A Template for Change
Designing and building a new hospital takes creativity and determination. Ushering several new hospitals at once through the demanding California regulatory process takes focus and dedication. Opening as many as 20 new, replacement, or expanded hospitals in the next 10 years in the midst of escalating material costs, a tightening labor market, advancing technology, evolving standards of patient care, increased environmental concern, and the speed-to-market demands of a burgeoning patient population takes innovation, daring, and a whole new approach to healthcare design and construction.
That's exactly what was created when Kaiser Permanente, the nation's largest integrated healthcare system, recently engaged a joint venture of the architecture firms SmithGroup and Chong Partners Architecture (now part of Stantec).
To meet the fast-growing demand for the healthcare services in California and stringent new seismic regulations, the two firms worked together with Kaiser Permanente's National Facilities Services Division, state regulators and two contracting companies—Harbison-Mahoney-Higgins Builders and the Whiting-Turner Contracting Company—to develop a state-or-the-art template hospital design.
The template provides Kaiser Permanente with a facility design that is flexible enough to adapt to specific clinical and community needs yet standard enough to be built and managed efficiently.
Based in Oakland, California, Kaiser Permanente operates the country's largest not-for-profit health plan. The organization, which has 8.2 million members nationwide, runs 32 hospitals and more than 400 medical offices and clinics, in nine states and the District of Columbia. Thirty of Kaiser Permanente's 32 hospitals are in California, where the combination of membership growth and the need to replace more than one-third of its hospitals by 2008/2013 because of new seismic regulations imposed by the state created a tremendous construction challenge for the healthcare giant.
Kaiser Permanente realized its ambitious construction plans could not be met by reinventing the hospital on every site. To help overcome the difficulties of such a bold capital plan, the group drew on its decades-long history of innovative thinking about healthcare design. This includes the recent Templates 2000 program, which Kaiser Permanente developed to capture and codify best practices for all departmental rooms, equipment, planning, and functional programs. With the help of the SmithGroup and Chong Partners joint venture, the organization decided to broaden the scope of the template dramatically to cover the entire hospital.
“The challenge of the project was to create a design that was not a mere cookie-cutter approach, but a dynamic vision that could adapt to a variety of needs, both now and in the future,” says Christine L. Malcolm, Senior Vice-President, Hospital Strategy and National Facilities for Kaiser Foundation Health Plan and Hospitals. “The template was not intended to be a one-size-fits-all response that was unreflective of or unresponsive to the unique needs of each medical institution.”
Kaiser Permanente National Facilities Services Standards, Planning and Design team was very aware that current healthcare delivery exists in a rapidly changing and challenging environment in which concerns about consistency in performance and quality are vital in support of a health system's brand. “Maintaining the balance between standardization and flexibility was key to the template's long-term success,” says Malcolm.
Kaiser Permanente saw the template hospital as an opportunity to leverage the collective expertise of professionals both inside and outside the organization. The design-bid-build process was a collaborative venture that included the architects, engineers, contractors, and all hospital constituents—physicians, clinical staff, labor, and administration—from the very beginning. Regulators from the California Office of Statewide Health Planning and Development (OSHPD) were also an integral part of the team.
The team approach helped define the best operational practices and departmental relationships within the hospital. Based on these practices and relationships, the template outlines common structural and building systems, planning concepts, floor plans, equipment, and furnishings and construction techniques adaptable to a variety of site conditions. The template is also easily adapted to meet the business case needs of each individual hospital (figure 1). For example, it can be configured with a four-, five-, or six-story bed tower to allow for the variability in the number of required beds at each location.
The template design allows for variations in the façade treatment and additional floors to accommodate the varying community needs and business cases
Standardizing these areas will simplify Kaiser Permanente's staffing and training procedures and enable the organization to provide a consistent level of care system-wide. At the same time, signature design elements included in the template, such as a distinctive, circular main entrance, provide a visual identity for the Kaiser Permanente brand (figure 2).
One of the template's signature design elements is the circular main entrance, enhanced by a large translucent canopy
Standardization also yields a safer environment for patients, physicians, and staff. Careful, consistent design reduces opportunities for clinical error. Patient safety issues and workplace ergonomics are addressed in the template, as are opportunities to increase communication and lessen staff fatigue. Security was also a factor in the design (figure 3).
The standardized, consistent design of the patient room yields a safer environment for patients, staff, and visitors
The use of sustainable, nontoxic materials and an energy-efficient infrastructure improves the environment both in and out of the hospital. Stringent infection-control design measures likewise benefit the entire community. An innovative structural bracing system is designed to protect those in the hospital and enable the facility to continue to serve the area in the event of an earthquake.
