Sağlık örgütlenmesi yaklaşımları ve Türkiye'de hastane binalarını prefabrikasyon teknolojilerine göre planlama sorunu üzerinde bir araştırma
An approach to health organizations and a research on the problem of planning hospital buildings with prefabrication technologies in Turkey
Yazar: GAYE OĞULTEKİN
Danışman: PROF. DR. EROL KULAKSIZOĞLU
İstanbul Teknik Üniversitesi / Fen Bilimleri Enstitüsü / Mimarlık Ana Bilim Dalı
Derece: Yüksek Lisans, 2001
Konu: Mimarlık = Architecture
Dizin: Bina bilgisi = Building information ; Hastane binaları = Hospital buildings ; Hastaneler = Hospitals ; Prefabrikasyon = Prefabrication

Özet:
Bu tezde, birinci bölüm olan giriş bölümünde, Türkiye'de tutarlı bir sağlık örgütlenmesinin planlanması ve uygulanmasında ihtiyaç duyulan hastane binası açığının, eldeki kaynakları etkin kullanarak, hastane ihtiyaç programı özelliklerine uyumlu prefabrikasyon teknolojileri ile hızla karşılanabilmesi sorunları şeklindeki tez konusu kısaca tanıtılmaktadır. İkinci bölümde, hastane binaları konusunda genellikler ele alınmaktadır. Hastane binalarının tarihsel gelişimi kapsamında, hastane binalarının plan şemalarının tipolojik analizi incelenmektedir. Sağlık örgütlenmeleri içinde hastanenin yeri belirtilmekte ve tanımlanmaktadır. Yurtdışında mevcut sağlık örgütlenmeleri kısaca özetlenmektedir. Çağdaş sağlık örgütlenmesinin temel ilkeleri ışığında çağdaş hastane tanımlanmaktadır. Üçüncü bölümde, hastane tipleri ve ihtiyaç programı özellikleri ele alınmaktadır. Hastane tipleri araştırması kapsamında, hastane sınıflandırmaları, plan kuruluş düzeni (tek veya çift koridorlu, kare veya daire) ve hastane mekan biçimi özellikleri konuları üzerinde çalışılmaktadır. Dördüncü bölümde, hastane ihtiyacı ve hastane açığı sorunları ele alınmaktadır. Hastane ihtiyacının belirlenmesinde çağdaş ölçütler kapsamında, hastanelerde yer seçimi, hastane kullanıcıları ve kullanımı, hastane kullanımını etkileyen kuruluşsal ve kullanıcıya ilişkin etkenler ve sağlık sistemi kavramı konuları incelenmektedir. Türkiye'de mevcut sağlık örgütlenmesi ve planlanmasının niteliksel boyutları kapsamında, sosyal strüktür ve maddi strüktür çalışılmaktadır. Türkiye'de mevcut sağlık örgütlenmesi ve planlanmasının niceliksel boyutları kapsamında, Türkiye'de yataklı ve yataksız sağlık kurumları, kamu ve özel yataklı sağlık kurumları, sağlık personelinin sayısal gelişimi üzerine DİE ve DPT'nin tablo ve grafiklerden yararlanılmaktadır. Türkiye'de tutarlı bir sağlık örgütlenmesi araştırması ve önerileri kapsamında Parrows, Schultz ve Johnson'm sağlık sistemi-hükümetler ilişkilendirmesi, hastanelerde kullanılan bilgi teknolojileri, hastanede insan kaynakları yönetiminin elemanları, sağlık eğitimi ve kentsel sağlık örgütlenmesi modeli yaklaşımı ele alınmaktadır. Yurtdışında mevcut sağlık örgütlenmeleri kapsamında, Avrupa ülkelerindeki sağlık reform stratejilerinden: temel reform stratejileri, kaynak kıtlığına karşı koyma stratejileri, kaynakların etkili bir şekilde finanse edilme stratejileri, yaşam şekli sağlık sistemi ilişkisi ele alınmakta, Almanya Sosyal Güvenlik Sistemi Örneği verilmekte, Herkes için sağlık politikası (HİS), NATO sağlık hizmetleri çalışması, ekonomik seviye, sağlık sistemi strüktürü üzerinde çalışılmaktadır. Yabancı ülkelerden sağlık örgütlenmeleri örnekleri, Amerika, Avrupa ülkeleri ve Asya'dan ülkelerden örnekler verilmektedir. Türkiye'de hastane ihtiyacının niteliksel ve niceliksel boyutlarının saptanması kapsamında, DİE'nin 1998 istatistik tablolarından, Ertürk İ.'nin