DIFFERENT TYPOLOGIES

CURRENT 226

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PROPOSED

hospital core domestic grain

PLACING PROGRAMS INDIVIDUAL BUILDINGS WITH DIFFERENT FUNCTIONS AND IDENTITIES

commercial

core

community

education

inpatient hotels

geriatric

mental health

retail food communal/ social education hotels integrated living offices services hospital core domestic grain

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retail food

communal/ social education

hotels integrated living

offices services hospital core

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Chapter 4: A typology of typologies SPACES AWAY FROM THE CURRENT HOSPITALThe PLACE outdated paradigm A SIMPLIFIED SITE PROGRAMME

Accommodation

Wellbeing and community

- Non-health related typologies could act as programs enabling the transition from sick to well, from confinement to independence. The conventional pathway to wellness has always been to stay in bed, get served food and make the occasional visit outdoors. they also also faced with having to put up with inhumane spaces. However, my wellness process goes from the patient being dependent to being independent. By ‘normalizing’ place in hospitals I provide a model for enhancement that also includes the wellbeing of patients.

I propose embedding programs that are culturally relevant to care and place in today’s contemporary society (left)

Retail and Food

(photographs on right) - Inside North Shore Hospital, and the mentality held about the image of care and place (or lack of).

Core, infrastructure and offices

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MARKETABLE SPACES

A

B

retail food communal/ social education hotels integrated living offices services hospital core domestic grain

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A.

VIEW TOWARDS THE HOSPITAL ROAD, FROM THE PEDESTRIAN CORRIDOR

B.

MARKETABLE SPACES IN THE FORM OF RETAIL AND FOOD TO ATTRACT THE COMMUNITY INTO PLACE

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WELLBEING AND COMMUNITY SUPPORT SPACES

A. a public library between the inpatient wards and suburbs, creating areas for the bored and restless.

A

B retail food communal/ social education hotels integrated living offices services hospital core domestic grain

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B.

A series of recreational spaces on the gentle slopes under the inpatient wards - large, undisturbed greenlands connecting lake, to school, to hospital - spaces for all facets of the community

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ACCOMMODATION

(OPPOSITE) A. A grand lobby and light-wells puncture deep plans with intense exposure to the environment, while creating a comfortable, well lit converging place for the sick to catch up with visitors for a cup of coffee.

B. integrated living as seen in the geriatric ward: the common corridor references the direction of carmel college and fronts lake pupuke and its landscape.

B

A

retail food communal/ social education hotels integrated living offices services hospital core domestic grain

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A

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(OPPOSITE) A. Internal circulation around a large zen-inspired garden.

B. a bridge connection runs between the elective surgery centre and the inpatient wards for straightforward access.

B

retail food

A

communal/ social education hotels integrated living offices services hospital core domestic grain

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CARE IN PROCESS: INFRASTRUCTURE

A

Care in Place

B

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THE AESTHETICS OF PLACE-MAKING: VIEWS

Towards Rangitoto Island

CURRENT PLAN

Several views from the inpatient ward

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ABOUT VIEWS Staff I had talked to often mention that the saving grace is the linear corridor and the spectacular views in the current hospital ward, and I wanted to preserve that in my design.

While the legibility of space has been shown through the use of few, common public corridors, the proposed buildings are also arranged in a way so the inpatient wards still gain maximum views towards the greenscape and the lake.

PROPOSED PLAN

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ACCESSING NATURAL VIEWS

A. Views from inpatient wards are elongated and framed to provide an atmosphere of generous serenity and spaciousness. Taken from the communal lounge at the tip of the inpatient ward.

B. Windows are site just above the bed level for patients to be able to partake in the views from their bed while they are being cared for, or when sitting down at their table eating a meal.

Taken from the mental health unit, sited next to the lake.

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ACCESSING THE DAILY PLACE

A A and B. Views in more public buildings are exposed, almost ‘publicized’ to the external environment. These are located towards Shakespeare road and landscaped gardens, giving inhabitatants a constant sense of orientation in the day. Images taken from research spaces in the education building.

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B

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Images on this page: Often getting bored and restless in spaces that come with an inherent degree of sterility and infinity such as in a hospital corridor, it is a relief to find a relaxing image of place to reconnect with ordinary life. Here, the inpatient wards in both general department and mental health unit have a series of windows that break any form of monotony in space.

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LIGHTWELLS TO ACCESS PLACE FOR CARE

Elevations with lightwells

Example of a cross section showing lightwells, with the community health and education buildings

Often it cannot be helped that hospital buildings are inherently larger than most buildings; with a deeper floor plan, it is harder to get an actual view of the natural landscape.

The incorporation of light-wells then allows the access of light, air and internal open spaces (or courtyards).

The above simple massing strategy shows light-wells cut into buildings to increase the sense of connectivity to external place – to views and to sky, and to life.

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A and B. Large lightwells in public areas create inspiring breaks in what could have been large and mundane interior spaces, spaces to encourage social activity. Taken from the centre of the education building.

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Lightwells also create gentle, calming movement from the sky and clouds, which makes the experience of internal spaces feel human. Taken from the waiting area around the operating theatres in the hospital core, where people wait in distress and anxiety while their loved one is being operated on.

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Lightwells can become like mini atriums that guide people around space. Taken from the main corridor in the geriatric ward.

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Smaller lightwells in wards to compliment the moments of contemplative thinking in those times of loneliness and isolation.

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Lightwells to create therapeutic moments of quietness in the midst of a busy scene. Taken from the commercial building, where the interior space of the building folds into itself and up towards the sky.

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LANDSCAPE IN PLACE

PERMEABILITY (OR IMPERMEABILITY) OF CURRENT SITE

CURRENT MODEL AND LANDSCAPE DESIGN. The lack of planning in location of trees and landscape makes the current landscape consistently uninspiring, messy and disorienting.

