It’s been about 20 years since Planetree’s model of patient-centered care first came alive inside a San Francisco medical center. Huge changes have rocked hospitals since then, including a shift in the health delivery system, an influx of technology and new rules for patient privacy, yet the model remains as relevant as ever.

From cold to cozy

Originally founded in 1978, Planetree (www.planetree.org) is a nonprofit consulting organization that works with hospitals to develop and implement patient-centered care in healing environments. Many of the current trends in hospital design trace directly back to Planetree, which was named for the tree under which Hippocrates taught the first medical students. And, while the initial Planetree test site no longer exists, the Planetree organization continues to grow and evolve.

Cold, sterile, institutional environments were the only kinds of hospitals most Americans knew in the late 1970s. By contrast, Planetree envisioned a hospital where patients would receive support and healing at all levels. It espoused patient empowerment and developed a model for change that Planetree affiliates still use. The model promotes an organizational culture that makes patients feel valued and encourages them to be partners in their care, and a physical environment that supports that culture.

As noted in the book Putting Patients First—Designing and Practicing Patient-Centered Care (Jossey-Bass, 2003), original Planetree architect Roslyn Lindheim emphasized that health care environments should:

Welcome the patient’s family and friends;

Value human beings over technology;

Enable patients to fully participate as partners in their own care;

Provide flexibility to personalize the care of each patient;

Encourage caregivers to be responsive to patients; and

Foster a connection to nature and beauty.

Planetree’s membership currently includes 104 hospitals. Requirements for using the Planetree designation is tightening, and the organization is embarking on a new project aimed at quantifying how its approach supports healing.

Change begets success

Since 1991, when Planetree launched its affiliate program, members have been free to make or not make physical changes at their facilities. Planetree is now rolling out a designation process for patient-centered hospitals. The process sets criteria to guide a hospital’s implementation efforts during its initial three-year membership term, and it includes a mentor-level designation that recognizes significant achievement and innovation in patient-centered approaches to care. Planetree is piloting the process this year and will do a rollout in 2007.

At hospitals that have remodeled, renovated or built new facilities to incorporate Planetree design principles, results commonly include improved patient satisfaction and greater patient loyalty, increased staff satisfaction, easier recruiting and reduced staff turnover, reduced staff sick time and a healthier bottom line.

“We are in discussion with Samueli Institute regarding a joint research project at several Planetree hospitals to look at the impact of the Planetree model on patient outcomes,” says Planetree President Susan Frampton. “Planetree has always been interested in evidence-based design. Our early evidence came from qualitative studies with the thousands of patients we talked to each year in focus groups on health and healing in hospital environments across the country. More recently, we’ve been focusing on more structured, quantitative research approaches to this.”

Shaping environment

“The early Planetree model was based more on social science research,” notes Marc Schweitzer, senior architect, The Design Partnership, San Francisco. “It was about the connectiveness and social interactions that people need to stay well and then giving them a place where they can interact well and lower stress.”

Schweitzer worked on most of the five original Planetree test sites. The sites incorporated the same design principles that continue to guide affiliates today. “We would reverse the nurse station, make it more open and inviting, so it was more of an encompassing, embracing space with cafe tables or dining tables where patients could sit down with staff and go over their charts,” says Schweitzer. “That nurse station would typically be placed somewhere at the heart of the unit to create a center. Adjacent to that would be a lounge where patients and families could hang out. A library would either be part of the lounge or a separate room, and the intention there was to create an educational-social focus to the unit. So, rather than just being a place where nurses worked it became a center where people could congregate, information could be exchanged and there could be general interactions.

“It’s always been important to have a residential-type kitchen on the unit that was open to patients and family so they could bring in food from the outside and prepare it,” adds Schweitzer. “We tried to create nooks and crannies where all wheelchairs, utilities, and other rolling stock could be kept out of the hallway. There was a de-emphasis of linear corridors, trying to create places with seating or highlighting and artwork. So, instead of just [an institutional] passageway to walk through there were places where patients could rest while encouraging their mobility out of the room.

