"Observation as a Way of Knowing and Measuring Open Hospital Spaces", in F. Giofrè, Z. Djukanovic (edited by), Health Spaces. Hospital Outdoor Environment, Tesis, Firenze 2015

Health spaces Hospital Outdoor Environment Edited by Francesca Giofrè and Zoran Ðukanović Published by TESIS Inter-University Research Centre Systems and Technologies for Social and Healthcare Facilities University of Florence Copyright 2015 Health space. Hospital Outdoor Environment / Edited by Francesca Giofrè and Zoran Ðukanović. Copyright of individual chapters is retained by copyright holders as detailed for each chapter. All rights reserved for the publisher Inter-University Research Centre TESIS “Systems and Technologies for Healthcare Buildings” Univerity of Florece, Street San Niccolò 93, 50125 Florence; Sapienza, University of Rome, Department Planning Design Technology of Architecture, Street Flaminia 72, 00196 Rome. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the publisher. For more information on all TESIS publications visit http://www.tesis.unii.it Authors: Rosalba Belibani, Nađa Beretić, Ružica Božović-Stamenović, Martina Cardi, Rosalba D’Onofrio, Zoran Ðukanović, Anna Maria Giovenale, Francesca Giofrè, Vesna Mandić, Ivana Miletić, Valentina Napoli, Giuseppe Primiceri, Fabio Quici, Tamara Stanisavljević, Ferdinando Terranova, Elio Trusiani Foreword: Romano Del Nord and Vladan Đokić Design credits: Nađa Beretić ISBN: 978-88-907872-9-4 First edition, 2015 Sapienza University of Rome, Department Planning Design Technology of Architecture, Italy Faculty of Architecture, University of Belgrade, Serbia Public Art & Public Space program, Faculty of Architecture, University of Belgrade, Serbia Content Foreword Romano Del Nord vi-vii Vladan Đokić viii-ix Introduction Francesca Giofrè and Zoran Đukanović x-xv 01_ Hospital open spaces and urban open spaces Zoran Đukanović_ 16-57 02_ Regeneration and restoration of the hospital spaces Ferdinando Terranova_ 58-95 03_ Healing environments design Nađa Beretić_ 96-125 04_ Observation as a way of knowing and measuring open hospital spaces Fabio Quici_ 126-147 05_ Exploring the relationship between outdoor and indoor environments in the hospital design process Francesca Giofrè_ 148-169 Health spaces. Hospital Outdoor Environments 06_ Hospital outdoor environments on dualities and contradiction Ružica Božović Stamenović_ 170-199 07_ Health facilities and open spaces: integrated policies at the landscape and territorial level Rosalba D’Onofrio and Elio Trusiani_ 200-219 08_ A Master Plan for regeneration: Piacenza Hospital complex, Italy Anna Maria Giovenale_ 220-237 09_ Barriers between hospital and city: seven Italian case studies Francesca Giofrè_ 238-261 10_ Image of a hospital city: clinical center of Serbia Ivana Miletić _ 262-287 11_ The role of outdoor public space in a pavilion university hospital. Case study: Policlinico Umberto I of Rome, Italy Valentina Napoli and Giuseppe Primiceri_ 288-311 12_ Hospital open spaces. Healing or threatening environments. Case study: Clinical centre of Niš and Clinical centre of Vojvodina in Novi Sad, Serbia Vesna Mandić and Tamara Stanisavljević_ 312-343 13_ Analysis of some renovation projects indoor and outdoor. Case study: Policlinico Umberto I of Rome, Italy Rosalba Belibani and Martina Cardi_ 344-369 Francesca Giofrè and Zoran Ðukanović, Editors 04 Observation as a way of knowing and measuring open hospital spaces Fabio Quici Abstract: To speak of open hospital spaces is to explore, irst and foremost, their identity, as well as their role and their function in practical terms. Can they be considered places ? Can it be said that the open spaces of today s hospital structures present characteristics suicient to qualify them as public spaces? The public that frequents hospital structures has a well-deined identity, consisting of patients, visitors and medical staf, each with its own speciic needs and expectations. The spaces in question are not those traditionally found in urban areas, such as squares or streets, nor are they traditional urban parks. The irst step towards understanding the nature and the function of open hospital spaces, in order to be able to plan and design them adequately, is to investigate the behaviour and the expectations of the users of such spaces. What is needed is a survey of the current conditions and uses of the existing structures, in the form of a critical examination of the behaviour of the people who deal with the distribution of time and spaces in hospitals on a daily basis. Using the approach to analysing human behaviour in open spaces developed by Jan Gehl, an attempt is made to calibrate this methodology to the distinctive characteristics of open hospital spaces, in order to arrive at an understanding of their dynamics and, as a result, succeed in adequately ine-tuning the objectives of their design and planning. Quantifying the users in light of their diferent activities, determining the various categories, identifying the areas where individuals tend to concentrate, observing the activities that predominate in order to gain an understanding of real needs, recording the duration of such activities: these are the goals of a survey carried out through an attentive observation and collection of the available data. A number of recent experiences point to a radical change in outlook in the design and planning of hospital structures, with the starting point for such change tied to the increased attention paid to the therapeutic component of their outdoor spaces. An example is what has been done at the John Hopkins