By PAL ANDRAS RUTKAI, MSc Arch, MPS-H
Financial models of the Hungarian and American health care system are very different. This
fundamentally affects many aspects of the healthcare delivery, the infrastructure around the process
and eventually the hospital buildings. Construction costs are about five times higher in the United
States, even if we adjust prices to the local GDP. Many American examples are therefore far from the
current Hungarian reality. However, when we talk about how the infrastructural background of
Hungarian healthcare should look like in the near and distant future, it is worth to keep an open eye
and look around in the world for new ideas and expertise. The sometimes radically different design
and operational solutions should also be examined. US hospital design accomplished many great
buildings and design solutions in the past decade that are well worth to be studied.
I spent the 2014/15 academic year in New York on a Fulbright scholarship, taking part in the healthcare
design program of New York School of Interior Design. After completing my 11 months training I
embarked on a month‐long trip across the United States. The goal of the tour was to gain first‐hand
experience and see how design ideas work in realized buildings. The journey led me to 17 hospitals in
11 different states from coast to coast. I tried to assemble a diverse mix with urban, suburban,
university affiliated, stand alone, ambulatory, and children’s hospitals. In some facilities I could only
have access to a typical medical‐surgical floor and a patient room, but often times I could tour the
whole building from the mechanical areas in the basement to the heliport on top.
It took about three months to arrange the trip. Traveling to a new town or state every other day was a
real challenge, not to mention strict security measures in hospitals. During the preparation I came to
realize that having access to these buildings is like organizing visits to nuclear facilities. Often times,
someone from the senior level of leadership had to be reached in order to have access. The faculty at
New York School of Interior Design and their broad network of healthcare design professionals was an
essential help in this process. In some cases I was shown around by someone from the C‐suite but
usually it was the leader of the facility management team. During the visit I always tried to ask medical
staff how they like the spaces. Perhaps their feedback was the most useful. They told if the envisioned
design solution was working in reality or not.
According to American design guidelines, newly built hospitals have to be built with single patient
rooms .It is possible to stay with multiple patient rooms in case of renovations and in large cities ‐
especially on the coastal areas, where demand is huge ‐ some organizations stick with their double or
triple rooms but the long‐term goal is to achieve private rooms throughout.
Single patient room design has critics and supporters too. Those who disagree point out the excessive
isolation of patients and the increased walking distances of nurses. Supporters however argue with the
radically reduced number of hospital acquired infections and a calmer environment for the patient.
Both are true and there are many new ways to manage this situation. The classic nurse station is
decentralized to create smaller pods around the unit. In many cases it is found outside the room with
visual access to the patient or often it is placed right next to the patient bed. The latter allows
administration ‐ a more and more time‐consuming activity ‐ to be done directly at the patient. Thus,
the doctor or nurse spends more time with the patient, which is a very important factor for both
parties. Equipping a whole unit to this level with the required IT infrastructure is a costly undertaking
but comes with a great leap in efficiency. With the current human resources crises of the healthcare
sector, it might be worth considering.
Single occupancy patient rooms also provide the opportunity to create three well‐defined zones for
the three user groups: patient, medical staff and family. The patient room is at the hearth of the
patient experience. Position of the bed, design of the bathroom or lighting all have a major effect on
the patient weather it is a comfort feature or clinical necessity. Certain built elements or
environmental factors have a proven effect on the patient’s state of mind, pain intensity or the
efficiency of drugs. Considering these key issues in the design process will not only result in more
comfortable buildings but can have a direct contribution to the healing process as well.
Now‐a‐days presence of family members is essential to the healing process. Social support is proven to
have a huge impact on healing. Family also has a vital role in the caregiving process. Decreasing
number of nurses and an aging workforce can only be bridged by active participation of the family.
Aging societies often pair with aging medical workers. Even the US is facing a huge problem when it
comes to the number of active nurses and caregivers. In order to get the family involved space has to
be provided for them. Family zone is an essential part of an American patient room, often times
adjacent to the entry door, out of the way not to disturb caregivers.
Out of the 17 hospitals that I visited, I have chosen 6 to study in depth. Below are a few highlights and
interesting features that could be worth examined or adopted.
