Recently, two million square feet of farm land bordering the Sea of Marmara just outside Instanbul, Turkey, was transformed into the beginnings of a modern medical campus designed to show Turkey's mastery of 21st-century medicine and contemporary healthcare design. The Anadolu Health Village, as it is called, got off to an auspicious start with the completion of a 209-bed acute care hospital/MOB/retail area in 2005. Eventually the campus will encompass a nursing home, a rehabilitation center, a hospice, nursing and allied health education schools, dormitories, and a residential hotel.

The invitation to work on so grand a project came as an initial surprise to the American architectural firm Rees Associates, as the firm had declined to collaborate with project sponsors on a les-ambitious, proposed project with the Cleveland Clinic. “But they told us that they wanted to create a U.S.-style hospital offering care and outcomes that were at least equal to American standards,” says Principal Frank Rees Jr., “and we appreciated the opportunity to create a hospital from scratch. They also wanted consultation on operating such a facility, which enabled us to go beyond functioning as an architectural firm.” Teaming up with local architect HAS Mimarlik Ltd., a medical staff headed by Dr. Murat Dayanikli, and in partnership with the Johns Hopkins Medical Institutions, REES started working. What follows is an interview with Frank Rees Jr., AIA, President and CEO, and Jerome W. Hovorka, Vice-President—Healthcare Practice at the time of this writing, on the special challenges involved and the features that emerged for this groundbreaking new hospital. Questions were posed by HEALTHCARE DESIGN Editor-in-Chief Richard L. Peck.

Richard L. Peck: What was the initial concept of this project?

Frank Rees Jr., AIA: Beginning this project was a challenge because, in the United States, you usually have an existing hospital organization to work with or a market demand study to guide you. Here we began with the sponsor's concept—they wished to capture a relatively upscale market, the top 3 to 6% of Turkey's income groups—in other words, not private planes, but first class. Another challenge was that, traditionally in Turkey, hospitals were either very small private hospitals or huge, archaic public hospitals. They wanted a U.S.-style hospital built and operated to U.S. standards and, for it, a unique brand name. All of the physicians involved had been trained in either the United States or the United Kingdom and knew what they wanted. A collaborative arrangement with the Johns Hopkins Medical Institutions sealed the deal, and the arrangement has worked out with phenomenal success.

Peck: What were some of the cultural considerations you had to address in completing the design?

Rees: I remember once we were in the middle of a planning session and we had 8 or 10 of the country's leading obstetrical, neonatal, and pediatric physicians, all board-certified or -eligible in the United States, talking about “centers of excellence” for their respective specialties. Someone tossed out the thought of placing a separate entry on the north side for women's and children's services and a neonatologist said, “We're just getting the right to walk in the front door—putting us out on the side is the last thing we need.” That was an eye-opener. Another thing we noticed was that, in traditional hospitals, the doors to patient rooms were always piled with flowers and in the rooms there'd be 10 or 15 people standing by. We knew we had do design the rooms to accommodate at least five to eight family members at any one time.

Peck: What were some of the other local factors that influenced the design?

Rees: The site of this building had never been built upon in 4,000 years. It had a wonderful view of the Sea of Marmara. We knew of the evidence indicating that patients with calming views heal faster and that water has a particularly calming effect. So we designed the patient towers as triangles jutting toward the Sea of Marmara so that every patient room has a sea view (figure 1).

Jerome W. Hovorka, AIA: Because each tower is triangular rather than rectangular, every room has a more than 180-degree view of the sea. There were several other features reflecting local tastes and conditions—for example, the use of color for the interior walls and floors is restrained, with lots of neutrals and natural wood tones. To the Turkish medical community this clean look is state-of-the-art in a healthcare facility. Interestingly, synthetic interior design products are not readily available in Turkey but building materials such as natural stone, marble, and granite that can be prohibitively expensive in the United States are as readily available as vinyl tile in this country. The patient care areas feature hard, seamless materials for infection control, with carpeting only in the admitting areas (figures 2, 3).

Rees: Of course the fabrics and drapes are quite colorful…

Hovorka: Yes, like facilities in the Middle East, such as in Saudi Arabia, textiles and fabrics are colorful, highly patterned, and geometric.

Peck: Is natural light a noticeable feature here?

Hovorka: Yes, there is extensive glazing of this structure (figures 4, 5), with large windows at the ends of corridors and extensive use of sky lighting. The structure has a relatively deep floor plate, so a lot of natural light is introduced internally around vertical circulation stairs (figures 6, 7).

Peck: What are some of the exterior features of the facility?

Rees: There is quite a bit of exposed steel structure, but also a lot of exterior detail that you can't always apply in the United States. They have lots of skilled labor getting paid two dollars a day, and there is an incredible opportunity for American architects to do things in this country that they can't normally afford to do. Other features include a water feature that echoes the city's relationship to the Bosporus. Everything in the city revolves around the Bosporus and there was a lot of discussion about this in planning. In acknowledgment, we have created a waterfall at the hospital, leading to a waterway winding its way through the site, with miniature bridges across it emulating the bridges across the Bosporus. This water feature will be developed further as more buildings are added to the site. Interestingly, the water used is actually gray water from the hospital, which is also used for landscaping and fire protection. The price for water disposal is so high in Turkey that the local planners wanted to use as much wastewater as possible.

Hovorka: It is also worth noting the technology planning that went into this project. The physicians who had been trained in the United States and United Kingdom came back with lots of ideas about how the surgical suites and treatment areas should be set up—except that here, everything was going to be digital, even more so than in the United States, with flat-screen TV panels, advanced imaging, and more. The hospital is actually a beta site for Siemens in developing new hospital technologies.

Rees: Also, thanks to lower construction costs in general, this hospital is designed to expand upward, more so than in a typical U.S. hospital project. Moreover, we can provide extra structural integrity at minimal cost. In fact, our work on seismic resistance was the principal reason we got the initial call to join this project. Turkey is of course highly sensitive to the need for seismic resistance, being located in a major earthquake zone and having suffered a particularly devastating quake in 1999. We had done a lot of work on seismic resistance at the University of Southern California teaching hospital in 1993, where we had installed base isolators that enable that facility to survive the Northridge earthquake of 1994 with minimal damage. This was the first fully earthquake-proof hospital in the world at the time. With base isolators you can use much less building material for the structure itself. However, for the Anadolu project, importing base isolators into the country was prohibitively expensive but, thanks to the low materials cost, we were able to build earthquake resistance into the structure. The foundations rest 23 feet below level, with 32′ x 32′ spans, reinforced concrete columns, and waffle slabs to minimize vibrations, especially in surgical suites (figure 8).

Peck: Any final observations?

Hovorka: Interestingly, the Anadolu hospital was the only hospital to gain designation as one of the nine outstanding new buildings in Europe in 2005, according to the Urban Land Institute.

Rees: This project is not only offering Turkey the best in 21st-century healthcare but is spurring further development of the area, with new roads, schools, and more—yet another important benefit of creating projects of this type. Just as the Bosporus is a bridge between Europe and Asia, the interactive design approach ensured that this hospital bridges the technology of the West and the culture of the East. HD

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Healthcare Design 2008 October;8(10):30-35