Hospital in Baltimore, as well as recent projects in Europe where the design of open spaces played a key role in the overall planning and design strategies. Keywords: survey, behavior, outdoor, hospital. Introduction «Public spaces consist of open spaces (such as roads, sidewalks, squares, gardens and parks) and covered spaces built not for proit, but for the common good (...). Both types of spaces, when they possess a clear-cut identity, can be considered “places”. The ultimate goal is for all public spaces to become places”. So states point 8 of the Charter of Public Space drawn up on the occasion of the Biennial of Public Space in 2013. But can the outside spaces of today s hospital complexes be considered places? And, even more importantly, to what extent can these spaces be characterised as public? The fact that the term open spaces is used with regard to their design does not necessarily mean that they are public spaces , much less that they constitute locations. The evidence is there for everyone to see. Hospital complexes are often isolated from the surrounding urban context by barriers, or they are found in areas landscaped as generic greenery, based on a modernist tradition that seeks to combine the functional eiciency and hygienic condition of the buildings with extensive open spaces. In the case of the buildings, the space that separates them from the surrounding barriers serves as an interstice interpreted irst and foremost in infrastructural terms (access ways for vehicles and pedestrians, parking facilities, utility installations etc.), with any stopping or lingering viewed primarily as an impediment to the frenetic motion of the hospital. In the case of the large lawns or planted ields, they place the spectre of illness at a remove, relegating it to functionalist cathedrals that society appears to wish to banish from its day-to-day existence. In both cases, we are dealing with what, according to Peter Buchanan, should be an open space, or an architectonic event , and therefore a place . But in actual fact, open hospital spaces, for the most part, are not eve addressed as an urban-planning or landscaping problem. To what extent can they be considered public? They are spaces frequented by the public, but were they really designed with the public in mind? Were they planned for the types of individuals and activities that actually put them to use? The public that frequents hospital facilities presents well-deined characteristics. It is made up of patients, visitors and medical staf, each group with its own speciic needs and expectations. We are not dealing with traditional urban spaces, such as squares or streets, that attract all types of people and are capable of accommodating and encouraging all the traditional activities that take place in a public space. Nor are we taking about urban parks, with their leisure-time activities. An outside hospital 128 04_Observation as a way of knowing and measuring open hospital spaces space, when designed with its users in mind, so as to meet their actual needs, is a space arranged in diferent settings geared towards guaranteeing mobility, privacy and places of rest or pause (1). Areas of greenery are established as ilters, to separate the hospital from the road. Porticos are built with roofs or awnings to mark of the areas where vehicles stop to let of passengers, and they hold seats or benches, signs providing directions and various services. In the case of hospitals that consist of a number of diferent pavilions, the green areas (landscape grounds) with pedestrian walkways and sites for pausing and stopping can be used both as connections between the buildings and for moment of waiting or recreational pauses. The designs that work hardest to ensure the physical and psychological comfort of patients can include gardens for convalescence , meaning healthful sites for meditation and healing, planned to host both active and passive activities: contemplating the garden from a window, sitting in it, eating, reading, walking, exercising etc. But apart from the customary procedures that establish the zoning of an open hospital space, the planning and design of these settings should start with the use of what is an indispensable tool for any architect of outdoor spaces, Figure 1: The observation of the use of public spaces as fundamental parameter for their design 129 Fabio Quici and namely a knowledge of the actual behaviour and expectations of the users (which can difer from country to country, or even from region to region), something that can obtained only through close and attentive observation. Surveying the use of outdoor spaces The operation of surveying – and, therefore, gaining knowledge of – an urban space, in the same way as the surveying of architecture, is a speciic process whose objective is to arrive at «a critical, scientiic knowledge (meaning knowledge that is focused, analytical, veriiable and transmittable), together with an ordered documentation, of the quantitative and qualitative dimensions (physical-spatial, metric, historical, regarding the state of use and preservation etc.) of its archaeological, architectonic and landscaping assets, all of which the survey itself contributes to deining» (Ugo, 1994). This objective is normally achieved through the establishment of models based on the diferent disciplines drawn on for the operations of measurement. But while there is no question that the notion of measurement , in connection with public spaces, is of key importance in determining the components and proportions that conigure and give form to the physical