Abstract
In the context of the central role that health plays in human life, operating theaters are among the most critically important departments in hospitals, where a functional architectural planning that serves this role is at the forefront. It is essential to create a safe and efficient healthcare environment in operating theaters, where surgical procedures are performed, and the design should be meticulously designed to create this environment. Planning principles and design standards applied for hospitals and operating theaters may vary from country to country and even between different regions within the same country. Although it is difficult to find common architectural standards covering all countries, conducting reviews and studies focused on current operating theater architecture and design standards applied in certain countries and addressing them together and comparatively with the standards used in other parts of the world to the extent possible seems to be the most accurate way to address operating theater architecture comprehensively.
In the last 20 years, healthcare buildings constructed in Türkiye have witnessed radical changes in typology and design standards. This change process, which is an extension of the upper-scale decisions taken by the state for the development of healthcare services, has led to the construction of numerous new healthcare buildings. It is possible to say that the “Health Transformation Program,” implemented by the Ministry of Health in 2003 and included regulations regarding different dimensions of healthcare, was the first important step in initiating this process. Although the priority of this program was not regulations regarding healthcare building design, the first architectural regulations concretely concerning this service were included here within the framework of a comprehensive healthcare service change program. With the momentum created by this program, both unwritten current applications were implemented, and some design standards for the healthcare building in general and specific units began to be implemented through various official documents. Accordingly, significant changes have occurred in hospital design in Türkiye, and operating theaters are among the hospital departments where these changes are intensely observed. A comprehensive study has not yet been conducted to address how these new standards, realized in the operating theaters of recently constructed public hospitals, are reflected in the operating theater design and the functionality of the service, and what kind of new practices have been implemented. In this context, this study examines the operating theater architecture, which is a subject that has not been sufficiently studied in the field of healthcare building architecture in Türkiye, through architectural projects and practical applications of operating theater departments of certain hospitals built on the basis of current design standards.
Objective
This article aims to examine the current design standards and practical applications that shape the architectural planning of operating theater departments in Turkish public hospitals to reveal the effects of these standards on this department and the provision of healthcare services throughout the hospital, to contribute to the elimination of the lack of information and resources in the literature on the subject, and to create a resource that will provide new perspectives on future studies on operating theater design by outlining current practices in the world. In addition to evaluating the applicability of these standards, most of which are published by the Republic of Türkiye Ministry of Health through circulars and guides, and the problems that arise in practice, an examination is also made on their capacity to adapt to changing needs and current developments in healthcare services, and their effects on the development of operating theater architecture. To conduct a comprehensive review, the article examines operating theaters in terms of the current design standards applied, the spaces they contain, the functional flow of the service, the building materials used, and the regulations regarding the provision of sterilization. In addition, the article provides a brief overview of new standards and technologies related to operating theaters around the world, with the aim of outlining the current developments in operating theater design, albeit in general terms.
Methodology
Although there were not many design standards that were officially put into practice for public hospitals in Türkiye before 2003, new design standards were put into practice in the following period, the majority of which were the standards included in the documents titled “Türkiye Healthcare Buildings Minimum Design Standards 2010 Guide” published by the Ministry of Health in 2010 and “Issues to be Complied with During the Project Phase for Healthcare Buildings to be Built within the Scope of the Health Transformation Project” published by the Ministry of Health in 2012 (Figure 1(a) and (b)). In addition, there is another guide prepared by the Ministry of Health in June 2022, titled “Healthcare Buildings Standard Guide,” which contains design criteria for public hospitals. This study examines the standards published between 2003 and the present regarding the design of operating theater departments in public hospitals in Türkiye, as well as the conditions and level of their implementation in practice. It is impossible to conduct a comprehensive analysis that includes every public hospital in Türkiye. For this reason, it analyzes the applications carried out in this context in hospitals completed after 2012. As the basic method in the study, the operating theater departments of three public hospitals constructed at different intervals from 2012 to the present are selected, and the current architectural design standards applied in the operating theaters are revealed by examining their architectural projects and current physical conditions. With this examination method, observing the problems encountered and the changes in implementing the standards has become possible. The primary purpose here is to observe how the standards are implemented in these hospitals built after 2012 and the common aspects and differences in implementing the standards. By examining the standards applied in the operating theaters of the hospitals examined as an example and the extent to which these hospitals comply with the standards, it is possible to shed light on the applicability and prevalence of the relevant standards and the problems encountered.
(a) First page of circular dated 2012; “issues to be complied with during the project phase for healthcare buildings to be built within the scope of the health transformation project” (Republic of Turkey Ministry of Health, 2012). (b) Cover page of Türkiye Healthcare Buildings Minimum Design Standards 2010 Guide (Republic of Turkey Ministry of Health, 2010).