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5.3 Landscape

steep contours

^

proposed gridlines parcel and road boundaries private healthcare services

PROPOSED BUILDING PLAN OVERLAYED ON WHAT I TREATED AS A GREENFIELD SITE.

greenfields water / water ways carparking recreational courts quarry

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Design by Place - preservation of landscape, complimenting landscape

A DESIGN BY PLACE: WORKING AROUND THE LANDSCAPE BUILT FORM AND THE DIALOGUE WITH LANDSCAPE: AN ITERATIVE STUDY

Initiation

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Infrastructural development and tree areas

5.3 Built form + Landscape dialogue - iterative study

Designing a series of spaces that compliments sense of place

Designing a wayfinding system that connects series of spaces together.

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Landscape Plan LANDSCAPE STRATEGY --

I came up with a landscape plan!

One version real one, the other one more diagrammatic

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Connectivity in place: images taken from the meandering pathways fronting the lake, that connect landscaped gardens and gardens to buildings.

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5 6

1 3

7

4

2 9

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8

Design to a series of places LANDSCAPE STRATEGY A series of unique gardened spaces, drawing inspiration from the suburban context

1. Kowhai Entryway

2. Commercial

3. Entryway into General Hospital

4. Zen garden

5. Colourful garden

6. Geriatric ward

7. Native potholes

8. Pohutukawa

9. Mental ward

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Cheerful and optimistic: Kowhai Entryway An optimistic and cheerful point of entry to attract people from surrounding place.

1.

CHEERFUL AND OPTIMISTIC: An attractive and linear point of entry from the direction of Smales Farm, lined with Kowhai trees.

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Composed: Commercial I designed everything to a series of spaces in place: Top plan with the garden overlay I have a zen garden, a commercial hedge garden, colourful garden, and native gardens. All of them have a unique character and contributes towards care in different ways.

Page 101 – Hedge garden – draw people in, prim and proper structured look Page 102 – Kowhai entrance Page 103 – Zen Garden for quiet contemplation Page 104 – Colourful garden to go with the communal fringe, and be visually exciting Page 105 – Native pot-hole gardens: Freedom, escapist.

Page 106 – Pohutukawa tree garden Page 107 – Mental ward - areas to hide in and be sad (Page 108, 109, 110 – renders on large scale)

2.

A composed layout for the commercial-oriented building with the use of hedges, which also serves to modestly accentuate the low-rise horizontality of the building.

Current view of Taharoto Road

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Inviting: Entryway into General Hospital

Current appearance of entryways into hospital building.

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Contemplative: Zen garden

Current gardenspaces in hospital

4.

A zen garden contoured in the middle of the hospital for people to look contemplatively in space, as they wait for an appointment or for a loved one, or even for bad news.

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Vibrant: The New Zealand backyard

current garden at Shakespeare Road

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5.

Garden spaces fronting suburbia at Shakespeare Road take on the image of the classic New Zealand garden, which creates nodes of vibrance lining along Shakespeare Road beckoning people to visit.

Clear and calm: geriatric ward

6.

Pockets of well-tempered garden spaces lined with trees of medium height in between the rows of the geriatric ward, for the elderly to take a stroll in private.

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Meandering: Native potholes

7.

Nodes of native planting of mainly flax, koromiko and kumarahou create an area of subtle intervention with a weakened colour palette of greens, lining the land around the lake, connected by pathways concrete and mowed grass that run across the slopes, with minimal disruption to the landscape, 268

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Free: Pohutukawa end

8.

At the end of the meandering path lies a pohutukawa spot, where one finds the closest connection to the lake.

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Sombre: Mental ward

9: Between the mortuary and the mental health units lie a dense grove of trees and rock formation for those who need a place to inspire reflection or to facilitate bereavement.

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9: Where landscape cannot be accessed directly, they can be captured in internal courtyards. Image taken from the mental health unit courtyards.

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Orientation Strategy PLACE BECOMES THE NAVIGATION SYSTEM IN CARE

patient with / without diagnosis

outpatient treatment

patient with / without diagnosis

outpatient treatment

EMERGENCY

visitors MAIN

central admissions area

driveway for the bedridden

visitors MAIN I

interdisciplinary emergency y department for first aid, acute c diagnosis and stabilization o

central admissions area

patientt data entered into n computer e + admitted

health centres e / polyclinics

elective ssurgery in-patient ward: orthopedic medical surgical general

waiting area (patients)

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health centres / polyclinics

elective surgery in-patient ward: orthopedic medical surgical general

administrative a admission + paperworkk processing

Way-finding systems in hospitals are still represented int the form of process diagrams. However, by creating and accentuating place in architecture, place becomes a humane navigation system,where people can easily read a space and orientate themselves around place with ease. without feeling more stressed and anxious than they would usually be in large, unfamiliar spaces.

driveway for the bedridden

interdisciplinary emergency y department for first aid, acute c diagnosis and stabilization o

patient data entered into computer + admitted

examination o rooms o for thorough specialist medical m examination (e.g. endoscopy s p and x-ray). interdisciplinary r dept only used outside doctor’s o r hours

transferred to admissions dept for observation, for up to 24 hours

EMERGENCY

discharged / exit

waiting area (patients)

transferred to admissions dept for observation, for up to 24 hours

examination rooms for thorough specialist medical examination (e.g. endoscopy and x-ray). interdisciplinary dept only used outside doctor’s hours

administrative a admission + paperworkk processing

discharged / exit

Orientation Strategy

patient with / without diagnosis

outpatient treatment

diagnosis

outpatient treatment

EMERGENCY

visitors MAIN

central admissions area

driveway for the bedridden

visitors MAIN I

interdisciplinary emergency department for first aid, acute diagnosis and stabilization

central admissions d area

patient data entered into computer + admitted

health centres / polyclinics

elective surgery in-patient ward: orthopedic medical surgical general

waiting area (patients)

transferred to admissions dept for observation, for up to 24 hours

EMERGENCY driveway for the bedridden

interdisciplinary emergency department for first aid, acute diagnosis and stabilization

patient data entered into computer + admitted

examination rooms for thorough specialist medical examination (e.g. endoscopy and x-ray). interdisciplinary dept only used outside doctor’s hours

health centres e / polyclinics

elective ssurgery in-patient ward: orthopedic medical surgical general

administrative a admission + paperworkk processing

discharged / exit

waiting area (patients)

transferred to admissions dept for observation, for up to 24 hours

examination rooms for thorough specialist medical examination (e.g. endoscopy and x-ray). interdisciplinary dept only used outside doctor’s hours

administrative admission + paperwork processing

discharged / exit

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By being able to view familiar buildings in the backdrop, such as the Telstraclear building on the right of the image, one can tell he is close to the public roads and Smales Farm.