space, it is not equally suited to observing the use that is made of the space. An analysis of the use of public spaces centred on people s behaviour – spontaneous and/or brought about by the environmental conditions or the planned space – would allow us to assess the quality of urban spaces, so as to obtain parameters of use in fulilling the expectations of the users of such spaces. It follows that another type of measurement , together with other operating instruments, must be brought into play if we are to fully appreciate this aspect which, though so readily apparent, proves diicult to measure and transcribe. One of the more attentive, as well as innovative, experts on public life is Jan Gehl (2). His analyses take their bearings from earlier studies, such as those carried out in the ield of urban design by Gordon Cullen, or the sociological observations of Jane Jacobs, plus the thinking of Aldo Rossi on cities, together with the studies of Las Vegas done by Robert Venturi, Steven Izenour and Denise Scott Brown, as well as Kevin Lynch s work on the principles of perceptive orientation in cities. The thinking and analyzing method developed by Jan Gehl across the years begin with his design practice and it is returned in a systematic way at irst in the book Life Between Buildings (1971), then in Cities for the People (2010) and more recently in 130 04_Observation as a way of knowing and measuring open hospital spaces How to Study Public Life (2013). The aim of Jan Gehl’s analyses is to arrive at a form of urban planning on a human scale, grounded in the activities and behaviour of actual people, and therefore relecting the activities habitually carried out in open public spaces. Any design operation should be preceded – as Jan Gehl sees it – by an analysis of human behaviour. Such an analysis revolves around the realization that design, gender (male-female), age, inancial resources, cultural background and any other factors determine how we use, and how we do not use, public spaces. The main instrument for studies of life in public spaces is direct observation. “The study of the behaviour of individuals in public spaces can be compared to the study and structuring of other forms of living organisms. Whether animals or cells are involved, the total number is counted, the speed at which they move under various conditions is observed, and an overall description of how they behave is arrived at through systematic observation” (3). Based on these considerations, Gehl has listed what he considers to be the ive main questions to be answered through the observation of human behaviour in public spaces: - How many? A quantiication of the individuals who move through a space, or who spend time in it, is the irst variable that can and must be evaluated. In this way, for example, the dynamics of the lows can be understood and the predominant activities can be quantiied. - Who? The second priority is to understand who the primary users are and what groups of people (measured according to a variety of parameters, such as gender and age) use a given public space. - Where? The third focus of observation and evaluation are modes of behaviour; consideration must be given to where people usually go and where they prefer to stop and spend time (along the boundaries of a space or at its epicentre, or do they distribute themselves indiferently throughout the space? Do they prefer spaces that are public, semi-public, private etc.?). - What? The fourth observation evaluates what takes place in the urban space, what are the primary activities to which it gives rise: walking, stopping, sitting, playing, interacting, remaining by oneself etc. - How long? The ifth question entails measurement of the temporal dimension, meaning the amount of time that people devote to the diferent activities. A place that is inhospitable or otherwise inadequate, for example, leads people to pass through quickly, whereas a well-proportioned, welcoming place encourages people to stop and linger. 131 Fabio Quici These observations, which are elementary in appearance alone, can aid in arriving at an understanding of the spontaneous or conditioned behaviour of individuals, together with their needs and expectations. The questions posed can help reach an understanding of the role of a place where design and planning work shall be done and of the primary behaviour patterns of the types of individuals who shall be the inal users. At the same time, a behavioural analysis always proves to be the most efective tool for evaluating, after the fact, whether or not a public space has been properly designed. Now we shall try posing these same questions with regard to a generic open hospital space. How many? This is the primary question in the case of areas pertaining to hospital facilities, as well as the one used, in practical terms, to set the main design and planning guidelines. The evaluation of the number of users and the related lows of movement determines the positioning of the pedestrian and vehicle access points, together with the related paths of circulation, which are diferentiated in accordance with whether they carry medical, public or logistical traic (4). Hospital design would still appear to respond to this question above all others when it comes to deciding the forms of outdoor spaces. But what if we are looking to give to a portion of these spaces features and functions that make them viable settings for a public considered not only to be merely passing through? In this case, steps must be taken to quantify the large number of people who, in addition to moving through