What are the important lessons learned from some of the most innovative and groundbreaking health care facility projects? How can the unique challenges of creating a "Celebration Health," "Northwestern Memorial Hospital" or "Griffin Hospital" enlighten the design and construction industry about the future of health care environments?
In 2002, the authors began researching and presenting a lecture series entitled, "How the Icons Have Fared," at industry functions such as the American Society for Healthcare Engineering and AIA/Academy of Architecture for Health's Planning, Design and Construction (PDC) Conference and the Symposium on Healthcare Design. The task was to investigate some of the decade's best-known health facility projects to determine if and how they met their project goals and objectives.
The facilities were selected based on levels of innovation, design awards, public interest or controversy, and their impacts on new forms of patient care. All of the facilities were risk-takers, and the desire was to understand their leadership strategies, their architects' inspirations and the final assessment of the project outcomes.
A case study process included interviews with administrators, hospital staff, architects and project managers. In addition, there were literature searches, analyses of current project data, plan surveys, on-site walk-throughs and photography.
Common experiences, valued truths
After studying and speaking on these unique facilities for the past three years, the authors extracted a list of 10 lessons learned that summarize the common experiences and valued truths discovered by these important new health care facilities. They include the following:
1. All icon projects had a visionary leader. Most of these icon health care projects were initiated or inspired by an innovative and determined health care CEO. These project leaders played the role of vision-keeper, using their communication and team-building skills to drive the project forward. Some project leaders, like Pat Charmel, CEO at the Griffin Hospital, Derby, Conn., and Bruce Komiske, past-CEO of Hasbro Children's Hospital, Providence, R.I., have gone on to directly influence the development of important new hospitals in other parts of the United States.
Charmel was hospitalized at a time when his own hospital was financially troubled. He came to realize that the patient experience was extraordinarily awful.
He reasoned that a focus on his patients' experience at the hospital might capture the imagination of his staff and potential patients, thereby allowing his hospital to regain market share and financial strength. He led an effort to find the best systems of patient-centered care and inspired a team of core converts to lead a profound process of change in the Griffin Hospital culture.
Overcoming a variety of project critics, Dr. Jonas Salk used both his visionary and analytical skills to promote the new East Addition to The Salk Institute, La Jolla, Calif. Dr. Salk was directly involved in most aspects of facility planning and met personally with project critics to explain the architectural and scientific importance of this new research facility.
Likewise, Young S. Suh, former CEO of the Genesys Health System, took on the monumental task of merging four existing hospitals to create a "first of its kind," fully integrated medical campus. Genesys Regional Medical Center, Grand Blanc, Mich., successfully aligned a 380-bed hospital, outpatient clinics, retail services and physician offices into a single, medical megastructure.
2. Groundbreaking projects require back-breaking effort. The iconic projects became health care's newest archetypes. Foregoing off-the-shelf solutions, architects and consultants worked long hours to conceive and create these innovative new building types. As project design fees dwindled, the work often became a labor of love.
Architectural controversy over the expansion to the Salk Institute caused the architects to redesign and modify the project's proposed site plans six different times. Schematic planning took three years to complete.
Architects and planners for Northwestern Memorial's 17-story replacement hospital in Chicago were required to coordinate and collect project data from over 125 different user groups.
Griffin Hospital took the time to pre-test ideas as a way to minimize mistakes and revisions. Before embarking on a new inpatient tower, the hospital commissioned the architects to develop both an LDRP unit and the renovation of a med-surg unit along Planetree lines, allowing the hospital administration, staff and architects to test-drive concepts well in advance of design work for the new building.
3. High-profile projects require unwavering support. The decision to create an innovative, new health facility inevitably invites attention from eager patients, doubtful doctors, nervous board members and envious competitors. The visionary leaders of these projects knew they were attracting attention and used the opportunity to build consensus that saw each project through periods of doubt and challenge.
Asked how Children's Hospital of San Diego was able to implement so many unique, new design concepts, architect Jim Jonassen, principal with NBBJ replies, "Don't attempt a project like this with only lukewarm support from your hospital's board and administration."
On the other hand, despite strong support from hospital leaders, local labor unions resisted the Genesys Regional Medical Center concept for small, cross-trained nursing teams. Without buy-in from the nurses, the new operational strategy for decentralized nursing teams eventually had to be changed.
4. No one got it "exactly" right. Being first is important, but it isn't always best. It's harder to know what's around the corner when no one has ever turned the corner. The importance of embedded flexibility is critical to the design of any hospital; all the more so in an innovative facility.
Disney-inspired Celebration Health in Celebration, Fla., is inherently flexible and successfully fills a fundamentally different mission than originally planned. The commitment to a flexible planning module and universal rooms has paid off in simple transformations and easier additions.
An aging local patient population has altered the service mix at Sutter Maternity & Surgical Hospital, Santa Cruz, Calif. Growing surgical volumes for aging baby boomers have now outpaced the facility's original maternity-care programs. The hospital has redirected itself toward these new surgical and recovery services for both women and men.
Some icons aren't sufficiently flexible to accommodate changes. For example, a pod-based plan in one icon doesn't accommodate new medical technologies or adapt easily to automated distribution systems. Other icons were planned around delivery modalities that changed: one was planned around the notion of co-located inpatient and outpatient services just as the system learned that outpatient services were more appropriately provided out in the community.
5. Bravery counts, but it can cost too! For many of these hospitals, being brave and trying new ideas was a necessary precondition to developing an extraordinary new building. Bravery has netted increased market share, greater public notice, improved staff retention and lower recruiting costs, but it has also created a few problems.
