Specificity of general zones in large modern European multispeciality hospitals – selected case studies

: The present paper shows the results of research on general zones in large European multispeciality hospitals. A dozen or so institutions, flagship examples of large contemporary hospitals, were selected for the study. The research focused on internal zones, in particular the reception area linked to the main communication system of the hospital which functions as a public space offering a range of services, and provides the space for communi -cation, waiting and meetings. This work aims to determine design trends in the location and forms of general zones, their characteristics and proportion to other zones in hospitals, architectural features and functional-spatial solutions. The relationships between the shape of the hospital, its internal general zones, and their percentage share in the total building area were examined. Art and greenery in these zones were also investigated, along with the presence of natural lighting, the colours, and the type of finishing materials used in this type of space today. The study revealed noticeable differences between the form of general zones in large contemporary as well as 20 th -century hospitals. In addition to their form, the arrangement of zones has also changed, and they often do not resemble a hospital space. Art and greenery play an increasingly important role. The general zone is a hospital’s essential communication hub, constituting the main public space where people may meet.


Introduction
Large multispeciality hospitals provide a broad spectrum of care. They can be divided into large general hospitals and university hospitals. The features of large multispeciality hospitals include the presence of at least a dozen specialised departments, a large surface area and a significant bed stock (representing several hundred or more patient beds). Hospitals are one element of the health care system that serves the inhabitants of a given area [1]. medical specialisations in a given facility. The vast majority are among the largest hospitals in their respective countries. The hospitals studied were built between 2000 and 2020 (the first of the researched facilities was opened in 2007, but the classification also includes the planning and design period, which in the case of this type of establishment takes at least several years until construction work can begin). Other selection criteria included the area of the hospital and the number of beds. The facilities investigated are often characterised by original architectural and spatial-functional solutions. It is also noticeable that their design draws on contemporary research on health care buildings -as evidenced, among other things, by the presence of art and greenery in the facilities. Despite their large scale, the selected hospitals have a less institutional character than similar buildings from the previous century and place greater emphasis on patient comfort. Firstly, various contemporary hospitals in Europe which met the study criteria were taken into consideration. Approximately 40 large multispeciality hospitals in Europe were built between 2000 and 2021. The facilities selected for examination had materials available including drawings, floor plans and similar studies necessary for carrying out research. Hospitals where access to detailed materials was difficult were not included in the detailed study.
After analysing the criteria described above, fourteen hospital complexes which corresponded most closely to the research objectives were chosen. Therefore, the 14 hospitals selected can be perceived as representatives of large contemporary multispeciality hospitals in Europe. Secondly, the arrangement, scale and form of the general zones in these facilities were analysed. The results are graphically presented in Fig. 2, which shows the proportions and location of given zones in the context of the whole hospital establishment. The remaining zones marked in grey are administrative, diagnostic, consultation and operating areas.
Thirdly, the architectural solutions applied in general zones, the form of the zones, prevalent materials, colours, elements of art and greenery were discussed. Attention was also paid to the features and roles of particular zones. Research materials included photographs and information obtained from publications, websites of design offices, hospitals and architectural websites. The average area of the studied complexes of large hospitals was about 117,745 m 2 .
For the purpose of this paper, the author defined a hospital general zone as a publicly accessible space, functioning as a public space where everyone is free to visit. This zone includes a representative entrance hall with a reception desk, information desks, a passageway with seats, a café/restaurant, a pharmacy, various types of shops (grocery, newsagent's, florist's) and services (hairdresser's, beauty parlour), a chapel, etc. It does not include corridors in other parts of the hospital, e.g. in diagnostic areas, outpatient clinics, bed wards and places of a similar nature, where there is usually some form of access restriction. People usually come to these zones for a specific purpose, such as an appointment or examination. Most often their identity is verified, e.g. when they are admitted to a ward or when they come to visit a patient.

