When Barry Rabner, president and chief executive officer of the Princeton HealthCare System, started planning for the new $522.7 million state-of-the-art hospital to replace the existing one, he insisted on a process that used evidence-based design, which uses research to learn how a built environment can affect health outcomes, rather than basing the design on existing facilities.
“One would think that with 5,000 hospitals in operation in the country, there would be a really clear understanding of which design features work best, but there isn’t,” he says. When research was either nonexistent or insufficient, the decision making was guided by experience, instinct, and the desire to start with the most up-to-date health equipment.
One important decision in the area of energy efficiency and sustainability was whether the air handling system should be designed to use 100 percent fresh air as a way of controlling infection — rather than recycling a percentage of the air, as almost all existing hospitals do. Research suggested that fresh air was effective in controlling infections in the emergency room but said nothing about the rest of a hospital.
Using its clinical judgment, the design team decided to go with 100 percent fresh air in the entire hospital because retrofitting later would be far too expensive, and the hospital is committed to doing research going forward on this decision’s impact to add to the body of knowledge.
To start, the design team articulated a set of guiding principles that were hung on the wall at every design meeting. “These were based on the understanding that a building is more than a container,” says Rabner. “It is not simply holding people and things. If designed properly, it can help you achieve very important organizational goals.”
The team’s goals included reducing infections, errors, and falls; improving clinical outcomes, patient outcomes and satisfaction, and privacy and confidentiality; and lowering operating costs.
To get through the 1,200 pieces of research relevant to the design of the new hospital, one group was responsible for reviewing every piece of research and testing questions and decision-making against it. Whenever the team faced a difficult or costly decision, this group would share the relevant research.
“Some things were easy enough that they were integrated into the design, and sometimes the research suggested a direction but wasn’t conclusive,” says Rabner. “The challenge is that we had to make a decision now, understanding that we never will be able to retrofit some of the solutions, that if we don’t do it now, we’re never going to.”
In addition to academic research, the hospital used focus groups with patients early on to determine what they needed to do and to test design ideas and goals, and then later to see if the hospital was delivering what patients wanted.
This process propelled an intricate decision-making process that yielded answers regarding how to structure space; what equipment to install, where to put it, and how to connect it; how to link sophisticated computers to automate all manner of hospital processes; how to make the whole building sustainable; and even how to select art that would promote healing.
Four examples that exemplify how this process worked are the interior design of patient rooms, the selection of art that promotes healing, and the decisions to make all rooms serving the same function identical and to have only single rooms.
Looking to stop the spread of infection and decrease falls, room design began with the creation of mockup rooms from plywood and Styrofoam to understand basic logistics like where the bed should be positioned, how pieces of equipment would function, how caregivers would get around, and where family members would care for the patient or stay overnight. This stage yielded more than 300 changes to the existing design.
The design team then took an unusual second step. “Princeton went one extra step and said, ‘Let’s build a room on one existing floor and let patients and nurses use the room,’' says Rosalyn Cama, board chair of the Center for Health Design, and a New Haven, Connecticut-based designer specializing in hospital interiors.
Changes were based on how patients, nurses, and visitors used the room as well as simulations, for example, of code blue emergencies, to ensure that equipment and staff were where they needed to be.
And indeed this mockup enabled further tweaking of the design, from small changes like the placement of the track for the curtains around the bed, to large ones like moving the bathroom to the other side of the room.
They also changed how nurses get supplies. Now each room has a supply closet customized to the needs of a particular patient, with doors opening to the room as well as to the hallway, for restocking. “We learned that if we can put certain resources at the point of care nurses will spend more time with patients, which nurses want to do,” says Cama.
To stop the spread of infection, the sink was positioned just inside the door so that staff members can wash their hands prior to examining a patient. To limit falls if a woozy patient gets out of bed without requesting help, the bathroom is off the wall nearest the patient’s head, with a short, floor-lit handrail from the bed to the bathroom.
In a small study comparing the new room with existing ones for patients with hip and knee replacements, the new room outperformed the old one on every variable. There were no falls or infections, nursing care was rated better though the actual nurses were the same, and pain medication was used less often.
The process of selecting art began by having a committee of people from the art community, with Cama’s help, pore through the research, which suggested that a connection to nature reduces stress and anxiety, and that this in turn creates a better environment for healing.
