A HUMANIZING HEALTH CARE TEACHING HOSPITAL IN MEXICO · Universidad Panamericana, a private...

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Elliot Paul Rothman, AIA

Elliot Paul Rothman is Chairman ofRothman Partners, Incorporated, afirm he founded in 1969. He servedas Associate Professor of Architectureat the Harvard Graduate School of

Design from 1967 to 1969. With degrees in architec-ture, city planning and urban design, Elliot’s careerhas focused on urban teaching medical centers andresearch laboratories. His international healthcareprojects include a new teaching hospital forUniversidad Panamericana, Mexico City and theAsian Eye Institute in Manila. Within the UnitedStates, he was Project Director at RothmanPartners for the Behrakis Health Sciences Center, pro-viding teaching space for students in the allied healthsciences and teaching laboratories for the University.

A HUMANIZING HEALTH CARE TEACHING HOSPITAL IN MEXICO

Elliot Paul Rothman

I. STRESS REDUCING DESIGNSTRATEGIES AND TOOLSStress reducing design strategies for the futureUniversidad Panamericana Medical SchoolHospital depend on cultural familiarity, a sustai-nable environment, and hospitality to assure com-fort and healing for inpatients and outpatients.

Stress reducing design starts with the ethics of thehealthcare system. This ethic will permeate theteaching environment, infuse a system of clinicsthat serve the poor, and culminate in the teachinghospital.

Universidad Panamericana, a private universityin Mexico City, provides professional healthca-re education within a profound human and ethi-cal formation, fostering hospitality in patientcare that reduces stress. The strategiesemployed to reduce stress relate to the phi-losophy of Universidad Panamericana’s Schoolof Medicine, its concept of patient service, andits commitment to foster this philosophy in anew teaching hospital. The University createdits medical and nursing schools in 1996. Theirstrategic plan encompasses a health care systemthat includes a university hospital and urbanand rural satellite clinics.

The Universidad Panamericana School ofMedicine has many affiliations. Governmentagencies include the Secretaria de DesarrocloSocial (ISDESOL), Secretaria de EducacionPublicia (SEP), Secretaria deCommunicaciones Y Transportes (SCT), and

South Elevation, Universidad Panamericana School of Medicine

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International Academy for Design and Health

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the Secretaria de Salud (SSA). Foundationsinclude the Mazahua Foundation, the ZabalketaFoundation (Spain), and the NedicinaAsistencia Social Foundation (MAS). Internalto the University are faculty physicians,m23edical students and other schools of theUniversity including its esteemed Schools ofBusiness, Law, and Hospitality Volunteerorganizations such as the MAS Foundation for-ward the Medical School’s agenda. TheUniversidad Panamericana School of MedicineTeaching Hospital is part of the CLFPHSsystem of Mexican Hospitals.

The Medical School is international in scope,and includes an affiliation with the Universityof Navarra and its Hospital in Pamplona, Spain.

Universidad Panamericana’s Medical Schooland Nursing Schools extend themselves by sen-ding students to many international locales forlearning and training. Students are educated atBaylor College of Medicine (Houston),Northwestern University (Chicago), TuftsUniversity Medical School, and HarvardMedical School (Boston) and the University ofNavarra (Barcelona) among other venues.Students from the American Universities travelto the Universidad Panamericana clinics tostudy and deliver medical care, experiencingmedical practice in an impoverished communi-ty. On-site education, long distance learning,and the benefits of international communica-tions provide enhanced resources required fortelemedicine, diagnosis and treatment.

North Western University Students in Tlapa



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II. UNIVERSIDAD PANAMERICNANETWORK CLINICS

Prototype for the ClinicsUniversidad Panamericana commissionedRothman Partners Architects to design a proto-type for its system of clinics for the most indi-gent populations of Mexico. UniversidadPanamericana’s medical and nursing studentsstaff this network of clinics that serve the indi-gent population surrounding Mexico City andin the south.

