John Kouletsis is the national director of strategy, planning, and design with Kaiser Permanente’s National Facilities Services (NFS) in Oakland, California. As the largest managed care organization in the United States, Kaiser Permanente (KP) has 8.8 million health plan members, 167,178 employees, 15,853 physicians, 37 medical centers, and more than 500 medical offices/outpatient buildings in nine U.S. states and the District of Columbia.
While at NFS, Kouletsis has been responsible for developing the KP Standards Program. He has also been the program director for Templates 2000, an initiative to research all of the clinical spaces that KP builds and test them with frontline staff in terms of function and workflow. Extensive internal and external benchmarking, as well as design sessions with more than 1,000 clinicians and support staff over a period of 18 months, built the basis for KP’s Standards Program as it exists today.
Kouletsis is also the executive director for KP’s Templated Hospital Project, hospital of the future project, and High Performance Buildings Initiative. His department is responsible for the continuous development and improvement of the KP Standards Program, and he is one of the sponsors of the Sidney R. Garfield Centers for Health Care Innovation. Prior to joining the NFS Core Group, Kouletsis worked as a project manager at KP’s Vallejo Medical Center.
Kouletsis spent the first 15 years of his career as an architect in architecture and engineering firms that specialized in healthcare design. His clients included Kaiser Permanente, as well as other healthcare providers in the United States and Japan.
A member of the Facility Guidelines Institute’s Healthcare Guidelines Revision Committee and EDAC (Evidence-Based Design Accreditation and Certification) Advisory Council, Kouletsis is a contributor and frequent participant in the Hospital and Healthcare Environments of the Future working sessions at the Health Technology Center in San Francisco. He has spoken widely on design excellence, high-performance design, and sustainable design and operations.
And, this year, Kouletsis is the winner of The Center for Health Design’s annual Changemaker Award, which was presented to him in November at the HEALTHCARE DESIGN Conference in Nashville. The award is given by The Center’s board of directors to an individual or group that has demonstrated the exceptional ability to affect change in healthcare facility design.
Earlier this year, I caught up with Kouletsis on a beautiful August day at his office, located in a high-rise building in Oakland, California. Given all his responsibilities, he can be hard to pin down for a conversation. But he was relaxed and reflective about his career and the impact both he and Kaiser Permanente have had on the healthcare design industry. We spoke for a little longer than an hour. Here are some salient points from our conversation.
Sara Marberry: What made you make the switch from working in an architectural/engineering firm to working in a healthcare organization?
John Kouletsis: I came to Kaiser Permanente from a very large international architecture and engineering firm. As I was leaving, the president of the firm said to me, “I don’t think an architect will be happy working in a healthcare organization, so if it doesn’t work out in three or six months, you will always have a home here.” It was good to know I had a safety net. I fully believed I was going to tough it out for two to three years and then go back to the architectural firm. The other day I woke up and sat up in bed, and thought, “It’s been almost 20 years. How did this happen?”
It’s been a fascinating journey to see the entire healthcare process—not just the piece architects traditionally see—but the business drivers, public health connections, and the company’s vision put into bricks and mortar. I still feel like I’m in Kaiser Permanente graduate school on every project I work on.
Marberry: Tell me a little bit about some of the projects you’ve been involved in at Kaiser Permanente.
Kouletsis: Some of the early projects I did had to do with building a national standards program around planning, design, and construction. Kaiser Permanente had always had a fairly robust standards program, but it was not a national program. None of our regions had a comprehensive approach to facility design. There was not necessarily a corporate attitude toward design or any kind of facility brand. So we started asking ourselves how we could personalize healthcare.
We asked people, “What does healthcare mean to you? What do you think about health? How does Kaiser Permanente fit into your view of health?” We discovered that most people didn’t have particularly positive feelings about healthcare. They were very positive about healthy eating and active living, but when it came to healthcare, they immediately switched to, “Oh, that’s that big bureaucratic thing I have to struggle with when I get sick.”
With that research, we worked with a firm that does both architecture and brand development to look at what the healthcare journey is like from the patient’s point of view. We identified 21 emotional touch points a typical patient or family might experience while at our medical centers, and we developed comprehensive design standards to build Kaiser Permanente’s mission of improving members’ total health—mind, body, and spirit—into our buildings.