Indeed patients in much of the building have views of the outdoors, but a similar effect can be obtained elsewhere through art that reflects nature. “We are genetically predisposed to back ourselves up against some protection and be high on a hill and overlook the savannah where the predators are coming from,” says Cama. “That’s why people love mountains or the beach, with long views of nature.”
These nature pictures — which might include flowers, trees with leaves, pleasant nature scenes, or nonthreatening animals — are in patient rooms as well as waiting rooms where patients might be anxious about meeting a physician or waiting for the results of some test.
Regarding the decision to make all rooms with the same function — general medical and surgical rooms, emergency department, neonatal, intensive care — identical, Rabner says, “The research clearly indicates that the more variability in design, the more likely it was for staff to make mistakes.”
In patient rooms, for example, all the switches, outlets, gases, and suction are in the same location, which means, says Rabner, that it takes no practice to know what items are in the room and where supplies are stored. Similarly, any shared equipment, for example, a “crash cart” used if a patient is in distress or other emergency supplies, is stored in exactly the same way at the same location on every floor.
Regarding single-patient rooms, the research suggests that with only one patient in a room, not only do infections go down, but the quality of the communication between the patient and the caregiver improves, which in turn reduces errors. That makes sense, says Rabner, because when other people, whether roommates or their visitors, are listening, patients are more likely to edit themselves and be less complete when talking to a nurse or doctor.
Additionally, because in some cases they could not successfully match patients in double rooms, due to sex or type of illness, the old hospital typically had 15 to 20 empty beds when the hospital was “full.” Being able to fill all beds in the new hospital will actually help cover the cost of the bigger building, says Rabner.
But perhaps the most fascinating results of the evidence-based design process are the technologies, large and small, that should help the new hospital to effectively and efficiently promote healing while running a safe, cost-effective, environmentally friendly, technologically up-to-date operation.
Electricity, heating, and cooling in a single package. The smacking-new technological gargantua that comprise the cogeneration plant — designed, built, owned, and operated by NRG Energy of Carnegie Center— provide the hospital with electricity, steam for heating, and chilled water for cooling. What is particularly impressive about the facility, beyond the technologies it comprises, are its built-in redundancies, environmental sensitivity, and integration.
The hospital’s primary source of electricity is a spinning turbine that is fueled by natural gas compressed to a pressure of 300 pounds per square inch. The turbine turns the generator, which produces 4.6 megawatts of electricity, enough to power about 3,680 homes.
Gas turbines, however, have a byproduct — very hot exhaust — similar to that of a jet engine. “You see in a jet engine that nobody ever stands behind it, because the exhaust is 900 degrees,” says Rabner. Whereas in big municipal power plants this hot exhaust usually goes up the smokestack into the atmosphere, yielding only 30 to 35 percent efficiency, NRG Energy’s cogeneration plant is able to use this energy that would otherwise go to waste.
“In a co-generation plant you capture the heat and use it to produce steam that is used for purposes of sterilizing equipment and heating the building,” says Rabner. “You are using waste to do something important.”
The exhaust is funneled into a heat recovery steam generator, where it is used to transform water into steam at a pressure of 125 pounds per square inch that is pumped through the hospital to heat it.
As the heat is used in the hospital, the steam condenses back into water, about 85 percent of which is recovered and pumped back to the plant. There it must be heated to 227 degrees before it can go back into the steam generator, thereby completing the cycle. Any additional outside water must be softened before entering the steam generator.
If, during the winter months, the steam generator does not produce sufficient steam to heat the hospital, three gas-fired boilers are on hand to increase steam output.
The cogeneration plant is also responsible for cooling the hospital. Water is chilled by three huge chilling units, each with a capacity of 1,000 tons of water; they function somewhat like refrigerators except that they are cooling water rather than air.
These chillers, whose compressors use a non-chlorofulorocarbon refrigerant, typically run in the evening and overnight when electricity is cheaper to chill water for the 1 million-gallon thermal energy storage tank. The tank is then discharged during the day when electricity prices are higher.
The chilling plant also has a 700-ton absorption refrigeration unit that is designed to use any unfired exhaust steam from the cogeneration plant to achieve significant efficiencies.
