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A new architecture for health care

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Title:
A new architecture for health care future models for health care design
Creator:
McKahan, Donald C
Language:
English
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2 volumes : illustrations, color photograph ; 28 cm

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Subjects / Keywords:
Health facilities -- Planning ( lcsh )
Health facilities -- Designs and plans ( lcsh )
Health facilities ( fast )
Health facilities -- Planning ( fast )
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Architectural drawings. ( fast )
Academic theses. ( lcgft )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )
Architectural drawings ( fast )
Academic theses ( lcgft )

Notes

Bibliography:
Includes bibliographical references.
General Note:
Vol. 2 entitled: Programming documents Castle Rock Health Center.
General Note:
Submitted in partial fulfillment of the requirements for the degree, Master of Architecture, College of Architecture and Planning.
Statement of Responsibility:
by Donald C. McKahan.

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Source Institution:
University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
19958203 ( OCLC )
ocm19958203
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LD1190.A72 1989 .M3147 ( lcc )

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Full Text
A NEW ARCHITECTURE FOR HEALTH CARE:
FUTURE MODELS FOR HEALTH CARE DESIGN
THESIS DOCUMENT
BY
Donald C. McKahan School of Architecture and Planning University of Colorado at Denver
May 11, 1989


A NEW ARCHITECTURE FOR HEALTH CARE:
FUTURE MODELS FOR HEALTH CARE DESIGN
BY
DONALD C. MCKAHAN
A Thesis submitted to the faculty of The School of Architecture and Planning University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Architecture


This thesis for the Master of Architecure degree by
Donald C. McKahan
has been approved by the
Architecture Program
School of Architecture and Planning
Frances M. Downing, Associate Professor of Architecture, UCD
Faculty Advisor
u
M. Gordon Brown, Associate Professor of Architecture, UCD
Faculty Advisor
Leland R. Kaiser, Ph.D., Associate Professor,
Health Services Administration, Graduate School of Business, UCD
Professional Advisor


Acknowledgements:
I would like to thank my Thesis Advisors for their interest and guidance in this project, as well as my office colleagues and professional contacts in health care for their valued insight and ideas. Finally, I must thank my family for providing me with the love, the support, and the dining room table for these past two years of thesis research.


TABLE OF CONTENTS
Introduction 1
o Problem Context 1
o Problem Statement 4
o Problem Discussion 6
A New Image for Health Care 9
o Imagery and Meaning in the Castle Rock Health Center 12
o Designed Images of the Castle Rock Health Center 14
Health Care's System of Exchange 22
o A System of Rewards 22
o Retail Design Concepts for Health Care 25
o New Spatial Structures for Health Care 35
Prescriptive Environments for Health Care 41
o Design of the Healing Environment 44
o Contact and the Context of Healing 46
Conclusion 50
Appendix: Program Synopsis and CRHC Graphics 51
Graphic and Photo Acknowledgements 56
References
57


INTRODUCTION
PROBLEM CONTEXT
"If you have your health, you have everything." Over the past decade the American culture has become absorbed in the concepts of personal health and wellness. Health clubs preach the doctrines of exercise and fitness. Americans attend health fairs, watch health shows on television and go to health shops to get the latest health-related best selling books. The media is saturated with the latest news stories on organ transplants, the AIDS epidemic, and medical technology.1 At almost 12% of our gross national product, no other nation in the world invests as much money in its health care system as the United States. Health care is now our third largest industry. Americans are interested in the length of their life and in many ways, believe health is now the most important indicator of their quality of life.
This medicalization of our culture is built upon the dynamic and sometimes unstable evolution of America's new health care systems. The U.S. system of health care is currently undergoing an unprecedented rate of change and upheaval. The historic evolution of medicine has now become a revolution in health care.


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Economic Changes Include:
o DRG's (Diagnosis Related Groups) and the new financial controls of prospective payment;
o Deregulation and increased competition between health care providers; o Increased emphasis on outpatient care; o A wave of patient consumerism in health care; and
o Mergers, buy-outs, and closure of many community hospitals.2
Social Changes Include:
o The rise of the patient/consumer in the hierarchy of health care;
o Medicine's loss of power and control within its own market place; and
o The aging of America. One of eight Americans will be over 65 by the year
2000.
Technical Changes Include:
o The continued evolution of scientific medicine; and o An increased interest in holistic, high-touch medicine.
Experts can now envision a wide variety of future scenarios for U.S. health care. New methods for funding health care may create a multi-tiered, public and private system of hospitals; a system of self-funded medical I.R.A.'s; and the potential of rationing the quality or quantity of health care services. Futurists predict both high-tech centers of excellence and high-touch, holistic medical care. Hospitals may be decentralized into medical malls, outpatient facilities, and home care medical units. A new entrepreneurial spirit may produce joint ventures between hospitals and medical research corporations (Coile, 1986 and Kaiser, 1986). While none of these scenarios will be true in total, they are probably all true in part. The study of health care's many predicted futures reveals three recurring "megatrends" of medicine:


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1. A major change is occurring in the hierarchy and relationship between patients and health care providers. With more providers pursuing fewer patients, the polarity or attraction between these groups has been reversed. The monopoly of power and control once exclusive to medical care organizations is now shifting to the hands of patients and the groups that represent them. "So long as demand for health care services exceeded the available supply, consumers were unable to express their preference. The combination of excess supply and deregulation has made health care providers face much the same market base allocation of resources that other consumer oriented industries have learned to anticipate" (Philbin, 1988).
The health care industry must now respond to the market they once controlled. The needs and wants of the medical consumer now take precedence over that of the medical care organization.
2. The U.S. health care system has created a distinct medical market place. More of this nation's health care cost is being shifted from government and public insurance programs to private paying patient groups. Medicine's historic system of exchange is now fueled by a system of financial rewards.3 The new finance based health care model looks to the concept of product line management and the retailing of health care services. The new medical market place now requires health care facilities that are more accessible, attractive, familiar and flexible. "Major industries, such as health care, airlines, and specialty retailing, are following the leads of jeans and cosmetics manufacturers, using design as a means of appealing to consumers" (Friedrichs, 1988). The medicalization of America has created the commercialization of health care.
3. A new dual philosophy in medical care has created both a high-tech and high-touch approach to healing. Caring for the patient's body and mind


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requires a holistic integration of medical technology and personal touches to balance the physical and mental aspects of the total healing process.
Throughout the remainder of this thesis document, these new socio-economic trends of medicine will be explored as the basis of a new architecture for health.
As a means to demonstrate these new trends and their resultant design consequence, this paper outlines the development of a health care center for the year 2000. The design program for the Castle Rock Health Center (CRHC) is summarized in the Appendix of this paper. For a more complete description of the CRHC design context, see "Programming Documents, Castle Rock Health Center" (McKahan, 1988).
PROBLEM STATEMENT
Over the past decade health care architects have attempted to distill and understand these new trends in medicine. New patterns and paradigms are beginning to emerge within the health care industry, but there remains a great deal of confusion and indecision as to architecture's direction in the future of medicine. Hospital architects have attempted to become future oriented, transitioning their thinking from three dimensional space to the fourth dimension of time.
What are the future trends of health care and which trends will hold the highest priority for medical architecture? What principles and theories of design will support the new market place and trends of health care? Can these design principles create an effective new architecture for health care?
My graduate thesis project attempts to resolve some of this uncertainty and propose new directions for the future of health care architecture. My process for developing this thesis problem has been:


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1. To identify the forecasts and trend lines that will have a major impact on the future of health care design;
2. To distill from these future forecasts a scenario for a health care center of the future;
3. To translate that scenario into a series of concepts for future health care design; and
4. To demonstrate these proposed concepts in the architectural design of a new community health care campus for the year 2000.
My inquiries into the future of health care have involved the following: o Review of future forecasting methodologies; o Readings and interviews with experts and forecasters in the health care industry;
o Meetings and seminars with the AIA Committee on Architecture for Health;
o Studies with members of my thesis committee; and
o Site visits and investigations of future oriented health facilities throughout the country.
I hope this thesis problem can assist the profession of architecture by providing an evolutionary view to the next horizon of health care design. With the rapid rate of change in health care over the last decade, architects have been forced to play a game of "catch up." I believe health care architects must progress from their current reactive position, to a design philosophy that takes a proactive role in the future of health care. Architecture can do more than simply reflect the new medical marketplace, it can help create and design health care's future. The goal of this thesis research is to direct, assist, and enlighten the design professions toward a new view of architecture for health.


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PROBLEM DISCUSSION
There is a strong physical and philosophical linkage between the professions of architecture and medicine. They are both a science and an art. The science of building and the art of healing attempt to meet the social needs of mankind by understanding and responding to the physical needs of humans. The physical relationship between medicine and architecture is symbiotic. As medicine provides profess^nal challenge and financial rewards to architecture, it receives in return functional structures and the physical image of the health care industry. The philosophical linkage between medicine and architecture involves a common language, structure and set of values.4 This symbiotic, philosophical relationship is clearly evidenced in the period between 1910 and 1980 with the attraction of modern medicine to modern architecture.
o Both modern architecture and medicine developed a more scientific and systematic approach to their individual disciplines, o Both modern architecture and medicine used new technology as a solution to old problems.
o Both modern architecture and medicine developed a rational,
efficient, and mechanistic philosophy to their individual disciplines.
Conclusion
This physical and philosophical relationship between medicine and architecture will continue to evolve, creating new principles for the future of health care design.
The three medical "megatrends" can be translated into three architectural principles which respond to and support these new philosophies of health care.
1. The changing relationship between patients and providers will also change the physical image of hospitals and health care facilities. The designed image of modern medicine was one of power, technology and the


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"authority to heal" (Starr, 1982). The new patient oriented market place will require that the hospital's physical image match its mission of healing. The designed image of health care facilities will change from that of authority and technology to a more humanistic architectural image of caring, wellness and health.
2. Hospitals are no longer just the "doctor's workshop." They are now the central market place in health care's process of exchange. The architectural evolution of health care will create hospitals that can adopt and adapt the successful market oriented design concepts of retail centers.
3. The integration of high-tech and high-touch healing brings a new holistic philosophy to the future of medical care. Treatment programs that involve the whole person, body and mind, provide new opportunities to involve architecture in the total healing process. A patient's psychological response to his physical surroundings will involve architectural design in the holistic paradigm of creating "prescriptive environments" for healing.
The remainder of this document expands upon these concepts of public image, the place of exchange, and environments for healing. The paper will outline the origins and evolution of these concepts as well as their potential role in establishing the foundation of a new architecture for health care.


CHAPTER NOTES
1. The new public focus on health care has resulted in an increased awareness and interest in medical architecture. Architectural journals now commonly feature articles on health care facilities. The largest subcommittee of the American Institute of Architects is the Committee on Architecture For Health; both Interiors magazine and Modern Health Care magazine have instituted yearly awards programs for outstanding design in health care architecture.
2. Eighty-one U.S. community hospitals were closed in 1988. This is the highest rate of hospital closure since the depression of the early 1930's.
3. The increased financial rewards of health care have promoted the growth of for-profit hospitals in the U.S. This corporatization of medicine has continued; 35% of U.S. hospitals were owned by for-profit chains in 1988 (Stoline and Weiner, 1988).
4. The common language, structure and values shared by medicine and architectural design are detailed in the document "From Hospice to Hospital," (McKahan, 1988).


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A NEW IMAGE FOR HEALTH CARE
Imagine a tribe of people who created a specific place in their culture for the healing of their family members, birth of their children, and death of their elders. We would expect this place to be considered as sacred ground, a place charged with meaning and spiritual energy, rich with images for that culture. While all these events occur in the modern hospital, little of the meaning and almost :ione of the imagery exists with it.
The changing relationship between patients and providers will change the public image of hospitals and health care facilities. As health care architects create new environments for healing, there will evolve a new use of design imagery, transforming the modern hospital into a special place charged with the meaning of health and life.
All physical forms, and particularly architectural forms, have the potential to evoke images. As a design tool, imagery is a mnemonic device, recalling the feelings, spirit and meaning associated with built form. With the use of design imagery the "new hospital" can regain a recognizable public or personal image, a "sense of place", and a significant meaning within our culture. To understand the role of imagery in health care it is important to review some of the historical relationships that have existed between man, medicine, and facilities for healing.
The early Christian infirmaries were the transition point between life and death, earth and heaven. They were places charged with spiritual meaning and their architecture reinforced this meaning through a variety of symbols and design imagery. The infirmaries had soaring vaulted ceilings flooded with a celestial light from stained glass windows high above the patients' beds. Each infirmary had a chapel space that was elevated above the main floor, expressing the difference between heaven and earth through architectural design. The Christian infirmaries gave meaning to illness as a transition or bridge to heaven. The rich use of both


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secular and sacred imagery gave spiritual meaning to the process of sickness and healing.
In a similar way the baroque pavilion style hospital of the 1600's reflected an image of a more humanistic era of patient care and treatment. The image portrayed by the pavilion hospital symbolized a new compassion in the social relationship between men.1 The evolution of this hospital pavilion design expresses meaning through the new cultural values it represented.
Just as the ancient shamans and medicine men used imagery to reinforce their authority to heal, our modern "high-tech" shamans (physicians) use their scientific image to reinforce their power and authority for healing. Modern medicine is associated with a clean, efficient and technological image created in the modern hospital. The new architecture of the Bauhaus was based on the design philosophy of "starting from zero." This precept of Modernism has interrupted any historic continuity in the architectural design of hospitals.
Modernism has created a generation of hospitals which have no architectural origin or historic meaning for health.


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THE MODERN HOSPITAL - "STARTING FROM ZERO."
The new relationship between patients and health care providers will create a new message and meaning for health care facilities. Changing the control and hierarchy of the health care market place will change the image and message found in the architectural design of hospitals. Hospitals will no longer portray an image of the "doctor's workshop."
"Those who rejoiced in the advances of technology also witness a frightening coldness toward the human spirit: the best money can buy, the most cost efficient, often describe assembly lines and warehouses but not health care centers" (Bengtsson, 1985). While modern medicine transformed the hospital into an arsenal of technology and a model of efficiency, the "new hospital" will speak to more than simply the functional needs of scientific medicine. I believe the modern hospital's architectural image of authority, power, and control will give way to a new image and meaning for the patient/consumer. The meaning and mission of health care is not authority, power and technology. The hospital's primary mission is health and the hospital's physical image should reflect that mission.
Re-prioritizing the architectural images and meaning of medicine can provide hospitals with a new message of caring, wellness, and health. With this new image and the restoration of its traditional mission in health, hospitals can provide their patients with new meanings in the process of healing: o Respect for the quality and potential of human life;
o Awareness of our life's cycle through birth, health, sickness, and death; and
o Meaning through a process of self discovery in healing and human potentiation.


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IMAGERY AND MEANING IN THE CASTLE ROCK HEALTH CENTER
To respond to the new hierarchy of patient oriented health care, the architectural design of the Castle Rock Health Center (CRHC) is centered on the themes of the human life cycle:2
o The life cycle is an unending process of rebirth of the life/spirit;
o The life cycle has a cosmological link to nature and the universe; and
o The life cycle is a story of passage and a process of self discovery.
MIDDLE AGE
ADOLESCENCE
MATURITY
The remainder of this chapter describes principles for using this design imagery as a tool to instill new meanings and messages into health care facilities of the future. Descriptions and examples from the CRHC design problem will demonstrate these principles of design imagery.
Public Image of the Castle Rock Health Center
The modern, market-oriented hospital uses architectural design to communicate a specific public image, personality, and mission to its community of users. Research oriented hospital systems create their "state of the art" image through "high-tech" architectural design. "High-touch" personal service hospitals use low scale residential designs, while large powerful hospital systems build soaring patient towers to instill confidence and authority in their hospital's healing image. This variety of designed public images plays a significant role in attracting a specific market group to any hospital or health care system.


