Future of healthcare: an interview with Cleveland Clinic

Cleveland Clinic is many things. It’s one of the largest and most respected hospitals in the US, ranked the second best in the world by Newsweek. It’s a non-profit academic medical centre with an operating revenue of over US$10bn. It is employer to 67,500 caregivers worldwide, skilled in 140 specialties. It’s 6,026 beds spread over a 165-acre campus near downtown Cleveland, Ohio, as well as 11 regional hospitals, more than 220 outpatient facilities, and locations in south-east Florida, Las Vegas, Toronto, Abu Dhabi and London.

Yet no matter what part of this vast health system its 2.4 million annual patients visit, they will find a distinctive look and feel. “We’re very focused not only on the patient experience, but also that of the caregivers,” says executive director Pat Rios. “If the caregiver is positively impacted by the built environment, they’re going to give the patient a more positive interaction and a more direct, tangible sense of wellness.”

Rios directs management of Cleveland Clinic’s 3.4 million m² facilities and real estate portfolio, as well as its $2.5bn global construction programme, working with Christopher Connell, who joined in 2017 from Foster + Partners as chief design officer. Connell is responsible for making sure that the physical space provides the right type of healing environment, and Rios is the person who makes it happen.

The Cleveland approach might be characterized by thoughtfulness, coupled with an extreme attention to detail. “We’re known for a very clean design. It’s not just about the white and the grey, it’s in the most subtle details — if you look at the ceiling, you’ll see that the sprinkler heads, the lights and the detectors are all lined up so it’s very symmetrical, very crafted.”

This lack of clutter is reassuring for the patient, but also efficient for the caregiver, Rios says. “They have access to what they need quickly so they can go in, do what they need to,and then let the patient focus on healing and resting.” Unusually, all patient facilities are outward-facing, so they feel connected to exterior spaces. The rooms are “optimally” sized, says Rios, “from an operational perspective, but also so that the patient doesn’t feel confined or like they’re just moving through a process.” In Avon Hospital, Ohio, the beds are arranged so that a nurse walking past a patient’s room can easily see their face. “It’s a visual check on health. The caregiver can just walk down the hallway and see all the patients without having to disturb them.”

There are tensions that need to be resolved — on energy, for example. “We want to let in as much light as possible, but windows are not as thermally efficient as walls. So that requires a lot of thought.” In the recently completed Taussig Cancer Centre, for example, there is floor-to-ceiling glass curtain walling, but the energy cost per ft² is still low thanks to features such as heating that is targeted on where the patient will be — in an infusion chair, say — rather than the whole space. “It’s using heat when the patient needs it, but also connecting them with the environment.” At Cleveland’s new 185-hospital in London, due to open in 2021, even the building structure is part of creating a serene environment. “The floors are very thick and each room is isolated. It’s not just the concrete flooring — each wall is isolated by wood blocks, then the screed flooring is isolated room to room, and all the jacks are offset from each other so there’s no sound conductivity. The detail of the insulation, the amount of dry wall, the panelling — all of that is about creating an ultra-quiet hospital.”

Of course this standard of product costs more — although not necessarily as much as you would think. When Rios joined three years ago, he conducted a benchmarking exercise of Cleveland’s projects, and found that the construction cost per ft² was below the industry median. He puts this down to the way it approaches project delivery: Cleveland nurtures long-term relationships with core partners, and remains closely involved through its model of owner-controlled project delivery. “Particularly with technically complex projects, you need to manage it as an owner.” On one project, Cleveland used an integrated contract, where the designer, constructor and key trades had a profit-sharing agreement with a target value delivery. “It was fascinating how much that changed behaviours. I think a joint-risk continuum is going to be the future for this industry.”

As well as new projects, Rios is also engaged in renewing the clinic’s older buildings. Renovating older spaces usually includes meeting much higher life safety standards, boosting wireless bandwidth to serve nurse and patient tracking systems and installing cabling for power and data. “Technology integration is an incredible challenge. Not a lot of it is bespoke, you’re just buying a bunch of commercial off-the-shelf stuff and assembling it into a kit that works.” Rios’ team install new data and power equipment in overhead areas, as well as reconfiguring the heating, ventilation and air conditioning systems that support it — but all without taking too much space from clinical functions. “We want to renew the facility, give a greater capability, but also deliver the same or better clinical throughput. Nobody wants to invest in a new technology that cuts revenue.”

So how much future change do they try to anticipate on new projects? “As we’re programming facilities, we definitely have an eye for how much column space we need, how the rooms are set up — we don’t have a future use in mind, but we do think through how to optimize it for future use.” As for technology, Rios anticipates further increases in demand for power and data. “We try to imagine, within currently available technology, what capabilities we need to build into the building — so, larger trays, more power, slots for extra back-up generators. You have to balance it. In a lot of cases we’re willing to spend money upfront to extend life cycle.”

Rios’ team is in talks about the technological vision for a 400,000ft² neurological institute on the main campus, anticipated to begin design in 2021. “The institute chair wants patients to be able to go through different tests as part of the entry experience. They walk in, they pick up a patient tracker, and their gait is filmed as part of the natural process of moving through the building. They might have to fill out a form with a pencil and it would log how hard they squeeze it. So the clinician already has a view of their capabilities when they get there, which means they don’t have to go through a physical exam.”

Telemedicine or virtual medicine is another exciting development, though Rios says it will be important to “right-size” it so it is only used when appropriate: “We’re still working on it. We’re trying to create the infrastructure, but simultaneously figure out how it’s going to impact our care delivery in the future. It obviously has impacts from beginning to end of the process, so we’re still thinking about how that’s going to work.”

This article appeared in The Possible issue 06, as part of a longer feature on the future of healthcare

Main image: The Cleveland Clinic campus in Cleveland, Ohio. Photo: Cleveland Clinic