The Johns Hopkins Hospital ‐ Sheikh Zayed Tower and C. R. Bloomberg Children’s Center ‐
Baltimore, Maryland
Architect: Perkins + Will
The Johns Hopkins hospital has a worldwide reputation. Together with the Johns Hopkins University, it
is one of the centers of modern American medicine. It was the birthplace of a handful of medical
traditions, techniques and specialties, including the ‘rounds’ or neurosurgery. The new, 600 bed
extension is formed by a 6 level high diagnostic, treatment and service building with two patient
towers on its top. The two towers accommodate the adult and children’s units separately, but using
the shared functions below leads to a great degree of efficiency.
The institution is a real city‐hospital with thousands of people coming here on a daily basis. In modern
healthcare trends, the emphasis is shifting from costly inpatient care to outpatient models, whenever
it is possible. Therefore, traffic and easy access to these facilities is becoming an ever more important
aspect. Development of the Baltimore subway system was also driven by the necessity that the
hospital needed a direct subway link. The new extension building is fully integrated to the internal
circulation system of the existing campus. This is the result of a comprehensive master plan that lays
out the long‐term development of the whole campus area. It also allows for further sustainable and
flexible extensions in the future.
Visitors have to register upon entry and wear a bracelet at all times. Mobile equipment, staff and
patients are wearing radio identification accessories. This enables the hospital to monitor movements
within its premises. The collected data is then used to examine the flow of people and equipment and
to design better logistics and optimal usage of human and medical resources.
The adult tower consists of 350 while the pediatrics tower has 200 beds, all in a single patient room
arrangement, providing space for family members within the room. The treatment area includes 33
operating theatres and separate adult and pediatric emergency departments with a total of 100 bays.
Acoustic planning was a major issue during the design process. Emitted sounds were minimalized by
using mobile devices instead of an overhead paging system. Acoustic comfort is maintained with high
performance absorbing panels placed at key locations.
Most of the heat and energy for the building is produced on site with a CHP cogeneration plant having
a high efficiency by using the excess heat produced during the electricity generation. The 15MW
system provides for backup energy too. The gas run plant can switch to diesel in case of a shortage.
Center for Advanced Medicine ‐ Lake Success, New York state
architect: EwingCole
Monter Cancer Center is located in a former gyroscope factory build in the 1940’s. Creative reuse of
the building means the existing long span structures are adopted and provide ample flexibility. Using
the enormous complex for healthcare purposes may sound extraordinary at first. However the
exceptional building highlights that almost any kind of building can be utilized if planning and
execution standards are as high as in Lake Success’s case.
To achieve the same results, interior design has to meet this level as well. From the various design
solutions, indoor plants have to be highlighted in the first place since they contribute a lot to
humanizing the spaces. Plants in healthcare settings are generally not advised, because damp soil can
house a range of different bacteria. This is especially important in oncology facilities where patients
are immunosuppressed due to chemotherapy and are at greater risk. To avoid any chance of
contamination a special soil and separation layer was used. Irrigation is automated and tubes are
running under the separation layer.
West Shore Hospital, Pinnacle Health System ‐ Harrisburg, Pennsylvania
architect: Stantec
West Shore Hospital was built to reduce patient load of the main campus in the center of Harrisburg
and goes against the usual centralizing trends in healthcare.
The 110 bed facility occupies 17.000m2. This means 150 m2/bed space usage which is due to the
single bed arrangement and the emergency department. Operating at full capacity, 500 staff are
needed to run the hospital.
Each of the rooms is equipped with digital boards that help the medical team and the patient to follow
the available medical information. Using the computerized system, administration happens right next
to the patient allowing for more communication between the doctor and the patient.
Prior to the actual programming and architectural design, a comprehensive demographic and mortality
study was commissioned. In addition, local residents were surveyed about their needs and priorities.
The gathered information was than summarized to lay out short and long‐term goals. Design and
construction took only two years to complete mostly due to systematic design and high level of
prefabrication. Future flexibility was a key factor. All levels of the hospital building can be extended
without modifying the actual functional program weather it is a patient unit, operating suite or the
emergency department.
