Principles: New Paradigms for a New Century

We have been raised to believe in medical miracles. And with good reason. Within the last century, medicine evolved from the relatively ineffectual-and often downright harmful-study and palliation of illness and injury to a system of positive, effective, life-prolonging intervention. That intervention has increasingly emphasized the component of diagnosis, so that the trend has been toward earlier intervention and, most recently, prevention or, as it is more accurately termed, “wellness.” All students of medical technology agree that genetic science and drug therapies will play an increasingly important role in medicine during the current century; this idea poses profound moral questions; it also promises not merely the effective alleviation of much suffering, but its absolute avoidance.

If you ask the proverbial man on the street to list the medical issues that most concern him, you are apt to get various answers. A younger man might mention AIDS, a middle-aged man cancer, an older man Alzheimers-all still incurable diseases-despite frequent reports of medical advances concerning them. A conservative man might worry about the ramifications of genetic cloning, a more liberal one about the privacy of his medical history. However, there is one concern that is almost certain to figure on the list: How will I pay for medical care?

Many, maybe most, people fear the cost of illness almost as much as illness itself. Healthcare costs have persistently exceeded general inflation, and, as many employers find it difficult or impossible to continue providing the level of healthcare insurance American workers have long taken for granted, millions are finding themselves with inadequate insurance or none at all. And almost everyone has felt the bite of recent cost-containment measures by their employers or their insurance companies. Despite almost two decades of talk about reform, the only serious attempt at comprehensive reform ended in a near political disaster for former President Bill Clinton. Everyone still wants access to high-quality healthcare, yet still there is precious little consensus on how to fund it. A poll conducted by the Gallup organization a decade ago detailed a range of confusion over the issue that has hardly changed, although the percentages may have. As reported by Health Care Strategic Management, Gallup identified six types of healthcare consumers (1990).

1. The Young and Skeptical (then, about 15 percent of the population). These well-educated men and women, in their thirties and forties, are unhappy with the healthcare they receive and generally distrust the medical profession. While they support increased government involvement in funding healthcare, they are skeptical about government’s ability to manage major programs.

2. The Self Reliants (15 percent of the adult population). A well-educated, upper-income man in his fifties, the “Self Reliant” believes that government should stay out of most healthcare funding and that the individual is responsible for his own welfare.

3. The Secure and Satisfieds (24 percent of the adult population). Highly educated, financially secure men and women in their mid-forties, this group is generally happy with the way they receive healthcare, but nevertheless supports a federally funded health insurance program.

4. The Passives (13 percent of the adult population). Young men and women with lower levels of education and income, the “Passives” are generally unhappy with the healthcare they receive, support federal health spending, but are unwilling to pay higher taxes for healthcare programs.

5. The Coping but Concerned (18 percent of the adult population). Middle-aged and older working Americans in their fifties and sixties, these people have low incomes and feel they have little control over their lives. Like the “Passives,” they are largely dissatisfied with the healthcare they receive, believe the federal government has a responsibility to take care of its citizens, yet are doubtful about large-scale, federally funded programs.

6. The Struggling Singles (15 percent of the adult population). The typical “Struggling Single” is a single mother in her late thirties who, having difficulty making ends meet, is very concerned about paying for healthcare and depends heavily on government assistance in this area.

Looking at such data, politicians and policy makers struggled to discern an unambiguous mandate, but they hardly succeeded. If anything, what Americans want in way of a healthcare system has become murkier today than it was a decade ago. Two points, however, have emerged clearly and certainly. The first is that, in the face of spiraling costs and the unprofitability, impracticality, even impossibility of insurance fully funding these costs, managed care and related cost-containment programs, which were the “wave of the future” in the 1980s and which dominate the health insurance field today, are here to stay. Despite much grumbling about HMOs among professionals and even the occasional public outrage at the callousness of the hybrid managed-care system that has developed, as it were, in the political vacuum, such programs become increasingly stringent in the controls they apply. The second point is even more basic: A population that was regarded traditionally as a pool of patients and potential patients is now seen as a pool of “healthcare consumers” participating in a “healthcare marketplace.”

Healthcare providers, including those responsible for planning and administrating hospitals and healthcare facilities, are understandably anxious about the growing impact of managed care and cost containment, but it is the startlingly rapid transition from the provider-dominated payment systems of the mid- to late twentieth century to the turn-of-the-century consumer-centered marketplace that is the more profound paradigm shift.

