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Evidence Based Design In Healthcare Facilities

The Right Prescription: Evidence-based Design In Healthcare Facilities

Evidence-based design in healthcare facilities plays a big role in promoting the healing process

Light a scented candle in one of the hydrotherapy rooms at CareMeridian, a Phoenix rehabilitation facility specializing in spine and traumatic brain injury, and imagine you are in a Scottsdale resort’s luxury spa.

The blue ceiling and sea-themed art on the wall, dimmable lighting and large window overlooking the outside garden are designed to evoke the tranquility of nature. The massive, high-back whirlpool tub, which faces away from the window so patients can enjoy natural light and privacy simultaneously, dominates the center of the space like a throne.

But the faux-wood-plank walls are, in fact, made of durable and easy-to-clean porcelain tile, and the flooring is designed to look elegant but provide easy wheelchair movement, an infection barrier and sound muffling, says Mark LaPalm, president of Blue Desert Interiors.

LaPalm piloted the makeover of an aging nursing home into the high-tech but homelike treatment center for catastrophically ill or injured patients.

The hydrotherapy rooms reflect his use of evidence-based design (EBD), a scientific approach to the architecture and engineering of new and renovated buildings.

CareMeridian administrator Lara Bowles says she is often tempted at the end of day to grab a book and some candles and de-stress in the spa-like setting.

But for a patient, the benefits are substantial — measurably and significantly lowering blood pressure and heartbeat as well as providing the medically indicated hydrotherapy treatment, she says.

Many other CareMeridian features, from use of color to placement of art to the floor and furniture coverings, are EBD-inspired, and Bowles says the design elements help relieve patient and employee stress and enhance patient healing.

Creating the right environment

For healthcare facilities, the EBD concept has become almost de rigueur, says architect Mark Patterson, SmithGroupJJR vice president and Phoenix-based health studio leader.

Patterson is one of about 1,000 healthcare design professionals accredited by the Center for Health Design, an organization with the stated goal: “A world where all healthcare environments are created using an evidence-based design process.”

The philosophy is simple, Patterson says, employing the same scientific principles to building design that govern the practice of medicine, that is, identify a problem, hypothesize a solution, test it, analyze results, and apply new knowledge.

A recent National Institutes of Health report compiled the results of hundreds of such studies indicating a direct correlation between facility design and patient safety.

Some of the bottom-line findings:

  • Single-patient rooms reduce the spread of infections, reduce medical errors and increase patient satisfaction.
  • Flooring materials, lighting and location of nursing work areas can impact patient safety, especially in reducing falls.

“Three common themes — promote healing, recruit and retain staff, and reduce operating costs — prevail in any healthcare project,” says Linda Delano, principal of Phoenix-based Building Possibilities. Delano’s client list includes small doctors offices, large corporate hospitals and everything in between.

It’s relatively easy to convince decision-makers at a large hospital group that eliminating multiple-patient rooms to reduce the spread of infection, or designing a room where the path from bed to toilet is short and obstruction-free, will reduce patient falls and save dollars in the long run.

“It can cost more to build, but if initial construction (of a hospital) is $12 million more, and they avoid one patient fall per year, they have made up for that in just a few years,”  Delano says.

But smaller healthcare providers are slow to come to the table, she says.

And for many of the ethereal elements of healthcare building design espoused by EBD proponents, the evidence is more anecdotal than measurable.

The hypotheses are many, for example, governing the impact of color, noise, daylight, nature, music, art and other environmental factors on patient healing.

Research has attempted to quantify these aspects through patient satisfaction surveys, staff interviews, and even calculating changes in patient length of stay and staff retention. But attributing even positive improvements to a single factor isn’t easy.

Still, Patterson says even if it’s difficult to measure, research shows a connection to nature positively affects patient outcomes.

And that governed the central design of Banner Page Hospital’s recent expansion, which was fashioned in the shape of a nautilus shell with the patient rooms spiraling from the central nurses station and the heads of ER beds facing windows overlooking the “healing garden.”