doktora tezinde pratik hastane ihtiyacı hesaplanması yönteminden (1998 nüfus sayımı esas alınarak nüfus / hizmet ettiği nüfus şeklinde) ve Karataş B.'nin katlı regrasyon örneği ile 1990 nüfus verilerinden yararlanılarak 2000 senesine ait tahmini hesaplamalar yapılmaktadır. Karataş B.'nin katlı regrasyon örneğine dayanılarak yapılan hesaplamalar sonucunda çok fazla hastaneye yani Türkiye genelinde yaklaşık 2,285 yeni hastaneye ihtiyaç olduğu ortaya çıkmaktadır. Bu duruma göre yeterince hastane binası inşa edilememiş olduğu ve ancak İstanbul, İzmir, Ankara gibi metropoliten şehirlerde büyük hastaneler inşa edildiği, köy ve kasabalardan büyük şehir hastanelerine hasta yığılması oluştuğu anlaşılmaktadır. O halde Türkiye genelinde ancak büyük hastane açığının karşılanması ile her bölgede eşit ve kaliteli sağlık örgütlenmesi ve sağlık hizmeti sağlanabilecektir. Bu açığın hızla kapatılması ve bu suretle tutarlı bir sağlık örgütlenmesinin işleyebilmesi için prefabrikasyon teknolojilerinin kullanılması kaçınılmaz olmaktadır. Fazlaca olan hastane binası ihtiyacı önümüzdeki birkaç yıl içinde kapatılabilirse Türkiye'nin her bölgesinde eşit ve kaliteli bir sağlık hizmeti verilebilecektir. Beşinci bölümde, uyumlu prefabrikasyon teknolojileri ile hastane planlaması sorunları ve ilkeler ele alınmaktadır. Hastane binaları plan düzeni ve uyumlu teknoloji sorunu kapsamında, öncelikle teknoloji kavramının tanımı yapılarak prefabrikasyon teknolojilerinin hastanelerde kullanım koşulları araştırılmaktadır. Prefabrikasyonun yapımda hız ve kalite getirmesi, planlamada büyümeye izin vermesi, iç planda esnekliye uygun olması gibi avantajları anlatılmaktadır. Prefabrikasyon teknolojisi konusu çalışılmakta, bu teknolojilerin Türkiye'de kullanımı üzerinde durulmaktadır. Hastane planlamasında uyumlu teknolojiler araştırmasında uyumlu prefabrike sistemler, geliştirilmiş geleneksel sitemler ve özellikleri analiz edilmektedir. Ayaydın Y., Tapan M. ve Sey Y.'nin araştırmalarından alman hastane planlamasına uyumlu yapım sistemleri (prefabrike ve geliştirilmiş geleneksel) ve alt başlık olarak yapı sistemleri (iskelet, panel, hücre, kalıp, hazır bileşen) seçenekleri çizelgeler aracılığıyla anlatılmaktadır. Altıncı bölümde, prefabrikasyon teknolojilerine dayalı hastane planlaması araştırması ele alınmaktadır. Bu kapsamda, planlamanın bağlı olacağı kuramlar araştırılmakta ve plan örnekleri araştırmasına gidilmektedir. Türkiye ve yurtdışından prefabrikasyon teknolojilerinin kullanıldığı bina örnekleri verilmektedir. En son bina teknolojilerinin kullanıldığı örnekler genelde İstanbul'dan seçilerek, tez konusu ile ilgili belirli kriterlere göre sistematik incelemelerde bulunulmakta, endüstrileşme düzeyi tespit tablosu başlığında prefabrikasyon teknolojilerine yer verme durumları araştırılmaktadır. Bu örnekler: Acıbadem Kadıköy, İstanbul Memorial Şişli, Acıbadem Carousel Bakırköy hastaneleridir. Bu hastanelerde akıllı bina özelliği vardır. Bu özellik bina servis sistemleri ve bina otomasyon sistemlerinin bilgisayar kontrollü olarak çalıştırılmasını sağlamaktadır.Yedinci bölümde, sonuç olarak, düzenli işleyen bir sağlık örgütlenmesi amaçlandığında, Türkiye için belirlenen hastane ihtiyacının önümüzdeki birkaç senede hızlı bir şekilde ve eldeki kaynakların ekonomik kullanımı doğrultusunda kapatılabilmesi hedefinin gerçekleştirilebilmesinde gerek taşıyıcı sistem gerekse iç plan düzeni olarak veya giydirme cephe olarak başvurulabilecek prefabrikayon teknolojilerine ilişkin seçenekler sunulabilmektedir.