“Part of the interior design was to introduce elements or materials that were more friendly at the time, such as hand rails that were custom-milled, so that you would get a sense that somebody cared about the environment,” adds Schweitzer. “We tried to go with a different lighting scheme so instead of a general, overall illumination there were hot spots, cool spots, shadows and highlighting of artwork. There was more use of carpeting, soft fabrics and materials on walls and windows, trying to liven the place up, make it a little warmer and acoustically friendlier.”

Continuous improvement

Mid-Columbia Medical Center, The Dalles, Ore.; Griffin Hospital, Derby, Conn.; Highline Medical Center, Burien, Wash.; and Page (Ariz.) Hospital all first tested patient-centered care design concepts at least a decade ago and have continued to expand the Planetree model as new opportunities arise. With each new project, they learn and improve.

Of Griffin’s initial Planetree project, a renovated med-surg unit, Bill Karanian, principal, The SLAM Collaborative, says, “Other than a reconfiguration of nursing stations, a lot of what we did there was cosmetic. The beauty of the [newer] North Wing was that it was building an inpatient facility from the ground up. We were really able to get into the planning of that, look at organizational behavior changes Griffin wanted to make, and see how we could impact that in a positive way through planning and the environment.”

Carter describes the Celilo Cancer Center that Mid-Columbia Medical Center built in 2001 as the culmination of everything they’d learned over 10 years of practicing Planetree philosophy. “Every feature within the facility was considered, from the experience of walking the hallways to what you see from each angle as you come through the facility,” he says. “It was a detailed approach to trying to create sacred space.”

Improvements also come through new and better products and materials. And because patients know more. Ten years ago, when Page Hospital held focus groups to learn what patients would like in a new OR, participants were stumped by the question. Five years later, the hospital again held focus groups to find out what patients would want in a new acute care wing. This time, patients had a list: private rooms, family space inside rooms, family gathering areas outside rooms, bigger beds, more toys and activities for pediatric patients, and they didn’t want the place to look like an institution. Page fulfilled the wish list.

New challenges and solutions

“There’s so much technology in hospitals now, whether it’s hanging off the walls in patient rooms or these huge MRI machines, it’s created something more of a challenge in how to soften those environments,” notes Frampton. “Hospitals have gotten very creative in terms of hiding medical gases and equipment behind artwork, wooden cabinetry, or wooden headboards built into beds. In some radiology areas, they’re cognizant of the patient’s view, so when patients are looking up, they’re seeing backlit ceiling tiles or photographs, decorative ceiling tiles or mobiles.”

With the advent of the Health Insurance Portability and Accountability Act rules, the open nurses’ station also has come under fire. Planetree still champions the open station, even suggesting it as a way to meet the organization’s new criteria related to removing barriers between staff and patients.

Because Planetree affiliates aim for the same kind of physical environment—one that is warm, welcoming, nurturing, holistic—they tend to incorporate many of the solutions that were used in the early model sites. There is no design formula, however, and affiliates are encouraged to do what’s appropriate for their regions and the communities they serve.

In May 2005, Highline Medical Center opened a distinctive 24,600-square-foot cancer center designed by Northwest Architectural Co. “We created a two-story, heavy timber construction space that you arrive to,” says Dick Salogga, principal, Northwest Architectural Co., Seattle. “It’s got fantastic skylights and feels like a lodge. There’s a fireplace in the main entry area and a balcony. For infusion areas, we created bay windows that look over the valley to Mount Rainier.”

Page Hospital is on the south shore of Lake Powell, adjacent to a Navajo reservation, and about half of its patients are Native American. Page included water features throughout its facility and constructed a cedar hogan, or traditional Navajo dwelling, on campus.

Bruce Arneill, chairman emeritus, The SLAM Collaborative, Glastonbury, Conn., likens the experience of arriving at Griffin Hospital’s North Wing to entering an intimate lobby at a boutique hotel. Griffin, incidentally, is also where Planetree moved its headquarters in 1998.

“Mid-Columbia Medical Center sits in an area with the second greatest number of freshwater waterfalls on the continent,” says Randy Carter, Planetree’s vice president of organizational development and strategy, and formerly Mid-Columbia’s administrative director of facilities and education. “There are a number of water features within this facility to emphasize the connection.”

A model for the ages