Palomar Medical Center‐ Escondido, California
architect: CO Architects
The ever‐changing needs and requirements of healthcare spaces are hard to meet with the current
flexibility buildings can provide. Especially when it comes to the rapid change in medicine itself. New
tools, techniques and specialties emerge on a daily basis. However the healing infrastructure can be
prepared to support changes with minimalized intervention. Palomar Medical Center was built with
flexibility and future proof solutions in mind.
Diagnostic and treatment areas are situated next to the patient tower with a separate structural
layout. This common solution was taken to the next level with a special ‐ almost 30 meters long ‐
bridge like structure that allows for maximum flexibility underneath. The 2000 m2 area can be
rearranged later without any structural constraints. Vertical circulation cores, patient and utility
elevators and staircases were placed on the perimeter to provide further flexibility.
Atop the operating theatres is a unique landscape enhancing views from patient rooms. Putting the
two functions together, even if there is a mechanical level over the ORs seems to be a risky move. The
California climate means lower exposure for green roofs than in Hungary, but excessive summer heat
can be a real challenge. Water lining problems or leaks can be quickly localized using a 10 by 10 cm
grid of detectors, making this a safe and easy to maintain solution.
University of Colorado Anschutz Children’s Hospital, Denver, Colorado
architect: Zimmer, Gunsel and Frasca Architects
Denver is not only the capital and most populous city of Colorado, but also one of the centers of the
western mountain region. It’s catchment region spans hundreds of kilometers. Serving such a huge
population, the institution has to be ready to treat a wide range of patients and needs from specialty
clinics to a highest level trauma center. The complex function led to a complex design solution.
The three patient towers are located on top of a 4 story high building mass that contains the rest of
the functions. One of the towers can be accessed separately through its own lobby space, but staff and
service roots are connected to all necessary parts of the main building.
A grand scale 4 story high atrium helps to create a sense of space. It guides patients and visitors by
enhancing way‐finding. Access to the main cafeteria is through this atrium space on the ground floor.
It attracts not only staff and visitors, but also people from nearby buildings of the campus. In order to
deal with high demand, architects used design methods typically used on cruise liners. Another great
feature is the in‐house radio studio that connects to the lobby with a huge glazed wall. This is a place
where children staying in the hospital can participate in making radio programs that are aired in the
hospital. Right next to the studio is the volunteer center. The culture of devoting time to voluntarily
help enhance children’s hospital stay is common in the United States. Whether it is the local basketball
team visiting the hospital, a volunteer bringing a therapy dog or a painting session for hospitalized
children there is ample space for events, offices or service areas. The building was subject to a range of
post‐occupancy evaluations that all back up previous studies highlighting the beneficial effects of
natural light or acoustic design on the patient‐caregiver relationship. The building showcases
hospitality style interior finishes and solutions while meeting LEED (Leadership in Energy and
Environmental Design) standards.
Rush University Medical Center ‐Chicago, Illinois
architect: Perkins + Will
Medical campuses located in big cities often face the problem of insufficient space to grow and huge
environmental burden from traffic and pollution. Rush University faced the same difficulties when it
needed to expand its spaces. The relatively small available plot and the adjacent highway and subway
line created a double challenge.
The lower five floors of the realized building contain the functions less sensitive to environmental load,
functions that do not necessarily need windows and those areas that have to be near the ground.
Patient units are located on the top of the diagnostic and treatment zones lifting them out of the more
polluted and noise exposed environment. Rooms are mechanically ventilated and windows have
special sound insulation. With this arrangement the hospital can provide the necessary calm
environment and benefit from the urban infrastructure and accessibility.
Double loaded corridors or using two corridors with a support area between those two are common
and well working practices of hospital design. This system was reconsidered during the design of Rush
Medical. The unusual arrangement has two corridors at the center of the building that taper towards
the end of the wings. The unique design creates service spaces only near the center of the building
leading to a range of operational benefits. It also helps to separate patient, visitor and service routes, a
basic need in modern healthcare environments. The tapering wings also create a unique shape that is
a great contribution to the Chicago skyline.