By Laura Thomas
Second of two articles
In the beginning, Sidney Garfield and Henry Kaiser, promoters of the fledging Kaiser Permanente Health Plan, didn’t have to think: do we build a big hospital, or a small hospital? With only a few thousand members in 1945, they only had to consider “where, and how quick?
The first clinics were primitive and small, often in space adapted from an office building, storefront, old home, or automobile dealership. Atmosphere and aesthetics didn’t figure into the mix.
But that was to change phenomenally over the next few decades. In 1950, KP Northern California membership, with the recent addition of the longshoremen’s union and some government employers, was 120,000. In Southern California, with longshoremen and retail clerks, the number was smaller: 20,000.
By 1990, KP Northern California boasted more than 2 million members; Southern California had about the same. Where hospitals in Los Angeles, Fontana, and Harbor City had sufficed in the 1950s, by 1990 there were seven more: San Diego, Bellflower, Anaheim, Woodland Hills, Riverside, West Los Angeles, and Panorama City.
Where Oakland, Richmond, San Francisco, South San Francisco, and Walnut Creek had been enough for the north in the 1950s, by 1990 there were eight more: San Rafael, Hayward, Santa Clara, Redwood City, Santa Teresa, Sacramento, South Sacramento, and Martinez.
Big hospitals draw from satellite clinics
These hospitals, varying in size from 100 beds to over 500, played the role of kingpin to a network of medical office buildings (MOBs) in communities within a reasonable distance. If patients needed emergency care, surgery, or had to be hospitalized for any reason, they were taken to the hub hospital.
Generally, KP has grown by establishing satellite offices in areas where membership numbers can support an MOB. Then when membership grows in an area and overwhelms established MOBs, another clinic is built in a nearby area. When the MOBs start to overwhelm the designated hospital, another hospital is built to take the overflow. This has been the trend.
For example, when membership in the San Jose area outgrew the Santa Clara Medical Center, built in 1964, KP purchased a community hospital and established a second medical center, Santa Teresa in 1976. Similarly, when the Fairfield-Vacaville area membership outgrew Vallejo Medical Center, a Vacaville Medical Center was built in 2009. When Los Angeles Medical Center became stuffed with too many patients, Baldwin Park Medical Center was established nearby in 1995.
Facility planners get a workout
By now, membership in both regions has soared to more than 8 million, and that means more hospitals and MOBs. By last count, KP has 35 medical centers (including Ontario to open later this year) and about 430 MOBs in California. All this growth and construction has given KP facilities planners plenty of experience, and caused them to spend a bucketful of money.
So in the late 1980s and early 1990s, planners began to “plan” for a more efficient way of meeting the demand for more medical office and hospital space. Taking best practices and design success stories, they developed a template that could be used to build new buildings with a minimum of effort, lead time, and government review. Gateway was the first template developed in the 1990s and was used in part to design and build the Fresno Medical Center, Roseville Medical Center, and others.
Today’s flexible template calls for efficiency, sustainability, and beauty
The current version of the template calls for the combination of hospital and medical offices in one structure with a common entrance. However, the template is flexible and constantly evolving to address specific needs of each KP service area. The template ideas have been garnered from many sources and have been reviewed by a wide array of stakeholders, including labor, medical staff, and other employees. The functionality has been tested in mocked-up clinical situations, and designs have been validated by leading health care designers.
Throughout the years, KP architects have retained many of Sidney Garfield’s innovative ideas and incorporated them into updated hospital designs. Garfield’s idea of decentralizing nursing by creating “circles of service” survives to the present day in the triangular towers built in gateway and template model Kaiser Permanente facilities from the late 1980s onward. With the nursing station at the center and patient rooms surrounding, nurses save steps and are closer to their patients, thus they’re able to provide better care.
Garfield and architect Clarence Mayhew pioneered the design in 1962 with the construction of the first “binocular” hospital in Panorama City. It was used again for Santa Clara hospital built in 1964, but this time the circular towers were enclosed in rectangles. Garfield’s early hospital designs also called for the latest available technology. (See previous blog: “What’s the Big Idea?” posted Oct.18.)
The current iteration of the hospital template informs future construction in functionality, as well as sustainability, patient comfort, efficiency for staff, accommodation of the latest technology, effective use of light, and more. In 2008, KP opened the exquisitely designed Modesto Medical Center, a showplace for the newly evolved template and for accompanying green initiatives.
