The New Hospitals: Design Science

From September through November 2011, Pam Murphy drove from her house in Upper Arlington to the James Cancer Hospital at the Ohio State University Wexner Medical Center five days a week. She'd park on the top floor of the parking garage and walk along the surface of each ramp, slowly descending the slopes, level to level, down to the hospital's main entrance. An avid runner, 64-year-old Murphy led an active lifestyle before she was diagnosed with throat cancer after a tonsillectomy that summer. After she had endured her daily dose of radiation therapy, she'd walk back to her car the same way, and although the second trek was more painful, she'd soak in the sun and relish the cool breeze nonetheless.

Despite her illness, she tried to remain as active as possible; the exercise helped keep her energized. It also satisfied her desire for fresh air, because once she arrived in the hospital's main lobby, she'd take the elevator down to the radiology department in the building's windowless basement for her appointment. Sometimes, she'd wait for an hour or more until it was her turn to receive her 20 minutes of treatment.

"It was rather depressing to go downstairs into the basement. It was dark and dingy," says Murphy, now 67. "And when you have cancer, you don't need to be depressed. You need a positive attitude."

Murphy isn't the only cancer patient who felt this way. When physicians and nurses helped to plan the design for the new cancer hospital, set to open in December, they asked former patients what the hospital could do differently to make their treatment more convenient, more comfortable, less burdensome.

"Every day coming in for treatment, the first thing [patients] do is go down the elevator into a subterranean area with no natural light exposure," says Dr. David Schuller, vice president for medical center expansion and outreach for the Ohio State University Wexner Medical Center. "They requested, if possible, we move that up into space that's not just at ground level but above ground."

That's why the new James Cancer Hospital will feature an above-ground radiation oncology unit with eight treatment rooms-the only facility like it in the country. Because radiation treatment emits rays that can be harmful to those who aren't undergoing treatment, they're typically built underground. A second-floor unit like the one at the new James essentially requires six protective walls of high-density concrete, rather than just one. Architects also incorporated into the design a series of hallways running north and south that allow natural light to penetrate rooms on all floors from both directions.

These are just a couple ways in which this and other new hospitals are being designed with patient experience as the No. 1 priority. A bed's position in a room, the angle at which sunlight shines through a window, the colors painted on a wall-while individually they might seem like insignificant details, together these calculated design elements form hospitals with more favorable healing environments, better workflow and, ultimately, lower rates of patient admission with higher rates of patient satisfaction.

Though it's still under construction, the new 21-story medical tower that will house the James Cancer Hospital and Solove Research Institute and Critical Care Center is mostly in place. From state Route 315, Ohio State's campus and even parts of Victorian Village, you can see the sun bounce from the tower.

"If you take a look at that building, there is an abundance of glass," Schuller says. "The primary reason is an abundance of natural light does have a positive impact on the rate of recovery." Clinical studies support this, he says, by reporting "shorter lengths of stay, lesser use of pain medication and decreased incidents of depression, which are common among cancer patients."

All 276 rooms designated for cancer patients and 144 critical-care rooms-most will be used by critical non-cancer patients-will be exposed to sunlight that, thanks to the building's design and the angles of its walls and window openings, will never shine directly into patients' eyes.

The new OhioHealth Riverside Methodist Hospital Neuroscience Center has also been designed to amplify natural-light exposure. The 9-story tower, set to open fall 2015, will feature a central atrium that allows natural light to flow through the building. The six floors designated for patients will have two rings of rooms, one set with windows facing outside the hospital and another with windows opening to the atrium garden. This way, all 224 patient rooms have a view. It's a positive distraction, says Dr. Janet Bay, vice president and physician leader for neuroscience at OhioHealth.

"Sometimes you just want to look out the window and take a break from your troubles," Bay says. A second-floor concourse allows a stream of light into the operating unit, including pre- and post-op rooms as well as waiting areas.

These sources of natural light help patients and caregivers maintain their bearings of night and day. "You can imagine, to be in the hospital for a significant period of time, being able to orient yourself to light and dark cycles is important," Bay says.