Rothman Partners Architects developed theprototypical concept for the clinic. The Clinicin Tlapa was occupied. UniversidadPanamericana staff provide modern patient care,respond to the culture of patients and visitors,treat patients with dignity, and work within afunctional plan that facilitates modern flow ofpatients, physicians, nurses, staff and materials.Program elements include Emergency (with fullservice in Phase 2 construction); Radiology andImaging; Laboratory; Obstetrics andGynecology; Adult Medicine; Mental Health;Dentistry; Ophthalmology and Otolaryngology;and Pediatrics and Immunization. MerwynBagan M.D. MPH, FACS, Consultant, stressedthe need for a separate area for immunization

located in the main courtyard.Because funds are raised over a long time peri-od, the clinic needed to be built in phases. TheClinic also required internal flexibility tochange over time. The first phase of construc-tion was designed to include trauma, radiologyand an examination and treatment area, allorganized around two public spaces conceivedby Rothman Partners Architects. An externalplaza and a walled courtyard, both traditionaland familiar spaces in Mexico, were designed tobe partially covered in order to shield patientsfrom the intense sun.

Interior and exterior spaces were conceived as“green” spaces used to conserve energy and redu-ce impact on the environment. The design redu-ced stress because spaces were familiar, comfor-table and culturally relevant within the context ofcontemporary design, typical of Mexican moder-nism. A large plaza introduces the main entran-ce. Once inside, patients and their families alsoenjoy a large private courtyard whereImmunization is located. Both provide gatheringspaces and open spaces that help reduce stress forpatients waiting for diagnosis and treatment.

Rothman Partners Architects proposed designguidelines that use indigenous materials ininnovative ways. We designed the structure




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with laminated wood trusses supporting a claytile roof. The design prototype proposed expo-sed galvanized steel columns on pier footings.The exterior walls are made of double wytheconcrete units of a type commonly used in thearea as underlayment for stucco. Instead ofcovering the masonry though, we chose toexpose it and devised a coursing pattern thatgave richness and interest to an otherwise verymodest material. We designed windows to beoperable, with screens. Procedure rooms areclad with locally made ceramic tile. Typical flo-ors were designed with 30 cm x 30 cm cementtiles, mud-set. The final build-out of all phasesis approximately 20,000 gross sq. ft., 1,948 M2.



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The Tlapa Clinic, Tlapa,Guerero, Mexico, (MAS Foundation)The first clinic was built at Tlapa. Funded bythe MAS Foundation. The Foundation built anew medical clinic to displace its former inade-quate facilities. Tlapa is one of the poorest andmost arid regions of Mexico with a catchmentarea of about 600,000 people, many of whomspeak only Indian dialects.

Arq. José Luis Razo implemented the finaldesign application for the prototype at Tlapa.Although some changes had to be made to ful-fill Mexican regulations, the essential programelements were included. A total of 1,064 m2 wasconstructed; 884 m2 is to be added. Land areatotals 5,052 m2.

The Friends of the Tlapa Clinic, an extraordi-nary volunteer group, is comprised of concer-ned women in Mexico City. Most travel mont-hly to Tlapa. The Friends teach nutrition andhelp the Indians learn to cook nutritional food,using the scarce crop resources available, maln-utrition being a serious and rampant disease.

The Toshi Clinic, Atlacomulco, Estado deMexicao (Mazahua Foundation)The Toshi Clinic, recently completed, is locatedtwo hours northwest of Mexico City and is asmaller version of the Tlapa Clinic. It too fol-lows Rothman Partners Architects’ guidelines.Its successful courtyards and spaces are verycomforting and responsive to Mexican sensibi-lities, modern in its architecture. Arq. Juan

Entry to Classroom, Tlapa Clinic



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Alberto González designed the clinic.Future Plan for the ClinicsEach of the clinics has flexibility to grow. TheUniversidad Panamericana School of Medicinewill enhance telemedicine capabilities in order tofacilitate teaching, diagnosis, and improve outco-mes. They will construct the second phase of theTlapa Clinic for surgery. Two to three morerural clinics will be built. Other schools of theUniversity will become involved. Students fromNorth America, including students fromNorthwestern University and Harvard MedicalSchool, will travel to learn from the poor.

Often funded by private philanthropy, these cli-nics are part of the caring system thatUniversidad Panamericana fosters. TheMazahua Foundation supported the ToshiClinic, completed in 2003.

Patient Courtyard to Examination Rooms, Tlapa Clinic

Approach to Toshi Clinic

Courtyard, Toshi Clinic

III. THE CONCEPT FOR A NEW UNIVERSIDADPANAMERICANA TEACHING HOSPITAL

The clinic prototype provided the basis forRothman Partners Architects design concepts forthe new Universidad Panamericana TeachingHospital in Mexico City.