the outside spaces, also manifest a need to stop and spend time in them, even if the spaces are not equipped for such use. Whoever has spent any time in a hospital structure – even to simply visit or accompany a patient – is familiar with the vital need (both physical and psychological) to go outside and “get some air” on a nearly periodic basis throughout the stay. Nevertheless, this concern is usually neglected during the planning and design work, or it is addressed by assuming that a few seats or benches placed without following any particular criteria constitute an adequate response. Who? Who are the users of open hospital spaces? Normally this is considered a generic classiication that covers visitors, patients and medical staf. But a more accurate examination of how these spaces are utilised could result in the identiication of subcategories presenting diferent needs. Visitors, for example, include individuals accompanying patients, who are often obliged to remain inside 132 04_Observation as a way of knowing and measuring open hospital spaces the hospital, or in its outside spaces, for medium-long periods of time, while smokers must necessarily use the outside spaces (5), in addition to which there are children and old people: both those able to move under their own power and others unable to do so. Patients needs also vary widely, depending on their health, their pathologies and the length of time they are hospitalised. This is why optimal planning and design work makes provisions for healing gardens , meaning sheltered, healthful sites set aside for psychophysical relaxation and healing. In the case of the personnel as well, even though they have limited time to use the outdoor spaces, there is no mistaking the tendency to seek and to consider contact with the outside as an indispensable element in improving working conditions. Where? Observing where people are likely to go or stop and spend time within an urban context (be it a street, a square, an entire neighbourhood or a generic empty urban space) can provide the dimensions and parameters of the logic underlying the movements of people as they use public spaces, together with their levels of satisfaction. In the areas bordering on healthcare facilities, and within their areas of pertinence, the main directions considered under planning and design work are those consisting of entry and exit movements. If observation is also made of where people are accustomed to stop and spend time, then it will become apparent that their decisions, under the most frequent conditions, are inluenced by the scarcity of spaces set aside for waiting or for other types of recreational activities designed speciically to be carried out in outdoor spaces. The highest concentrations of presences will be recorded in and around the entry points to the structures or in the vicinity of the zones ofering food service and refreshments (normally found inside the buildings, near the entrances) or where there are seats or benches, even if these are found in isolated, leftover areas of the outdoor design, along connecting roads or amidst parking areas. In such cases, the observations recorded may have little real meaning, given that the directions of movement and assembly may be inluenced by the layout of the locations or by the fact that the sites available leave little room for free choice. Still, based on the behaviour patterns that people are led to follow, considerations can be formulated for corrective work or for a full reformulation of the overall planning of the areas set aside for public use. What? This is the single most important question that can be answered by observing the activities that occur in outside hospital areas; close observation of the main activities engaged in by users can prove to be of fundamental importance in good 133 Fabio Quici Figure 2: Open areas next to Rome’s hospitals become marginal and residual areas. Sant’Andrea Hospital (above) and Gemelli General Hospital (below) 134 04_Observation as a way of knowing and measuring open hospital spaces San Giovanni Hospital (above) and San Camillo Hospital (below) 135 Fabio Quici planning and design. First of all, it can be determined whether or not those spaces satisfy the all important function of facilitating the eforts of visitors to orient themselves, and therefore move about. All too often this activity is left to be carried out by a redundant superstructure of ambient graphics (signs and signals) that do not always do the job efectively. Secondly, it can be noted that most people who are obliged to frequent hospitals (patients and visitors) spend the bulk of their time merely waiting. Apart from the appropriately outitted waiting rooms, the areas of distribution, the rooms for the patients and the spaces for food service and refreshments, a large part of the time is spent in some connection with the outside spaces. This relationship can be said to be established even through nothing more than the simple visual link sought out from the inside, through the windows, during waiting times. It is during the time spent waiting that a great many of the other activities that can be observed take place. There are people who wish to be of by themselves (one of the needs given the least attention), while others seek out interaction in order to exchange experiences or simply make contact with people willing to listen to them; others feel the need to move about constantly; while still others are merely looking for a place to sit and watch the activities going around them, as a simple but invigorating form of distraction. When