The Hospital and Community

By Tony Bracali, AIA

The hospital needs to be able to stand on its own, with redundancies for every major mechanical and life support system. Even small, private hospital systems are often regarded by their communities as major civic and public institutions. And hospitals often come with campuses or major land holdings that put them in position to influence how a community develops and changes over time. Most unique is that, arguably, the hospital is the one type of building that HAD to function during the pandemic JUST as it had functioned before. That is, hospitals should already have been designed to adjust to and support what was needed to serve communities in times of crisis.

We are learning more now about how hospitals responded to these challenges. And, while at the time of this writing we cannot say we are beyond the pandemic, we can start to think about some of the ways our hospital buildings need to adapt and change to serve communities and form a “workplace of the future” for our patients and essential staff.

CAMPUS AS

PLACE OF HEALING

During its prime, the city of Rome was home to a number of well-maintained and lavish public gardens. Many of the gardens were originally reserved as places of respite for the ruling class or even the emperor. Over time, Roman leaders recognized the importance of providing amenities to the public to win their favor and ultimately maintain control. In a more altruistic sense, the gardens were also places for necessary exercise and included walking paths and trails marked with distances. They allowed citizens who were normally subject to the dense and un-sanitary conditions of an urban center to retreat into nature for refreshment and rejuvenation.

It’s been documented that the pandemic has stressed social and emotional and even political discourse in America. Hospitals are in a unique position to provide a reparative and healing process for patients that begins before someone even enters through the front doors.

As noted earlier, hospital systems often control considerable property. And it’s increasingly accepted that open space and nature is therapeutic for people. What if we thought about these expansive sites as having the potential to be places of “rejuvenation and restoration” the way the Romans did. We could design our campuses to serve as something akin to the “pleasure gardens” of ancient Rome.

At the Jefferson Center City hospital campus, we undertook plans many years ago for a two (2) phase development to replace a 1980’s two story garage. Phase 1 was completed and phase 2 was never built. The unintended benefit of the second building never being constructed was that we were left with ample space to provide a new campus park. The park is passive and accommodates people of all ages. The park is a “canvas” to allow people to engage with us and have a positive experience. We hear often from students, staff and neighbors that this is a place of “respite” for them.

Hospital employees and staff will also obviously benefit from these outdoor spaces as places for revival and refreshment. As a result of hybrid and remote work scenarios, many businesses are returning to office with a significant reduction in their daily population. This trend is exactly the opposite in the medical field. Hospitals are going to require even more staff than in the past to get the job done. In fact, the Bureau of Labor and Statistics recently projected that medical fields would experience 16% job growth, a significant number more than any other professional field.

With more people needed “in person” the role of open spaces as places for re-charge will take on even greater importance. And it’s not simply the site that needs to be considered, but the entire experience that begins with arrival on the property and leads to the front door.

WHAT CAN A

LOBBY BECOME?

In 2019, New Orleans opened a major renovation of the Louis Armstrong International Airport. Articles at the time focused on the open, light filled design by Caesar Pelli. However, the feature mentioned in almost every article was one of the most mundane — a large, central space for TSA to expand and contract their security operations as needed, with up to 17 lanes of service as needed. Of course, this was design thinking born of the post 9-11 space planning needs. Hospitals can learn from this.

The pandemic dictated new space requirements at hospital entrances. The physical distancing requirements recommended to manage COVID meant that available space was quickly consumed. Many hospitals added temporary tents and portable buildings beyond the entrances and into the surrounding grounds to create needed extra space. Many hospitals just didn’t have enough interior space to offer as lobbies had just not been oversized enough or designed to be that flexible or adaptable. In Washington State, the first hospital to receive COVID patients decided to have people wait in their cars for appointments because their lobby was so undersized.

We should be thinking about hospital lobbies like the New Orleans airport.

After high-profile flooding disasters that decimated hospitals in New Orleans and New York City, the organization of the hospital entrance sequence is being revisited. With new hospitals planning critical backup systems and programs to be housed above the first floor, we will, as a result, have more space to work with at the ground level than ever before.

At Jefferson, our new ambulatory care building under construction includes a first-floor plan that is almost 60% lobby, public space, open space and automobile drop-off. All this space gives us the opportunity to re-purpose and re-plan as needed. It gives us the ability to provide additional screening areas and space to manage physical distancing if needed. It also allows for us to expand our security perimeter as needed to control access if we need to. While not the case in our location, in buildings where flooding is possible, added open space at the lobby level can provide a “buffer zone” for storm surges.

The added space requirements to allow for all the above outlined issues don’t just stop with the public areas. Employees and staff are going to require more significant amenity spaces. Fitness centers, lounges, and doctors’ quarters are all going to need to expand and be upgraded post-pandemic. Hospitals need to ensure that critical workers can “distance” themselves from the intensity of their professional activities, so the spaces we design will need to take an even further step away from the aesthetics of clinical environments. These should be considered as places of isolated retreat and reflection where the physical connection to the hospital is minimized or entirely hidden.

We have been asking our essential workers to carry a heavy burden. That of balancing all of the personal and family emotions and intensity while providing that same type of care and compassion to the people that they care for.

