A Healthy Dialogue: Putting Interiors and Exteriors in Conversation in Healthcare

Susan S. Szenasy talked to members of the Miami office of Perkins+Will about the mutually supportive role interior and exterior spaces play in healthcare environments.

A patient at Spaulding Rehabilitation Hospital in Boston, Massachusetts utilizes physical therapy facilities, which are strategically connected to the exterior environment.

Courtesy Anton Grassl

Throughout 2015 and into 2016, Metropolis’s publisher and editor in chief, Susan S. Szenasy, has moderated a series of discussions with leading architecture and design firms on pressing issues surrounding human-centered design. Last December 8, she talked to members of the Miami, Florida office of Perkins+Will about the mutually supportive role interior and exterior spaces play in healthcare environments as well as the opportunities and limitations of healthcare design. What follows is an edited transcript of the conversation.

Learning from Ghana

Pat Bosch, Design Director, P+W, Miami (PB): Our hospital in Accra, Ghana, has 566 beds and will enhance healthcare services for women and children by targeting the issues of women’s preventive medicine and infant mortality.

This project is off the grid by necessity. We had to deal with issues of natural ventilation and design a hospital infrastructure that does not rely on electricity to sustain operations. A key issue was controlling infectious diseases with the architecture by creating pavilions, outdoor connections, and flows that support non-mechanically supported systems.

For us, one of the most wonderful things about the project was investigating and learning about new healthcare models. We borrowed from British and French models of healthcare and infused these with what we knew about North American models.

Susan S, Szenasy, Metropolis (SSS): Americans are paranoid about infectious diseases in hospitals, so we seal them up and then brew even more infectious diseases. What is the lesson you learned in Ghana about how they’re able to deal with off the grid, natural ventilation?

PB: For us it was about understanding how to create thresholds of control. So, we located breezeways off the outdoor waiting areas ; if a patient is suspected of an infectious disease, he or she can quickly be taken to a controlled environment, to a series of sequential rooms where the relative risk level is assessed. We provided pavilions that are semi-naturally ventilated. If there is a surge of something that happens in one pavilion, the facility can shut it off.

A rendering of the Perkins + Will hospital in Accra, Ghana which will aim to target the issues of women’s preventative medicine and infant mortality.

Courtesy Perkins + Will

Spaulding Rehabilitation Hospital

PB: Healthcare is not just on the inside. We need to understand the importance of bringing nature into our spaces so that people feel human again, especially in the hospital. One of the most debilitating aspects of healthcare is that you’re just this thing that people are taking care of. So, bringing back humanity is very important and these spaces are all about that.

At Spaulding in Boston, MA, we utilized the exterior as part of the healing process by creating a series of events around the building, where patients can do their exercises and their rehabilitation. We also utilized the hospital’s location near the water as another calming strategy.

In the patient rooms we made sure that windows were at a certain height so that, no matter where you are, whether in bed or in a chair, you’re always able to look outside. Even in small public areas or collaboration areas we tried to maximize the views and daylighting.

We visited the center one day and heard from patients who said that the ships passing by the hospital were very calming for them. They started to understand what ships were going by and when. It was wonderful for them to be able to experience the building’s micro-context through the presence of the ships.

SSS: It’s amazing that you can open the windows at Spaulding. What did you have to do in order to do that?

PB: It depends on the acuity level of a patient. Only certain rooms have operable windows. If you’re in rehab and not at a level of acuity where you could get an infection, you might be placed in a room where the windows can be opened. In rooms where you might spend 10, 12 hours in rehab, simply seeing the afternoon sun arrive becomes very important. And so this ability to give patients a balcony and access to nature was a “hot topic.” There were a lot of these controversial moves; we would ask, “how much operability is effective and acceptable?”

Tatiana Guimaraes, Senior Medical Planner, P+W, Miami (TG): These issues can vary a lot depending on the culture of a country. This building that our office is in, for instance, is all closed off–you can’t open a window because there is a concern about affecting HVAC systems, their functionality and efficiency. But we’re starting to look across the world where they don’t have restrictions like we do and bring those experiences into our projects. It was easier to do this in Spaulding, because people undergoing physical therapy tend to have longer lengths of stay than usual. This requires them to breathe fresh air, even for a little bit of their day.

PB: There’s something extraordinary that we learn by doing international work, where the humanistic aspect is actually regulated. Working in the British or French system we found codes that tell you that all rooms in the hospital must have daylight. In the Nordic countries you see hospitals that are fully punctured–they have all these bright spaces and little courtyards. Our first reaction to them was “Really? Must we?” But now we’re seeing that there is evidence coming from so many other countries about the need to regulate exposure to nature. We, as a country, haven’t gotten there yet.

The patients at the Spaulding Rehabilitation Hospital can open windows, and watch ships go by in the Boston Harbor, activities which Perkins + Will has found to be rehabilitating in and of themselves.

Courtesy Anton Grassl

SSS: What’s the basis of our regulations? Is it tied to economics or something else?

TG: A lot of it is tied to efficiency and infection control. It’s very hard to debate when somebody brings up an infection control issue that could lead to a patient’s death. Mortality is a constant healthcare focus; it has an impact on what doctors and hospitals do and how they operate. These experiences inform the code. There have been some efforts to evolve to a more holistic approach, but it’s very hard to change a whole system, a whole mentality. We need to find a balance, because neither approach is right or wrong. It’s just about balancing what the needs are—from an operational perspective, from infection control—with a holistic approach to care and patient experience in mind.

SSS: The original codes had good intentions. But at some point they need to be reassessed because we have new knowledge, new understanding. I think we seem to have hit that right moment.