You’ll now find things like clearly marked signage to ease the stress of visiting an unfamiliar hospital; stairwells designed to encourage people to take the stairs; outdoor and indoor spaces for emotional respite; abundant windows and natural light; positive distractions; full spectrum color palettes; and cafes with nutritious food among other patient- and family-centered design solutions at our medical centers. And you will find these at all our new hospitals and medical offices, or those we’re remodeling.
We are also using design to help Kaiser Permanente do early intervention with patients who have chronic disease. How would we make it as convenient as possible for members to receive care? Could we do home visits? What would happen if there were a clinic in their school, in their office, or next to their drycleaners? Kaiser Permanente engages medical planners, architects, and engineers to help them think through all of this.
We’re now building dozens of small storefront medical offices into shopping plazas, office buildings, and other places in the neighborhood to make accessing care more convenient for members. We have several state-of-art mobile clinics that take preventive health screenings and other important primary care services directly to our members where they live. The clinics are wired to Kaiser Permanente’s electronic health record system, al
lowing real-time updates and video consultants with specialists. This is all part of our goal: “healthcare anywhere.”
Marberry: What’s been your greatest impact at Kaiser Permanente?
Kouletsis: Before I came here, the whole notion of evidence-based design—which, at the time, wasn’t being talked about much— was whatever you learned in architectural school. That’s the evidence, and if I go to graduate school I’ll get some more evidence. It didn’t occur to me that it could be an ongoing, living thing. Through my incredible multiyear association with The Center for Health Design, I’ve learned a lot about what it means to grow and mature in the industry, particularly around how much information you need to be a good designer and how you develop that information on an ongoing basis.
As I’ve grown, I’ve been able to bring that back to my group of about 40 equipment planners, medical and space planners, architects, engineers, and facility operations professionals. We learn from other healthcare organizations. We learn from other not-for-profit organizations. It’s one of the things I appreciate about Kaiser Permanente. It is a learning organization, and we are very eager to find out what the best practices are out there and how we can bring those home.
I had a conversation several months ago with two leaders of our quality department, people who I’ve known for more than 15 years. When I started talking to them about evidence-based design and how architects, planners, and engineers could contribute to patient outcomes, they were stunned. They told me it would have never occurred to them to talk to a designer or engineer about health outcomes. It seemed pretty logical to me that we had a role to play, but it was interesting to see how unprepared they were to hear architects talk about the core values of a healthcare organization.
Marberry: Tell me about the Templated Hospital Project.
Kouletsis: When the California State Legislature decided to require that inpatient facilities be brought up to current seismic codes, the decision just so happened to coincide with our ambitious plan to build a large number of new hospitals. Suddenly we were faced with an overwhelming number of projects with a relatively short deadline for delivery.
We immediately started looking at other ways to deliver projects. We ended up designing and building a templated hospital. We designed it with the help of hundreds of frontline people, including nurses, doctors, patients, maintenance staff, etc. The modular template design adapts easily for variations in geography, demographics, and service delivery programs, and the hospital is designed with ideal adjacencies and workflow for staff.
Replicating the design helps expedite the design, approval, and construction process, shaving nearly two years off overall project delivery times. Even though it met our functional need, it was never intended to be the be-all, end-all. It was intended to be a work in progress. But it has worked out in a pretty remarkable way. We will open our fifth template hospital next month in Ontario, Canada, and the design continues to evolve along the way.
The most recent genesis of the template idea is the “Small Hospital, Big Idea” competition, which we are conducting for a prototype we can use to build smaller hospitals. We’re working with three firms now to finalize their designs. Doing this allowed us to talk to people in a way we normally don’t have time to do. We are asking some of the best minds in healthcare, “What are the best things you’ve seen across the country? What are the best workflows? What are the best environments? What are the best experiences for the patient? How can technology and innovation be used to improve patients’ clinical experience?” The competition is like having that conversation with 100 of your best friends over several months.
Marberry: So you collected a lot of great ideas?
Kouletsis: There were about 108 submittals that we put through a rigorous evaluation process to see which ones would rise to the top. Many of the submittals came from firms we work with every day. When they were given the opportunity to be thoughtful, some amazing ideas surfaced. Normally, the conversation is, “Here’s the budget, here’s the schedule, and how are you going to make up the fact that we’re already three months behind?” So we don’t always get to have the thoughtful discussions we’d like to have.
Marberry: How do you feel about evidence-based design?
Kouletsis: A friend of mine, who’s also an architect, told me I used to hate evidence-based design, and now I was a flag-waver. I don’t think I ever hated evidence-based design; I just questioned some of the ideas people had that were supposed to be predicated on evidence. As I learned more about evidence-based design, I discovered we had always done some level of evidence-based design at Kaiser Permanente. We just didn’t call it that.