Operating Theater Departments in Hospitals and Their Architectural Characteristics
In the operating theater, a safe, functional, and controlled environment must be provided for complex medical procedures, especially surgical interventions, by prioritizing the health of both patients and healthcare personnel (Ministry of Health Malaysia, 2018). It should be stated that incorrect or incomplete planning of the operating theater layout, where architectural design is the most basic determinant, can prevent the flow of personnel, patients, materials, and equipment in the operating room and cause interruptions in healthcare services during surgery (Ahmad et al., 2016; Palmer et al., 2013). It is possible to provide a more functional and safe service environment within the operating theater department through several critical elements that can be achieved with the contribution of design (Joseph et al., 2018). Architectural design is essential, especially in ensuring sterilization, infection control, and efficient service flow. The smooth physical connection between the operating theater and other functionally related departments within the hospital is critical in providing quality healthcare services. The connection between the operating theater and the emergency service, delivery room, intensive care unit, and inpatient service should be practical and straightforward. The architectural design of the operating theater department is vital in increasing the efficiency of service and ensuring the safety of patients and personnel. Within the operating theater departments, operating rooms, preoperative and postoperative areas, hand washing units, and clean or dirty areas are planned to provide a basic, clean, simple, safe, and functional service flow (Harsoor & Bhaskar, 2007). The primary goals in operating theater design can be listed as ensuring the smooth and uninterrupted movement of patients and personnel, creating a sterile spatial structure in the department, keeping contamination at a minimum level, setting boundaries for specific areas within the operating theater, using high-quality materials, and integrating advanced technology.
It is possible to provide a more functional and safe service environment within the operating theater department through several critical elements that can be achieved with the contribution of design (Joseph et al., 2018). Architectural design is essential, especially in ensuring sterilization, infection control, and efficient service flow.
Ensuring the smooth and uninterrupted movement of patients and personnel, creating a sterile spatial structure in the department, keeping contamination at a minimum level, setting boundaries for specific areas within the operating theater, using high-quality materials, and integrating advanced technology.
The most common sections in operating theater departments, defined within the framework of a zoning approach according to the sterility level of the environment, are dirty, semisterile, and fully sterile areas. The messy area's first section usually serves as a central monitoring point responsible for controlling the entry of patients, personnel, and materials. Nonsurgical, everyday clothes can be worn in this area. The second section, the semisterile area, includes peripheral areas around the surgical unit and stores sterile materials. This area, which provides work areas for preparing surgical instruments and resting healthcare personnel, is connected to more controlled areas where corridors and operating rooms are located. The last section, the fully sterile area, which includes the rooms where surgeries are performed, includes operating rooms, clean storage, sterilization room, and cleaning areas (sink, hand washing unit, etc.) (Figure 2). In this section, surgical dress codes must be strictly followed, including wearing caps and gloves. Material selection is of critical importance, especially in this section of the operating theater, as it affects the level of cleanability and can increase the risk of infection by causing surface contamination (Frabetti et al., 2009).
Fully sterile area of operating theater department of Kahramanmaraş/Elbistan Public Hospital in Türkiye, including operating rooms, sterile corridor, and hand washing units (Photo by: Authors).
All building materials and other architectural elements used in the design of rooms where operations are performed should be made of materials that prevent the formation of dirt or bacteria, are easy to clean, and do not negatively affect the sterility of the environment but rather contribute to the opposite. In addition, the coating materials selected for floor, wall, and ceiling coverings and built-in equipment should be of high quality, preventing possible infections during and after the operation. In the design of the rooms, it is essential to eliminate gaps or corners with a risk of dirt and dust accumulation. In order to minimize this risk, it is recommended to use materials and components that create nonporous and flat surfaces as much as possible (Harsoor & Bhaskar, 2007). It is necessary to avoid arrangements that restrict the movement of patients and personnel in both operating theaters and other parts of the hospital.
Infection control, which is frequently addressed in studies conducted on operating theater design and services today and is defined by protocols or guidelines that are constantly updated due to evolving design concepts and technologies, is an important issue that must be prioritized in the design process, “due to the invasive procedures performed” in operating rooms. “The prevention and control of infection in operating units requires a multitude of provisions including HEPA filtered operating rooms with specified air changes per hour, scrub facilities for doctors and nurses, sterile stock storage with access to the OR's either directly or via sealed carts.” (TAHPI-Part: D, 2025). Controlling the flow of patients and staff and regulating entry and exit to operating rooms is essential for ensuring infection control. For example, “donning and doffing rooms located at the entry to a unit will assist the staff to enter and exit the facility according to the strict infection control protocols required, thereby reducing the risk of contamination.” Contemporary engineering practices related to air-conditioning and pressurization should also be implemented properly for providing infection control in operating theater spaces. The provision of “operating rooms being positive pressure rooms relative to adjacent areas,” and “the uni-directional airflow from the operating room to the surrounding areas by the pressure gradient” that are necessary for ensuring infection control, are implemented with these practices (TAHPI-Part: D, 2025). An infection control-focused planning approach is one of the most fundamental elements of evidence-based design, which has become a key component of hospital design today. Evidence-based design approaches, which are fundamentally based on the “desire to create human-centered spaces” and the principle of “combining reliable and clear information obtained from research and experience into a more efficient design philosophy,” are applied in operating theater departments to ensure infection control (Republic of Türkiye Ministry of Health, HBSG, Fascicle 3, 2022).