Since Thomas S. Kuhn’s groundbreaking book, The Structure of Scientific Revolutions, many of us have learned to think not in terms of an era’s “Zeitgeist,” but in terms of changing paradigms: models, patterns, sets of assumptions about a field, profession, or society that explain that field, profession, or society to us and thereby guide our thinking and behavior in relation to the field, profession, or society.

In The Social Transformation of American Medicine, Paul Starr traced the accumulation of economic, social, and political power by American physicians and chronicled the evolution of the hospital, which is intimately bound up with the elevation of the physician. Starr outlined three phases in the evolution of the American hospital.

The first, spanning from 1750 to 1850, witnessed the development of two kinds of institutions: “voluntary hospitals,” which were operated by charitable lay boards, though usually affiliated with some Protestant religious body; and public hospitals, operated by municipal or county governments and developed from the almshouses maintained by many colonial communities. The second phase, which began during the mid-nineteenth century and ran to its end, saw the formation of “particularistic” hospitals funded by religious or ethnic institutions. The period also witnessed the growth of specialized hospitals for women and for treating certain diseases. In addition, homeopaths and other members of “medical sects” opened their own specialized hospitals. Finally, from 1890 and into the first three decades of the twentieth century, profit-making hospitals came into operation, funded and run by corporations or by physicians themselves.

This development reflected the emergence of a paradigm shift from a healthcare system controlled by religious, charitable, and governmental authority to a system centered on and controlled by the healthcare providers themselves, chiefly physicians. By the first quarter of the twentieth century, physicians had focused the practice of medicine on the hospital institution, much as the clergy had for centuries focused the practice of religion on the church. Moreover, physicians structured payment systems in such a way that the “doctor-patient” relationship was free from “lay” interference, the healthcare provider setting fees and enjoying unrestricted and sovereign discretion in using the hospital’s resources to resolve his patient’s problem. To be sure, the wealthy could afford to buy more-and often better-medical care than the less fortunate. However, as Starr pointed out, even the elite voluntary and municipal hospitals as well as the most prestigious private hospitals, which were teaching hospitals associated with universities and medical schools, actually brought together the top and bottom strata of society. Physicians needed patients who could afford to pay, but they also needed poorer patients for research and teaching purposes. For some five decades, this provider-centered paradigm not only worked but was accepted uncritically. Like the hospital itself, it had become an “institution” in the social sense. Then, by the middle of the 1980s, apparently in direct response to a faltering economy, reduction in insurance benefits, and sharply rising healthcare costs, this paradigm shifted rapidly from those who provide the care to those who pay for the care.

The shift came with such apparent suddenness that it was perceived as a crisis, not only by financially beleaguered patients (“consumers”), but by healthcare providers and by those who plan and administer hospitals. By the close of the 1980s, within the hospital industry, profit margins sharply declined, beds were empty, “product portfolio” had matured, administration became an entrenched and coagulated bureaucracy, CEOs were hired and fired at a rate outpaced only by the entertainment industry, and, in desperation, management embarked on an epidemic of poorly-thought-out attempts at diversification into other industries-some related to healthcare, many totally unrelated.

In 1985, for example, inpatient hospital use declined by almost 20 percent, while profit margins remained high. Two years later, even in the face of declining inpatient population, hospitals enjoyed revenues 100 percent above 1980 levels. Yet, after another two years, by the end of 1989, the record-setting margins had evaporated, and it was administrator turnover, at 25 to 30 percent annually, that broke all records. Administrators perceived all of this as a crisis and feared for the survival not only of their particular hospital, but of all hospitals. The crisis mentality was only fed by the growing power of managed-care programs in the 1990s. When the insurance companies took increasing control of healthcare decision-making-from dictating when their policy holders could see specialists to which specialists they could see to which treatments they would allow the specialists to prescribe-that frustrated medical professionals who saw the system as breaking down rather than undergoing a paradigm shift.

In the short run, while major regional institutions are doubtless safe and will endure, many other traditional acute-care hospitals have begun closing and will probably continue to close. In the longer term, hospitals of all kinds-those flexible enough to adapt to the paradigm shift by focusing on such services as early diagnosis, wellness, outpatient treatment, and the management of chronic illnesses-are likely to survive, even prosper, albeit as significantly different institutions from what had been the norm in the second half of the twentieth century.