Kaiser Permanente's template design has been deemed appropriate for 13 of the 20 sites chosen by Kaiser Permanente for hospital development. The first of three simultaneously built hospitals to use the template specifications opened in November 2007 in Antioch, California. The two other hospitals, in Modesto and Irvine, will open later this year.
Teamwork throughout the design process not only resulted in efficient and safe hospital design, it sped the delivery of each facility and significantly reduced construction costs. OSHPD review, which typically takes 18 months or longer, was completed in just 13 months for the Antioch, Modesto, and Irvine hospitals, with only nine months for the most recent OSHPD review. This expedited process enabled the builders to procure subcontractors and preorder materials during preconstruction, a strategy that helped avoid cost overruns when the price of steel skyrocketed early in the project. Change orders and requests for information during construction were reduced by upfront communication and contractor involvement in design meetings. The initial hospitals built to this design each met project cost goals.
One of Kaiser Permanente's main project objectives was to create a comfortable, convenient environment for patients. The design's intuitive wayfinding plan is organized around a central spine filled with natural light (figure 4). Daylight enters the building from all directions through windows, glass-walled walkways, and an interior landscaped courtyard with a healing garden and dining terrace (figure 5). The windows are arranged to take advantage of light regardless of the building's orientation.
The template design features intuitive wayfinding organized along a natural light-filled circulation spine that links the hospital and the medical office building
The central courtyard adjacent to the cafeteria offers staff, patients, family, and friends a unique space for social interaction
To increase patient privacy and hospital efficiency, staff and patient circulation routes are separate from public routes. Spaces for privacy and respite for patients, staff, and visitors are included throughout the building.
The nursing towers are configured in a triangular shape, with a desk for a unit clerk at the entrance to the unit and decentralized nurse stations wrapping the core. Patient rooms are arranged around the central work space core. This layout offers nurses quick and easy access to patients, patient records and supplies. There are two 24-bed units per floor, with a unit-to-unit connection for caregivers. Patient rooms include an area for family and visitors, as well as convertible furniture for overnight guests.
The design incorporates many strategies for long-term use of the template hospitals. For instance, structural brace frames were moved to the perimeter of the building. Open floor plans free of obstructions are easily adapted to other uses. Acuity-adaptable patient rooms will also lend themselves to change. The nursing floor layout supports a distributed nursing model that is compatible with advancing technologies, such as paperless medical records. Corridors have been widened from a standard eight feet to 15 feet to allow increased visibility and room for distributed computer workstations in the hallways, a first in California (figure 6).
The 15-foot-wide corridors with distributed workstations position the caregiver close to the patient while providing quick, easy access to records and supplies in the central workspace core
In many hospital designs, the nursing units are placed on top of the diagnostic and treatment block. In the Kaiser Permanente template, these components were unbundled and built next to one another to facilitate construction and to allow for future expansion. Consolidated and strategic shell space within the hospital and space for additional construction onsite will also help simplify future growth. The entire design is scalable, to fit the needs of various sized communities. During the hospital design, consideration was given to future flexibility and anticipating growth. The site organization, utility systems planning, and final site plan preserves the location for future horizontal expansion so as to minimize disruption to operations and cost when development occurs.
In addition to the template hospital component, the template design provides for an attached medical office building (MOB) component. This allows patients a single point of access and ensures a continuum of care. Although the facility appears seamless to users, the hospital and MOB components are divided according to occupancy levels. Traditionally, hospitals must comply with more restrictive occupancy codes, while medical office buildings fall under a less intense “mixed occupancy” code. Separating the hospital and MOB functions in the template prevents the need to “over design” certain areas to meet higher occupancy regulations than they would otherwise require.
The template design will continue to evolve as lessons learned in the initial template hospitals are incorporated into the design.
Risks and rewards
John Kouletsis, national director of strategy, planning and design for Kaiser Permanente, says the organization recognized from the start the potential savings and potential pitfalls of embarking on the hospital template project.
“Everyone on the team had to be fearless,” Kouletsis says. “We agreed that the collaborative process would cause some issues and difficulties. But because it was a continuous, self-correcting system, those issues were resolved quickly and efficiently. It turned out that the system worked–the team met the aggressive schedule and budget we set for the first three hospitals–and we're very pleased with the results. Because of the lessons learned along the way, I'm confident we have increased capacity to improve our hospitals now and in the future.” HD
Carl Christiansen, AIA, LEED AP, is a SmithGroup vice-president and served as the firm's principal-in-charge for the Kaiser Templates project; Simon Bruce, RIBA, is a vice-president and senior medical planner; and Heather Chung, Assoc. AIA, LEED AP, is an associate and medical programmer.