SPeAR as a Tool for Sustainability Impact Assessment of Hospital Master Plans: King Hamad University Hospital, Bahrain

Abstract

Sustainability impact assessment (SIA) has been developed as a tool for the evaluation of proposed or existing development projects to improve their environmental quality, economic feasibility, and social commitment. Several approaches and tools have been used for SIA to facilitate the study and analysis of sustainability levels. Increasing attention has been directed to sustainability in hospital master plans yet little attention is paid to SIA as a tool for the management and control of their sustainability levels. King Hamad University Hospital (KHUH) in Bahrain is a leading health institution in the country and the region. There are no publicly available documents of its master planning and there is no reference for sustainability planning and management in any of the available resources. This research uses the sustainable project appraisal routine “SPeAR” as an SIA tool for the assessment of social and environmental components of the master plan of KHUH. The research reveals that there is a need for the preparation of a sustainable master plan for KHUH with suitable sustainability indicators and measures with continuous monitoring. The research represents the first attempt to study the master plan of KHUH and its sustainability levels. It provides a guideline for other hospitals in Bahrain and the region.

1. Introduction

Hospitals are considered among the most important components of the built environment because of their functional, operational, and spatial complexity. They also represent the institutions for the protection of human life, which is one of the main five essential objectives of Islamic law “Makasid Al-Shari’ah” [1]. The development of hospital planning, design, and management is therefore considered a vital necessity for community development and a serious responsibility for both private and governmental bodies and institutions. Healthcare services consume quite a considerable percentage of the gross national product and domestic national product worldwide. From this expenditure, hospital development consumes the largest portion. Although statistics can be available through the World Health Organization, research on hospital development and investment does not respond to the increasing demand for hospitals [2]. Modern hospitals have changed the nineteenth-century image as places where people wait to die. In the twenty-first century, hospitals have been facing many changes, for example, mobility of healthcare workers, new treatment technologies, changing patterns of diseases, and complying with sustainability demands in planning construction and function. Hospital planning is increasingly affected by several factors that include new trends in community healthcare services and innovations in building materials and construction technologies [3]. One new approach to the planning of hospitals is that which concentrates on the circulation of both pedestrians and vehicles with an emphasis on visibility and easy access to the main entrance, clear connection with the main public space, separation between different types of entrances, and convenient drop-off and parking [4]. This planning approach, in addition to other considerations, such as required services, the number of users, required spaces, and building systems, all need to be adjusted and tuned until arriving at a flexible and expandable hospital design concept.

The hospital is a distinguished component of the built environment where all issues of the three pillars of sustainability mingle together in a very complex manner. The need here is for a sort of framework to bring balance and tranquility to the interrelated connections of many factors [5]. Social and cultural manifestations express the way people look at hospitals in terms of the sense of place, the spatial experience, and the attitudes toward services. They also do exist in the conduct ethics of the staff and their values. Sustainable hospitals need to provide a venue where all these interactions can positively enhance the health of the community. More importantly, it is the master plan, which can cater to this through the treatment of interior and exterior spaces, buildings, and the landscape. It is this treatment that also can provide for the care for resources in terms of land area, built-up area, building cost, and energy consumption. All this eventually will determine to what extent this hospital is hostile to the environment or friendly, adding to its value by decreasing pollution, preserving natural habitat, and preventing contamination [6]. Sustainability has evolved as a response to the escalating environmental, social, and economic problems of the modern production cycles. Healthcare is one of the important fields desperately striving for sustainability [7]. Sustainability is not only needed for the management and operation of hospitals, to cut costs and increase savings, or to control hazardous materials. It starts from the early stages of searching for a site and extends to site development and building construction. The development of sustainable hospitals would never fulfill its goals without the availability of sustainable sites and buildings for hospital services.

The master plan is a document of long-term planning to establish a framework for development and improvement, setting out inputs, outputs, gains, and costs. This is in addition to steps, phases, work plans, and monitoring and feedback. All these processes are time-bound, and the temporal framework of the master plan has great importance to define points of fulfilling goals and evaluating progress [8]. As a form of planning, the master plan is future-oriented and depends on past outcomes and present developments. It draws the overall framework for steps to follow. In the built environment, the master plan of a development project is part of the planning system, which is the government program for the control and management of land use development [9]. The master plan is usually a set of site maps, plans, images, and documents that all illustrate the development process of an area. Its level varies from regional scale to medium and small scale. It includes present and future land use, urban design, and landscaping. The main purpose of the master plan is to help create the most suitable form of the built environment with high-quality standards of living. It connects people and spaces in such a way to enhance social interaction and the sense of place [8]. The master plan is by nature a sustainability framework for the preservation of land, the conservation of the environment, and providing prosperous happy living places.