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IT SHOULD BE IMPRESSIVE ENOUGH TO INSPIRE CONFIDENCE AND AWE-BUT NOT SO ORNATE THAT PEOPLE WILL LAUGH UPROARIOUSLY WHEN YOU SAY 'MONPROFIT HOSPITAL.'
AN IMAGE PROBLEM
Health Care and a "Sense of Place"
In the future, medical facilities will attempt to establish a "sense of place" within the health care community. As competition in the medical market increases, instilling a sense of attachment and community loyalty will be a major focus of any hospital's design image. The goal of this imagery is to give hospitals a special meaning and place in the life of its patients.
Creating hospitals that have a "sense of place" requires matching a facility's mission to its designed image. Many hospitals hold little significance and are faceless and placeless institutions within their communities. Often times this is due to a mismatch between the architecturally designed message or image of a facility and the goals or mission that the hospital hopes to promote.
Hospitals cannot successfully promote a mission of caring and wellness in a facility that portrays an image that is impersonal and cold. "The very size of modern hospitals, their increasing bureaucratic organization, and the impersonal, technologically sophisticated treatments they have developed, have contributed a dehumanizing element to hospital care" (Rosenberg, 1987). The hospital's mission


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and design image are often in conflict. These mixed messages undermine the hospital's attempt to develop an attachment or "sense of place" within their community of users.
DESIGNED IMAGES OF THE CASTLE ROCK HEALTH CENTER
Health care systems of the future may de-centralize the traditional hospital megastructure into * variety of distinct health care functions and facilities. The CRHC campus provides individual architectural images in separate facilities for birthing, wellness, self-care, medical offices, and hospice programs. As satellites of the outpatient/hospital facility, each building can establish a distinct image appropriate to the care and treatment of its patients. Matching the appropriate meaning and design image to the significant events of birth, healing, and death can instill within a building a "sense of place" for its mission in health care.
The Holistic Image
The architectural design of the CRHC will reflect the wide variety of high-tech and high-touch health care services and treatments found in the year 2000. Campus buildings are a mix of architectural styles from low scale residential to high-tech and high-rise. By juxtaposing these diverse architectural elements, the CRHC design captures the eclectic "fire and ice" philosophy of modern holistic medicine.
WELLNESS CENTER


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The CRHC design attempts to maintain medicine's public trust and "authority to heal" without creating an authoritarian public image. The success of any health care system depends on the confidence and credibility promoted in its physical image. This design projects an architectural image that is professional, but not powerful or intimidating.
Historic Imagery
The creation of a new public image for health care may involve the revival of specific, historic architectural designs. Using archaic or archetypal remnants, designers can recreate historic images recalling a place, time, or experience in our conscience or subconscious mind. The patterns and archetypes of the past can recapture historic images and meanings for hospitals of the future.
"Art, ornament, and symbolism have been essential to architecture because they heighten its meaning, make it clear, and give it greater resonance" (Jencks, 1984). The CRHC design borrows from post-modernism by using processional entry ways, large cathedral-like atrium spaces, and murals and art work which describe the historic evolution of modern medicine.
This design attempts to recapture some of the uplifting spiritual images found in the original Christian infirmaries. Using the literal designs of the past can provide a new source of imagery for hospitals of the future. In addition, a well-spring of meaningful ideas may be contained in other, more fundamental design symbols.


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The Imagery of Symbols
"Because there are innumerable things beyond the range of human understanding, we constantly use symbolic terms to represent concepts that we cannot define or fully comprehend" Oung, 1964). Symbolic forms have historically been used to represent and communicate spiritualcultural, and scientific ideas. It is possible to use symbolic form in collective cultural images to transmit messages of health and healing. "We can also see that the arrangement of archetypal symbols follows a pattern of wholeness in the individual, and an appropriate understanding of these symbols can have a healing effect"
(Von Franz, in Jung, 1964).
Geometric Forms. Many of the CRHC plan forms are based on the geometry of the circle. The historic symbol of the circle represents the totality of the life cycle and the wholeness or unity of any living system. The concentric rings of roadways and landscaping in the CRHC radiate from major entry points, unifying the campus plan. The site plan's half circle is symbolic of the sky over earth, describing a cosmological link between the life cycle and the universe. From the earliest spiritual concepts to those of modern physics, the circle reflects both the atomistic and cosmologic image of the universe.
CIRCULAR PLAN FORMS OF THE CRHC


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Natural Forms. Historically the process of healing has involved a variety of natural elements and forms. This important environmental connection can be maintained in a design using the patterns of water and the symbolic geometry of trees and mountains.
The CRHC design uses water and water features in three symbolic ways:
1. To reflect the human life spirit embodied in the spirit of water;
2. As an image of the cleansing and healing aspects of water; and
3. To represent the various passages and transition points in the life cycle.
The life spirit of these water features begins with a large fountain outside
the birthing facility of the CRHC. The water passes through many transformations, changing its mood and spirit in fountains, waterfalls, streams and ponds. These water features and streams wind their way through the CRHC campus and return to the earth as irrigation for a landscaped park outside the hospice facility. This cycle of water symbolizes passages in the life cycle from birth, through healing, to death. The water recycles and replenishes the earth in a process of rebirth.


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Mountains and Tree Forms. The CRHC captures images of sacred sites and the healing mountains in the terraced land forms of the outpatient/hospital building. This hospital building mirrors the recognizable geographic forms of the Castle Rock.
Tree forms and the symbolic tree of life have a recognizable traditional meaning in the process of healing. The deciduous tree symbolizes the annual rebirth of foliage and the rebirth of life. The architectural forms of the CRHC capture these images of the tree of life in the design of arcades, trellises, building forms, and indoor plantscaping. "Buildings perform their highest function when they relate to human life within, and natural efflorescence without; and develop and maintain the harmony of a true cord between them" (F. L. Wright, in Bengtsson, 1985).
TREES AND TRELLIS / ARCADE


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Images of the Life Cycle: The Themes of Passage and Transition
The story of the human life cycle is a story of passage and transition.
Human development and passage from birth through adolescence, adulthood, maturity, death and rebirth are integrated with the process of life and healing. The holistic message and meaning of the life cycle theme is expressed in many of the design concepts of the CRHC. Each building design captures images of these ages in our life, while the pedestrian pathways reflect the transitions and passages between these stages of the life cycle.
Circulation Systems and Passageways. The pedestrian circulation systems and elevated bridge system both physically and symbolically connect the buildings and life ages in the CRHC campus. Movement between these buildings is designed as a physical and psychological experience of passage and transition. The architectural and landscape designs mark these passage points with a variety of changes in light, sound, texture, views, and spatial arrangement. The journey and experience of life's passage is portrayed in the physical and symbolic images of the CRHC architectural design and patterns of movement.
CRHC BRIDGE SYSTEM


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Building Images of the Castle Rock Health Center. The decentralized site plan of the CRHC allows each building to express an individual image and age within the human life cycle:
Birthing Center (Birth) Creation, Beginnings, Bonding,
Celebration
Outpatient Center (Youth) Energy, Growth, Exploration,
Playfulness
Wellness Pavilion (Young Adult) Learning, Changing, Independence,
Uncertainty
Self-Care (Middle Age) Support, Family Caring,
Focus
Hospital (Maturity) Experience, Confidence, Stability,
Openness
Hospice (Death/Rebirth) Reflection, Escape, Transition,
Peace
(REFERENCE APPENDIX OF THIS DOCUMENT FOR DRAWINGS OF EACH CRHC BUILDING)
As an image of health, hospitals of the future have a mission to make the life cycle of human existence meaningful. The passages of birth, sickness, healing, and death are linked to an essential discovery of self. "We find that as we recover our health, we are discovering ourself1 (Priest, 1983). The use of imagery in health care design may allow us to understand our physical frailties, emotional strengths, and personal potential. In doing this, health care architects can use imagery to instill the "new hospital" with the existential meanings of understanding, healing, and life.


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CHAPTER NOTES
1. This evolution in architectural style was promoted and funded by the European monarchy who modeled these new hospitals on their pavilion styled country homes.
2. The Castle Rock Health Center is a medical facility of the year 2000. The complete programmatic description of the CRHC design can be found in the "Programming Notes for the Castle Rock Health Center" (McKahan, 1988).


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HEALTH CARPS SYSTEM OF EXCHANGE
Hospitals, like hermit crabs, have historically adapted the architectural shells of other building types. The evolution of the hospital archetype mirrors the evolution of medicine and its relationship to social structure. "The development of medical care, like other institutions, takes place within larger fields of power and social structure" (Starr, 1982). From the spiritual culture of the early healing temples to the mechanistic, scientific philosophy of in the modern hospital, architectural design has supported the functional, intellectual, and spiritual needs of medical care.
A SYSTEM OF REWARDS
Any market place operates on a system of exchange and health care is no different. The term "medical market place" has appeared only recently, but the concept of a health care market is not a new one. Throughout history, the knowledge to treat illness and heal the sick has been exchanged for a variety of spiritual, personal/social or financial rewards.
Spiritual Rewards
The early Christian concept of receiving spiritual grace in return for sheltering and healing the sick was fundamental in the establishment of church hospitals. Christian stewardship under the moral model of "the good Samaritan," was linked in the gothic abbeys and church infirmaries of the Middle Ages. The architectural design of these church/hospitals was believed to improve both the patient's physical health and spiritual condition.
(4) <4>
THE DEVIL AND DISEASE INFIRMARY OF ST. GALL CIRCA 700


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Personal/Social Rewards
The arrival of modern, scientific medicine in the mid 1800's broke the linkage between spiritual and physical health. Health care began using the popularity of scientific medicine to convert the spiritual exchange model to a system of personal and social rewards. Medical organizations used the new pavilion style hospitals of the 1800's, and eventually the modern high-rise hospital of the 1900's, as a means to change the status and professional position of the medical care organization. With the rise of clinical research and physician training, many pavilion style hospitals were transformed into the archetype of an educational campus. These large pavilion hospitals supported health care's process of exchange with a wide variety of personal and professional rewards. "Physicians were paid in prestige and clinical access; trustees in deference and opportunity for social accomplishment; nurses and patients were compensated with creature comforts: food, heat, and a place to sleep. . . Few dollars changed hands but the system worked in its limited way for those who participated in it" (Rosenberg, 1987). The educational campus plans of the pavilion hospitals provided the growing field of medicine with a facility suited to the production and reproduction of medical knowledge.


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Financial Rewards
The new scientific hospital was successful in providing medicine with additional sources of medical knowledge, authority and prestige; however, it operated on more than just personal rewards. By the early 1900's health care's process of exchange required greater amounts of financial fuel. The medical care organizations of the early twentieth century quickly learned how to convert their new found power and authority into a system of substantial financial gains. The use of medical technology and efficient high-rise health care changed hospitals into the modern "doctor's workshop" (Starr, 1982). "In much the same way that manufacturing technology shaped the factories and shops necessary to its efficient use, medical technology influenced the development of the modern hospital" (Ackerknecht, 1982).
In these three historic examples we can see a direct relationship between health care's system of exchange and the creation of new hospital designs. "For almost 2000 years the design of hospitals and their healing mission were linked" (Breakstone, 1987). The spiritual reward system relied on the moralistic design concepts of churches; personal and intellectual rewards depended on an educational model for hospitals; and financial rewards demanded the modern efficiency of a medical factory. I believe that the changing systems of spiritual, personal, and financial rewards were a major cause in creating these new


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hospital archetypes. We can see in each of these examples that the medium of exchange affected the hospital's place of exchange.
As health care's system of exchange continues to look for new sources of financial fuel, the highly competitive market place and new emphasis on the patient/consumer will give rise to the retailing of health care. "The merchandising of health care is just beginning. Health care is not a product like soap, but it can be sold to customers, to individual consumers in the community and to major purchasers" (Coile, 1986). If hospitals are to remain as the central market place in health care's process of exchange, they must learn to adopt and adapt the successful market oriented design concepts of retail centers. The merchandising of health care services requires the "new hospital" to be more attractive, accessible, integrated, and flexible. The remainder of this section describes these new retail concepts for health care and demonstrates these principles in the design of the Castle Rock Health Center.
RETAIL DESIGN CONCEPTS FOR HEALTH CARE
Hospitals have become service oriented health care systems in which the patient is also a customer. To provide these services more efficiently, medicine has focused its treatment programs on a variety of outpatient health care programs. This collection of health care services now extends to ambulatory surgery, portable radiology departments, freestanding birthing centers, storefront medical labs, neighborhood emergicare centers and a variety of retail medical offices and stores.1
We can see that in the future, health care's system of exchange will be increasingly dependent on the retailing and marketing of medical services. For over 30 years, the commercial market place has relied on the design concepts of shopping centers to attract and serve consumers. The architectural evolution of health care will continue as hospitals learn to acquire these successful retail


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concepts to fit their own outpatient oriented market. The following are three major retail concepts that will affect the future of hospitals and health care facilities. I will explain and demonstrate the use of these retailing principles in the CRHC design problem.
1. Attracting The Patient/Customer
The new health care market place has caused a reversal in the attraction or polarity between hospitals and their patients. As more providers seek fewer patients, health care must now attract the customers that used to come automatically. "Doctors will have to begin appreciating our business and striving to keep it" (Stoline & Weiner, 1988). As we once were sent to the hospital, the hospital now attempts to send out a new message and new image to attract patients/customers to its services. The CRHC design uses a variety of design concepts to attract a community of users to its health care facilities, o The CRHC design promotes a new public image of health, wellness and caring;
o The CRHC design attracts the outpatient market with the convenience of providing a complete continuum of care within a single integrated health care center;
o The CRHC uses attractive architectural design features such as extensive landscaping, building atriums and water features; and o The CRHC design reduces anxiety of both patients and visitors by making accessibility and wayfinding a design priority.
2. Accessibility and Wayfinding
Throughout history there have been remarkable similarities between the educational disciplines of teaching and the hospital's role in healing. It is not surprising, therefore, that both hospitals and educational programs would evolve into a similar campus design setting. The modeVn hospital campus, like an


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educational campus, has been a cloistered environment for the treatment of patients and production/reproduction of medical knowledge. Scientific medicine of the 1900's turned hospitals into institutionalized "body shops." Health care facilities were closed, controlled medical establishments, focused on treatment and curative care. Patients were guided throughout the hospital system with most access and control focused on the needs of health care providers.
The current outpatient oriented market will require the replacement of this outdated educational campus model. The new health care center must be much more permeable, and accessible to the patient/consumer. The new emphasis on wellness and outpatient care requires ambulatory patients and visitors to be self directed and move easily throughout the health care system. The following design concepts can provide medical centers with greater accessibility for the new outpatient market.
Permeability. The ability to access and enter any health care system begins at its perimeter street entrance. Segregating patient and visitor entry points from staff and service entries can eliminate much of the confusion and ambiguity associated with the traditional health care campus. The CRHC design has only two major


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points of public access, one which approaches the retail/educational buildings, and one which accesses the medical treatment facilities. Each building within the CRHC design has a dominant public entrance. The architectural design of all major public access points is accentuated from all other secondary service and staff entry ways.
Previewing and Visibility. Analogous to a battleship with its accompanying flotilla, most modern health care centers consists of a large regional hospital linked to medical office buildings, parking structures, nursing homes, and a variety of outpatient treatment centers. The ability to create an accessible and intelligible health care center is dependent on the patient/consumer's ability to preview its system of circulation. "The problem of wayfinding is particularly acute in most urban health care institutions, where finding the emergency room, the x-ray department, the laboratory, or even one's own doctor is frequently a source of frustration, anxiety, and even anger" (Scurlock and Wise, 1985). To reduce confusion and anxiety, the entrance to a health care center should provide an


overview or preview of building entry points as well as pedestrian and vehicular circulation systems. Providing public entry points on the most elevated portion of the site will allow users to preview the health care campus and develop a cognitive mental map of its layout.
OVERLOOKS AND PREVIEWING
The design of the CRHC provides for previewing the system at both a global and local level. The global preview of the CRHC begins with an orientation and vista of the mountain ranges to the west and the Castle Rock to the south. These two major geographic formations are familiar to all residents of the area and can serve as recognizable compass points for constant visual orientation.
The global preview of the CRHC also reveals a distinct hierarchy of scale between the variety of campus buildings. The largest of all facilities is the outpatient/hospital building located at the center point of the health care center.
In a "disneyesque" arrangement, all secondary campus buildings are positioned as satellites radiating off the central outpatient/hospital building. Each of these satellite facilities has a recognizable architectural image, visible in a preview of the health center.
Circulation patterns and trafficways are modeled on two distinct geometric patterns. Pedestrian building connections are designed as straight radial bridges emanating from the central outpatient/hospital; parking lots and roadways are


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circular and circumferential. Building entry points are accentuated by the processional designs of their pedestrian bridges and contrast against the circular vehicular traffic ways.
As patients approach their destination in the health care center, their movement and direction should be reinforced with local sources of orientation and recognition. Too many hospital campuses have become dependent on a bewildering array of signage to resolve this wayfinding problem. Building entries, and vehicle drop-off points must be delineated in the architectural design of each facility. The CRHC design assists previewing at the local level by providing most pedestrian circulation on bridges above the drives and parking lots. This planar separation provides a three dimensional distinction between vehicular and pedestrian circulation systems. From these upper level pedestrian bridges most aspects of the health care center can be previewed. Uninterrupted views of both buildings and the surrounding hills and mountains provide focal points for orientation and patient wayfinding.
The use of large open spaces such as plazas, atriums, and malls improves accessibility in the design of shopping centers. "Hospitals may be replaced by medical malls, which will be much like department stores for centralizing a variety of specialized health care services" (Mann, 1987).