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Covered walkways with an open view to Shakespeare road can tell a person that he is nearing towards the suburbs.

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In the private staff corridor between the hospital core and the inpatient wards, the view towards the pedestrian corridor and retail spaces at the end is a reminder to anyone that they are near a food joint.

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And one can follow the Riparian corridor towards the lake with an unobstructed view or path, guided by the aesthetics of nature.

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REFLECTIONS ‘How can design attitudes towards the hospital evolve to reclaim its role as a place of care?

Shifting paradigms necessitate efforts to refresh the hospital that is both functionally effective and culturally connected’ to reclaim their civic roles in communities by attaching symbolic meaning and local sense of place.1 Apart from issues of lifestyle, aesthetics, or specific relation to the reconstituted hospital and medical center, the field of healthcare architecture had not fostered a tradition of research, and there is a paucity of nursing research that focuses on congruous person-environment interactions and merits of the physical design of a treatment setting are much discussed, but infrequently tested in empirical ways. Generally, research has overlooked the role of the physical environment in patient well-being, and that the research process in health care settings is exceedingly difficult.2 This thesis continued as an investigation into a whole host of opportunities outside of healthcare.

The main intention of the thesis was to investigate how design attitudes can evolve towards the treatment of hospital design as a subject of renewed architectural exploration. To a great extent, the thesis was an opportunity to re-consider my personal attitude towards hospital design. By bringing out key points for discussion at the beginning of the thesis, I had attempted to extract what is demonstrated as paeleologic issues – prehistoric arguments that has its roots in stiff attitudes and is relatively impervious to logical analysis.

Place and care has been made as clear and comprehensive as possible throughout the written component of the thesis and the process of design follows loosely in line with the findings of the thesis. The level of local appropriateness also offers enormous scope for the architectural content of my proposal. The idea of place and care has however not been mentioned explicitly within the body of the design process; not only is it less defined, but also exponentially harder to define, and many subsequent design decisions made were based not only on what was gathered from research, but on personal and instinctive opinions and philosophies of care and place. Despite the depth of research input into the discussion around care and place, to me the essence of these qualities still remain vague and subjective and applies to anyone, regardless of whether they are sick or well.

1 2

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Corbett Lyon, “Interrogating the Type,” Architecture Australia 91, no. 4 Jul/Aug (2002): 56.

Allison B Arneill and Ann Sloan Devlin, “Health Care Environments and Patient Outcomes: A Review of the Literature,” Environment and Behavior 35, no. 5 (2003): 667.

Gaining insight into the healthcare system in order to design care in place was a significant challenge.

One of the things I would have done differently in my design process would have been learning to let go of the bureaucratic nature of hospital design, and not letting the rules and restrictions get in the way of creating great architectural moments. It is impossible to omit the fact that many of the issues hospitals faced and still currently face are due to the need to conform to systems and number-crunching that tends to dilute the presence of care and place. Economic imperatives in healthcare delivery are after all, process driven, and the search for perfection, at several stages, becomes so pervasive to the point that notions of explicit meaning and cultural relevance feel lost. This is also not restricted to the hospital management system, programmatics, decanting between different hospitals, and number-crunching. I have since come to conclude that hospital design is a – horrifyingly – wicked issue, where solutions for care need to be holistic and multi-faceted because at many times it is not the architecture, but the rules and regulations and bureaucracy that suppresses any potentially exuberant design. 3 Numerous studies reveal that many of the weaknesses of the hospital were a function of the necessarily evil constraints under which design was produced.4 Additionally, as much as advocates for deinstitutionalization promote a reduction in the size of built form, the enormity of hospital compared to many other buildings cannot be simply removed, and the mere provision of domestic accoutrements does not necessarily counteract institutionalization. I found that any design solution can only be effective if it relates to a particular context and its inhabitants.5 In the end, perhaps caring and contextually sympathetic architecture is only be conceived in terms of their materiality but also as the material embodiment of human relations in all their variability and variety6 For example, it needs an appreciation of the role the environment plays in meeting fundamental psychological needs such as stimulation, security and identity. All this requires an approach to the design and organization of space that does not treat it, as so much architecture does, as a physical construct, but as a social and psychological one.7 In that respect, the design practice of the thesis findings shifted from addressing built form, to that of a large, human-scale and diffused therapeutic community where treatment and counseling were inextricably interrelated. In the care process, patients should be enabled to play an active part in their own and one another’s healing process and be able to continue their personal lifestyle as much as possible.8 The existence of normal people in hospitals are 3

4

5 6

7

8

David Canter and Sandra Canter, “Creating Therapeutic Environments,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 344.

David Canter and Cheryl Kenny, “Evaluating Acute General Hospitals,” in Understanding and Evaluating Therapeutic Environments for Children, ed. David Canter and Sandra Canter (Great Britain: John Wiley & Sons, Ltd, 1979), 313.

Canter and Canter, “Creating Therapeutic Environments,” 344.

Abram de Swaan, “Constraints and Challenges in Designing Hospitals: the Sociological View,” in The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: Nai Publishers, 2006), 94.

Bryan Lawson, “Healing Architecture,” Arts & Health: An International Journal for Research, Policy and Practice 2, no. 2 (2010): 103.

Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands (Rotterdam: Nai Publishers, 2010), 166.

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then the game changers,9 for people are attracted to nice places; More people in place makes everyone feel at home and makes architecture look inviting. Hence we have a whole range of facilities that makes healthcare look normal.

It is in this context that architecture returns again to a prominent role: it becomes an advocate of cultural trends, which require an adjustment of architectural spaces beyond their functionality. Openness and clarity of structure in place become paramount for a hospital, not only from a functional but also from a cultural point of view.

