[Originally published 1st quarter 2007 in arcCA 07.1, “Patronage.”]
Author Clark Kellogg helps organizations create better futures using design, clarity, strategy, and communication. He also teaches, facilitates, lectures, writes, and designs. Clark is often accused of deploying stealth levels of advanced common sense.
Kaiser Permanente is one of California’s largest architecture clients. The health care provider has over $24 billion of construction in the works. The surge in facilities construction is fueled by both membership growth and California’s seismic safety legislation. Enacted in 1994, Senate Bill 1953 requires California hospitals to be earthquake resistant so they remain operable after a major quake. But Kaiser Permanente is also building to accommodate membership growth and to reshape its facilities in alignment with its vision of promoting health, safety, and environmental sustainability.
The concept of patronage has two dimensions at Kaiser Permanente. One of them is recognizable as a twenty-first-century extension of the classical model. The other is not. And it is here that the concept of patronage presents its most challenging and provocative twist. But the future patronage is rooted in the present model, and that’s where our story begins.
Kaiser Permanente has organized all its facility functions in one group called National Facilities Services (NFS). Under the leadership of Christine Malcolm, Kaiser Permanente’s Senior Vice President of Hospital Strategy and National Facilities, the group includes strategy, planning, design, real estate, facilities operations, project operations, program management, and finance. This integrated view of facilities is designed to align these functions with Kaiser Permanente’s brand promise to its members, employees, and society.
To accomplish this broad and aggressive agenda, Kaiser Permanente maintains a network of pre-qualified architecture firms to streamline the architect selection decisions as well as the design and construction processes. Called the Alliance Program, it consists of architecture, engineering, and general contracting firms. This model is similar to the classical models of patronage, yet there are notable differences in both purpose and function. The goal of the Alliance is not to aggrandize power or wealth. It is to achieve better architecture and to create operational and cost efficiencies.
Firms are selected for partnership based on their expertise in healthcare, their size and location, and the degree to which a firm is a cultural fit with the Kaiser Permanente model and people. Malcolm says, “We value an architect’s ability to stimulate new ideas about our buildings. The best work we do is with firms that completely understand our vision. They know what we’re trying to deliver to our members and integrate it beautifully into our facilities.” That can be a tall order for a traditional, object-oriented architecture firm, so Kaiser Permanente selects its Alliance Partners with a mix of pragmatism and promise. As John Kouletsis, Director of Strategy, Planning and Design puts it, “It’s like higher education. We’ve done the undergraduate course work for the Alliance Partner. We look for firms that can take that knowledge and build on it. We want these firms to grapple with higher-level issues and then make the case for change based on solid evidence-based research and breakthrough thinking.”
Unlike patronage relationships of the past, Kaiser Permanente doesn’t want to be a firm’s only client. In fact, they don’t even want to be their primary client. “We’re most comfortable when Kaiser Permanente represents no more than 30% of a firm’s work,” says Kouletsis. “Being top-heavy with Kaiser Permanente work is a risk to both of us.”
There is a certain level of mutual frustration in the Alliance Program. Architects complain that Kaiser Permanente restricts their creativity with too many predefined elements and components. Kaiser Permanente complains that some architects fiddle with the small stuff at the expense of bigger, more important issues. “It’s not about being published in Architectural Record,” said Kouletsis, “It’s about creating better health outcomes.” Yet, the patronage concept has created a working partnership that tilts the creative abrasion toward good results. As Malcolm said, “Sometimes we’ll walk through a new facility and it’s like magic. The architects embraced the constraints and created a building in which the sum is so much greater than the parts. It works, it’s beautiful, and it makes people happy. That’s what the Alliance Program is supposed to do, and that’s what we are supposed to do.”
Recently, Kaiser Permanente created a new position, Vice President, Delivery System Strategy, and recruited Michele Flanagin, from Rush University Medical Center, for the role. Just a few weeks into it, Flanagin claims to be “just getting my toe in the water,” but clearly she has been thinking of some bigger ideas. “When people here talk about the Kaiser Permanente credo—‘Our cause is health. Our passion is service. We’re here to make lives better’— they mean it. The implications of that for our facilities, our members and employees is profound,” she said. “I’m here to help create a direct link between our strategy and our buildings.” The leaders of NFS think that direct link will be found in the sweet spot where Kaiser Permanente and the Alliance Partners overlap. “Perhaps it’s an idealized view,” says Malcolm, “but we believe if we are accountable for the standardized component of a facility, it frees up the architects to grapple with bigger, more important issues. The location of bathrooms in a patient room is a problem we’ve solved. It’s not a higher-order issue for us. Digital work flows, patient safety, and the implications of new clinical technologies are.” If the Alliance Program is an extension of an old patronage model, then Kaiser Permanente is on the verge of a new one. On a recent day in January, Malcolm, Kouletsis, and Flanagin had just finished a two-hour conference call with three other Kaiser Permanente executives. It was about being patrons. “It’s patronage with a different kind of twist,” said Kouletsis. Their conversation had been about being the patrons of an idea. “We want to change the face of healthcare in this country,” said Malcolm. How that might happen is a different kind of patronage altogether.
Kaiser Permanente is big. Their size can be both an advantage and a hindrance. When Malcolm arrived two years ago, approval for a facilities project required 173 internal signoffs before it could begin construction. On the other hand, when Kaiser Permanente does make a move, it has an impact on the whole industry. Not long ago, Kaiser Permanente asked latex exam glove suppliers to reformulate them to be latex free (12% of the population is allergic to latex). Today, latex-free exam gloves are used throughout the healthcare industry. More recently, Kaiser Permanente decided to end its use of PVC in flooring materials because of the environmental and human health concerns related to the production and disposal of PVC. Instead, Kaiser Permanente facilities now use rubber or other non-PVC flooring materials. Other healthcare providers are following suit. (An unanticipated outcome of switching floor materials is a reduction of leg and back pain among employees who stand and walk for a large part of their day). Because of the sheer size of Kaiser Permanente, its moves often change the industry. But what will happen when Kaiser Permanente changes the focus of its patronage from bricks and mortar to patronage of an idea designed to change how an industry thinks?
“We are becoming patrons of an idea,” Malcolm said, “Healthcare needs to be about keeping people healthy and safe, treating and healing them when they’re not, and doing the same thing for the planet.” This is a big idea, but Kaiser Permanente is a big player, and the idea isn’t completely new. The well-known “Thrive” advertising platform is an expression of the same thinking. It is the Kaiser Permanente brand, and it drives decision making throughout the organization. The connection between brand and architecture is not hard to make. But it’s a lot harder to change the healthcare industry.
The two dimensions of patronage that Kaiser Permanente is employing create a significant opportunity for architects. If Kaiser Permanente is going to change the face of healthcare, then it needs to design and build facilities that embody their thinking. To be patrons of an idea requires that they also be patrons of, among other things, architecture that makes those ideas come true. To be an architect in Kaiser Permanente’s Alliance Program will be challenging, because they are being asked to innovate at warp speed within the significant constraints of time, budgets, and a highly regulated building type while still operating in the profession’s outmoded 200- year old business model. This, surely, will test the power of patronage–old and new. Will it work? We won’t know for years, but Kaiser Permanente is one of the few organizations in the healthcare industry that just might pull it off.