Forms, shape and location of general zones
General zones, starting from the reception area, form the main communication routes in the hospital, while also being the most accessible and representative public spaces. They are closely linked to the form of the hospital. Changes in the approach to shaping the form of both the hospital and general zones can be observed in the institutions under study. The most popular layout of a hospital in the late twentieth century was a vertical structure with a "wide foot" or a "podium", which provided space on the horizontally extended ground floor for diagnostic, treatment and administrative zones, while the ward sections lay vertically above [30]. The first hospital type, distinguished in 50% of the facilities under examination, was developed on the basis of similar assumptions. The main difference is that the so-called "podium" occupies from 1 to 3 storeys above which are mostly wards or areas with similar functions. However, they are not structured like a high tower, but as fragmented low pavilions located above the podium in a more horizontal manner. Modern buildings featuring this structure usually have a linear layout as well [31], which also determines the shape of the general zone. Obtaining a legible and clear functional division in large hospitals, which facilitates movement around the building for all groups of users, is possible especially with a band-shaped arrangement of the hospital. It also allows the complex to be further developed while maintaining the functional transparency of the facility [16].
The second type of a hospital observed among the examined institutions is also linear and represents a combination of ridge and mono-block (with atria and courtyards) layouts. Fully mono-block structures (Centre Hospitalier de Marne-la-Vallee) and pavilion layouts (Can Misses Hospital) are the rarest. Regardless of the spatial layout, contemporary general zones are linear. In half of the hospitals included in the study, this zone was between one and two storeys high. 21% of the facilities had a three-storey zone and in 29% of them the height of this space ranged between 4 and 6 storeys. The common feature of the general zone in the hospitals studied here was good natural lighting via skylights or full roof and partial wall glazing (especially in the case of high glazed entrance atria) In some cases, good lighting is provided by courtyards covered with greenery which also provide relaxing views from general zones. One example of this form of the general zone is presented by Jeroen Bosch Hospital, where the greenery merges directly with the main communication zone, which is the general zone of the hospital.
The general zone is located in the centre of the complex, forming the main axis (axes) of communication and composition. It is usually the main hub of the site linked with other parts of the hospital, i.e. specialised spaces with controlled access. General zones account for almost 1/10 of the total space of the hospital complex. In their immediate vicinity, groupings of bed wards are located on the upper floors.

Colour scheme, materials, art elements in general zones
Grey, beige and white colours prevail in the researched facilities. This colour scheme is often broken by blue, green, orange and yellow accents. General zones are usually finished in natural materials such as wood, stone and terrazzo. The general zone in Rey Juan Carlos Hospital is an example of this combination of materials and colours, but it stands out from other hospitals because it is a very elegant space, with simple geometric shapes, austere in form, without embellishment -the main accent is on the material finish and appropriate choice of furniture.
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Colour scheme, materials, art elements in general zones
Grey, beige and white colours prevail in the researched facilities. This colour scheme is often broken by blue, green, orange and yellow accents. General zones are usually finished in natural materials such as wood, stone and terrazzo. The general zone in Rey Juan Carlos Hospital is an example of this combination of materials and colours, but it stands out from other hospitals because it is a very elegant space, with simple geometric shapes, austere in form, without embellishment -the main accent is on the material finish and appropriate choice of furniture. Many studies on colour and light have revealed their influence on human behaviour, mood and concentration. Cool colours (such as green, blue) promote relaxation and calmer activities, while warm colours (red, orange, yellow) stimulate physical and social activities. In contrast, colours such as beige and grey limit attention. Colour in the public space of a hospital can also be an element facilitating orientation and navigation within the building [14]. In addition to colours, views from different zones are also essential. According to a study by Serbian researchers, it is important to provide views on the outside areas of the hospital, not only for safety, but also psychological reasons. Constant access to the outside world reduces feelings of isolation and claustrophobia [28]. Many studies on colour and light have revealed their influence on human behaviour, mood and concentration. Cool colours (such as green, blue) promote relaxation and calmer activities, while warm colours (red, orange, yellow) stimulate physical and social activities. In contrast, colours such as beige and grey limit attention. Colour in the public space of a hospital can also be an element facilitating orientation and navigation within the building [14]. In addition to colours, views from different zones are also essential. According to a study by Serbian researchers, it is important to provide views on the outside areas of the hospital, not only for safety, but also psychological reasons. Constant access to the outside world reduces feelings of isolation and claustrophobia [28].
In the facilities created in the last five years, general zones are characterised by the inclusion of art in many forms. These include art installations, the form of lighting, seating and similar elements of small architecture, as well as colourful graphics. Sculptures can also be found in some hospitals. According to research by the curator of art in health care Mary Grehan, art in the hospital should be balanced so that it engages and stimulates users, without being provocative, bearing in mind varying degrees of emotional sensitivity [19].