There is a serious cultural role for a health-care facility in the contemporary world. A modern hospital can potentially enhance inclusiveness and social cohesion, and since hospital spaces have both a functional and cultural meaning, they deserve more mention in medical education.10 They will loom ever larger in our lives, even if our stays may be shorter. In the end, my hospital design does not really propose a solution; there are no surefire ways to a wicked issue such as hospital design! However, it proposes possibilities about how architecture can act as a part of a broader cultural process which helps people through illness and reintegrates hospital back in its place. Charles Jencks’ comparison to an architectural placebo Is intriguing for it acknowledges the powerlessness of architecture to exert real medical benefits, but they can reintroduce an idea that architecture can be at the heart of health and that the hospital, possibly the most hybrid of all building types, could once again play a richer and more compelling role in culture and the city.11

9

10 11

Marek H Dominiczak, “The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals,” The Lancet 377, no.

9759 Jan (2011): 23.

Ibid.

Edwin Heathcote, “Architecture and Health,” in The Architecture of Hope: Maggie’s Cancer Caring Centres, ed. Edwin Heathcote Charles Jencks (London: Frances Lincoln Ltd, 2010), 91.

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LIST OF FIGURES Chapter One and Two 1.

2.

An image of care in place, at the North Shore Hospital thesis Proposal in Auckland, New Zealand. Illustration by author.

Interior spaces of the Denver General Hospital, Colorado, USA. Photograph taken from Wikimedia Commons, 2011, at http://upload.wikimedia.org/wikipedia/commons/7/77/ES_16Denver_Genergal-Hospital_Staircase_Coffered_Ceiling.jpg. Accessed 23 February 2013

3.

Arcbitectenbureau Swinkels en Salemans, Vijverdal Maastricht.

Photograph taken from Mens, Noor, and Cor Wagenaar. Health care Architecture in the Netherlands, 150.

4.

5.

6.

4. Summary of thesis structure. Diagram by author.

Robert Neal Hind, Miss Nightingale in the Hospital of Scutari. 1958, London.

Helsingor Psychiatric Hospital Medical Centre, completed 2009.

Photographs taken from Bjarke Ingels Group, at http://www.big.dk/#projects-psy. Accessed 14 May 2012.

7.

Skidmore, Owings and Merrill. LLP, 50-Year masterplan for Cincinnati Children’s Hospital, 2005.

Illustrations taken from Archello, at http://www.archello.com/en/project/cincinnati-childrens-hospital-medical-center/image-1. Accessed 14 May 2012.

8.

A physician visiting the sick in the hospital.

Illustration taken from Wikimedia Commons, at http://upload.wikimedia.org/wikipedia/commons/6/6c/Physician_in_hospital_sickroom_printed_1682.jpg. Accessed 15 March 2012.

9.

10.

11.

12.

13.

An image of care in place in a thesis proposal for North Shore Hospital, Auckland, New Zealand. Illustration by author.

A brief evolution of hospitals. Diagram by author.

Development of symptoms of hospital architecture. Diagram by author.

Architectural Plans of North Shore Hospital. Illustrations taken from Jasmax. 2011.

Edward Stevens, Design for Control: Surgery, Science and Space at the Royal Victoria Hospital, Montreal, 1893-1956, Illustration taken from OpenI, at http://openi.nlm.nih.gov/imgs/rescaled512/1483187_medhis5003-303-09.png. Accessed 15 March 2012.

14.

Ivo Cristante, Operating theatre.

Photograph taken from Ivo Cristante, Creating an Artificial Impression of a Realistic Healthcare Setting: How Designers Might Avoid Institutional and Predictable Designs, 2006.

15.

16.

From complex to simple buildings. Diagram by author.

Presbyterian Hospital in New York, 1930.

Photograph taken from Noor Mens and Cor Wagenaar. Health care Architecture in the Netherlands, 46.

17.

18.

A classic image of monumentality. Illustration by author.

Charite, Berlin, Germany.

Sketch taken from Henk de Jong. Towards a New Outpatient Department, 486.

19.

W.F Lughart. Diaconessenhuis, Eindhoven, the Netherlands.

Diagram taken from Noor Mens and Cor Wagenaar. Health care Architecture in the Netherlands, 143.

20. Centre Hospitalier, Lille, 2009.

Photograph taken from Philip Goad, Cameron Logan, and Julie Willis. Modern Hospitals as Historic Places. 619.

21.

Parisette, L’Hopital Beaujon, Clichy, Paris, 1937.

Photograph taken from Wikimedia Commons, at http://commons.wikimedia.org/wiki/File:H%C3%B4pital_beaujon.jpg. Accessed 20 August 2012.

22.

Diaconessenhuis, Eindhoven, the Netherlands.

Photograph taken from Noor Mens and Cor Wagenaar. Health care Architecture in the Netherlands, 142.

23.

Corridor at Sint Jozefziekenhuis, 1904.

Photograph taken from Noor Mens and Cor Wagenaar. Health care Architecture in the Netherlands, 46.

24. Corridor at Hôtel-Dieu de Paris, 1877.

Photograph taken from http://upload.wikimedia.org/wikipedia/commons/e/e1/H%C3%B4tel-Dieu_2012_59.jpg. Accessed 20 August 2012.

25.

Corridor in Lancaster Royal Hospital.

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287

Photograph taken from Apollo Lighting, at http://www.apollolighting.co.uk/showcase/lancaster_royal/bromley_corridor.jpg. Accessed 12 March 2012.

26. A series of Standardisation (compiled by author).

Images taken from Mens and Cor Wagenaar. Health care Architecture in the Netherlands,

27.

Presbyterian Hospital, New York, 1930.

Photographs taken from Noor Mens and Cor Wagenaar. Health care Architecture in the Netherlands, 46.

28.

David Stinson, Columbia Medical Center, 2010.

Photograph taken from Dead Ball Baseball, at http://deadballbaseball.com/wp-content/uploads/2010/12/IMG_5738-copyright.jpg. Accessed 5 September 2012.

29. An image of isolation from place. Illustration by author.

30. G. Wentink, Design for Veldwijk, Ermelo, 1884.

Photograph taken from Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands, 23.

