Ohtel --- Part 1

1 Introduction


1.1 In search of a new kind of care hotel in the context of market-driven heath care for the middle aged bourgeois

This care hotel is specially designed to respond to the changing health care insurance system in the Netherlands. Since 1st January 2006, Dutch health care insurance has being transforming towards a private and consumer-driven health care system. This means that people have freedom to choose the most suitable health care for themselves. In this kind of health care system, how to create the additional value for the care hotel is very important for strengthening their competitiveness in the market. For this care hotel, the patient group is specified as the people from the middle income group and are aged from 40-65 because in the major cities of the Netherlands, such as Rotterdam, the percentage of the population in the lowest income group always exceeds 50%.[1] However, children, students and elders are possibly also counted in this group. These 3 sub-groups in lower income should be excluded because children and students can be cared by their parents when they are sick, and the elders usually receive good care in nursing home. So, the actual percentage of lower income group may be lower than 50%. On the other hand, the percentage of middle income group in the total population in Rotterdam is 30,4. The demographic prediction made by CBS also indicates that middle aged people are in the largest group of population in Rotterdam in 2020. Normally these people can take care of themselves, but they need help because they are single or their partners may not have time to take care of them because they also need to go to work. The middle income group, the bourgeois, is very smart consumer because they are very aware of quality and price. Most of them are searching the products with high quality, but these products were usually too expensive for them to afford. The product with high quality and lower price is always their first choice.[2]

So, what kind of care hotel should we provide for these middle aged bourgeois?



1.2 Problem statement

Aedes-Actiz Kenniscentrum Woon-Zorg (Knowledge centre of Living-Care), a Dutch institute specializing in the research of living and care, defines care hotel as follows: “Care hotel should provide temporary stay with 24 hours care and service in a hotel-like setting which contains a service-orientated environment in a comfortable accommodation with hotel facilities.” [3] Also, according to the databank of care hotel, among all 23 care hotels in the Netherlands, the target groups are mostly elders and physically handicapped people. Some care hotels also host the people with dementia, people with intellectual handicap, and the psychiatric patients.[4] It means that care hotel has to provide general solution and environment for different kinds of patients. On the other hand, care hotel also needs to contain all the resources needed for all kinds of patients. Apparently, these two phenomena limit the quality of care and also result in higher cost. In the context of market driven health care, consumers are very aware of the relation between quality and price of a product. The product with higher quality and lower price is always consumers’ first choice. In this way, if any care hotel can provide higher quality at lower price, can the other ordinary care hotels still compete with it? So, my first problem is as follows:


Most care hotels in the Netherlands host the patients with different kind of diseases. Is this appropriate in the context of the market-driven health care?


Also, based on the definition of care hotel made by Aedes-Actiz Kenniscentrum Woon-Zorg, care hotel should be designed like a hotel to provide service and comfortable environment for the patients. However, the essence of the design is almost the same as hospital, and it just looks like a hospital decorated in the style of hotel. Taking the care hotel Leo Polak in Amsterdam Osdorp as example, it has a delicately decorated entrance hall which is similar to the interior design of hotel. However, in the corridor which connects patient’s rooms, the texture of walls is very rough, and the doors are just facing with each other. The space of corridor is closed without any opening for daylight. It just reminds me the corridor of hospital or even the jail. Also, the patient’s rooms are just the same as the single room in the hospital. Comparing with the mock-up of the single room in the Erasmus Medical Centre in Rotterdam, this single room is smaller and crude. So, in my opinion, the second problem of care hotel in the Netherlands is as follows:


Is care hotel a hospital-like building which decorates like a hotel? Can anything else other than decoration also benefit patients?