“It’s a beautiful setting. The staff likes working there, and the patients are happier (as) they are treated with dignity,” Patterson says.

Sometimes the one-with-nature theme can be achieved with simple design changes, Patterson says.

“At Banner Ironwood, we put windows at the end of the long hallways. The natural light brings a connection to nature,” he says. “And we added a smaller lobby, opening onto big external gardens.”

In fact, Banner is poised at the leading edge of the evidence-based design trend, Patterson says.

Kip Edwards, Banner Health vice president for development and construction, shies away from the term, but he is a big proponent of the EBD concept.

Banner is like a big research lab using standard designs that the organization is constantly analyzing and evolving as it plans new builds or renovations of older structures, he says.

For example, Banner’s own research yielded evidence that single-patient rooms provide better infection control, adhere to current and upcoming privacy laws, and, most importantly, promote healing. And they are bottom-line effective, Edwards says.

“There is a cost to single-patient rooms, but it’s fully warranted,” he says. “There are financial penalties for readmission, and just limiting infection problems probably pays for itself.”

Also among the Banner design initiatives garnered through research: reconfiguring nurses work areas to smaller stations outside patient rooms instead of big central hubs improved staff effectiveness and increased nurses’ time with patients — or at least patients’ perceptions of that, he says.

“We test that through patient satisfaction surveys,” he says.

As to the gardens and whether they help reduce patient stays, increase staff retention or boost Banner’s bottom line, Edwards says that’s just intuitive.

“The healthcare environment needs to be calming, peaceful, pleasant, conducive to helping heal. Gardens, natural light, pleasant colors — we think all are important,” Edwards says. “It’s not a fad. It’s well-founded in experience and logic.”

PCH ICUJeff Stouffer, HKS Architects’ healthcare academic and pediatric leader, says that it may not be voluminous, but there is documented evidence about the healing benefits of a connection to nature.

“Some research shows that patients use less medications and are discharged sooner,” he says.

HKS established an in-house research group to compile and analyze evidence to guide healthcare design.

“EBD is a key element in all our healthcare projects, especially in pediatric design,” says Stouffer, who recently completed a new 12-story tower at Phoenix Children’s Hospital.

The company was able to determine, through its own research, that standardizing medication room layouts reduces medical errors. As does standardizing the patient rooms’ size, shape, furniture and even headwalls, which provide access to essential medical services, he says.

Headed in the right direction

Another hot-button for EBD proponents is wayfinding, since studies show navigating through winding hospital corridors can be a big stress-inducer for hospital patients, families and visitors.

At CareMeridian, carpet design, wall art and T-junction focal points are designed to ease wayfinding, LaPalm says.

At PCH, each floor has a designated color and animal symbol, Stouffer says, making it easy for even pre-school-age patients and their families to orient themselves.

That’s one of many child-focused EBD elements HKS incorporated into the new wing.

LED lights along the floor that change color and keep kids hopping from one to another, and a “theater of light” in a three-story atrium are what Stouffer dubs, “positive distractions,” aimed at reducing stress for kids and their parents and “letting kids be kids.”

HKS research indicates children’s healing is impacted by parents’ involvement, so the PCH design focused on the worried parents as well as their sick children, he says.

That included orienting the front entrance towards the parking structure and designing family-sized patient rooms. The rooms in the new wing are big enough — and inviting enough — to accommodate parents overnight, even providing room for them to store belongings and work on laptops, Stouffer says.

And the requisite connection to nature is crucial for confined and anxious parents as well as the patients, so every room has a window with a mountain view.

“(Connection to nature) was a recurring theme when we met with parent advisory groups,” Stouffer says.

Scottsdale Healthcare Healing GardenScottsdale Healthcare Thompson Peak’s healing garden incorporates water, light, “meditation pathways” and desert plants to provide a “therapeutic environment” for patients, according to global design firm Gensler.

It’s a good example of the company’s use of the EBD philosophy in healthcare settings, says Beth Harmon-Vaughan, director of Gensler’s Phoenix office.