2. Sustainable hospital master plans in Arab countries

A survey for sustainable hospital master plans in some of the Arab countries in the Gulf Region was conducted at the beginning of 2022 using Google search. The aim was to discover to what extent these hospitals and healthcare facilities are concerned about sustainability and sustainable hospital master plans.

The hospitals that were reviewed included:

• Citymed Hospital, Riyadh, Saudi Arabia [10].

• Johns Hopkins Aramco Healthcare [11].

• Jeddah Medical City, Jeddah, Saudi Arabia [12].

• Interhealth Canada [13].

• King Saud University—Medical City, Riyadh, Saudi Arabia [14].

• Farwaniya Hospital in Kuwait [15].

• Jahra Medical City, Kuwait [16].

• Primary Health Care Corporation “PHCC,” Qatar [17].

• The American Hospital Dubai [18].

These hospitals and similar Arab hospitals, medical cities, and healthcare facilities constitute multi-billion industries and many of them represent giant projects of millions of square meters. Despite their distinguished master plans and the special environmental, economic, and social settings, they provide very little information, if nothing at all, about these master plans and their relationships with their special contexts. No documentation is publicly available about sustainability issues to present their achievements and to educate the public. This highlights the need to work hard on the preparation of comprehensive hospital master plans within the framework of sustainability and its assessment indicators and measures.

3. Sustainable hospital master plans in North America

Case studies for this purpose have been chosen through an online search using the Google search engine. They have been randomly chosen according to their consideration of sustainability. It is regrettably admitted here that nothing was found on precise consideration of SIA in these master plans.

3.1 Children’s hospital and regional medical center concept plan, City of Seattle, USA

This master plan carefully dealt with the goals, objectives, design principles, and environment. Generally, many aspects of sustainability are considered without any concentration on sustainability or SIA. Design principles and environmental stewardship sections of the master plan indirectly considered some sustainability issues [19].

3.2 The Cayuga Medical Centre, Ithaca, USA

The master plan’s main purpose was to provide a comprehensive indoor and outdoor healing environment. Great concern was paid to the landscape not only in outdoor spaces but also to bringing it forward to indoor spaces as well. Architecture, landscape, stormwater management, and sustainable agriculture all met together to enhance the sustainability of the master plan. This interest in providing an increased dose of natural environment and landscaping to provide a distinguished healing environment helps the hospital to achieve LEED silver certificate for sustainable sites [20].

3.3 Delta hospital high level concept plan, delta, British Columbia, Canada

The master plan report of March 2012 provides a good account of several sustainability issues, including environmental, economic, and social parts. Sustainability is namely used twice: the first time as a guiding planning principle and the second as an approach to rethinking healthcare facilities. No consideration is given to the assessment of these sustainability practices [21].

3.4 The University of Texas at Austin Medical District Master Plan, USA

Several recommendations were made to enhance the sustainability level of the medical district. Interestingly, they constitute a way for measurement and assessment. Despite the importance of these points, they did not formulate a comprehensive framework for sustainability assessment, especially in the land-use master plan. The planning and development of the medical district paid attention to many sustainability issues that would be applied in the master plan. They include, among many other points, parking, stormwater, energy, landscape, community, mobility, and economic development [22].

4. Concluding remarks on North American hospitals

On the contrary to Arab hospitals presented in the previous section, the North American hospitals showed since the late twentieth century, a well-informed consideration of hospital master planning with some level of consideration of sustainability criteria and environmental quality. The above hospital master plans show interest in enhancing the level of sustainability. This reflects a belief in the importance of sustainability for the development of hospitals as vital environmental and socioeconomic institutions. The main concern in these projects remained too much bounded by environmental issues, such as resource conservation, especially energy and water. It is also evident that these master plans did not show a common ground for any kind of framework for sustainability applications, evaluation, and assessment. This clearly highlights the need to search for such a framework.