Operating Theater Architecture and Design Standards in Public Hospitals in Türkiye
Following the “Health Transformation Program” (2003), more comprehensive standards and practices were implemented through circulars or design guides compared to the previous ones and started to be used in hospital constructions. In this context, the first design guide prepared by the Ministry of Health, “Türkiye Healthcare Buildings Minimum Design Standards 2010 Guide,” was published. This guide, published in 2010, was the first comprehensive design guide published by the state until that period. Although it remained merely a recommendation, the standards it contains regarding operating theater departments are examined in the following section, as it has begun to be used as a reference in the design of public hospitals, and a significant portion of its provisions have been implemented in hospitals. On the other hand, another official document, which is one of the most decisive sources in the process extending to the present day for the design of healthcare buildings in Türkiye, was started to be prepared by the Ministry of Health, close to the publication of the 2010 guide. The name of this document, which was published in 2012 in a circular format, is “Issues to be Complied with During the Project Phase for Healthcare Buildings to be Built within the Scope of the Health Transformation Project.” With the introduction of the obligation to comply with the regulations specified in the construction of healthcare buildings, this document becomes a design guide. This circular includes issues related to architectural design, such as size and building material on the one hand, and on the other hand, it is a text to which new engineering standards have been added. In this study, where the architecture and design standards of operating theaters in recent public hospitals in Türkiye are examined, an evaluation will be made mainly on the standards specified in this circular, since it is mandatory to comply with all its provisions, and it is the most widely used document in design. The “Healthcare Buildings Standard Guide” published by the Ministry of Health in June 2022 also includes standards related to operating theaters. However, since compliance with its provisions is not officially mandatory and the period between its preparation and the present day is short, it is not possible to obtain comprehensive data and results regarding the level of implementation of the standards it includes in hospitals. Therefore, this study did not conduct an examination based on this guide. On the other hand, in order to present the most up-to-date standards for operating theater design in Türkiye and the new practices applied/to be applied in this context, some new operating theater design standards that were not included in previous guidelines but are included for the first time in the 2022 guideline are also briefly mentioned at the end of this section.
In this period, where many interventions and changes were made in different departments, from the addition of new units to the building materials used, from the implementation of current technologies to the engineering infrastructure, the most radical change was witnessed in the operating theater designs. In this context, some changes were made regarding the floor, wall, and ceiling materials used to construct the operating theaters. While jointed materials such as ceramics or tiles were seen on the walls and floors of hospitals built before the 2000s, continuous and jointless materials such as polyvinyl chloride (PVC) began to be used on the floors of all operating theater units during this period. The use of antibacterial paint has begun on the walls and ceilings of operating theaters in public hospitals, and in general, care is taken to ensure that the floor, wall, and ceiling covering components have antibacterial, antistatic properties and are resistant to disinfection fluids. Antibacterial paint usage on the walls has become standard, depending on the sterility needs of the relevant unit; in parallel, the use of jointless plasterboard panels painted with antibacterial paint on the ceilings of all operating theater units has begun (Figures 3 and 4).
An operating room in Yalova Training and Research Hospital in Türkiye with antibacterial paint on its walls, plasterboard panel on its ceiling, and polyvinyl chloride (PVC) on its floor (Photo by: Authors).
An operating room in Kocaeli Public Hospital in Türkiye with antibacterial paint on its walls, plasterboard panel on its ceiling, and polyvinyl chloride (PVC) on its floor (Photo by: Authors).
In addition, hybrid and robotic operating rooms, which are new types of (specialized) operating rooms defined in the 2022 guide, are new and up-to-date practices planned and implemented for operating theater departments in public hospitals. Hybrid operating rooms, which are currently available in only a few hospitals in Türkiye, are rooms equipped with the technological and spatial infrastructure that “enables interventional radiology and surgical procedures to be performed within the same operating room” (Republic of Türkiye Ministry of Health, HBSG, Fascicle 4, 2022). The architectural design of these rooms requires planning that takes into account the size and location of the imaging devices used during the surgical process. The 2022 guide also covers principles regarding the architectural requirements of robotic operating rooms, where robotic surgery—a surgical model that contributes to the implementation of digital integration in operating rooms and has recently begun to be used in public hospitals across the country—is performed. When designing operating rooms where robotic surgery is performed, architectural planning must be carried out that takes into account the positioning and movement of the robotic units used. The 2022 guide was prepared with content that presents not just a single model for operating room layout planning and patient, staff, clean, and dirty flow but rather different suggestions and arrangements together and as alternatives. As in previous guides, operating theater spaces are grouped under the headings of dirty, semisterile, and fully sterile areas. However, different layout models for operating room placement, such as single corridor, racetrack, and cluster designs, are introduced in the 2022 guide for the first time. It is observed that some of the models mentioned contain layouts that differ from previous guides and have been designed and implemented in some city hospitals built in recent years.
Operating Theaters in “Türkiye Healthcare Buildings Minimum Design Standards 2010 Guide”
The architectural arrangements implemented for operating theater design with the 2010 guide are primarily based on obtaining a more sterile environment, which is the most basic requirement of the health service provided in this department. In this context, it is stated for the first time in this guideline that three areas should be planned in operating theater departments in public hospitals: dirty area, semisterile area, and fully sterile area. With this article, the spatial organization and service flow diagram of the operating theater department have been established within a defined framework, and operating theaters of public hospitals have started to be planned based on this diagram. Apart from this, new units have been defined to be located in operating theaters; “preoperative (Preop) patient room” for the preparation of patients before surgery, Postoperative (Postop) room for the recovery process after surgery and stretcher transfer hall, which serves as a stretcher transfer area between dirty and semisterile area for patients right in front of the operating theater department entrance were first mentioned in this guide and started to be used in hospital designs (Republic of Türkiye Ministry of Health, 2010) (Figures 5–7). With these new regulations, a design approach was widely implemented to control clean air by creating dirty, semisterile, and fully sterile areas using sliding doors within the operating theater. Again, in this guide, it was stated that the operating theater department should be planned in a location where irrelevant traffic cannot pass and should be in a location that provides direct and easy access to the emergency service and intensive care unit (Kabo et al., 2023; Republic of Türkiye Ministry of Health, 2010).