We might look for ways to better connect our employee’s homes and communities in a symbiotic way to their workplace. To consider mixed-use planning models that allow healthcare workers to live closer to where they work, reduce commuting times, and incorporate other amenities they need to live a more balanced life. A few hospital systems have already begun to make changes in this direction.

DON’T JUST EXPAND,

LOOK INWARD

Throughout the 1990’s, department store anchored retail and shopping centers sprouted at the edges of cities across the country. Each generally required several “anchor” tenants whose brand strength lured shoppers and attracted smaller retail tenants and whose financial viability and creditworthiness made them attractive to the developer and their lenders. How times change…

The vast number of vacant retail “boxes” present many options to a hospital system looking to expand. Additionally, shopping mall owners (and more importantly their lenders) have come to view the institutional user as a more viable tenant than their retail counterparts of the past. As a result, many hospital systems have pursued a strategy of growth through suburban expansion. On one hand, this is simply about delivering the services to where people live. On the other hand, it’s a basic reaction to the realities of the suburban real estate market. So these new “infill” suburban clinics take advantage of available space and pair with existing community-serving retail.

A different approach is emerging on the northeast outskirts of Denver. A new $650 million hospital building for SCL Health is rising from the ground and is scheduled to open in 2024. The new facility will have approximately 350 beds and operate as a level two trauma center. Surrounding the 26-acre hospital campus is nearly 90 acres of related development. This includes a convenience store and gas station, 310-unit luxury apartment community and a retail and restaurant destination with a central public space. All of this is blended with other recreational and open space. In this development the hospital is the central user, the “anchor” tenant. They are the catalyst for the other uses and activities and the user that makes the project financially viable.

But there is an even more important reason than economics for the hospital to be the “anchor” user. At the recent American Society of Healthcare Engineering’s (ASHE) Planning & Design conference, several sessions touched on the concept of the hospital as “community-wide” resource – a place of safety, shelter, and security. The sessions pointed out that this concept is consistent with a common view of the hospital by the public as a place of refuge and recovery.

Hospitals should be thinking not only about how we can bring services to communities but how we can bring the services communities want to our existing hospital campuses.

A “mixed use” approach to hospital planning can best accommodate our patients, their families, and our critical staff. Beyond just well-designed open spaces outlined earlier in this article, we should be considering the addition of retail and housing that has a relationship to our services. Even community centers and recreation would be suitable partners and could provide fitness space and meeting rooms that could give hospitals added space to support rehab and physical therapy programs. Many hospital systems are adding research and life sciences buildings to the mix. And one of the most obvious additions would be senior living; seniors with housing situated proximate to the hospital campus have easy access to services.

CONCLUSION

The hospital is a vital workplace that had to adapt during COVID and will have to adapt again to future challenges that are unclear. We need to be planning that spatial flexibility into our buildings right now. Our society has been strained by the pandemic, social unrest, and negative political discourse. However, people and communities are resilient and while it may seem difficult in the moment, we will recover from these challenges to meet the challenges to come.

Hospital campuses are uniquely positioned to help our communities rebuild.

In fact, we should recognize our responsibility as providers of care to rebuild. Since hospitals are viewed as places of refuge by their communities, they are uniquely positioned to provide this type of service. And it goes beyond conventional health care. We can provide spaces to help rebuild social connections, spaces that our neighbors and patients can enjoy and areas for a staff to refresh and recharge. These should be places that encourage civic dialogue and connections. A hospital campus should be a place of emotional health and well-being.

Importantly, hospital missions are already aligned with these goals and ideals. To advance this type of planning, we need to align funding priorities and capital plans with this thinking. This will be the big challenge as many hospitals have a deep backlog of costly deferred maintenance. In the long run, incorporating ideas like these into our hospitals will ensure they remain as modern, essential, secure, and safe institutions in our communities.

Tony Bracali is the Senior Director of Planning, Design and Construction at Thomas Jefferson University and Hospital. Prior to joining Jefferson, he was the Vice President of Design and Director of Architecture at The Goldenberg Group. He lives in West Philadelphia with his family and is a proud Philadelphian.

Sources: Marsano, Annalisa (2020, May 20) Walking, talking and showing off – a history of Roman gardens. The University of Reading. (https://research.reading.ac.uk/research-blog/walking-talking-and-showing-off-a-history-of-roman-gardens/). Wilkinson, Missy (2019, Mar 29) A sleek new MSY terminal ‘reflects’ next-century New Orleans, architect says; see renderings. (www.nola.com) https://www.nola.com/entertainment_life/article_39d587a4-2e38-5c0d-94ac-60c94cc64b50.html). Booth, Micheal (2021, June 1) Lutheran Medical Center making a $650 million move just a few miles west in Wheat Ridge, opening up prime land for redevelopment. The Colorado Sun. (https://coloradosun.com/2021/06/01/lutheran-medical-center-moving-to-clear-creek-crossing-by-2024). Clear Creek Crossing (https://cccrossing.com/). SCL Health Lutheran (https://www.sclhealth.org/locations/new-lutheran-medical-center/legacy-campus/).