For Griffin Hospital, acting decisively and simply surviving was the extent of bravery's objective. However, the hospital is now locked into a site that doesn't lend itself to growth at a time when expansion is its newest objective.
The original operational plan for Genesys Regional Medical Center was both innovative and controversial. Traditional staffing patterns and hospital culture eventually forced both operational and architectural changes on the project, reaffirming that "Culture eats strategy."
Celebration Health is a success by almost any measure, but no hospital could meet the high expectations that were created by its preconstruction publicity. And so, because expectations were unrealistically high, a very good hospital is regarded by some as ordinary. It takes vision to create the force that drives an iconic hospital and that vision creates expectations that sometimes are difficult to realize.
6. Risk can provide rewards. Often, the risk/reward equation ends up favoring the innovator. The commitment to change and self-improvement can provide a significant return on investment, helping ensure a new health facility's future success.
Providence, R.I.-based Hasbro Children's Hospital's (HCH) commitment to innovation and its emphasis on engaging the imagination of families, patients and donors allowed HCH to conduct a capital campaign that surpassed expectations. The community's involvement and excitement translated into major donations for future project improvements.
Sutter Maternity & Surgical Hospital took five years to reach a "financial break even" but it now holds the highest patient satisfaction scores in the Sutter Healthcare System.
The unique design concepts and new public image of Children's Hospital of San Diego helped differentiate it and increase its regional market share. This small, unknown pediatric hospital soon became a magnet for specialized staff, medical research and philanthropy.
7. A successful beginning can inspire future successes. The mission, vision and conviction of the health care organizations that built these facilities continues to activate and drive new programs within them, even after the passage of a decade.
For instance, the arts program at HCH continues to grow. The program was originally implemented only in the major public spaces, but now permeates the entire facility and communicates the hospital's special relationship with its patients.
Likewise, the Salk Institute's long-term investment in interstitial mechanical space allows for efficient and rapid remodeling of its research labs. This flexible, interstitial concept allows the Salk Institute to continually renew its facilities, remaining "forever young."
Additionally, Griffin Hospital has evolved from being just a Planetree maternity suite, to a Planetree inpatient hospital, then a pioneer Planetree ambulatory/outpatient program and, finally, becoming a touchstone site for the therapeutic environments movement. It's all pretty heady stuff for a hospital that was just trying to avoid bankruptcy.
8. Know that "tomorrow" quickly becomes "yesterday." What's considered visionary today can become problematic tomorrow. Projects that adopted the latest health care trends often wished they had taken a longer view.
For instance, in an effort to improve operational efficiency, one hospital planned to care for both outpatients and inpatients in shared diagnostic/testing units. Mixing healthy and sick patients was not a popular concept, so freestanding outpatient centers are now being developed on the campus. In another example mentioned previously, fixed-form nursing-pod clusters were not amenable to conversion or change, and the plan's forward-thinking design became an obstacle when anything new was introduced.
9. Before icon building, there's team building. These innovative, new health care facilities often required multiskilled teams of architects, artists and engineers. Team building was, oftentimes, a significant first step for these hospital projects.
Northwestern Memorial Hospital involved the marriage of four architectural firms, various engineering disciplines and a construction manager. To better serve the project, architects formed a joint staff of over 100 individuals who shared offices on-site with the client.
Whitby Psychiatric Hospital, Whitby, Ontario, Canada, involved a comparably diverse team on a much smaller project. The team was composed of a programmer/planner and three architectural firms forming a joint venture.
Griffin Hospital benefited from the ongoing, collective education of the design team--and the client--about a new idea: patient-centered care and Planetree. The project's success was assisted by the commitment to educate and embrace the entire design team and clinical staff about this new and novel approach to health care delivery. This self-educated team of consultants, clients and clinicians are now teaching others throughout the world about Planetree and the value of patient-centered health care.
10. Icon projects can dominate a consultant's reputation. Involvement in a "legacy" hospital project can expand an architect's reputation and sometimes typecast them as well.
Ellerbe, VOA & HOK's shared involvement with the Northwestern Memorial Hospital project provided important industry recognition for each firm. Five years later, each of these firms is doing major academic medical centers and VOA is still working with Northwestern.
Based on his hospital's renowned design innovations, Children's Hospital CEO Blair Sadler has now become an international spokesman for family- focused health care environments.
Whitby Psychiatric has become a touchstone project for both Cannon and Moffat Kinoshita architects. Each has gone on to do multiple large psychiatric hospitals in other regions of the United States and Canada.
Before the publicity about Griffin Hospital, the SLAM Collaborative's work was largely located in Connecticut and its adjoining states. After Griffin, SLAM has competed successfully for projects throughout the United States and United Kingdom.
Worth the journey
In the end, the final destinations were worth the long journeys. Health care architects, clinicians and patients are all well-served when vision, creativity and commitment combine to create an iconic hospital.
Revisiting these projects provides important lessons about "what went right" and teaches equally important lessons about the benefits of flexibility.
Though these hospitals can occasionally be found lacking on this latter point, they largely remain vital and successful, and have spawned a generation of even better hospitals in their wake.
Donald McKahan, AIA, FACHA, is an architect and health facility planner with McKahan Planning Group of Del Mar, Calif., and the current president of the American College of Healthcare Architects. He can be reached at dmckahan@mckahan.com. Francis M. Pitts, AIA, FACHA, is president of architecture+ in Troy, N.Y., and a past president of the AIA/Academy of Architecture for Health. He can be reached at pittsf@aplususa.com. The opinions expressed in this article are their own.
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