That’s a hospital?
Health-care architects are changing the design of healing spaces

by Doug Childers
for Virginia Business
July 2007

More than 30 years ago, Chuck Means decided that he wanted to specialize in health-care architecture. His move dumbfounded a fellow architecture student. Why, he asked, would anyone want to build big, ugly box-like hospitals? “That was the image hospitals had in the 1970s,” says Means, principal at HKS Inc. in Richmond. “They were often the tallest, ugliest buildings in town.”

Now, thanks to architects like Means, hospitals have a new image. The cold, antiseptic look is gone. Patient rooms in many hospitals now feature wooden floors and crown molding, and the public areas often offer fare from Starbucks and Subway restaurants. “Our mantra is, ‘I can’t believe it’s a hospital,’” says Means.

Business is booming for Virginia-based health-care architects. In the last decade, four major hospitals have gone up in the commonwealth, and the Virginia Department of Health has approved the construction of several others. Among the recently approved projects are Southside Regional Medical Center in Petersburg, Rockingham Memorial Hospital in Harrisonburg and two hospitals in the Fredericksburg area. A replacement for Martha Jefferson Hospital in Charlottesville is under review.

Since 1997, the total spent in Virginia on new hospital construction, renovation and expansion comes to more than $4 billion. “The conventional wisdom is that we’re seeing more construction, replacement and renovation than we were seeing 10 years ago,” says Erik Bodin, director of the Virginia Department of Health’s Division of Certificate of Public Need.

These new hospitals are a far cry from the facilities deplored by architecture students back in the 1970s.

Hospitals of yesteryear weren’t meant to be ugly. The Hill-Burton Act of 1946 provided federal grants and guaranteed loans to improve U.S. health-care facilities. The public viewed the new community hospitals with civic pride. “The design was typically in the Beaux Arts tradition — an edifice on top of a hill, with the focus on symmetry and order,” says John Pangrazio, a partner at the Seattle architectural/design firm NBBJ. “The buildings were primarily bed towers since isolation and bed rest were the treatment of the day.”

Over time, hospital administrators added diagnostic and treatment facilities. “Facilities tended to grow in a very organic but often disorganized way,” says Pangrazio. “As the building grew out, the center of the complex was the oldest and the most difficult to get to and replace.” And that’s when many hospitals began to appear unwieldy, if not ugly.

Meanwhile, Medicare emerged as a major component of President Johnson’s Great Society initiatives in the 1960s, and the federal government began taking a larger role in how hospitals provide health care. But in the early 1980s, the government set limits on what Medicare would pay for a variety of medical procedures, using diagnostic-related groups (DRG) as a guide. “If you went for a medical procedure, there was a DRG code: ‘Your care ought to cost this much, and the government doesn’t plan to pay more,’” says Ray Pentecost, director of health-care architecture for Clark Nexsen Architecture & Engineering in Norfolk.

This change in federal coverage placed a greater emphasis on hospital efficiency, and hospital administrators turned to specialists from the growing field of health-care architecture for help. The goal was simple, Pentecost says: “To efficiently, cost-effectively move patients through the process.”

The emerging field of evidence-based design, which bases architectural decisions on scientific research, helped strengthen the partnership between hospital administrators and health-care architects. In the early 1980s, for example, a study conducted by evidence-based design pioneer Roger Ulrich found that recovering patients who were able to look out the window at natural scenery recovered at faster rates than patients whose view offered only a brick wall. “All of a sudden, the architect could look at the hospital administrator and say, ‘There’s research that says if we design a building this way, it’s a better experience for the patients and staff, and it’s more cost-effective,’” says Pentecost. “Science was giving architecture cues on how to build hospitals that are healing places and that are more cost-efficient. We’re living in the era of evidence-based design.”

Backed by studies that suggest an attractive environment can enhance the healing process, health-care architects today are radically rethinking design. They focus on creating aesthetically appealing, comfortable environments. A single-patient room — now the norm — has grown from an average 120 square feet in the 1970s to 300 square feet today. And patient bed floors now are larger as well, with space dedicated to patient services, patient advocates and even kitchens where families can prepare food for patients.

his reverses a trend established in the mid-1990s, when the focus on managed care and wellness outside the hospital led to hospitals with fewer beds. “There was even some expectation that we’d be building hospitals without any beds,” recalls Means. “We’d have beds for the high-acuity patients. That philosophy never came true. Currently, we’re going back to those hospitals and building bed towers.”

Virginia Commonwealth Univer­sity’s new critical-care hospital is a good example of today’s philosophy about design. The $167 million facility, which will be completed in fall 2008, will feature a number of cutting-edge concepts, including acuity-adaptable rooms designed to allow patients to remain in the same place throughout much of their hospital stay. “A surgery patient will typically move six times while they’re there,” says Means, whose firm designed the VCU facility. “Each time they move, the risk of injury or medical error compounds. So minimizing the patient’s moves increases the patient’s safety.”

To encourage family care, 226 of the 232 patient beds at the VCU facility will be in private rooms, as will 40 cribs in the neonatal intensive care unit. Each private room has a family area that includes a desk, a sleeper sofa and a flat-screen TV.

Single-patient rooms offer greater protection against the spread of infection. John Duval, CEO of MCV Hospitals, VCU Health System, says the university “made a major commitment to designing rooms that could easily adapt to isolation needs that may exist in the future.” More than 15 percent of the rooms can be used to isolate patients with contagious diseases. By comparison, the national average for new hospitals is 8 to 10 percent. One entire floor, which holds 28 rooms, can be converted into an isolation floor.
Baby boomers are playing a key role in defining the new expectations for hospitals. “The first boomers hit 60 last year, and they are transforming health care,” says Pangrazio. “They have economic clout, and they’re discriminating customers. They expect prompt, empathetic care. They want comfortable, reassuring surroundings, and they make their own choices.” Their expectations have caused a tremendous ripple effect through design. The affluent American public, led by boomers, “can afford to make a choice, and hospitals know that,” says Means.

Today, health-care architects work closely with hospital administrators to design spaces that help promote healing. “Hospitals are making commitments to healing patients, and they have to,” says Means. “But then they have to deliver on that promise — and do it in an environment that is reflective of that commitment. Architecture is becoming a great part of their branding. We work with them to define their brand, and we create the architecture that meets that need.”

Architectural design can also help recruit and retain medical staff. “It’s a very competitive environment, and the look and feel of the building make a difference,” says Pangrazio. Take the nation’s shortage of nurses, for example. VCU worked with HKS on the design of its critical-care hospital to ensure nurses will have well-lit, comfortable work spaces.

The fortunes of architects often follow the swings of the economy. Yet health-care architects expect to see a strong demand for their services. An aging population, notes Pangrazio, and the need to replace hospitals built just after World War II will drive the market for years. Health-care already accounts for about 16 percent of the national gross domestic product. That number is expected to increase to 20 percent in the next eight years. “The construction will follow population,” predicts Pangrazio. “Places that are growing are where you’ll see health-care facilities.”