Healthcare infrastructure around the world is entering a period of rapid redevelopment. The economic resurgence in Asia, Latin America and Eastern Europe is translating into demands for more and better care in more attractive, convenient environments.
The countries of Western Europe, emerging from their economic doldrums, are finding the money and the political willpower to invest in major upgrades of their basic health facilities.
What will those new hospitals and clinics look like? How will their design reflect the values that those societies attach to healthcare? How is the latest thinking about clinical excellence and economic prudence being incorporated into the next generation of hospitals?
In Stockholm in June, about 300 healthcare professionals, architects, artists, builders and designers gathered to present and hear the latest worldwide research in healthcare design.
Co-sponsored by the Karolinska Institute, the major medical center in Stockholm, and Texas A&M University's architecture school, the Second International Conference on Health and Design highlighted the growing body of evidence that quality of design can affect patient outcomes.
Some of the environmental properties that can affect patient outcomes:
Noise is a major annoyance to patients, especially in intensive-care units. It can lead to greater stress and high blood pressure. Sunlight has beneficial health effects. It elevates mood. Windows in critical-care units are associated with calmer patients. Single rooms, compared with open wards, lead to lower rates of nosocomial infection. Furniture arrangements can affect eating and social behavior in geriatric patients. Visual art, especially scenes of nature, can lessen anxiety and pain in surgical patients. Carpeting in a hallway can give the elderly more secure footing, compared with shiny, hard floors.
Brutalistic architecture, such as the enormous concrete and brick edifices built in the late 1960s and early 1970s, can actually impair patient recovery, experts say.
``Stress is a starting point for understanding how design affects medical outcomes,'' says Roger Ulrich of Texas A&M University. Ulrich conducted a pioneering study in the 1980s of how visual stimuli affect patient outcomes. Manifestations of stress, he says, include the psychological, such as anxiety, depression, anger and helplessness; the physiological, such as elevated blood pressure and decreased immune function; and the behavioral, such as sleeplessness, verbal outbursts and drug abuse.
Hospital designers themselves are among the severest critics of the hospital experience. A survey of U.S. hospital architects revealed far more negative observations than positive ones.
The architects didn't like the hard surfaces, cramped rooms, absence of plants and gardens, dull colors, excessive noise and lack of privacy. They complained that it was hard to find their way around and that there was nothing to look at on the ceilings.
The inpatient room is by far the most important source of pleasure or discontent, the survey showed. And since the more people feel they can control their environment, the happier they are, the architects especially liked it if they could choose the art to be hung in their rooms.
A change in style.
For years, hospitals in Europe have been built on a mass-production scale, says Alan Dilani, a professor at the Karolinska Institute. Pointing to a picture of a multistory concrete bunker of a Swedish hospital built in the 1960s, he says: ``If you came to this hospital you would be a lot more stressed. The modular, brutalist building elements are more suitable to a petroleum factory.''
The hospital architecture followed the treatment model of the time: Fix the patient according to industrial principles. This ``pathogenic'' model of care, Dilani says, divided patients into sick parts to be treated and fixed.
A consequence of the pathogenic perspective, Dilani says, is that ``the psychological, social and spiritual needs of patients have been largely disregarded in the design of healthcare facilities, and often marginalized in the philosophy for delivering care.'' These functionally efficient facilities are not supportive of the patient's psychological needs, he says.
That is now starting to give way to a ``salutogenic'' perspective, which considers causes of health and wellness instead of merely treating sickness.
Dilani believes, along with many conference participants, that placing the patient's social and psychological needs at the forefront of the design program will foster wellness. It also motivates and uplifts the healthcare professionals who work in the facilities.
Many architects and designers presented case studies looking at design innovations and how they affected patient care.
George Tingwald, M.D., of Skidmore Owings & Merrill's San Francisco office, described an ambulatory building for Kaiser Permanente in Vallejo, Calif., that puts all the aesthetic resources into the public areas, in the expectation that the clinical areas will become obsolete within a few years and be replaced.