31.

Indianapolis VA Regional Office, Photograph taken from Indianapolis VA Regional Office, at www.benefits.va.gov. Accessed 4 March 2013.

32.

DAUMY, Cite Hospitaliere, Lille, 1935-1953, Photograph taken from Map France, at http://www.map-france.com/Loos-59120/photos-Loos.html. Accessed 5 September 2012.

33.

Soundlandscapes, Hôtel-Dieu de Paris, 1877.

Photograph taken from Soundlandscape’s Blog. at http://soundlandscapes.files.wordpress.com/2013/03/053.jpg. Accessed 20 June 2013.

34. J. Gerl, Allgemeines Krankenhaus (General Hospital), Vienna, 1783.

Illustration taken from The Architecture of Hospitals, edited by Cor Wagenaar, 27.

35.

Sir Christopher Wren, Royal Naval Hospital, Greenwich 1694.

Photograph taken from Noor Mens and Cor Wagenaar. Health care Architecture in the Netherlands, 13.

36. Closed urban islands. Diagram by author.

37. Hotel-Dieu de Paris, 1877.

Photograph taken from Philipp Meuser and Christoph Schirmer, From 'House for the Sick' to Hospital, 13.

38. EBM and EBD development. Diagram by author.

39. David Gillis, EBD: The competing forces of Art and Science, 2011.

Diagram taken from UX Magazine, at http://uxmag.com/articles/the-art-science-of-evidence-based-design. Accessed 20 June 2013.

40. 40. David Gillis, EBD: The competing forces of Art and Science, 2011.

Diagram taken from UX Magazine, at http://uxmag.com/articles/the-art-science-of-evidence-based-design. Accessed 20 June 2013.

Chapter Three 1.

2.

Relationship between hospital and city. Diagram by author.

Aldo Rossi, City Analogous, 1976.

Taken from The Architecture of Analogy. http://cameronmcewan.files.wordpress.com/2012/03/rossi-a-1976-analogical-city-panel-and-montage-diagram.jpg, Accessed 4 May 2012

3.

4.

Evolving architectural model of care. Diagram by author.

Lewis Mumford, My Kind Of Town.

Illustration taken from Architecture Today, at http://www.architecturetoday.co.uk/?p=16420. Accessed 20 June 2012.

5.

6.

A shift towards the hospital-city. Diagram by author.

Sir Colin Buchanan, An analogy of the hospital. 1963.

Illustration taken from Traffic in Towns, London, 41.

7.

Sir Colin Buchanan, An analogy of the hospital. 1963.

Diagram taken from Traffic in Towns, London, 41.

8.

The Modern and Humane Hospital.

Illustration taken from Cor Wagenaar. The Architecture of Hospitals, 9.

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9.

George Dodd, British Military Hospital, Balaklava, 1856.

Illustration taken from Wikimedia Commons, at http://commons.wikimedia.org/wiki/File:British_Military_Hospital,_Balaklava._George_Dodd._Pictorial_history_of_the_Russian_war_1854-5-6.jpg. Accessed 30 November 2012.

10.

Hopital Bichat.

Illustration taken from Bruno Gaudi, The Hospital and the City, 116.

11.

Hopital Saint-Louis.

Illustration taken from Bruno Gaudi, The Hospital and the City, 116.

12.

Hotel-dieu de Paris.

Illustration taken from Bruno Gaudi, The Hospital and the City, 116.

13.

14.

15.

Developmental Plan for the Academisch Ziekenhuisa Groningen, 1976.

Illustration taken from Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands, 164.

The decentralised hospital. Diagram by author.

EGM Architecten, Scenario planning in the Netherlands.

Illustration taken from Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands.

16.

Hopital Lariboisiere, Paris, Illustration taken from The Architecture of Hospitals, edited by Cor Wagenaar, 29.

17.

A Nuffield Hospital Design Study, The Pavilion Principle, 1937.

Illustration taken from Henry Currey FRIBA (1820–1900): leading Victorian, hospital architect, and early exponent of the “pavilion principle. 355.

18.

Henry Currey, The old St Thomas Hospital, 1871.

Illustration taken from King’s College London, at http://kingscollections.org/exhibitions/specialcollections/nightingale-and-hospital-design/st-thomass-hospital. Accessed 1 August 2012.

19.

A comprehensive range of buildings.

Illustration taken from Open City: Designing Coexistence, 312.

20. RIBA Futures Studies, Healthcare Model for 2020, 2002.

Diagram taken from 2020 Vision - Our Future Healthcare Environments - UK Guidelines, 17.

21. 21. RIBA Futures Studies, Healthcare Model for 2020, 2002.

Diagram taken from 2020 Vision - Our Future Healthcare Environments - UK Guidelines, 17.

22. The European model of care. Diagram by author.

23. The indeterminacy of care. Diagram by author.

24. The evolution of the built form of hospitals in the city. Diagram by author.

25. The evolution of the healthcare model from a medicalized to public. Diagram by author.

26. Rohmer, Residential Care Center, Nijmegen, the Netherlands, 2009.

27.

28.

Photograph taken from Noor Mens and Cor Wagenaar, Health care Architecture in the Netherlands, 168.

Open access at the edge of hospitals, in North Shore Hospital, Auckland. Illustration by author.

Tom Turner, Relationships between proposed developments and its place.

Illustration taken from Max Robinson, Place-making: The notion of Centre, 150.

Design proposal for North Shore hospital, Auckland. Illustration by author.

29.

30.1-3. Le Corbusier, Venice Hospital.

Illustrations taken from Hashim Sarkis. Le Corbusier's Venice Hospital and the Mat Building Revival.

30.4 Dioniso Gonzalez, fotomontaje del Hospital de Venecia de Le Corbusier (Photomontage of the Venice Hospital).

Illustration taken from Love You so Mat, at http://loveyousomat.tumblr.com/page/24, accessed 20 December 2012.

31.1-3 Isala Clinics, Zwolle, the Netherlands.

Images Taken from Stevens van Dijck, at http://old.stevensenvandijck.nl/nieuws?id=69&p=8. Accessed 4 March 2013.