• The Reality of Paradigm Shift

The perception of crisis is the product of an exclusive focus on the short term. Unfortunately, the term “paradigm” itself has become such a buzzword among management consultants that the concept it connotes-the very assumptions by which we structure our reality-may also be confused with the paraphernalia of crisis and quick fix. Analyzing, understanding, adapting to, and, finally, anticipating paradigm shifts are essential to seeing beyond-and getting beyond-immediate crises in order to seize the larger, longer-term opportunities for which a crisis often serves as a messenger.

The transition from a provider-centered to a consumer-centered healthcare system is only one among a number of profound and interrelated paradigm shifts currently active and shaping the emerging social and technological climate in which architects, healthcare and hospital administrators and planners, healthcare providers, and public policy makers must collaborate to create hospital and healthcare facilities with quality, cost effectiveness, and flexibility sufficient to carry them through the twenty-first century.

As architects who design extensively for the healthcare industry, we have been struck by the profound and governing presence of four major paradigm shifts and a welter of less sweeping, but still significant, minor shifts listed below:

• From youth to maturity: Since the beginning of the industrial age, we have preferred to abandon what is old or outdated, whether things or people. Now that paradigm is changing and giving way to maturity, which means neither young nor aged, new nor old. Maturity entails the acquisition of an evolving wisdom that transcends either-or stereotypes.

• From remediation to health: In medicine today, the key terms are wellness, prevention, outpatient service, diagnostic services. Fifteen years ago, hospital stays, high tech, specialist services, and acute care were buzzwords. Contemporary American medicine is undergoing a dramatic shift from remediation (the pure art of healing) to health-an art of well-being and health maintenance. The new paradigm has greatly affected hospital architecture and also figures in the needs of those who use virtually every other type of building as well.

• From specialization to wholeness: More and more, architects are asked to create “womb to tomb” environmental solutions-structures and facilities that serve a multiplicity of users and that are capable of evolving with maturing needs. Twenty-five years ago, we built hospitals; fifteen years ago, the cutting edge was the healthcare campus; now the emerging state-of-the-art thinking centers around such concepts as the “health park,” which is wholly integrated within a community, “medical mall,” or “medical hotel.”

• From reaction to anticipation: It is no longer sufficient for a facilities planner, hospital administrator, healthcare policy maker, or architect to recognize a need and respond to it. Human needs are by their nature dynamic; contemporary technology has accelerated that dynamism. Structures-whether social or physical-designed for human beings must, therefore, emulate that dynamism by embodying the anticipation of evolving needs.

In addition to getting in sync with these major paradigm shifts, hospital planners and designers also need to recognize the following transitions.

• From exclusivity to system: The traditional definition of the “healthcare system” does not define a health care system at all, but, rather, a disease care system. And “system,” by this definition, encompasses only that portion of the population actually and currently receiving professional treatment. The rest of the population is outside the “system.” Therefore, taking the larger view, this traditional definition emphasizes fragmentation rather than a genuine system. The current paradigm shift places the entire population within a healthcare system. At any particular time, any individual may be located along a continuum within a whole system of healthcare. The hospital or healthcare facility must learn to serve those in the community who currently require treatment as well as those healthy individuals who may benefit from wellness programs. Architects will be called upon to plan facilities that provide for extensive community outreach and that overcome the image of the hospital as an isolated fortress surrounded by a cordon sanitaire.

• Related to the above is a shift from a focus on SICKNESS to WELLNESS: Intervention exclusively during illness or injury is fragmented, episodic care. Emerging healthcare delivery systems will focus on wellness and health maintenance. In accommodating this shift, hospitals will undoubtedly become more closely integrated into the community.

• From fragmentation to integration: In the past, integration of medical care meant gathering a panoply of doctors and a warehouse full of equipment under one enormous roof and calling the result a hospital. In fact, in the early Industrial Age, such an arrangement was less fragmented and more efficient than if physicians had labored in total isolation from one another. In the Information Age, however, it is no longer sufficient-and no longer always necessary-to gather personnel and equipment into a single building or complex. The technology now exists for deep integration of treatment among any number of healthcare professionals. Care delivery functions, finance, and administration can be thoroughly integrated, and data can be disseminated communitywide, statewide, nationwide, and internationally. On the simplest level, planning and designing a hospital will involve accommodating information technology. More significantly, this technology provides further incentive for decentralizing healthcare facilities. For example, a physician will be able to transmit data from his office to the hospital rather than compel his patient to visit the hospital in person.