Three areas should be planned in operating theater departments in public hospitals: dirty area, semisterile area, and fully sterile area.
Operating theater department plan of Edirne Sultan 1. Murat Public Hospital showing dirty/semisterile/full sterile areas, preoperative and postoperative room, and stretcher transfer hallway (Project by: Selda Gümüşdoğrayan Architecture Office).
Operating theater department plan of Şanlıurfa Hilvan Public Hospital showing dirty/semisterile/full sterile areas, preoperative and postoperative room, and stretcher transfer Hall (Project by: BTG Architecture Office).
Operating theater department plan of Yalova Training and Research Hospital showing dirty/semisterile/full sterile areas, preoperative and postoperative room, and stretcher transfer Hall (Project by: Gönül Architecture Office).
The 2010 guide also includes standards regarding the dimensions of operating rooms according to their features. Within this framework, it is stated that for general operating rooms, “each medium-sized room must have a minimum floor area of 42 m2 and one wall of the room must be at least 6 meters long, while special/large operating rooms including cardiovascular, orthopedic, neurological and other special procedure rooms must have a minimum floor area of 50 m2 and one wall must be at least 6 meters long” (These dimensions don’t include fixed or wall-mounted cabinets and built-in shelves) (Republic of Türkiye Ministry of Health, 2010). In addition, the guide suggests new spatial elements to improve healthcare services, such as the orthopedic operation room, rapid sterilization room, medical gas storage unit, and personnel changing area to serve the department. New spaces, such as the ones in the operating room, are also described with their architectural features and technical infrastructure (Republic of Türkiye Ministry of Health, 2010). Although it includes significant regulations for a sterile environment to be achieved in operating theaters and for the functional circulation of patients/personnel, the 2010 guide doesn’t have sufficient coverage regarding the architectural and engineering aspects of the subject. In the 2012 circular, more detailed architectural standards regarding the operating theaters were added, and, unlike the 2010 guide, standards that include new engineering technologies were included.
Operating Theater Departments in 2012 Dated Circular
The vast majority of the architectural arrangements stated in the 2012 dated circular consist of design decisions taken for the hospital units such as intensive care, operating theater, emergency service, patient bedrooms, and polyclinics, which are the most actively used units of the hospital, and standard provisions for the basic elements of architectural design such as new scale, size, building material and number of users for the hospital interior/exterior. It is possible to address the architectural arrangements put forward by this circular regarding the operating theater department under two headings: arrangements concerning only the operating rooms and the operating theater department in general. There are 12 articles regarding the operating theater department in the circular. In this part, these articles will be addressed within the framework of the specified headings, not in numerical order. When looking at the standards concerning the operating theater department in general, the first thing that stands out is the existence of units added or increased in number, mainly concerned with obtaining a more sterile environment and ensuring asepsis. Within this framework, it is possible to list the main standards in the circular as “creation of a slipper changing room at the entrances of the operating theater personnel” in Article 1, two aseptic areas for doctors and nurses, two as male and female for staff, and four in total in Article 6 (in hospitals with more than 200 beds) in operating theaters and “planning the operating theater organization desk in the project where at least three people can work in a place that will not block the entrance and exit in the semi-sterile area of the operating theater” in Article 9 (Republic of Türkiye Ministry of Health, 2012). The aseptic areas specified for the operating theater staff are planned between the dirty and semisterile areas, and it is intended that the personnel enter the operating theater after ensuring the necessary cleaning. It is aimed to control the entrance and exit of the operating theaters, corridors, preop and postop rooms, and current patient/staff circulation through the organization desk, which is stated to be planned in a semisterile area. The article regarding the slipper changing room, which is usually planned at the point of transition from a semisterile area to a fully sterile area, aims for the personnel to enter the fully sterile area more cleanly (Figures 8 and 9).
When looking at the standards concerning the operating theater department in general, the first thing that stands out is the existence of units added or increased in number, mainly concerned with obtaining a more sterile environment and ensuring asepsis.
Operating theater personnel flow scheme related to the slipper changing room in circular dated 2012 (Republic of Turkey Ministry of Health, 2012).
Slipper changing room in operating theater department of Yalova Training and Research Hospital (Photo by: Authors).
The standard included in Article 8: “The number of beds in the operating theater for post-operative room should be half of the number of operating rooms, a nurse's desk should be considered for post-operative room, the bed head unit for this room should be considered next to the bed so as not to prevent the personnel from working at the patient's bedside, one door of the room should open to the semi-sterile area and the other door to the fully sterile area,” and the standard included in Article 11; “the planning of a storage area with a manual sliding door of approximately 25 m2 where medical devices will be stored in the fully sterile area and the planning of a stretcher pocket (one stretcher for every five operating rooms) in proportion to the number of operating rooms in the fully sterile area, are the standards included in the circular regarding the outside of the operating room” (Republic of Türkiye Ministry of Health, 2012).
The article on the postoperative room, which was also mentioned in the 2010 guide, suggested planning a postoperative room in a semisterile area, where patients can be admitted after surgery, and certain standardization was introduced to the design of this area within the operating theater department. The fact that this area was planned to include two doors, one opening to the semisterile area and the other to the fully sterile area, was also a design approach implemented through this standard. In addition, the statement in the seventh article of the circular stating that “a dining room in a semi-sterile area (with a controlled connection from the semi-sterile area) should be planned for operating theater personnel in hospitals with 200 beds and above” aims to reduce the time lost by personnel leaving the unit during the eating process and to enable more surgeries to be performed (Republic of Türkiye Ministry of Health, 2012).