32.1 St Olav’s Hospital, Norway.

Photograph taken fromSt. Olav’s Hospital, at http://www.stolav.no/MEDIA/Bilder-for-media/Flyfoto/, Accessed 4 April 2013.

32.2 St Olav’s Hospital, Norway.

Photograph taken from Hage, at http://www.bygg.no/2011/02/69173.0. Accessed 4 April 2013

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33.

Process Summary towards designing a hospital in place. Diagram by author.

Chapter Four 1.

Gordon Friesen, Cover of Architectural Review in June 1965.

Illustration taken from Jonathan Hughes. Hospital-City, 267.

2.

3.

4.

5.

Evolutionary pathway of hospitals, based on studies by the Berlage Institute and Sunand Prasad. Diagram by author.

Five General Models of Care, based on a study by David and Sandra Canter. Diagram by author.

Campus model for hospitals. Illustration by author.

Microsoft Campus in Redmond, Washington, USA. Photograph taken from Wikimedia Commons, at http://commons.wikimedia.org/wiki/File:Aerial_Microsoft_West_Campus_August_2009.jpg. Accessed 13 May 2013.

6.

Dutch Health Architects, The influences of different typologies for a hospital.

Diagrams taken from Dutch Health Architects, 58-61.

7.

Berlage Institute, Care Boulevards in European Countries.

Diagram taken from Cor Wagenaar, The Architecture of Hospitals, 250.

8.

9.

10.

11.

Bumrungrad International Hospital, Bangkok, Thailand.

Photographs taken from Bumrungrad International Hospital, at http://www.bumrungrad.com/thailandhospital. Accessed 3 June 2013.

The idea of shopping strips. Diagram by author.

Elevation of a possible shopping strip. Diagram by author.

The Baths of Caracalla, Rome, Italy.

Illustration taken from Skyscrapercity, at http://www.skyscrapercity.com/showthread.php?t=184389. Accessed 14 March 2012.

12.

Berlage Institute, The development of Erasmus MC University Medical Centre.

Illustration taken from Cor Wagenaar. The Architecture of Hospitals, 257.

13.

A proposal for Denmark Hill Centre.

Illustrations taken from BD Online, at http://www.bdonline.co.uk/buildings/first-look/first-look-duggan-morris-brings-a-flexible-approach-to-denmark-hill-centre/5026095.article#. Accessed 20 June 2013.

14.

15.

16.

Peter Ebner, Interethnisches Wohnen in Vienna, 1991.

Photograph taken from Integrated Living, edited by Christian Schittich, 19.

Geriatric ward garden design. Illustration by author.

Phoenix Weymouth Hospital.

Photograph taken from EPR Architects, at http://www.epr.co.uk/projects/architects-specialist-sectors/weymouth-street/. Accessed 30 September 2012.

17.

(1-6) Maggies Day Centres.

Photographs taken from Charles Jencks, at http://www.charlesjencks.com/#!maggie's-centres. Accessed 20 June 2013

18.

Renzo Piano Building, Kansai Airport.

Diagram taken from Lawrence Nield, Postscript: Reinventing the Hospital, 252.

19.

Deventer Hospital.

Illustration taken from Dutch Health Architects, 12.

20. Deventer Hospital.

Diagram taken from Cor Wagenaar, Health care Architecture in the Netherlands, 310.

21.

Comparison between the processes within an airport and a hospital.

Diagram taken from Lawrence Nield, Postscript: Reinventing the Hospital, 253.

22.

23.

Academisch Medisch Centrum (AMC), Amsterdam.

Photograph taken from Cor Wagenaar, Healthcare Architecture in the Netherlands, 197.

Operating theatres in Wilheim Schulthess Klink, Zurich.

Photograph taken from Lawrence Nield, Postscript: Reinventing the Hospital, 254.

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Chapter Five 1.

George Dodd, Barrack Hospital, Scutari, 1854.

Illustration taken from Pictorial History of the Russian War 1854-5-6, 309.

2.

3.

4.

5.

6.

Image of a patient receiving care, in the thesis proposal for North Shore Hospital, Auckland. Illustration by author.

The making of place. Diagram by author.

Views from a bed. Diagram by author.

Views while moving from place to place in a corridor. Diagram by author.

(1) Alvar Aalto, Paimio Sanatorium.

Photograph taken from Cor Wagenaar, Healthcare Architecture in the Netherlands.

(2) Alvar Aalto, Paimio Sanatorium Interior.

7.

8.

9.

10.

Photograph taken by Marek Dominiczak, The Art of Medicine: Of Wandering Doctors, Cities, and Humane Hospitals, 22.

Views from a window in the hospital. Photograph by author.

Herzog and de Meuron, REHAB, Basel, Switzerland.

Photographs taken from Joe Perez-Green, at http://www.swissmade-architecture.com/?seite=Overview&pid=31. Accessed 25 June 2013.

Light-well in North Shore Hospital, Auckland. Illustration by author.

Hitoshi Abe, Matuda Dental Clinic Photograph taken from A Note on the Situation of Contemporary Japanese Clinic Design, edited by Cor Wagenaar, 425.

11.

Good Samaritan Hospital, Portland, Oregon.

Photograph taken from Clare Cooper Marcus, Healing Gardens in Hospitals, 317-18.

12.

Institute for Child and Adolescent Development, Wellesley, Massachusetts.

Photograph taken from Clare Cooper Marcus, Healing Gardens in Hospitals, 325.

13.

Hitoshi Abe, Sekii Maternity Clinic.

Photograph taken from A Note on the Situation of Contemporary Japanese Clinic Design, edited by Cor Wagenaar, 429.

14.

(1-6) MASS Architects and Harvard Medical School, Butaro Hospital, Rwanda.

Photographs taken by Iwan Bann, from http://www.designboom.com/architecture/mass-design-group-butaro-hospital-rwanda/. Accessed 25 June 2013.

15.

Rijnland Ziekenhuis (Hospital Rhine), the Netherlands.

Photograph taken from Cor Wagenaar, Healthcare Architecture in the Netherlands, 277.

16.

17.

18.