Bay has been involved in the planning process for the $321 million expansion-which increases the size of Riverside's campus by 30 percent-since day one. She was among the physicians and nurses who worked closely with architects as they planned the building's layout and design elements and toured mockups of patient and operating rooms to provide feedback.

They also used some unorthodox methods to remind themselves what was really important: During meetings, a replica of Wilson from "Cast Away," the inanimate friend of Tom Hank's character in the movie, sat in the center of the table.

"We decided we needed a surrogate for the patient," Bay says. "Whether we were discussing how wide the doors would be or where the TV is in patient rooms, we'd have a patient in the center of the decision-making."

Hundreds of other Wilsons are now scattered throughout OhioHealth Riverside Methodist Hospital in Plexiglas cases. They continue to remind staff that everything they do affects the patient.

That focus influenced interior design decisions, like the color schemes for paint, furniture and decor.

In designing the neuroscience tower, architects used organization and navigation to decrease stress for both patients and their families. The building is meant to unify the hospital grounds and provide "a clear means by which patients and visitors can understand how to get into the campus and circulate around the campus," says Tim Fishking, a principal at architecture firm NBBJ.

"You begin to see the structure as you approach from 315, and it's very evident that it's the entry point for the campus," Fishking says. "From a patient's perspective of arriving at a hospital campus with lots of different buildings that might not be cohesive … the neuroscience center simplifies that with one clear point of entry."

The lobby inside has been extended and "is like an airport concourse," Fishking says. Though all the other hospital and office buildings maintain separate entrances, they also connect through the neuroscience center. "We wanted to have a clear way of accessing all the buildings … that connects you from point to point and one end to another."

To do that, architects included a broad concourse, with high ceilings and open hallways at the front of the building. Not only does it allow natural daylight to flood the lobby, but it also serves as the hub-the primary means of access to get to other areas of campus. Fishking says they designed connecting pathways with similar patterns, flooring, lighting, colors and seating to clearly mark them as transitional areas-the paths you find and follow when you're trying to get somewhere else. Architects commonly use the term "wayfinding" to refer to design elements that streamline navigation and better orient people with their environment.

Signs demarcating directions and destinations are designed to be supplemental, he says; people should be able to find their way without them. The design also keeps an established color-coding system for buildings: The heart hospital is red, for example, while two patient towers are yellow and orange.

For a textbook example of this type of cohesive, hospital-wide navigation system, consider Nationwide Children's Hospital.

The main lobby of the new hospital, which opened in 2012 as part of a $783 million expansion, is open and bright, with floor-to-ceiling windows that flood the white-washed space with sunlight. Two-dimensional images depicting nature scenes-trees, birds, butterflies, woodland creatures-are plastered on the walls in grays and electric greens, pinks and blues. Figurine birds are frozen in flight, suspended from the ceiling by nearly invisible wire. Speakers emit recorded sounds of nature that change throughout the day. A loon calls and crickets chirp during early morning hours, while birds sing in the afternoon.

"It brings nature into the building," says Scott McClure, project manager for design and construction. "Not necessarily in an obvious way, but more understated."

Like a thorough marketing campaign, the hospital is consistently branded with colors and decor reminding visitors where to look to find their way. The nature theme is incorporated in patterns throughout the hospital. Reminiscent of Dorothy's yellow brick road to Oz, each color painted in a swirling line on the floor is a pathway to a certain department. Follow blue to find the pharmacy and purple for the nurses' station. Admissions, radiology, even the cafeteria have designated colors, and each destination is marked by a burst of leaf outlines splashed on the floor.

"The kids love them," McClure says of the linear maps. "They follow the lines, even when other people are in their way."

Another component of Nationwide's 12-story main hospital is a floor plan that separates public traffic, like incoming patients and their families, from behind-the-scenes activity, like a nurse transporting a patient to a new room. Staff call these "on-stage" and "off-stage."

