INO

November 27, 2023 John Dale

INO

Intensive Care, Emergency, Laboratory and Surgical Center

Project Data

Bern, Switzerland

Location

Primary System: 4D PLUS General Planner (architect: Kamm+Kundig) Secondary System: Itten and Brechühl AG

Architects

Office for Real Estate and Public Buildings of the Swiss Canton of Bern (OPB); Giorgio Macchi, Chief Architect and Director of the OPB Office

Client

2007 - 2013

Construction

51,000 m2 (550,000 ft2) for flexible use.

Building area

Framework is of concrete construction with a column grid of 8.4 x 8.4 m using precast concrete columns, in-situ concrete slabs with ‘knock-out’ panels at the center of each column bay

Primary System

Conventional construction for non-loadbearing walls; secondary system ‘floating’ concrete slab separated from primary system slab by a waterproof membrane

Secondary System

Background

Giorgio Macchi, Chief Architect and Director of the OPB Office, told the author in a private conversation: “Instead of being refined over time, what was being built on the Inselspital Campus at a specific time, to a large extent, conflicts more and more with what ought to be. Dealing with change should become a fundamental aspect of how we perceive architecture, and consequently also how we conceive it. As long as time is not a guiding factor the planning processes will be dominated by stress.”

The INO offers insights into a strategy for overcoming this basic dilemma. The strategy is called System Separation (SYS). The core principle of this strategy for designing buildings is this: fix few things, to keep flexibility, but fix them firmly, to achieve reliability. What emerges is high utility value. Buildings of high utility value remain useful over a very long time, are effectively renewable, convertible, and developable, and generate a growing cultural identity. SYS fosters sustainability and facilitates change necessitated by technical lifecycles or by lifespans of use.

The Office for Real Estate and Public Buildings of the Swiss Canton of Bern (OPB) started developing the strategy in 1998. It has since become a binding guideline for all projects (more than 25 at time of writing this book). Their portfolio includes approximately 2000 public buildings worth five billion Swiss Francs ($5.6 billion), as well as annual investments of 150–200 million Swiss Francs ($170 – 225 million).

SYS separates both requirement planning and building design into three levels, referring to long, medium, and short-term perspectives. The managerial backbone concept of SYS is divide, allocate and delegate. Components and steps are well-defined and manageable. The whole maintains complexity at a specific time as well as over time. Architecture – conceived and perceived in this way – emerges through its use.

Decision-makers generally dislike openness and particularly uncertainty. Their job is to eliminate openness and uncertainty by means of decisions. However, they are accessible to priorities and especially to hierarchies. The idea of SYS used the comparison with a bottle-crate to communicate the basis ideas of SYS to skeptical bureaucrats.

The crate stands for the long term, the bottles for the medium term, and the drinks for the short term. Crate, bottles, and drinks are a useful, reliable, and proven product and procedure.

System separation’s first project

The INO project was launched in the mid-nineties. It is the first project guided by SYS. As part of the University Hospital of Bern, it has to fulfil high-tech requirements in a comprehensive academic medical center. INO mainly involves the intensive care units, emergencies, surgeries, and laboratories. Substantial changes took place already during the planning and realization phases. The first intensive transformation while the building was in use concerned the laboratories.

The PS was the result of an international competition (typical for Swiss public projects) and was designed by architects without specific experience in hospital planning. Fittingly, the project was called “Time-Space”, showing that the authors had caught on to the essential idea of the architectural task that SYS imposed.

The subsequent competition for the SS was open exclusively to highly experienced hospital planners. The possibility to compare very different solutions for SSs within the same PS was a paradigm shift in decision-making. The team for the TS was selected based on its experience, as was the team for project management.

The three levels for building design are the Primary System (PS), the Secondary System (SS), and the Tertiary System (TS). The PS (Base Building) is oriented on the long-term and concerns the building structure, including the facades and the site area’s development availability. The SS (the Infill or Fit-Out) is oriented on the medium term and concerns the internal non-structural building construction, the technical installations and mechanical systems. The TS is oriented on the short term and concerns the building facilities, devices, equipment and furnishings. Designing and managing the planning and building procedure respecting this hierarchy of lifespans means that replacement or modification of shorter-life elements does not affect or damage those of greater durability or longer use.