When the standards specified in the 2012 dated circular regarding the design of operating rooms are examined, it is seen that the determining approach is to create a hygienic, germ-free, and easily cleanable space. The sensitivity in providing a sterile operating environment, which begins with replacing the coating materials used in operating rooms with antibacterial materials that hold less dirt, is raised to a higher level with the items added to the circular. In this context, Article 4 of the circular states that “the ceiling and wall junction points of operating rooms should be cornerless and oval” regarding the design of operating rooms, and it is stated that “the walls will be ovalized with the help of plasterboard” and “the details will be shown in the projects” (Figure 10) (Republic of Türkiye Ministry of Health, 2012). This article aims to ovalize all flat and corner points on all surfaces in the room to make them cornerless, eliminate spatial components that will produce or harbor microbes, and create easy-to-clean surfaces. Another design standard specified in the circular in this context is related to the material and placement of cabinets in the operating room. The statement “the cabinets in the operating room will be built into the wall between two operating rooms, and one operating room will use half of them and the other half will be used by the other. The cabinet doors will be at the same level and slope as the operating room walls and will be made of the necessary metal material (Chrome-Nickel, etc.) to be antibacterial.” Written in the second article indicates that all cabinets in the room should be designed to be built into the wall between two operating rooms and to serve both rooms in the opposite direction. In connection with this, the standard written in Article 3 “There will be no intermediate spaces in the cabinet doors manufactured in operating rooms made of framed glass that will harbor microbes or be difficult to sterilize” aims to ensure that the cabinet doors are flush with the room wall and consist of flat surfaces that will prevent possible microbe or bacterial accumulation and are made of a single piece of framed glass, making them easy to clean (Figure 10).
When the standards specified in the 2012 dated circular regarding the design of operating rooms are examined, it is seen that the determining approach is to create a hygienic, germ-free, and easily cleanable space.
Operating room design scheme shown in circular dated 2012 (Republic of Turkey Ministry of Health, 2012).
The number and types of operating rooms in planned hospitals are also standardized with this circular. In Article 5 of the circular, where the number of hospital beds is taken as the determining parameter, the number and types of operating rooms required are expressed as follows: For 1–10 beds = 1 local operating room For 11–24 beds = 1 general operating room For 25–49 beds = 1 general +1 local operating room For 50–75 beds = 2 general +1 local operating rooms For 76–100 beds = 3 general +1 local operating rooms (Ministry of Health, 2012)
As the number of beds in hospitals increases, the rate at which the number of operating rooms will increase in line with this increase is defined in the same article as “at least one operating room will be added for every 50 beds in hospitals with a bed capacity of 100–300, and one operating room for every 30 beds in hospitals with a bed capacity of over 300” (Republic of Türkiye Ministry of Health, 2012). Article 10 of the circular, which standardizes the requirement for operating rooms with a laminar-flow system in hospitals of a specific size, includes the provision that “Unless otherwise stated, one out of every four operating rooms will be laminar-flow” (Republic of Türkiye Ministry of Health, 2012). One of the necessary issues for maintaining indoor air quality in operating rooms is to remove particles that stick to the personnel's clothing and are carried indoors despite the pressurized doors from the operating area (Maxemos et al., 2021). The relevant article has standardized the integration of laminar flow systems that serve this function into these rooms. Regarding the operating rooms, in this article, which also includes regulatory provisions, it is stated that “one out of every eight operating rooms must have dimensions between 50–60 m2 and this room must have a laminar-flow system.” In order to provide security against harmful rays that will be emitted in the event of an X-ray or MRI during the operation process, the following provision was added to the same article of the circular: “At least one of the laminar-flow operating rooms will be covered with lead; if the number of operating rooms is one, this room will also be covered with lead” (Republic of Türkiye Ministry of Health, 2012).
A Comparative Analysis of the Application of Operating Theater Design Standards
In this section, three public hospitals that were completed at different times after 2012 and are currently in service are selected; the operating theater departments of these hospitals are comparatively analyzed in terms of their compliance with the standards in the 2012 dated circular and their general architectural features. The hospitals selected for the study are located in the Hilvan district of Şanlıurfa province and the provinces of Edirne and Yalova in Türkiye and have different sizes and bed capacities. The hospital's name in Hilvan is Hilvan Şehit Halit Şiltak Public Hospital, and its construction was completed in 2016; the name of the hospital in Edirne is Edirne Sultan 1. Murat Public Hospital and its construction was completed in 2015. The construction of hospital in Yalova was completed in 2022 under the name of Yalova Training and Research Hospital (Figure 11(a) to (c)). The implementation status of the standards in the circular regarding the operating theaters in selected hospital buildings is examined through architectural projects and visuals of the current status of the buildings. During the evaluation process, it will be revealed which standards exist or not in which hospitals and to what extent they are implemented, both in the text and through a table prepared to show all standards and their implementation status in hospitals, and then an analysis will be carried out on why the relevant standards are implemented or not, and various suggestions will be put forward.