There are different levels of rigor involved in evidence-based design. Clearly, things that involve patient safety are going to require a much higher level of documentation and science behind them, but there are other things that may be good enough to say there seems to be every indication this is the right thing to do. I was worried that evidence-based design would push intuition and experience off the table. I was delighted to find out that, at least in my practice at Kaiser Permanente, it all had a place.
Marberry: What’s the connection between evidence-based design and green design?
Kouletsis: Kaiser Permanente has a long history of being engaged in sustainability, starting in the 1960s with Rachel Carson and her book “Silent Spring.” So, it wasn’t a new idea that we should be doing sustainable design, just like it wasn’t a new idea that we should do evidence-based design.
About 10 years ago, we started rethinking our piecemeal approach to sustainable design. Although, it was highly effective and was moving the healthcare industry in some interesting ways, it needed to be more integrated and systematic.
We started reaching out to partners in the community and in public health to build a team that would look at all aspects of sustainability. As an example, when Kaiser Permanente stopped ordering latex gloves, we were involved in the discussion about why we were doing it, what effect it might have on the health of our patients and the health of our caregivers, and what effect it might have on the industry. In that case, it created a huge ripple through the industry that was fairly disruptive. It made us think more about the accountability we have, not only to our patients but to the people at Kaiser Permanente who provide care, to the communities in which we serve, and to the industries that support us. It made us think in a much more holistic way about healthcare design.
Marberry: How did you get involved in working on the facility guidelines?
Kouletsis: It was somewhat of a happy accident. My supervisor had been asked to be on the guidelines revision committee, but when she took a different position at Kaiser Permanente, she asked if I could take her place. Three revisions later, I’m still involved. When I went to my first meeting and walked into the room of 135 people, I thought it was going to be overwhelming.
After a while, I began to form relationships with like-minded individuals and I realized my experience with one of the largest U.S. healthcare providers, with one of the largest capital construction programs, was what I had to offer. I found out quickly it was a two-way street: I le
arned things from people like Robin Guenther, Walt Vernon, Doug Erikson, Judene Bartley, and others that I never would have learned on my own.
If you look at what’s happening right now in the healthcare community—the economy is stuttering once again—yet we have projections of enormous growth. Reimbursements from the government will be lower than ever before, and yet we are challenged with unprecedented growth. All of these things are new problems, but that is the thing I love about this industry: You always have a new challenge.
Right now we’re at an incredible tipping point and the industry could look radically different in five years than it looks today. I don’t think we know all the answers, but I think an integrated panel of experts in the healthcare and design industries is capable of coming up with some incredibly innovative solutions to those problems.
Marberry: Where do you see yourself in five or 10 years from now?
Kouletsis: We had a conversation with another healthcare system about how they were going to get to net-zero energy. They had a 40-year plan, and they told us, “The first three years we’ve got a lot of detail, and after that we don’t have a clue. There will be some kind of miracle that’ll occur.” I like to think of my career that way. I can imagine today what it might be like in five to 10 years, but I’m hoping I’ll be totally surprised.
Marberry: What kind of advice do you have for others who are in similar positions as you are, the healthcare systems or facing the same kind of challenges you are?
Kouletsis: Don’t ever be afraid to reinvent yourself. Don’t ever be afraid of challenges, and don’t ever take the safe route. Someone once told me, “Do one scary thing every day.” The challenge for me is not to become overwhelmed by the tyranny of the mundane, but to allow myself to insert surprise and whimsy into my work.
Marberry: Any final thoughts?
Kouletsis: On New Year’s Eve, I used to pull out my old paper calendar, flip through it, and think about what I’d done each month, and what I had taken away from it. The Changemaker Award is like my old paper calendar. It has allowed me to look at my career over a period of 35 years and think about what I’ve done and the people who have changed my life, and what I must do and learn in the future.
I’m thinking I’ve got to earn this award in whatever I have left of my career. The bar is higher now. So, in a way, darn you, I was thinking, “I’m in my salad years. I should be able to coast to retirement.” And now you’ve thrown an interesting challenge my way. What’s the next major thing I will do to make healthcare delivery that much better? And I don’t have a clue. But what a great challenge. Thank you. HCD
Sara O. Marberry is the Executive Vice President and Chief Operating Officer of The Center for Health Design. For more information on The Center, please visit www.healthdesign.org.