Designing for the international healthcare market involves more than just a change in time zone. It means understanding a different healthcare system and comprehending the nuances of a different culture, as well. These principles held true—and presented some exciting challenges—when RTKL designed a new rehabilitation hospital for Healthcare Japan.

Located in the Chiba Prefecture of Greater Tokyo, the available site for Tokyo Bay Rehabilitation Hospital was quite small—3736.52 square meters, which is slightly less than one acre. In addition, the project was subject to government codes restricting the size of the building and the amount of shadow it would create. Despite these limitations, economic considerations demanded a 160-bed facility.

The client wanted the new hospital to incorporate innovative ideas and yet maintain a connection to traditional Japanese culture. Maximizing natural light, including elements of nature, and creating flexible indoor spaces were primary considerations. Easy wayfinding between the new facility and the existing Yatsu-Hoken Hospital, several blocks away, was also important.

Finding the design solution in Japanese traditions

RTKL found the design answer in a circle, a positive shape in Japanese culture. The circle successfully accommodated the maximum floor-area ratio (FAR) to allow for 160 beds. It became the basis for the architects' holistic approach in creating an airy and open, five-story, 90,000-square-foot structure. The shape was extruded into an impressive cylindrical atrium used to orient all the required spaces within the facility and to honor the Japanese tradition of bringing nature inside.

The shape of the atrium is complemented by the bath tower, which was stretched into an oval and placed outside the main circle. Since hydrotherapy is unique to rehabilitation facilities, locating it in a distinct tower helps celebrate this defining service. The tower's placement on the site makes it a wayfinding element, as well—it is the segment of the facility that can be seen down the street as a person walks over from the main hospital.

To maximize space within the hospital, open spaces were designed to adjust to a variety of needs. The dining areas and day rooms on each floor can double as rehab areas or be used for art-therapy classes or other such functions. This spacious floor plan also allows natural light to reach most of the inner areas of the building.

Another benefit of the open plan is a visual and auditory connection between patients and staff. Since rehabilitation patients are often in the facility for extended periods, the architects wanted to make sure patients felt neither isolated nor institutionalized. With this design, they can see into the corridors and the atrium—a helpful distraction for those who tend to get disheartened by long hospital stays.

Access to nature is equally important in cheering patients. Healing gardens, located both at ground level and rooftop level, include plant containers set at an accessible height so patients can garden as part of their therapy. Other outdoor amenities include dining facilities that extend onto a terrace and balconies outside all patient rooms. The balconies offer a direct and unfettered connection to the outside that is very different from patient room design in the United States.

Integrating into the culture

RTKL's American designers had an important advantage when they worked in Japan—the firm's Tokyo office could play host, providing advice and translations when necessary. Although many of the Japanese partners on the project spoke English, cultural nuances became easier to understand when explained by a knowing third party. In Japan, many opinions are implied through tone and emphasis—critical elements in understanding the true intention of spoken words.

Furthermore, knowledge of government and local authority regulations is paramount, and the design of the Tokyo Bay Rehabilitation Hospital was impacted by the details within the applicable laws. RTKL partnered with a local architecture firm that helped develop the detailed designs to ensure they adhered to these rules.

For example, in the United States, corridors must be eight feet wide; in Japan, the width can vary. When there are doors on both sides, a hallway must be 2.7 meters (8.9 feet), but with doors on just one side, the size can shrink to 1.8 meters (5.9 feet). For this project, the varying corridor sizes worked to the designers' advantage. Not only did the regulations help save space overall, the different sizes also created visual interest and a unique design aesthetic.

Since foreign architects are often unable to participate in working with government agencies, as was the case here, a local partner is not only advantageous, it is required. In situations when a partner is not required and a firm chooses to work on its own, it is imperative, just as it is in the United States, to understand specific national and local building and healthcare policies before beginning design work.

Understanding the economies of scale

As with any project, design decisions for the Tokyo Bay Rehabilitation Hospital were affected by cost. Many of these decisions were made because of intricacies in Japanese culture and law. Japan's national healthcare program sets fees for each specific aspect of a hospital stay, therefore the design of the facility was affected by the opportunity for reimbursement. RTKL needed to find an equilibrium between minimal design—including the four-bed wards where care is paid for through the healthcare system—and extra amenities, such as private rooms, for patients who choose to pay the difference out of their own pockets.

The delicate balance of private and four-bed rooms was further affected by the hospital's bed allocation. The project could not exceed the approved 160-bed maximum, and the client had already determined that any fewer beds would render the project unacceptable from a financial point of view. Therefore, exactly 160 beds had to be accommodated in the design regardless of the constraints encountered.

When in Rome… or Tokyo…

While prefabricated materials in the United States are often viewed as hallmarks of lower-end construction, in Japan they are highly designed and use quality materials in their assembly. Across the country, projects favor using as many preassembled parts as possible, since they can be incorporated quickly and easily into the overall construction. On this project the bathrooms were mass-produced because they were designed as repeatable units.

Another cultural difference—discussions of costs in Japan can present a particular challenge. Money is never mentioned openly, and euphemisms may be used. The client often spoke about “value engineering” to imply that the material costs were higher than expected. In turn, the client proposed a wide variety of alternatives with the idea that substitutions could be made if they didn't detract from the overall design. Paying close attention to this type of subtle communication not only helped preserve the design, but it also forced the design team to evaluate alternatives as part of an ongoing process. This re-evaluation is becoming increasingly common during construction in Japan and must be considered carefully when making a fee proposal.

For the Tokyo Bay Rehabilitation Hospital project, as with any international project, understanding local traditions and economics and becoming integrated into the culture were all part of the architects' job. The result is a hospital that incorporates innovative ideas, honors Japanese culture, and adheres to required standards. HD

Beau Herr, Associate AIA, RIBA, is a Vice- President with RTKL. He was educated in both the United States and the United Kingdom and has been working in the international market since 1989. Herr served as the Principal-in-Charge and lead designer for the Tokyo Bay Rehabilitation Hospital

He can be reached at bherr@rtkl.com. For more information about RTKL, please visit http://www.rtkl.com. To comment on this article, visit http://healthcaredesi.wpengine.com.