Identifying the Wasted Spaces within Hospital Buildings in Pakistan

The built environment of hospital buildings are generally not accepted to be pleasant. In the design of healthcare facility, it is quite important that its design, spatial arrangement and areal distribution must respond to curative needs of people so as the outcome emerge in the form of healing environment in the physical spaces.This kind of healing environment is quite adequately available in the developed countries of the global north. However; in developing countries of the global south like Pakistan, the healing environment in healthcare facilities is neither documented nor evident in any available published literature. Whereas, it needs to be well documented and analyzed. Thus, this study aims to identify the healing environment in two selected hospital buildings in Pakistan that is ICP (Peshawar Institute of Cardiology) and FCP (FC Hospital Peshawar) by determining the percentage of wasted spaces within the building. The selected buildings are analyzed from the following aspects; circulation pattern in the hospital, accessibility, connectivity and barrier free movement within buildings, along with the walkability status of over stressed staff inside the hospital building while navigating, functionality of the schematic designs, the problem of the users concerning repetitiveness in their circulation pattern and the way to increase the efficiency of spaces, their spread and flow in the hospital building. In general, three key factors were investigated in this study, therefore, design determinents, areal distribution and adequate spatial organization. In this regard, total eight design determinants were investigated, i.e. entry, parking, waiting area, connectivity, visibility, walkability, accessibility, and way finding. Study approached the spatial simulation method therefore 3M analysis which is a Japanese model referred as Muda (waste), Muri (over burden), Mura (unevenness) based on the Kaizen theory for eliminating wasted spaces from Hospital buildings. Based on the findings and through the approached tools, the waste spaces within the hospital buildings were removed up to 40%.

These case studies were analysed in three key factors therefore, Design Determinants, Areal Distribution modeling and Spatial Organization by using 3M Analysis tool based on Kaizen theory to identify the waste spaces with in hospital building.
The professional contributions of proposed research are the development of practical guidelines for professionals in terms of local design determinants and spatial organization of hospital buildings [7][8][9]. The development of possible local standards for areal distribution of hospital buildings in Pakistan would lead to development of professional regulations and bylaws that may be pertinently applicable for local context.

Literature Review
The literature review consists of eight main aspects. It begins by understanding the concept of healing environment and defining hospital buildings in Pakistan.
Then three aspects of ensuring healing environment in hospital buildings were studied [10]. These included the concepts of design determinants, spatial organization and areal distribution.  [4]. Before UD is used as the basis for rehabilitation, more research is required to identify the values shaping its principles, to evaluate how far they represent the most coherent approach to creating an accessible built environment.

Identifying the Wasted Spaces within Hospital Buildings in Pakistan
There are a number of great attempts to develop an indoor navigation that provide the most optimal path and guidance. Finding a way in large buildings can be a challenging task [5].

Definition of Healing Environment
Healing environment concept emerged in mid-19th century which indicates treatment of the environment to be curative [7]. In 1960's, the concept of healing there is a collective understanding that a healing environment is beneficial for patients and for healthcare staff. Healing principles [9] and evidence based design [12] are applied to augment and optimize the outcomes of care quality. The user's instinctive healing ability is developed by incorporating specified aspects of architectural design in healing spaces [4]. As these theories on healing environment were applied at international level and widely used within the developed world of the global north. Logically, it requires that, such concepts may be tested in developing countries of global south or new such theories may be developed. In this regard the context of Pakistan is proposed to be a significant case study where these concepts and theories may be applied and tested [13][14][15].

Definition of Hospital Buildings in Pakistan
There is no single definition to describe the hospital buildings in Pakistan because the nature and scale of such structures vary to greater extent from one room polyclinic to large scale tertiary level hospitals [21].
Therefore, this research describes about the distinctiveness of healthcare innovation and apply concept of synergy of healing spaces in architecture of hospitals in Pakistan. The synergism concept is driven from the emerging precise state-of-the-art technology, as a source of an effective design for stimulation of healing for the individuals who is utilizing the healthcare setting [16]. This concept needs to be applied in the context of Pakistan.

Muda
Muda (Japanese for waste) that includes seven forms of waste: transportation, waiting, overproduction, inventory, movement, extra processing, and defects. Muda also means the basic waste at the workplace. There are various attributes of the concept of waste such as those factors that do not contribute to the processes going on in any hospital building [22]. Various kinds of wastes generated in a hospital building in terms of wasted spaces as well as wasted efforts of staff and other employees.
Muda is any activity or process that does not add value; a physical waste of your time, resources and ultimately your money. These wastes were categorized by TaiichiOhno within the Toyota production system. Many "lean" initiatives fail to see past the elimination of Muda and believe that the point of Lean is to just eliminate waste. This leads to implementations that initially appear to save money but quickly fall apart and revert as problems such as customer demand fluctuations and supplier problems occur.

Muri
Muri is waste caused by overstressing people, equipment, or systems and this concept was developed as a total quality model for hospital buildings [18][19].
The concept of Muri is like taking heavy mental or physical burden by workers on production sites.
Similarly, for machinery it means excess workloads to equipment more than its normal capability. In hospital buildings this Muri is quite evident as the doctors, staff and nurses usually remained in excess workload more than their normal capability which cause issues that needs to be resolved.
Muri is to cause overburden, which mean giving unnecessary stress to employees and processes. This is caused by Mura and a host of other failures in a system such as lack of training, unclear or no defined ways of working, the wrong tools, and ill thought out measures of performance again Mura causes Muda, the seven wastes are symptoms of our failure to tackle Mura and Muri within the processes not the root cause.