The cool water is piped to the hospital’s air-conditioning system. Though the cooling system is important in the summer, the hospital has lots of equipment that needs cooling year round, for example, the information technology room.
Redundancy for these systems is critical, and the system provides different kinds. “There will never be another case like LA of a hospital without power,” says Joey Bowser, an operator of the cogeneration plant. “In a hotel if you lose power it’s not a big deal; if it’s in an ER or an operating room, you don’t want to lose power.”
To ensure a constant electrical supply, the gas turbine runs in parallel with the electrical grid. The hospital is fed by redundant electrical feeders to bring in electricity from the PSE&G grid. Though only one is necessary to run the hospital, both will be on all the time so that if one fails, the load will switch automatically to its twin.
As a second level of backup, the plant has three two-megawatt generators, which are capable of providing more backup generation than what is produced by the primary turbines. One of the generators alone could run the whole hospital as well as the cogeneration plant. The generators run on diesel fuel, which is stored in two 40,000-gallon underground tanks.
To save energy, the plant’s chillers, pumps, fans, and power-generation equipment can function at variable speed levels rather than just in the two extreme modes of on and off. As a result, their level of functioning can be adjusted to closely match energy output requirements, thereby creating significant energy savings.
The cogeneration plant is run to adapt to energy market conditions, ensuring that the hospital receives the lowest-cost electricity.
Energy recovery system. The hospital also has an energy recovery system, whereby fresh air entering the hospital takes advantage of the heat or coolness of air leaving the hospital. In the summer when the hot fresh air entering the hospital needs to be cooled, it first passes over fins that are carrying cooler air that has already made its way through the system and will be exhausted into the atmosphere.
The cooler air that is exiting cools the entering hotter air, which is further cooled by chilled water from the cogeneration plant, then dehumidified, filtered, and sent through the building to cool it. In the winter the very cold air entering from outside passes over the exiting warm air and then is further warmed by hot steam from the plant.
A field of photovoltaic cells. Separate from the cogeneration plant, the hospital also has created a field of solar voltaic cells to produce an amount of electricity for the hospital equal to that needed for 1,500 houses.
Though this will provide only a small percentage of the hospital’s power usage, Rabner sees three benefits. First, it provides some redundancy. Secondly, it will help reduce the hospital’s carbon footprint. Third, it will reduce operating costs. “We are doing the right thing by our patients, by the environment, and for the business.”
MRI and CT and PET scanners. “The radiology department is being built from the ground up with a wide array of new technology and new facilities that are going to allow us to meet patient needs and provide outstanding care more efficiently,” says Dr. David Youmans, chief of radiology at the hospital. In the new building, infusion therapy and radiation are next to each other, integrating cancer treatment and support services in a single location.
Because the outpatient facility is now close to but separate from the inpatient facility, says Youmans, it will be free of that “inpatient feel” and feel more like a doctor’s office.
TrueBeam Linear Accelerator. The new $3.6 million TrueBeam Linear Accelerator treats cancer with image-guided radiotherapy. Its very precise imaging allows it to see exactly where a tumor is located, in the moment, and compensate for any tumor movement by readjusting its position during delivery of radiation.
It also delivers radiation with 10 times the precision and up to four times faster than other radiosurgery systems. On the ceiling of the room are panes of glass sporting cherry trees backed by blue skies and puffy white clouds.
Its giant gray arm sits in a room with three-foot walls, made of concrete and lead, and a door heavy enough to guard Fort Knox. Though it is only one of 200 such devices in the world, it was so much better than the current technology that the decision was easy to make.
“It is better because it damages less healthy tissue, requires fewer treatments, and each treatment requires less time,” says Rabner. “When you are starting from scratch, you get to make those decisions.”
3T MRI Unit. The new 3T magnetic resonance imagining unit sends out a magnetic impulse that makes the body’s hydrogen ions resonate. Deriving information from this hydrogen hum, the MRI’s complex software generates a clearer digital image than is available on older machines. The new state-of-the-art unit is also flexible and can change the way it sends out and listens to magnetic pulses and can stack new pulses on top of the original ones to tease out certain kinds of information.
The unit can also be used to design different protocols to investigate bodily processes in specific sites like the liver or kidney.