Architects vie for best small hospital design
Meanwhile, this year KP asked architects around the world to design a new prototype for a small hospital, one that challenged the status quo way of thinking about health care delivery. The Small Hospital, Big Idea competition, with three finalists still in the running, will conclude with the presentation of final designs in late January. If the stars are happily aligned, the new small hospital design may offer a viable alternative for KP to move into new areas with a self-contained, integrated medical facility.
In the competition, KP asked all contenders to think about how to make the hospital an inviting place associated with “health,” rather than “health care,” according to John Kouletsis, vice president of facilities planning. “It should be a ‘wow’ experience,” he said, “where people come out of it and say, ‘this was difficult in terms of the clinical things, but it was such a great experience. The facility was beautiful. It supported me in every way’.”
Snooping for a glimpse at the “Big Idea” design
Submissions from six semi-finalists offer a picture of what the new facility might be like. Many responded to the mandate for stressing wellness by seeing the new hospital as a place for patient health education where members can come to use a fitness center or attend classes in a facility designed to be attractive and welcoming.
In Kaiser Permanente’s new small hospital, telecommunicating expertise will help staff expand their ability to offer a range of acute, diagnostic, and surgical services as well as emergency and, perhaps, maternity care. There are numerous visions of making the facility blend both functionally and physically with the community with the possibility for storefront clinics in nearby neighborhoods or a farmers market, vegetable garden, or community park on the site.
The gadgetry so favored by Garfield in patient rooms will be ever more sophisticated and will also move into the hands of members in the guise of mobile devices that monitor their health, connect them to medical staff, and provide education and advice in the hopes of keeping them away from the hospital.
No doubt the design or designs accepted for the small hospital will incorporate the concepts so important to creating the “total health” experience in all KP’s facilities. Also, Garfield’s ideas of keeping patients healthy through illness prevention and health education will come through in plans for the compact hospital to be a pleasant place where support for healthy lifestyles and learning is paramount.
By Laura Thomas
First of two articles
When the winner of Kaiser Permanente’s “Small Hospital, Big Idea” design contest is announced in February, at first glance it may appear the 65-year-old health plan is taking a major turn off the road it followed for decades: building large hospitals as hubs for satellite medical clinics in surrounding communities.
In the competition, architects have been asked to dream up a model for a community health center with many of the features of a larger KP hospital, including surgery, emergency, laboratory, and pharmacy. The small hospital will leverage the newest diagnostic, treatment, and communications tools for outpatient and inpatient basic and acute care — all in one cutting edge hospital.
The key for planners is to find a set of design concepts that will balance the latest in technology with a humanistic approach in providing efficient, affordable, and high quality care. The “hospital” will create a place to encourage and nurture a healthy lifestyle for KP’s members and the community at large.
The winning design will be used to wildly modernize and perfect the self-sufficient hospital design pioneered by Garfield on construction sites in the Southern California desert and the Grand Coulee Dam in Washington State in the 1930s and 1940s.
The plans, promising to be ingenious, will be the blueprint for construction of the “best of the best” small KP hospital, likely to be built in the High Desert northeast of Los Angeles. Rather than being a major departure from tradition, the Small Hospital, Big Idea concept will bring the medical plan’s legacy of hospital building full circle.
Ironically, the setting for the early Garfield hospital designs, as well as the imminent creation of the KP futuristic “Big Idea” small hospital, was and is the Southern California Mojave Desert.
Ingenious health care for Garfield’s time
Garfield’s ability to keep 11,000 Los Angeles Aqueduct workers healthy improved greatly as the men came in for routine checkups instead of waiting until they were really sick. His other initial foray into prevention was direct: To reduce head injuries and nail punctures, he went to the job sites and lectured the workers about pounding down nails and then inspected tunnels for dangerous shoring.
Garfield eventually built three hospitals in the desert, equipping them with air conditioning — the latest technology — and newly invented venetian blinds. He furnished the wards with soothing color schemes, flower containers, and personal radios to elevate patients’ moods.
Garfield’s three hospitals were far flung — the first at Desert Center, another at the east end of the aqueduct at Parker Dam, and the third at the Imperial Dam near Yuma, Arizona. He staffed each with a physician, and he zipped back and forth by car across 100-mile stretches of desert to perform surgery.
