status and perspective of hospital architecture in japan

- 1 - thursday may 16.

Status and Perspective of Hospital Architecture in Japan

New Development of the University of Tokyo Teaching Hospital Project Yasushi Nagasawa, Dr. Eng. Dip. HFP, JIA Professor, Department of Architecture, Graduate School of Engineering, The University of Tokyo Vice-President, Healthcare Engineering Association of Japan

Office : Department of Architecture, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8656, Japan Tel: +81-3-5841-6169, Fax: +81-3-5841-8516, e-mail : [email protected]

Home : 4-1-3 Higashi Gotanda, Shinagawa-ku, Tokyo 141-0022 Japan Tel: +81-3-3441-6057, Fax: +81-3-3441-6057, e-mail: [email protected]

BIOGRAPHY

Yasushi Nagasawa is Professor of the Department of Architecture at the University of Tokyo. He has had a distinguished career as an eminent Japanese planner for hospitals and other healthcare buildings in Japan and overseas, including consultation tasks with the World Health Organization. He is the Council member of IFHE, Vice-President / International Committee Chairman of Healthcare Engineering Association of Japan (HEAJ). He is designated as the Chairman of the 2002 Annual HEAJ Conference / Exhibition (Hospex Japan 2002). He is also Vice-President of Men-Environment Research Association (MERA), Director-General of Global University Programs in Healthcare Architecture (GUPHA) as well as a board member of Japan Institute of Healthcare Architecture (JIHA) and Japanese Society of Hospital Administration (JSHA). From 1997 to 1999, he was the Chairman of the Department of Architecture. From 1989 he had been an Associate Professor at the University of Tokyo. In 1994 he was awarded an Architectural Institute of Japan Prize in research and promoted to full professorship. From 1980 to 1988 he was a senior research architect at the National Institute of Hospital Administration, Ministry of Health and Welfare, where he was a research architect from 1974 to 1979. He began his architectural design career at Yoshinobu Ashihara Architect and Associates, where he worked from 1968 to 1974. He holds a Doctor of Engineering Degree from the University of Tokyo (1987) and post-graduate Diploma in Health Facility Planning from the Council for National Academic Awards, UK (1978). He graduated from the post-graduate course in Health Facility Planning at the Medical Architecture Research Unit, Polytechnic of North London (1978). He became a qualified architect in Japan in 1972. He graduated from the Department of Architecture, Faculty of Engineering, The University of Tokyo (1968) where he obtained a Bachelor of Engineering degree.


Status and Perspective of Hospital Architecture in Japan

New Development of the University of Tokyo Teaching Hospital Project

WHAT IS THIS PRESENTATION ? The objective of this presentation is to introduce briefly the evolution of heath facility design and engineering in Japan on the basis of an overview of recent developments at the University of Tokyo Teaching Hospital Project, which represents the state-of-the-art hospital architecture in Japan. However, the emphasis here will focus on the perspective of year the 2000 and beyond, in current design trends in health facility planning and design, and precedents trend in this specialized field through out the 20th century.

IN WHAT WAY WERE JAPANESE HOSPITAL BUILDINGS DEVELOPED ? Chinese culture, principally Buddhism, exerted an overwhelming influence upon Japanese culture from the earliest days. Religion, as well as medical care, was based on Chinese medical technology, e.g. herbal medicine, acupuncture, massage. Buddhism temples provided treatment and accommodation for the poor and the sick. Christianity was introduced by Spanish missionaries and the first Western style hospital was built in the 16th century by Portuguese missionaries, however, this tradition ceased by the 17th century. This occurred because Christianity was banned as Japan closed its doors to overseas countries during the Edo period for over 250 years until the mid-19th century. In the mid-17th century, Dutch medicine was introduced in the Nagasaki Concession, this being the single area permitting communication with the outside world during the Edo period. Dutch influence continued until the Meiji Restoration in the 19th century (1968) when the Meiji government decided to follow the model of German medicine for medical education.

The University of Tokyo Teaching Hospital (UTH) was established at its present site in 1876 as the first teaching hospital in Japan and has been the site of excellent medical research and teaching advancements since that time. The architectural development of UTH is significant because it has reflected various nationwide influences to incorporate various innovations in medical and building technologies at each stage of the institution’s development.