NBBJ incorporated a similar feature into the design of OhioHealth's neuroscience tower.

"It's not always a pleasant experience if you're taking a patient from the ER to the elevators to go up to surgery and that traffic is commingled with other patients and families," Fishking says. So they designed the tower in a way that "pulls the public circulation away from the back-of-the-house circulation" and helps prevent those "discomforting, awkward mixes" throughout the hospital.

In a similar vein, how about undergoing an invasive medical exam or answering in detail questions about your symptoms while a stranger sits in bed on the other side of a curtain? Well, patients can say goodbye to sharing their rooms. Rooms in today's hospitals are completely private, and some even offer attached spaces where family members and caregivers can spend the night, shower and use the restroom.

Sure, private rooms are more comfortable and convenient for patients. But there are medical benefits, too, like combating the risk of hospital-associated infections.

In Ohio, hospital-associated infections affect five to 10 percent of hospitalized patients annually, resulting in more than 80,000 infections and nearly 4,000 deaths, according to the Ohio Department of Health.

"What data reveals is the incident of hospital-based infections is dramatically reduced when all rooms are private," Schuller says. "It reduces the transmission of infection if they're not that close to one another."

Most patient rooms in the current James Cancer Hospital, which was built in 1990, are private, but there's a portion that are shared. The new hospital will feature only private rooms that will allow patients to receive most of their treatment-like chemotherapy-bedside, limiting the need to bounce from room to room. The rooms were intentionally oversized to accommodate that feature, Schuller says.

They'll also be same-handed-every room will be identical, or nearly identical, to its neighbor. Historically, adjacent hospital rooms have typically been mirrored, connected by a shared wall that houses all the utility lines for both rooms. Walk into any given room and it could be flip-flopped from the one before. The new rooms, however, will be arranged exactly the same.

"This building is serving cancer patients and, unfortunately, cancer patients have a greater incidence of major medical emergencies, and in major medical emergencies, every second counts," Schuller says. "It is critically important that time is not wasted because the people helping to intervene are looking for suction or oxygen because they don't know where it's located."

OhioHealth employed the same logic in choosing a same-handed design for the private rooms in the new neuroscience center. "The intent is to bring efficiency to the care being provided," Fishking says.

Throughout their design process, architects and health care providers reviewed the layout of patient rooms with a fine-toothed comb and made minor tweaks. They softened the corners in the rooms to ease the degree at which they intersected in an effort to prevent bruised hips and other bumps during high-stress, fast-paced situations. They tested the angle of storage compartments and alcoves to make sure they were easy to maneuver.

"How easy is it to get a soiled-linen hamper out of an enclosure quickly? That's the level of detail we were scrutinizing," ensuring that "everything works in the most efficient and effective way possible," Fishking says.

Designing hospitals that are good for patients sometimes means forgetting the bottom line. Sometimes, what's best for the patient and what's cost-effective don't match up. It's cheaper and more efficient to run multiple sets of utility line through one wall, but "with this design, that's not possible," Schuller says.

Incorporating a second-floor radiology unit into the design required major architectural and engineering adjustments. "Nearly all radiation units are either below ground or at ground level," Schuller says. "It's easier and more cost effective." But a second-floor unit has six outside walls that need to be specially sealed to protect outsiders from exposure to radiation. The design called for high-density concrete, which costs nearly $2,700 more per cubic yard than conventional concrete. It also added an extra five million pounds to the weight of the building and required the type of structural beams typically used in 60-story office towers for support. (A federal grant footed the roughly $100 million bill.)

Schuller says it "speaks to our commitments to our patients, prioritizing and creating an optimal environment for treatment. There is evidence that shows it's better to put it up in the air and allow natural light in, and that's why we went after it."

There are other incentives motivating this shift toward hospitals designed with the ideal patient experience in mind.

"It's not only a reflection of the desires of our patients and the clinical side of it," says Charles Cataline, vice president for health care economics and policy for the Ohio Hospital Association. "We have to keep in mind overall satisfaction."