Garfield’s next project was to refurbish and outfit a rundown 35-bed facility for Henry Kaiser’s workers on the Grand Coulee Dam project in Mason City, Washington. The union was excited when Garfield promised air conditioning, but Kaiser’s son Edgar, who was running the project, said no. (Garfield installed it anyway, paying for it out of his pocket; a slightly annoyed Kaiser reimbursed him).
That small hospital, with its early team of group practice doctors, went full bore into preventive care for the 15,000 residents (workers and their families) in the company town.
“They saw simple acute appendicitis instead of peritonitis; earaches instead of mastoiditis; upper respiratory infections and less pneumonia; early lumps in the breast instead of metastatic carcinoma,” writes Dr. John Smillie in his history of the Permanente Medical Group. “The Coulee physicians were capable of handling just about any case that came their way, including serious cancer surgeries. Only one patient, a suspected brain tumor, had to be referred to Spokane.”
They also established a satellite community service: Millie Cutting, a nurse and wife of job site physician Cecil Cutting, solicited funds door-to-door — and received generous contributions from the brothel madams — to set up a well baby clinic in a local church.
Bigger challenges on the Home Front
The urgent need for quality health care for Kaiser West Coast Shipyards workers during World War II dictated the facilities Henry Kaiser and Sidney Garfield could establish for their often sick, weak, and injured patients. The Richmond Field Hospital, later serving the community at large, was thrown up in a hurry and opened with 10 beds in August of 1942.
Garfield carefully designed the modern 70-bed Oakland Medical Center, although it was the hurried resurrection of the surviving maternity wing of the Victorian Fabiola hospital, which had been torn down years before. The Oakland hospital, also opening in August of 1942, expanded twice (to 145 beds) before the end of the war and its successor structures remain the hub of East Bay facilities to this day.
With World War II behind him and the Kaiser Permanente medical plan beginning to grow, Sidney Garfield was able to experiment with various ways of using architecture and design to improve both the efficiency of staff and services and patient comfort as well. In the early 1950s, Garfield, whose boyhood dream was to become an architect, designed his first two large “dream” hospitals in San Francisco and Los Angeles and his last two “small city” hospitals in Walnut Creek and Fontana.
Innovative, efficient mid-century designs
He designed them all around principles he held dear: efficiency, economy, and patient comfort. Renowned architect Clarence Mayhew designed Walnut Creek and Fontana to echo the mid-century desire to have the indoors and the outdoors meld. Each was Y-shaped with two wings of rooms that opened to the natural environment to both soothe the patient and give visitors access while nurses, doctors, and orderlies circulated freely down an interior corridor.
Despite being small, they incorporated the features of the larger hospitals. The central work area was abolished in favor of stations distributed along the corridor so each nurse would be a few steps from her patients with records and supplies shelved nearby.
And the mostly private patient rooms were equipped with all manner of modern convenience with power-drawn curtains and bed adjustments operated by push buttons, a built-in lavatory, toilet, closets, oxygen outlet, plus phonograph outlet and radio.
Garfield received national attention for his rooming-in maternity section where babies were kept close to their mothers, but also within reach of the nurses through a bassinet that slid between the room and nursery.
Architectural Forum magazine in July 1954 lauded all the new technology and design innovations in Walnut Creek: “For all its luxuries, care at Walnut Creek actually costs less than at older hospitals. The gadgets speed recuperation and encourage patients to care for their own minor needs.” Thus, the nurses’ time spent as errand girls would be reduced. He was a great believer in the power of human contact in the healing process.
Garfield said in the KP Reporter in 1963, “Over the years, we have been working for development of functional design in hospitals in which our staffs can serve patients with a minimum of wasted time and energy. They will then have more time to be with patients, and this human contact makes for happier patients, more stimulus to recovery.”
View a 1953 video about the Kaiser Permanente “dream” hospitals.DreamHospital
Next time: Kaiser Permanente member growth spurs new thinking on how to create the ultimate patient experience.
By Ginny McPartland
At first glance, one would think the newly released novel “Wax” is about women working in the West Coast shipyards during World War II. Famed photographer Dorothea Lange’s powerful photo of proud, bold “girls” stomping through the yard implies a story about their struggles and triumphs in that setting.
Once inside, however, the reader pretty quickly understands that the stories to be told play out far from the shipyards. Three young women who met in Henry J. Kaiser’s Richmond Shipyards in 1943 formed friendships that endured for decades. The “Rosies” earned a bit of freedom and independence that they would refuse to relinquish when they returned home.