Patients undergoing MRIs on older machines have often felt claustrophobic inside the machine because the magnet covered most of their bodies and there was little wiggle room. Though the doctors would try to calm them with music, it didn’t always work.
“If people are nervous enough and they are fidgety, their movement interferes with the picture,” says Youmans. The new MRI unit has an open architecture that is more user-friendly: the area that covers a person’s body, the “bore,” is shorter and has more space between a person’s skin and the inside of the tube.
One particularly exciting use of this new MRI is in evaluating the heart. Youmans says, “Because of the speed and sophistication of this magnet, we will be able to do evaluation of both the anatomy and the function of the heart.”
128-slice CT Scanner. The new, state-of-the-art 128-slice CT, or computerized tomography, scanner is like a fancy X-ray machine that rotates and takes a bunch of pictures by sending out several beams simultaneously from different angles.
It then uses powerful computer software to produce a very clear image. Because it is able to take more image “slices,” the result is less distortion and a smoother, clearer image. Youmans compares it to high-definition television vis-a-vis older models.
Not only does the new device allow faster and more precise scanning in general but it offers particular benefits for cardiac evaluation. Working with dye introduced intravenously rather than the conventional approach of squirting dye through the groin, it does its work in less than 45 seconds and the result is a three-dimensional picture of the heart.
Ultrasound equipment. The new ultrasounds also allow three-dimensional reprocessing. As Youmans explains, “With one sweep of the ultrasound wand, you get data that can be reproduced in three dimensions.”
Nuclear medicine. The new technologies will also aid nuclear medicine, which involves injecting a liquid with a low level of radiation into a vein and then using special cameras to detect where the radioactivity gathers. In a positron emission tomography, or PET, scan, the radioactivity attaches to sugar molecules, and the scanner can see if they are gathering in unusual places and thereby identify a tumor.
The new PET scanners have a CT scanner built in, which allows precise pictures from the CT scan to be superimposed on the PET scan. By combining the information from the two scans, physicians will be able to look at both function and anatomy simultaneously and hence be able to direct therapy more precisely. Formerly physicians had to look at the two scans separately.
The radiology department also has a treatment arm, interventional radiology, which uses imaging as a means for guiding therapy. One example is the treatment for uterine fibroids called uterine artery embolization; this is a minimally invasive surgery whereby the physician blocks tiny vessels that lead to the fibroids, thereby starving them and causing them to die.
For certain tumors in the liver, kidney, and lungs physicians use microwaves during minimally invasive surgery, and improved equipment enables them to visualize these organs more clearly and quickly.
At the new hospital, because the interventional radiology space is near the conventional operating rooms, physicians doing these procedures will be able to use the same pre- and post-operative rooms for their patients as do other surgeons. Youmans says, “The coordinated care regimen is the same as for all other surgery. This allows things to be more consistent and efficient, which always translates to better care.”
The new operating rooms, which are twice the size as in the old hospital, exude the feeling of science fiction. Doctors are surrounded by computer screens that hang from the ceiling on articulating arms and can be custom set for each physician to view, for example, CT, PET, or other images or an enlarged view of the operation in progress, and to monitor anesthesia during surgery.
With pretty much all the equipment suspended from the ceiling except the operating table and the nurse’s control table, large pieces of equipment can be moved more easily, the staff is safer, and the room can be cleaned faster. The physician can control lighting, temperature, and data on the screens by voice. The operating room is connected to a computer-controlled vacuum tube system, about 8 inches in diameter, that runs throughout the hospital.
After doing a biopsy, a doctor can quickly send the tissue to a pathologist via the vacuum tube system for analysis; the surgeon would give this sample top priority, which would stop all other capsules in the system and give this one a priority route.
The surgeon can also send the pathologist an image of exactly where the tissue was removed, using a medical camera set into the clusters of high-intensity lights that shine on the operating table. Additionally, the surgeon can use a telestrator, a device that allows freehand sketching over an image, to mark on a photo of the surgical site exactly what the pathologist should look at.