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The creation of malls and atrium spaces can provide attractive, accessible and familiar architectural solutions for a variety of new health care facilities. The open space of medical malls will provide an increased ability for customer previewing and a familiar, traditional solution to the problems of wayfinding. Malls can provide unobstructed axial views of entry points as well as improve visual access to outdoor orientation such as daylight, streets, and land forms. Open circulation systems such as atriums and medical malls can replace modern medicine's traditional labyrinth of disorienting, maze-like corridors.
TYPICAL MEDICAL MALL PLAN
Adapting to its new socio-economic market place will require health care to adopt the retailing concepts of the commercial market place. The ability to preview the health care center's global and local circulation systems can provide hospitals with the same access and intelligibility as a good retail shopping center. Circulation Systems. Operating 24 hours a day, the modern health care campus is inundated by waves vehicular and pedestrian traffic. Trafficways for trucks, service vehicles, ambulances, buses, and pedestrians must coexist with large numbers of cars from visitors and staff. Parking areas must be properly located to accommodate the different needs of inpatients and outpatients. Roadway systems must segregate service and emergency vehicles from patient and pedestrian access ways.


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HOSPITAL VEHICULAR ACCESS PATTERNS {5)
PACKING
Buildings in a health care complex differ from educational campuses in that the acuity of most patients and the transport of costly equipment between buildings require most facilities to be physically linked through protected walkway systems. While health care systems of the future will require more integration and accessibility, this variety of trafficways, circulation, and physical connections can create new barriers and problems for architectural design.
The site design of the CRHC resolves many of these circulation conflicts by segregating pedestrian, vehicular and service trafficways. Patients and visitors to the CRHC can access buildings through airport type drop-off ramps or from parking lots that radiate out from each building entry point. After parking, they can ascend stairs or elevators to the upper level pedestrian bridge system. While some service connections are in below grade tunnels, most pedestrian circulation takes place on covered passageways and bridges above the parking lots and roadways. All service vehicles and ambulances are provided separate entry points to the campus on segregated service roads along the health center's perimeter. Segregating these three systems of circulation and carefully controlling their connecting points can eliminate traffic conflicts, congestion, and add a new level of clarity to the variety of circulation systems in the CRHC.
For increased efficiency of its circulation patterns, the CRHC has grouped interdependent health care buildings within zones of the health care complex. This design uses the outpatient hospital facility as the central anchor tenant surrounded


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by peripheral satellite health care services. The CRHC design recognizes certain symbiotic relationships such as birthing and the hospital building, and retail health shops and the medical office buildings; these are placed in close proximity. The CRHC is divided into five distinct zones for the grouping of these interdependent services.
(Zone 2) Accessible Health Care - Health Education/Wellness, Emergency Care (Zone 3) Core Health Care - Outpatient/Hospital, Self-Care Facility, Birthing Center (Zone 4) Ancillary Services - Administration, Research and Development, Plant Services
(Zone 5) Health Care Secluded - Residential Hospice
"The plans and programs of a health care institution establishes its future and are the key to its survival" (Porter, 1982.) As health care invests in making their facilities more accessible and identifiable, they must protect that investment by maintaining an organized set of planning concepts. The segregation of circulation systems and zoning of interdependent health care facilities can provide master planning principles for a more organized and accessible health care center of the future.


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3. Flexibility
Traditionally, most hospitals have been built as lasting monuments to medicine and the art of healing. Similar to a memorial, cast in stone, the monumental old hospital was built to be strong, permanent, and unchanging. From their sturdy concrete frame to the finishing of the interiors, hospitals reflected a strength and permanence, legitimizing the role of medical science in our society. While adequate for hospitals of the past, it is doubtful that these institutional dinosaurs will meet the dynamic, changing needs of health care in the future.
The new medical market place requires a tremendous diversity in health care treatment and technology, with an increasing emphasis on the cost and quality of care. Health care centers must become as flexible and responsive as the dynamic market place they serve.
To support this dynamic new medical market, hospitals must abandon the past design concepts of a single, durable construction type. Health care facilities of the future may be constructed of two distinct, but interdependent building components: a functional shell infrastructure and a supporting interior infrastructure. The CRHC design describes the respective attributes and design characteristics of a infrastructure/intrastructure building type.
Castle Rock Health Center Infrastructure. Unlike the classroom buildings of an educational campus, hospital facilities cannot be repeated as duplicate structures.
An educational campus can evolve in a repetitive, segmented fashion, while health care buildings must be constantly subjected to remodels and additions to provide new space. Hospitals and health care facilities must grow through an organic process of building one addition on to another.
REMODEL,
REMODEL.


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To accommodate this pattern of growth, the superstructure of health care facilities should be a modular infrastructure grid capable of rapid expansion and numerous structural penetrations for future mechanical and electrical systems. The infrastructure design should accommodate interstitial spaces for component electrical and mechanical medical systems. These interstitial spaces would maximize flexibility and minimize downtime for remodeling and refitting of new medical equipment. The design and planning of the CRHC infrastructure is considered an investment for the lifetime of this health care facility.
Intrastructure. The creation of the medical malls and freestanding outpatient centers is a response to the new era of "boutique medicine." New products and services such as sports medicine, laser surgery, and stress clinics come and go quickly in the health care market place. In addition, new break-throughs in medical technologies such as lithotripters and digital imaging systems are announced almost daily. The CRHC employs a flexible interior intrastructure to provide moveable or disposable building components for these high turnover areas in health care. In each case the spaces and design materials are matched to that department's predicted life span. Planning for obsolescence by "value engineering" the intrastructure will allow hospitals to focus technology and dollars more appropriately within any new health care facility. Creating health care facilities with a master planned infrastructure and a flexible infrastructure will allow for the wide variety of treatments, technologies, and services needed for the new age of health care.
NEW SPATIAL STRUCTURES FOR HEALTH CARE
The new social and market structure of medicine will require a new spatial structure for health care facilities. The introduction of a new retail


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model for health care will produce a corresponding change in the spatial geometry of health care designs.
As previously discussed, since the mid 1800's many hospitals have been modeled after the educational campus. The closed and controlled spatial systems of these educational campus models provided scientific medicine with a spatial structure conducive to the social and functional needs of medical science at that time.
"Medicine's rise to power was built on a monopoly of scientific medical knowledge" (Starr, 1982). The creation and reproduction of the "knowledge to heal" was contained and controlled within the modern hospital. The modern hospital with its labyrinth of corridors and segregated spatial systems was controlled and understood solely by physicians and hospital personnel. The power and control that the medical staff held over patients was reinforced by the hospital's intimidating spatial structure. "High status professions almost always maintain prestige through some form of distancing and control of interface between professional and client, doctor and patient" (Brown, 1988).
The closed and cloistered educational model also supported the increased departmentalization of the modern hospital. With the rising complexity of medical care in the early 1900's came the distinct divisions of labor within the medical care organization. The new scientific philosophy of the "body/machine" transformed hospitals into departmentalized medical factories. The segregated spatial systems of the modern hospital have been used to control and reinforce the departmentalized concept of systematic "assembly line medicine." The use of a new retail genotype for health care centers will require the addition of a new spatial structure that is both open and integrated.
The creation and distribution of knowledge is fundamental to the process of healing. "With built space, people move and encounter each other to transmit


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information. . (Brown, 1987). The diagnosis and treatment of any illness is dependent on the integrated activities of a number of medical disciplines. The work of specialty departments in radiology, laboratory and internal medicine must be linked to the activities of staff providing treatment to the patient. This integrated knowledge system extends ultimately to the patient in the form of health education. Today's more holistic approach to medical care requires a more integrated spatial culture for the interaction of ideas and sharing of knowledge between these medical disciplines of the hospital.
The open and more integrated spatial culture of health care facilities can also assist in the more horizontal management structure of the "new hospital." As independent cost centers, each hospital department has become increasingly autonomous and is often times internally managed. The horizontal medical care organization can be more effectively managed in a more open and integrated system which promotes face to face contact and "management by walking around" (Peters and Austin, 1985).
Spatial Syntax Studies
Studies of past, present, and future hospital plan geometries show an interesting evolution in the spatial arrangement of modern health care. Created by the Barlett School of Architecture and Planning, University College, London, the space syntax method is used to analyze and record the interconnections of physical spatial systems. The two syntax diagrams shown below describe the difference between a closed, controlled treatment oriented hospital system and the more open integrated spatial systems found in outpatient preventative health care.2


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THE OPEN, INTEGRATED SPATIAL SYSTEM
THE CLOSED, CONTROLED SPATIAL SYSTEM
Controlled Spatial System
Departmentalized medical systems require a controlled spatial system which provides surveillance points and control through ante-rooms. These spatial systems are segregated from one another and produce very deep inaccessible spaces within the system. The traditional medical concept of "bed rest" for patients was conducive to the deep spatial arrangements of hospitals. High-tech medical treatments will continue to benefit from this segregated, departmentalized spatial arrangement as it supports the efficient process of a systematized medical practice. The Integrated Spatial System
The spatial geometry of integrated systems shows more points of contact between a variety of spaces in the network. A single starting point branches quickly in this shallow, integrated spatial network. Health care designs such as medical malls can benefit from the increased accessibility provided under such spatial arrangements. Outpatients can access a variety of departments and services from a single open space in this integrated spatial system.


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Spatial Arrangements of the Castle Rock Health Center
The concepts of spatial integration are demonstrated in many of the retail design concepts of the Castle Rock Health Center. Providing spatial and circulation systems which are networked to be open and interactive will make the CRHC a more accessible outpatient health care center.
The zoning or cloistering of CRHC buildings provides an integrated, symbiotic collection of health care services. The interconnecting landscape elements, parking areas, walkways, and bridge systems assist in the total concept of an integrated health care center. Many of the CRHC facilities such as the medical offices, outpatient/hospital, wellness center and self-care building contain atriums or medical mall spaces. These large, open volumes of space can be used to integrate a wide variety of health care services in the traditional retail design model. These malls and atriums provide users the ability to preview a series of entry points, familiarizing patients with a wider collection of health care services.3 As the central, circulatory connecting point, these malls, atriums and plazas are the ideal point of personal contact between physicians, staff, patients, and visitors to the Castle Rock Health Center.
With the increase in outpatient medical services the CRHC attempts to use these open and interactive spatial systems to provide a more accessible retail oriented design model for the CRHC. The CRHC design will provide a combination of both controlled and interconnected spatial networks appropriate to specific medical treatments and preventative programs found in health care centers of the future.


CHAPTER NOTES
1. These freestanding centers feature a unique retail concept of outpatient, drive-up medicine euphemistically known as "Doc in the Box."
2. The comparison of these old and new spatial geometries of hospitals is derived from the comparative plan studies of M. Gordon Brown. 3
3. Many outpatient services such as health education programs rely on the retail concepts of "point of contact sales" and "impulse buying."


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PRESCRIPTIVE ENVIRONMENTS FOR HEALTH CARE
Over the last decade western medicine has discovered limitations in the paradigms and practices of high technology healing. Dealing with the body separate from the mind has limited the healing process to treating symptoms without understanding the context of many diseases. "Bolstered by a blizzard of research on the psychology of illness, practitioners who once split mind and body are trying to put them back together" (Ferguson, 1980). The new holistic paradigm of western medicine now regards the mind and body as a single entity in the total healing process. The most successful new tool in this therapeutic revolution is the rediscovery of guided or healing imagery.
Throughout history healing imagery has played a key role in almost all eras of medicine. The ancient shamans or medicine men used imagery to instill a sense of well being in their patients and promote the healing process. The Greek healer Asclepius was influential in early medicine and the development of healing imagery. Over 200 healing temples were erected throughout Greece, Italy and Turkey to honor his practice of dream healing.
The first record of a designed environment for healing was in ancient Egypt. "The Egyptians believed that if they painted beautiful murals of nature in a place of healing, a person would have a vitality and an interest in life. This would physically aid the healing process" (Maxion, 1988).
Healing with the imagination was adapted from the Asclepian temples and implemented by the Christian church infirmaries. "During the twilight state between sleep and wakefulness, the patients would have images of the revered healers, who would provide diagnostic information and administer cures" (Achterberg, 1985).
From the ancient shamans to the Navajo medicine man, many cultures of medicine have invoked the powers of the mind to heal the body. "The most


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important thing I learned from my grandfathers is that there is a part of the mind we don't really know about; it is that part which is most important in whether we become sick or remain well" (Thomas Largewhiskers, Navajo Medicine Man, in Achterberg, 1985).
This history of medical practices shows that mental visualization is integral to many healing processes. Only the era of western scientific medicine, beginning in the early 1800's, attempted to divorce mind and body in its medical treatments. Rational scientific medicine saw the human body as a mechanical model and believed technology provided the primary means to repair the damage of disease. This high technology, mechanistic approach to healing was a major contributor to the creation of the "body shop" image of the modern hospital. "By 1910, the hospital had already begun to appear to some of its critics as a monolith and impersonal medical factory" (Rosenberg, 1987).
The shared philosophies of modern medicine and modern architecture saw both the process of healing and hospital design as a problem in functional mechanics. This brief 150 year period in medical history was the only era which did not recognize the linkage between body and mind in health care. Only as modern medicine began to rediscover the value of a more holistic approach to healing, has it become respectable to again explore the role of the mind in health and medicine. The new holistic concepts of medicine reunite mind and body using the therapeutic tools of healing imagery.
"A major cause of both health and sickness, the image is the world's oldest healing resource" (Achterberg, 1985). Healing imagery is the thought process that evokes the therapeutic linkage between perception, emotion, and bodily change. Guided imagery can harness the powers of the conscious and subconscious mind to produce a somatic response to a mental image. The therapeutic concepts of healing imagery have gained credibility with the re-discovered link between mental


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images and the parasympathetic nervous system. This portion of the nervous system has the ability to control and stimulate the human immune system. "According to new research, a variety of techniques -- specific images, positive feelings, suggestions, learning to respond to stressors in a relaxed way — all have the potential for increasing the ability of the immune system to counter disease. Very current studies have shown that the immune system itself is under the direct control of the central nervous system, particularly those areas of the brain implicated in the transmission of the image to the body" (Achterberg, 1985). Imagery is now being studied at all levels of medicine from diagnosis to rehabilitative treatment. Development of modern bio-feedback techniques relies on mental imagery, allowing patients to control their own heart rates and blood pressure levels. Cancer patients who imagined their immunological systems attacking tumors showed significant and statistically verified improvement over patients who were not exposed to these techniques of healing imagery (Ahsen, 1984).
The relationship between healing imagery and architectural design has been researched by Stephen Verderber of Tulane University. These studies show that hospital patients with windows viewing the outdoor environment heal quicker, require less medication, and are discharged sooner from the hospital.1 Like many of the past cultures of medicine, these patients have benefited from a designed environment which promotes visualization and healing imagery. I believe their early discharge from the hospital results from a positive somatic response related to their increased ability to imagine themselves as healthy.
As the new holism of medicine reunites body and mind in the healing process, a dramatic transformation will take place in the design of health care facilities. I believe the hospital"body shop" will give way to new health care facilities designed to harness the mind's potential in the total healing process.


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The re-introduction of the mind's role in medical treatment presents health care architects with major new challenges and opportunities to participate in the total healing process. Health care designs which can optimize the healing, somatic linkage between body and mind will require a greater understanding and an infusion of concepts from environmental psychology. As holistic medicine can now prescribe guided images for healing, architecture must reinforce the imagery process, creating "prescriptive environments" for health.
DESIGN OF THE HEALING ENVIRONMENT
"Psycho-architecture will be used to heal and teach. The type of knowledge possessed by the cathedral builders of the Middle Ages will enter this time in a high-tech environment" (Kaiser, 1986). These new "high-push" environments for healing will be focused on maximizing the therapeutic value of conscious and subconscious images. The "psycho-architecture" proposed by Dr. Kaiser would require a "prescriptive environment" affecting a variety of senses to reinforce and help "push" the therapeutic healing image.
"Humans crave information about their surroundings. In the process of constantly endeavoring to comprehend and make sense of our surroundings, all five sensory modalities have come to bear on the processing of information about our environment" (Verderber, 1986). Confined to patient rooms and treatment areas, hospital patients are particularly attuned to their limited range of physical surroundings. Because they lack stimulation and distraction from other sources, non-ambulatory hospital patients will have a greater exposure and potentially a greater response to these "prescriptive environments" for healing.


