Taller Transdisciplinario EAP: April 2007

Strategic Innovation: The Children's Hospital at Montefiore

Dr. Irwin Redlener has spent his career devising solutions to large-scale problems of health care for disenfranchised children. The latest expression of his single-minded agenda combines excellence in pediatric care with cutting-edge design, the latest technology, and the worldview of Carl Sagan.

From: Issue 58 | April 2002 | Page 64 | By: Polly LaBarre | Photographs By: Daniela Stallinger
Who: The Children's Hospital at Montefiore
Home Base: The Bronx, New York
Year Founded: 2001
The first thing you see when you walk into the Children's Hospital at Montefiore is a glowing glass mural of the Milky Way. The swirl of cosmic blues and purples envelops a white-hot center marked with a tiny red dot. It reads, "You are here."

It's a reminder that "here" is not just a busy hilltop in the northwest corner of the Bronx. Nor is "here" merely one of the most technologically advanced children's hospitals in the world. "Here" happens to be in the middle of a scaled-down model of the solar system crafted out of lustrous materials and graceful curves. "Here" also serves as both an entry into the hospital and an entry into the hospital's unique mission: to take children on a journey to health, discovery, and possibility.

Every inch of the hospital -- an impressive $123 million addition to the sprawling Montefiore Medical Center that serves southern Westchester County and the Bronx -- is loaded with information and inspiration about the universe, from the microscopic functions of life to the outer reaches of space. The inspiration for the science theme is the cosmic worldview of the late Carl Sagan, astronomer, author, and scientific philosopher. The exhibit-quality artistry and meticulous layers of detail are the contribution of David Rockwell, whose firm, Rockwell Group, is best known for creating theatrical extravaganzas, smart restaurants, and ultrahip hotels. The effect is part high-tech classroom, part cutting-edge science museum, part futuristic playground. Combined, it is a powerful statement of what a children's hospital needs to be.

And not just any children's hospital, but one set in the Bronx, home to 450,000 children, some of whom are the most medically underserved and at risk in the nation. It's the latest manifestation of Dr. Irwin Redlener's single-minded agenda: to establish a "medical home" for every child who lacks continuous access to high-quality, comprehensive health care and, in the process, to rethink the nature of hospitals, the role of doctors, and the standard approach to pediatric health care. "For me, it's never been just a question of providing health services to children in need," says Redlener. "It's about using health care as a lever to address the global needs of the most disadvantaged kids. For these children, health care is a foot in the door to the future. If we give them a shot at being happy and healthy while they're young, we give them the opportunity to realize their potential as adults."

Redlener, 57, is a pediatrician -- but he has never been just a doctor. For more than 30 years, while helping sick kids get better, he has also worked as a forceful advocate and creative problem solver on behalf of the world's most disenfranchised children and families. From his early days as medical director of a health center run by Volunteers in Service to America (VISTA) in rural east Arkansas, Redlener went on to develop innovative programs for the management and prevention of child abuse and to lead relief efforts in places such as Ethiopia, Guatemala, and Sudan. As medical director of USA for Africa and Hands Across America, Redlener forged a friendship with music legend Paul Simon and later built a partnership to tackle the monumental challenge of quality health care for homeless children in New York City. Launched out of a van outside a welfare hotel, the Children's Health Fund is now the largest health-care system for homeless children in the nation, with a network of 16 innovative urban and rural programs.

A combination of kindly family doctor, political animal, and aggressive entrepreneur, Redlener describes himself as an "impatient entrepreneur." The title reflects his abiding awareness that, despite his 30 years spent facing down children's health-care issues, nearly 20% of the nation's children still live in poverty, nearly 11 million children lack health insurance, and almost 10 million more are without reasonable access to quality health care. Redlener knows that the only way to move the needle on numbers like that is to reframe the issue. The question isn't just, How do you create an accessible health-care system? The deeper question is, How do you unlock the future for millions of kids with no sense of hope?

Which is why the galaxy is in the lobby at the Children's Hospital at Montefiore. In 1997, the president of Montefiore Medical Center, Dr. Spencer Foreman, raised $20 million in startup grants from Montefiore trustees Martin Davis and Lionel Pincus. Then he tapped Redlener to take a leadership role in the children's hospital. Redlener seized the opportunity.