John Zeisel, president of Hearthstone Alzheimer Care in Lexington, Mass., showed pictures of nursing homes that take into account the limited memory and false perceptions of Alzheimer's patients.
Philip Monteleoni, vice president of Perkins Eastman Architects in New York, converted a corporate office building on the Connecticut shore to a hospice for dying patients who will be able to see the sea from their beds. Terminal patients find such vistas deeply comforting, he said. Architect Jon Buggy, of Ellerbe Becket in Minneapolis, said that at the New York Psychiatric Institute in New York City, fewer patients have to be restrained because the bright, open spaces reduce their stress levels.
Blair Sadler, president of Children's Hospital and Health Center in San Diego, explained how design was used to make a new pavilion ``feel like a children's hospital. We wanted to create a place that's fundamentally different for children,'' he said. Since it opened in January 1993, the 271-bed hospital's volume has steadily increased in a shrinking market, he said.
Yet patient-focused design can also yield unintended results in staff dissatisfaction and turnover. Faye LeDoux, a project director for Ellerbe Becket, conducted a short survey of neonatal intensive-care units while preparing to design one for a Milwaukee hospital.
The trend in NICUs has been to shrink the size of the room. Instead of 40 babies in bassinets in one big ward, hospitals have been building ``pods'' of six to eight bassinets, which afford the families more privacy and intimacy with their infants.
Yet when she visited these new NICUs, the staff were demoralized and upset.
``The nurses had worked in an open ward,'' LeDoux says. ``They liked the easy communication and camaraderie and eye contact.''
They felt alienated and separated from the team in the more private setting. At one hospital, four of six NICU nurse managers had quit in the previous six months.
``These caring individuals celebrate every victory and mourn every loss,'' she says. ``They get to know these babies very well. They are very self-effacing. They are not looking after their own self-interest. Their interest is making sure the environment is comfortable for the baby and the family. They didn't think of what that would mean to them as individuals and the team.''
In Europe the issue is not NICU design--they don't have as many preterm babies as in the U.S.--but patient privacy and comfort.
Patient-care units in most European hospitals are still designed as wards, with six or more patients in a room, and a bathroom down the hall. Patients are becoming more sensitive to the lack of privacy, and physicians and hospital administrators are becoming more alert to other compromises in quality of care.
Double rooms, and increasingly, single rooms, are being planned in new European hospitals. Traditionally, government-run health systems believed single rooms were not affordable. Yet compelling evidence was presented that the clinical and psychological benefits of single rooms should not be discounted.
For example, patients in singles are less susceptible to nosocomial infections from a roommate.
Here is one place where reimbursement protocols have a part in dictating how hospitals make decisions on layout. In a fixed-payment regime such as the American DRG system, the hospital bears the extra cost of the infection. But in a socialized system, there are no financial consequences to the hospital for keeping the patient a few extra days to recover from the infection.
``There's a definite move toward single rooms,'' Norwegian architect Knut Bergsland says.
``There have been no rules on how many beds should be in a ward. In a 20-bed ward, you might have four singles and eight doubles.''
The huge University Hospital project in Trondheim, Norway, which will accommodate 950 beds when completed, has only single rooms. ``They found out you could get 24 single rooms for as much as double rooms,'' Bergsland says. ``But in some cases the rooms do not have private baths.''
Some rooms are often so small that there is little room for medical equipment and patients and families feel cramped. The square-footage permitted for such rooms is rising gradually.
Architects have found that certain other rooms, such as exam rooms and doctor/patient conference rooms, can be eliminated if all the patients are in singles.
A focus on yesterday's problems?
Clearly, vast resources of a scale never seen before are being pumped into healthcare infrastructure in Europe.
Yet some critics wonder if a huge opportunity to rethink the role of the hospital in the context of national and community health is being squandered. Is it possible that national and local governments are building hospitals that address the problems of 10 years ago and will be obsolete by the time they are finished, three, five, or even 10 years hence? The Trondheim project in Norway, for example, will not be finished until 2010.
Few American hospital projects can rival what is being built in these countries:
Britain's National Health Service is building an 800-bed hospital outside Norwich, England, to replace a handful of smaller community facilities in the town.