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The Castle Rock Health Center
The design concepts of the Castle Rock Health Center demonstrate a variety of ideas as a "high push" environment for healing.
o Visual stimulation is increased through the use of prescribed colors, textures, and forms;2
o Art work is provided as a tool for healing imagery. "Since the very
beginning of time, man has used art as a way to make his imagination palatable. The Egyptians would paint the ceilings blue like the sky and the floors green like the meadows of the Nile and often create little gardens right outside of their healing places or ancient hospitals" (Maxion, 1988); o The CRHC has an electronic sound system for environmental sound tracks and prescriptive, subliminal messages; and o As proposed in the original Nightingale hospitals, the CRHC has operable windows that re-introduce the use of fresh outdoor air in a health care facility.
Certain aspects of the CRHC design attempt to tap the knowledge and powers of the cathedral builders as described by Dr. Kaiser. The historic, mythic qualities of sacred structures are reflected in the pyramidal forms of the CRHC wellness center. Tree forms are found in the bridge, arcades and atrium of the medical office building. The terraced shape of a ziggurat provides the basic concept of the outpatient/hospital building. This eclectic combination of natural forms and built structures attempts to revive a variety of historic, physical forms as a mnemonic tool of collective subconscious imagery. Health care designs of the future may employ architectural styles, from pre-history to post-modern, and from grass huts to geodesics, to create a holistic healing environment and a new architecture for health.


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CONTACT AND THE CONTEXT OF HEALING
Prior to modern antiseptic theory, hospitalized patients often died from a variety of contagious diseases known as "hospital fever." While modern hygiene and antiseptic procedure brought these contagiums under control, the sterile, antiseptic modern hospital seems to have created a new form of anxiety and "hospital fever." The institutional designs of modern health care are often frightening and psychologically disruptive to hospitalized patients. "Being admitted to a modern hospital can be like entering the twilight zone" (Breakstone, 1987). The institutional setting removes patients from the supportive contact and context of family, friends and the outdoor environment. The tradition of bringing flowers to a friend in the hospital is a simple attempt to replace this loss of context in the hospital setting. The design of "prescriptive environments" must recognize this loss of context and replace it in two ways: first, by maximizing opportunities for the healing physical contact of family, friends and environment; and second, by providing improved visual contact with human activity and the environment.
The CRHC design provides numerous opportunities for patient/family contact. The use of atriums, medical malls, courtyards, day rooms, and lobby space will promote increased patient ambulation and therapeutic social contact within the hospital system. Atriums and malls can also replace a loss of contact with the natural outdoor environment. The CRHC uses indoor landscaping in greenhouse atrium spaces of both the hospital and self-care center. These atriums are an extension of the health center's exterior landscaping; bringing trees, streams, rocks, plants, and flowers indoors helps bridge the loss of contact with nature.


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New health care designs may employ indoor plantscaping and greater social interaction, but the major point of contact with the outdoor environment remains dependent on patient views. The value of windows and viewing has been demonstrated in research showing patients with views of an outdoor environment have a shorter length of hospitalization.1 Direct visual images of life and human activity in the environment can provide an endless supply of positive healing images for the recuperating patient. I believe that all types of patients can benefit from the visualization and views of an active, healthy world. This visualization helps maintain a conscious mental focus outside the hospital setting. As part of the total healing process, a patient must be both physically and mentally prepared to leave the hospital.
As an example, most Coloradans have a strong personal image of the activities and the "good times" enjoyed in the Rocky Mountains. These images and memories are a positive part of our regional culture and can assist in creating a positive healing image. The Castle Rock Health Center uses windows, view corridors, and strategic siting to enhance these conscious and subconscious images of the mountains and outdoor environment. The terraced design of the inpatient hospital provides most patient rooms with a view and small deck area looking over


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the foothills and front range. The birthing center and self-care facility have interior courtyards and views of the natural open space of the health center. A view deck is integral to the upper bridge level of the hospice facility, and each patient room has a small patio overlooking the hospice grounds and mountains beyond.
From the time of the Creek Asclepian temples, certain sacred sites are believed to have possessed special healing powers. The Castle Rock Health Center may not hold the mystic quality of a sacred site of healing, but I do believe its position, elevation and commanding views of the city, valley and mountains beyond can enhance the process of visualization and the healing images that are integral to its holistic program of health.
FEELING BETTER ALREADY


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CHAPTER NOTES
1. Records made between 1972 and 1981 showed that 23 patients with views of natural settings had shorter postoperative hospital stays, received fewer negative evaluations in nurses' notes and took fewer painkillers than 23 patients assigned to similar rooms with windows facing a wall.
2. Studies by Stephen Verderben show a positive patient response to creative and stimulating designs in ceiling systems. Hospitals of the future may have modular wall/ceiling colors and textures prescribed to assist in visual stimulation and healing techniques.


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CONCLUSION
"The future should be known as a goal or value in itself. Knowledge about the future is useful for achieving new values and goals" (Dror, 1975).
This thesis project demonstrates an architectural response to the future needs of health care. The future of health care is not predetermined; therefore, its architectural response is never totally predictable.
The real value of any exercise in futures forecasting does not lie with its total accuracy, but with its ability to increase our awareness of future trends and future potential. The effectiveness of the ideas, scenarios, and concepts found in this paper should be judged on their ability to affect the design of the new health care industry. "The scenario is not just a means of exploring possible interactions of various events, but a way that we can shape the future" (Cornish, 1977). I believe these ideas can help "shape the future" of health care design.


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APPENDIX
Program Synopsis of the Castle Rock Health Center
The following is a brief synopsis of the programming document for the Castle Rock Health Center. The CRHC is an outpatient oriented regional health center serving the bedroom communities of south Denver and northern Colorado Springs in the year 2000. The health center provides its patients with a variety of primary and secondary care including inpatient care, level two intensive care, self-care, outpatient diagnostics, health education, birthing, and hospice care. The hospital facility contains 110 inpatient beds and is integrated into the outpatient care unit. For a complete review of the demographic projections behind the CRHC design, see "Programming Documents, Castle Rock Health Center"
(McKahan, 1988).
The design of this health care center is based on the following economic, social/political and technological scenarios for the year 2000.
Economic Scenarios - Year 2000
o A free market for health care services now exists. Aside from government funded programs, the supply of health care services now matches the demand.
o Most hospital systems are now managed on a regional basis. The new
health care system in Castle Rock is predicted to be more cost effective and responsive to community needs because of its regionally managed structure, o Most regional health care systems now follow retail models of marketing and product line management.
o Despite federal attempts to regulate the U.S. health care system throughout the 1990's, the west, and particularly Colorado, remain independent and use a competitive free market to regulate the cost of health care.


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o A two-tiered private and government funded system of health care exists in the year 2000.
o The two-tiered system of health care has both better and worse qualities than the old systems of the 1980's. Private care is more personal and patient oriented, while public care is burdened by its administrative controls and impersonal approach.
o To offset increasing federal expenditures the Medicare program has reduced coverage and care in most areas. Medicare provides coverage for retirees only in the lower half of retirement income brackets. Retirement age is now 68.
o A system of tax deductible savings for health care costs has been established: a medical I.R.A. program.
o The private sector has absorbed more of the cost and most of the control over medical insurance coverage.
o DRC'S have been expanded and adopted by most regional business groups purchasing health care protection for their employees.
o As business is now required to provide "adequate" insurance coverage, many groups and industries have become self insured. As deductibles have risen, more health care is paid for "out of pocket."
o Almost all "fee for service" reimbursement programs have been
abandoned. Care is now provided on a contract basis through group coverage or government funded programs.
o Very few health care systems and hospitals are still considered entirely nonprofit. Most systems are now "poly-corporate," with both taxable and non-taxable programs operating under the same management.


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o Many hospitals and health care systems have venture partners in medical research and development projects. The symbiotic relationship between private research groups and hospitals has been a financial benefit to both parties.
o The new health care facility in Castle Rock has an agreement with Hewlett-Packard Corporation for R & D on new micro-telemetry units used for monitoring organ transplants and bionic implants after surgery, o The Western United States continues to profit from the shorter lengths of
stay in its hospitals. The Medicare DRC program believes the managed care programs and holistic treatment programs found in the Western U.S. are partially responsible for this lower hospital length of stay, o Since businesses now provide the bulk of group insurance coverage, they have played the major role in the redesign of the U.S. health care system.
As the cost of health care has risen, these insurance benefits are the primary component of any employee compensation plan, o The Surgeon General's report of 1992 relating stress and disease has caused a new emphasis on stress reduction programs. Many hospitals now feature "stress centers" as an independent business group within their poly-corporate structure. The popularity of stress centers has made them very profitable facilities by the year 2000.
Social/Political Scenarios - Year 2000
o Decreases in the numbers of licensed physicians has eroded the AMA's historic power base.


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o Allopathic medicine is now losing popularity to other forms of osteopathic and holistic medicine. California and the western United States are considered the birth place and stronghold of the new holistic medical concepts.
o Now in their fifties, the "baby boomers" generation has focused on issues of social concern and quality of life.
o The regulatory era of the 1990's has subsided and a new wave of
volunteerism appears imminent. The Castle Rock area is considered prime for tapping into this new force of volunteers for providing community charity care.
o Many health care providers including nurses, physician assistants and even doctors are now considered to be "medical tradesmen" rather than independent professionals.
o Most low risk pregnancies are now delivered in outpatient birthing units.
o Early diagnosis and health education are now the hallmark of all HMO
programs. Subscribers are now required to maintain these preventative programs in order to continue receiving care.
o Free-standing hospice programs have continued to gain popularity since the early 1990's. As a less costly alternative to acute care hospitals, hospice programs now care for over 75% of America's terminal patient population.
Medical/Scientific Scenarios - Year 2000
o Most X-ray equipment of the 1990's has now been replaced by digital
imaging systems. Few X-ray films are used in the year 2000 and satellite transmission of images allows for centralized reading of diagnostic images.
o Many health care campuses have instituted minimal care or self-care
facilities as a part of their total program. These step-down patient units


55
have minimal nursing supervision and allow patients an easier transition back to independent living. Colorado was the first state to popularize and license these self-care units within its regional health care systems.
o New electronic technology and two-way video conferencing now link a network of health care specialists in both city and rural hospital systems.
o The use of bio-technology has exploded in the 1990's. For those who can afford it, implants are now available for replacing, ear, heart, and kidney systems.
o DNA research has now produced immuno-therapy treatments that are successful in arresting 40% of the early diagnosed cancer cases.
o New drugs and catheterization techniques have replaced most vascular and open heart surgeries.
o Bionic implants and transplants now make up the bulk of surgical procedures in the year 2000.
o The implementation of artificial intelligence has allowed for great
advancement in computerized diagnostic systems. Computers from all acute care hospitals are linked to a common, ever increasing diagnostic database. The use of computer diagnosis has eliminated many specialty physicians from the health care system.
o Many Americans now subscribe to two-way health care cable systems.
These systems allow for at-home diagnosis, two-way contact with various medical practitioners and monitoring of elderly home-care patients.


GRAPHIC AND PHOTO ACKNOWLEDGEMENTS
Some of the graphic drawings and all of the photography in this document are reprinted. The following index of graphics and photos acknowledges the original texts as the source for these pictures.
(1) Dalio, Carl J. Architectural Rendering of Castle Rock Health Center. May, 1989.
(2) Hanks, K. and Belliston, L. Rapid Viz. Los Altos, California: William Kaufman, Inc. 1980.
(3) Health Facilities Review 1988. Washington, D.C.: AIA Press, 1988.
(4) Lyons, Albert. Medicine: An Illustrated History. New York: Abrams Publishing, 1983.
(5) Porter, David R. Hospital Architecture. Ann Arbor, Michigan: Health Administsration Press, 1982.
(6) Thompson, John. The Hospital: A Social and Architectural History. New Haven, Connecticut, Yale University Presse, 1975.
(7)
Torre, L. Azeo. Site Perspectives. New York: Van Nostrand Reinhold Company, 1986.


57
REFERENCES
Achterberg, Jeanne. Imagery In Healing: Shamanism and Modern Healing. Boston, Massachusetts: New Science Library. 1985.
Ackerknecht, Erwin H. A Short History of Medicine. Johns Hopkins University Press. 1982.
Ahsen, Akhter. ISM: The Triple Code Model for Imagery and Psychophysiology. Journal of Mental Imagery. 1984.
Bengtsson, Jeanne B. The Humanistic Approach to Healthcare. In the International Hospital Federation Yearbook. 1985.
Breakstone, Jerry. History Offers Architectural Guidance to Hospitals. Modern Healthcare. October 23, 1987.
Brown, M. Cordon. The Choreography of Problem Solving. Arizona State Research Fund, November, 1987.
Brown, M. Gordon. The Spatial Structure of a Hospital Floor. Paper presented to American Institute of Architects, Committee on Architecture For Health. New York, May, 1988.
Coile, Russell C. The New Hospital: Future Strategies for a Changing Industry. Rockville, Maryland: Aspen Publishers Inc., 1986.
Cornish, E. The Study of the Future. Washington, D.C.: World Future Society Publishing. 1977.
Dror, Y. Some Fundamental, Philosophical and Intellectual Assumptions on Future Studies. In CIBA Symposium, The Future as an Academic Discipline. New York: Elsevier Publishing. 1975.
Ferguson, Marilyn. The Aquarian Conspiracy. Los Angeles: New Science Library. 1980.
Friedrichs, Edward C. In Aging Physical Plants: Holdovers From Another Era? Hospitals. February 20, 1988.


Jencks, Charles. The Language of Post-Modern Architecture. New York: Rizzoli International Publications Inc. 1984.
58
Jung, Carl G. Man and His Symbols. New York: Doubleday and Company Inc. 1964.
Kaiser, Leland R. Anticipating Your High-Tech Tomorrow. Healthcare Forum Magazine. November, 1986.
Mann, George J. Beyond the Hospital: Building for a Healthier Future. The Futurist. January/February, 1987.
Maxion, Cynthia. Art of Healing, lournal of Health Care Interior Design. May, 1988.
Philbin, Patrick W. The Healthcare Campus and Vertical Hospital. Healthcare Planning and Design. May, 1988.
Peters, Tom and Austin, Nancy. A Passion for Excellence. New York: Random House. 1985.
Porter, David R. Hospital Architecture. Ann Arbor, Michigan: Health Administration Press. 1982.
Priest, Kathleen. Healing Crisis: Emergence of a New Medical Model. Beginnings. The American Holistic Nurses Association. May, 1983.
Rosenberg, Charles E. The Care of Strangers: The Rise of America's Hospital System. New York: Basic Books, Inc. 1987.
Scurlock, Charles and Wise, James. Wayfinding in the Complex Architectural Environment: A Process Tracing Approach. In Proceedings of the International Conference on Buildings Use and Safety Technology. 1985.
Starr, Paul. The Transformation of American Medicine. New York: Basic Books, Inc. 1982.


59
Stoline, Anne and Weiner, Jonathan. The New Medical Marketplace: A Physician's Guide to the Healthcare Revolution. Baltimore: Johns Hopkins University Press. 1988.
Verderber, Stephen. A Case for Reassessing the Design and Function of Windows and Ceilings in the Healthcare Environment. Research of School of Architecture. Tulane University, New Orleans, Louisiana. 1986.
Excerpts from the following unpublished manuscripts have been used and referenced throughout this document:
McKahan, Donald C. An Overview of Medical Care Organization in the United States: 1840 - 1992. University of Colorado at Denver. December, 1988.
McKahan, Donald C. Imagery and the Faceless, Placeless Hospital. University of Colorado at Denver. September, 1988.
McKahan, Donald C. A New Future for the Healthcare Campus. University of Colorado at Denver. July, 1988.
McKahan, Donald C. From Hospice to Hospital: Architectural Theory in the Evolution of Healthcare. University of Colorado at Denver. May, 1988.
McKahan, Donald C. The Validity and Value of Futures Forecasting. University of Colorado at Denver. November, 1987.
McKahan, Donald C. Programming Documents, Castle Rock Health Center. University of Colorado at Denver. December 15, 1988.