Abstract:
On this thesis, on the first chapter, as introduction chapter, the importance of using prefabrication technologies to meet the need for hospitals for a consistent health organisation is emphasized. On the second chapter of the thesis, the general considerations for hospital buildings are told. On this chapter, on the subject of the historical development of hospital buildings, the analysis of hospital building's plan typologies are searched. The position and the definition of hospital building in the health organisations, present health organisations in the foreign countries, the definition of contemporary hospital building, the content of contemporary health organisations are examined. Hippocrates' rules are the beginning of the science of medicine. At first, the hospital buildings were placed according to easy access in transportation, but now they are placed according to manegarial and economic achivement. In the 1940's the hospital buildings were planned in the shape of Y, T, L, H, U and planned as horizontal blocks, in the 1990s the hospital buildings were planned as the combination of square, circle and rectangular forms in which polyclinics and operation rooms are situated in the horizontal block and multistory bed-floors are situated in the vertical block. In Turkey, the first step of the health organisation is Health House and the upper level is the Group Hospital. Private clinics also help governmental organisations. The Ministry of Health is responsible with the authority to provide medical care and preventive health services, to train health personnel, to establish and operate health institutions, to control public and private organisations, to regulate prices of medical drugs and to provide equal medical services for every person in villages and cities. Health education and health system protect physical and mental public health. Public Health Services are grouped in two categories according to the services offered. First category is Preventive Health Services and Second category is Medical Care Services. Health Personnel are physicians, nurses and pharmacists. The present health organisation in foreign countries covers the member countries of World Health Organisation which have the policy called Health For All. In America, there is a pluralistic health system. In Europe, The Bismarck Model is preferred in health system in which the public health service is provided by government and supplied by the private service. A contemporary health system covers the properties like equality, being inclusive, accessibility and being renewable. A contemporary hospital building has the qualifications like: being intelligent building, providing progresive patient care, having the material quality standarts like ISO9000, (International Standart Organisation), manegarial quality standarts like JCIA (Joint Commission Of International Accreditation) etc. On the third chapter of the thesis, a research of hospital plan typologies and various hospital building programmes are told. Hospital plans are classified and hospital building requirement programmes are studied. Hospital buildings are classified according to some criterias: According to the type of health service given: general, university or specialised hospitals (like cancer). According to the properties: public or private. According to the type of treatment: with beds, without beds. According to the number of beds: small hospitals (50 beds), medium hospitals (60 beds), big hospitals (150-500 beds), very big hospitals (more than 500 beds). Nowadays, 300- bed hospital is preferred. According to the function: general, specialised or continuous hospitals, rehabilitation hospitals. According to the shape of the mass: low buildings, high rise buildings (multistory buildings). According to the inner circulation of plan types: double corridor system, single corridor system. Single corridor system means that corridor is surrounded by the patient rooms and the service rooms (nurse station, diagnosis room). Double corridor system means that there is a service zone (nurse station, diagnosis room) in the middle, which is surrounded by double sided corridor and double sided patient rooms. According to the geometric form of the plan: square plan, circular plan. According to the rules of building design and construction: restoration, addition to the existing building, new building construction. According to the type of plan: Y, T, L, U, H plan types. According to the patients and the type of treatment: inpatient treatment and outpatient treatment. Being functional and user satisfied hospital programs are the main criterias for a well qualified health service given. The number of beds needed, the type of health service (cancer treatment), and progresive patient care defines the hospital building program. The elements of progresive patient care are intensive care, intermediate intensive care, long term care, polyclinic care, treatment at home and nursing home care. There are some general principles in hospital planning as follows: estimating the spaces according to the needs (for example: 31m2 floor area per bed, 1 WC for 10 women patient); the quality standarts for building materials (ISO9000), the quality standarts for dimensions (1.20m width doors to let patient bed and stretchergo through), good interior design for patients psychological needs; the core design (sufficient number of elevators and stairs). Service stations and operation rooms and patient rooms should be connected with each other by the inner circulaion Osystem. The operation room which contains heavy health equipments should be planned on the first floor. The careful design of intensive care rooms and patient care rooms are also very important. A patient care unit contains 25 bed rooms, nurse room, doctor room, service room and WC units. Patient rooms could be planned as one-bed, two-bed, three-bed rooms. Infectious diseases, normal patient care, intermediate patient care, intensive patient care rooms have different qualifications. The components of hospital building are as follows: foundation, basement floor, ceiling, terrace, roof construction, horizontal connectors (corridors), vertical connectors (stairs and elevators), patient care unit (usually with 25-bed room, which contains 2, 3, 4 patient room, doctor room, service room, bath and storage). In planning and construction, the properties of health equipments, the needs of doctors