The University will construct a new 130-bedteaching hospital. The new hospital will interna-lize the values of the University and its MedicalSchool, creating a spiritual and physically thera-peutic environment for its patients, visitors andstaff. Many of its patients include the emergingmiddle class seeking a more responsive privatecare model than the public system affords. TheMedical School currently is in the process ofrecruiting chiefs, faculty and staff.

IMEC International is UniversidadPanamericana’s Strategic Consultant, withRothman Partners as Master Planner andArchitect.

Models and prototypes influencing the Hospital Design

The School of Medicine relies upon its Mexicanand Spanish culture, its spiritual support, and itsinternational medical student exchange to achi-eve its goals. The University of NavarraHospital in Pamplona, Spain, for example, pro-vides paradigms for hospitality.




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The University of Navarra, in Pamplona,Spain is a model for hospitality by the poli-cies and procedures its laundry and dietarydepartments follow.

Martha L. Rothman, President of RothmanPartners Architects (RPA), Elliot Paul Rothman,Chairman of RPA, and Gabriel Yaari, Principalof Design for RPA toured the University ofNavarra Hospital in Pamplona. They observedseveral characteristics, which reinforce the con-cept of a caring environment. The nursing ser-vice had a caring professional style with highmorale. The support services truly enhanced thecaring environment at a level of hospitality thatwas indeed unique in a hospital.

• DietaryAs visitors, Rothman Partners Architects enteredthe Navarra Hospital kitchen on ground levelwhere a cook was neatly cutting steaks from afresh swordfish. This immediately suggestedthat the institution cared about its patient’s cul-ture and diet. The fish was fresh and the mealwas to be prepared using natural ingredients.

Next we observed the workflow. Dietary admi-nistration created a computerized meal orderingsystem that permitted staff to identify specialcharacteristics for each food tray. An assemblyline with four or five staff members assembledeach tray and visually inspected the quality. Thecooked food was sent by elevator to the patientson heated carts.

In a typical hospital, patients complain that theycannot obtain food between meals when theybecome hungry or thirsty. The University ofNavarra Hospital adopted a ready supply foodservice process that provides each patient animmediate response to their off schedule foodrequests. A ready supply refrigerator in dietary islocated next to a dedicated dumbwaiter. Uponrequest for a snack from the patient or the pati-ent’s caregiver, a computerized note is immedia-tely sent to a dietary staff member who fills the

request and returns the order by dumbwaiter.Accompanied by computer notification, the mealis then served.

• LaundryIt is important that patients wear dignified appa-rel. To achieve that goal, Navarra has a full ser-vice laundry where it designs and sews its ownnon-revealing patient gowns. Infants were notonly swaddled in diapers, but also covered com-fortably with shirts, pants and dresses that all ofus, as parents, would want to see our infants clot-hed in, all made by seamstresses in the laundryservice. The seamstresses also fabricated hospi-tal uniforms, differentiating each group by har-monious pastel colors. All staff members wereproud of this special attention and variety.Linens and special garments were carefully pres-sed by the most advanced machines. Navarra’slaundry staff was not relegated to a dingy lifelessbasement. The facility was on grade with win-dows providing views and natural daylight.

THE PROGRAM FOR THE UNIVERSIDADPANAMERICANA TEACHING HOSPITAL

Features for Stress Reductionin a New Teaching HospitalThrough IMEC, International, StrategicConsultant, the Universidad PanamericanaSchool of Medicine invited Rothman PartnersArchitects to develop a new teaching hospitalcommitted to patient care in a healing environ-ment. The new medical school sought excellencein medical care, within a new therapeutic physicalenvironment. As in the Clinics, The UniversidadPanamericana School of Medicine and theUniversity draw upon their basicMexican/Spanish culture for strong spiritual sup-port, international medical exchange, and interna-tional design resources, all to achieve their goals.

Descriptions of the New HospitalThe existing medical school campus is located atthe site of the original University, formerly a haci-enda located in the southwest area of Mexico City.



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The new teaching hospital is planned to be loca-ted in a valley distant from the main campus.The Medical School anticipates an ambulatorycare and in-patient facility that can be phased asfunds become available. Academic Chiefs ofDepartments, teaching physicians, nursingeducators and nurses will participate in planningas part of the medical community. The spaceprogram currently includes Ambulatory CareFacilities, the Radiology and ImagingTechnologies Center, an EmergencyDepartment, and an Ambulatory PatientSurgical Suite that will also serve in-patients inlater phases. Approximately 120 to 130 beds willbe constructed in phased construction.