Once the pathologist has mounted a slide of the specimen, an image of the cells under a microscope can be flashed electronically back to the surgeon. If there are no cancerous cells, the surgery is over, but if there are the pathologist can mark how close the sample is to the margins and together the physicians can decide exactly how the surgery should proceed. “Everything is collaborative,” says chief of surgery Jack Heim. “We have lots of people whose input is important.”
The air in the operating room changes 27 times an hour, coming down through large panels in the ceiling and leaving through special vents closer to the floor. And there’s more, as Rabner explains. “In the operating room, before the air enters the room, it goes through another HEPA filtration system in the ceiling that further cleans the air — to same degree you find in a pharmaceutical manufacturer.”
The operating room also has a closed-circuit television system, and cameras in the operating room can be controlled robotically so that residents, students, and others can view the surgery remotely. Heim will be able to download films of all his surgeries from a video archive to make sure his motions were efficient during surgery.
To maximize the amount of time nurses spend with patients requires minimizing the time they spend “hunting and gathering” — going around the building looking for supplies.
So they designed a cabinet to the right of the door in every patient room that stores disposables, linens, and drugs, which will be stocked by non-nursing personnel from a door in the hallway. A computerized materials-management system will maintain records on what is needed, what has been used, and what has been stocked in the supply cabinet.
Using the computer a nurse can also locate any equipment needed, for example, an IV pump, by way of a tiny radio transmitter attached to it. In the old hospital, says Rabner, they had to keep buying more and more stuff because they couldn’t locate what they had.
Whenever a drug is administered, this too is noted in the computer, which reports it to the pharmacy.
When a patient is discharged, the nurse pushes a button and a signal is sent to environmental services to clean the room. When they are done, they push a button to show the room is clean and ready for a new patient. “It is an integrated system that speeds things up and makes everyone’s job easier,” says Rabner.
Room TVs. The decision for the television in patient rooms to be as large as they are took some testing. They chose a 42-inch flat screen, mounted on the wall opposite the patient’s bed, because the television is central to patient communication with the hospital. The patient needs to be able to read off the television to order meals, to send messages to nursing and to housekeeping, and to read medical information — not to mention entertainment via the Internet, movies, and television shows.
The food ordering system is integrated with the limitations on a patient’s diet. Rabner says, “The menu is as diverse as your limited diet will allow, but it won’t allow you to select foods that are contraindicated.”
Once the patient orders, the computer sends a message to dietary services, which prepares the meals and sends them up to a patient’s room — when the patient wants it, within a half hour of ordering. “It works like a restaurant, but it is not just an amenity,” says Rabner. “It allows us to be sure people are not getting food they shouldn’t, and that people will get food when they’re hungry. That’s important because nutrition is important. Delivering it at prescribed times isn’t good enough.”
Nurses notify the computer when they administer a painkiller, and the computer tells the television to ask patients every 20 minutes to rate their level of pain, using a series of faces from smiling to frowning. If a patient rates the pain as “poor,” then the television will ask a nurse to come to the room for a consult.
The television also elicits other types of feedback; for example, under a category titled “Rate Your Hospital Experience,” is the question: “How are your nurses doing listening and explaining things to you?” If the response is not “great,” but “not good,” or simply “okay,” the nurse will check in with the patient.
Because the television also works with the iPhone, family members with pictures of children or grandchildren can press an icon to display those pictures on the screen. Similarly, a physician with an iPad can access an x-ray digitally off the in-house system, touch an icon, and display that x-ray on the television screen, dragging a finger across the iPad screen to direct the patient to a particular spot on the x-ray.
The television can also supply more esoteric information: for example, the hospital librarian can send a patient information in Spanish on rehabilation after a joint replacement, via the television screen.
Because natural light has a positive impact on healing and rate of recovery, reduces stress, and helps people remain oriented, the building faces south so that 90 percent of patient care areas are lit naturally. Light sensors in most rooms ensure that only as much artificial light as necessary is used, based on the amount of natural light entering.
But the challenge is that a lot of heat accompanies this sunlight, and the solution is horizontal shades on the exterior and interior of the building’s south side that work like an awning to reduce the direct light and the amount of heat generated. Further, the engineers set the shades at an angle that maximizes the amount of light in December and minimizes it in August.
The players involved in the creation of the new hospital come from very different backgrounds.