SITE PLAN
CASTLE ROCK HEALTH CENTER
CASTLE ROCK COLORADO (YEAR 2002)
W"W


HOSPITAL / OUTPATIENT CENTER


MEDICAL OFFICE BUILDING
SELF CARE CENTER


WELLNESS CENTER
BIRTHING CENTER


RESIDENTIAL HOSPICE
QD


Full Text

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A NEW ARCHITECTURE FOR HEALTH CARE: FUTURE MODELS FOR HEALTH CARE DESIGN THESIS DOCUMENT BY Donald C. McKahan School of Architecture and Planning University of Colorado at Denver May 11, 1989

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A NEW ARCHITECTURE FOR HEALTH CARE: FUTURE MODELS FOR HEALTH CARE DESIGN BY DONALD C. MCKAHAN A Thesis submitted to the faculty of The School of Architecture and Planning University of Colorado at Denver in partial fulfillment of the requirements for the degree of Master of Architecture

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This thesis for the Master of Architecure degree by Donald C. McKahan has been approved by the Architecture Program School of Architecture and Planning Frances M. Downing, Associate Professor of Architecture, UCD M. Gordon Brown, Associate Professor of Architecture, UCD Faculty Advisor Leland R. Kaiser, Ph.D., Associate Professor , Health Services Administration, Graduate School of Business, UCD Professional Advisor

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Acknowledgements: I would like to thank my Thesis Advisors for their interest and guidance in this project, as well as my office colleagues and professional contacts in health c are for their valued insight and ideas. Finally, I must thank my family for providing me with the love, the support, and the dining room table for these past two years of thesis research.

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TABLE OF CONTENTS Introduction 1 o Problem Context 1 o Problem Statement 4 o Problem Discussion 6 A New Image for Health Care 9 o Imagery and Meaning in the Castle Rock Health Center 12 o Designed Images of the Castle Rock Health Center 14 Health Care's System of Exchange 22 o A System of Rewards 22 o Retail Design Concepts for Health Care 25 o New Spatial Structures for Health Care 35 Prescriptive Environments for Health Care 41 o Design of the Healing Environment 44 o Contact and the Context of Healing 46 Conclusion 50 Appendix: Program Synopsis and CRHC Graphics Graphic and Photo Acknowledgements References 51 56 57

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I INTRODUCTION PROBLEM CONTEXT "If you have your health, you have everything." Over the past decade the American culture has become absorbed in the concepts of personal health and wellness. Health clubs preach the doctrines of exercise and fitness. Americans attend health fairs, watch health shows on television and go to health shops to get the latest health-related best selling books. The media is saturated with the latest news stories on organ transplants, the AIDS epidemic, and medical technology. , At almost 12% of our gross national product, no other nation in the world invests as much money in its health care system as the United States. Health care is now our third largest industry. Americans are interested in the length of their life and in many ways, believe health is now the most important indicator of their quality of life. This medicalization of our culture is built upon the dynamic and sometimes unstable evolution of America's new health care systems. The U.S. system of health care is currently undergoing an unprecedented rate of change and upheaval. The historic evolution of medicine has now become a revolution in health care.

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Economic Changes Include: o DRG's (Diagnosis Related Groups) and the new financial controls of prospective payment; o Deregulation and increased competition between health care providers; o Increased emphasis on outpatient care; o A wave of patient consumerism in health care; and o Mergers, buy-outs, and closure of many community hospitals.2 Social Changes Include: o The rise of the patient/consumer in the hierarchy of health care; o Medicine's loss of power and control within its own market place; and o The aging of America. One of eight Americans will be over 65 by the year 2000. Technical Changes Include: o The continued evolution of scientific medicine; and o An increased interest in holistic, high-touch medicine. Experts can now envision a wide variety of future scenarios for U.S. health care. New methods for funding health care may create a multi-tiered , public and private system of hospitals; a system of self-funded medical I.R.A.'s; and the potential of rationing the quality or quantity of health care services. Futurists predict both high-tech centers of excellence and high-touch, holistic medical care. Hospitals may be decentralized into medical malls, outpatient facilities, and home care medical units. A new entrepreneurial spirit may produce joint ventures between hospitals and medical research corporations (Coile, 1986 and Kaiser, 1986). While none of these scenarios will be true in total , they are probably all true in part. The study of health care's many predicted futures reveals three recurring " megatrends " of medicine: 2

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3 1. A major change is occurring in the hierarchy and relationship between patients and health care providers. With more providers pursuing fewer patients, the polarity or attraction between these groups has been reversed. The monopoly of power and control once exclusive to medical care organizations is now shifting to the hands of patients and the groups that represent them. "So long as demand for health care services exceeded the available supply, consun1ers were unable to express their preference. The combination of excess supply and deregulation has made health care providers face much the same market base allocation of resources that other consumer oriented industries have learned to anticipate" (Philbin, 1988). The health care industry must now respond to the market they once controlled. The needs and wants of the medical consumer now take precedence over that of the medical care organization. 2. The U.S. health care system has created a distinct medical market place. More of this nation's health care cost is being shifted from government and public insurance programs to private paying patient groups. Medicine's historic system of exchange is now fueled by a system of financial rewards.3 The new finance based health care model looks to the concept of product line management and the retailing of health care services. The new medical market place now requires health care facilities that are more accessible , attractive, familiar and flexible. "Major industries, such as health care, airlines, and specialty retailing, are following the leads of jeans and cosmetics manufacturers, using design as a means of appealing to consumers" (Friedrichs, 1988). The medicalization of America has created the commercialization of health care. 3. A new dual philosophy in medical care has created both a high-tech and high-touch approach to healing. Caring for the patient's body and mind

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requires a holistic integration of medical technology and personal touches to balance the physical and mental aspects of the total healing process. 4 Throughout the remainder of this thesis document, these new socio-economic trends of medicine will be explored as the basis of a new architecture for health. As a means to demonstrate these new trends and their resultant design consequence, this paper outlines the development of a health care center for the year 2000. The design program for the Castle Rock Health Center (CRHC) is summarized in the Appendix of this paper. For a more complete description of the CRHC design context, see "Programming Documents, Castle Rock Health Center " (McKahan, 1988). PROBLEM STATEMENT Over the past decade health care architects have attempted to distill and understand these new trends in medicine . New patterns and paradigms are beginning to emerge within the health care industry, but there remains a great deal of confusion and indecision as to architecture's direction in the future of medicine. Hospital architects have attempted to become future oriented, transitioning their thinking from three dimensional space to the fourth dimension of time. What are the future trends of health care and which trends will hold the highest priority for medical architecture? What principles and theories of design will support the new market place and trends of health care? Can these design principles create an effective new architecture for health care? My graduate thesis project attempts to resolve some of this uncertainty and propose new directions for the future of health care architecture. My process for developing this thesis problem has been:

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1. To identify the forecasts and trend lines that will have a major impact on the future of health care design; 2. To distill from these future forecasts a scenario for a health care center of the future; 3. To translate that scenario into a series of concepts for future health care design; and 4. To demonstrate these proposed concepts in the architectural design of a new community health care campus for the year 2000. My inquiries into the future of health care have involved the following: o Review of future forecasting methodologies; o Readings and interviews with experts and forecasters in the health care industry; o Meetings and seminars with the AlA Committee on Architecture for Health; o Studies with members of my thesis committee; and 5 o Site visits and investigations of future oriented health facilities throughout the country. I hope this thesis problem can assist the profession of architecture by providing an evolutionary view to the next horizon of health care design. With the rapid rate of change in health care over the last decade , architects have been forced to play a game of "catch up." I believe health care architects must progress from their current reactive position, to a design philosophy that takes a proactive role in the future of health care. Architecture can do more than simply reflect the new medical marketplace, it can help create and design health care ' s future. The goal of this thesis research is to direct, assist, and enlighten the design profe ssions toward a new view of architecture for health.

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6 PROBLEM DISCUSSION There is a strong physical and philosophical linkage between the p rofession s of architecture and medicine . They are both a science and an art . The scienc e of building and the art of healing attempt to meet the social needs of mankind b y understanding and responding to the physical needs of humans. The physical relationship between medicine and architecture is symbiotic. As medicine provides profes s : Jnal challenge and financial rewards to architecture , it receives i n return functional structures and the physical image of the health care industry . T h e philosophical linkage between medicine and architecture involves a common language , structure and set of values.4 This symbiotic, philosophical relationship i s clearly evidenced in the period between 1910 and 1980 with the attraction o f modern medicine to modern architecture. o Both modern architecture and medicine developed a more scientific and systematic approach to their individual disciplines. o Both modern architecture and medicine used new technology as a solut io n to old problems. o Both modern architecture and medicine developed a rational , efficient, and mechanistic philosophy to their individual disciplines. Conclusion This physical and philosophical relationship between medicine and architecture w ill continue to evolve, creating new principles for the future of health care design. The three medical " megatrends " can be translated into three architectural principl e s which respond to and support these new philosophies of health care. 1. The changing relationship between patients and providers will also change the physical image of hospitals and health care facilities. The designed image of modern medicine was one of power , technology and the

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7 "authority to heal" (Starr, 1982). The new patient oriented market place will require that the hospital's physical image match its mission of healing. The designed image of health care facilities will change from that of authority and technology to a more humanistic architectural image of caring, wellness and health. 2. Hospitals are no longer just the "doctor's workshop." They are now the central market place in health care's process of exchange. The architectural evolution of health care will create hospitals that can adopt and adapt the successful market oriented design concepts of retail centers. 3. The integration of high-tech and high-touch healing brings a new holistic philosophy to the future of medical care. Treatment programs that involve the whole person, body and mind, provide new opportunities to involve architecture in the total healing process. A patient's psychological response to his physical surroundings will involve architectural design in the holistic paradigm of creating "prescriptive environments" for healing. The remainder of this document expands upon these concepts of public image, the place of exchange, and environments for healing. The paper will outline the origins and evolution of these concepts as well as their potential role in establishing the foundation of a new architecture for health care.

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CHAPTER NOTES 1. The new public focus on health care has resulted in an increased awareness and interest in medical architecture. Architectural journals now commonly feature articles on health care facilities. The largest subcommittee of the American Institute of Architects is the Committee on Architecture For Health; both Interiors magazine and Modern Health Care magazine have instituted yearly awards programs for outstanding design in health care architecture. 2. Eighty-one U.S. community hospitals were closed in 1988. This is the highest rate of hospital closure since the depression of the early 1930's. 3. The increased financial rewards of health care have promoted the growth of for-profit hospitals in the U.S. This corporatization of medicine has continued; 35% of U.S. hospitals were owned by for profit chains in 1988 (Stoline and Weiner, 1988). 4. The common language, structure and values shared by medicine and architectural design are detailed in the document "From Hospice to Hospital," (McKahan, 1988). 8

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9 A NEW IMAGE FOR HEALTH CARE Imagine a tribe of people who created a specific place in their culture for the healing of their family members, birth of their children, and death of their elders. We would expect this place to be considered as sacred ground, a place charged with meaning and spiritual energy, rich with images for that culture. While all these events occur in the modern hospital, little of the meaning and almost : ,one of the imagery exists with it. The changing relationship between patients and providers will change the public image of hospitals and health care facilities. As health care architects create new environments for healing, there will evolve a new use of design imagery, transforming the modern hospital into a special place charged with the meaning of health and life. All physical forms, and particularly architectural forms, have the potential to evoke images. As a design tool, imagery is a mnemonic device, recalling the feelings, spirit and meaning associated with built form. With the use of design imagery the 11new hospital11 can regain a recognizable public or personal image , a 11Sense of place11, and a significant meaning within our culture. To understand the role of imagery in health care it is important to review some of the historical relationships that have existed between man, medicine , and facilities for healing. The early Christian infirmaries were the transition point between life and death, earth and heaven. They were places charged with spiritual meaning and their architecture reinforced this meaning through a variety of symbols and design imagery. The infirmaries had soaring vaulted ceilings flooded with a celestial light from stained glass windows high above the patients' beds. Each infirmary had a chapel space that was elevated above the main floor, expressing the difference between heaven and earth through architectural design. The Christian infirmaries gave meaning to illness as a transition or bridge to heaven. The rich use of both

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secular and sacred imagery gave spiritual meaning to the process of s ickness and healing. OURSCAMP ABBEY I INFIRMARY, CIRCA 1200 (S) 10 In a similar way the baroque pavilion style hospital of the 1600's reflected an image of a more humanistic era of patient care and treatment. The image portrayed by the pavilion hospital symbolized a new compassion in the social relationship between men.1 The evolution of this hospital pavilion design expresses meaning through the new cultural values it represented. Just as the ancient shamans and medicine men used imagery to reinforce their authority to heal , our modern " high-tech " shamans ( physicians) use their scientific image to reinforce their power and authority for healing. Modern medicine is associated with a clean , efficient and technological image created i n the modern hospital. The new architecture of the Bauhaus was based on the design philosophy of " starting from zero. " This precept o f Modern ism has interrupted any historic continuity in the architectural design of hospitals. Modernism has created a generation of hospitals which have no architectural origin or historic meaning for health.

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(5) THE MODERN HOSPITAL "STARTING FROM ZERO." 11 The new relationship between patients and health care providers will create a new message and meaning for health care facilities. Changing the control and hierarchy of the health care market place will change the image and message found in the architectural design of hospitals. Hospitals will no longer portray an image of the .,doctor's workshop ... "Those who rejoiced in the advances of technology also witness a frightening coldness toward the human spirit: the best money can buy, the most cost efficient , often describe assembly lines and warehouses but not health care centers" (Bengtsson , 1985). While modern medicine transformed the hospital into an arsenal of technology and a model of efficiency, the "new hospital " will speak to more than simply the functional needs of scientific medicine. I believe the modern hospital's architectural image of authority , power, and control will give way to a new image and meaning for the patient/consumer. The meaning and mission -of health care is not authority, power and technology. The hospital's primary mission is health and the hospital's physical image should reflect that mission. Re-prioritizing the architectural images and meaning of medicine can provide hospitals with a new message of caring, wellness, and health . With this new image and the restoration of its traditional mission in health, hospitals can provide their patients with new meanings in the process of healing: o Respect for the quality and potential of human life ; o Awareness of our life's cycle through birth, health, sickness, and death; and o Meaning through a process of self discovery in healing and human potentiation.

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IMAGERY AND MEANING IN THE CASTLE ROCK HEALTH CENTER To respond to the new hierarchy of patient oriented health care, the architectural design of the Castle Rock Health Center (CRHC) is centered on the themes of the human life cycle:2 o The life cycle is an unending process of rebirth of the life/spirit; o The life cycle has a cosmological link to nature and the universe; and o The life cycle is a story of passage and a process of self discovery. MIDDLE AGE ADOLESCENCE LIFE CYCLE MATURITY BIRTH DEATH 12 The remainder of this chapter describes principles for using this design imagery as a tool to instill new meanings and messages into health care facilities of the future . Descriptions and examples from the CRHC design problem will demonstrate these principles of design imagery. Public Image of the Castle Rock Health Center The modern, market-oriented hospital uses architectural design to communicate a specific public image, personality, and mission to its community of users. Research oriented hospital systems create their "state of the art " image through " high-tech " architectural design. " High-touch" personal service hospitals use low scale residential designs, while large powerful hospital systems build soaring patient towers to instill confidence and authority in their hospital's healing image . This variety of designed public images plays a significant role in attracting a specific market group to any hospital or health care system.