and working conditions of doctors are important issues. Electric and mechanical installation are other important considerations. Products (furniters), human needs (designing for senses), innovative and creative design are important in interior design. On the forth chapter of the thesis, the need for hospital buildings and the problem of the shortage of hospital buildings are told. Main topics searched in this chapter are as follows: The contemporary criterias of need for hospitals, the qualitative and quantitative criterias of the present health organisation in Turkey, advices for a consistent health organisation in Turkey, models of present health organisations in foreign countries, the qualitative and quantitative criterias of the need for hospitals in Turkey, a practical calculation method used by Ertiirk İ.'s Phd thesis, DIE' s statistical table of the hospital need in each province, and Karataş B.'s multiple regression model, and the necessity of using prefabrication technologies to meet the need for hospitals. To reach the number of the need for hospitals, the number of patients, the need for a long term treatment are the criterias to be considered. Other factors which affect the hospital need and hospital design are accessibility to a hospital, organisational factors and users' demographic, economic, social qualifications. Health system contains health personnel and health institutions. In terms of qualitative criterias of the present health organisation in Turkey, social structure (public or private), aims, principles and policies, organisational and legitimate arrangements, financial structure (payment) are important issues. The present health organisation in Turkey is the public and private hospitals which is controlled by the Ministry Of Health. The Quantitative terms of the present health organisations and planning in Turkey depends on the number of physcians, the number of health personnel, the number of patients per physcians and the number of pharmacies and pharmacists etc. Practically, the need for hospital buildings are estimated by DIE's statistical tables (Institute Of State Statistics's) and the numbers are given on the table as the new buildings to be built on each provinces. In Turkey, the number of present hospital building is 19,461 in 1998, 1,138 of them are with bed. The number of health personnel are given on the tables prepared by DIE and DPT (Institute Of State Statistics and Institute of State Planning Organisation). A consistent health organisation in Turkey, necessitates a good manegement based on a democratic way of thinking. For a balanced health organisation in Turkey, total quality could be ensured by all members of the hospital. According to Deming's hospital system, input, process, and outcomes are the elements which make a hole to reach the same objective. Here, input stands for patient, process for treatment, outcome for the treated patient. The data processing technologies in hospital organisation necessitates building automation systems and computer usage. Urban health organisation begins with the health unit up to the levels such as university hospitals and health manager. The health organisation in foreign countries, which are the members of 'WHO' (World Health Organisation) is based on the principle of 'Health For All'. The health reform in European countries contains desantralisation in manegement, basic reform strategies and the strategy of preventing the shortage of resources. The resources should be allocated effectively. In America, there is a pluralistic approach to the health system, in which there is a public health organisation managed by the government and supplied by the private institutions. The Bismarck model is the new trend in health systems in Europe. The German Social Security System, which is a well developed structure helps the health system. In terms of qualitative criterias of the need for hospitals in Turkey, typology of the hospitals, requirement programme of hospitals, private or public health service, the quality of the health service determine the need for hospital buildings. In terms of quantitative criterias of the need for hospitals in Turkey, the number of beds, the accessibility to the hospital from the patient origin determine the need for hospital buildings. According to the estimation based on Ertiirk İ.'s practical need calculation formula which is total population / patient population, 440 new hospital buildings are needed in Turkey. According to the data given by DIE, 189 general hospital buildings are needed in Turkey. According to Karataş B.'s multiple regression model there should be 2,285 new hospitals to erect in Turkey. These results mean that 2,285 new hospitals could only be built by prefabrication technologies in a short time. More money and more quality ensurance in material and production will bring high XXquality to health buildings. If the big need for hospital buildings are met in a few years in Turkey, an equal and well qualified health service will be given in every region of Turkey. The need for hospital buildings is achieved by using prefabrication technologies with the advantages of being fast and good quality in architectural design. On the fifth chapter of the thesis, the problem and the principle of hospital planning with compatible prefabrication technologies are searched and evaluated. On this chapter, the concept of technology is the whole of the techniques which makes the material become a product which is being processed. Technology is the concept of organisation of the interrelation of design-production-usage. Technology is a relation system transferred to the architectural environment with the projects of Building structure systems, Building construction systems (construction techniques as a process), Supportive service systems and their details. On the multi-dimensional world-relation system, In which the scenario is arhitectural design, actors are architects, the process is technologic production, the system could only be soluted with industrialized building construction systems such as prefabrication technologies and conventional systems. The technologic approach to the hospital design has some different concepts such as basic, developed, appropriate, compatible, superior and advanced technologies. Hospital buildings are also high-tech and industrialised buildings which have flexible structure, easy installation systems, enough elevators in