October 17, 2011

What’s the big idea? Designing the small hospital of the future

Visitors to the early Walnut Creek hospital (1953) could access patient rooms from an outside walkway, leaving the central corridor of the nursing wing free for nurses.

Inpatient ward at Garfield's Contractors General Hospital at Desert Center, circa 1933

When the winner of Kaiser Permanente’s “Small Hospital, Big Idea” design contest is announced in February, at first glance it may appear the 65-year-old health plan is taking a major turn off the road it followed for decades: building large hospitals as hubs for satellite medical clinics in surrounding communities.

But, actually, a fuller story lies in Kaiser Permanente’s genesis in the small hospitals that founding physician Sidney Garfield built in the early part of his career.

In the competition, architects have been asked to dream up a model for a community health center with many of the features of a larger Kaiser Permanente hospital, including surgery, emergency, laboratory, and pharmacy. The small hospital will leverage the newest diagnostic, treatment, and communications tools for outpatient and inpatient basic and acute care — all in one cutting edge hospital.

KP Sunset Hospital in Los Angeles, built in 1953, was one of Dr. Sidney Garfield's "dream" hospitals.

The key for planners is to find a set of design concepts that will balance the latest in technology with a humanistic approach in providing efficient, affordable, and high quality care. The “hospital” will create a place to encourage and nurture a healthy lifestyle for Kaiser Permanente’s members and the community at large.

Of over 100 contest submissions, three made the final cut in May: Aditazz of Palo Alto, California; Gresham, Smith and Partners of Nashville, Tennessee; and San Francisco engineering firm Mazzetti Nash Lipsey Burch, working with Perkins+Will of New York. They each received a grant to refine and concretize their plans over several months.

The winning design will be used to wildly modernize and perfect the self-sufficient hospital design pioneered by Sidney Garfield, MD, on construction sites in the Southern California desert and the Grand Coulee Dam in Washington State in the 1930s and 1940s.

The plans, promising to be ingenious, will be the blueprint for construction of the “best of the best” small Kaiser Permanente hospital, likely to be built in the High Desert northeast of Los Angeles. Rather than being a major departure from tradition, the "small hospital, big idea" concept will bring the medical plan’s legacy of hospital building full circle.

Ironically, the setting for the early Garfield's hospital designs, as well as the imminent creation of the Kaiser Permanente futuristic “big idea” small hospital, was and is the Southern California Mojave Desert.

Ingenious health care for Garfield’s time

Garfield’s ability to keep 11,000 Los Angeles Aqueduct workers healthy improved greatly as the men came in for routine checkups instead of waiting until they were really sick. His other initial foray into prevention was direct: To reduce head injuries and nail punctures, he went to the job sites and lectured the workers about pounding down nails and then inspected tunnels for dangerous shoring.

Garfield's idea for a "small city" hospital featured plenty of natural light. This is the innovative Walnut Creek hospital built in 1953.

Garfield eventually built 3 hospitals in the desert, equipping them with air conditioning — the latest technology — and newly invented venetian blinds. He furnished the wards with soothing color schemes, flower containers, and personal radios to elevate patients’ moods.

Garfield’s 3 hospitals were far flung — the first at Desert Center, another at the east end of the aqueduct at Parker Dam, and the third at the Imperial Dam near Yuma, Arizona. He staffed each with a physician, and he zipped back and forth by car across 100-mile stretches of desert to perform surgery.

Garfield’s next project was to refurbish and outfit a rundown 35-bed facility for Henry Kaiser’s workers on the Grand Coulee Dam project in Mason City, Washington. The union was excited when Garfield promised air conditioning, but Kaiser’s son Edgar, who was running the project, said no. (Garfield installed it anyway, paying for it out of his pocket; a slightly annoyed Kaiser reimbursed him).

That small hospital, with its early team of group practice doctors, went full bore into preventive care for the 15,000 residents (workers and their families) in the company town.

“They saw simple acute appendicitis instead of peritonitis; earaches instead of mastoiditis; upper respiratory infections and less pneumonia; early lumps in the breast instead of metastatic carcinoma,” writes John Smillie, MD, in his history of the Permanente Medical Group. “The Coulee physicians were capable of handling just about any case that came their way, including serious cancer surgeries. Only one patient, a suspected brain tumor, had to be referred to Spokane.”

They also established a satellite community service: Millie Cutting, a nurse and wife of job site physician Cecil Cutting, solicited funds door-to-door — and received generous contributions from the brothel madams — to set up a well baby clinic in a local church.

Bigger challenges on the home front

The urgent need for quality health care for Kaiser west coast shipyards workers during World War II dictated the facilities Henry Kaiser and Sidney Garfield could establish for their often sick, weak, and injured patients. The Richmond Field Hospital, later serving the community at large, was thrown up in a hurry and opened with 10 beds in August of 1942.

Garfield carefully designed the modern 70-bed Oakland Medical Center, although it was the hurried resurrection of the surviving maternity wing of the Victorian Fabiola hospital, which had been torn down years before. The Oakland hospital, also opening in August of 1942, expanded twice (to 145 beds) before the end of the war and its successor structures remain the hub of East Bay facilities to this day.

The Panorama City Hospital in Southern California, built in 1962, featured two circular towers. Within the towers, the concept of "circles of service" was born. Later KP hospitals retained the basic design but the "binocular" towers were enclosed in rectangles.

With World War II behind him and the Kaiser Permanente medical plan beginning to grow, Sidney Garfield was able to experiment with various ways of using architecture and design to improve both the efficiency of staff and services and patient comfort as well. In the early 1950s, Garfield, whose boyhood dream was to become an architect, designed his first two large “dream” hospitals in San Francisco and Los Angeles and his last two “small city” hospitals in Walnut Creek and Fontana.

Innovative, efficient mid-century designs

He designed them all around principles he held dear: efficiency, economy, and patient comfort. Renowned architect Clarence Mayhew designed Walnut Creek and Fontana to echo the mid-century desire to have the indoors and the outdoors meld. Each was Y-shaped with two wings of rooms that opened to the natural environment to both soothe the patient and give visitors access while nurses, doctors, and orderlies circulated freely down an interior corridor.

Despite being small, they incorporated the features of the larger hospitals. The central work area was abolished in favor of stations distributed along the corridor so each nurse would be a few steps from her patients with records and supplies shelved nearby.

Santa Clara Medical Center, built in 1964, featured the decentralized interior corridor dictated by the circular design debuted in Panorama City.

And the mostly private patient rooms were equipped with all manner of modern convenience with power-drawn curtains and bed adjustments operated by push buttons, a built-in lavatory, toilet, closets, oxygen outlet, plus phonograph outlet and radio.

Garfield received national attention for his rooming-in maternity section where babies were kept close to their mothers, but also within reach of the nurses through a bassinet that slid between the room and nursery.

Architectural Forum magazine in July 1954 lauded all the new technology and design innovations in Walnut Creek: “For all its luxuries, care at Walnut Creek actually costs less than at older hospitals. The gadgets speed recuperation and encourage patients to care for their own minor needs.” Thus, the nurses’ time spent as errand girls would be reduced. He was a great believer in the power of human contact in the healing process.

Garfield said in the KP Reporter in 1963, “Over the years, we have been working for development of functional design in hospitals in which our staffs can serve patients with a minimum of wasted time and energy. They will then have more time to be with patients, and this human contact makes for happier patients, more stimulus to recovery.”

View a 1953 video about the Kaiser Permanente "dream" hospitals below.