Project Summary

Client: Laguna Honda Hospital Architects: Anshen + Allen; Stantec Architecture
Associate Architect, Interior Design: Fougeron Architecture

Interior Design: Kai-Yee Woo and Associates

Associate Architects: Powell & Partners Architects; Tsang Architecture
Associate Architect and Planner: Aviva Litman Cleper Architects

MEP Engineer: Arup & Partners California

Construction Manager At-Risk: Turner Construction

Photography: ©2010 David Wakely

Construction Square Footage: 156,993 (south residence); 208,377 (east residence); 143,044 (link building); 150,000 (renovation)

Total Project Cost: $584,946,602

Construction Cost (new): $363,000,000

Cost/Sq. Ft. (new): $726

Construction Cost (remodel): $32,000,000

Cost/Sq. Ft. (remodel): $213

To call the 150-year-old Laguna Honda Hospital a “hospital” is most definitely a misnomer. Emerging from a 10-year design, new construction, and renovation process, the 150-year-old facility now offers a complete range of services: long-term care, rehabilitation, special care for Alzheimer's disease and HIV/AIDs populations, and hospice. It uses the latest concepts in long-term care, offering a personalized environment extending well beyond the usual acute care hospital design. Along the way the project achieved the first LEED Silver registration of any healthcare facility in California. Perhaps the signature achievement of the new design is to translate large-sized 780 mostly skilled nursing beds into homelike accommodation suitable for an average 17 month length of stay. Discussing how this was done, and such unusual features as fully operable windows, are Laguna Honda Associate Administrator Larry Funk; architects Jeff Logan and Sharon Woodworth, Director of Design and Senior Architect, respectively, for Anshen + Allen; and Larry Bongort, Senior Health Architect, Stantec Architects, interviewed by HEALTHCARE DESIGN Contributing Editor Richard L. Peck.

Larry Funk: We wanted to transform Laguna Honda from our former self, with large, four-patient rooms, to a modern, polished, state-of-the-art facility providing high-quality, culturally competent rehabilitation and skilled nursing services for the San Francisco community. We wanted to set the standard for enhanced quality of life for our residents and patients-and I believe that we have succeeded in raising the bar for “best in class” services in the United States and, possibly, the world.

The initial planning for this was a wonderful educational experience, thanks largely to Derek Parker, Director Emeritus at Anshen + Allen, who insisted that we do our homework, including national benchmarking. After a two-day visioning conference involving some 60 local leaders and international experts, we toured facilities in New York City and State, Chicago and Wisconsin, taking copious notes on the best design practices of a variety of facilities. We synthesized these into best practices for our own facility, and started programming with a direction and a compass. Leaders from The Center for Health Design provided us with great assistance, including Roger Ulrich, Craig Zimring, Kirk Hamilton, and Blair Sadler. We never could have achieved this project without this background effort.

Sharon Woodworth: Probably the biggest change in the program was moving from the four-patient room with shared bathroom to a design encompassing seven different room types, including singles, single isolation, doubles in toe-to-toe arrangement, and closed and open triples, the latter for residents in need of total assist. The basic idea behind this was to offer residents choice, one of the main concepts of today's long-term care. Even in a facility as large as 1,200 beds, which eventually evolved to 780 beds, we weren't out to create beds per se, but places. This approach to patient rooms contrasts with acute care hospital design, in which the bulk of patient rooms are for general acute care, with about 20% for critical care, 5% for labor and delivery, and units set aside for pediatric care. In long-term care the patient isn't just aging in place, but changing in place, and should have available to them the choice of environments encouraging maximum level of function at all stages.

Jeff Logan: Another difference is that, in hospital design, the patient towers tend toward the monolithic. Here we had a level of crenellation along the edges of the residence buildings that allowed us to create nooks and crannies and a sense of privacy within. Each of the residence buildings-a seven-story tower on the north hill and a six-story tower on the south hill-offers a sense of layering of space inside. It ranges from the private, to the household, to the neighborhood, to the social gathering places in the horizontal component connecting them called the Pavilion, the “link building,” as we called it during design development.

Funk: Each resident has an operable window by the bed, so each has a view and can open the sash and control the blinds. This adds to the resident's sense of autonomy and independence.

Larry Bongort: This happened because, in our early visioning sessions, the desire for operable windows came up repeatedly.

