Why Good Hospital Planning Starts with the Processes

When I am asked what is the most complicated thing about hospital construction, most expect an answer about operating rooms, sterile supply, or medical technology. The expectation is in vain. A hospital has never failed due to technology. It is indeed demanding – but manageable. Failures occur elsewhere: in strategic planning and communication. Around 80% of the problems that arise in hospital projects, in my experience, are communication problems.

For three decades I have been planning hospitals. In 1995, together with Petra Hemmi, I founded the office Hemmi Fayet Architekten AG, an office that specialized early on in healthcare construction and has been part of Architekten und Ingeneure since the beginning of 2023. Our projects include the new building South 2 of the University Hospital Zurich and the renovation and restructuring of the Swiss Paraplegic Center in Nottwil.

The specialization was a conscious decision. We realized that the healthcare sector is full of people whose sole task is to help people who are not doing well. Architects are not directly involved in the treatment – but certainly in the conditions under which it takes place.

What a Mars mission reveals about Integral Planning
My favorite image for Integral Planning comes from a documentary about NASA. Nine months of flight to Mars, an interdisciplinary team in a capsule, highly sophisticated technology – and at some point, the film shifts away from the technology to the soft skills. Because the greatest risk of the mission is not the hardware. It is the interaction between the people who cannot disembark for nine months.

Anyone who wants to work in hospital construction must like people – this is not just a pleasant additional trait but a professional prerequisite. Hardly any other use brings so many stakeholders under one roof: medicine, care, logistics, administration, technology, client, politics. Everyone has an opinion, everyone has a different perspective.

This continuously leads to goal conflicts. They are not an annoyance on the edge of the project but its core: I like to compare it to swimming: Those who complain about getting wet while swimming might perhaps reconsider swimming.

Doing the right things – before doing them right
Integral planning means first doing the right things, and only afterward doing things right.

Reading easement contracts and building rights does not belong to the attractive tasks – but they are exactly those that determine everything else. An excellently organized construction process loses its justification completely if the finished building does not create measurable added value for the processes. Efficiency without effectiveness is dearly bought activity.

Where the real knowledge lies
To find the right task, one must understand how a hospital actually functions. And that is rarely found in the documents one receives at the beginning. Patient paths, horizontal and vertical connections, well-prepared process diagrams from management – all of this is necessary, but it remains theoretical.

The crucial information lies one level deeper, in hundreds of micro-processes, of which the management knows nothing and does not need to know anything. They lie with the people who work every day in the ward, in the operating room, or in the laboratory. Additionally complicating matters: These teams always function. They arrange themselves with any floor plan, they cannot blame a bad plan. Bad processes therefore become invisible – they must be patiently moderated out.

This also includes the question of who is consulted for what. A CEO speaks quickly and willingly about the flooring in the corridor. But that is not the question one should ask a CEO.

Unpacking Expert Knowledge
Between planning and operation lies a reciprocal relationship between experts and laypeople. Some know how planning works, others know how medicine and care function. To make this relationship productive, a change of perspective is needed – as well as the willingness to translate one's own knowledge advantage.

I call this unpacking. And for me, there is a clear responsibility: If the layperson does not understand the expert, it is not the layperson's problem. It is the expert's problem, who could not unpack it.

A simple example shows what this looks like in practice: The usual question to a group of users is: How many cubic meters of air exchange do you need in this room? A nurse cannot answer this question – it is posed in the wrong language. The usable question is: How long should it take before it smells good in this room again? Fifteen minutes, says the user. The engineer calculates the air exchange from that herself.

Planning Costs Instead of Calculating Costs
In architectural education, costs are considered annoying, something that prevents creative work. This is a fundamental error. Costs are a topic, whether one likes it or not – similar to how communication cannot be avoided. The crucial difference is between calculating costs and planning costs. Calculation is done at the end, when one has long fallen in love with a design and the number then calls everything into question. Planning is done from the start, and then costs become a control instrument for the design.

This is exactly what we are working on in our team. A hospital comprises around forty different types of processes, from neonatology to the cardiac catheter laboratory, each with its own procedures and benchmarks. The range of costs per square meter varies from about 5,000 to over 25,000 francs. These benchmarks can be recalculated from completed projects and extrapolated for new projects – so that, in the strategic phase, solid decision-making foundations are created instead of overly optimistic estimates that later cause liquidity bottlenecks.

The problem is structural: Such methods are only as good as the database. And that is difficult to access because hospitals protect their cost situation like a business secret – even though they perform public duties, are subject to public procurement, and are mostly publicly owned. A valuable knowledge treasure remains unused.

What Still Holds True in Forty Years
Hospitals are built for decades, while medicine changes roughly every five years. How does one plan for that? The answer is uncomfortable: Building a hospital for forty years cannot be done properly. It is not possible. It is one of those problems that cannot be solved but can only be contained as best as possible.

The knowledge for this has long been available and does not require hype: sensible grids, uniform floor heights, a solid support concept, lightweight walls, adaptive fire protection, good access, and options for additional stories and expansion. Complete flexibility is economically unfeasible, complete rigidity functionally unsuitable – what is needed is a balance in between.

Things become concrete in the highly equipped areas. Building four reserve operating rooms would be uneconomical. Only building precisely what is needed today is also uneconomical: If the operating room landscape needs to expand by one room in ten years and there is no space, all existing rooms will have to be rebuilt elsewhere. One or two reserve spaces, not even equipped, prevent exactly that. Hospitals struggle with this.

Building is the Solution, Processes are the Task
What needs to fundamentally change in healthcare construction? Not a standard or a funding amount, but a habit of thought. Architects and engineers quickly think in volumes, structures, concrete, and stone. In hospital construction, it is not initially about building, but about how healthcare can be best offered.

My wish for the future of hospital construction architecture can be summed up in one sentence: away from static infrastructure thinking, towards dynamic process thinking. For an integral working planning office, this is not a side note, but the actual basis of work – and the reason why good planning processes are indeed no coincidence.