Traditionally, Nightingale wards like those once used at Laguna Honda contained about 24 to 34 beds, which made patient privacy an impossibility.
When I started writing this article a little more than a month ago, I hadn’t yet had two bulging disks flare up, putting me in excruciating pain. I hadn’t yet had a neck epidural where, as I sat in a hospital gown designed for someone three times my size, the R.N. inserted the IV into the arm on the side that was in such distress. I hadn’t had to spend my half hour of recovery time in a Nightingale ward — those wards with rows of beds divided by the thinnest of sliding curtains that allow you to hear all the particulars of your neighbors’ condition and all the sounds of their discomfort. I hadn’t had to sit in a row of wheelchairs (no other seating was provided) while waiting to consult with the surgeon after the procedure. The procedure went fine and I’m slowly improving, but in my woozy post-op state I had ample time to think yet again about how the experience of health care could be so vastly improved.
So let’s move away from my story — which was unpleasant but is getting better — and toward the more positive one I had begun to prepare, the story of a skilled nursing and rehabilitation facility called Laguna Honda, in San Francisco.
When it was founded in 1867, Laguna Honda was known as the Almshouse, and housed an indigent population with either no family to care for them or no money for other care. Back then, most institutions had names that seemed perfectly, and tragically, aligned with their level of care, names like the Industrial Home for Crippled Children or the Home for Orphans, Indigent, and Aged. Over the decades, some of these names have changed, but a trip “to the home” remains a fate not desired by anyone.
Laguna Honda is for people in need of long-term rehabilitation, or nursing home care, city-run and meant for those unable to afford any other alternative. There’s no doubt that for periods in its long history, it was one of those places you wouldn’t have wanted to end up. Until recently it was using the aforementioned Nightingale wards for long-term and permanent patients, something I’d always associated with triage units or British war films. But now, freshly renovated, the new Laguna Honda suggests an inspired way of thinking about not only institutionalized care but of what a truly effective health care facility might look, feel and act like.
When Anshen + Allen (now Anshen + Allen / Stantec Architecture Joint Venture Partners) were commissioned 10 years ago to renovate and create a new building for the 150-year-old Laguna Honda, the firm was asked to design a campus for 1,200 beds. “From day one, we did not want Laguna Honda to be about 1,200 beds but about 1,200 places,” says Sharon Woodworth, senior architect with Anshen/Stantec, who helped lead the charge to scale the number back to a more humane 780. “The intent was always to create a ‘home,’ not an institution. Even if the project had been 120 or just 60 beds we still would have sought to create a sense of place beyond the bed the individual slept in — a place that felt like home — in a community setting. The community setting is a key difference.”
As is what Woodworth considers the defining characteristic of the project: natural light.
Most of us associate health care facilities with flickering fluorescents, but at Laguna Honda, as Woodworth explained to me on a recent tour, each space is infused with natural light from the resident bedrooms to the gymnasiums, the therapy spaces to the staff work areas, which “is unprecedented in a health care setting; regardless of time of day or season of year, residents, staff, and families can sense the outdoors to experience the greater world.”
So an over-reliance on artificial light was out, but so too were conventional notions about hospital rooms. Laguna Honda’s bedrooms, for example, are organized into “households” for 15 residents who all have their own room, and each of these households has its own dining and living room with residential-style bathrooms shared by one, two or three residents in private bedroom suites or semi-private, dorm-style bedrooms. Four households on each floor create a neighborhood of 60 residents. In the end, it’s less institution, and more of a mixed-use, walkable community within a building.
Inside that building, as Woodworth says, “details provide dignity.” Every resident has an operable window, making not only sunlight but fresh air a real option. Mercifully, the design team has done away with those radically ineffective — noisy but not noise-canceling — hospital curtains. Anshen/Stantec’s 18 months of predesign and user research led them to develop a 44-inch-wide sliding door that’s safer and easier for both patients and staff to use — but which was against building code. That code is now being re-evaluated, remarkable given that regulatory oversight for hospitals is more numerous than for nuclear reactors.
The building has just opened, and it will take months for staff and residents to move in. As they customize their surroundings, distinct neighborhoods will be allowed to form. A significant amount of artwork has already been installed but not for the reasons you might think. Anyone who has wandered helplessly through seemingly identical hospital hallways will appreciate how each wing, hall and floor has visual markers that serve not only an aesthetic function but a practical one. The murals on one floor and the tactile sculpture on the other are also memory devices. Residents begin to associate their space with a particular wall color or work of art: this keeps their minds active and enhances their self-sufficiency.
Rehabilitation encompasses the creative mind and the social being here, too. In contrast to the often drab, typically unusable “public spaces” in similar environments, Laguna Honda has an aviary, library, art studio, hair salon, theater and chapel. Living rooms have floor-to-ceiling windows. (The idea initially met with opposition. “People thought seniors would be afraid!” said Woodworth.)
But perhaps the most wonderful surprise and dramatic example of difference is to be found outside. Laguna Honda extends far beyond its walls. There’s a basketball court, a sculpture garden and an organic farm where residents can grow and harvest produce, and then have it cooked in the kitchen. Public transit that’s easily accessible is just across the street, as well as a shuttle bus that stops throughout the city, making the outside world part of daily life and not off-limits. There is even an apartment where residents who will be returning to life outside Laguna Honda can live either alone or with their families to relearn and regroup.
I was in terrible pain this past month but I will improve and am lucky to have the help of family and friends to see me through it. For those who must either spend an extended period of time recovering from truly serious injury or set up permanent residence in a place like Laguna Honda, Anshen/Stantec’s new way of thinking about a hospital’s staff and its patients and their families is a shining example not only of what is possible but what should be required.