Keeping the privacy of the guests is an important task for hotel, and it’s also valid in the care hotel. However, this demanded privacy often results in isolation to the surroundings. Care hotels in the Netherlands are located both in the countryside and city. The care hotels in the countryside create this isolation in order to reduce the disturbance from the outside world. They hope that the patients can concentrate on recovering from disease in a very quiet and natural environment. The care hotels in the city also create isolation for privacy. However, this isolation is created by the architecture itself, but not by its location. For example, the care hotel de Palatijn in Alkmaar and the care hotel Leo Polak in Amsterdam Osdorp are both located in the city, but they don’t have any function which can also provide for the people from outside. In my opinion, when the building in the city centre isolates itself to the surroundings, it makes itself a very strange presence in the neighbourhood. Especially the site of this project is located closed to the famous cultural and trendy area, Witte de Withstraat, where the density of museum and gallery is the highest in Rotterdam. The isolation will become more significant than the other care hotels in the city. That’s the reason why I think that the third problem of care hotel is:


Should care hotels in the city isolated to the surroundings?



1.3 Research related to the problems

Based on those 3 problems I mentioned in the last part, I would like to introduce two fields of research which are relevant to the problems. The first one is about the “Focused factory” in the market driven health care. This research provides a solution for the first problem. It is mainly about how to resize the health care system to create higher quality at lower price. The second field of research is about Evidence Based Design”. This research is introduced here to show how to create a low stress environment which has positive impact on patient’s health. It also responds the second problem about the factors other than decoration which can benefit the patients in the healing environment.


- “Focused factory” creates the product with high quality cheaper price in the market-driven health care


What is “The focused factory”?

Since health care becomes a product, the relation between its quality and price are getting more and more important. Consumers always expect the product with higher quality and lower price. If the general solution and service provided by the current care hotels can’t bring the ideal product to consumers, we should think about resizing. Resizing is a fundamental change just like trading fat for muscle. In the book, Market-Driven Health Care, the writer Regina Herzlinger, professor at Harvard Business School, mentions about using “Focused factory” to resize health care system.[5] “Focused factory” is a new term in the health care, but in fact this term is found in the article written by Professor Wickham Skinner at Harvard Business School in 1974 to presage that many companies in the American manufacturing sector has since been revitalized by resizing diet. In his research, he pointed out that “a factory that focuses on a narrow product mix for a particular market niche will outperform the conventional plant, which attempts a broader mission.”[6] The focused factory can concentrate on a limited task for one set of customers, and lower the costs. It can become a competitive weapon because its entire apparatus is focused to accomplish one task. His “Focused factory” is now also adapted in the health care. The Shouldice Hospital in Toronto is the representative example of the focused factory in the health care because it provides high-quality health care at lower costs.


Learning from the Shouldice Hospital in Toronto

Shouldice Hospital[7] focuses only on one surgical procedure, the abdominal hernia operations. Normally the focus of general purpose hospital is diffused because of its wider range of services. In the Souldice hospital all the resources are used on one disease. For example, the surgical team repeats do the same surgery continuously, so they work together on one procedure work more fluidly and efficiently than the surgeons in the general purpose hospital. In this way the recurrence is lower, and the quality is improved at the same time. In order to decrease costs and increase quality effectively, they design an integrated operating system for this special hospital. In this system each of its activities reinforces the others, and purposefully places considerable demands on the patients.[8] For example, patients are prompted to walk more because meals are only served in the public dining room. Also, the absence of amenities in the rooms encourages patients to leave their beds and walk more for exercising. The patient here is not just a passive lump. They are active healer and teacher. The patient has to prepare himself for surgery, speed his own healing by exercising more and help to instruct other new arrivals about what to expect in the surgery. The self-empowerment created by the integrated operating system makes the patients love this hospital.[9] They even have alumni to commemorating the repair of their abdominal hernia at Shouldice hospital. The self-empowerment of patient and the higher familiarity of operation are two key points to keep high quality of care and result in the decrease of the cost at the same time.


- Low stress healing environment created by Evidence Based Design(EBD)

In most care hotels in the Netherlands, the interior space is decorated like a hotel to create low stress healing environment because hotel represents a relaxed atmosphere. However, can anything other than the decoration also create low stress healing environment? In the article “Evidence Based Healthcare Design” written by Roger Ulrich[10], he points out 4 factors which can create low stress environment in the hospital. The factors of reducing stress are social support, nature views, daylight, garden, and single-bed room.