Logan: But the operable windows were a very difficult element of this design. It requires different mechanical elements relying more on local evaporative cooling coils than on the typical cooling towers, but in the process saving about eight gallons of water a minute. Operable windows also raise the issue of control, as in whether residents or staff can control the windows and exposure to outside air. But what makes it work, in the last analysis, is San Francisco's moderate climate, with relatively few high-cooling or high-heating days during the year. Altogether they were a key element in helping us achieve the LEED Silver rating.

Woodworth: As Jeff mentioned, the residence buildings are organized as 15 patient rooms creating a “household” and four households creating a neighborhood on each floor. The “household/neighborhood” concept is a fairly recent development in long-term care design aimed at breaking down a large institution into places that can be comfortably inhabited by individuals for months or even years. Each 15-room household has its own living room and dining room, giving residents the choice of dining in the household or in the larger cafeteria downstairs. Four households make a neighborhood for the entire floor. Each neighborhood has ready access to the third-floor Esplanade in the Pavilion, with a beauty shop, a barber shop, a general store, a library, a community room, the general cafeteria and a 100-seat theater.

Bongort: The household concept is the basic model allowing for close control of the living environment for a variety of patient populations, including not only long-term care, but Alzheimer's disease, traumatic brain injury, bariatric patients and the hospice, each modified somewhat to accommodate these residents' particular needs.

Logan: Along with the Esplanade, the Pavilion contains therapy pools and a gymnasium on the first floor and a common service corridor above the Esplanade. As a horizontal structure linking things together, it represents the future of long-term care. The residence buildings are modern interpretations of the past, offering a contemporary interpretation of the Spanish Revival style that typified the older structure.

Funk: There is an accent on nature throughout. The residences are oriented toward the south, with lots of glass used to maximize daylighting everywhere in the facility. Every resident room has direct access to the outdoors, whether via a balcony or terrace or one of the 11 therapeutic gardens. We offer a greenhouse and planting gardens for r
esidents' use, as well as an orchard and an animal farm with duck pond.

Woodworth: Three-fourths of all households are turned in such a way that the living rooms and dining rooms are exposed to the southern sun.

Bongort: The buildings have a relatively slender footprint so that daylighting reaches practically every space. This, of course, reduces the need for electrical lighting. Other sustainable features include recycled demolition materials for parking lots; reduced use of PVCs, including sheathing of plenum wiring; and specially selected flooring materials-essentially nonslip linoleum and rubber, which require no waxing or buffing and which can be cleaned with nontoxic cleaning materials

Bongort: There are many design issues in a facility such as this that you would not encounter in the typical hospital project. In fact, hospital designers might consider these in designing future hospitals to make them more accommodating of the elderly. The floor materials I discussed is one issue-smooth shiny floors are really not indicated for the elderly, who can find them slippery, full of glare, and sometimes confusing. Wayfinding signage needs to be of sufficient size and contrast to stand out for aging eyes. Similarly, color schemes featuring blue and green can turn gray-ish due to yellowing of the cornea, and warm colors are much more appropriate as base colors for this age group. Lighting levels need to be brighter and of higher quality for the elderly, which is of course true as well for staff. Responding to these issues can in fact lead to better design for everyone.

Funk: As a recipient of public funding, the project was required by city ordinance to devote 2% of the capital construction cost to art. As a result, we had $3.9 million to purchase and develop art for the site. We now have a museum-quality art collection, as well as two art studios for residents' use focusing on painting and ceramics/sculpture.

Logan: This was one of the most fantastic experiences I've had as an architect. In the latter stages of schematic design and design development we worked with artists to develop strategies for the placement of their art. We were able to indicate and even build out spaces where we thought art would be particularly helpful.

Woodworth: The art clearly marks entrances and exits for the household wings, and we even built out the household walls specifically for placement of art. The artists created the art and we figured out the anchorage details and lighting requirements. One outstanding example of the art for this facility is a triptych of well-known San Francisco landscapes displayed prominently in the Esplanade; it beautifully creates a sense of place for residents and staff. Another example is a wonderful bronze handrail that enables people in wheelchairs-about 70% of the patient population-to negotiate corridors and enjoy the trip along the way. The artist, Cliff Garten, encountered some Americans with Disabilities Act difficulties at first, but he came up with a wonderfully elegant solution that enlivens the environment.