The teaching hospital reflects the values ofUniversidad Panamericana and physical charac-teristics of its campuses. Features include land-scaped and paved courtyards, well-scaled outdo-or spaces, unity of color, art, and detail in theclassrooms themselves. Rooftop terraces fordining, also important in the UniversidadPanamericana Business School, are included inthe hospital design.

Rothman Partners Architects designed innovativepatient floors. On-line education for medical andnursing students is included at each patient floor.Information systems and computer technologiesare drivers for a small medical school, becausethey link students to international informationthat simulates patient cases they would not ordi-narily experience. Computers are located in eachpatient room to facilitate information transferand work orders, reducing the role of the tradi-tional nursing station. As a result, nurses anddoctors will spend more time with their patients.

Rothman proposed a patient floor of about 28beds to 30 beds for each nursing unit. Individualoccupancy is favored in the Mexican culture just asit is becoming the standard in U.S. hospitals.Sitting and meeting areas in the corridors thatallow natural light separate groups of 4 to 8 bedsand eliminate tedious corridors. This bedarrangement provides flexibility in the assignment

of inpatient rooms. Organized for personal carenursing, one key nurse is responsible for a pati-ent during his or her entire stay, providing conti-nuity, coordinating other staff, fostering hospita-lity and reducing stress.

The team recognizes that a teaching hospitaloperates with a high ratio of nurses to patients.The ratio is based on acuity of patients and thetime required to teach medical and nursing stu-dents about each patient. Unique to this hospi-tal is the extent of teaching space on each floor,including computer work space, small caserooms and meeting space.

Due to the steeply sloping site, architecturalmonitors bring natural light into conferenceand seminar rooms that are located against thehillside.

The program includes a chapel for 200 peoplefor the spiritual health of its patients. The cha-pel, located at the entry to the courtyard, inspi-res patients about the role that spiritual comfortplays in medicine, in wellness, in stress reduc-tion, and in cultural associations with healthca-re from birth to end stage illness.

New Patient RoomsIn the United States, there have been many stu-dies of in patient rooms similar to NorthwesternUniversity’s new patient room, valued byUniversidad Panamericana as a model. Thepatient rooms at Universidad Panamericana willinclude a work zone for the physician and nurse,a toilet room with shower, the patient bed area,and a sitting area for family members whose pre-sence and assistance serves to reduce stress.Rothman Partners Architects developed a slee-ping alcove next to the outdoor balcony in eachroom for a family member. All rooms face sout-herly. Balcony and alcove respond to the clima-te and the large role that Mexican families playin hospital-based healthcare.

Outpatient/Ambulatory Care FacilitiesA strong outpatient model requires wayfinding andefficient work flow. Examination and consultation




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Balcony SouthPatient Bedroom Conceptual Sketch

rooms are designed to be large enough foreducating medical and nursing students andfamily members. Inpatient rooms should beexposed to natural sunlight. The patient envi-ronment should be designed for hospitality,comfort and reduction of stress. RothmanPartners Architects presented their innovativeprototype for examination and diagnosticrooms when they presented their design of theCarl J. Shapiro Clinical Center at Beth IsraelDeaconess Medical Center, Boston, at theDesign and Health World Congress atTrondheim, Norway in 1997.

THE MASTER PLAN FOR THE UNIVERSIDADPANAMERICANA SCHOOL OF MEDICINETEACHING HOSPITAL

Understanding the Existing CampusesEarly in the planning phase, the team took longwalks through two of Universidad Panamericana’scampuses - the Academic/Medical School campusand the Business School campus. These walks

made a lasting impression and taught the designteam valuable lessons about the disposition ofbuildings on the land, the picturesque relation-ships generated, the absence of formal axis as ameans of organization and, above all, about theessential part outdoor spaces play in establi-shing a sense of place for an entire community.

The Site MissionIn their preliminary design, Rothman PartnersArchitects incorporated the lessons learned fromthe tours. The designers intend to create spacesand buildings that are specific to Mexico Cityand its hilly terrain. The team’s objective was togenerate an environment that fulfills the missionof the departments of the hospital in an efficientand practical manner. Designs were to be con-sistent with the dedication of the institution tothe most advanced practice and instruction ofmedicine. The team introduced an environ-ment of human poetry, believing that functionalenvironments must be elevated through designto perform the healing objective.