Formation of general zones and functional links with other parts of the hospital
Furthermore, hospital public spaces are often embellished with greenery (e.g. trees in pots), which fosters cosiness in a given zone. Greenery has a positive effect on stress management, especially when spending time in hospital -for patients, visitors and staff alike [12]. Seats arranged in rows are rarely used. Today, they are often individually designed for a specific hospital. This is illustrated by the seats at the Hospital Nova, being wooden benches with comfortable oval-shaped backs. Wooden sculptural compositions and the shape of lighting provide additional accents in that hospital. In the Rigshospitalet Hospital North Wing, art comes in the form of a spiral staircase and colourful ornaments beneath some flights of steps.
Despite the large scale of the hospital and its general zone, such architectural and design solutions often make the space cosier and more friendly for patients and other users. They also make a facility seem less of an institution, which was one of the main features of 20 th century hospitals. Most contemporary general zones of large hospitals do not resemble a hospital interior, but look more like the inside of a gallery or hotel lobby. These spaces often can resemble shopping arcades with cafés, restaurants, shops (e.g. grocery shops), florists, kiosks and even exhibition spaces. These areas play a very important role as places where people can meet and socialise, and as such there are many clusters of seats there, not only in waiting areas. Besides, information desks and waiting areas can be found around this zone. Nearby, chapels and prayer rooms are located too. In some hospitals built in recent years, chapels are divided into zones for different faith communities, for example at Jeroen Bosch Hospital (The Netherlands, 2010) and Queen Elizabeth Hospital Birmingham (UK, 2010).
The growing importance of public spaces in hospitals is linked to the desire for integration with urban structures. These spaces are shaped as shopping arcades offering services. They can also take the form of squares. In the case of outdoor spaces, these are most often gardens and courtyards with art elements. Adequate lighting of the public zones influences hospital forms, resulting in more fragmented hospital layouts with fewer storeys [16]. General zones in hospitals usually begin with a spacious reception hall. The linear general zone may also be divided into one or more places by glazed atria. This is noticeable in the Meander Medical Center, among others, with its clearly accentuated main entrance and generous glazing. This large-scale space contains many clusters offering various places to sit. It is also a kind of communication hub for the entire establishment. A similar entrance hall can be found at Queen Elizabeth Hospital, with mainly white and blue accents. The high entrance hall distinguishes also Lillebaelt Kolding Hospital, where the atmosphere is additionally invigorated by big flower pots with trees surrounded by seats.
The examined general zones usually constitute a hospital's central public axis of communication around which public functions are concentrated. In this hierarchy, they are followed by diagnostic areas, the ED and outpatient clinics, which have separate passageways accessed from the general zone and require undergoing access control. Only after passing through the general zone and then the internal passageway can one reach the hospital's medical facilities such as diagnostics, outpatient clinics etc. In addition to the services and public functions directly linked to the general zones, the space on the ground floor usually provides access to outpatient care, diagnostics, rehabilitation etc. At certain intervals, the general zone has access to vertical communication that connects it to upper floors where bed wards, operating theatres and the administrative area tend to be located (Fig. 4). Regarding the form of general zones and their links with individual functions of the facility, four solutions were distinguished among the 14 hospitals researched (Fig. 5). The first three solutions are clearly linear. In the first layout, the general zone begins and ends with a similar-sized entrance hall with a reception area. Along the general zone are the previously mentioned public functions (shops, café, etc.) and vertical communication. Perpendicular to the main axis of the general zone, there are passages to specific parts of the establishment. Most often, one side of the axis leads to zones for outpatient care, while the other side to zones for the ED, diagnostics, rehabilitation etc. Vertical communication provides access from the general zone to the higher parts of the facility with bed wards, operating theatre, administration etc. This is the layout of Akershus University Hospital in Oslo, among others (Fig. 6).
The second layout of the general zone differs from the first in that the proportions of the entrance areas at both ends are different. In this case, there is one main hall, much larger than the other one, and also much larger than the entire passageway that makes up the whole general zone. It can assume the form of a tall glazed atrium. The third layout consists of at least two passageways between which are located both public functions and services such as ambulatory care etc. This type of solution is most often found in clearly horizontal hospitals with a low-rise structure. As well as vertical communication, spacious green atriums are arranged along the general zones in order to maximise light.
The last layout differs considerably from the above in that it is not clearly linear and can be found in slightly smaller hospitals. In this case, public functions are located around a central general zone. It is linked in several places to other parts of the complex.