The PS has no structural complications, a minimum of structural barriers, high net loads, high floor heights, and stated spatial reserves for installations, and it strictly respects the partitioning or disentanglement of building components. There are no pipes or conduits in the PS. The precautions for site area availability, besides guaranteeing a general openness, are justified by the fact that all traffic and transport to and from a building has almost the same impact on the environment as the building’s operation. The potential of well-connected areas must therefore be built up to the maximum, whether at the time of construction or in the future, even if current building regulations do not yet allow this. The robust PS therefore enables vertical and horizontal expansions.

The PS has a characteristic shape and comprises 51,000 m2 (550,000 ft2) on very spacious floors for variable use. The framework is of concrete construction with a column grid of 8.4 x 8.4 m (27.5 x 27.5 ft). The lateral stabilizing structural elements are limited to four cross-shaped shear walls. Statically, each field or cell of the column grid allows for an opening of 3.6 x 3.6 m (11.8 x 11.8 ft) to be cut out of the floor slab. (Figure 3) These “knock-out fields” can be used on the level of the SS to enable daylight, visual contact, and vertical access, during the planning as well as later on for transformations. (Figure 4) All technical installations supplying a given floor are installed on that same floor, including drainage and other piping and air handling ductwork. Each column-head has four block-outs (pipe sleeves) for vertical outlets for drainage pipes. The concrete floor structure is strictly free of installations, in line with the principle of the partition of building components.

Figure 4

Figure 5

Partitioning building systems: A management strategy

Handling these system levels in a strategic way generates the three main principles of SYS: the partition of building components – limiting all entanglements on or across the three levels to a minimum; flexibility – above all ensured by the structural capacity and geometries of the PS and appropriate SSs, and site area availability – ensured by appropriate PSs in order to develop the building site densely over time.

Tasks and mandates have to be aligned with the principles of SYS from the very beginning. Planning in line with SYS is not just an additional planning criterion. It is a radical new way to do things.

Planners including architects, structural engineers, engineers for technical installations and experts for operation domains have to cooperate to optimize the whole. Because SYS differentiates the whole into long-, middle- and short-term perspectives the organizational structure of the cooperation of the planners must be in compliance with this paradigm shift. The strategy of separation defines new starting positions for all parties involved and for all components to be built and installed.

Figure 6

Changes

During the planning for the Secondary System, the Chief of Surgery left for a position at another hospital. His team had worked out a surgery suite layout with the secondary system architects. When the new head of Surgery was hired, he insisted on another layout of the surgery suite. The capacity of the primary system was immediately evident because the new layout was quickly adopted and implemented.

After the building was in operation for several years, the medical laboratories needed to be reconfigured to accommodate new research equipment. This too was accommodated quickly with no disruption to other functions in the building. This was enabled in part due to the secondary system ‘floating’ concrete slab which is separated from the primary system slab by a waterproof membrane. Some conduits are in this floating slab.

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

Phase two

After the INO was already in operation for several years, the hospital decided to complete Phase II. This time, due to budgetary constraints, the original double skin façade was dropped, but the same structural grid and pattern of skylights and light wells were maintained. (Figure 9)

Figure 12

Sammy Ofer Heart Building

November 27, 2023 John Dale

Project Data

Tel Aviv, Israel

Location

Ranni Ziss Architects and Sharon Architects

Architects

Tel Aviv Sourasky Medical Center in Israel

Client

70,000 m2 (753,500 sq. ft.)

Building area

Design started in 2005. Primary system constructed in 2008 – 2011; Secondary and Tertiary systems ongoing construction from 2008.

Design/Construction

Structural grid of 7.6 x 7.6 m (25 x 25 ft), central core of elevators and stairs, distributed MEP shafts, and the building envelope.

Primary System

Non-loadbearing walls and MEP systems.

Secondary System

Ward equipment, including medical devices, digital tech, and furniture.