• From hierarchical to functional: Traditional hospitals are organized according to management hierarchies. Like many large corporations, hospitals tend to suffer from bloated layers of management, which mask the fact that, at its most basic and essential, a hospital is a “neighborhood” business centered on a relationship between the doctor and the patient. The shift toward the functional reduces management hierarchies and calls for building designs that are less corporate and more humanly scaled, that are flexible enough to treat a patient’s condition rather than fit a patient into a particular department, and that are generally less monolithic in concept as well as appearance.

• From passive participation to active participation: Along with a healthcare marketplace that was wholly provider-centered was the doctor-patient relationship in which the patient was expected to (in a phrase so common we take it for granted) put himself “in the hands of” the physician, as if he were in a state of perpetual anesthesia. As the market has shifted from the provider to the patient, so the patient expects-and is expected to-take a more active role in his treatment, making more informed choices and collaborating with, rather than submitting to, health professionals. Hospital and health-facility architecture will accommodate this shift by drawing more extensively on retail and hospitality models of design and by including in their designs information-access facilities open to patients.

• From institutional to noninstitutional: This may be the single most visible shift, so far as design is concerned. The architecture of traditional hospitals invokes the overwhelming and oppressive majesty of the institution and is aimed at impressing the individual with his comparative insignificance. The new, noninstitutional paradigm seeks, through design, to empower the individual, not to debilitate him. Architects are turning from the traditional institutional models to retail, hospitality, and residential models of design in order to create friendly, nonthreatening hospital environments.

These are the broadest of the paradigm shifts that place hospital and healthcare facilities design on the cutting edge. From these are the following specific trends.

• From inpatient to ambulatory care.

• From freestanding community hospitals to mega-corporation-owned facilities.

• From urgency care to primary care: Traditionally, patients with urgent (but nonemergency) medical needs entered the hospital emergency department if they had not established a relationship with a “family physician.” Increasingly, ambulatory care centers, conceived along the lines of a retail model, have replaced the hospital emergency room (and even the personal physician) for urgent care. To remain competitive, hospitals are sponsoring primary-care centers distinct from the traditional emergency room.

• From nursing home to subacute center: Long-term-care facilities may be integrated with hospitals and will emphasize rehabilitation over “warehousing” or maintenance. Instead of being consigned to a nursing home, the hospital-based nursing home will care for a patient for shorter periods of time, fostering more extended periods of home care, self care, or semisheltered care.

In general, medicine will see a shift from institutional dependency to self care. Architects will work with administrators and facilities planners to create design strategies that will enable the hospital to participate in and foster this movement toward self care.

• Speaking the Language of Business

In the pages that follow, we will consider strategies for accommodating and anticipating the paradigm shifts just outlined. All of the traditional concerns of the architect still apply, and the architect or facilities planner also needs to be sensitive to the social, economic, and technological issues that impact healthcare today. In the new market-driven healthcare climate, however, all of those involved in planning, designing, and allocating resources for hospitals and healthcare facilities must become fluent in the language of business if they are to be heard.

What is the language of business? Following the old paradigm, it was simply stating matters in terms of dollars and cents. Following the new paradigm, it is the art of expressing oneself in terms of cost effectiveness-a very different thing.

How does one become fluent in the language of business? By making the shift to the new paradigms of business. In the past, hospitals could operate on the assumption that monies were available to cover costs, whereas now the trend is toward cost containment and managed care. Formerly, medical services were provider-driven; now, they are market-driven. The purchasers of healthcare were obliged traditionally to assume all economic risks; now, providers take on more of the risk. In the past, high cost was almost casually equated with high quality; consumers have learned to differentiate between the two and, formally or informally, evaluate the services they choose by applying this equation: Value = Cost + Quality. Along with this comes a questioning of the appropriateness of the cost and quality offered by the healthcare provider because consumers shop for value.

Healthcare providers also look out for value. Investment in technology was formerly based on clinical benefits; technology purchases are now evaluated in terms of cost versus benefit. Concomitant with this, whereas healthcare providers once set no limit on access to technology, they now evaluate its appropriate usage. Providers can no longer assume unlimited pass-through of costs and profits; prices are now subject to the discipline of the marketplace and must be perceived as equivalent to “product value.” However, one item of technology formerly perceived as optional, infotechnology, is now seen as an absolute requirement.