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IT SBOULD BE IMPRESSIVE EtiOUGH TO INSPIRE CONFIDEUCE AND AWEBUT NOT SO ORIIATE THAT PEOPLE WILL LAUGH UPROARIOUSLY WilEN YOU SAY 'tiONPROFIT HOSPITAL.' Health Care and a 11Sense of Placeu AN IMAGE PROBLEM 13 In the future, medical facilities will attempt to establish a "sense of place " within the health care community. As competition in the medical market increases, instilling a sense of attachment and community loyalty will be a major focus of any hospital's design image. The goal of this imagery is to give hospitals a special meaning and place in the life of its patients. Creating hospitals that have a 11Sense of place11 requires matching a facility's mission to its designed image. Many hospitals hold little significance and are faceless and placeless institutions within their communities. Often times this is due to a mismatch between the architecturally designed message or image of a facility and the goals or mission that the hospital hopes to promote. Hospitals cannot successfully promote a mission of caring and wei/ness in a facility that portrays an image that is impersonal and cold. "The very size of modern hospitals, their increasing bureaucratic organization, and the impersonal , technologically sophisticated treatments they have developed , have contributed a dehumanizing element to hospital care" (Rosenberg, 1987). The hospital's mission

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I I and design image are often in conflict. These mixed messages undermine the hospital's attempt to develop an attachment or "sense of place" within their community of users. DESIGNED IMAGES OF THE CASTLE ROCK HEALTH CENTER 14 Health care systems of the future may de-centralize the traditional hospital megastructure into variety of distinct health care functions and facilities. The CRHC campus provides individual architectural images in separate facilities for birthing, wellness, self-care, medical offices, and hospice programs. As satellites of the outpatient/hospital facility, each building can establish a distinct image appropriate to the care and treatment of its patients. Matching the appropriate meaning and design image to the significant events of birth, healing, and death can instill within a building a "sense of place" for its mission in health care. The Holistic Image The architectural design of the CRHC will reflect the wide variety of high tech and high-touch health care services and treatments found in the year 2000. Campus buildings are a mix of architectural styles from low scale residential to high-tech and high-rise. By juxtaposing these diverse architectural elements, the CRHC design captures the eclectic "fire and ice" philosophy of modern holistic medicine. BIRTHING CENTER MEDICAL OFFICES WELLNESS CENTER

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15 The CRHC design attempts to maintain medicine's public trust and " authority to heal " without creating an authoritarian public image. The success of any health care system depends on the confidence and credibility promoted in its physical image. This design projects an architectural image that is professional , but not powerful or intimidating . Historic Imagery The creation of a new public image for health care may involve the revival of specific, historic architectural designs. Using archaic or archetypal remnants , designers can recreate historic images recalling a place, time, or experience in our conscience or subconscious mind. The patterns and archetypes of the past can recapture historic images and meanings for hospitals of the future. "Art, ornament, and symbolism have been essential to architecture because they heighten its meaning, make it clear, and give it greater resonance " Uencks, 1984). The CRHC design borrows from post-modernism by using processional entry ways, large cathedral-like atrium spaces, and murals and art work which describe the historic evolution of modern medicine . ENTRY BRIDGE RESIDENTIAL HOSPICE This design attempts to recapture some of the uplifting spiritual images found in t h e original Christian infirmaries. Using the literal designs of the past can provide a new source of imagery for hospitals of the future. In addition, a well-spring of meaningful ideas may be contained in other , more fundamental design symbols.

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16 The Imagery of Symbols "Because there are innumerable things beyond the range of human understanding, we constantly use symbolic terms to represent concepts that we cannot define or fully comprehend" Uung, 1964). Symbolic forms have historically been used to represent and communicate spiritual, cultural, and scientific ideas. It is possible to use symbolic form in collective cultural images to transmit messages of health and healing. "We can also see that the arrangement of archetypal symbols follows a pattern of wholeness in the individual, and an appropriate understanding of these symbols can have a healing effect " (Von Franz, in Jung, 1964). Geometric Forms. Many of the CRHC plan forms are based on the geometry of the circle. The historic symbol of the circle represents the totality of the life cycle and the wholeness or unity of any living system. The concentric rings of roadways and landscaping in the CRHC radiate from major entry points, unifying the campus plan. The site plan's half circle is symbolic of the sky over earth, describing a cosmological link between the life cycle and the universe. From the earliest spiritual concepts to those of modern physics, the circle reflects both the atomistic and cosmologic image of the universe. CIRCULAR PLAN FORMS OF THE CRHC

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Natural Forms. Historically the process of healing has involved a variety of natural elements and forms. This important environmental connection can be m::1intained in a design using the patterns of water and the symbolic geometry of trees and mountains. The CRHC design uses water and water features in three symbolic ways: 1. To reflect the human life spirit embodied in the spirit of water; 2. As an image of the cleansing and healing aspects of water; and 3. To represent the various passages and transition points in the life cycle. 17 The life spirit of these water features begins with a large fountain outside the birthing facility of the CRHC. The water passes through many transformations, changing its mood and spirit in fountains, waterfalls, streams and ponds. These water features and streams wind their way through the CRHC campus and return to the earth as irrigation for a landscaped park outside the hospice facility. This cycle of water symbolizes passages in the life cycle from birth, through healing, to death. The water recycles and replenishes the earth in a process of rebirth. HOSPICE REFLECTING POND WATER FEATURE (7 ) BIRTHING FOUNTAIN

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18 Mountains and Tree Forms. The CRHC captures images of sacred sites and the healing mountains in the terraced land forms of the outpatient/hospital building. This hospital building mirrors the recognizable geographic forms of the Castle Rock. Tree forms and the symbolic tree of life have a recognizable traditional meaning in the process of healing. The deciduous tree symbolizes the annual rebirth of foliage and the rebirth of life. The architectural forms of the CRHC capture these images of the tree of life in the design of arcades, trellises, building forms, and indoor plantscaping. " Buildings perform their highest function when they relate to human life within , and natural efflorescence without; and develop and maintain the harmony of a true cord between them " (F. L. Wright , in Bengtsson, 1985). / PROFILE OF CASTLE ROCK ... AND CRHC HOSPITAL TREES AND TRELLIS I ARCADE

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19 Images of the Life Cycle: The Themes of Passage and Transition The story of the human life cycle is a story of passage and transition. Human devel_opment and passage from birth through adolescence , adulthood, maturity, death and rebirth are integrated with the process of life and healing . The holistic message and meaning of the life cycle theme is expressed in many of the design concepts of the CRHC. Each building design captures images of these ages in our life, while the pedestrian pathways reflect the transitions and passages between these stages of the life cycle. Circulation Systems and Passageways. The pedestrian circulation systems and elevated bridge system. both physically and symbolically connect the buildings and life ages in the CRHC campus. Movement between these buildings is designed as a physical and psychological experience of passage and transition. The architectural and landscape designs mark these passage points with a variety of changes in light, sound, texture, views, and spatial arrangement. The journey and experience of life's passage is portrayed in the physical and symbolic images of the CRHC architectural _ design and patterns of movement. CRHC BRIDGE SYSTEM

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20 Building Images of the Castle Rock Health Center. The decentralized site plan of the CRHC allows each building to express an individual image and age within the human life cycle: Birthing Center (Birth) Outpatient Center (Youth) Wellness Pavilion (Young Adult) Self-Care (Middle Age) Hospital (Maturity) Hospice (Death/Rebirth) Creation, Beginnings, Bonding , Celebration Energy, Growth, Exploration, Playfulness Learning, Changing, Independence, Uncertainty Support, Family Caring, Focus Experience, Confidence, Stability, Openness Reflection, Escape, Transition , Peace (REFERENCE APPENDIX OF THIS DOCUMENT FOR DRAWINGS OF EACH CRHC BUILDING ) As an image of health , hospitals of the future have a mission to make the life c ycle of human existence meaningful. The passages of birth , sickness, healing, and death are linked to an essential discovery of self. "We find that as we recover our health, we are discovering ourself' (Priest , 1983). The use of imagery in health care design may allow us to understand our physical frailties, emotional strengths , and personal potential. In doing this, health care architects can use imagery to instill the " new hospital" with the existential meanings of understanding , healing , and life .

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CHAPTER NOTES 1. This evolution in architectural style was promoted and funded by the European monarchy who modeled these new hospitals on their pavilion styled country homes. 21 2. The Castle Rock Health Center is a medical facility of the year 2000. The complete programmatic description of the CRHC design can be found in the "Programming Notes for the Castle Rock Health Center" (McKahan, 1988 ) .

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22 HEALTH CARE'S SYSTEM OF EXCHANGE Hospitals, like hermit crabs, have historically adapted the architectural shells of other building types. The evolution of the hospital archetype mirrors the evolution of medicine and its relationship to social structure. "The development of medical care, like other institutions, takes place within larger fields of power and social structure" (Starr, 1982). From the spiritual culture of the early healing temples to the mechc>:--.istic, scientific philosophy of in the modern hospital, architectural design has supported the functional, intellectual, and spiritual need s of medical care. A SYSTEM OF REWARDS Any market place operates on a system of exchange and health care is no different. The term " medical market place " has appeared only recently, but the concept of a health care market is not a new one. Throughout history, the knowledge to treat illness and heal the sick has been exchanged for a variety of spiritual, personal/social or financial rewards. Spiritual Rewards The early Christian concept of receiving spiritual grace in return for sheltering and healing the sick was fundamental in the establishment of church hospitals. Christian stewardship under the moral model of " the good Samaritan," was linked in the gothic abbeys and church infirmaries of the Middle Ages. The architectural design of these church/hospitals was believed to improve both the patient's physical health and spiritual condition. (4) THE DEVIL AND DISEASE

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Personal/Social Rewards The arrival of modern, scientific medicine in the mid 1800's broke the linkage between spiritual and physical health. Health care began using the popularity of scientific medicine to convert the spiritual exchange model to a 23 system of personal and social rewards. Medical organizations used the new pavilion style hospitals of the 1800's, and eventually the modern high-rise hospital of the 1900's, as a means to change the status and professional position of the medical care organization. With the rise of clinical research and physician training , many pavilion style hospitals were transformed into the archetype of an educational campus. These large pavilion hospitals supported health care's process of exchange with a wide variety of personal and professional rewards. "Physicians were paid in prestige and clinical access; trustees in deference and opportunity for social accomplishment; nurses and patients were compensated with creature comforts: food, heat, and a place to sleep. . . Few dollars changed hands but the system worked in its limited way for those who participated in it" (Rosenberg, 1987). The educational campus plans of the pavilion hospitals provided the growing field o f medicine with a facility suited to the production and reproduction of medical knowledge. PAVILLION HOSPITAL OF 1840

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24 Financial Rewards The new scientific hospital was successful in providing medicine with additional sources of medical knowledge, authority and prestige; however, it operated on more than just personal rewards. By the early 1900 ' s health care' s process of exchange required greater amounts of financial fuel. The medical care organizations of the early twentieth century quickly learned how to convert their new found power and authority into a system of substc> .. tial financial gains. The use of medical technology and efficient high-rise health care changed hospitals into the modern "doctor's workshop" (Starr, 1982). "In much the same way that manufacturing technology shaped the factories and shops necessary to its efficient use, medical technology influenced the development of the modern hospital" (Ackerknecht, 1982). In these three historic examples we can see a direct relationship between health care's system of exchange and the creation of new hospital designs. "For almost 2000 years the design of hospitals and their healing mission were linked " (Breakstone, 1987). The spiritual reward system relied on the moralistic design concepts of churches; personal and intellectual rewards depended on an educational model for hospitals; and financial rewards demanded the modern efficiency of a medical factory. I believe that the changing systems of spiritual, personal, and financial rewards were a major cause in creating these new

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25 hospital archetypes. We can see in each of these examples that the medium of exchange affected the hospital's place of exchange. As health care's system of exchange continues to look for new sources of financial fuel, the highly competitive market place and new emphasis on the patient/consumer will give rise to the retailing of health care. "The merchandising of health care is just beginning. Health care is not a product like soap, but it can be sole:! to customers, to individual consumers in the community and to major purchasers " (Coile, 1986). If hospitals are to remain as the central market place in health care's process of exchange, they must learn to adopt and adapt the successful market oriented design concepts of retail centers. The merchandising of health care services requires the "new hospital " to be more attractive, accessible, integrated, and flexible. The remainder of this section describes these new retail concepts for health care and demonstrates these principles in the design of the Castle Rock Health Center. RETAIL DESIGN CONCEPTS FOR HEALTH CARE Hospitals have become service oriented health care systems in which the patient is also a customer. To provide these services more efficiently, medicine has focused its treatment programs on a variety of outpatient health care programs. This collection of health care services now extends to ambulatory surgery , portable radiology departments , freestanding birthing centers, storefront medical labs, neighborhood emergicare centers and a variety of retail medical offices and stores.1 We can see that in the future, health care's system of exchange will be increasingly dependent on the retailing and marketing of medical services. For over 30 years, the commercial market place has relied on the design concepts o f shopping centers to attract and serve consumers. The architectural evolution o f health care will continue as hospitals learn to acquire these successful retail

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26 concepts to fit their own outpatient oriented market. The following are three major retail concepts that will affect the future of hospitals and health care facilities . will explain and demonstrate the use of these retailing principles in the CRHC design problem. 1. Attracting The Patient/Customer The new health care market place has caused a reversal in the attraction or polarity between hospitals and their patients. As more providers seek fewer patients, health care must now attract the customers that used to come automatically. "Doctors will have to begin appreciating our business and striving to keep it" (Stoline & Weiner, 1988). As we once were sent to the hospital, the hospital now attempts to send out a new message and new image to attract patients/customers to its services. The CRHC design uses a variety of design concepts to attract a community of users to its health care facilities. o The CRHC design promotes a new public image of health, wellness and caring; o The CRHC design attracts the outpatient market with the convenience of providing a complete continuum of care within a single integrated health care center; o The CRHC uses attractive architectural design features such as extensive landscaping , building atriums and water features; and o The CRHC design reduces anxiety of both patients and visitors by making accessibility and wayfinding a design priority. 2. Accessibility and Wayfinding Throughout history there have been remarkable similarities between the educational disciplines of teaching and the hospital's role in healing. It is not surprising, therefore , that both hospitals and educational programs would evolve into a similar campus design setting. The modern hospital campus , like an

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27 educational campus, has been a cloistered environment for the treatment of patients and production / reproduction of medical knowledge. Scientific medicin e of the 1900 ' s turned hospitals into institutionalized "body shops." Health care facil ities were closed , controlled medical establishments , focused on treatment and cur ativ e care. Patients were guided throughout the hospital system with most access and control focused on the needs of health care providers. Surgery Flow (5) WAYFINDING IN " THE BODY SHOP " The current outpatient oriented market will require the replacement of this outdated educational campus model. The new health care center must be much more permeable, and accessible to the patient/consumer. The new emphasis on wei/ness and outpatient care requires ambulatory patients and visitors to be self directed and move easily throughout the health care system. The foll owing design concepts can provide medical centers with greater accessibility for the new outpatient market. Permeability. The ability to access and enter any health care system begins at its perimeter street entrance. Segregating patient and visitor entry points from staff and service entries can eliminate much of the confusion and ambiguity associated with the traditional health care campus. The CRHC design has onl y two major

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28 points of public access, one which approaches the retail/educational buildings, and one which accesses the medical treatment facilities. Each building within the CRHC design has a dominant public entrance. The architectural design of all major public access points is accentuated from all other secondary service and staff entry ways. _) MAJOR INPATIENT ENTRY OUTPATIENT ENTRY j Previewing and Visibility. Analogous to a battl eship with its accompanying flotilla, most modern health care centers consists of a large regional hospital linked to medical office buildings, parking structures, nursing homes, and a variety of outpatient treatment centers. The ability to create an accessible and intelligible health care center is dependent on the patient/consumer's ability to preview its system of circulation. "The problem of wayfinding is particularly acute in mos t urban health care institutions, where finding the emergency room, the x-ray department , the laboratory, or even one's own doctor is frequently a source of frustration , anxiety, and even anger " (Scurlock and Wise , 1985). To reduce confusion and anxiety, the entrance to a health care center should provide an

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29 overview or preview of building entry points as well as pedestrian and vehicular circulation systems. Providing public entry points on the most elevated portion of the site will allow users to preview the health care campus and develop a cognitive mental map of its layout. OVERLOOKS AND PREVIEWING The design of the CRHC provides for previewing the system at both a global and local level. The global preview of the CRHC begins with an orientation and vista of the mountain ranges to the west and the Castle Rock to the south. These two major geographic formations are familiar to all residents of the area and can serve as recognizable compass points for constant visual orientation. The global preview of the CRHC also reveals a distinct hierarchy of scale between the variety of campus buildings. The largest of all facilities is the outpatient/hospital building located at the center point of the health care center . In a "disneyesque " arrangement, all secondary campus buildings are positioned as satellites radiating off the central outpatient/hospital building. Each of these satellite facilities has a recognizable architectural image , visible in a preview of the health center. Circulation patterns and trafficways are modeled on two distinct geometric patterns. Pedestrian building connections are designed as straight radial bridges emanating from the central outpatient/hospital; parking lots and roadways are

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circular and circumferential. Building entry points are accentuated by the processional designs of their pedestrian bridges and contrast against the circular vehicular traffic ways. 30 As patients approach their destination in the health care center, their movement and direction should be reinforced with local sources of orientation and recognition. Too many hospital campuses have become dependent on a bewildering array of to resolve this wayfinding problem. Building entries, and vehicle drop-off points must be delineated in the architectural design of each facility. The CRHC design assists previewing at the local level by providing most pedestrian circulation on bridges above the drives and parking lots. This planar separation provides a three dimensional distinction between vehicular and pedestrian circulation systems. From these upper level pedestrian bridges most aspects of the health care center can be previewed. Uninterrupted views of both buildings and the surrounding hills and mountains provide focal points for orientation and patient wayfinding. The use of large open spaces such as plazas, atriums, and malls improves accessibility in the design of shopping centers. " Hospitals may be replaced by medical malls, which will be much like department stores for centralizing a variety of specialized health care services" (Mann, 1987). COPLEY MEDICAL MALL AURORA, ILLINOIS (J)

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31 The creation of malls and atrium spaces can provide attractive, accessible and familiar architectural solutions for a variety of new health care facilities. The open space of medical malls will provide an increased ability for customer previewing and a familiar, traditional solution to the problems of wayfinding. Malls can provide unobstructed axial views of entry points as well as improve visual access to outdoor orientation such as daylight, streets, and land forms. Open circulation systems such as atriums and medical malls can replace modern medicine's traditional labyrinth of disorienting, maze-like corridors. OUIPA'11.eNT TYPICAL MEDICAL MALL PLAN O<.J'Ts l r::e VIEVV Eb Adapting to its new socio-economic market place will require health care to adopt the retailing concepts of the commercial market place. The ability to preview the health care center's global and local circulation systems can provide hospitals with the same access and intelligibility as a good retail shopping center. Circulation Systems. Operating 24 hours a day, the modern health care campus is inundated by waves vehicular and pedestrian traffic. Trafficways for trucks , service vehicles, ambulances, buses, and pedestrians must coexist with large numbers of cars from visitors and staff. Parking areas must be properly located to accommodate the different needs of inpatients and outpatients. Roadway systems must segregate service and emergency vehicles from patient and pedestrian access ways.

