John Currie, FAIA, FRSPH and Frank Zilm,D.Arch.,FAIA
Early Health Care in Eastern Mediterranean
The earliest records of health care in Egypt and Greece are tied to religious beliefs, with priests and temples playing major roles in attempts at diagnosis and care. Greek physicians believed a person’s health was affected by an imbalance among the four humors (and their associated conditions) – blood (hot), phlegm (cold), black bile (moisture), and yellow bile (dry) – and the four elements –earth, air, fire, and water. (Currie, page 20)
The Aesklepion at Pergamon, Anatolia, Turkey. Reputed to be the place where the great physician Galenpracticed. Galen was a Roman citizen of Greek extraction whose medical teachings were in use well into the renaissance. Many of the Roman physicians were trained in Greece, and many of the Roman health related structures were copied from or strongly influenced by Greek civilization. This center, established in the 4th century BCE, saw its greatest popularity under the early Roman occupation in the 1st century CE.
The image at the left shows a model of a Valetudinarium. The Roman Valetudinaria are Roman Military Hospitals built at strategic locations throughout the empire beginning ca 100 BCE. One of the best preserved ruins of such a hospital is found in modern day Scotland at Inchtuthil (now Victoria). Roman society did not provide hospitals as we understand the term for its citizens at large. Most care was delivered at the practitioner’s home clinic or at the citizen’s home. Facilities were built to allow for separating those with infectious disease from the general population – a practice continued well into the Renaissance. However, the Romans were great civil engineers and were responsible for major advances in public health through their creative work for waste disposal and clean water sources. Roman life and health in part was centered on the classic Roman Baths such as that built by Emperors Diocletian and Caracalla.
The cruciform planhospital is perhaps the clearest example of borrowing a successful plan from the Religious world that was technically well-understood and has a strong symbolic meaning connecting medicine and religion. Shown here are The Temple of the Sun in Armenia (1st Century CE), The Church of St. Simeon Stylitesin Syria (5th Century CE), and the Osepedale Maggiore in Milan Italy (ca 1500 CE).
The evolution of Christian monasteries frequently included courtyards and sleeping porches used to accommodate sick seeking care. These “hospices” were frequently found along pilgrimage and crusade routes throughout the Mediterranean and into central Europe. Later examples such as the Monastery ay St. Gallin Switzerland around 1200 CE had more specialized facilities.
“In the early Middle Ages, especially after the fall of the Byzantine Empire, care of the sick and other unfortunates was largely provided by those in religious orders as charitable work. Health care was approached differently in the Arab world, however. The Arabic body of medical knowledge was based on carefully observed and documented cases measuring the effects of treatment on specific diseases. This was a very early example of the scientific method applied to medicine.” (Currie page 25)
St. Basil(the Great), 330-379 CE, was a major religious leader of the time responsible for a long list of good works including a large complex just outside the Cappadocian town of Caesarea, called the Basiliad or Basileias, which included a poorhouse, hospice, and hospital, and was regarded at the time as one of the wonders of the world. The Basiliad, this great philanthropic foundation established by St. Basil where the poor, the diseased, orphans and the aged could receive food, shelter, and medical care free of charge from monks and nuns who lived out their monastic vocation through a life of service, working with physicians and other lay people. The late Professor Roy Porter of London’s Wellcome Institute for the History of Medicine considered the Basiliad (also called a ptochotropheion) the first real western hospital meaning that this was the first center built specifically for the care of the sick and provided with a certain level of specialized departments. There are other contemporaneous examples in the Middle East and Egypt.
The Byzantine Empire, building upon the Greek medical and architectural traditions, and supported by Constantine, established centers for care of utilizing the cruciform plan which practice continued well into the Renaissance ca 1400 - 1600 CE. The cruciform hospital made its way to the western hemisphere due to the so-called Columbian Exchange beginning with an early hospital at Hispaniola followed by the Hospital of the Immaculate Conception in Mexico City. (plan and courtyard view shown below)
Health Care in High Middle Ages and Renaissance Europe from 1000 CE to 1600 CE
The High Middle Ages (1000 -1300 CE) saw a growing population in Europe with social and political change and the population increase greatly strengthened the economy. This growth and expansion of the economy was halted by a series of calamities such as the Black Death, numerous wars, and economic stagnation. The great monastery churches were the sites of facilities for pilgrims and for the isolation of the sick.