This is what it means to design cost-effective structures, and the new paradigm entails some very difficult choices. In the recent past, healthcare providers worked in a culture of healthcare entitlement. The predominant culture still endorses healthcare for everyone but necessitates rationing of technology. In the recent past, healthcare providers were “mission-oriented.” Today, that mission is to varying degrees defined as delivering value to market. In the past, purchasers of healthcare services focused on episode costs. Today, the trend is toward a focus on the cost of caring for a defined population, and, whereas healthcare providers have been accustomed to emphasizing services and procedures-the hospital was where you went when you were sick-the trend now is promoting, managing, and maintaining the health of the community. Finally, healthcare providers have resisted any policy that questioned the cost of sustaining life. “Life at any cost” was, after all, as old as the Hippocratic Oath. Today, healthcare providers at every level are questioning those costs.

• Architecture and Medicine

Learning the language of business is invaluable for planning and communicating design strategies in the field of healthcare. But, in speaking this language, we must never forget that hospitals are more than businesses. They reach to the very core of society and civilization as expressions and instruments of our deepest humanity and compassion.

The architect’s role in shaping these expressions and instruments is a socially crucial one. Indeed, the practice of medicine and the practice of architecture are more intimately related than may be superficially apparent. When the social reform-minded dramatist Henrik Ibsen wrote The Master Builder in 1892, it was natural for him to choose as his hero-and the ideal of the socially responsible man-an architect. Since ancient times, the vocation of architecture had been seen as nothing less than the vocation of building, shaping, and rebuilding the human world. Beset with the burgeoning urban squalor of the Industrial Revolution at full tilt, no era turned more earnestly to the architect than the age of Ibsen. From the late-nineteenth century to the mid-twentieth, social thinkers looked to the architect for society’s salvation. In a different play, The Enemy of the People, Ibsen found another metaphorical figure to represent the socially responsible man: the physician.

That the playwright should have chosen an architect and a physician to represent essentially the same thing makes perfect sense. At its best, architecture is a profession of wellness-a sister, in fact, to the medical profession. Our firm, Earl Swensson Associates, which for more than thirty-five years has designed hospitals, wellness centers, elderly care facilities, hotels, industrial and office buildings, educational facilities, apartment buildings, retail stores, and correctional facilities, has coined a new term to describe this approach to architecture. Synergenial® Design was created from synergism and geniality to describe a design approach that acknowledges both the synergistic nature of the problem-solving process and the congenial, user-sensitive attributes of a successfully designed solution. Synergenial buildings are functional environments that evoke positive responses from their users on physical, intellectual, and emotional levels.

The synergism comes from combining state-of-the-art technology and sound economics with the information-scientific and functional-at the contemporary architect’s disposal to produce an effective design inspired by the people who are going to use it. The hope is that a design so inspired will appeal to all the human senses all the time, making its attraction subtle, sophisticated, even subconscious-genial rather than critical. However, “Synergeniality” can be evaluated in terms of “the Five Ps”.

People

· The test of synergism. Time management: The management technique for accomplishing a proposed design.

·The test of geniality. Senses: Eliciting desired human responses from all aspects of a proposed design.

Purpose

· The test of synergism. Client/User: Determining the desires of the client and the needs of the users of a design in order to satisfy them.

· The test of geniality. Task performance: Establishing the ergonomic and psychological conditions that optimize a proposed design’s effectiveness.

Price

· The test of synergism. Financing: Identifying all factors affecting the financing of a proposed design, as well as any financial limits, conditions, and time restrictions.

· The test of geniality. Lifetime cost: Anticipating total financial ramifications during the lifetime of a design, from initial investment to future returns.

Place

· The test of synergism. Locale: The accurate report of existing physical and legal conditions that affect a proposed design and the acknowledgment of anticipated changes.

· The test of geniality. Climatic setting: Acknowledging the atmospheric conditions of a design that affect the senses and emotions.

Perspective

· The test of synergism. Technology: Utilizing technical advances to execute a proposed design.

· The test of geniality. Historical/cultural setting: Cultivating the proper appreciation for a design’s cultural context.