The first stage of UTH building in the 19th century was a pavilion-type wood structure. In the early part of the 20th century, hospital buildings in elsewhere in Japan were orientated to emulate the medical teaching hospitals. Many pavilion type sanatoria were built as tuberculosis and other infectious diseases spread throughout the country. From the beginning of the 20th century, UTH buildings were renovated, representing the second major wave of construction activity. Western style red roof tiles were in use during this period, although most of these structures were destroyed in the Great Kanto Earthquake in 1924. As the third stage of construction activity corresponded following the 1924 earthquake, Prof. Y. Uchida of the Department of Architecture was co-assigned as Chief Architect of the University. He had an important role in creating an overall campus master plan in the aftermath of the Earthquake. The hospital started the process of reconstructing its facilities in the College Gothic style with steel-reinforced concrete structures in order to resist future earth tremors. The symmetrical layout plan of the hospital was drawn according to German planning concepts, i.e. the core Medical block on the left and core Surgical block on the right. The out-patient department (OPD) block was located in front and administration block, which was located on the other side of court yard from the OPD block. Actually only the OPD was completed in 1934, and the medical block was constructed just before 1945.


American concepts of effective hospital administration were introduced following World War II and new medical laws were legislated. The National Institute of Hospital Administration, now called NIHSM, was established under the Ministry of Health and Welfare in order to train hospital directors (Japanese trained-physicians) and other (nursing/business) directors in contemporary principles of information management, modern hospital care and contemporary frontiers of health facility planning and management. This oversight also extended to the design of the numerous new facilities which were needed in the post-war years. Based on the concept of centralization of diagnosis/therapeutic and servicing/logistic functions, a model plan for a 180-bed general hospital was developed in 1954 by Prof. Y. Yoshitake of the University. Since that time, research work on the planning of hospital buildings and engineering, studies of healthcare buildings have been carried out on or ongoing basis at the University of Tokyo, as well as at other universities and organizations such as the Healthcare Engineering Association of Japan (HEAJ) and Japan Institute of Healthcare Architecture (JIHA).

The period of 1952 to 1968 represented the forth stage of the development of the UTH campus. Prof. Y. Yoshitake designed centralized the D/T department, e.g. operating theaters, radiology, path-labs, as well as various supporting departments, e.g. catering, laundry and the CSSD, under extremely tight budgets. In 1954, central operating theatres were completed as the first centralized units of their type in Japan. In 1964, an 11 story tower- ward, one of the first double corridor configurations in Japan was constructed on the campus.

The span of 1968 to 1982, characterized by 1960s-70s student struggles in the Universities, was a period of only minor renovations in the physical plant, implemented without any consistent master plan in effect. However, the earlier implementation of National Health Insurance System, in 1961, encouraged the nation to provide on unprecedented number of hospital beds in order to cope with the increasing demand for hospital care, in response to the post-war generation. Various hospital owners in both the public and private sectors built and operated hospitals with relatively few serious restrictions placed on them. The total number of hospitals and hospital beds in Japan are at present 9,500 and 1.7 million respectively (versus 1.4 million in the US) i.e. there is at present one hospital bed per every 76 persons in Japan (versus one per every 171 persons in the US). However, this does not mean Japanese hospital beds are accessible easily by patients since the length of inpatients' stay in Japanese general hospitals is a little shorter than 30 days at the present time, far longer than in other developed countries. Yet, tight capital investment budgets have resulted in shortages of floor area in relation to the needs to accommodate many inpatients, out-patients, and a parade of new high tech medical equipment and attendant procedures. In the course of the period of rapid economic development, the situation of tight floor space gradually moderated, but is still below comparable standards in other developed countries.

In 1982, a new master plan for the UTH, called “System Master Plan”, was developed. This master plan has 4 phases, each aiming to firmly establish its place as a state-of-the-art center of excellence within the family of teaching hospitals across Japan. The first phase was the D/T Department, containing operating, path-lab and radiology and CSSD completed in 1987. The second phase was the OPD, completed in 1993 with about 2700 patient visits per day. The third phase was an inpatient tower, completed in 2000 with the first patient admitted in October of 2001.

This system master plan was originally developed by Prof. S. Suzuki of the University, in association with Shinichi Okada Architect and Associates, with extensive support provided by the Facility Department of the University and the Future Plan Promotion Unit of the UTH. Since 1989 the author has been the principal consultant to the project.

One of the characteristics of the UTH system master plan is the location of clear pedestrian mall, hospital streets connecting each relevant department, which provides effective way finding for users and maximum flexibility within a complex network of diagnostic and treatment domain areas.


Interstitial spaces (ISS) were introduced for ease of modifying the layout of rooms and to accommodate highly sophisticated engineering support systems. All building system installations, such as air conditioning, electric, automatic transportation and information wirings, are separate from the building super structure, reflecting differences in the life spans of various building technical support systems and sub-systems.