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HOSPITAL VEHICULAR ACCESS PATTERNS (S) 32 Buildings in a health care complex differ from edur::..1tional campuses in that the acuity of most patients and the transport of costly equipment between buildings require most facilities to be physically linked through protected walkway systems. While health care systems of the future will require more integration and accessibility, this variety of trafficways, circulation, and physical connections can create new barriers and problems for architectural design. The site design of the CRHC resolves many of these circulation conflicts by segregating pedestrian, vehicular and service trafficways. Patients and visitors to the CRHC can access buildings through airport type drop-off ramps or from parking lots that radiate out from each building entry point. After parking, they can ascend stairs or elevators to the upper level pedestrian bridge system. While some service connections are in below grade tunnels, most pedestrian circulation takes place on covered passageways and bridges above the parking lots and roadways. All service vehicles and ambulances are provided separate entry points to the campus on segregated service roads along the health center's perimeter. Segregating these three systems of circulation and carefully controlling their connecting points can eliminate traffic conflicts, congestion, and add a new level of clarity to the variety of circulation systems in the CRHC. For increased efficiency of its circulation patterns, the CRHC has grouped interdependent health care buildings within zones of the health care complex. This design uses the outpatient hospital facility as the central anchor tenant surrounded

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33 by peripheral satellite health care services. The CRHC design recognizes certain symbiotic relationships such as birthing and the hospital building, and retail health shops and the medical office buildings; these are placed in close proximity. The CRHC is divided into five distinct zones for the grouping of these interdependent services. I \ I \ \ I CRHC ZONING PATTERNS I I (Zone 1) Health Care/Retail Health Shops and Medical Office Buildings (Zone 2) Accessible Health Care Health Education/Wellness, Emergency Care (Zone 3) Core Health Care Outpatient/Hospital, Self-Care Facility, Birthing Center (Zone 4) Ancillary Services Administration, Research and Development, Plant Services (Zone 5) Health Care Secluded Residential Hospice "The plans and programs of a health care institution establishes its future and are the key to its survival" (Porter, 1982.) As health care invests in making their facilities more accessible and identifiable, they must protect that investment by maintaining an organized set of planning concepts. The segregation of Circulation systems and zoning of interdependent health care facilities can provide master planning principles for a more organized and accessible health care center of the future.

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34 3. Flexibility Traditionally, most hospitals have been built as lasting monuments to medicine and the art of healing. Similar to a memorial, cast in stone, the monumental old hospital was built to be strong, permanent, and unchanging. From their sturdy concrete frame to the finishing of the interiors, hospitals reflected a strength and permanence, legitimizing the role of medical science in our society. While adequate for hospitals of the past, it is doubtful that these institutional dinosaurs will meet the dynamic, changing needs of health care in the future. The new medical market place requires a tremendous diversity in health care treatment and technology, with an increasing emphasis on the cost and quality of care. Health care centers must become as flexible and responsive as the dynamic market place they serve. To support this dynamic new medical market, hospitals must abandon the past design concepts of a single, durable construction type. Health care facilities of the future may be constructed of two distinct, but interdependent building components: a functional shell infrastructure and a supporting interior intrastructure. The CRHC design describes the respective attributes and design characteristics of a infrastructure/intrastructure building type. Castle Rock Health Center Infrastructure. Unlike the classroom buildings of an educational campus, hospital facilities cannot be repeated as duplicate structures. An educational campus can evolve in a repetitive, segmented fashion , while health care buildings must be constantly subjected to remodels and additions to provide new space. Hospitals and health care facilities must grow through an organic process of building one addition on to another. REMODEl., REMODEL, REMODEL.

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35 To accommodate this pattern of growth, the superstructure of health care facilities should be a modular infrastructure grid capable of rapid expansion and numerous structural penetrations for future mechanical and electrical systems. The infrastructure design should accommodate interstitial spaces for component electrical and mechanical medical systems. These interstitial spaces would maximize flexibility and minimize downtime for remodeling and refitting of new medical equipment. The design and plann :11g of the CRHC infrastructure is considered an investment for the lifetime of this health care facility. lntrastructure. The creation of the medical malls and freestanding outpatient centers is a response to the new era of "boutique medicine." New products and services such as sports medicine, laser surgery, and stress clinics come and go quickly in the health care market place. In addition, new break-throughs in medical technologies such as lithotripters and digital imaging systems are announced almost daily. The CRHC employs a flexible interior intrastructure to provide moveable or disposable building components for these high turnover areas in health care. In each case the spaces and design materials are matched to that department's predicted life span. Planning for obsolescence by " value engineering " the intrastructure will allow hospitals to focus technology and dollars more appropriately within any new health care facility. Creating health care facilities with a master planned infrastructure and a flexible intrastructure will allow for the wide variety of treatments, technologies, and services needed for the new age o f health care. NEW SPATIAL STRUCTURES FOR HEALTH CARE The new social and market structure of medicine will require a new spatial structure for health care facilities. The introduction of a new retail

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model for health care will produce a corresponding change in the spatial geometry of health care designs. As previously discussed, since the mid 1800's many hospitals have been modeled after the educational campus. The closed and controlled spatial systems of these educational campus models provided scientific medicine with a spatial structure conducive to the social and functional needs of medical science at that time . 36 " Medicine's rise to power was built on a monopoly of scientific medical knowledge " (Starr, 1982). The creation and reproduction of the " knowledge to heal" was contained and controlled within the modern hospital. The modern hospital with its labyrinth of corridors and segregated spatial systems was controlled and understood solely by physicians and hospital personnel. The power and control that the medical staff held over patients was reinforced by the hospital ' s intimidating spatial structure. " High status professions almost always maintain pres tige through some form of distancing and control of interface between professional and client , doctor and patient" (Brown, 1988). The closed and cloistered educational model also supported the increased departmentalization of the modern hospital. With the rising complexity of medical care in the early 1900's came the distinct divisions of labor within the medical care organization. The new scientific philosophy of the "body / machine " transformed hospitals into departmentalized medical factories. The segregated spatial systems of the modern hospital have been used to control and reinforce the departmentalized concept of systematic " assembly line medicine. " The use of a new retail genotype for health care centers will require the addition of a new spatial structure that is both open and integrated. The creation and distribution of knowledge is fundamental to the process of healing. " With built space, people move and encounter each other to transmi t

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37 information ... " (Brown, 1987). The diagnosis and treatment of any illness is dependent on the integrated activities of a number of medical disciplines. The work of specialty departments in radiology, laboratory and internal medicine must be linked to the activities of staff providing treatment to the patient. This inte grated knowledge system extends ultimately to the patient in the form of health education. Today's more holistic approach to medical care requires a more integrated spatial culture for the interaction of ideas and sharing of knowledc;e between these medical disciplines of the hospital. The open and more integrated spatial culture of health care facilities can also assist in the more horizontal management structure of the "new hospital." As independent cost centers, each hospital department has become increasingly autonomous and is often times internally managed. The horizontal medical care organization can be more effectively managed in a more open and integrated system which promotes face to face contact and "management by walking around " (Peters and Austin, 1985). Spatial Syntax Studies Studies of past , present, and future hospital plan geometries show an interesting evolution in the spatial arrangement of modern health care. Created by the Barlett School of Architecture and Planning, University College , London, the space syntax method is used to analyze and record the interconnections of physical spatial systems. The two syntax diagrams shown below describe the difference between a closed, controlled treatment oriented hospital system and the more open integrated spatial systems found in outpatient preventative health care.2

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THE OPEN, INTEGRATED SPATIAL SYSTEM Controlled Spatial System 38 THE CLOSED, CONTROLED SPATIAL SYSTEM Departmentalized medical systems require a controlled spatial system which provides surveillance points and control through ante-rooms. These spatial systems are segregated from one another and produce very deep inaccessible spaces within the system. The traditional medical concept of " bed rest" for patients was conducive to the deep spatial arrangements of hospitals. High-tech medical treatments will continue to benefit from this segregated, departmentalized spatial arrangement as it supports the efficient process of a systematized medical pra c ti ce. The Integrated Spatial System The spatial geometry of integrated systems shows more points of conta ct between a variety of spaces in the network. A single starting point branches quickly in this shallow, integrated spatial network. Health care designs such as medical malls can benefit from the increased accessibility provided under such spatial arrangements. Outpatients can access a variety of departments and services from a single open space in this integrated spatial system.

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39 Spatial Arrangements of the Castle Rock Health Center The concepts of spatial integration are demonstrated in many of the retail design concepts of the Castle Rock Health Center. Providing spatial and circulation systems which are networked to be open and interactive will make the CRHC a more accessible outpatient health care center. The zoning or cloistering of CRHC buildings provides an integrated, symbiotic collection of health care services. The interconnecting landscape elements , parking areas, walkways , and bridge systems assist in the total concept of an integrated health care center. Many of the CRHC facilities such as the medical offices, outpatient/hospital, wellness center and self-care building contain atriums or medical mall spaces. These large, open volumes of space can be used to integrate a wide variety of health care services in the traditional retail design model. These malls and atriums provide users the ability to preview a series of entry points, familiarizing patients with a wider collection of health care services.3 As the central, circulatory connecting point, these malls, atriums and plazas are the ideal point of personal contact between physicians , staff, patients, and visitors to the Castle Rock Health Center. With the increase in outpatient medical services the CRHC attempts to use these open and interactive spatial systems to provide a more accessible retail oriented design model for the CRHC. The CRHC design will provide a combination of both controlled and interconnected spatial networks appropriate to specific medical treatments and preventative programs found in health care centers of the future.

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CHAPTER NOTES 1 . These freestanding centers feature a unique retail concept of outpatient , drive-up medicine euphemistically known as " Doc in the Box. " 2. The comparison of these old and new spatial geometries of hospitals is derived from the comparative plan studies of M. Gordon Brown. 3. Many outpatient services such as health education programs rely on the retail concepts of "point of contact sales" and "impulse> buying. " 40

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41 PRESCRIPTIVE ENVIRONMENTS FOR HEALTH CARE Over the last decade western medicine has discovered limitations in the paradigms and practices of high technology healing. Dealing with the body separate from the mind has limited the healing process to treating symptoms without understanding the context of many d iseases. " Bolstered b y a blizzard of research on the psychology of illness, practitioners who once split mind and bo d y are trying t o put them back together " (Fergus on , 1980 ) . The new holistic paradigm of western medicine now regards the mind and body as a single entity i n the total healing process. The most successful new tool in this therapeutic revolution is the rediscovery of guided or healing imagery. Throughout history healing imagery has played a key role in almost all eras of medicine. The ancient shamans or medicine men used imagery to instill a sense of well being in their patients and promote the healing process. The Greek hea ler Asclepius was influential in early medicine and the development of healing imagery. Over 200 healing temples were erected throughout Greece , Italy and Turkey to honor his practice of dream healing . The first record of a designed environment for healing was in a ncient Egypt. " The Egyptians believed that if they painted beautiful murals of nature in a place of healing, a person would have a vitality and an interest in life. This w ould physicall y aid the healing process" (Maxion , 1988). H e aling with the imagination was adapted from the Asclep ian temples and implemented by the Christian church infirmaries. "During the twilight state between sleep and wakefulness , the patients would have images of the revered healers , who would provide diagnostic information and administer cures" ( Achterberg , 1985). From the ancient shamans to the Navajo medicine man, many cultures of medicine have invoked the powers of the mind to heal the body . " The most

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42 important thing I learned from my grandfathers is that there is a part of the mind we don't really know about; it is that part which is most important in whether we become sick or remain well " (Thomas Largewhiskers, Navajo Medicine Man, in Achterberg, 1985). This history of medical practices shows that mental visualization is integral to many healing processes. Only the era of western scientific medicine, beginning in the early 1800's, attempted to divorce mind and body in its medical treatments . Rational scientific medicine saw the human body as a mechanical model and believed technology provided the primary means to repair the damage of disease. This high technology, mechanistic approach to healing was a major contributor to the creation of the "body shop" image of the modern hospital. "By 1910, the hospital had already begun to appear to some of its critics as a monolith and impersonal medical factory" (Rosenberg, 1987). The shared philosophies of modern medicine and modern architecture saw both the process of healing and hospital design as a problem in functional mechanics. This brief 150 year period in medical history was the only era which did not recognize the linkage between body and mind in health care. Only as modern medicine began to rediscover the value of a more holistic approach to healing, has it become respectable to again explore the role of the mind in health and medicine. The new holistic concepts of medicine reunite mind and body using the therapeutic tools of healing imagery. "A major cause of both health and sickness, the image is the world's oldest healing resource" (Achterberg, 1985). Healing imagery is the thought process that evokes the therapeutic linkage between perception, emotion, and bodily change. Guided imagery _ can harness the powers of the conscious and subconscious mind to produce a somatic response to a mental image. The therapeutic concepts of . healing imagery have gained credibility with the re-discovered link between mental

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43 images and the parasympathetic nervous system. This portion of the nervous system has the ability to control and stimulate the human immune system. " According to new research, a variety of techniques -specific images, positive feelings, suggestions, learning to respond to stressors in a relaxed way -all have the potential for increasing the ability of the immune system to counter disease. Very current studies have shown that the immune system itself is under the direct control of the central nervous system, those areas of the brain implicated in the transmission of the image to the body" (Achterberg, 1985). Imagery is now being studied at all levels of medicine from diagnosis to rehabilitative treatment. Development of modern bio-feedback techniques relies on mental imagery, allowing patients to control their own heart rates and blood pressure levels. Cancer patients who imagined their immunological systems attacking tumors showed significant and statistically verified improvement over patients who were not exposed to these techniques of healing imagery (Ahsen, 1984). The relationship between healing imagery and architectural design has been researched by Stephen Verderber of Tulane University. These studies show that hospital patients with windows viewing the outdoor environment heal quicker, require less medication, and are discharged sooner from the hospital. , Like many of the past cultures of medicine, these patients have benefited from a designed environment which promotes visualization and healing imagery. I believe their early discharge from the hospital results from a positive somatic response related to their increased ability to imagine themselves as healthy. As the new holism of medicine reunites body and mind in the healing process, a dramatic transformation will take place in the design of health care facilities. I believe the hospital 11body shop11 will give way to new health care facilities designed to harness the mind's potential in the total healing process.

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The re-introduction of the mind's role in medical treatment presents health care architects with major new challenges and opportunities to participate in the total healing process. Health care designs which can optimize the healing, somatic linkage between body and mind will require a greater understanding and an infusion of concepts from environmental psychology. As holistic medicine can now prescribe guided images for healing, architecture must reinforce the imagery process, creating .. prescriptive environments .. for health. DESIGN OF THE HEALING ENVIRONMENT 44 "Psycho-architecture will be used to heal and teach. The type of knowledge possessed by the cathedral builders of the Middle Ages will enter this time in a high-tech environment" (Kaiser, 1986). These new "high-push" environments for healing will be focused on maximizing the therapeutic value of conscious and subconscious images. The "psycho-architecture " proposed by Dr. Kaiser would require a " prescriptive environment " affecting a variety of senses to reinforce and help "push " the therapeutic healing image. "Humans crave information about their surroundings. In the process of constantly endeavoring to comprehend and make sense of our surroundings, all five sensory modalities have come to bear on the processing of information about our environment " (Verderber, 1986). Confined to patient rooms and treatment areas, hospital patients are particularly attuned to their limited range of physical surroundings. Because they lack stimulation and distraction from other sources, non-ambulatory hospital patients will have a greater exposure and potentially a greater response to these "prescriptive environments" for healing.