5. Sustainability impact assessment, SIA

In the built environment, it is no longer acceptable to limit sustainability to the use of solar panels or to increasing green areas or providing bicycle lanes. There is a need for a more holistic approach that considers all the three pillars of sustainability: environment, economy, and society [23]. This is in addition to their branches and sub-branches as one complete set. This process is continuous and needs continuous input and monitoring. It also includes assessment and measurements using both qualitative and quantitative techniques that provide more controls on the sustainable development process [24]. To measure the level of sustainability in any project, and to know to what extent it is committed to sustainability, several sustainability indicators and measures need to be determined. It is argued that the number of sustainable indicators sets in use worldwide exceeds 600. Indicators are a means of collecting data in a systematic way regarding sustainability issues and practices. They provide the base for the understanding, analysis, and counting of these data [25]. Indicators are used to control and manage urban development and its sustainable impacts. Yet it should be addressed here that using indicators would never mean achieving sustainability in an ideal form. They only provide a tool to examine successes and failures in caring for the environment, resources, and community in a more general wishful manner. And therefore, with the use of indicators, SIA can help to prepare policies for development and strategies for improvement. It can help to identify objectives and to apply monitoring and control. SIA also provides a comprehensive framework to link the site with buildings and with the surrounding context [26]. At the same time, it is argued that SIA is not easy and straightforward, and it includes difficult decision-making process that that might sometimes restrain the decision makers [27]. This highlights the need for careful introduction of SIA in the planning and design of healthcare facilities, especially large hospitals.

6. SPeAR tool for SIA

Several approaches and frameworks have been studied to get deeper insight on the suitable tool to be used for the assessment of this research. It is beyond the scope of this research to provide a comprehensive survey of these tools and their characteristics or to provide a comparative analysis of them. Sieber Stefan et al. ([23], p. 76) evaluated five SIA tools based on seven criteria that included: “fairness, transparency, information quality, neutrality of process, opportunity to influence outcome, cost effectiveness, and ability to lead to out of the box solutions”. Looking at the tool of SPeAR with a relevant perspective, Mcgregor and Cole [28], believe that SPeAR has many advantages including adaptability, transparency of the assessment methodology, identification of improvement opportunities, optimization of the indicators and measures, and the possibility to trace all assessment steps easily and clearly. Within this framework, it was decided to use SPeAR tool for the study and analysis of sustainability levels at KHUH.

Sustainable Project Appraisal Routine (SPeAR) was developed by ARUP company as a holistic flexible software tool for sustainability assessment of development projects throughout their whole life cycle [29]. It referred to several internationally common indicator-based frameworks, such as leadership in energy and environmental design, LEED, GRI Draft CRESS (construction & real estate sector supplement), UN Indicators of Sustainable Development, and UK Indicators for Sustainable Development [30]. The aim was to arrive at the best sets of indicators and sub-indicators that cover the widest spectrum of sustainability main segments: environmental, economic, and social. SPeAR uses questions to evaluate all these sets of indicators and sub-indicators on a scale from (−1) for the worst case to (3) for the best case (Figure 1). This scale does not represent actual numerical values for the indicators or sub-indicators. It is like the scale of the Likert questionnaires. Some of the questions can be answered based on qualitative judgment and many others can use quantitative measures. It also has no representations for geographical information of any type to link the indicators, sub-indicators, and measures with project sites and contexts. On the other hand, SPeAR is distinguished by its comprehensiveness and its easy and simple maneuvering of the assessment process.

Figure 1.