First-time novelist Therese Ambrosi Smith says she wrote the book about “Rosie the Riveter” to spark an interest among today’s young people, especially girls. Rosie national park Ranger Elizabeth Tucker turned Smith on to actual Rosie oral histories, and the would-be author was off on her quest.
World War II’s sociological impacts explored
Smith proclaims the novel’s premise on the front cover: “Pearl Harbor Changed Everything.” Historians know this fact, and they have written millions of words about the social, economic and political effects of World War II.
Smith’s approach is to place a spotlight on personal lives. She creates three main characters, Tilly Bettencourt from a small town near Half Moon Bay, California; Doris Jura from Pittsburg, PA, both in their early 20s; and slightly older Sylvia Manning, 32, from Kansas City. She shows a smattering of their shipyard employment experiences and then places them back in their peacetime lives. These war-time experiences will color all they do from then on.
Author Smith takes the theme of women’s independence full bore as the young women return home and establish a candle factory on their own. (Yes, that’s where the book title comes from!) Such a bold move had seemed impossible before the war. Despite obstacles, Doris and Tilly’s dream comes to fruition.
Life lessons learned in the shipyards
Other life lessons are to be learned as well. At the shipyards, the girls awaken to the idea that blacks should be treated equally with whites. Smith writes of Tilly’s encounter with a caring black coworker who helps her to the clinic when she receives a serious eye injury and is temporarily blind.
Later, Tilly ponders the experience: “I don’t know why,” she (Tilly) told Doris, “but this whole thing has rattled me. I mean being helped by a colored.” Smith as narrator explains: “There weren’t any coloreds in Montara or Moss Beach; she had no history with them.”
Tilly then comes to the realization: “The work was dangerous and difficult, and everyone who did it, regardless of color or background, was helping to win the war. They were all in it together.”
Doris chimes in with: “I feel like we are seeing the world up close here. It looks different.”
Although this book is fairly light on the historical significance of the Rosie experience, I enjoyed it. The characters are creditable and the description of the settings took me there. At times, I felt like I was sitting in Tilly’s uncle’s comfortable café perched on the coast near Half Moon Bay.
More about Rosies at the Home Front Festival Saturday October 15
Learn more about the Rosie experience from 11 a.m. to 6 p.m. this Saturday at the Fifth Annual Home Front Festival in the Craneway Pavilion at the southern end of Harbour Way in Richmond, California. Admission is free.
Area historical societies, the Rosie national park and the Pacific Region of the National Archives will have exhibits and information to share with visitors. Kaiser Permanente Heritage Resources will have displays highlighting the pioneering medical staff who launched the Permanente Medical Care Program in the Kaiser Shipyards during the war.
The Red Oak Victory, a World War II ship built at the Richmond Kaiser Shipyards, will be open on Saturday for visitors to tour. The ship, owned by the Richmond Museum of History, is just returning to the shipyard Friday from dry dock where it has received an extensive renovation.
Historian Steve Gilford will debut his new book on Saturday aboard the ship. Gilford will be signing the book, “Build ‘Em by the Mile, Cut ‘Em off by the Yard, How Henry Kaiser and the Rosies helped Win World War II,” from 2 to 4 p.m. on the ship. Shuttles will ferry visitors between the Craneway and the Red Oak.
Lena Horne tribute at USO Dance Friday, Oct. 14
The Home Front party actually starts on Friday night with the Rosie the Riveter 1940s USO Dance, featuring a tribute to Lena Horne, also in the Craneway Pavilion. Robin Gregory will play the role of the legendary singer. Also on the bill are the Singing Blue Stars, Junius Courtney’s Big Band and the dance group Swing or Nothing!
Tickets for the dance may be purchased online at www.HFF2011.com or by calling the Richmond Chamber of Commerce at 510-234-3512. Advance tickets are $20 general and $15 for seniors; tickets may be purchased at the door for $25 general, $20 senior. Anyone showing a military i.d. or wearing an armed forces uniform will be admitted for free.
Event: Home Front festival
Description: Historical exhibits and 1940s-era entertainment
When: Saturday, 11 a.m. to 6 p.m., Oct. 15, 2011
Where: Craneway Pavilion (end of South Harbour Way  in Richmond, California)