Most historians agree that the Renaissance began in Florence, Italy, in the 14th century. During the Renaissance period we begin to see the development of distinct health care facilities. TheOspedale degli Innocenti('Hospital of the Innocents', also known in oldTuscan dialectas theSpedale degli Innocenti) is a historical building inFlorence, centralItaly. Designed byFilippo Brunelleschiwho received the commission in 1419, it was originally a children's orphanage. It is regarded as a notable example of early Italian Renaissance architecture. The hospital, which features a nine bayloggiafacing thePiazza SS. Annunziata, was built and managed by the "Arte della Seta" or SilkGuild of Florence. That guild was one of the wealthiest in the city and, like most guilds, took upon itself philanthropic duties. (Wikipedia)
Leonardo DaVinci pursued his anatomical studies at the Hospital of St. Maria Nuovo in Florence from the late 1200’s which had early specialized surgical facilities. St Bartholomew’s hospital (founded 1123) and St. Thomas’s hospital (founded 1106) in London are further examples of hospitals created to address the social and disease issues of the time. These hospitals are in service today having been rebuilt many times over the years.
Perhaps the best known example of late Renaissance hospital was Hotel Dieuin Paris. It was founded by Saint Landry in 651 on the same site as it now stands on the Ile de la Cité directly adjacent to the Cathedral of Notre Dame. From 1580 the hospital’s regulations specified that doctors and surgeons were to visit patients twice a week. During this period the hospital often housed more than 3500 patients at the same time, with up to six patients in a single bed. The hospital was redesigned in the 1700’s in response to the dreadful conditions observed by a commission of expert physicians and reformers. This new design is an early use of the pavilion plan concept.
Health Care in 18th, 19th, and Early 20th Century Europe and North America
Florence Nightingale, the Sanitary Reform Movement, and the Pavilion Plan Concept
“Perhaps the most spectacular overarching medical advance of the 19th century was the conclusive demonstration that certain diseases as well as the infection of surgical wounds, were directly caused by minute living organisms.” Levy, M. ed. The Ideas that Changed the World. Fall River Press and Encyclopedia Britannica, New York, 2010.
The reader is referred to the stories of many scientists and doctors involved in this critical contribution to understanding and eventually treating disease. Louis Pasteur, Robert Koch and Joseph Lister come immediately to mind.
And perhaps no single individual has had as significant effect on hospital design as Florence Nightingale(1820-1910). Her influence is a fascinating story in perseverance, vision, somewhat misguided science, and politics.Born to a rich, upper-class family, Florence had the opportunity to travel to many parts of the world and to make contact with British political leaders, including the Secretary of War, Sidney Herbert. Despite the objections of her mother and family, Florence chose a career in nursing in 1844. She played a major role in crafting the nursing profession into a respected career.
During her early work in support of a cholera epidemic in England she became a supporter of the “sanitarian” philosophy of Sir Edwin Chadwick. One of the pioneers in the concept of public health, Chadwick argued that there was a link between a lack of sanitation (especially in water treatment and supply) and disease. Germ theory was still competing with the “Miasma Theory” as the source of disease at this time. The miasma theory held that bad air and gases were a major cause of disease. If the patient could be kept clean, and if there was good air circulation the probability of recovery was significantly increased. While the Miasma theory was incorrect it was a driving force in improvements in hospital design and layout.
A confluence of events provided Nightingale the opportunity to dramatically demonstrate the sanitarian concept. In 1854 Britain entered into the Crimean war. A base for operations was established in Istanbul. One of the major sites for “caring” for wounded soldiers was a converted military barrack call Scutari Hospital. Conditions were horrible, dirty, and unsanitary. Mortality rates were exceptionally high, exceeding 40% of the patients admitted to the hospital. Among the many problems with the facility, it was discovered that a water line into the hospital passed through the carcass of a dead horse.[i]
The Crimean war was the first major war to see modern communications technology affect public policy. Teletype cables allowed British journalists to report on the terrible conditions at Scutari, placing the ruling government under extreme political pressure. War Secretary Herbert contacted Nightingale to see if she could help. She returned to England a respected and powerful force in public health, nursing, and hospital administration.
Nightingale contributed major design recommendations for a pavilionmodel of hospital design. Again, working on the miasma theory of disease, the pavilion model was designed to maximize air circulation, clean, uncluttered, nursing units, typically connected circulation corridor.
The pavilion model became the dominant architectural plan for major hospitals into the 1920’s. In the United States, Brigham and Women’s hospital in Boston, Johns Hopkins in Baltimore and many other institutions integrated this concept into their plans. The adjacent illustration shows the 1925 plan for the University of Cincinnati Medical Center. This model was executed and utilized up until the mid 1960’s. Over time, the pavilion nursing units design developed dozens of layout variations, including the Y-shape design, the cruciform, circular units, and hubs with interconnected links. Two excellent examples in Great Britain are the Herbert Hospital at Woolwich (1861) and St. Thomas’s Hospital at London (1868). Nightingale was consulted on both designs.