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of at least two passageways between which are located both public functions and services such as ambulatory care etc. This type of solution is most often found in clearly horizontal hospitals with a low-rise structure. As well as vertical communication, spacious green atriums are arranged along the general zones in order to maximise light.
The last layout differs considerably from the above in that it is not clearly linear and can be found in slightly smaller hospitals. In this case, public functions are located around a central general zone. It is linked in several places to other parts of the complex.

Features of modern general zones
Compared to hospitals of the 20 th century, modern general zones in large multispeciality hospitals differ significantly. Above all, in contemporary developments, proportions, human scale and the key role of daylight have transformed the aura of these spaces. This also applies to the form of the "hospital street", which can now resemble a shopping arcade or a hotel lobby. The perception of this space has changed in particular with a much bolder approach to the extensive use of natural materials such as wood and stone. Greenery can also be found increasingly often, not only outside in the atriums, but also inside the building. How the general zones are arranged, apart from the materials, the role of daylight and greenery, also involves well-chosen colours and art elements that make it easier to navigate the building.
The height of these zones ranges between one and four storeys so that their scale is not too overwhelming. The linearity of general zones does not mean, however, that they are always simple long passages. Contemporary general zones can also have undulating forms or change their width and height throughout, depending on functional and compositional factors.

Conclusions
The conducted research revealed a trend towards a linear structure for general zones in large multispeciality hospitals in Europe. This arrangement is related to a change in the shape of hospitals in the 21st century -from vertical (popular in the late 20 th century) to horizontal forms today. General zones occupy almost 1/10 of the total hospital area. This is the primary area which, in addition to its communication role, provides space for reception, information, interpersonal contact and other services.
Regardless of the hospital's form, the general zone in large complexes is linear. Moreover, the materials used to finish contemporary hospitals have undergone an observable change, especially in the general zones. A large proportion of natural materials, such as wood or stone, can be noticed there. Elements of greenery, which humanise the hospital interior, are increasingly popular. Artistic elements play an important role both in general zones and wards, which is particularly evident in hospitals built during the last five years. The architectural solutions and interior design of the examined zones illustrate the evolution in the approach taken by European hospitals from the 20 th -century form of "machines for treating the sick" to hospitals that are patient-friendly, adapted to a more human scale and prioritising patients' not only physical but also psychological comfort, as evidenced by art in hospitals and the increasing role played by greenery.