His dream for the hospital included three nonnegotiable mind flips about health care and the institutions that provide it. First, this facility couldn't just be a hospital -- it had to be the hub of a comprehensive children's health system throughout the Bronx. "The problem with most children's hospitals," says Redlener, "is that they are passive. They are high quality. They are filled with the best doctors. But their function is to wait until kids get sick and get referred in. I wanted to establish a much more dynamic relationship between a children's hospital and the community." Second, there could be no financial barriers to service. The hospital had to be fully free and open to every child in the Bronx, regardless of ability to pay. Third, Redlener wanted to incorporate "an agenda beyond healing that would be appropriate, unique, and perhaps even life changing for this patient population."

The result: the Children's Hospital at Montefiore (CHAM), a new state-of-the-art medical facility staffed by the renowned faculty of the Albert Einstein College of Medicine. The stunning new hospital, which opened its doors late last October, is linked to a network of more than 30 community-based health facilities, including the largest school-based health program in the country, a cutting-edge neonatal intensive-care unit, the city's leading child-protection program, and a fleet of mobile medical units. Most remarkable, elaborate design artistry, inventive technology tools, and Carl Sagan's cosmic worldview have fused there into an engaging discovery zone.

"We wanted to recast the idea of what could be achieved in a children's hospital," Redlener says. "We decided to change the expectation of what happens during treatment and recovery. Our mission was to provide excellent health care and a total environment that ignites the imagination of children. Hospitals are about healing. This one is about changing lives."

"Dreams are Maps": Asking Courageous Questions

There is a VISTA recruitment poster on the wall in Redlener's office at the Children's Health Fund (CHF) headquarters on Manhattan's Upper East Side. It features a haunting black-and-white photograph of a young man with his back to the camera. He is carrying a doctor's bag, walking along a set of deserted railroad tracks in a rural area. It's a meditative image, punctuated by a phone number and a call to arms: "Sign up for a year of tough practice in the other America."

Redlener saw that poster 31 years ago in the dining room of the children's hospital in Denver where he was training to become a pediatrician. He called the number. Four months later, he left for the Arkansas Delta. It was 1971, and he was 26 years old. He never looked back. Since then, Redlener has spent his entire career as a forceful advocate for the most vulnerable children and families. But nothing prepared him for the day in 1986 when he took Paul Simon on a tour of "the invisible New York City."

Fresh from their efforts on We Are the World and USA for Africa, Redlener and Simon wanted to do something about hunger and homelessness in the United States. They visited a series of nurseries for crack babies and other special programs for sick, homeless children in New York. Then they stepped inside the Martinique Welfare Hotel, a once-glorious midtown hotel that had crumbled into a monstrous, squalid building used as a warehouse shelter for homeless families. "There were a thousand children and their parents in that building," Redlener remembers. "It was total chaos. The elevators were broken, there were drug deals going on, and there were about 80 kids waiting outside the dining room for the one meal they'd get that day. Even though I had already been very immersed in the problems of underserved children, I was stunned. And Paul Simon was absolutely speechless. The question after the visit was, What can we do?"

The answer: Create a pediatric clinic on wheels to bring high-quality, continuous medical care to children in the shelter system and on the streets. Simon and Redlener recruited Redlener's wife, Karen -- a health administrator he had met as a VISTA volunteer -- to design the program. The team launched CHF in 1987 with a single mobile unit that Simon paid for. Today in New York, there are five bright-blue, 35-foot vans that function as fully equipped clinics, complete with waiting areas, nurses' stations, the latest computers, two exam rooms, and sophisticated diagnostic equipment. For the most disadvantaged communities, the vans represent a stable source of services. And CHF has expanded into 16 other rural and urban programs that address the problem of access to health care for extremely disadvantaged children. During the past 15 years, CHF has served 300,000 kids in 750,000 encounters across the country. Redlener and his team raise between $6 million and $7 million a year for the fund.

And yet, as successful as the mobile units are, Redlener never saw them as the answer to children's health care. "Children really deserve to be in neighborhood-based, fixed-place primary health-care environments," he says. "The mobile units are really a stopgap measure."

Redlener's real dream is on display on the sixth floor of the adolescent inpatient unit at CHAM. Take the elevator up, and the doors open to a beautiful tile mosaic of the night sky over the Bronx. A young person in silhouette sits in the corner, gazing up at the city lights sparkling like constellations. Just below, the words of Carl Sagan offer a gentle push: "Dreams are maps. We make the world significant by the courage of our questions and the depth of our answers."