David Youmans, the chief of radiology, graduated from Stanford in 1985, served four years in the U.S. Navy, and then spent a year doing medical research at the Cardiovascular Research Institute at the University of California, San Francisco. He received his M.D. from the University of California, San Diego, in 1994 and completed his diagnostic radiology residency at Washington University in St. Louis.
He then moved to Yale University, where he was an instructor in diagnostic radiology and a fellow in vascular and interventional Radiology. While in New Haven he was also an attending physician in the department of radiology at the Veterans Administration Hospital in West Haven. He has been an attending radiologist at University Medical Center at Princeton and a member of Princeton Radiology Associates since 1999.
Cama grew up in New Haven, Connecticut, where her parents were first-generation Americans. Her father, a World War II veteran, left high school to enlist, and in the military trained as a machinist. When he returned stateside, he went into business for himself and eventually owned several franchises for Napa auto part stores. His mother, who had an associate degree, probably in secretarial sciences, helped his father manage the business finances and raised four children.
After earning a bachelor of science in interior design at the University of Connecticut, Cama graduated in the middle of a recession. Though she was moving in the direction of graduate school in architecture, her mother noticed an ad in the newspaper about a job at the hospital.
She took it, forgot about grad school, and 29 years ago started her own firm that designs hospitals nationwide. She partners with architectural firms and healthcare facilities to work with architectural teams and is known as a strong proponent of evidence-based design.
Rabner’s parents were Holocaust survivors who came to the United States after five years in a displaced-persons camp following the war. “Their lives were so disrupted, and then they came here to build a new life, but what they were really trying to do was build a life for their kids,” says Rabner. “It was so important to them that you fulfill their dreams, it tends to keep you focused and drives you to do the best you can so you don’t let them down.”
He grew up in Passaic, and one might say that he began his career in healthcare during high school, when he was an orderly in a nursing home. But his health-care roots really go back to his mother, who was a nurse for 60 years, first in the Russian Army and then at several hospitals in New Jersey, including Passaic General, Barnert Hospital in Paterson, and Daughters of Miriam in Clifton.
His father worked in a bakery as a deliveryman and in a warehouse for a company that manufactured electric light components. His education had been interrupted by the war, and in the camp he had been trained as a draftsman, with the idea that he would immigrate to Israel, but Rabner’s parents ended up coming instead to the United States.
Rabner graduated from the University of Maryland in 1974 with a bachelor of science in zoology and chemistry and then spent a year studying French language and philosophy at the Sorbonne. In 1977 he completed a master of public administration, focused particularly on health administration, at Rutgers.
From 1976 through 1978, he was an instructor and project manager at Boston University’s Henry M. Goldman School of Graduate Dentistry in the department of public health and community dentistry.
In 1979 he began as director of program development at the 152-bed Moss Rehabilitation Hospital, where he was promoted to vice president of administration and program development in 1982, vice president of operations in 1984, and then served from 1986 to 1992, as executive vice president and chief operating officer, directing the clinical care, marketing, education, and human resource departments.
From 1992 through 1998, he was president and chief executive officer of the 143-bed Bryn Mawr Rehabilitation Hospital in Pennsylvania, and during the same period was president of Rehabilitation Affiliates in Wayne, Pennsylvania.
In 1997 he moved to the Jefferson Health System, which comprised nine acute-care hospitals, three rehab hospitals, three long-term care facilities, a psychiatric hospital, and several ancillary corporations. From 1997 through 1999, he was senior vice president of strategic planning, and from 1996 to 1998, senior vice president of the nonacute services division.
He then moved to one of Jefferson’s member systems, Main Line Health in Wayne, Pennsylvania, where he served as its senior vice president as well as president of Main Line Hospitals, Main Line Affiliates, and Main Line Extended Care from 1998 to 2001, and then as chief executive officer.
Rabner has been president and CEO of Princeton HealthCare System since 2002. Commenting on the design process that started in 2003 and involved an estimated 10,000-plus individuals, Rabner says, “It’s a remarkable process and for me personally it is the highlight of my professional career. We spent $522.7 million to create this facility, and I think we will redefine how care is delivered.”
University Medical Center of Princeton at Plainsboro, 1 Plainsboro Road, Plainsboro 08536. 609-853-7000. wwwprincetonhcs.org