Posts Tagged ‘circles of service’

Experiments in radial hospital design – Denver’s Saint Joseph and Kaiser Permanente’s Panorama City

posted on February 17, 2017

Lincoln Cushing
Heritage writer


Kaiser Permanente Panorama City Hospital, California
Built 1962, decommissioned 2008, demolished 2016
Designed by Clarence Mayhew with partner Hal “H.L.” Thiederman, Dr. Sidney R. Garfield as medical consultant.

Saint Joseph Hospital, Denver, Colorado
Built 1964, demolished 2016
Designed by Robert Irwin.



Saint Joseph Hospital, Denver, circa 1970

When I was touring Denver’s Kaiser Permanente facilities in late 2016, my host pointed out a hospital that was being demolished. It was the venerable Saint Joseph Hospital, and what I noticed immediately was that it had two paired cylindrical (or “radial”) towers, just like our former Panorama City hospital, a design universally described as “binoculars.” But taller.

Even though the Kaiser Permanente Health Plan has been operating in Colorado since 1969, and has built numerous state-of-the-art medical office buildings, it has always contracted with local facilities for hospital space. Saint Joseph is one of them.

Although there’s no firm evidence that the Saint Joseph design was influenced by Panorama City, it’s surely not a coincidence. The workflow logic was identical, and the main differences were the stairwell, lobby placement, and lack of an external balcony. It looked more like an overhead view of the Starship Enterprise than a pair of binoculars.


Blueprint, Saint Joseph Hospital, July 27, 1961

“Building started at Saint Joseph,” Rocky Mountain News, Oct. 26, 1961:

Groundbreaking rites were held Wednesday for the new $8,771,560 addition to Saint Joseph Hospital. The new building, to replace most of the north hall of the hospital, will consist of a pair of 11-story circular towers. Each will a have nurses’ stations at the center, and no station will be more than 20 feet from any room.

The new circular towers will be the heart of the 88-year-old hospital. Saint Joseph will be the nation’s largest example of the new hospital design, according to Robert Irwin, architect. The circular concept means patients’ rooms and wards will radiate from the nurses’ stations in the center.

Fourth floor plan of tower, Kaiser Foundation Hospital at Panorama City. 1961 [circa]. [TPMG P1283]

Fourth floor plan of tower, Kaiser Foundation Hospital at Panorama City, circa 1961

Kaiser Permanente’s original Panorama City Medical Center was featured as The Modern Hospital’s “modern hospital of the month” in November 1962. In the seven-page article “Good Nursing is Core of Panorama Plan,” Sidney Garfield, MD, explained the “circles of service” design concept:

It saves steps for the nurses [in this case, patients are within 20 feet of the nursing station]; it reduces the number of special duty nurses; it keeps the nurses to a central area outside the patients’ door, and it is particularly useful for keeping patients under observation at night with a reduced nursing staff.


Old and new Saint Joseph hospitals, circa 1964

Saint Joseph Hospital Communications Manager Colleen Magorian added these details:

The Saint Joseph Hospital “twin towers” were dedicated in 1964, so they were just more than 50 years old when our new hospital opened. The towers were part of an ever-expanding hospital that had been on the same site since 1898 and were inspired, in part, by the towers of the preexisting structure.

Predecessors to this design were a never-built Kaiser Permanente geodesic-dome-based facility from 1957, followed by the “Atomedic Hospital,” which originated in the early 1960s. But these facilities were never meant to be more than one or two stories tall.

Hospital architecture scholars Stephen Verderber and David J. Fine have noted that there are a few other examples of multistory “radial” layouts in the United States, all built in 1964-1965. These include the Lorain Community Hospital (Lorain, Ohio), the Scott & White Memorial Hospital (Temple, Texas), and the Central Kansas Medical Center (Great Bend, Kansas). The Prentice Women’s Hospital and Maternity Center in Chicago, which opened in 1975, was a unique version of this style with four radial towers. It was vacated in 2011 and was the subject of intense preservation efforts to avoid demolition. It was eventually torn down in 2014.