As this architectural form was refined and evolved Architects, Engineers, and writers organized the underlying principles and formalized the criteria for design. Reader is referred to The Architect and the Pavilion Hospital by Jeremy Taylor, Leicester University Press, London, 1997
Mid 20th Century Influences and on to the 21st Century
The high-rise and modern hospital
As with many other building types, the elevator and integration of mechanical heating and ventilation systems led to the era of high rise hospital, particularly in dense urban areas. The general model that emerged was to stack inpatient nursing units on top of a larger base block of space containing diagnostic, treatment, and support services. Fundamentally these building were designed with the nursing tower defining the key structural and circulation system on the lower levels. The requirements of outside windows for inpatient nursing units generated a variety of building shapes including the rectangular nursing wings, Y shaped units, circular and triangular geometries.
Columbia Presbyterian Medical CenterNew York NY by James Gamble Rogers
Prentice Hospital Chicago IL by Bertrand Goldberg
During the late 1940’s and early 1950’s access to healthcare, particularly for the poor, became a political issue, particularly in rural areas of the United States. TheHospital Survey and Construction Act(or theHill–Burton Act) is aU.S. Federal lawpassed in 1946, during the79th United States Congress. It was sponsored bySenator Harold Burtonof Ohio andSenator Lister Hillof Alabama. (Thompson and Goldin) The Act responded to the first ofPresident Truman'sproposals for reforming the nation’s health system (the other was an early version of Medicare) and was designed to provide Federal grants and guaranteed loans to improve the physical plant of the nation’s hospital system. Money was designated to the states to achieve 4.5 beds per 1,000 people. The states allocated the available money to their various municipalities, but the law provided for a rotation mechanism, so that an area that received funding moved to the bottom of the list for further funding.
Facilities that received Hill-Burton funding had to adhere to several requirements:They were not allowed to discriminate based on race, color, national origin, or creed, thoughseparate but equalfacilities in the same area were allowed. The U.S. Supreme Court struck down this segregation in 1963.
Facilities that received funding were also required to provide a ‘reasonable volume’ of free care each year for those residents in the facility’s area who needed care but could not afford to pay. Hospitals wereinitially required to provide uncompensated care for 20 years after receiving funding. The Federal money was also only provided in cases where the state and local municipality were willing and able to match the federal grant or loan, so that the federal portion only accounted for one third of the total construction or renovation cost. (Wikipedia)
This period also saw the emergence of healthcare architecture as a design specialty. The technical requirements, understanding of medical terminology, and integration of building systems favored architects who focused their careers in this area. Experienced architects were also able to create new building solutions and innovations. Among the early leaders in specialization were E. Todd Wheeler, Gordon Freisen, James Souder, Isadore Rosenfield. One of the first specialty committees of the American Institute of Architects was the Committee on Architecture for Health. This group later evolved into the AIA Academy for Architecture for Health, one of the largest and most active components of the AIA.
E. Todd Wheeler, FAIA (1906-1987) was a leading health care architect in the '60's through '70's in the United States, author, partner, and director of the health facilities division, of the firm of Perkins and Will Partnership. Mr. Wheeler authored two major publications on health care planning and design - Hospital Design and Function, and Hospital Modernization and Expansion. Wheeler and other early practitioners pioneered early quantitative analysis of space needs, publishing benchmark area requirements for hospitals based on bed size.
This period also witnessed the emergence of consultants with knowledge and experience in hospital administration, nursing, and other specialties. Alternative construction delivery models, including fast track construction, design-build, and construction management were introduced as approaches that could either shorten construction timelines, reduce costs, or otherwise more effectively manage the construction process.
The hospital as a machine –
The influence of the scientific model of medicine, the success of “systems” thinking in space and the military, the rapid changes in medical technology, and modern design styles created a model for hospital design focused on efficiency, adaptability, and systems. Influence by the concepts of an “interstitial” mechanical floor developed by Louis Kahn and Earl Walls & Associates at the Salk Institute, healthcare architects strove to translate this model into hospital design. One of the early examples of this model was McMaster Medical Center. Designed by Eberhart Zeidlerthis massive, “megahospital” built seven foot interstitial floors between every functional floor, allowing ample space to access and adapt mechanical and plumbing systems as needs of the hospital changed.
This concept was taken to a new level of development by the Veterans Admirationin the late 60’ with the development of the VA building system. Created through a joint venture with Stone, Marraccini, and Pattersonand Ezra Erenkrantz, this approach took the concept of flexibility and long term adaptability to its physical limits by creating vertical zones in the interstitial space for specific mechanical and electrical systems. Long space structures were utilized to increase remodeling opportunities.