Tertiary System

Dr. Nirit Pilosof

Case Study report

Introduction

The case of the Sammy Ofer Heart Building at Tel Aviv Sourasky Medical Center demonstrates the contribution of the Open Building approach to the evolutionary process of a healthcare building over time. While most hospital facilities are “tailor-made” - designed for a highly detailed functional program, the design team of the Sammy Ofer Heart Building challenged this traditional practice and proposed a flexible design for unknown future functions (Pilosof, 2020; Sharon, 2012). To maximize the value of a private donation and expand the hospital capacity to evolve in the future, the hospital CEO decided to defer the decision on the uses of seven of its eleven floors for later consideration. Accordingly, the need to design a Base Building as a “container with capacity” that could accommodate unknown functional programs led to the implementation of system separation (Figure 4). Although the open building approach (Kendall, 2008) was not explicitly stated by anyone in the design process, its methods of system separation and distributed design management implicitly supported the construction of the project in phases, enabled the design of a variety of changing functional spaces, and enhanced the management and coordination of the design process by different consultants, designers and contractors.

The design process

The project was designed by Sharon Architects and Ranni Ziss Architects, a joint venture, and was developed starting in 2005 and constructed in 2008 - 2011. The building, located in the center of Tel Aviv, was designed as a monolithic cube clad in glass with prominent red recessed balconies. The building was designed to connect to an adjacent, historical ‘Bauhaus’ hospital building through an atrium with iconic red recessed balconies (Figure 1). The 70m (230ft.) high building consists of 55,000 m2 (592,000 sq. ft.) and includes 13 medical floors of 3,100 m2 (33,300 sq. ft.) per floor, and four underground parking floors designed with the possibility of conversion to an emergency 650-bed hospital. The 15,000 m2 (161,400 sq. ft.) underground “sheltered” floors were designed in an innovative way to be resistant to chemical and biological warfare.

The main force behind the design and construction of the building was the generous donation of the Sammy Ofer family to the Tel Aviv Sourasky Medical Center in 2005. Since hospital development in Israel relies primarily on private funding, hospital directors attempt to maximize the potential of each donation. In the case of Tel Aviv Sourasky Medical Center, it was clear from the start that the hospital would construct the most extensive structure possible even by applying pressure on the municipality planning guideline limitations (Figure 3). This strategy led to the design of a base building with seven shell floors for future completion, and was even more evident in the ‘last minute’ decision to add two more shell floors to the building just before construction began. This change of the buildings’ height required redesigning the buildings’ primary system, including the structure, MEP systems and facades and caused a delay of a few months in the design and construction process. In 2022, a decade after the building was opened, the hospital management decided to add three more floors to the top of the existing building to offer more space in the highly dense urban site. (Figure 3)

The project was programmed and designed by the architects in collaboration with the hospital CEO, deputy director, head of cardiology units, head nurse, and various internal and external consultants and project managers. Like most hospital facilities, the project was planned under tight budgetary, regulatory and environmental constraints. The design process, which began in 2005, reflected a variety of concepts. The realization of the project depended on finding a solution for an existing (but now obsolete) two-story outpatient building that had been constructed on the site in the 1960s for use as an emergency department. After much discussion, that building was demolished. Because the hospital management was undecided regarding their strategy and program, the design team developed a method of presenting and evaluating diverse design options for the new project.

The building, defined as a cardiac care center, was initially programmed to relocate all the hospital cardiac units, clinics, and surgery division onto three main floors and include an additional two floors for internal medicine units and outpatient clinics. Seven additional floors were also built but left empty for future programming and Infill or fit-out. Accordingly, the new building was constructed in five main phases: (1) the underground emergency hospital, (2) core and envelope (Base Building) of floors 1-10 including a mechanical roof floor, (3) interior fit-out of floors 0-3, (4) interior fit-out of floors 4-6, and (5) interior fit-out of floors 7-10. The hospital plans to construct three additional floors on top of the existing building in 2023, adding 8,500 m2 (91,500 sq. ft) for diverse inpatient and outpatient units (Figure 3).