1. Segment pie chart, 2 performance scale, 3. Social segment pie chart, and 4. environmental segment pie chart.

7. King Hamad University Hospital

King Hamad University Hospital (KHUH) was established by Royal Decree No. 31 of 2010, which affiliated it to the Bahrain Defense Force. It was officially opened by his majesty King Hamad Bin Isa AL Khalifa on 2/2/2012. KHUH is a university hospital primarily serving the Royal College of Surgeons of Ireland, Bahrain branch, which is located at its western border. KHUH has a capacity of 312 beds, with 1731 employees [31]. The project started in 2003 as King Hamad General Hospital to help meet the increasing healthcare needs in Bahrain. KHUH now is a specialized hospital for the delivery of state-of-the-art healthcare, teaching, and research, in addition to fulfilling the national agenda defined in Bahrain Vision 2030 [32]. The site lies in a distinguished area close to all amenities in the cities of Moharraq and Manama (Figure 2). The area of the hospital site is 227,000 m², while the total floor area of the buildings is 64,000 m². The building complex is composed of three buildings of three floors all rise above a large podium. The building complex is laid in the center of the site surrounded by huge parking lots on all sides separated from the buildings and from each other with small green areas. A long ramp leads to the main entrance of the hospital in the central building. Although the main entrance exists on the north façade, it is covered with what is believed to be one of the longest canopies in the world [33] (Figure 3). Large areas of green grass occupy the area in front of the main building entrance, while the approach road to the entrance is defined by rows of trees on both sides. An unshaded visitor’s car park with very little green occupies the west side of the building (Figure 4). A shaded staff car park was constructed at the northern edge of the site (Figure 5).

Figure 2.

KHUH site.

Figure 3.

KHUH main buildings with the main entrance in the middle.

Figure 4.

KHUH visitor’s car park.

Figure 5.

KHUH staff northern car park.

8. Methodology

This research depends on the case study methodology. It uses SPeAR as an SIA tool for the assessment of sustainability levels in the master plan of KHUH in the city of Muharraq, Bahrain. Therefore, it is twofold, the first is to determine what data is available on the master plan of KHUH. And the second is to determine the suitable segments, indicators, and variables or measures of SPeAR to be used for the assessment.

8.1 KHUH data

Unfortunately, no document was found on the master planning of KHUH hospital. The author approached the administration of the hospital seeking information on its planning, design, and construction. The denial of giving any access to any information on the hospital came in an official letter from the lieutenant colonel director of the hospital even though some information was already available on the Internet. The hospital is also open to the public despite being under the administration of the Bahrain Defense Force. The description and analysis of the hospital depended on the personal visits of the author to the hospital and the surrounding areas and on information available on the Internet. No quantitative data are used, and all data used in the assessment are qualitative. Despite the disadvantages of this approach, it represents the first attempt to refer to the severe shortages in the information available on master planning of healthcare facilities, in Bahrain and in the Gulf countries, in general. It is also the first attempt to highlight the importance of sustainability in these hospitals and the need to use SIA procedures for the control and management of its quality in these healthcare facilities.

8.2 SPeAR for KHUH

This research used KHUH qualitative data on the sustainability segments, indicators, and sub-indicators of the Evaluation Version of ARUP SPeAR V. 11.1.4.02013, Oasys Ltd.

The economic segment of SPeAR was ignored for the lack of information. For the same reason, not all the indicators and sub-indicators in the social and environmental segments were used nor all the questions were considered. Some of the questions were also altered to suit the ability of judgment on the issue.

9. Results and analysis

After entering the data in SPeAR according to the chosen segments, indicators, sub-indicators, and questions, it gives the results in detailed reports in rtf and excel file format. These reports show the evaluation scale, the segments pie chart, and the total average evaluation scores of the indicators (Figure 1). This is in addition to long text tables containing the details of the evaluations.

Table 1 shows the results brief of the environmental segment with the justifications for the scores used. Four indicators were used with a total of ten sub-indicators in all of them. The average score of each indicator is the sum of the scores of the sub-indicators divided by their number. Similarly, the average score of the segment is the score of the indicators divided by their number. The indicators of soil, land, and biodiversity got “0” score, which means they are at standard practice level fulfilling minimum requirements. In contrast, the indicators of waste and materials got “2” score, which means they are at the level of best practices. This indicates that the development of the project concentrated more on the buildings, while less concentration was directed on the outdoor spaces and their natural components.