children are present, the outside space proves all the more important in terms of providing opportunities for entertaining activities, even when there is no equipment speciically designed for the purpose. To accommodate all these activities, there is often nothing more than a few seats and benches arranged without any particular criteria or, when all else fails, low walls, stairways or portico that serve as stopgap measures to meet these needs. When patients are involved, the outside spaces are often the scene of the irst rehabilitation movements they make on their own, or such spaces represent their sole contact with the outside world , or their initially contact following a lengthy period of hospitalization. How long? The duration of the activities – meaning the evaluation of the time factor – measures the extent to which them outside spaces meet the users needs (6). If it is found that too much time is needed to reach the wards and the clinics, then it is common practice to introduce corrective measures, seeing that the parameter in question inluences the level of eiciency aimed at by the healthcare structures. On the other hand, when the environment and the structures of the outside areas do not favour the activities referred to above, his consideration would not appear 136 04_Observation as a way of knowing and measuring open hospital spaces to be given an equal amount of consideration. It is no accident that, in many Italian hospital structures, the day-to-day rhythm is linked to the frenetic pace of hospital operations. What is more, the fact that the hospital is often experienced as a negative setting, with its connotation of illness, appears to keep the public from staying or lingering. And yet the time spent waiting to visit hospitalized friends or relatives, or waiting one s turn for medical examinations and appointments, make these sites the most heavily traicked, and most vigorous, public squares when it comes to social interaction. What can be done to establish a parameter of eiciency that also takes into account the capacity of outside hospital areas to accommo-date stopping and waiting while exercising their therapeutic and socialising efects? First and foremost, a radical cultural change is needed. From observation to planning and design. Success stories Hospital architecture is a ield still strongly inluenced, in many instances, by the school of modernist eiciency, an introverted approach geared primarily towards the functional performance of the healthcare machine , without paying heed to its relationship with its users, the city or the surrounding countryside (7). The conception of outside spaces that results lacks any overall vision, nor does it contribute in any way to achieving the physical and psychological wellbeing that constitutes the general objective which such structures are meant to pursue. In the same way as the open spaces of modern cities, the outside spaces of hospital areas have not been conceived of, codiied or theorized in concrete terms, meaning that their planning has not taken into consideration factors of architecture, landscaping, aesthetics or any therapeutic efect; instead it has been deined abstractly, though only in a negative sense, as the empty spaces produced by the layout on the terrain of the architectural plans (8). Still, a number of recent experiences point to the rise of a radical change in the current mindset. The irm of Herzog & de Meuron in Basel, for example, has developed a number of cutting-edge projects meant to renew the very concept of hospital structures, drawing on the experience it gained with the REHAB Rehabilitation Centre (for spinal cord and brain injuries, built in 2003); a two-storey building faced with wood components and designed in close relationship with the surrounding countryside, its area of pertinence – though designed to provide the necessary privacy and tranquillity – is free of any barriers around its circumference or visual obstacles. The new advance represented 137 Fabio Quici REHAB led to the development of projects on a larger scale for the Kinderspital of Zurich and for the NYT Hospital Nordsjælland in Hillerød (Denmark), both of which won their respective design contests, precisely because they proposed a type of hospital design able to represent an alternative to the usual massive structures. The irst project was for a three-storey paediatrics hospital structured around a series of courtyards, as if it were a small city looking in upon itself. The wood facing, the horizontal layout of the structure and a use of greenery that, in addition to linking up with the connection to the surrounding city, also occupies roof areas, all contribute to an overall atmosphere characterised by a familiar, human touch. Just a short distance away is a second, cylindrical structure that provides the geometric counterpoint to the hospital, establishing a dialogue with its surroundings as it provides a separate venue housing activities of education and research. The layout used in the design of the Hillerød hospital is horizontal as well, only in this case the distribution of the volumes is organic, running along curved lines that enclose, in their central portion, extensive surface areas rendered as gardens, including both a series of courtyards and a rooing surface designed to be usable as an open Figure 3: Open spaces designed like a park in the Universitatsklinikum Carl Gustav Carus in Dresden 138 04_Observation as a way of knowing and measuring open hospital spaces space. The green core of the building establishes a dialogue, as well as