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Healthcare Design Approaches the Millennium
Interior Expressions, November 1998
As the twentieth century draws to a close, a new generation of health care facilities has emerged that looks very different from familiar institutional models. Based on patient-centered care and committed to healing the whole person, these new facilities connect patients to nature; they break the institutional grid; they empower patients by partnering with them and by providing options for control. These health centers are spiritual sanctuaries, not grim, scary places. The temples of healing have gardens, fountains, natural light, art, music ... they embrace the joy of living and are a celebration of wellness.
But we should not congratulate ourselves too quickly, for despite these successes, the majority of medical centers across the nation are still starkly institutional, designed like fortresses: maze-like corridors, little natural light, rows of semi-private patient rooms, centralized nurse stations with 42-inch-high barriers, waiting rooms with a TV bracketed to the wall near the ceiling and metal frame seating, linked together, encircling the room. These buildings have shiny white vinyl composition floors, full-height stainless steel corner guards, stainless steel kick panels on high traffic doors, surface-mounted fluorescent luminaries with cool white lamps, and color - if used at all - is pastel. The good news is that many of these hospitals will be scheduled for replacement in coming years and one would hope that more life-enhancing design would be embraced.
Health care cannot be separated from the settings in which it is delivered. Researchers, for example, are documenting how healing can be promoted by surroundings that reduce stress and engage the senses in therapeutic ways. The quality and character of the built environment can influence the healing process and can make it easy or difficult for staff to do things well.
Recent research in the neurosciences has revealed that emotions are linked to disease and that billions of neurons in the brain convert feelings of hope and confidence into chemical substances that boost the immune system. In fact, few question the mind/body connection. Scientists tell us that our brain is writing a prescription for our body every minute of every day. When we feel sad, our bodies produce sad chemicals which affect the functioning of internal organs and this can eventually suppress the immune system.
Continually, environmental design theories are being validated by scientific evidence reinforcing the mind/body link. The Center for Health Design is engaged in a major research effort to determine how the built environment affects patients' medical outcomes. In collaboration with the Program for Medical Technology and Practice Assessment of Johns Hopkins University and principal research, Dr. Haya Rubin, the center is engaged in a multi-year study with an ambitious research agenda. It has been a privilege for me to be a member of the center's research committee, because I have been promoting a research-based approach to inform design decisions for some twenty years. My most recent book, Hospital Interior Architecture, was an attempt to bring research to the health care design community as well as show applications of it. I hoped that book would create a bridge between environmental design researchers and design practitioners.
The Center for Health Design celebrated its tenth anniversary last November in San Diego, which was an emotional and moving event for those of us who have been associated with it since its beginning. One cannot deny the tremendous influence the symposium has had in shaping our ideas about life-enhancing design and in providing a forum for discussion, a place where we could share ideas with other health care design professionals, health care management, and product vendors. Barely a week passes without people I meet mentioning to me a significant moment during a symposium event when they felt enlightened by a new idea that changed their way of thinking. As I sat with my fellow trustees two weeks ago at the Center for Health Design's board meeting in Sausalito, I felt an enormous sense of pride and satisfaction about what had been accomplished in the past ten years as well as a sense of urgency about what has yet to be successfully achieved.
Few question the mind/body connection. Scientists tell us that our brain is writing a prescription for our body every minute of every day.
My personal agenda for the next few years will be to explore a new direction in health care design that goes way beyond the way we currently describe healing environments. In preparation for writing a new book, I have been studying the design of sacred spaces for the past year, searching for clues to why certain structures historically have created a sense of awe in those who experience them.
An example that immediately comes to mind is the renowned courtyard of the Salk Institute with the channel of water that extends to the ocean and sky. While this is a monumental project created by a very gifted architect in collaboration with a great client, there are works of lesser importance that have a similar effect. Sometimes these are humble structures crafted with indigenous materials and used for healing rituals. There is a cemetery in Stockholm that is famous for its unique landscape architecture. A series of stairs extending up toward the sky carries one's eye to the heavens in a way that is very spiritual.