But it’s only one tool in the architects’ toolbox, she says.

“EBD has been part of our approach for the last four or five years, but we are always looking to innovate, and a strictly EBD approach may miss opportunities,” Harmon-Vaughan says.

The relatively new trend is, in fact, always looking backwards at proven results, but Harmon-Vaughan says designers have to look ahead, too.

She cites, for example, a Tulsa, Okla., cancer-treatment facility Gensler recently designed.

“In this case, we wanted to dig deeper into interviews with doctors to understand the nature of the issues, and we discovered cancer treatment is going to change. They don’t know how it will change, but they know change is coming as the disease (morphs) from fatal to chronic,” she says. “So we needed to design around change.”

For example, the treatment center may need a large number of suites for chemotherapy infusion now, but infusion may not even be a regular cancer treatment in the future.

“They may not need 60 exam rooms with plumbing in the walls,” Harmon-Vaughan says.

The design solution, which she describes more as out-of-the-box than evidence-based, includes dismountable walls, nurses stations and even the vault, sliding barn doors, flexible flooring and under-floor access to everything — from technology to plumbing — that might otherwise be in the walls.

“We put it together like LEGOS,” she says.

And it’s not just cancer treatment centers that need to be adaptable.

“Right now, the healthcare industry is going though transformational change. Hospitals in 20 years won’t look the same, but the changes will be based on outcomes,” says SmithGroupJJR’s Patterson.

Since EBD is a process and not specific elements, Patterson says it will be a key factor in future healthcare design.

“I believe it is big. It’s not a fad,” he says.

Building Possibilities’ Delano agrees that as the body of evidence grows, the concept will be compelling to everyone in the healthcare industry.

“Will we call it EBD in 20 years? I don’t know. But we’ll still be using these principles,” she says.

Healthcare construction

Healthcare Facilities: Just What The Doctor Ordered

Construction of healthcare facilities in Arizona boldly forged ahead in 2010, despite an economy that refuses to rebound and uncertainty over the impact of federal healthcare reform.

Officials figure that Arizona’s population will continue to grow and age, and because of the new federal law more people will have access to health insurance, which indicates a greater need for healthcare facilities.

Major players in the healthcare field from the Metro Phoenix area to outlying rural communities are investing in the future in a big way. Arizona healthcare facility projects with a total estimated cost of nearly $1B are finished, nearing completion or in the planning stage.

Banner Health has four projects totaling almost $300M: Banner Ironwood in Queen Creek, Banner Good Samaritan in Phoenix (expansion), and the Banner MD Anderson Cancer Center and Banner Gateway Medical Office II in Gilbert.

“You might say we’re in the business of being futurists,” says Peter Fine, president and CEO of Banner Health. “The risk of investments is not for the faint of heart.”

Technology a Driving Force in Healthcare Facilities

There is concern regarding healthcare reform that focuses mainly on how reimbursements will occur. Federal officials are pushing for more accountability in patient care outcomes, tying reimbursements to those efforts. As a result, information technology is becoming a key factor.

Mark Peterson of SmithGroup, a design and engineering firm, is working with clients to create healthcare facilities that play a direct role in patient care. It’s called evidence-based design.

“We’re providing clients with building solutions that support their patient-care mission and can be proven that there is a direct correlation between building design and improved patient outcomes,” Peterson says.

While the need for healthcare facilities most certainly is growing, some say the bad economy is resulting in a slight decrease in the utilization of hospitals. Experts say people are going to their doctor more and using hospitals less than they did a few years ago, especially those who have lost their jobs and may not have insurance coverage for an expensive hospital stay.

Another trend, experts say, is an industry focus on the word “healthy,” rather than the word “sick.”

“With a focus on healthy, what does this landscape look like?” queries MaryAnn Guera, CEO of BioAccel, a nonprofit organization that drives economic development through commercialization of late-stage basic and applied research in the life sciences. “Health or sickness? The look of the buildings we need will change around that.”