continuity, with the natural surrounding countryside – on which it appears to rest – to the point where the passage from the internal spaces to the outside ones becomes almost imperceptible. The trend that sees terraced loors and roof surfaces used to house gardens in the available open spaces (9) of hospital structures would appear to be conirmed in recent years by the increasingly frequent appearance of such gardens in the United States. Especially worthy of note are the Schwab Rehabilitation Hospital Rooftop Garden in Chicago (arch.: Douglas Hills Associates, 2013), the therapeutical garden (healing garden) on 7th loor of the Smilow Cancer Hospital in Yale ”arch.: Shepley Bulinch, 2010), the St. Louis Children’s Hospital Rooftop Garden ”arch: Mackey Mitchell Architects e EDAW, 2007) and the Rooftop Garden of the Mary Catherine Bunting Center at Mercy in Baltimore ”arch: Ellerbe Becket con Mahan Rykiel Associates, 2010). The fact that Healing Gardens open both to patients and the public would appear to have become an indispensable prerequisite in the United States ”10). Indeed, the Joint Commission on Accreditation of Healthcare Organizations recently introduced the presence of nature and public greenery as a factor in the evaluation of hospital structures (11). A project of particular importance, in light of this trend, would appear to be that developed by the Olin irm for the John Hopkins Hospital in Baltimore. The design laid out and gave form to four diferent public spaces: the Entry Court Gardens, the Western Courtyard Gardens (containing: the Entrance Garden, the Healing Garden and the Meditation Garden), the Phillips Courtyard and the Little Prince Garden. As stated by Susan Weiler, a partner of the Olin irm, the project has created a new standard of excellence for patient care and hospital design. The gardens have been designed as places of orienta-tion, respite, rejuvenation and calm, with a visual simplicity that accentuates the aesthetic pleasures of the gardens. The newly conceived circulation pattern allowed us to keep one-third of the enormous football-ield-sized site for the courtyard gardens ”12). The spaces were designed with both patients and visitors in mind, in such a way that they can either be experienced directly or provide comfort through the windows of the patients’ rooms, simply by being seen. The conceptual work on each detail is meant to enhance physical and psychological wellbeing while facilitating the orientation of visitors and patients by means of an outside space that not only performs in a functional sense but, even more importantly, places the hospital’s relationship with the visitors and the patients on a more friendly footing. “The Entry Court is 139 Fabio Quici Figure 4-5: Herzog & de Meuron, The design for the Children’s Hospital in Zürich, Switzerland 140 04_Observation as a way of knowing and measuring open hospital spaces Figure 6 - 7: Herzog & de Meuron. The design for the NYT Hospital Nordsjælland in Hillerød, Denmark (above) and Henning Larsen Architects. The design for the recover and extension of the Hospital in Herlev, Denmark (below) 141 Fabio Quici designed to facilitate pedestrian safety as well as to provide ease of movement and clear views for anxious drivers (…) The rich and durable paving palette of bluestone, brick, quartzite and granite will provide visual continuity to the vehicular and garden spaces. This continuity helps to emphasize the patterns and colors of the paving and planting, which is also intended to be viewed from above by patients, visitors and staf”. The Western Courtyard Gardens, including the Entrance Garden, the Healing Garden and the Meditation Garden make available diferent kind of space’s experiences through the use of diferent shapes, articulations, plants, colors and sounds. The plants selected for the Entrance Garden, for example, help mitigate traic noise, both by serving as a carrier and thanks to the ofsetting sound made by their leaves. The Healing Garden consists of two distinct spaces: one more open, and therefore better suited as a site for social relations, and the other more secluded – almost a secret garden. The presence of the water, along with the noise it makes, is inspired by the oriental tradition for endowing each space with the right atmosphere. The Meditation Garden, on the other hand, is designed to be a full ledged oasis of peace and quiet. Decorative elements and plants provide the proper scale, the visual focal points and exactly the right mood for undisturbed contemplation. In order to accommodate recreational areas, as well as a hub of attraction for the external spaces, the plans call for a hospital cafeteria that is to be connected directly to the Phipps Courtyard. Meanwhile the Little Prince Garden is an area set aside for the entertainment of children, inspired by theme and motifs from the adventures of The Little Prince by Saint’Exupéry. The increasing tendency to ensure that open hospital spaces serve a purpose, including a therapeutic beneit, by paying particular attention to each and every type of user, would also appear to be conirmed by European models, as can be observed in France, Great Britain and Denmark. The Henning Larsen Architects irm recently won an international competition for the restoration and expansion of the Herlev Hospital in Denmark (13). The existing hospital was housed in a 120 metre tower based on a stereometric geometry and isolated from the surrounding context, in accordance with the tenets of the functionalist style. The new proposal calls for the construction of a second complex, adjoining