(a) Yalova training and research hospital (2022) (Photo: https://www.yalovagazetesi.com/hastaneye-ucretsiz-ulasim-persembe-gunu-basliyor). (b) Hilvan Public Hospital (2016) (Photo: https://www.sanliurfa63.com/hilvan-devlet-hastanesine-personel-alinacak/4547/). (c) Edirne Sultan 1. Murat Public Hospital (2015) (Photo: https://www.bilimteknikmedikal.com.tr/sayfa/referanslar/devlet-universite-hastaneleri-/edirne-sultan-1 murat-devlet-hastanesi-460-yatak/).
When we examine how the standard in the first article of the circular related to the slipper changing room is implemented in three hospitals, we see that this standard is interpreted differently in each hospital. In Hilvan Public Hospital, it is seen that the room is planned in accordance with the standard at the transition point from semisterile area to fully sterile area; however, it is seen that asepsis isn’t planned at the transition from dirty area to semisterile area, as it should be, but at the transition from semisterile area to fully sterile area. Therefore, although it is seen that the standard is implemented in practice, the fact that personnel use the slipper changing room when passing from a semisterile area to a fully sterile area without first using asepsis is an element that disrupts the cleaning flow of personnel (Figure 12(a)). In Edirne Public Hospital, it is seen that the personnel service flow is made from the dirty area to the asepsis section, from there it is directly connected to the slipper changing room and passes to the semisterile area, and no area is planned for the transition from this area to a fully sterile. Since the slipper changing room should be present in the transition to the fully sterile area according to the standard, it is seen that the specified standard is not complied with here either, and the room is applied while passing to the semisterile area (Figure 12(b)). It is seen that the arrangement here does not comply with the standard, as it causes the medical personnel to enter the semisterile corridor directly, not the fully sterile corridor, after changing their slippers. It is seen that the personnel service flow in Yalova Training and Research Hospital is from the dirty corridor directly to the semisterile area through the asepsis section, and the transition from this section to the fully sterile area is provided by the slipper changing room by standard (Figure 12(c)). In this context, it is seen that the slipper changing room design among the three hospitals is only made in Yalova Hospital by the standard.
(a) Operating theater department plan of Hilvan public hospital showing the arrangements related to 1, 6, and 8 numbered articles in circular dated 2012 (Project Owner: BTG Architecture Office). (b) Operating theater department plan of Edirne 1. Murat Public Hospital showing the arrangements related to 1, 6, and 8 numbered articles in circular dated 2012 (Project Owner: Selda Gümüşdoğrayan Architecture Office). (c) Operating theater department plan of Yalova training and research hospital showing the arrangements related to 1, 6, and 8 numbered articles in circular dated 2012 (Project Owner: Gönül Architecture Office).
When we look at how the standards written in Articles 2 and 3 of the circular regarding the cabinets to be used in operating rooms are implemented in these three hospitals, it is seen that the built-in cabinet manufacturing specified in the standards is implemented in all three hospitals (Figure 13(a) to (c)). However, some different decisions are adopted in terms of design in each. It is noteworthy that in the operating rooms of the hospitals in Hilvan and Edirne, the fixed cabinets consist of built-in cabinets positioned at the same level as the walls in accordance with the article; in Hilvan, the cabinets are placed on the walls between the rooms in accordance with the standard, while in Edirne, the cabinets are not placed on the walls between the rooms. On the other hand, in Yalova Hospital, although it is seen that the cabinets are kept at the same level as the walls, their positions vary between the operating rooms; in some rooms, the cabinets are placed between the common wall and an arrangement by the standard is made, while in some rooms this is not observed. The standard in the fourth article, which requires the ceiling and wall junctions of operating rooms to be cornerless and oval, is implemented in all three hospitals (Figure 13(a) to (c)).
(a) Design of built-in cabinets in operating rooms of Hilvan, Edirne, and Yalova Hospitals (Project Owners: BTG, Selda Gümüşdoğrayan, and Gönül Architecture Offices). (b) Built-in cabinets used in the operating rooms of Yalova training and research hospital (Photo by: Authors). (c) Operating room floor, wall, and ceiling joints in Yalova training and research hospital (Photo by: Authors).
It is seen that the standard, which specifies the minimum number of operating rooms that hospitals should have according to their bed capacity in Article 5, is complied with in all three hospitals. It is seen that the 70-bed Hilvan Public Hospital more than meets the minimum 3-room requirement by the standard, the 300-bed Edirne Public Hospital more than meets the minimum 8-room requirement with its nine operating rooms, and the 400-bed Yalova Hospital more than meets the minimum 10-room requirement with its 16 rooms (Figure 14(a) to (c)). When the applications implemented in these hospitals regarding the standard, which specifies the number of asepsis rooms in Article 6, are examined, it is seen that the Hilvan Public Hospital meets the minimum two asepsis room requirement required for hospitals with a capacity of less than 200 beds, specified in the standard, with the two asepsis rooms in its project. It is seen that Edirne Public Hospital, which exceeds the 200-bed threshold, meets the minimum required number of four asepsis rooms with four asepsis rooms in its project. Yalova Hospital does not meet the standard because it has one fewer asepsis room than the required number and three asepsis rooms in its project (Figure 12(a) to (c)). Regarding the standard that states that a dining room should be planned in semisterile areas of hospitals with minimum 200 beds in the seventh article; it is seen that in Edirne Public Hospital, this room is planned by the standard, in Hilvan, although no dining room is planned, it is not mandatory to comply with the standard because the number of beds is below 200 beds, and in Yalova, this standard is not complied with because no dining room is provided (Figure 14(a) to (c)).