If there is any single yardstick to apply in evaluating the buildings discussed in this book, always in the context of the emerging paradigms governing society in general and the healthcare industry in particular, it is the concept of Synergenial Design. This approach grew primarily from thirty-five-plus years of practice rather than from a predisposition to develop a comprehensive, all-encompassing theory; it is no accident that its most intensive development came in connection with our firm’s extensive work in the healthcare field. We witnessed firsthand the shift away from acute-care hospitals. In the early 1980s, our hospital clients asked us to develop a panoply of new types of facilities: outpatient clinics, wellness centers, and medical office buildings with ambulatory surgery capabilities.

As we-and others-studied the changing nature of medical care and the effect it was having on architecture, we began to discover just how much an effect architecture had on medicine. Patients exposed to noise or stuck in windowless rooms required stronger painkillers, became anxious or even delirious more readily, and more often fell into depression. When a patient could gaze out a window for even a few minutes at trees, water, or gardens, his or her blood pressure dropped dramatically. Clearly, there were healthy rooms and unhealthy rooms, and we began to extrapolate from there, cautiously working toward the somewhat dangerous notion of a healthy architecture-one that, like contemporary medicine, seeks to be preventive, to promote health, rather than to be remedial, to “cure” ills already present.

Now, as an aesthetic category, “health” has a long pedigree. The notion of health was basic to Aristotle’s poetics, a fact recognized and exploited by the University of Chicago’s “New School” of literary criticism back in the 1950s. Opponents of the so-called Chicago school found the pronouncing of this or that work of literature or art healthy or unhealthy not merely irresponsible exegesis but intellectually quite dangerous, no doubt hearing in the word the echoes of Nazi aesthetics. The idea of health as a normative value has been so abused that one could easily be leery of applying it-even when appropriate. Yet, undeniably, there are healthy buildings and unhealthy ones, and a responsible and judicious approach to the concept should not be dismissed simply because the term was misused politically in the past.

Nothing would seem more natural than to look to hospitals themselves for examples of healthy architecture, since, by definition, they should be structures intended primarily to promote the good health of their users. Yet, as everyone knows, hospitals have traditionally been distinctly unhealthy environments, places to avoid unless you are so ill that you cannot do so. Not only are many hospitals unhealthy in the strictest sense of the word, they are far too often inhospitable.

So far as existing hospitals are concerned, this is the rule rather than the exception: Sick men and women, accompanied by anxious and worried families, arrive at most hospitals only to be greeted by harsh lights, stark corridors, weird-sounding equipment, acrid and unpleasant smells, and a cold, soulless expanse of marblelike hardness and stainless steel. Not only are patients denied access to medical information, they are stripped of their privacy upon arrival and given no opportunity or space for intimate talks or private grief. Under the acceleration of medical technology, many hospitals became huge machines, built-or, more often, awkwardly retrofitted-to accommodate rapidly changing equipment and ever more bureaucratic staffs. In the name of technology a host of dehumanizing structures were built, and, in the name of sanitation, sterile environments were created.

Far from promoting health, hospitals can actually make sick people more unhealthy. As Wayne Ruga, an organizer of the annual Symposium on Healthcare Design, said: “When a patient’s anxiety increases, the immune system is suppressed, and the body is weakened in its ability to fight disease.” There is actually a phenomenon known as “ICU syndrome,” which occurs when a critically ill patient is subjected twenty-four hours a day to harsh and unvarying fluorescent light, the incessant beep of monitors and thump of respirators, and the disorienting sameness of the stark white or sickly green walls still typical of many intensive care units. The syndrome consists of sleep disturbances, hallucinations, and, on occasion, mild psychosis.

As the paradigms shift, these sick buildings will not only harm those who use them, but will also injure, perhaps fatally, the institutions of which they are the physical expression. They cannot compete in the emerging healthcare marketplace. The new consumer will not tolerate, let alone choose them.

Undeniably, the role of the traditional, acute-care hospital is diminishing. In the language of business, its market share is decreasing. Is this, then, a singularly inopportune time to promote new construction? Hardly. For it is not that the hospital is dying. Rather, it is being redefined in the name of survival as well as service-by physicians, researchers, technologists, politicians, insurance providers, government bureaucrats, and patients. Working with and among all of these people, the architect gives form to the emerging redefinitions. In the hospital project, the architect faces the opportunity and challenge of creating new, exciting, useful, and humane structures-“healthy” buildings.

Also by the authors:
New Directions in Hospital and Healthcare Design