About the first factor, social support, Ulrich indicates that “social support refers to emotional support or caring received through interpersonal relationships, and tangible assistance from others.”[11] Generally patient gets social support from the interaction between patients and from their families and visitors. The social interaction between patients can be strongly influenced by environmental design. For example, the design of collective space such as lounge with comfortable and movable chairs can increase the beneficial social support. Also, according to Ulrich, patient in the single-bed room gets more social support from his/her family or visitors than the patients in the multi-bed rooms. It is because that in the single-bed room the space and furniture per patient for accommodating visitors and the privacy for patient-family interaction are more than in multi-bed rooms. Also, the presence of roommate heightens stress because of the loss of privacy, noise, worsened sleep, or a roommate who is unfriendly or seriously ill.[12]


Green is another factor which creates low stress healing environment. It has been proved in many scientific studies that real or simulating views of nature effectively and quickly reduce stress and pain.[13] According to Ulrich, if patient is exposed to certain types of natural setting, the patient’s physiological stress will be eased within 3 to 5 minutes at most. Garden provides the real view of nature to people. It is also a pleasant place for patients and staff for walking, sitting and creating social interaction and support. Based on the post occupancy evaluations which Ulrich mentioned in his article, patients, family, and staff who use gardens in hospitals report reduced stress and improved emotional well-being. Garden can be even more effective in reducing stress if contains prominent green or verdant vegetation, water, flowers, spatial openness, and grassy space with trees and shrubs.[14] In the interior space, despite of using real plants, the natural view can also provided by the images or films displayed on the TV mounted on the wall, and it works also very well on the patients in reducing stress. Daylight has the same effect as green in reducing stress and pain. High level of daylight exposure in patient rooms can effectively alleviate depression and pain.[15] Patients living in the bright rooms took 22% less pain medication than those in the dim rooms.[16] In this way, the cost on medication can also go lower. That is why architect should seriously take daylight into account for the design of patient’s room. Too small window openings, shadow caused by the adjacent buildings, and the “deep plan” of building should be avoided in the design.

1.4 Research question

Based on the different problems in the problem statement and their related research, I propose three research questions as follows:


- How can care hotel become a focused factory to provide the high quality service with lower price in the market-driven health care?

- How can care hotel keep involving with people’s life? Can going to care hotel become part of people’s life?

- Besides decorating like a hotel and making low stress environment, can building itself further become a tool to help people for rehabilitation?



1.5 Purpose statement

- Care hotel as the “focused factory” for one disease

In a consumer-driven health care system, the health care itself becomes a product and will need to compete with the other service providers of health care. Quality and price are two crucial factors for the consumers to choose which kind of health care they would like to pay for. Care hotel, as one of the service provider in the health care system, should provide high quality at the lower price to attract consumers especially when they are bourgeois. In this way, care hotel can’t just be the ward outside hospital, but it needs to provide more delicate service and healing environment. How the patient group can benefit from the service and healing environment to help them quickly recover from the disease is very important because this is the main reason to convince people to stay in the care hotel instead of returning home after surgery. That’s why I think that this care hotel should be developed based on the concept of “the focused factory” in the market-driven health care and the successful story of the Shouldice Hospital. In this way, care hotel should also focus on caring the patients with the same disease to provide high quality care at lower price.


- Total solution for a common disease with different levels of pain

Furthermore, care hotel can’t just be a hotel to host patients. It can be a health centre to provide total solution for the main patient group and other “potential patients” in the same disease because some diseases affect people with different levels of pain from very light to very severe. Because different levels of pain need different treatments, these treatments can be functionally interpreted as the new inputs in the program. Also, the concept of total solution on one disease can generate a reliable and professional image for this care hotel, and build up the tight relationship with the patients just like the Shouldice Hospital.


- Integrate with surroundings

Care hotel can be even not only used for the patients or the potential patients. It can be integrated with the surroundings, and be an important part of the community. Part of the functions in the care hotel should be homogeneous to those in the surroundings, and should correspond to the existing character of the neighbourhood. It’s because that this care hotel is located nearby the famous cultural and trendy area where the density of museum and gallery is the highest in Rotterdam. In such context I think that this area is highly tolerant for the new inputs in the program such as restaurant and shop which are also open to the non-patients. In this way, the care hotel can have much closer relation with the surroundings.