Elina Cardet, Interior Design Director, P+W, Miami (EC): The codes are functional. They are about the preservation of life. It’s the architect and designer’s responsibility to bring aesthetics into the code and use the code as a guideline for the fundamental pieces that are required to obtain the quality of air, preservation of life, safety, infection control, and air exchanges. If we think holistically, the innate human need for beauty is, in our view, an aspect of wellbeing and the healing process and therefore must be an integral part of healthcare design.

PB: I think that you can interpret the code in many ways and it really is our responsibility to bring that humanistic factor back into it, because a window is not just a window.

The Role of Urban Planning

SSS: I would like to start deconstructing this with Cesar. As an urban planner you’re looking at buildings in a larger context, and we know that we really have to look at our buildings much more than as individual structures. The philosophy of an urban environment that includes buildings, nature, and connectivity to other services is really key to all this. Can you expand on this?

Cesar Garcia-Pons, Senior Urban Designer, P+W, Miami (CG-P): There are two types of environments. We have green fields where you’re building from scratch, and then we have the infill situation where we have to react to existing conditions. These are very different project types, and very different attitudes are appropriate to each situation.

I’ll talk about the infill because retrofitting existing conditions is more interesting and more difficult than building anew. Thinking locally, Jackson Memorial Hospital is an example that we all might know. In the same general area, we have the county-run Jackson Health System, the University of Miami Hospital (formerly known as Cedars Hospital), and the VA Hospital. So, a bunch of different organizations share the space, but they don’t communicate with each other nor do they work together very well. So then it is our job, my job in particular, to figure out how we can organize them into an integrated system that works for all of them.

Many of the older versions of our Health District facilities were insular. Then the design decisions were about the inside of the building. In order to get them to communicate, we started talking about the health benefits of going outside, whether for the exercise, stress relief, access to food, or just having something to do. So we created all this through what we called health walks, or linear greenways.

For all of these campuses to connect they needed to realize that they are part of a larger system. Once they started looking outside of the building, they began to say: “We have a Health District.” And we find that they all do better by having this mixed-use attitude, economically and in terms of the hospitality and educational aspects.

PB: We need to understand what interdependency means. We’re creating these eco-communities with buildings that are interdependent on each other. For instance, if a research hospital is generating thousands of gallons of water a day with their condensate, that water can be used to help another center in the district. We’re seeing much more of that nowadays. Internationally we’re seeing a lot of hospitals and health districts trying to be as off the grid as possible.

The Perkins + Will hospital in Accra, Ghana is off the grid by necessity. The design had to incorporate natural ventilation and a hospital infrastructure that would not rely on electricity to sustain operations.

Courtesy Perkins + Will

The Role of Landscape Design

SSS: In all of this, landscape design is very important, the kind of systems approach to collecting and saving water, understanding local flora, and more things related to the land. What does nature mean in terms of these new healthcare and wellness buildings that you are designing these days?

CG-P: If we go back to the origin of hospitals, there’s the medieval monastic infirmary garden where a part of the treatment was exposure to fresh air. Even as far as the 1900s there were gardens in state hospitals. Today’s hospitals have become machines that have divorced themselves from allowing a patient to go outside and breathe air and get sunlight and all of the things that we know we need for survival.

What we’re swinging back towards is integrating landscape as part of the function of the building in two ways. One being the way people experience buildings through the healing gardens that invite them to go outside and get a little bit of socialization. The other aspect is control. The staff, and not the patients, control most activities in hospitals today. But in some cases, patients can take back control by taking a walk, for instance. Having some modicum of control, even if it’s just opening a window or having the ability to go outside, is a very important thing emotionally.

PB: A 90-year old Alzheimer’s patient and a four year old child understand what a tree is, what a sky is, what a leaf is. We have a universal understanding through nature. The understanding and the connectivity with nature becomes one of the key factors, not only for patients, but the staff as well.

Healthy Materials

SSS: At Perkins + Will you have redefined the architecture community’s material dialogue with your Precautionary List some 15 years ago. But the issue at hand is incredibly complex, how do you find the kinds of materials that bring people outdoors?

EC: We start with basic materials, almost looking back to things that have been around for a very long time and that are known to be not that harmful. We think of stone. We think of wood. Those are not the monstrous hybrids that we have formulated with the advancement of technology.

SSS: But as the Earth’s population grows, the resources that used to be available–the woods and the fibers–are harder to come by and will be more so in the future. We really need to invent other, safe materials that are beautiful, high performing, and healthy. What are you looking for in that area?

EC: It’s not easy because the manufacturing industry is not one hundred percent there yet. Unfortunately, we end up looking at things that are not as bad as others, rather than things that are ideal. We use a lot of recycled materials, for example, and reuse things that are difficult to extract. In the nineties no one was doing this right. Now, a lot of manufacturers are trying, but when you go really deep, there are still some problematic components, even with one hundred percent recycled materials.

SSS: What would you ask the manufacturers about their products? And, for the manufacturers, what do you want from the designers? It’s really important to have that kind of cross communication between the two entities.

PB: Perkins + Will’s perspective with the Precautionary List was to invite manufacturers to be honest about their processes, elaborate on these synthetic materials, and enter into a healthier intellectual partnership with us, the designers.

Obviously, we can’t deplete the Earth’s natural resources. We now have to create new ways of doing things. In the process, we want to know what the manufacturing process is like. What we did with the Precautionary List was put forth a challenge and said, “We’re not just going to buy something because you’re telling us it’s going to last 50 years. We’re going to buy something because while it lasts 50 years, it’s not going to harm people or create a cause for diseases.” The industry has to become more responsible for what they put out there. I think that’s what the Precautionary List started doing, challenging that responsibility and saying, “You’re also responsible for what you’re giving us. You’re responsible for what you’re leaving behind.”

This Metropolis Think Tank conversation is presented in partnership with Bretford, DuPont Corian, Sunbrella, and USG.

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