(a) Operating theater department plan of Hilvan public hospital showing the arrangements related to 5, 7, 9, 10, and 11 numbered articles in circular dated 2012. (Project Owner: BTG Architecture Office). (b) Operating theater department plan of Edirne 1. Murat Public Hospital showing the arrangements related to 5, 7, 9, 10, and 11 numbered articles in circular dated 2012. (Project Owner: Selda Gümüşdoğrayan Architecture Office). (c) Operating theater department plan of Yalova training and research hospital showing the arrangements related to 5, 7, 9, 10, and 11 numbered articles in circular dated 2012. (Project Owner: Gönül Architecture Office).
When the implementation status of the standard in Article 8 regarding the postoperative room is examined, it is seen that the postoperative rooms provide the required number of beds by the standard in all three hospitals. It is seen that the postoperative room is positioned in a way that will establish a connection between the semisterile and fully sterile areas by the standard in two hospitals other than the hospital in Yalova. It is seen that the nurse's desk isn’t planned in the hospitals in Hilvan and Yalova, but is planned in accordance with the standard only in the postoperative room of the hospital in Edirne. On the other hand, although it isn’t in the project, during the visit to the operating theaters of Yalova Hospital, it was determined that a nurse's desk was added to the room (Figure 12(a) to (c)). When the designs implemented in the projects regarding Article 9, which states that an organization desk should be designed in the semisterile area, are examined, it is seen that this desk is planned in all three hospitals. However, it is seen that this was planned in a semisterile area only in the hospital in Yalova, in the hospital in Hilvan, this desk was planned in the dirty area, and in the hospital in Edirne, it was planned inside the stretcher transfer hall that provides the transition from the dirty area to the semisterile area (Figure 14(a) to (c)).
When the implementations regarding the 10th article are examined, it is seen that a room with an area of 50–60 m2 wasn’t planned in the hospital in Hilvan; however, since there are three operating rooms in the hospital, this isn’t a mandatory standard to comply with; the hospital in Yalova has an operating room of this size, and the standard is met. However, in Edirne, although necessary, an operating room of this size isn’t planned (Figure 14(a) to (c)). In examining the projects, it is seen that only in Hilvan, a lead-coated room is planned, and the necessary information regarding lead coating couldn’t be obtained for projects belonging to other hospitals. The standard for manufacturing laminar-flow systems in operating rooms was excluded from the evaluation since it is a subject outside the architecture. When the implementation status of the standard specified in Article 11 is examined, it is seen that the storage area is planned by the standard in all hospitals, even if each of them does not provide the necessary sliding door and m2. On the other hand, the stretcher pocket is planned only in the project of Edirne Hospital; however, it isn’t planned in any of the other hospitals, and the standard isn’t applied in them (Figure 14(a) to (c)). The 12th article of the circular is excluded from the evaluation because it is unrelated to architecture.
General Evaluation
When the analysis table prepared to see the implementation status of the standards in the hospitals is examined, one of the first striking points is that all of the standards numbered 2, 3, and 4, which concern the operating rooms, have been implemented in all three hospitals (Table 1). The main reason for this is that since all three standards concern the operating room, they are not affected by possible different approaches in the design process of the operating theater department in general. They include arrangements such as construction materials and technical equipment that can be efficiently planned by standard during the design. It is possible to evaluate the fact that only the application locations of the built-in cabinets differ in one hospital as a preferred approach in the design process. It is seen that the other standards that are met in all three hospitals are standards numbered 5 and 6. In this context, it is seen that the required number of operating rooms is provided in all three hospitals, and the number of aseptic rooms is provided by the standard in all hospitals, except for one missing aseptic room in Yalova (Table 1). At this point, it should be emphasized that, in addition to the fact that it is possible to plan the number of rooms required in the project preparation process despite different locations and conditions, the fact that achieving these numbers is deemed essential by the Ministry of Health is also decisive. It is possible to interpret the complete compliance with the standards concerning the operating rooms through the fact that the operating room is given more importance than other units. It should be emphasized that the fact that the article of planning one of the operating rooms to be 50–60 m2, which is stated in Article 10, is not complied with in Edirne, despite the standard requiring it for a hospital of this size, constitutes a contradiction in this sense and a deficiency in design decisions. Although the number of beds required for the postoperative room, which is mentioned in Article 8 and concerns a single location, is provided in all hospitals, the fact that a similar common practice isn’t seen in the nurse's desk and the doors opening to semi/fully sterile areas should be seen as important deficiencies that were easy to plan but were overlooked in the design process. On the other hand, the table shows that the common application level is lower in general standards concerning the operating theaters (Table 1). For example, it is seen that the standard regarding the necessity of designing a dining room in Article 7 is applied only in Edirne and not in Yalova. It is thought that the reason for not applying this standard is that the standard in question has the potential to seriously affect the service flow chart and sterility.
The Application Level of Design Standards in Circular Dated 2012 in Three Case Study Hospitals.
◻ Answering “no” to this criterion does not negatively impact compliance. ⊠ Meeting this criterion is not mandatory for this hospital.