Typical floor layouts of the recently-built wards are considered to afford far better observation of patients by staff, and significantly greater comfort levels for patients. Bed rooms mainly consist of single bed rooms, some of which are used as semi-private rooms in order to accommodate the requisite number of beds in the transition period until the final stage of the master plan is completed. It is the first attempt in Japan to locate patients’ WC/Shower unit on the window side of the room in order to enable maximum flexibility in the corridor side.

The fourth stage of UTH development will be the extension of D/T department followed by the extension of wards. At the final stage of the master plan’s implementation, 1300 beds will be equipped and available for service.

WHAT DO CURRENT JAPANESE HOSPIALS LOOK LIKE? Although UTH is enjoying a very high standard of services of its buildings and engineering support services, most other Japanese hospitals that been also experienced extensive expansions and redevelopment during the 20th century. Each has its own merits and demerits in terms of its physical plant and operational aspects. This typology of hospital can be described in terms of a set of descriptive labels or “nicknames”. Eight of these are as follows:

1. Japanese hospitals which look like the Morning Market, where large numbers of outpatients get together hours before receiving consultation. Despite this, better service is not guaranteed by ones early arrival. This stems from an ineffective appointment system.

2. Japanese hospitals which look like the Rush-Hour Train, brimming with “passengers” all packed tightly within a very limited floor area. Floor area per bed in Japanese general hospitals is about 60 square meters, compared to more than 100 square meters in the USA and Europe. This problem stems from the limitation of capital investment, and cost limitations which necessitate the selection of small sites for the construction of hospitals.

3. Japanese hospitals which look like the Chowder Soup in a pot, which different types of patients mixed in hospital wards, and also in situations where more than 50 patients are routinely accommodated in one small nursing unit. These patients may be acute or long-term, children, or elderly people. This syndrome stems from lack of a designated role of each hospital, symptomatic of a lack of regional networking as well as a chronic shortage of nursing staff.

4. Japanese hospitals which look like Department Stores, rather than specialty shops. The majority of hospitals provide medical services to all types of patients. From the hospital administrative point of view, it is necessary to allocate all types of specialties in order to cope with all patients’ needs. This also stems from a lack of regional planning and patients’ lack of freedom of selection among multiple hospital choices for receiving care.

5. Japanese hospitals which look like the High-Tech Box, within artificial environments such as air conditioning, mechanical ventilation and lighting, containing high-tech medical equipment such as computer tomography (CT), magnetic resonance imaging (MRI), automatic analyzers, material handling conveyors and various computer systems. This stems from the fact that both Japanese patients and staff are fond of high-tech equipment without their being concomitantly conscious of matters of cost-effectiveness.


6. Japanese hospitals which look like the Scrap and Build Shrines, similar to the ISE Shinto Shrine, which has been renewed once every 20 years for thousands of years. This stems from a national obsession with ‘newer is better’ in Japan. When a hospital is standing for 10 years, it may be regarded as old by the Japanese. As a result Japanese hospitals tend to have an unusually short life-span, and old facilities frequently suffer from poor maintenance.

7. Japanese hospitals which look like Slum Housing, dirty and crowded buildings with long waiting times and an unfriendly, uninviting atmosphere. This frequently stems from poor awareness of and often a disconcern disconcert for patients’ amenity and satisfaction in terms of the care and management of the built-environment.

8. Japanese hospitals which look like the Clone Animals, arrayed from north to south throughout the country. These hospitals are easily recognized from their exterior appearance. Whether public or private, these buildings all look similar. This also stems from the general attitude of the hospital administrators which operate these facilities. They want to follow precedent alone and their neighbor’s idea above all else.

These eight distinctions help one to provide a general understanding of recent trends within Japan.

ON THE HOSPITAL OF THE FUTURE Japanese hospitals have been characterized in the preceding discussion as being directly reflective of myriad political, economical, social, technological and cultural factors. As a result, Japanese hospital buildings themselves contain and express the following three physical features: Immense and Independent, Compact Footprint and Tall, and Stand-alone and Uniform.

However, a key quality of life indicator, life expectancy at birth, is 77.2 years for males and 83.8 years for females in Japan, which at present is the longest in the world. The country enjoys high quality in its health services with a relatively low cost of governmental expenditure. There are several recent movements aimed at improving the current situation.

Regional healthcare planning law has been recently introduced, now requiring each local government to work out a comprehensive health services provisional plan including the demonstrate in of need through the submittal of a certificate of need report in relation to each new hospital bed requested. A link between the hospital local clinics is requisite to meet this requirement. Although each hospital is still principally independent, without affiliation in a larger network, the case often remains where institutions house duplicative equipment including multiple sets of diagnostic and treatment services in the future it is likely that hospital will regain to share costly diagnostic equipment and services. Various off-site services have very recently become widely available in Japan. Many hospital administrators are discussing, for the first time, the out-sourcing of hospital services and the necessity of networking not only for diagnosis and treatment but also for material purchasing, catering, sterilization and pharmaceutical operations, because past redundancies in terms of specialties /services within the same region can not be supported nor economically justified any longer.