- Use green, daylight, and architectural elements to create healing environment

In this project, green and daylight are chosen among all the factors of low stress healing environment defined by Roger Ulrich. For the patient’s room, I would like to introduce daylight into interior space as much as possible. However, for the collective space, I want to use different strategies to introduce daylight and green to create different spatial qualities for different functions.



1.6 Osteoarthritis (OA): a common disease of middle aged people

In the purpose statement, I mentioned that care hotel will not only have the care facilities, but also can expand itself to become a health centre for helping people to recover from certain kind of disease in different ways. The choice of different user groups brought to this care hotel should be decided on the basis of the same disease. This disease should have different levels of syndrome which need different levels of treatment. In my opinion the patients of osteoarthritis is an optimal choice for the main patient group of this care hotel because osteoarthritis is a very common disease mostly affecting the people aged from 40. The treatment of osteoarthritis differs from exercise to surgery in order to cure the levels of pain. In the program, additional functions such as fitness centre, acupuncture clinic, and healthy food restaurant are integrated into the care hotel to create a total solution for healing different levels of pain caused by osteoarthritis.


- About Osteoarthritis

Osteoarthritis (OA) is a chronic and degenerative joint disease. The cause of OA is still unknown, but we know that it can occur in any body joint. OA most frequently happens to weight-bearing joints: the hips, knees, feet, and hands. The entire joint structure including the ligaments, muscles, bone, and soft tissue are affected. The disease usually develops slowly and progresses in response to the breakdown of articular cartilage that cushions the ends of joint bones. Without cartilage, the bones directly rub against each other causing pain and inflammation. Cartilage inflammation stimulates the growth of bone spurs in the affected joint and small pieces of bone or cartilage can break off and float in the joint fluid, causing additional pain, inflammation, and damage. More than one-third of people over age 45 suffer joint symptoms that vary from occasional stiffness and aching after activity to permanent loss of motion and constant pain in at least one joint, usually the knee. It also causes long-term disability in people over age sixty-five. OA can produce a serious impact on the national economy. The cost of medical care, combined with non-medical costs such as lost wages and limited employment opportunities, creates a large burden on our society. In my opinion, these could be an important motivation for the middle aged bourgeois to choose the most effective and efficient way of healing.[17]


- 3 levels of pain & related treatments

Normally we can categorize the pain into 3 different levels: 1.light, 2. medium, 3. severe. The related treatments of different levels of osteoarthritis are all meant to reduce joint pain and inflammation while improving and maintaining joint function.


- Exercise for relieving the light level of pain

Regular exercise offers the very beneficial effects of minimizing joint stiffness, increasing the tone and strength of the muscles surrounding the joint, and helping with weight management. Low-impact activities such as cycling, walking on soft surfaces, or low-impact aerobics are recommended because high-impact exercise aggravates an arthritis joint.[18]


- Medication or alternative treatment for the medium level of pain

Medication for osteoarthritis includes the prescription medication and the medication without prescription. The traditional medication, the over-the-counter pain relievers, can be obtained without prescription. However, if people use it for long-term pain relief, it will possibly bring gastrointestinal side effects or the liver toxicity. NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) are the prescription medication. They have fewer side effects than the normal pain relievers, but patients requiring long-term use of NSAIDs are demanded to do blood test every 3 to 6 months to monitor liver and kidney function. [19]

Besides medication, nowadays people also seek help from alternative treatment such as Chinese acupuncture. It has remarkable effect on reducing the pain caused by the osteoarthritis. According to the research of the US National Institutes of Health, acupuncture patients showed a 40% decrease in pain, and a nearly 40% improvement in knee function.[20]