Prentice was designed by Bertrand Goldberg, who drew on learnings from anthropology and the field of “proxemics” (“the study of our use of space and how various differences in that use can make us feel more relaxed or anxious.”) It was praised for its innovative design and engineering prowess. However, many of the design weaknesses of the wedge-shaped rooms were noted as well. Architect and critic Jain Malkin pointed out that the most heavily trafficked side of the room was the narrowest, and in the case of Prentice, that the rounded exterior wall reflected and amplified sounds in a space that’s supposed to be quiet.

Of all of these architects, it was Dr. Garfield and his Panorama City vision that pioneered this bold experiment in improved workflow and patient care. And, as I saw in Denver that cold October morning, the circles of history closed in on the “circles of service.”


Special thanks to Stephen Verderber, and Colleen Magorian and Tiffany Anderson of Saint Joseph Hospital, for their help with this article.

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Kaiser’s geodesic dome clinic

posted on October 12, 2016

Lincoln Cushing
Heritage writer


Copy of plans for "Medical office building for Kaiser Foundation hospitals with Kaiser Aluminum dome" by Clarence Mayhew, with Sidney Garfield as consultant.1957-12-18. [TPMG P1283]

Plans for “Medical office building for Kaiser Foundation hospitals with Kaiser Aluminum dome.”

There are hospital rounds, and there are round hospitals.

While researching an earlier article on the Kaiser Permanente hospital designs created by founding physician Sidney Garfield and the architect Clarence Mayhew, I was looking through folders of drawings for the amazing 1962 Panorama City hospital.

Panorama City featured seven double circular floors, the best example of Dr. Garfield’s “circles of service” concept. But one set of plans didn’t quite look right.

We know that Henry J. Kaiser was a geodesic dome pioneer. Kaiser Aluminum and Chemical Corporation built two of the first civilian domes in 1957, one in Virginia and one in Hawaii. Geodesic domes are self-supported spherical structures composed of rigid triangles, which became very popular during the 1960s and 1970s as modernists and the counterculture embraced their (literally) “out of the box” features of openness and strength.

Fourth floor plan of tower, Kaiser Foundation Hospital at Panorama City. 1961 [circa]. [TPMG P1283]

Fourth floor plan of tower, Kaiser Foundation Hospital at Panorama City, circa 1961.

We also know that in the 1960s Dr. Garfield was intrigued by (but never followed through on) an innovative project called the Atomedic Hospital, based on a dome structure.

But this 1957 plan, by Mayhew (with Dr. Garfield as “medical consultant”) clearly says “Medical office building for the Kaiser Foundation Hospitals with Kaiser Aluminum dome.” It was to be 18,500 square feet, with 20 physicians on two floors.

As a round design, it had been misfiled with Panorama City. We don’t know why it was never built, but at least we now know that in the infancy of geodesic dome innovation Henry J. Kaiser and Dr. Sidney Garfield were creatively thinking outside the box.

Copy of plans for "Medical office building for Kaiser Foundation hospitals with Kaiser Aluminum dome" by Clarence Mayhew, with Sidney Garfield as consultant.1957-12-18. [TPMG P1283]

Plan credits, “Medical office building for Kaiser Foundation hospitals with Kaiser Aluminum dome,” by Clarence Mayhew, with Dr. Sidney Garfield as consultant. 12/18/1957.

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Creating the ultimate patient experience

posted on October 26, 2011

By Laura Thomas

Heritage correspondent

Second of two articles

KP Bellflower Hospital built in 1965 in Southern California

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.

Downey Medical Center replaced the Bellflower hospital in 2009.

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

Another view of Downey Medical Center.

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.

Vacaville Medical Center, built in 2009, serves members formerly part of Vallejo Medical Center area.

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.

Modesto Medical Center in Modesto, showcase of modern, green hospital design, 2008

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.)

Coincident with the idea to streamline the construction process, KP was also becoming aware of the need to make facilities “warmer” and for the configuration of structures to support a positive experience for the patient and visitors. Also, new technology spurred thinking about how a medical center could most efficiently function.

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

The latest KP hospital design calls for lots of natural light, as in the Ontario Medical Center lobby.

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.

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