Houston DeBakey VA Medical Center
Although it is recognized that the initial construction cost of this model is higher than conventional construction, the theory of the approach is that the life-cycle cost saving associated with easier remodeling would surpass the first dollar costs. Unfortunately there have not been major post-occupancy studies to verify this hypothesis.
Humanizing the hospital experience – the Planetree movement
The era of the late 1960’s and early ‘70’s witnessed many challenges to traditions and established culture in the United States. Healthcare was no exception. One of the most significant examples is the Planetreehealthcare movement. Initiated in 1978 by Angelica Theiriot at Pacific Medical Center (San Francisco), the concept of this approach to patient care recognizes the dignity of the patient, rights to the medical record, and integration of the family into patient care. The Planetree name came from the tree under which Hippocrates taught Greek medical students. The concept of family center care can be seen in an emphasis on patient/family education, open staff work areas design to encourage family interaction, and a kitchen on nursing units where families can prepare meals for patients.
Many of the concepts of Planetree have been integrated into standard nursing unit designs. Family support has been shown to have positive impacts on patients length of stay in hospitals, reduction on pain medication, and safety.
The track record for CONregulation of health care costs has been mixed. Many leaders and politicians argue that the bureaucracy of the process unnecessarily complicated hospital operations. As of June, 2010, thirty-seven states still maintain some form of Certificate of Need regulations. Many of these regulations are weak, with limited controls focused on long term care and other programs that require significant state support.A push toward “free market” approaches to healthcare were advocated in the late ‘80’s and ‘90’s, arguing that the marketplace would create more efficient, safe healthcare. Publications such as Market Driven Health Care, by Regina Herzlinger argued that a “focused factory” approach, emphasizing high-volume specialization, could result in lower costs and high quality. High volume cardiac programs, such as the Cleveland Clinic, and focused cancer care, such as M.D. Anderson, illustrate the power of this strategy.
This period also experienced seen a significant growth in “for profit” or “investor-owned” hospital systems, such as HCA, Tenent, and physician-owned specialty hospitals. In many cases the differentiation between “not for profits” and “for profits” has been strictly accounting. Non-profit hospitals seek to have excess revenue over expenses to provide for capital and other initiatives. In addition to these goals, for-profit corporations seek a return on investment of their stock holders.
The development of specialty surgery, dialysis, orthopedic, and cancer centers are examples of private sector initiatives to take advantage of favorable payment packages from Medicare and other programs. There is significant concern regarding the implications for the traditional hospital, which carries the burden for care of indigent and low reimbursed services. Some not-for-profit systems have sought joint-venture businesses with physicians and for-profit corporation to better position themselves for financial survival.
Potential financial conflicts of interest issues have emerged, particularly when physicians are investors in for-profit facilities. Is a referral to a facility owned by a physician due to medical needs of the patient or financial interest? Federal regulations have been implemented to control when self-referral is legitimate.
The Lean Hospital
The use of planning practices from other industries has resulted in the current interest in the LeanProduction System and process redesign is not new to the health care industry. The current economic picture in the United States has raised awareness of efficiency and quality. The recent move towards financial concerns has resulted in efforts to implement operational improvements. Some of these initiatives have a significant effect on hospital design and the process of design and construction. One management approach gaining popularity is the Lean (production) process.
Lean production (“Lean” term coined in the 1980’s by John Krafcik of International Motor Vehicle Program and later the CEO of Hyundai) uses less of everything to produce high quality results as compared to other production systems such as mass production. The idea of redesigning a business process can be traced to an industrial engineer, H. James Harrington who was working at IBM in the 1980’s. His proposition was to redesign processes to “remove waste” and to “streamline activities” and he published a set of tools to be used in the redesign effort. Engineer, mathematician, and physicist W. Edwards Deming who was a world renown teacher and consultant to Japanese industry served through the Union of Japanese Scientists and Engineers from 1950 through the mid 60’s. Dr. Deming is perhaps best known for this work in Japan, where from 1950 and onward he taught top management and engineering staff methods for management of quality. This teaching dramatically altered the economy of Japan. The Toyota Production System was born in part from Deming’s consulting and teaching.
The lean process stresses elimination of waste and a continuous improvement approach to care. There are numerous examples of waste in healthcare – waiting in the emergency service, underutilization of operating rooms, delays in admissions. Application of this approach in the emergency service, for example, has resulted in major physical reconfigurations of the design and reductions in space requirements.
The short term future of healthcare design in the United States will be driven by policy and care needs:
 See The Hospital: A Social and Architectural History, Thomson, and Goldin< Yale University Press, 1975, page 155
 . (http://www.ncsl.org/issues-research/health/con-certificate-of-need-state-laws.aspx)