Last year I had the pleasure of attending an academic conference on sacred space at the University of Cincinnati. Professors and researchers gathered from all points of the earth to deliver papers on a myriad of topics that expanded exponentially my ideas about this subject. From sacred geometry presented by mathematicians and physicists, to trails of rocks and boulders used as wayfinding devices by pilgrims in the Holy Land, to church and temple architecture, and sacred landscapes of Bali, I was never more convinced that the ultimate design for a center of healing will be a synthesis of architecture that has a spiritual context, outstanding landscape design, environmental research, and high technology.
Clearly the challenge will be to be able to create this type of architecture with the use of conventional building materials and construction techniques, as well as respond to building codes and budgets typical of health care projects. Acoustic tile ceiling, rooms with 90-degree corners, and vinyl composition tile floors are not stepping stones to achieving feng shui or the type of aesthetic harmony that would support the integration of complementary therapies with allopathic medicine. As the biomedical "repair of the broken machine" mechanistic approach to healing gives way to a more holistic concept, the treatment setting will have to change to more fluid organic forms.
Having said that, there will always be a need for variety in health care settings. For some, a hospitality ambience will be appropriate; for others, an upbeat retail milieu will define success: but the ultimate healing center for those who are burdened with illness and suffering will be a spiritual sanctuary, a place that is uncluttered, serene, quiet, and harmonious in all respects. Perhaps the surgical interventions and treatments take place in a high tech setting, but the patient is returned to a tranquil oasis, cared for by nurturing individuals. In this nirvana, healthy, aesthetically beautiful food would be served and patients might have the option (if feasible) of their beds being moved into a garden for a portion of the day; occasionally musicians would perform for their enjoyment, and they would be surrounded by healing works of art.
I know it is possible to achieve the image I have in my mind's eye because I have been teaching a workshop at Harvard University for the past six years in the Graduate School of Design. It is a four-day course for practicing professionals - for the most part health care architects - who, after participating in a two-day intensive course in healing environments design and research, work in charrette teams to rethink traditional approaches to the design of challenging health care settings. Each year the teams produce projects so innovative that I am emotionally overwhelmed by their accomplishments. They work with the creative freedom often denied them when working on an actual project that has an owner and a restrictive budget. I think they themselves are often amazed at what they have been able to create. These projects include outpatient oncology clinics' critical care units, emergency departments, sub-acute care, skilled nursing facilities, and the design of an integrated medicine center combining allopathic primary care with complementary therapies. I am hopeful that my new book will present the right combination of research and though-provoking examples from a variety of settings to enable a handful of talented health care architects to make the leap to the type of life-enhancing health care setting that will revolutionize our thinking as did Planetree.
Emergency Department Waiting Room
HealthEast St. John's Hospital
St. Paul, Minnesota
Interior Architecture: Jain Malkin Inc.
Probably the first time ever that someone has designed an emergency department waiting room as library/lounge/reading room. Familiar visual clues (fireplace, hearth, books, aquarium) elicit comfort in a potentially threatening environment.
Derived form the Arts & Crafts movement popular in the U.S. at the turn of the century, popularized by Gustaf Stickley in The Craftsman magazine as a rebellion against the industrial revolution. Includes leaded glass panels framed with wood, reproduction Art & Crafts ceramic tile, carpet,
Such dreams as these may seem impractical and impossible to imagine in the context of managed care, reduced lengths of stay, and with the focus on trimming the bottom line. But it would be unwise to dismiss them too quickly. When the Planetree model project hospital project was developed at California Pacific Hospital in San Francisco around 1980, it represented just as dramatic a shift from traditional patient care and facility design as that which I have proposed. I remember clearly all the naysayers who
ridiculed Planetree and said it would never work. Later, these critics said it could work in a small scale nursing unit, but it could never work in a whole hospital, yet Griffin Hospital in Derby, Connecticut, is alive and well and people come from around the world to learn about it. If Griffin is at the far end of the spectrum where operational protocols, space planning, complementary therapies, and patient-centered care are totally integrated, elements of Planetree philosophy have been adopted by hospitals throughout the nation. It makes me smile to think that a handful of people - the pioneers who conceived of Planetree - could set off a revolution in an industry as large as health care. With this in mind, I have no doubt that well-intentioned individuals can achieve a post-Planetree dream that incorporates a spiritual aesthetic in the next developmental stage of the sacred trust we call health care.
November, 1998: Interior Expressions