Mura
Mura is waste due to unevenness or variation [13]. Lean in healthcare refers to wastage which could be eradicated by application of standardization in design. The concept of Mura is an irregularity and a temporary fluctuation in the total volume or parts of a facility or workers. Similar situation is also evident in the hospital buildings that there occurs an irregularity in the form and functions due to some temporary situation and that affect the facility's or people's performance [15]. Mura is the waste of unevenness or inconsistency, but what does this mean and how does it affect us. Mura creates many of the seven wastes that we observe, Mura drives Muda.
By failing to smoothen out our demand we put unfair demands on our processes and people and cause the creation of inventory and other wastes. One obvious example is production processes where the manager is measured on monthly output, the department rushes like mad in the final week of the month to meet targets, using up components and producing parts not actually required.

Summary
The concepts of Muda, Muri and Mura suggests to remove the wasted efforts from hospital buildings and initiate value added works that may enhance the utility and functionality of hospital building and its people [23].

METHODOLOGY
Both qualitative (analyzed through software simulation by rating within a given range between 1-5 with 1 representing as the worst and 5 representing as the best.) and quantitative (assessed on planning and architectural drawings) research approaches has been employed in this research based on subjective assessment with the help of interviews taken from hospital users, staff, nurses, doctors and healthcare professionals, facility managers, and architects (a public opinion) was documented for further analysis regarding their perception of different spaces within the hospital.

Research Methods
For the objective or actual assessment of hospital plans, visibility graph and axial line application in space syntax software has been used. The method adopted for this research includes literature review of the key concepts of healing environment and its application in hospital buildings [16][17]. Total eight design determinants were investigated i.e. entry, parking, waiting area, connectivity, visibility, walkability, accessibility, and way finding [18]. With regard to spatial organization, the characteristics of individual space, site allocation plan and typology of circulation was especially examined [24][25]. Concerning areal distribution, the total spatial sizes, standards and areas allocated to individual rooms and spaces were studied of selected hospital buildings. These three key factors therefore design determinants, spatial organization and the areal distribution were analyzed and examined through the data obtained from interviews and 3M analyses tool which further eradicated the waste spaces in Space Syntax application.

Case Analysis
Two case studies of secondary and tertiary hospitals from

Descriptions of Analysis
The process of analysis began with the establishment of guidelines on TQM (Total Quality Management) for the design and development of healthier and happier hospitals fit for Peshawar [4]. In these acute care hospitals, the standard for healing design is achieved by providing mechanism for efficiency and productivity as well as healthier building design. It is tried to achieve more efficient and new vision where client's point of view was the prime significant element to reduce the size of building so that corridors become direct and barrier free with maximum efficiency and minimum wastage space [5].
Through interviews with hospital users, staff, nurses, doctors and healthcare professionals, facility managers, and architects a public opinion was documented for further analysis [6]. These include 3M analysis (i.e. Muda, Mura, and Muri), with these analyses a concept of zero defects in hospital buildings was introduced for future hospital development and to improve the healing environment.

Case-1: Institute of Cardiology Peshawar Hospital
ICP is a seven story hospital building which has a lot to offer to the patients and visitors. The building is located on the main road and the ground in between the hospital and the main road helps to minimize the traffic noise and     It could be summarized that Mura is inversely proportionate to Axial Line, i.e. Mura  Axial Line -1 . This is represented by orientation and corridor which shows (++) relationship that is highly positive.

Case-2: Frontier Corp Peshawar Hospital
Health is a state of physical, mental and social well-being Because vertical circulation is very comfortable as it has easy access to the necessary service area of the main hospital.
The first step in the analysis of spatial organization of FCP is to make AutoCAD drawings of the Hospital building. Fig. 6

Identifying the Wasted Spaces within Hospital Buildings in Pakistan
The Analysis of Spatial Organization in FCP Hospital The fifth step in the analysis of spatial organization of ICP is to take the feedback and opinion of the concerned people and users of the hospital building. Table 2

Areal Distribution Analysis
Areal distribution analysis is intended to study schematic

Synthesis of analysis
Conclusively, the 3M analyses has been done to identify the perfect healing environment, aerial distribution and adequate spatial organization with the application of Kaizen theory (Fig. 11).

When given two variables x and y, if y is directly
proportional to x, the relation is represented as, the the constant ratio, where Mura is directly proportionate to sort and straight, Muri is directly proportionate to Standardization and Muda is inversely proportionate to shine (Fig. 12).

RESULTS AND DISCUSSION
The (ii) Circulation areas should be generous-not less than one third of the waiting area.  Though Barrier free and egress has highly positive relationship denoted by (++).

Identifying the Wasted Spaces within Hospital Buildings in Pakistan
The purpose of this research is to study the existing facility available and to re-plan the entire hospital. The

Algorithm for Eliminating Wastage
As shown in Fig. 13, vicinity and direct are directly proportionate. It can also be denoted as Vicinity  Orientation since maximum visibility shows minimum stress. Also, Mura is inversely proportionate to Axial Line, i.e. Mura Axial Line -1 . This is represented by orientation and corridor which shows (++) relationship that is highly positive.
Whereas Muri  1/Space Syntax, which infers standardize aids circulation and variation confused staff and visitors.
FC hospital is open to sky and is using space to maximum efficiency while it is planned on grid. Label and orientation are positively related as studied at both the hospital in Peshawar.