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Courtyard Showing Thematic Red Paint and Stone Walls

Design StrategyAlthough the new hospital will be built in seve-ral phases, determined by financial and demo-graphic projections, the design team’s approachwas to envision it in its completed totality. Thedesign master plan envisions the hospital in itsentire program for the facility, giving specificityto each department and unit, its adjacencies,public and private movement, and to access byvehicular circulation.

Environmental considerations led the team toengage the natural site. Site design envisions aswitchback road from the top of the hill to therelatively flat valley below where the majority ofthe medical functions and their support servicesare to be located. Visitors and patients can enterthe hospital by automobile, via the hillside road,connecting to tiered, surface parking; or, they canenter from the top of the hill through an upperlobby and an elevated walkway to elevators.

The design proposes several interconnectedbuildings surrounding a landscaped plaza at thefloor of the valley. A traditional plaza recallsthe historic cloistered hospital. The plaza istrapezoidal in shape. Its long axis is orientednorth-south. Clearly identified buildings to bedeveloped over time surround an urban plaza.The design approach is very different from aNorth American hospital that expands from acentral core building by adding wings andextensions.

Buildings surrounding the plaza contain speci-fic activities: To the west – the ambulatory careand outpatient clinic; to the north – the radio-logy department and beyond it, the emergencyunit (with its own entry and ambulance court);to the east – the café/restaurant, the pharmacyand education programs; and to the south – thechapel that prominently articulates the entranceinto the Plaza.




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New Terrace Facing Hacienda of Original



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ER and SupportRadiology/ImagingCirculationCourtyard/PlazaAmbulatory Care FacilitiesPharmacyEducationDiningMechanical and Support

SurgeryRadiologyCirculationAmbulatory Care FacilitiesDiningInpatient SupportInpatient SupportMechanical and Support

East-West Cross Section

East-West Cross Section

Master Plan



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1. Elevator Lobby2. Single Bedrooms with

Balconies3. Light Well4. Central Nurses’ Station5. Support6. Computer Education

Center7. Gathering Space

In-Patient Floor Plan

The organization of activities takes advantageof the steeply sloping terrain. Inpatient bed flo-ors are set into the shoulder of the hill steppingup gradually. All patient rooms face southwest,each with a balcony.

The configuration of the hospital bed floors delibe-rately avoids endless and oppressive corridors;instead, it organizes a group of rooms that align agently curved corridor. Rooms and other spacesinclude nurse’s sub-stations, communal rooms,solaria, and support space. Natural light permeatescirculation spaces through these communal roomslocated at the west and southwest. On the “blind”side of the hill, truncated conical light wells, the fullheight of the building extend above the top of thehill and illuminate a signature skyline.

Administrative and doctors’ offices occupy the topfloor of the east building, affording views over theentire complex.

Within the plaza, the main loggia facing south cre-ates a strong public image without attempting to bemonumental or overpowering. Two and a half sto-ries high, it will be sheathed entirely in glass and beprotected by a deep overhanging roof supported onsteel columns. The loggia’s transparency acts as avisual foil and the chapel located opposite.

One approaches the chapel from the courtyardlevel by walking up a processional ramp. The cha-pel is a place of introspection and prayer. Its solidwalls are clad in stone. Natural light flows inwardthrough a large oculus. The oculus forms a domeover the worshippers, conveying a sense of com-munity within a large religious space.

Within the Universidad PanamericanaTeaching Hospital Campus, massing, articula-tion of the buildings forms, and natural materi-als respond to the region’s climate. They embo-dy the culture. They mirror examples of localarchitecture – both vernacular and modern.Overhangs, pergolas, galleries and porticos pro-vide shelter from the sun. Ranges of trees, flo-wering plants and lawns extend the naturalenvironment one encounters in Mexico City.




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Model of Universidad Panamericana Medical School Teaching Hospital



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CONCLUSIONExcellence in design, caring physicians, nursesand allied health professionals all reduce stressfor patients and families at the UniversidadPanamericana School of Medicine teaching hos-pital. Caring reduce stress. A caring physicalenvironment reduces stress. The UniversidadPanamericana Teaching Hospital fosters clinical

and spiritual well-being. It generates an ethoswhere caring medical and nursing students learnto mitigate stress. Long after they graduate,Universidad Panamericana’s medical and nursingstudents will benefit from the holistic approachthe design embodies. This new teaching hospi-tal in Mexico City will enhance wellness andreduce stress among patients, families and staff.

Pirámide del Sol, Teotihuacán, MexicoWork on Paper by Elliot Paul Rothman, July 2001


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