However, it is seen that some standards that don’t require such serious physical intervention aren’t applied in a standard way in all hospitals. The article that is seen to be applied in the most different ways among the three hospitals is the first article (Table 1). The main reason why the standard for the slipper changing room, which is observed to be complied with only in Yalova Hospital and applied at different points in the other two hospitals, can’t be complied with in every project is that it is tough to integrate this standard in the same way into different plan schemes that will emerge during the design processes of different operating theaters. At this point, defining the slipper changing room in a single space or compartment in a more straightforward and more adaptable way in the standard will increase the level of common applicability. Regarding the design of an organization desk expressed in the ninth article, it should be interpreted that this desk is planned in all three hospitals, considering that the desk, which is movable furniture, is relatively easy to apply within the architectural plan (Table 1). However, it is possible to evaluate the fact that the desk was planned in a semisterile area only in the hospital in Yalova, in full compliance with the standard, while it was planned in a different area in other hospitals, as a design decision taken contrary to an easy-to-comply standard. When the applications regarding the 11th standard are examined, it is seen that the storage area is planned in all hospitals. However, each does not provide the necessary sliding door and m2. It should also be noted that the failure to provide a sliding door and the required m2, despite being easy to design in the project, should be presented as a design decision deficiency. Similarly, although it is easy to include in the design, it should be stated that the stretcher pocket is shown only in the project of the hospital in Edirne, and that it was not planned in other hospitals, as one of the applications that do not comply with the standard.
Conclusion
This study reveals that the applications implemented within the framework of the new design standards have contributed to the higher quality of healthcare services provided in public hospitals in Türkiye. Although a one-to-one implementation obligation hasn’t been introduced, it is seen that the dirty, semisterile, and fully sterile area planning has become a widespread application in operating theaters through the standards specified in the 2010 guide. In connection with this, new spaces such as the preop room and the postup room have also been added to the operating theater department scheme through this guide; with all these arrangements, significant contributions have been made to the formation of a sterile operating environment. With the circular dated 2012, which included more detailed regulations, important steps were taken toward creating a predominantly sterile operating theater environment. This document brought significant innovations to operating theater design in Türkiye, with the effect of the obligation to comply with the standards included in it in all public hospitals. On the other hand, the fact that the standards were prepared on two separate dates (2010 and 2012) and without reference to each other caused some confusion in the implementation phase. Hospitals can implement different practices to realize some of the standards specified in the 2012 guide. It is thought that the main reason for this is that the possible problems or confusion that may be encountered in the health service, design, and construction processes are not sufficiently considered when determining the content of the standards.
As a result of this comparative analysis, it was observed that a significant portion of the standards determined for this department were implemented in all three hospitals. In this article, which examines the extent to which the circular standards dated 2012 were implemented in the operating theaters, it was observed that some standards could not be adopted one-to-one in all three hospitals and that different architectural arrangements could be implemented. It is thought that the fact that each hospital was built under different conditions and the different approaches put forward in the architectural design process are effective in this situation, and it can be said that this should be accepted as natural as long as it does not negatively affect the health service and the health of the users. In this context, one of the most fundamental findings of this study is that it is necessary to make scenarios and plans that take into account possible problems that may be encountered in all processes, from the design and construction stages to the service stage, when creating standards. Another important result of the study is that this and similar studies, which examine the standards applied in operating theaters in public hospitals and the extent to which these hospitals comply with the standards, can shed light to a great extent on the level of applicability of the relevant standards and the problems encountered in this regard. A general assessment of the operating theater design standards currently used worldwide reveals that applications implemented due to technological advancements such as digitalization, hybrid operating rooms, and robotic surgery have recently come to the forefront. Although design guidelines prepared prior to 2022 for public hospitals in Türkiye did not include these practices, the 2022 guidelines introduced definitions and standards for some of them for the first time, and they have been implemented in a small number of public hospitals. On the other hand, the International Health Facility Guidelines Part: B (2025), a current international design guide, presents applications such as “digital operating rooms, robotic surgery, use of imaging within the operating room, and sophistication of information systems” as trends that should be more widely used and easily accessible in the future (TAHPI-Part: B, 2025). This highlights that there are still aspects of these applications that need to be developed and that new studies need to be conducted in this regard.
Implications for Practice
The new design standards for the operating theaters in public hospitals in Türkiye expressed in this article are instructive and suggestive for the design of further operating theaters of many hospitals in different countries.
This article sheds light to a great extent on the level of adaptability and applicability of the existing operating theater design standards and the problems encountered in this regard.
Implementing the design standards evaluated in the article can contribute to forming more functional and sterile environments in operating theater departments.
The problems related to the constitution, content, and application of operating theater design standards that are evaluated in this study express that it is necessary to make comprehensive and detailed plans when creating these standards to prevent the problems that may occur during the construction and service processes of operating theaters.
This study increases awareness among healthcare professionals about the critical role of detailed architectural design in maintaining hygiene conditions and functionality in operating theaters. Increasing this awareness can contribute to integrating more functional and hygiene-focused criteria in new operating theater designs and promote demand for targeted refurbishment strategies in existing facilities.
Footnotes
Acknowledgments
This article is derived from the master's thesis titled “The Architecture of Operating Theaters and Current Design Standards in State Hospitals in Türkiye” prepared by Emma BEGOVIC under the supervision of Assoc. Prof. Dr. Mehmet ŞENER. The authors would like to thank Gönül Architecture, BTG Architecture, and Selda Gümüşdoğrayan Architecture offices for permitting the usage of their architectural projects in this article.
Ethical Considerations
As a research article that does not involve human participants, human data, or human tissues, ethical approval was not required.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.