Sagan, a longtime friend of the Redleners who died in 1996, provided both the challenge and the beginning of a response. While in the process of drafting his dream brief for CHAM, Redlener called Sagan's widow, Ann Druyan, to discuss the idea of memorializing Sagan. Was there a way to build on Sagan's sense of science to create a hospital that was as much about discovery as about recovery? The two then called on another mutual friend, then-vice president Al Gore. Gore put together a group of top-flight scientists and thinkers -- Stephen Jay Gould, Harvard professor and author; Daniel S. Goldin, former administrator of NASA; and Neil Tyson, director of the Hayden Planetarium -- for months of White House brainstorming.

Sagan's own ideas about using science and discovery to unlock the future for children became Redlener's map. "He believed that the process of finding out where you fit into the universe and the inspiration that comes from learning something about your world can be a gateway to a whole set of possibilities for children who have otherwise been contained in a very limited worldview," Redlener says. Transforming that cosmic blueprint into a meaningful experience required another set of unlikely collaborators.

"We Are Star Stuff": Making Important Connections

Redlener had his map. Now he needed an architect to help him turn it into working drawings. He turned to David Rockwell and his team at Rockwell Group. The firm's lavish spectacles, such as Cirque du Soleil's headquarters in Orlando and sets for theatrical productions of The Rocky Horror Show Live and Hairspray, seem a world away from the serious business of designing a hospital for sick children. But Rockwell and Redlener share a commitment to creating layered experiences that unfold and capture visitors' imaginations in diverse ways.

"For us, every project begins with reimagining everything about a space," says Rockwell. "The more time we spend tilting at windmills and pushing at dreams before we get to form or color or texture, the more profound the effect. The best projects, like Montefiore, start with pure ideas rather than ideas about design."

Redlener presented Rockwell with two animating ideas. The first was Sagan's principle, which stressed the interconnectedness of the universe and the joys of learning. The second was a radical change in perspective about medical services: "family-centered care." Family-centered care shifts nearly every dimension of traditional health-care facilities. It calls on hospitals to go from being doctorcentric, information-scarce, intimidating institutions to being places that focus on responding to the needs and comfort of families, sharing information, and enlisting parents as partners in their children's health care.

In the hands of Rockwell Group, these ideas became an organizing theme: "Children are explorers on a journey to health." The idea was to uncover "all of those moments in your experience as a child in a hospital that are terrifying, dehumanizing, and lacking in information and to use those as interventions to provide information, insight, and a sense of wonder and delight," says Rockwell.

To that end, Rockwell Group wove the Carl Sagan Discovery Program into the hospital's design at every level. Each of the hospital's seven patient floors has a unique theme and design palette. The elevator lobby on each floor is an entry into a richly conceived corner of the cosmos. Step off the elevator on the third-floor unit for ambulatory and outpatient procedures, and Sagan's idea that "we are star stuff" connected by our common origin in the Big Bang is rendered in a colorful etched-glass mural of sea worms, snowflakes, and stars. Travel to the fifth-floor unit dedicated to subspecialties involving illnesses of perception (craniofacial disorders, speech, and sight conditions), and you're in an interactive playground dedicated to exploring nonvisual senses.

The hospital's design doesn't just convey information about the universe and science; it also embodies the process of discovery. Layers of detail unfold with each encounter. In each inpatient room, the window shades are custom-designed murals depicting the Bronx in different time periods. One room has a shade that features the Bronx as farmland in the 19th century; another offers a view of the Bronx when dinosaurs roamed the earth. Patient rooms don't have numbers; they feature constellations, animals, or water creatures, depending on the floor's theme. A teenager might stay in the Big Dipper room, while an infant might stay in the Bumblebee room. And scattered about the patient floors are dozens of glass-covered niches displaying works of art by young children from around the city. The child-height exhibits encourage kids to create their own drawings, collages, and sculptures in the fully supplied lounges on each floor. It's an invitation to explore.