Figure 2

The design process from the beginning included capacity studies to analyze if the primary system could accommodate the predicted development of the building in the future as defined by the hospital CEO and medical directors. The preliminary studies included schematic drawings of a typical floor with two inpatient medical units to illustrate the capacity for both: two identical mirrored units vs one major unit with more ICU rooms and a minor unit with semi-private rooms (Figure 2). The client also required the architects to prepare a schematic design for the research lab and Neurology units that were expected to be installed in the shell (empty) floors of the building. The primary purpose of the capacity studies was to analyze if the primary system (Base Building) would support future anticipated programs, the location of heavy equipment, possible connections to MEP infrastructures and efficient configuration of functions. Research on the evolutionary process of the building over thirteen years revealed that the preliminary capacity analysis study drawings were retained and were later used to evaluate the potential of the building for future change and to analyze the interfaces between the different system levels (Pilosof, 2018). In this sense, these drawings became a communication tool between the initial design team and the following design teams, their importance unknown at the time of the initial design, to demonstrate the open building approach (which at that time had no formal name to the design team or client) and to explain the decision making throughout the design.

The evolution of the building

The Sammy Ofer Heart Building, defined and designed as a cardiology center, has changed its functional program considerably. The cardiology division in fact, occupies less than 30% of the building. The building now contains neurology, dermatology, internal medicine and oncology units in addition to research labs and outpatient clinics (Figures 3 and 4). The change of program can be explained by changing needs since cancer became the number one cause of death and statistically surpassed cardiac diseases. The logic of centralizing the oncology units in one location to enhance the hospital efficiency and health services could only have been accomplished in the new building. The hospital management also decided to relocate other functions to the building since their previous locations required renovation or extension or received funds to reconstruct a specific medical unit. In some cases, the decision to relocate medical units to the new building was the result of competition with other hospitals, or a strategy to attract highly accomplished medical directors. Throughout the years, the hospital’s dynamic development plan has been driven by forces of economics as well as internal and external organizational politics.

Figure 3

Figure 4

Most of the changes took place after the building was occupied. Although this process of deferred completion of secondary and tertiary systems was planned in advance, it still created a challenge both for the construction and the operation of the running units. The phasing stages, divided by the buildings’ floors, created a fit-out process from the bottom upwards. This strategy might be efficient in order to avoid interruptions of the completion to the operating units, but it limits decision- flexibility during the design process. In many cases the considerations in the fit-out installation phases overruled the importance of locating some medical functions close to other units for process optimization. For example, the inpatient internal medicine units under construction on the 9th floor should have been located on the 4th floor above the existing internal medical units (on the 3rd floor) to centralize the internal medicine division and enhance staff and equipment flows among the four units.

The separation of the building into system levels was also useful as a project management and budgeting tool in the design process. The long design process of thirteen years, which was still running in 2018, involved many different professionals and decision makers. Many of the project team members of the hospital were replaced, including the CEO of the hospital, heads of medical units and head nurses. Each change of personnel resulted in reconsideration of the design and requests for alternative design options. The design team included a collaboration of two architecture firms, the replacement of two project management firms, and consultants who changed over time. The development of the project by phases, using system levels, allowed the architects to divide the workload between the two offices. Each office was responsible for designing specific floors’ secondary systems, with minimal need for consultation and coordination. The design control was distributed between the two firms on each level (e.g. the primary, secondary and tertiary system levels) to avoid inequal division between the two firms. The study also indicates that capacity study drawings that were developed at a preliminary stage were used as communication tools later, among design teams not even known initially, because they defined the anticipated interfaces between the system levels. The recent decision to add three floors to the top of the building demonstrates the capacity of the original design to grow even beyond its initial build-out. It highlights the unpredictability of future needs and the necessity to plan for change over time.

Acknowledgments

This research was supported by the European Research Council grant (FP-7 ADG 340753), and by the Azrieli Foundation. I am grateful to the Tel Aviv Sourasky Medical Center management and staff, and to Ranni Ziss Architects, Sharon Architects, CPM and M. Iuclea project managers for their collaboration.

References

Pilosof, N. P. (2018). The evolution of a hospital planned for change. In S. H. Kendall (Ed.), Healthcare Architecture as Infrastructure (pp. 91–107). Routledge.

Pilosof, N. P. (2020). Building for Change: Comparative Case Study of Hospital Architecture. HERD: Health Environments Research & Design Journal, 193758672092702. https://doi.org/10.1177/1937586720927026

Sharon, A. (2012). Flexible building design offers future-proofing. IFHE DIGEST, 96–98.