Hospitals on the time axis: trends in the real world and implications for architectural education.

The Built Field Is Never FinishedHistoric buildings and neighborhoods-places one admires and likes to visit-are by nature coherent, varied, and also open-ended. They accommodate change and are thus sustainable. Furthermore, the work of making such complex environments is highly decentralized; no one party controls everything. These observations constitute the core of this article, both in regard to procuring healthcare facilities and in educating architecture students to cope with these realities.For example, a mansion once inhabited by a wealthy family is now a school; a building complex once occupied by a religious order is now a modern hospital; office buildings become apartments and condominiums and offices, medical clinics, furniture showrooms; and theaters now inhabit old warehouses and department stores. The main building at the Massachusetts Institute of Technology is a good example of a stately, highly ordered, and sustainable building that has accommodated and will continue to accommodate a wide variety of uses, and within categories of use, a variety of spatial layouts. These examples reveal the autonomy of form and function, as Denise Scott Brown points out in her assertion that form can evoke and enable function (Venturi & Scott Brown, 2004).Hospitals, like cities, are also never finished. In the best cases, architectural infrastructures retain value and maintain appropriate care flow patterns over many decades of change; interior layouts mutate, evolve, and alter in response to the dynamics of the healthcare field. Concepts of optimal patient care pathways clearly change and adjust. In the worst cases, architectural infrastructures fall out of favor and are found incapable of accommodating modes of practice, resulting in entire facilities, after several stages of functional downgrading, being demolished because they lack agility. "Infrastructure is a metaphor for a much bigger set of issues or a much deeper reckoning about the future. It's a metaphor for how we care about and cope with the future" (Morrish & Brown, citing Connery, 2008).These realities are well known and ubiquitous, but they are very difficult to document. Architecture as infrastructure is under-reported compared to the infrastructure of public works and transportation systems that constitute the urban planner's domain. The fourth dimension of architecture is so ordinary and obvious that it is not understood as meriting serious study, except occasionally as the subject of historians. Or possibly, the complexity of the phenomenon has foiled those who want to take its measure. One difficulty is that changes in buildings occur at various rates under quite complex patterns of control and are often indoors, thus escaping mainstream architectural discourse. In addition, the changes that need to be understood are often interdependent-a change in one part necessitates change in another part-producing perturbations that are disruptive, costly, often dangerous, and difficult to account for and measure.The changes that architects, engineers, and clients need to understand if they are to achieve a sustainable built field are the result of complex causal webs. Such forces include building codes and regulations, institutional politics, medical practices driven by competition or regulation, changes in the insurance industry, finance markets and underwriters, and so on. In fact, to the extent that medical facilities are part of the real estate development industry, "the way projects are underwritten today virtually guarantees that they will never meet the standards and longevity of pre-World War II buildings." Thus, "Over the past two generations, what for 5,000 years had been a 40-year asset class has been reduced to a seven- to tenyear economic lifespan for most projects....what would be required if developers wanted to build for the long term?" (Leinberger, 2003, p. 96).Real ImplicationsFifty years ago, some architectural pioneers in the field of healthcare architecture pointed out these issues and made proposals to address them, including the Veterans Administration Hospital Building System (VAHBS, 2006) and the Nucleus Healthcare Projects in the United Kingdom (Astley & Robinson, 2008). …