the core. With open system implications, each building components are produced in different factories and being connected in the same building sites. Open system provides an opportunity to choose various building components from catalogues. On this chapter, plan schemes of hospital planning and compatible prefabrication technologies with hospital planning are studied on examples. The qualifications of prefabrication technologies, such as dimensional coordination standardisation and precision are compatible with the dimensional and the geometric structure of the hospital buildings. The typical hospital plan is patient rooms with the repeated axe, which is compatible with the usage of prefabrication technologies. The reason for the usage of prefabrication technologies are being a prestigious building, the intention to catch the well developed medical technologies level, the flexibility in the interior design and the later expansions in the planning of hospitals. Samples of the level of prefabrication in developed countries and Turkey are presented for comparison in the examples. The European precast concrete industry has started to develop After World War II. There was an urgent need for housing and factories etc. The mass production of standard elements were supplied by the factories. These advanced production technologies contains the application of CAD-CAM (Computer Aided Design-Computer Aided Manufacturing), automation, robotising methods to the architecture. Few special problems of structure distinguish the hospital from other buildings, such as plumbing through the slabs, windows on the facade. Prefabrication technologies are preferred in the design of repeated elements of patient bedrooms on the facade, in the design of interior space, doors, patient care units, in the production of stairs and elevators. Ready mixed concrete is used in prefabrication technologies. There has been partial prefabrication implications by selecting building components from the open system catologues. In foreign countries, these technologies are used bravely in large range of buildings. So in Turkey, a bigger amount of money should be spent for enough hospital building construction. The practice of prefabrication technologies or conventional system as construction system in hospital planning is searched. The building structural systems are analized on the tables in accordance with the structural material and being high rise or low buildings. According to theclassification done by Sey Y., and Tapan M. 's Tübitak inventory study book, the compatible prefabrication technologies contains the structural systems such as sceleton systems (column, beam, floor, column-floor), panel systems (huge panels, small panels), cell systems (closed cell, open cell), mixed systems (sceleton+cell, panel+cell, panel+sceleton systems). Conventional or developed traditional systems contains the structural systems such as tunnel moulds, slide moulds, lift-slab moulds, filigran systems, permanent moulds and the conventional systems with precast building components. According to classification, done by Ayaydın Y., there are examples from foreign countries. Sample pages called the choices of structural systems available for the hospital planning, which explaines the properties of structural material and construction techniques. These structural systems are analized and evaluated according to the technology and architectural design criterias. The technological criterias are such as easy production, various and limited number of the components, easy assembly, easy transportation, limited number of connections, building construction in a short time, dry connection of building elements, high level of completion, the physical performance. The design criterias are: easy spatial organisation, flexible and modular planning, components with multi-purpose, precision in dimensions and forms, bearing the loads in long distances, compatible with small construction, open systems which is compatible with different products. These technologies give advantage of being fast and good in quality. The additions, restorations and extentions to existing building are easier by the prefabrication technologies. On the sixth chapter of the thesis, the planning process of hospital buildings with prefabrication technologies are told by giving examples. Industrialization level and spaces'names are listed on the tables. The planning theories with prefabrication technologies are dimensional coordination, technologic equipment, the components used in the facade, interior space design, interior building elements, partitition walls, prefabricated health units for example operation rooms, prototype projects, and space standardisation, the compatibility with the urban environment and the compatibility with the open prefabrication system. The semantic evaluation means maintenance, spaciousness, mood and sociability. There are examples of hospitals with prefabricated elements from Turkey and foreign countries. Examples are Acıbadem Hospital Kadıköy, Memorial Hospital Şişli, Acıbadem Courosel Hospital Bakırköy, Florance Nightingale Hospital (Şişli, Gayrettepe, Mecidiyeköy) in Turkey. These examples' plan drawings, sectional drawings and programme of spaces needed are given on the figures and tables. These examplified hospitals' construction systems are generally conventional systems which is reinforced concrete sceleton structure constructed in building site. The finishing building elements, curtain wall, and interior patition walls are produced from prefabricated elements. In these buildings, intelligent building system controls the building services with computers. These services are central heating, ventilation and air conditioning systems, building automation systems (data processing system, transition system, security system), fire prevention systems, central sterilization systems, trafos and energy supportive systems, conveying systems (elevators), installation systems. On the seventh chapter of the thesis, as conclusion, to meet the need for hospital buildings for an equal health service in every region of Turkey in a few years with the limited resources, the alternatives of open prefabrication technologies should be used. These technologies are used in the structural system such as column-beam- floor system, in the interior design of hospital buildings such as precast partitition walls and on the facade such as curtain walls.