Environmental segment
Indicators		Sub indicator score	Score	Av. score
Soil and land	Soil quality	The project although provided some protection of soil profiles and improved soil quality, no documentation was available on-site management, storm water management or landscape management.	0	0
	Drainage systems	Although the different treatment of the master plan and its landscaping show concern towards drainage issues, no sustainable drainage system has been applied.	0
Biodiversity	Protected species and habitats	Although KHUH enhances the natural life and biodiversity in the site, there is still a need to prepare and disseminate ecology and biodiversity management plans. On the other side, the performance was better in.	0	0
	Conserving and improving local biodiversity	The landscaping of the project will be contributing to the conservation and improvement of the biodiversity in the site but there is still a need to compensate for the disturbance in the natural environment due to the development of the project.	0
	Habitat connectivity	The project represents an important hub for connection between different natural elements in the context but there is a need for more in-depth studies and plans to mitigate the effect of the continuous movement in the site due to its function.	0
Waste	Waste in operation	KHUH represents a benchmark in the planning and management of waste since this is one of the most serious problems in hospitals. The details of the management plans in operation need to be disseminated for monitoring and feedback.	2	2
	Hazardous/special waste	KHUH also pays a greet attention to the safety measures in the treatment of hazardous waste and the discharge of its containers.	1
Materials	Materials efficiency	Materials used in the development of KHUH have been chosen according to high standards either in the buildings and the outdoor spaces without any clear sign of waste or neglect.	2	2
	Environmental and sustainability impacts of materials	Although there I apparent harm to the environment from the materials used in the project, there is a need for a detailed and in-depth study and analysis of the sustainability impact of these materials.	1
	Healthy materials	Health measures are clearly applied in the materials used in the hospital.	2
Overall segment average score				1

Table 1.

Indicators and sub-indicators of the environmental segment and their scores.

The overall performance of the environmental segment got “1” score, which means good practice level. This very general result shows that it was possible to achieve some good levels of sustainability in the environmental sectors of KHUH master plan. Still, there is a lot to be done to improve them including all the indicators and sub-indicators of SPeAR.

Table 2 shows the results brief of the social segment with the justifications for the scores used. Four indicators were used with a total of 19 sub-indicators in all of them. The social segment overall performance showed the best practice level. This is due to the strong institutional, educational, and healthcare structure of KHUH. All the sub-indicators got “1” score and above which means they all came in the good practices and best practices range. Art sub-indicator of culture indicator came below the standard level. There is a lack of public artworks in the outdoor spaces that would enhance the positive aesthetical experience of the users and their appreciation of the quality of the project. Also, there is a lack of space and landscape furniture that would be used for art activities in the project. In contrast, institutions and social network sub-indicator of health and wellbeing indicators got “3” score making it exceptional and exceeding the best practice level. This is because KHUH is a government hospital providing its services to its users regardless of their social class or ethnic origins. This result shows again that it was possible to achieve good levels of sustainability in the cultural sectors of KHUH master plan, but hard work is still needed to cover all the cultural indicators and sub-indicators and all the questions and issues that need to be comprehensively considered.