Most people, however, still enjoy easy access to hospitals almost everywhere in Japan without worrying about how much they have to pay due to the National Health Insurance program. Many hospitals are now introducing an appointment system for the first time for out-patients’ consultation. Now, especially in the case of tertiary hospitals, patients have to show a reference letter from another clinic or hospital, otherwise they have to pay a certain amount in the form of a registration fee.

The care of a growing number of elderly patients in general hospitals reveals the need to provide various options, besides the hospital, for them to receive care, e.g. speciality geriatric hospitals, halfway houses, skilled nursing homes, group homes and ordinary homes. Based on the rapid aging


of Japanese society, integration of institutional care with home-based care options is requisite. A new care insurance system for the elderly was introduced in 2000. This system is redefining the scope of care for the elderly. It has already begun to have a significant impact, although more research is needed on this issue. As the result, it is hoped a shortening of the length of the typical hospital inpatient stay will be achieved – this is a critical factor for the attainment of more efficient hospital management.

Recently, the revision of medical legislation enables hospitals to relate floor area to the level of medical remuneration, i.e. an increase in floor space becomes an incentive for hospital administrators to increase their monthly revenue. As many hospitals have begun to provide environments specifically for acute and long-term patients, these patients will be able to self-select the places which best suit the level of care one needs. In some of the most recently built hospitals, the average floor area is 80-100 square meters per patient.

The disadvantages of compact and tall hospital buildings fully supported by air conditioning and lighting were revealed in the aftermath of natural/man-made disasters and hazards such as earthquakes, industrial explosions, and incidence of cross-infection, all highlighted in the mass media in recent years. In addition, skyrocketing operational and maintenance cost have become crucial issues to cope with. Discussions, often rather heated, are at present occurring with respect to hospital building and engineering design principles in Japan. These debates crystallize the continuing pressure to reduce operational cost rather than capital cost, and improvements in progressive maintenance. These are the most frequently discussed themes. Life cycle cost, including the demolition of antiquated buildings, is also a hotly contested issue.

The clear distinction of acute and chronic hospitals will reconfigure large nursing units into more appropriate sizes dependent upon specific nursing requirements. High-tech medical technology will be more rapidly and more sophisticatedly developed in the 21st century and applied to critical care/life saving hospitals. In many developed countries, ambulant surgery is being given attention in order to reduce the length of inpatient stays in hospitals. This trend might stem partly from financial reasons. However, this technology will help Japanese patients to stay in their normal environment as long as possible in the future. Naturally, patients do not wish to stay in the hospital for a long time, if this is not necessary, in particularly in light of new treatment modalities.

On the other hand, more holistic and low-tech medical treatment will be also developed e.g. terminal care in hospices or in their one’s own home. Recent revisions to Japanese medical laws in the past few years to support this new direction. The physical provision of improved caring environments for patients, families, as well as of upgraded working environments for health care staff is expected.

Architecture is an expression of culture . Local climate and customs are essential ingredients which must continue to be taken into consideration when planning and building hospitals. Locally-based traditions in particular should be taken into serious consideration. Many such traditions have proven to co-exist successfully with internationally recognized principles of modern medical science.

As has been known since ancient times, the natural environment is a significant contributor to recovery from illness. The modern hospital, with its artificial environment which ultimately rendered the patient a little more than a machine cared for by the machines of the institution, lost this timeless aspect of care. It is important to re-create true 'healing environments' in hospitals and related health facilities. As hospital buildings and engineering technologies are regarded as the ‘hard’ dimensions of healing environments, it is essential to improve the ‘soft’ dimensions of healing environments, encompassing such attributes as a positive, cheerful staff, clean rooms, and satisfying food. Without patient-centered philosophies, well-designed buildings and high-tech


equipment cannot create a truly therapeutic healing environment. In this regard, the role of the Facility Manager in hospitals will grow in importance in the coming years in Japan and elsewhere.

Hospital Geography studies have been conducted by the author over the past numbers of years. These studies stand our in terms shedding light on the experience of the viewpoint of each individual person, including the patient, one’s family and the staff. Finally, a new organization, Global University Programs in Healthcare Architecture (GUPHA), founded as an international organization in 2000, links and promotes education and research programs in health care architecture internationally. This fledgling organization is currently undertaking studies on future healthcare environments for the year 2050.

status and perspective of hospital architecture in japan

Documents