What is the Hospital of the Future?
Palomar Pomerado Health in North San Diego County has spent the past six years with a certain question in mind during the planning and construction of its replacement hospital: What is the hospital of the future?
With a vision for a patient-focused healing environment upon completion, Palomar recognized that it was equally important to build and operate in an environmentally responsible way in order to provide a healing environment for the community and society as a whole. To achieve this, it committed to creating a culture that embodied those principles through its approach to planning, teamwork, and project implementation.
As part of the integrated team, Los Angeles-based CO Architects lead the design initiatives, working closely with Palomar to bring to reality its sustainable vision for Palomar Medical Center West.
The overriding principle was one of nature balanced with technology to meet clinical needs in a space that reduces stress and aids in wayfinding and navigation. Descriptors include “flexible,” “efficient,” “integrated,” “comforting,” and “patient-focused.” As described by Frances Moore, AIA, LEED AP, associate principal, CO Architects, “Palomar Pomerado’s hospital of the future benefits from the intersection of nature and technology—nature to soften technology, and technology to enhance the experience of nature.”
Due to the sheer size of the project and the more than six years needed to build it, Palomar knew special attention had to go toward integration of various players to carry it out. This went beyond the traditional integrated design team. With Palomar acting as general contractor, it needed to manage more than 100 individual subcontractors.
The leadership team balanced evidence and research with an integrated team approach with input from work groups and the community. Palomar Pomerado registered the project as a Pebble Partner with The Center for Health Design (CHD). The Center helped it create “champion teams” to coordinate an integrated and evidence-based approach to address:
- Unit configuration;
- An interventional platform;
- A healing environment; and
Recommendations were made based upon criteria related to their impact on quality and patient safety, customer service, financial strength, and the workforce.
A Kresge grant funded an “eco charrette” to gather varying perspectives on environmental stewardship. It included vendors, community members, and staff. Balancing nature with technology was of benefit to patients, but much of the design was dedicated to creating a healing environment for the staff as well. Conversations are underway with CHD to identify which topics will be researched once the building is complete.
Teamwork and communication
Wendy Cohen, director of facilities construction at Palomar, tries to see the space through the eyes of the people who are going to work there. She feels the design comes only with the understanding of how it works through a nurse’s eyes, for example. The construction staff stayed in the ER and experienced a trauma situation, and it led to deep conversation about the needs within that space.
While healthcare leaders may be experts in providing clinical care, they are not experts in construction. How does a construction team interact with a board, with a leadership team? How do they engage them in the process, help them find the balance of “need to know” with trusting the guidance of the construction team? How does the construction team prove that it can add value through designing a new space in a new way? Taking the time to earn that trust, speak a similar language, surround oneself with the best possible team, and understand the needs within the space are critical.
The construction team addressed worker engagement and communication in a variety of ways. It created an oversight committee made up of various players, where business partners had a seat and a voice at the table. This ongoing committee was part of all decision-making and maintained clear communications throughout. A consistent weekly dinner with 20 foremen (there are 120 foremen in total) and the team created an environment for sharing, identifying areas of concern, or making suggestions for improvement that were then relayed through an ongoing leadership meeting.
The integrated team and use of building information modeling (BIM) made for a truly collaborative and efficient process. The use of BIM allowed for better visualization and understanding of the building, and better integration of systems. Integrated project delivery was used as well. The contractors, architects, engineers, consultants, and owner’s representatives collaborated on the coordination and detailing of the project before construction started.
The model was shared with the contractors, and they built their work directly into it. Conflicts were identified in the model before they made it out into the field. This process—both the integrated team and the computer model—reduced errors and associated costs, and resulted in true collaboration.
While the future of healthcare may not be clear, flexibility, preparedness, and anticipated developing technologies required a space that can manage certain changes and modifications in the future. Planning included casting a wide net beyond healthcare and into other sectors to learn about technology, expansion, infrastructure, and preparedness. An expert advisory panel made up of experts both within and outside the healthcare sector critically reviewed schematic design plans and champion team proposals.
All workers viewed a video before they started work so they knew they were part of a team, working towards a common and very important goal. They were creating a healing space that they may be a part of in the future. The video aimed at sharing the big picture, so whether workers were installing walls, flooring, or energy systems, they knew they were part of an integrated approach to creating a healing space.
Integration of nature
Integration of nature into the space is maximized through the use of natural lighting wherever possible, and nature themes were integrated into the design and wayfinding system. The main building’s design starts with a root theme at the bottom, working its way up the building with various earth themes, like desert or tropical. It culminates at the top,
where the theme is sky. With the understanding that people rely on different cues for wayfinding, the indicators include words, colors, symbols, and images to identify a specific floor. A backlit image is found at each elevator vestibule to clearly identify the floor/unit.
Customer engagement identified community preferences regarding wayfinding and departmental identification. For example, healthcare workers may use specific language to refer to a technology or treatment area while another term may be preferred by the customer. A healthcare worker may be familiar with “radiology,” and the customer may more easily identify “X-ray.”
A connection to nature and natural light is maximized throughout the facility, even in the second floor operating room, which includes skylights and windows. Patient rooms are found on floors four through 11, with every floor enjoying three exterior balconies that provide the outdoor respite so important to patients, family, and staff. The main balcony off the central waiting area on each floor visually forms a vertical garden over the main entrance.
Rooms were designed with a single standard to provide consistency, simplify staff training, and reduce errors associated with room design. Patients feel in greater control by being able to manage room temperature, lighting level, entertainment, room service delivery, and access to medical records. All rooms are sound-proofed to reduce noise and improve quality of sleep and patient comfort. A railing extends from the patient bedside to the private restroom to reduce falls. Patients’ sunshades allow for control of natural daylighting and room temperature.
The third floor living roof provides a green view for patients and is designed with a series of waves, which relate to the rolling hills of the natural landscape in the region. While the roof is for viewing, a dining area, terrace, and café are adjacent to the space. The roof also serves to reduce the load on the heating and cooling systems, and to reduce runoff from rain.
The project used LEED for new construction standards complemented by The Green Guide for Health Care, which helped drive safer materials in construction with almost complete avoidance of chlorinated plastics. This was a very important component for many team members who felt that a healing environment required fewer toxic materials for both building supplies and interior design features.
Wire jacketing was the one area where PVC was not avoided. Mock-ups of rooms played an important role in educating the maintenance team regarding changes in cleaning and maintaining the new surfaces, like rubber and linoleum floors. The lead for environmental services participated on the sustainability team to ensure a smooth (as possible) transition.
More than 1,500 cubic yards of boulders that were unearthed from the existing fill were utilized in the finished landscaping scheme. Approximately 80,000 cubic yards of soil were processed (screened and crushed) and amended on site for use as topsoil. The onsite crushing operations made it possible to produce soil gradations that were suitable for use in roadways, landscapes, and building backfill. More than 50% of construction debris was segregated and recycled.
The hospital of tomorrow was designed and built with a vision for a healthier environment for patients, staff, family, and friends. While future needs may still be uncertain, evidence and teamwork ensure the hospital will be an environment that promotes healing and a healthy, positive work environment. HCD