the existing one and designed to mediate and mollify it proportions. The expansion consists of a set of buildings laid out horizontally, with a rectangular base holding three circular structures arranged in such a way as to create numerous small outdoor spaces in the form of courtyards 142 04_Observation as a way of knowing and measuring open hospital spaces and gardens. Underlying the proposal is the wish to interpret, on the level of design, the well known therapeutic and recreational efect that only the presence of greenery can provide. This quest has dictated the guidelines of the entire project, so luxuriant courtyards, green roof gardens, and a large, central green heart provide the new hospital with an altogether vibrante and life-airming atmosphere . The outdoor spaces of the hospital are designed to interact with the public in such a way that they prove attractive, serving as a stimulus for all the senses, even from the inside of the building; “as many of the hospital users have a view of the outside environment through the window of the building, the landscape is designed as a number of pictures varying with the rythm of the hospital and changing seasons . The need for a change on the design of hospital structures ca be traced, therefore, straight to the demand for a diferent type of eiciency, meaning one measured not only in terms of the functional performance of the organisational system, the technology and the structures, but also with regard to ties to users, the city and the countryside. The goal is to restore what Renzo Piano refers to as a “humanistic vision of the hospital by relecting on the state of mind of those who experience a hospitalization, either directly or indirectly”, so as to, “reduce the trauma caused by such moments to the greatest extent possible ”14). Thus Piano s proposal of an ideal hospital immersed in greenery, structured around volumes with a maximum of four loors, following the model of pavilion style hospitals, to create a structure whose spaces are measures on a human scale, and without winding up isolated from the rest of the urban fabric. The hospital features a ground loor providing all the services that could prove useful to patient and visitors, but which, at present, are often missing ”cafes, newsstands, laundry rooms, stores, lorists, hairdressers etc.) (15). This ideal design conceived of by Renzo Piano would appear to have reached fruition in the design proposals referred to above, simply taking the form of a response dysfunctional aspects and the unmistakable needs of existing hospital structures. The formulation of the ideal necessarily draws on a knowledge that can be accrued only through a survey of the open hospital space that takes note of the numbers, the identity, the behaviour, the actions and the reactions of the users. 143 Fabio Quici Notes (1) The design criteria outside hospital spaces should satisfy the following prerequisites: accessibility, visibility, feeling of control, feeling of security, physiological comfort, quiet, familiarity, flexibility, sustainability. The types considered include today: landscaped grounds, landscaped setbacks, front porches, entry porches, entry gardens, courtyards, plazas, roof terraces, roof gardens, healing gardens, meditation gardens, viewing gardens, the viewing/ walk-in garden, edile gardens; cfr. Gökçen Firdevs Yücel, Hospital Outdoor Landscape Design (cdn.intechopen.com/pdfs-wm/45442.pdf). (2) Founding Partner of Gehl Architects, Jan Gehl is Professor and Researcher at the Royal Danish Academy of Fine Arts, School of Architecture. Over the course of his career, he has published several books, including, Life Between Buildings (Van Nostrand Reinhold, New York 1987), Cities for People (Island Press, Washington D.C. 2010), New City Spaces, Public Spaces - Public Life, New City Life (with Lars Gemzøe, Island Press, Washington D.C. 2008). He is an honorary fellow of RIBA, AIA, RAIC, and PIA. More informations on the site gehlarchitects.com (3) Jan Gehl, Birgitte Svarre. How to Study Public Life, Washington DC: Island Press, 2013, p.3. The activities that contribute to performing this type of “survey” are listed by Jan Gehl: Counting, Mapping, Tracing, Following/Monitoring, Investigating, Photographing, Annotating, Testing/Walking. (4)As a rule, the outside circuits are catalogued in terms of flows of visitors, patents to be hospitalized, outpatients, emergency room patients, supply of pharmaceuticals, meals and materials and personnel employed by the structure. Each of these flows needs an access point to the building. The first three use the same entrance, while the other three categories should have separate points of entry. Cf. Nicoletta Setola, Percorsi, flussi e persone nella progettazione ospedaliera, Firenze University Press, 2013. (5) The current trend is to prohibit smoking even in open hospital spaces, as is the case at the hospitals of Rovigo, Udine and Prato. (6) As Jan Gehl pointed out, “registering human activity in relation to the physical environment presents a number of special problems, first and foremost because the question involves processes – chains of events – undergoing continuous change. One moment is not like the previous or the one to follow. In contrast to measuring buildings, for example, time is an important factor in activity studies”; J. Gehl, B. Svarre, cit. p.19. (7) When the topic of a lack of familiarity and failure to recognise the identity of hospital structures is brought up, at times it regards the relationship with the staff, but quite often the environmental factor comes into play