- Surgery for the severe level of pain

Replacement of an artificial joint is the ultimate treatment for severe osteoarthritis. If exercise and medication can’t reduce pain effectively, then the patient should consider the joint replacement. Due to the life span of artificial joint is about 10-15 years, patients and doctors should carefully consider the best timing for the surgery in order to avoid the chance of a revision for joint replacement. Nowadays hip and knee replacement surgery has become a common treatment for severe OA of these joints because of the good long-term success rate.[21] With the step by step rehabilitation, patients can be getting back to more normal in 4 weeks.[22]



- Inpatient group --- the patient of “Total Knee Replacement”

In relation to the concept of “Focused factory”, the inpatient group of this care hotel is focused on the patients of total “knee” replacement because it is the most common treatment for the severe OA of knee. Before the day of surgery, patients can stay in the care hotel to do pre-operative work up. After surgery patients can be sent back to care hotel for post-surgery rehabilitation. The post-surgery rehabilitation is very important because the successful knee replacement procedure counts not only on surgery but also on the quality of exercise program.
Normally the post-surgery rehabilitation takes 4 weeks to help people have good range of motion, fair strength, and moderate endurance. Care hotel can help patients and hospitals to ensure that the rehabilitation is on the right track.

1.7 Treatment, User groups, and their related functions


Figure 1.7.1 Related functions of each user group

[1] Kercijfers Rotterdam 2006, Gemeente Rotterdam
[2] Silvestein. M. J , Butman. J, , Treasure Hunt: Inside the Mind of the New Consumer, 2006, Portfolio Hardcover
[3] The website of Aedes-Actiz Kenniscentrum Woon-Zorg: http://www.kcwz.nl/zorghotel/index.html
[4] The databank of care hotels in the Netherlands: http://www.kcwz.nl/cgi-bin/databank.cgi?page=databank/zorghotel_lijst&soort=zorghotel
[5] Herzlinger. R, Market-Driven Health Care, Basic Book, 1997, Chapter 8 Resizing--- The “ Trade Fat for Muscle” Diet
[6] Herzlinger. R, Market-Driven Health Care, Basic Book, 1997, pp.163
[7] See more information in their website http://www.shouldice.com/
[8] Herzlinger. R, Market-Driven Health Care, Basic Book, 1997, pp.161
[9] Herzlinger. R, Market-Driven Health Care, Basic Book, 1997, pp.160
[10] Ulrich. R, 2006 “Evidence Based Healthcare Design”, In : The Architecture of Hospitals, edited by Col Wagenaar; pp.281-289, NAi Publishers
[11] Ulrich. R, 2006 “Evidence Based Healthcare Design”, In : The Architecture of Hospitals, edited by Col Wagenaar; pp.285, NAi Publishers
[12] Ulrich. R, 2006 “Evidence Based Healthcare Design”, In : The Architecture of Hospitals, edited by Col Wagenaar; pp.288, NAi Publishers
[13] Ulrich. R, 2006 “Evidence Based Healthcare Design”, In : The Architecture of Hospitals, edited by Col Wagenaar; pp.288, NAi Publishers
[14] See 10
[15] See 10
[16] Ulrich. R, 2006 “Evidence Based Healthcare Design”, In : The Architecture of Hospitals, edited by Col Wagenaar; pp.289, NAi Publishers
[17] Brugioni, D.J, Falkel, J, Total Knee Replacement & Rehabilitation, Hunter House Inc.,2004, pp.9
[18] Brugioni, D.J, Falkel, J, Total Knee Replacement & Rehabilitation, Hunter House Inc.,2004, pp.17
[19] Brugioni, D.J, Falkel, J, Total Knee Replacement & Rehabilitation, Hunter House Inc.,2004, pp.19
[20] “Acupuncture 'works for arthritis' ”, an report from the website of BBC News, 21st/ Dec/ 2004, http://news.bbc.co.uk/1/hi/health/4111047.stm
[21] Brugioni, D.J, Falkel, J, Total Knee Replacement & Rehabilitation, Hunter House Inc.,2004, pp.25
[22] Brugioni, D.J, Falkel, J, Total Knee Replacement & Rehabilitation, Hunter House Inc.,2004, pp.178