Nikken Sekkei, Taniyama Hospital, Kagoshima,Japan.

Photograph taken by Techni Staff, from http://www.nikken.co.jp/en/projects/healthcare/taniyama-hospital.html Accessed 30 April 2012.

An interconnected series of outdoor spaces in the thesis proposal for North Shore Hospital. Diagram by author.

Garden spaces at Good Samaritan Hospital, Portland, Oregon.

Photograph taken from Clare Cooper Marcus, Healing Gardens in Hospitals, 320.

19.

Waitamata District Health Board. North Shore Hospital Plan.

Illustration taken from http://www.waitematadhb.govt.nz/PatientsVisitors/NSHgettingthere.aspx. Accessed 20 February 2012.

20. Navigation on the road.

Taken from Francine Houben, Mobility: A Room with a View.

21. Academisch Medisch Centrum (AMC), Amsterdam, 1981-1985.

22. Photograph taken from Cor Wagenaar, Healthcare Architecture in the Netherlands, 217 23. (1-6) BIG. PLOT; JDS; and others, Helsingor Psychiatric Hospital, Denmark.

Photographs taken from BIG http://flash.big.dk/projects/psy/. Accessed 20 February 2012.

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Chapter Six 1.

2.

Photograph of Auckland City Hospital. Photograph by author.

Graphic Representation of hospital ‘throughput’ from Royal Melbourne Hospital .

Illustration taken from Cameron Logan, The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952, 68.

3.

‘The Vision Splendid’.

Illustration taken from Cameron Logan, The Modern Hospital as Dream and Machine - Modernism, Publicity and Transformation of Hospitals, 1932-1952, 68.

4.

Royal Melbourne Hospital.

Taken from Lawrence Nield, Changing Hospital Design in Australia, 229.

5.

Waiblingen Krankenhaus, Stuttgart, Germany, 1928.

Photograph by Richard Docker, in The Architecture of Hospitals, edited by Cor Wagenaar.

6.

Apollo Health Centre, Rosedale.

Photograph taken from Idealog, at http://www.idealog.co.nz/businessplan/apollomedical. Accessed 29 June 2013.

7.

Auckland City hospital.

Photograph taken from John Hunt, Critical Care - Auckland City Hospital. 39.

8.

Rory Langbridge, Nelson Hospital.

Photographs taken from Reconstructive Surgery for Hospital Landscape: Nelson Hospital.

9.

Lyons, Sunshine hospital.

Photographs taken from Paul Walker, Sunshine Hospital, 48-54.

10.

Lyons, Kyneton Hospital.

Photographs taken from Brent Allpress, Skin Doctors, 64-70.

Pages 175-277: Design Proposal for North Shore Hospital. All images produced by the author.

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APPENDIX:

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PROGRAMMATICS Categories

Sub-Categories

Departments

Inpatient Beds

Adult Medical

Adult Medical

Existing

Refurb

BEDS Proposed

Existing

185

106

186

292

0

0

30

40

0

0

56

150 16 0 351

97 0 0 203

50 0 12 62 413

Mental Health (Taharoto) SSOA (AT&R + MHSOA) Sub Total Mental Health + SSOA

Renal (Chairs) Stroke Unit - Combined Acute Medical and Rehab Adult Surgical

Adult Surgical Beds ICU / HDU Elective Surgery Beds

Sub Total Med Surg

Womens Services Paediatrics

Paediatrics acute assessment beds SCBU Sub Total Womens and Paediatrics Subtotals

TOTAL

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T and E at 35%

0

990

347

56

0

2520

882

79 4 49 404

176 20 49 623

0

4900 0 0 9800

2765 268 1862 14915

968 94 652 5220

39 0 12 51 254

44 6 8 58 462

83 6 20 109 732

2079

788

873 2952 2952

0 788 10588

1760 318 179 2256 17171

616 111 62 790 6010

39

0

63

63

0

3780

1323

79 118 531

0 0 270

184 247 709

184 247 979

0

8280 12060 29331

2898 4221 10231

1500 1500

0 0 0 0 0 525 525

0

2952

10588

1611 2 1 1 1 3 2 10

Acute Elective Surgery Theatre Cath Labs

12 0 1

0 0 0

Endoscopy Oupatients Sterilizing (SSU) Kitchen Staff Cafeteria

2

6

Subtotal

294

Sub Total

2279

Subtotal Operating Theatres

Subtotal

AREA (m2) Net New 6510

General X Ray Orthopaedic X Ray CT MRI Ultrasound Radiation Oncology

TOTAL

Refurb

4900

Imaging

Clinical Support

General Support

Total 2030

0 4 2 4

340 170 190 195 1611 4040 12 4 3 6

895 0 0

0 414 2080 744 873 521 4632 6243

0 1140 0 1044 1260 0 3444 4339

0 2400 376 2776 0 1360

0 840 132 972 0

711 1214 3284.96 7561

711 1214 1925 1925

476 0 249 425 1150 2646

retail and food

Revision O 8/7/09 Gross New Total Area Benchmark Assumptions Per Bed 8789 13689 35 Excludes Lakeview

outpatients community health education and seminars pharmacy

1200

1200

33

3402

3402

45

21 medical stroke, 21 rehab stroke, and 14 from the west

general administration / commercial medical records and archives

3733 362 2514 19999

8633 362 2514 29799

35 67 38

day-area - allied health

Area based on briefed concept plans

elective surgery theatres

APPENDIX: PROGRAMMATICS Excel sheets: Initial Programmatics Page from Jasmax who was constructing the hospital’s 2030 strategy. The size of programs were followed as closely as possible in the proposed masterplan, between current space size, and future spatial requirements for 2030.

elective surgery beds renal / dialysis (chairs) general xray

2376 429 240 3046 23044

3164 429 240 3834 33632

40 53 30

5103

5103

60

11178 16281 39325

11178 16281 49913

45

Immediate Left: Colour coded Detailed programmatics generated from the requirements of the hospital

orthopaedic xray CT MRI ultrasound cath labs geriatric (AT & R and MHSOA)

Assume all new beds, no refurb

mental adult medical adult surgical womens services - 2376 paediatrics

0 0 0 0 0 2025 2025

340 170 0 190 195 2025 2920

0 3240 508 3748

0 3240 508 3748 1140 1836 1044 2220 1639 7879 14546

1836 0 960 1639 4435 10207

170 170

As per draft CSP Version 4 Based on Auckland ASB Not included as in Lakeview

190 65 750

895 TOTAL EXCLUDE ONCOLOGY

security mortuary

6 elective 4 acute 2 non commissioned Area based on briefed concept plans Based on Auckland CSB

pathology archives biomed engineering engineering environmental services

190 68 44 2118 1214 3634

Per Procedure room Based on concept sketch 4872 meals per day (?)