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45 The Castle Rock Health Center The design concepts of the Castle Rock Health Center demonstrate a var iety of ideas as a "high push" environment for healing. o Visual stimulation is increased through the use of prescribed colors, textures, and forms;2 o Art work is provided as a tool for healing imagery. "Since the very beginning of time, man has used art as a way to make his imagination palatable. The Egyptians would paint the ceilings blue like the sky and the floors green like the meadows of the Nile and often create little gardens right outside of their healing places or ancient hospitals" (Maxion, 1988); o The CRHC has an electronic sound system for environmental sound tracks and prescriptive, subliminal messages; and o As proposed in the original Nightingale hospitals, the CRHC has operable windows that re-introduce the use of fresh outdoor air in a health care facility . Certain aspects of the CRHC design attempt to tap the knowledge and powers of the cathedral builders as described by Dr. Kaiser. The historic, mythic qualities of sacred structures are reflected in the pyramidal forms of the CRHC wellness center. Tree forms are found in the bridge, arcades and atrium of the medical office building. The terraced shape of a ziggurat provides the basic concept of the outpatient/hospital building. This eclectic combination of natural forms and built structures attempts to revive a variety of historic, physical forms as a mnemonic tool of collective subconscious imagery. Health care designs of the future may employ architectural styles, from pre-history to post modern, and from grass huts to geodesics , to create a holistic healing environment and a new architecture for health .

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46 CONTACT AND THE CONTEXT OF HEALING Prior to modern antiseptic theory, hospitalized patients often died from a variety of contagious diseases known as "hospital fever. " While modern hygiene and antiseptic procedure brought these contagiums under control, the sterile, antiseptic modern hospital seems to have created a new form of anxiety and " hospital fever." The institutional designs of modern health care are often frightening and psychologicall y disruptive to hospitalized patients. " Being admitted to a modern hospital can be like entering the twilight zone " (Breakstone, 1987). The institutional setting removes patients from the supportive contact and context of family , friends and the outdoor environment. The tradition of bringing flowers to a friend in the hospital is a simple attempt to replace this loss of context in the hospital setting. The design of " prescriptive environments " must recognize this loss of context and replace it in two ways: first, by maximizing opportunities for the healing physical contact of family, friends and environment; and second, by providing improved visual contact with human activity and the environment. The CRHC design provides numerous opportunities for patient/family contact. The use of atriums, medical malls, courtyards, day rooms, and lobby space will promote increased patient ambulation and therapeutic social contact within the hospital system. Atriums and malls can also replace a loss of contact with the natural outdoor environment. The CRHC uses indoor landscaping in greenhouse atrium spaces of both the hospital and self-care center. These atriums are an extension of the health center's exterior landscaping; bringing trees, streams, rocks, plants, and flowers indoors helps bridge the loss of contact with nature.

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47 New health care designs may employ indoor plantscaping and greater social interaction , but the major point of contact with the outdoor environment remains dependent on patient views. The value of windows and viewing has been demonstrated in research showing patients with views of an outdoor environment have a shorter length of hospitalization., Direct visual images of life and human activity in the environment can provide an endless supply of positive healing images for the recuperating patient. I believe that all types of patients can benefit from the visualization and views of an active, healthy world. This visualization helps maintain a conscious mental focus outside the hospital setting. As part of the total healing process, a patient must be both physically and mentally prepared to leave the hospital. As an example , most Coloradans have a strong personal image of the activities and the " good times " enjoyed in the Rocky Mountains. These images and memories are a positive part of our regional culture and can assist in creating a positive healing image. The Castle Rock Health Center uses windows, view corridors, and strategic siting to enhance these conscious and subconscious images of the mountains and outdoor environment. The terraced design of the inpatient hospital provides most patient rooms with a view and small deck area looking over

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48 the foothills and front range. The birthing center and self-care facility have interior courtyards and views of the natural open space of the health center. A view deck is integral to the upper bridge level of the hospice facility, and each patient room has a small patio overlooking the hospice grounds and mountains beyond. FEELING BETTER ALREADY _ _ I From the time of the Greek Asclepian temples, certain sacred sites are believed to have possessed special healing powers. The Castle Rock Health Center may not hold the mystic quality of a sacred site of healing, but I do believe its position, elevation and commanding views of the city, valley and mountains beyond can enhance the process of visualization and the healing images that are integral to its holistic program of health.

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49 CHAPTER NOTES 1. Records made between 1972 and 1981 showed that 23 patients with views of natural settings had shorter postoperative hospital stays, received fewer negative evaluations in nurses' notes and took fewer painkillers than 23 patients assigned to similar rooms with windows facing a wall. 2. Studies by Stephen Verderben show a positive patient response to creative and stimulating designs in ceiling systems. Hospitals of the future may have modular wall/ceiling colors and textures prescribed to assist in visual stimulation and healing techniques.

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so CONCLUSION " The future should be known as a goal or value in itself. Knowledge about the future is useful for achieving new values and goals" (Dror, 1975). This thesis project demonstrates an architectural response to the future needs of health care. The future of health care is not predetermined; therefore , its architectural response is never totally predictable. The real value of any exercise in futures forecasting does not lie with its total accuracy, but with its ability to increase our awareness of future trends and future potential. The effectiveness of the ideas, scenarios , and concepts found in this paper should be judged on their ability to affect the design of the new health care industry. " The scenario is not just a means of exploring possible interactions of various events, but a way that we can shape the future" (Cornish, 1977). believe these ideas can help "shape the future" of health care design.

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APPENDIX Program Synopsis of the Castle Rock Health Center 51 The following is a brief synopsis of the programming document for the Castle Rock Health Center. The CRHC is an outpatient oriented regional health center serving the bedroom communities of south Denver and northern Colorado Springs in the year 2000. The health center provides its patients with a variety of primary and secondary care including inpatient care, level two intensive care, selfcare, outpatient diagnostics, health education , birthing, and hospice care. The hospital facility contains 11 0 inpatient beds and is integrated into the outpatient care unit. For a complete review of the demographic projections behind the CRHC design, see "Programming Documents, Castle Rock Health Center" (McKahan, 1988). The design of this health care center is based on the following economic , social/political and technological scenarios for the year 2000. Economic Scenarios -Year 2000 o A free market for health care services now exists. Aside from government funded programs, the supply of health care services now matches the demand. o Most hospital systems are now managed on a regional basis. The new health care system in Castle Rock is predicted to be more cost effective and responsive to community needs because of its regionally managed structure. o Most regional health care systems now follow retail models of marketing and product line management. o Despite federal attempts to regulate the U.S. health care system throughout the 1990's, the west, and particularly Colorado , remain independent and use a competitive free market to regulate the cost of health care.

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52 o A two-tiered private and government funded system of health care exists in the year 2000. o The two-tiered system of health care has both better and worse qualities than the old systems of the 1980's. Private care is more personal and patient oriented, while public care is burdened by its administrative controls and impersonal approach. o To offset increasing federal expenditures the Medicare program has reduced coverage and care in most areas. Medicare provides coverage for retirees only in the lower half of retirement income brackets. Retirement age is now 68. o A system of tax deductible savings for health care costs has been established: a medical I.R.A. program. o The private sector has absorbed more of the cost and most of the control over medical in surance coverage. o DRG'S have been expanded and adopted by most regional business groups purchasing health care protection for their employees. o As business is now required to provide 11adequate11 insurance coverage, many groups and industries have become self insured. As deductibles have risen, more health care is paid for 110Ut of pocket.11 o Almost all 11fee for service11 reimbursement programs have been abandoned. Care is now provided on a contract basis through group coverage or government funded programs. o Very few health care systems and hospitals are still considered entirely non profit. Most systems are now 11poly-corporate,11 with both taxable and non taxable programs operating under the same management.

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o Many hospitals and health care systems have venture partners in medical research and development projects. The symbiotic relationship between private research groups and hospitals has been a financial benefit to both parties. 53 o The new health care facility in Castle Rock has an agreement with Hewlett Packard Corporation for R & 0 on new micro-telemetry units used for monitoring organ transplants and bionic implants after surgery. o The Western United States continues to profit from the shorter lengths of stay in its hospitals. The Medicare DRG program believes the managed care programs and holistic treatment programs found in the Western U.S. are partially responsible for this lower hospital length of stay. o Since businesses now provide the bulk of group insurance coverage, they have played the major role in the redesign of the U.S. health care system. As the cost of health care has risen, these insurance benefits are the primary component of any employee compensation plan. o The Surgeon General's report of 1992 relating stress and disease has caused a new emphasis on stress reduction programs. Many hospitals now feature "stress centers " as an independent business group within their poly-corporate structure. The popularity of stress centers has made them very profitable facilities by the year 2000. Social/Political Scenarios -Year 2000 o Decreases in the numbers of licensed physicians has eroded the AMA ' s historic power base.

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o Allopathic medicine is now losing popularity to other forms of osteopathic and holistic medicine. California and the western United States are considered the birth place and stronghold of the new holistic medical concepts. 54 o Now in their fifties, the " baby boomers " generation has focused on issues of social concern and quality of life. o The regulatory era of the 1990's has subsided and a new wave of volunteerism appears imminent. The Castle Rock area is considered prime for tapping into this new force of volunteers for providing community charity care. o Many health care providers including nurses, physician assistants and even doctors are now considered to be " medical tradesmen" rather than independent professionals. o Most low risk pregnancies are now delivered in outpatient birthing units. o Early diagnosis and health education are now the hallmark of all HMO programs. Subscribers are now required to maintain these preventative programs in order to continue receiving care. o Free-standing hospice programs have continued to gain popularity since the early 1990's. As a less costly alternative to acute care hospitals , hospice programs now care for over 75% of America's terminal patient population. Medical/Scientific Scenarios -Year 2000 o Most X-ray equipment of the 1990's has now been replaced by digital imaging systems. Few X -ray films are used in the year 2000 and satellite transmission of images allows for centralized reading of diagnostic image s . o Many health care campuses have instituted minimal care or self-care facilities as a part of their total program. These step-down pat i ent units

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55 have minimal nursing supervision and allow patients an easier transition back to independent living. Colorado was the first state to popularize and license these self-care units within its regional health care systems. o New electronic technology and two way video conferencing now link a network of health care specialists in both city and rural hospital systems. o The use of bio-technology has exploded in the 1990's . For those who can afford it, implants are now available for replacing, ear, heart, and kidney systems. o DNA research has now produced immuno-therapy treatments that are successful in arresting 40% of the early diagnosed cancer cases. o New drugs and catheterization techniques have replaced most vascular and open heart surgeries. o Bionic implants and transplants now make up the bulk of surgical procedures in the year 2000. o The implementation of artificial intelligence has allowed for great advancement in computerized diagnostic systems. Computers from all acute care hospitals are linked to a common, ever increasing diagnostic database. The use of computer diagnosis has eliminated many specialty physicians from the health care system. o Many Americans now subscribe to two-way health care cable systems. These systems allow for at-home diagnosis, two-way contact with various medical practitioners and monitoring of elderly home-care patients.

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GRAPHIC AND PHOTO ACKNOWLEDGEMENTS Some of the graphic drawings and all of the photography in this document are reprinted. The following index of graphics and photos acknowledges the original texts as the source for these pictures. (1) Dalio, Carl J. Architectural Rendering of Castle Rock Health Center. May , 1989. (2) Hanks, K. and Belliston, L. Rapid Viz. Los Altos, California: William Kaufman, Inc. 1980. (3) Health Facilities Review 1988. Washington, D.C.: AlA Press, 1988. (4) Lyons, Albert. Medicine: An Illustrated History. New York: Abrams Publishing, 1983. (5) Porter, David R. Hospital Architecture. Ann Arbor, Michigan: Health Administsration Press, 1982. (6) Thompson, John. The Hospital: A Social and Architectural History. New Haven, Connecticut, Yale University Presse, 1975. (7) Torre, L. Azeo. Site Perspectives. New York: Van Nostrand Reinhold Company, 1986 . 56

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57 REFERENCES Achterberg, jeanne. Imagery In Healing: Shamanism and Modern Healing. Boston, Massachusetts: New Science Library. 1985. Ackerknecht, Erwin H. A Short History of Medicine. johns Hopkins University Press. 1982. Ahsen, Akhter. ISM: The Triple Code Model for Imagery and Psychophysiology . journal of Mental :.nagery. 1984. Bengtsson , jeanne B. The Humanistic Approach to Healthcare. In the International Hospital Federation Yearbook. 1985. Breakstone, jerry. History Offers Architectural Guidance to Hospitals. Modern Healthcare. October 23, 1987. Brown, M. Gordon. The Choreography of Problem Solving. Arizona State Research Fund, November, 1987. Brown, M. Gordon. The Spatial Structure of a Hospital Floor. Paper presented to American Institute of Architects, Committee on Architecture For Health. New York, May, 1988. Coile, Russell C. The New Hospital: Future Strategies for a Changing Industry. Rockville, Maryland: Aspen Publishers Inc., 1986. Cornish, E. The Study of the Future. Washington, D.C.: World Future Society Publishing. 1977. Dror, Y. Some Fundamental, Philosophical and Intellectual Assumptions on Future Studies. In CIBA Symposium, The Future as an Academic Discipline . New York : Elsevier Publishing. 1975. Ferguson , Marilyn . The Aquarian Conspiracy. Los Angeles: New Science Library . 1980 . Friedrichs , Edward C. In Aging Physical Plants: Holdovers From Another Era? Hospitals. February 20 , 1988.

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Jencks, Charles. The Language of Post-Modern Architecture. New York: Rizzoli International Publications Inc. 1984. Jung, Carl G. Man and His Symbols. New York: Doubleday and Company Inc. 1964. Kaiser, Leland R. Anticipating Your High-Tech Tomorrow . Healthcare Forum Magazine. November, 1986. Mann, George J. Beyond the Hospital: Building for a Healthier Future. The Futurist. January/February, 1987. Maxion, Cynthia. Art of Healing. Journal of Health Care Interior Design. May , 1988. Philbin, Patrick W. The Healthcare Campus and Vertical Hospital. Healthcare Planning and Design. May, 1988. Peters, Tom and Austin, Nancy. A Passion for Excellence. New York: Random House. 1985. Porter, David R. Hospital Architecture. Ann Arbor, Michigan: Health Administration Press. 1982. 58 Priest, Kathleen. Healing Crisis: Emergence of a New Medical Model. Beginnings. The American Holistic Nurses Association. May, 1983. Rosenberg , Charles E. The Care of Strangers: The Rise of America ' s Hospital System. New York: Basic Books, Inc. 1987. Scurlock , Charles and Wise, James. Wayfinding in the Complex Architectural Environment: A Process Tracing Approach. In Proceedings of the International Conference on Buildings Use and Safety Technology. 1985. Starr, Paul. The Transformation of American Medicine. New York: Basic Books, Inc . 1982 .

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Stoline, Anne and Weiner, Jonathan. The New Medical Marketplace: A Physician's Guide to the Healthcare Revolution. Baltimore: Johns Hopkins University Press. 1988. Verderber, Stephen. A Case for Reassessing the Design and Function of Windows and Ceilings in the Healthcare Environment. Research of School of Architecture. Tulane University, New Orleans, Louisiana. 1986. Excerpts from the following unpublished manuscripts have been used and referenced throughout this document: McKahan, Donald C. An Overview of Medical Care Organization in the United States: 18401992. University of Colorado at Denver. December , 1988. McKahan, Donald C. Imagery and the Faceless, Placeless Hospital. University of Colorado at Denver. September, 1988. McKahan, Donald C. A New Future for the Healthcare Campus. University of Colorado at Denver. July, 1988. McKahan, Donald C. From Hospice to Hospital: Architectural Theory in the Evolution of Healthcare . University of Colorado at Denver. May, 1988. 59 McKahan, Donald C. The Validity and Value of Futures Forecasting. University of Colorado at Denver. November, 1987. McKahan, Donald C. Programming Documents, Castle Rock Health Center. University of Colorado at Denver. December 15, 1988.

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SITE PLAN CASTLE ROCK HEALTH CENTER c.o,sn ROCK. COU)ft.t.OO (YUR 20021 liC.IW..I.t ....... --------/ Ol.fiJ\Uil:N1 ICAL1H !JLAWIICtS -__ _)

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HOSPITAL I OUTPATIENT CENTER HOSPITAL I OUTPATIENT CENTER

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MEDICAL OFFICE BUILDING SELF CARE CENTER

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WELLNESS CENTER BIRTHING CENTER

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RESIDENTIAL HOSPICE