In Paris, the 850-bed Georges Pompidou European Hospital, which opened in December 1998, replaced three century-old hospitals on the Left Bank.
The Norwegian national government just built the huge National Hospital on the outskirts of Oslo.
In northern Norway, the University Hospital will be spread over several city blocks to give patients a sense of openness and comfort. The building cost is projected at 7.3 billion kroner, or more than $800 million.
In Montreal, the Canadian government wants to consolidate five old hospitals into one new facility.
In the Netherlands, a large hospital is being planned for Groningen.
``The projects in Europe are very large,'' LeDoux says, much larger than anything being contemplated in the U.S., with just a few exceptions.
``I think the use of the hospital is different in Asia and Europe because everybody is paying for the service. When they get sick, they go lie in a hospital bed,'' LeDoux says.
Some American architects, however, question whether these billion-dollar European megastructures are solving yesterday's problem. With the accelerating move toward outpatient care, these behemoths may be at least partly redundant by the time they are completed.
Tingwald, for one, believes inpatient care is on the way out, although it may take longer for that trend to accelerate in some countries. In the U.S., he said, 80% of people coming for healthcare in 1990 entered through ambulatory modes of care. By 2000, 90% of people use only ambulatory care. The well-known tower building of the Cleveland Clinic, for example, is entirely ambulatory.
Peter Eckroth, a planning and design consultant in Chicago, says the economic implications of hospital design were consistently underplayed in the agenda.
``If the design adds one full-time equivalent,'' says LeDoux, of Ellerbe Becket, ``that FTE is yours forever. I can't believe they're not aware of that, but then again, that's not an issue in Europe, and it's not an issue in Asia, based on my experience.''
In Korea, for example, a ``guardian,'' or family member, goes with you to the hospital. The hospital beds are designed with a trundle bed underneath. The family handles cooking and routine patient care, reducing the need for staff.
``The whole idea of what staff costs is not an issue,'' LeDoux says. ``In Moscow, the staff is so poorly paid--when they say a cab driver makes more than a doctor, they're not kidding. There isn't that correlation we have (in the U.S.) where the bricks and mortar are just a small part of your operating cost.''
The way a U.S. architect looks at the situation, she says, an efficient facility design might save 30 FTEs, which could translate to $900,000 per year, multiplied over the life of the building.
``And clients are complaining to me that this building is costing them $65 million!''
Comprehensive solutions. Some of the American architects, whose firms partially underwrote the conference, felt the complex quality of the research presented did not translate easily into workable design solutions.
Academic researchers are interested in the nth degree of detail in research, says Kirk Hamilton, of Watkins Hamilton Ross in Houston. ``The architect is committed to deal with all the aspects of design and the environment. We are looking for integration, synthesis and hypothesis.'' He wants to hear from somebody who can pull all these ideas together in a way that architects can use.
Maybe that's because their goals are different, says Clare Cooper Marcus, professor emeritus of landscape architecture at the University of California at Berkeley. ``Architects are under pressure to get the building done,'' she says. ``Academics have time to think about it and write it later. I can see why there would be some frustration.'' The trouble with architects, she adds, is they don't do research, and they don't read. They only want to look at pictures.
Still, Marcus found two things heartening about the Stockholm conference: First, the consensus of support for patient-centered design.
``Everybody was dealing with orienting their work to what patients see and want. I'm sure at a conference 10 or 20 years ago, that would not have been the emphasis. It would have been technology.''
Second, there is no longer any argument that gardens and views of nature are important design elements.
``Landscaping around hospitals is not just window dressing,'' she says. ``It's intrinsic to the healing process.'' Patients who look at nature scenes have less pain. Healing moves along faster and they go home sooner. This has a cost implication for hospitals, she says.
Perhaps, she says, it's time to start thinking about splitting hospitals into two parts: the medical intervention, and the recuperative healing component.
``Western medicine is so fixated on fixing things through drugs, surgery or medicine,'' she says.
``The body will heal itself very often.''