Logan: A final note on the overall design: the Laguna Honda Hospital clinical success rate over the years has been incredibly high. Recently, a local physician said to us that for the first time in her memory the design of the facility reflects that. As architects, that was a fantastic thing to hear. HD

View from the top

Comments from an interview with Mivic Hirose, CEO, and Michael Llewellyn, COO, Laguna Honda Hospital

The Laguna Honda project began in 1999 when the voters of San Francisco approved, by a 73% majority, the rebuilding of the 150-year-old hospital long known for supporting people in need-whether due to earthquakes, epidemics, or the ravages of old age. At a crucial junction in the project, between its near completion and the start of operations, are Mivic Hirose, CEO since 2009 after 10 years as the Assistant Director of Nursing and Chief Nursing Officer, and Michael Llewellyn, who signed on as Chief Operating Officer in 2008 after a career as a healthcare facilities manager and engineer. From their perspective as lead executives for the project client are their comments on its salient features and the design process:

Personalized environment

Mivic Hirose: Laguna Honda has always served the “safety net” population of San Francisco-people today who have a variety of complex clinical and social needs, and who come from a wealth of cultural backgrounds, often without families in the Bay Area, and who are today dependent on MediCal (the state's Medicaid program). Now, instead of the old-style wards of the existing structure, they will now have a much more personable environment to accommodate them. An important part of this is the operable window that each resident has, which gives them an important degree of control of their room's temperature and a view of the nature surrounding Laguna Honda. People like us who have offices equate feeling special with having a window in the office, and the same applies here for the Laguna Honda residents.

Michael Llewellyn: As an engineer who took care of patient ventilation and HVAC for years, I must admit I didn't like the idea of operable windows at first; for one thing, temperature control would not be ideal. But with our climate in San Francisco, this won't be a problem, and will eliminate the odor problems that many long-term care facilities suffer from. Residents will have the fresh air they've always been accustomed to. And they will have views from those windows-we are in a park-like setting, with 602 trees on 62 acres. Residents can see a forest of trees and, in some cases, even have an ocean view. The personalized environment continues on the Esplanade, with its aviaries, planting gardens, places for children to visit from local schools, and more. It is pure design that allows that sort of thing.

Neighborhood concept

Hirose: Today we have 28 “wards,” with 16 to 30 residents per unit. In the new Laguna Honda, residents on two of these units will join together to make a neighborhood. The neighborhood approach enables us to create a community of care which focuses our services and programs to individualize care for residents. For example, today we have two units that are gender specific for monolingual Chinese-speaking residents. In the new Laguna Honda, the two units will combine to provide skilled nursing services and meet the linguistic needs of the 60 Chinese-speaking residents. Within the neighborhood the community will have their residences, four living rooms and dining rooms, two nursing stations, a balcony, and a great room for joint activities. What the design also does is allow for enhanced programming and space for our long-existing services. For example, whereas we were able to renovate a couple of our existing units we weren't able to do the same for other units. In the new Laguna Honda, all neighborhoods, thus all residents, will have a new room and a community of care that is innovative in its design. In addition, the new Rehabilitation Center will have two new therapy pools, two gymnasiums, and street-front training areas for residents needing acute or skilled nursing rehabilitation.

Llewellyn: Also in the Pavilion building that houses the rehab facilities are the Esplanade on one floor and, a floor above, a very useful service corridor tying things together. It has a 70s hospital look, but that's all you need for a service corridor. Another structural element I noted as the building neared completion was built into the walls to provide wall protection against wheelchairs and gurneys and the like and saving on maintenance costs. This is another example of how technology has changed to improve things over the past 10 years, along with the other advances that were crucial to our achieving California's first LEED certification (Silver) for a healthcare facility.

Lessons learned

Llewellyn: First, get a good night's sleep every night because this can be a stressful situation that you think will never get done, but as you come closer to the finish line you see that you've created something that is out of this world in beauty and usefulness. You will also find the entire staff-administrators, nursing, facilities management, materials management, and so forth-working more closely together than ever because of their common interest in creating a project.

Hirose: I learned that it is very important to have a vision and that everyone is working together to achieve it. What helped us a great deal with this were a couple of retreats conducted early in the process by Anshen + Allen, where we had a free discussion among the architects, the clinical staff, engineers, and the community about what we wanted this to be. At one point Sharon Woodworth showed me a painting of a woman sitting in a bed with a window behind her and for some reason the image of that personalized patient environment grabbed me. At the same time Derek Parker, who was Anshen + Allen's Principal at the time, told me of seeing a resident in the old facility get out of bed and look both ways down the long ward corridors like someone crossing into traffic, and Derek wanted something better for that person. Others designers talked about their vision for the Esplanade, with its town center, and of a community of neighborhoods coming together. So you develop that vision together, and you work together to create it and make it come alive.

San Francisco, California

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Healthcare Design 2010 August;10(8):74-83