But what about the sick children who are confined to their beds? Redlener tapped Jeb Weisman, a cultural anthropologist and technology pioneer, to extend the Carl Sagan Discovery Program into an interactive bedside environment. The solution is stunning. Every child, parent, and family member who stays in the hospital gets her own smart card. Swipe the card through a reader at any of 120 locations around the hospital, and you're immediately connected to a customized virtual portal for information, entertainment, and communication. More advanced than any other patient-oriented commercial application on the market, the system can instantly switch from broadband video on demand to Gigabit Ethernet.

The motivation for building the system, says Weisman, was never about technology. It was about adding a new dimension to the hospital encounter -- and raising the stakes. "Wouldn't it be great if you could learn something about poetry, painting, chemistry, space, or oceanography while you were here?" asks Weisman. But even more important than access to new worlds is critical information about the one that kids find themselves experiencing at the moment. Says Weisman: "You should never be in a position where you are wondering about something and have no way to find out about it, whether your question is, Why does it hurt? or, What makes the sky blue?"

For Redlener, this level of design as experience is as vital as CHAM's cutting-edge medical facilities. The 106-bed hospital features a pediatric emergency room built from the ground up; a special multidisciplinary center for communication disorders; one of the nation's most advanced centers for the emergency treatment of asthma; a short-stay "day hospital" within the main hospital for children who need chemotherapy, dialysis, or other outpatient treatments; and the latest telemedical technology. A pioneering wireless, paperless order-entry system has replaced the standard chart system. Doctors can enter prescriptions directly into the system and access all available lab data on customized rolling kiosks placed on each patient floor. Almost every patient room is a single-bed private space with a sleek bathroom, a comfortable pullout sofa, a phone, and a laptop connection for families.

That's what the hospital has. To see how the hospital works, just stand in the lobby for a few minutes. One bright January day, Brandon, 13, stood mesmerized before the lobby's glass Ecosphere globe, a self-contained life system that needs no food, water, or cleaning to survive. Ask him to name his favorite part of the hospital, and he gives a breathless list: "The Ecosphere, the moving circles in the fifth-floor lobby, the pendulum ..." Ask his mother the same question, and she says, "Brandon has been coming to Montefiore since he was an infant. Today, I told him that we were going across the street to the new children's hospital, and he said, 'But mom, I'm not a child.' Then he walked in, saw the computer and the displays, and he said, 'Okay, I'll be a child.' "

Polly LaBarre (plabarre@fastcompany.com) is a Fast Company senior editor. Contact Irwin Redlener by email (iredlener@montefiore.org). Find out more about the Children's Hospital at Montefiore (www.montefiore.org) or the Children's Health Fund (www.childrenshealthfund.org) on the Web.

Sidebar: A Gigabit at the Bedside

When Jeb Weisman set out to build an interactive virtual portal as part of the Carl Sagan Discovery Program at the Children's Hospital at Montefiore, he didn't start with technology. Instead, the anthropologist, archaeologist, college professor, and software designer turned to Sagan. "His life was about asking questions and drilling down to that 'aha' moment," says Weisman. "I wanted to find a way for even the most severely ill children to tap into that power."

The product of that mission is a stunning bundle of technology, including smart cards, 42-inch flat-panel plasma displays, and bedside Gigabit Ethernet. It's also an extraordinary access point into a world of learning and play called the Explorer Network. Weisman built the system in 18 months for less than $3 million. His experience suggests three critical lessons.

Make It Personal: Customization and feedback are built into every aspect of the portal. When you log in at any of the hospital's 120 stations, your age and preferences dictate the content. Parents can restrict their child's access to information about his illness or to certain video games. The smart card used for log-in lets patients bookmark their work. Whether they come back in 15 minutes or 15 weeks, the system remembers where they were. "It's about the patient's ability to control his environment," says Weisman.

Build to Innovate: Weisman chose to build the Explorer Network on an open-source platform -- not only because it was free, but also because the network is now instantly adaptable and extendable. Most important, the open-source architecture is flexible enough to invite continuous innovation. Weisman's next move is to extend access to the 30-plus health centers in the Montefiore network and, ultimately, to kids' schools and homes.

Remember: Performance Is Everything: In addition to setting up a responsive help desk, Weisman has developed an Explainer Program to ensure smooth functioning of the system -- a top priority. When a 12-year-old cancer patient called Weisman's help line in distress about the malfunctioning of her smart-card reader, he had a stark realization: "You can't get it wrong with these kids. You just can't."

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