Total beds X 1.24m2

Benchmark for bed area 661 860 198 661

core / emergency: A&E and acute theatres, stroke unit: acute medical and er hab

LEAVE OUT 270 325 188

special care baby unit ICU/HCU

linen services supply / materials management waste management / loading dock s informationtechnology

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APPENDIX: AXONOMETRIC PLAN OF HOSPITAL BUILDINGS - BY FLOOR, DETAILED Refer to Individual building profiles in the following pages

GROUND FLOORS

296

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FIRST FLOORS

SECOND FLOORS

THIRD FLOORS

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APPENDIX: INDIVIDUAL BUILDINGS: COMMERCIAL BUILDING, BY TAHAROTO ROAD allied health services - private

engineering office

THIRD d care services for allied health day

commercial and general admin

retail r and shopping open spaces engineering office SECOND retail and shopping

void above basement carpark entry to carpark from hospital road entry into shops

allied health services

FIRST

retail and shopping

future basement carpark (unspecified levels) entry from taharoto road GROUND

298

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ADDITIONAL RENDERS

- Connection to place, does not resemble the image of a hospital: retail/shopping and commercial oďŹƒces linked toTaharoto Road and Smales Farm opposite, and Medlifecare to the North.

- Hedges for landscapes acting as wayfinding markers

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The interior public space of the commercial space at eye level. People are immediately self-oriented when they see the hospital through the open void (to the right of the carpark ramp) upon walking through this space.

300

Care in Place

APPENDIX: INDIVIDUAL BUILDINGS: HOSPITAL CORE connection bridge to inpatient wards temporary wards for post-elective surgery elective consultation rooms, prep room and operating theatres office entrance to elective surgery clinic renal / dialysis chairs maternity suites (2 levels) paediatrics and special care baby units open spaces SECOND imaging units endoscopy HCU / ICU core: general operating rooms staff offices pathology medical records

FIRST

double height outpatient lobby kitchens (mandatory for inpatients)

public entryway

assessment diagnostic units (ADU) / observation rooms core: general operating rooms staff offices pathology emergency operating rooms

GROUND

entrance and lobby to A&E outpatients and polyclinic services

public pharmacy

services entryway

BASEMENT

Care C Ca are e iin n Pl P Place lac ae

301

maternity ward, and a future roof garden on the open spaces as potential social space.

connection to the natural elements: the interior of the hospital core, at the operating theatres.

302

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INDIVIDUAL BUILDINGS: COMMUNITY HEALTH CENTRE AND EDUCATION + RESEARCH CENTRE private clinics for women and children

SECOND

community health centre

FIRST children / creche retail and shopping entry to upper floors GROUND COMMUNITY BUILDING

research and seminar rooms for educational purposes SECOND

sta rooms for research centre public library (first floor) private independent clinics (ground floor) FIRST public library (ground floor) entry to upper floors retail and shopping GROUND EDUCATION BUILDING

Care C Ca re iin n Pl P Place ace

303

ADDITIONAL RENDERS

VIew towards the community health centre.

Marketable space for visitors, sta and patients to visit and shop and socialize. Part of an enhancement / empowerment model for care.

Connection to places: Clear visual access to commercial building, hospital core and Shakespeare road via a colour coded road. / pedestrian corridor

304

Care in Place

Interior atrium-like space in the community health centre featuring clinical spaces (left of image) and a gallery (right), making it a positive space to be in while always maintaining a full view towards the pedestrian corridor

Clinics on the other side of the community building, featuring a lightwell.

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APPENDIX: INDIVIDUAL BUILDINGS: WARDS: GENERAL INPATIENT, GERIATRIC, AND MENTAL HEALTH

central communal lounge

corridor lobby SECOND + THIRD hotel lobby entrance

communal lounges

stroke units inpatient rooms

GROUND + FIRST

double loaded corridors services common corridor lobby + decentralised nurses stations services entry (under wards) restricted entry into inpatient wards and hospital core

306

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ADDITIONAL RENDERS

Bird’s eye view over the inpatient wards, featuring the large open space in the middle wing that is reminiscent of a hotel lobby, and within the landscape, towards carmel college on the left, the native planting within the greenscape, and the lake on the right.

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Left-most wing in the inpatient wards, overlooking the greenscapes via a glass covered walkway.

Inpatient hotel-like communal lounge 308

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INDIVIDUAL BUILDINGS: GERIATRIC AND MENTAL WARD UNITS communal areas

staff offices + meeting rooms FIRST

common corridor services (running through middle) wards GROUND

entry

entry + lobby (from first floor) FIRST

counselling + therapy

common corridor services (on inner side of wing) wards (on outer side of wing)

GROUND

double height communal areas staff offices

Care C Ca re iin n Pl P Place ace

309

ADDITIONAL RENDERS

A view of one of the smaller lightwells in the geriatric wards.

310

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The geriatric ward has generous views of the greenscape, towards the lake, the general inpatient wards and other buildings.

Bird’s eye perspective overlooking the mental health unit.

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ACCESSIBILITY IN PLACE: ADDITIONAL (TEST) RENDERS SHOWING ACCESSIBILITY, CONNECTIVITY WITH LOCAL PLACE, AND OF A HUMANE ENVIRONMENT FOR THE FACILITATION OF CARE

on the hospital road

at the colourful new zealand inspired garden 312

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clearly organised garden-scapes that contour themselves to the topography.

marketable spaces and clear wayfinding Care in Place

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314

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316

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