as well. (8) «While in cities of the past the physical relationship between full and empty volumes was defined in terms of proportions and qualities of perception, in the “open city” of modern times this relation tends to be undermined by the advent of a merely positivistic approach to urban spaces, conceptually considered to be the interval and the spacing between constructed objects» Cf. Pierre-Alain Cro-set, introduction to the section entitled “Modernism and the 144 04_Observation as a way of knowing and measuring open hospital spaces Codification of Open Spaces”, Casabella 597-598, monographic vol. The design of open spaces”, january-february 1993, p.11. (9) This solution was implemented, in particular, by the existing hospitals found within large urban agglomerations where it is difficult to find undeveloped areas at street level. (10) See the examples described in the recent book edited by Clare Cooper Marcus e Naomi A. Sachs, Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restor-ative Outdoor Spaces, John Wiley & Sons, Hoboken, New Jersey, 2013. (11) In 1995 the American Horticultural Therapy Association made a number of recommendations regarding the characteristics that therapeutic landscapes should present: therapeutic gardens in the hospital setting should be simple, unified and easily comprehended places; in the hospital garden setting, it is important to design and program for the widest possible range of user abilities – thera-peutic gardens commonly stimulate the full range of senses — memory, hearing, touch, smell and sometimes taste — as necessary supplements to the visual experience; therapeutic goals focus on mobility, motor skills, social interaction, cognitive ability and emotional status - restorative goals promote general well-being, with focus on play, relaxation, socialization, education and creativity; a profusion of plants and people/plant interactions is essential; edges of garden spaces and special zones of activities within the garden are intensified to direct the attention and energies of the user into the garden; modified features to improve accessibility. (12) Interview published on «Architect+Artisans», 12 april 2012. (13) The project won an international competition that was concluded in 2014. Construction is planned for 2017. Together with the firm of Henning Larsen Architects, the team includes Friis & Moltke, Brunsgaard & Laursen, Orbicon, Norconsult, NNE Pharmaplan and SLA. Of particular note are some excerpts from the comments accompanying the jury’s award, with respect to the change in outlook evidenced by the approach to hospital construction: “Based on a comprehensive analysis of developments in the healthcare sector and a strong focus on creating a welcoming, clear, worthy and sensuous setting for patients, relatives and staff, the vision of the competition team has been to create a symbiosis between the hospital and its surroundings. A symbiosis where the individual elements form part of a natural cycle and create a sensory hospital that will position Herlev Hospital as an exemplary and innovative spearhead in healthcare.” “The project powerfully unites building design and landscape into an architectural whole providing patients, relatives and staff with the experience that focus is on the individual”. The project must be emphasised for its high and wellargued ambition level for healing architecture. The healing potential of architecture is consistently translated into sensuous spaces - in an approach characterised by great variation and commitment at many different levels.”. ”14) Here reference is made to studies carried out by Renzo Piano in 2001 on a new model for hospital design, on behalf of the Minister of Health, Dr. Umberto Veronesi. (15) Along with the considerations on the humanisation of hospitals and their integration with the surrounding city, other points on which Piano calls for reflection are tied to the topics 145 Fabio Quici of innovation ”or flexibility of structures), reliability ”safety in terms of the environment, technical-construction con-cerns, plant engineering and hygiene of sites), research ”the presence of departments devoted to clinical–scientific research) and training (the hospital as a site for the training of personnel). References Cooper Marcus C., Francis C. ”1998) People Places, John Wiley & Sons, Hoboken, New Jersey; USA. Cooper Marcus C., Sachs N.A. ”2013), Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, John Wiley & Sons, Hoboken, New Jersey, USA. Croset P.-A. ”1993), introduction to the chapter Il Moderno e la codiicazione degli spazi aperti , Casabella, 597-598, monographic vol. Il disegno degli spazi aperti , gennaio-febbraio 1993, IT, p.11. Cullen G. (1961), The Concise Townscape, Architectural Press, London, UK . Firdevs Yücel G. ”2013), Hospital Outdoor Landscape Design”, available at cdn.intechopen.com/pdfs-wm/45442.pdf Gehl J. (1971) Life Between Buildings, Danish Architectural Press, Copenhagen, DK. Gehl J., Svarre B. (2013), How to Study Public Life, Island Press, Washington DC. Jacobs J. (1961), Death and Life of Great American Cities, Random House, New York, NY. Lynch K. (1960), The Image of the City, Cambridge ”Mass.) Technology Press, Cambridge, Mass. Rossi A. (1966), L’architettura della città, Marsilio, Padova, IT. Setola N. (2013), Percorsi, lussi e persone nella progettazione ospedaliera, Firenze University Press, Firenze, IT. Venturi R., Izenour S., Scott Brown D. ”1972), Learning fron Las Vegas, MIT Press, Cambridge, Mass. London, UK. 146 04_Observation as a way of knowing and measuring open hospital spaces