Indicators	Sub indicator	Justification	Score	Av. score
Community facilities	Education	KHUH is now considered the university hospital of RCSI-Bahrain. It is the newest and modernist medical education institution in the country. KHUH has its own educational spaces within its premises that are used by its staff, students, and outside guests.	2	2
	Healthcare	KHUH provides state of the art health care services for all people of Bahrain. It is equipped with all the necessary modern equipment and a qualified staff is available in all the medical services of the hospital. All medical services are offered free of charge for Bahraini citizens regardless of age, gender, ethnic group, or religion.	2
	Recreation	Although KHUH is not an open public space, it provides excellent indoor and outdoor leisure facilities and green spaces that can be easily used by the staff, visitors, the patients, and the students of RCSI.	2
	Retail	KHUH provides modern retail services to serve the staff, visitors, patients, and students of RCSI for the whole length of their stay in the hospital. These include small shops, a coffee shop, and a restaurant.	1
Culture	Respecting socio-cultural identity	KHUH represents with its modern design the dynamism of Bahraini culture that is open, livable, and developing. At the same time, it is preserving its roots and principles as an Arabic multi-ethnic multi-religion culture.	2	1
	Cultural and religious facilities	All cultural groups have equal access to all parts of the complex without any kind of barrier or discrimination.	2
	Use of environment	The site of KHUH was a vacant urban site. The project’s master plan transformed the site into a monumental landmark with wide and diversified green elements.	2
	Intergenerational and gender practice	KHUH respects the fact that most of the people of Bahrain are Arab Moslems. The freedom of dress, behave and worship is guaranteed for all including other religious groups.	2
	Art	Unfortunately, public art has not been considered in KHUH despite the high quality of its urban design and architectural design.	−1
Form and space	Density, scale, height and massing	KHUH fits well within its context and provides distinguished masses of buildings in a very prominent site. These building masses are surrounded by green spaces that serve all parts of the hospital. The scale of the buildings’ masses of the hospital is distinguished within its context providing a monumental gate for the city of Muharraq.	2	2
	Public-private relationship	KHUH provides clear separation between private and public spaces. Visitor parking is separate from those of the employees. The routes and entrances of the employees are separate from those of the patients and visitors. The zoning and spatial definition of the master plan is simple and clear and areas around buildings are wide and transparent.	1
	Landscaping	It is clear from the master plan of KHUH that landscaping was a main concern. It was treated to aid the environmental, visual, and social needs of the hospital. It was integrated with the buildings and the open spaces between and around them. It aids the sustainable drainage system by aiding the infiltration of rainwater and the prevention of flooding. At the same time, it naturally helps the development of habitat life in the site.	2
	Landscape, townscape, and visual impact	KHUH complements the general green structure of the area at the meeting border between the two cities of Manama and Muharraq. It is a continuation of the green structure on the roads to its south and east. As such, the project adds to the urban visual character of Bahrain and enhance the green culture of the community.	1
		KHUH provides good spatial openness and visual transparency of the spaces around the buildings and in the public open spaces of the site.
		Public and private spaces are clearly defined, and suitable lighting is provided for the public areas like parking lots and green spaces without affecting the buildings of the hospital. Surrounding residential areas to the north of the hospital are far enough to be affected.
	Security	KHUH provides good spatial openness and visual transparency of the spaces around the buildings and in the public open spaces of the site. Public and private spaces are clearly defined, and suitable lighting is provided for the public areas like parking lots and green spaces without affecting the buildings of the hospital. Surrounding residential areas to the north of the hospital are far enough to be affected.	2
	Connectivity	Within the nice natural environment and well-designed beautiful buildings and spaces, KHUH provides both the employees, patients, and visitors with a splendid chance of meeting, communication and cooperation in a lively and vibrant environment.	1
Health and wellbeing	Access to green space	KHUH added great value to the surrounding areas by transforming the vacant site into a monumental landmark with wide areas of greenery. It has enhanced the overall urban image of the area.	2	2
	Community cohesion	KHUH has been providing an excellent opportunity for the integration between the different groups of users without any discrimination based on color, gender, religion, or ethnic group. KHUH is the second largest healthcare facility in the country, and it has considered the future population growth of the citizens and expatriates. At the same time, KHUH has a wide range of services that respond to the different needs of the community.	2
	Institutions and social networks	KHUH is a government hospital working under the umbrella of the |Ministry of Health. The users of the hospital with all their classes are subjected to the government healthcare system in general and to the special high standards of the hospital. At the same time.	3
	Social vibrancy	KHUH provides enough open public spaces where people can meet like the clean well paved roads and parking lots. Nice, beautiful green spaces are also available for meeting and suitable social activities.	1
Overall segment average score				2

Table 2.

Indicators and sub-indicators of the cultural segment and their scores.

10. Conclusion

Nothing could compensate for the official document of the master plan for this very distinguished hospital that is considered a masterpiece of architectural and urban design in Bahrain and the region. It is here worthy to make an appeal to the hospital administrations in Bahrain to help disseminate information on the project because this practice is a sustainable conduct that is desperately needed for raising public awareness toward these important issues. The declared interest in sustainability from the decision makers can be hindered by the lack of information. It is no longer acceptable that other countries consider sustainability in the master plans of their hospitals since the eighties of the twentieth century and Bahrain and other Gulf Countries lag far behind this level in the twenty-first century. It is hoped that this research would find a way to be extended for a detailed and in-depth study for KHUH soon. On the side of SPeAR, it has been found helpful in giving general qualitative ideas on sustainability issues of the project. It is also flexible and user-friendly, and indicators, sub-indicators, and questions can be easily adapted to the needs of the user and the project under consideration. Yet, although it covers a wide range of sustainability issues, it is too broad and descriptive, which also leaves a wide gap for the subjective judgment of the sustainability practitioner. Many sustainability issues can be quantitatively measured and can have numerical ranges for the accepted levels. It is hoped that future research will be conducted on the development of SPeAR to provide more accurate and generalized quantitative models for sustainability impact assessment.

Conflict of interest

The author declares no conflict of interest.