Metro, Rural Areas See Activity

Jason Meszaros, vice president of Irgens Development Partners, says healthcare projects in the Phoenix area represent the only type of development “that has any legs.”

Compared to previous years, construction has fallen off somewhat, some medical condos are back on the market, and there is still a desire for medical office space on or near medical campuses, he says.

For Irgens, which is building a 51,000 SF medical office facility in Gilbert, and for most others in the field, activity in 2011 should be fairly moderate, Meszaros says. Healthcare reform, the economy and population growth are all factors.

“The healthcare reform act throws a little bit of uncertainty into it,” he says. “People are a little apprehensive to make a long-term commitment.”

Healthcare facilitiesEven so, there is no shortage of building activity in the healthcare field, not just in the metropolitan areas, but in rural parts of the state, as well. Money for these ongoing projects comes from various sources, including tax-exempt bonds, operating reserves, philanthropy and the federal government.

For example, Phoenix Children’s Hospital embarked on a $588M expansion project in 2008, which will be 90% completed by the end of 2010. Officials expect to have the ambulatory clinics open by January, and hope to occupy the 11-story patient tower by June, increasing the number of beds to 626 from 345.

Bob Meyer, Phoenix Children’s Hospital CEO, says the project is funded primarily with $320M in tax-exempt bonds, plus operating reserves, fundraising and philanthropy.

There were 900,000 children in Maricopa County in 2003 when Phoenix Children’s began planning for expansion. That number has increased to 1M, and by 2030 as many as 1.7M kids will be living in the Phoenix Metro area.

“That’s why we’re building the building,” Meyer says.

At the same time, people are living longer. The population over 80 continues to grow almost exponentially, creating an increase in demand for medical services.

“That’s what has most people in the industry concerned,” Meyer says. “Hopefully there will be magic drugs, but in today’s technology it’s going to be a challenge.”

Nathan Anspach, senior vice president for medical economics at John C. Lincoln Health Network, expects capital budgets to see increasing pressure from information technology investment. Basically, that means less money for hospital construction and more money earmarked for IT improvements.

“IT investments are going to be required as part of the healthcare reform act, and that will impact capital construction,” Anspach says. “Healthcare systems are all looking at IT investments for electronic records and electronic measures like WiFi, and that’s going to cramp the construction budget.”

Recognizing the growing importance of IT, John C. Lincoln is building a $6M data center adjacent to its new administrative headquarters in the North Valley near I-17. The 4,000 SF building is expected to be completed in the first quarter of 2011. Susan Fuchs, media relations specialist, says the new facility will provide “a more secure environment for data management and electronic medical records.”

“It’s the wave of the future,” she says.

An Investment for Arizona’s Future

At St. Joseph’s Hospital and Medical Center, affiliated with Catholic Healthcare West, Bob Campbell, vice president for business development in Arizona, says, “We are looking at making investments in our whole continuum of services, everything from physicians’ offices, outpatient services, joint ventures, hospitals that we have, and health plans that we operate.”

Suzanne Pfister, vice president of external affairs, says CHW is moving toward partnerships, not solely construction projects. She mentions a joint venture with SimonMed, an outpatient medical imaging system.

“Under healthcare reform, we see more of a push toward preventative, lower-level healthcare, less expensive healthcare,” Pfister says. “What we’re looking at is — how can the right patient be in the right place? Maybe that’s not a hospital. Maybe it’s urgent care, or into family practice with an after-hours clinic.”

In partnership with United Surgical Partners, CHW is building an orthopedic surgery hospital at 40th St. just south of Loop 202. The 75,000 SF facility is expected to open next spring.

Other healthcare facilities in the planning stage include a 16,000 SF cardiac catheterization lab at Chandler Regional Medical Center, and a 145,000 SF expansion of the patient tower adding about 100 beds.

“Connecting the dots between construction and healthcare reform is really going to force hospitals to partner more with community physicians and outpatient options,” Pfister says.

Banner Good Samaritan Medical Center launched a $71M expansion of its surgical services department. When completed in 2012, there will be 20 state-of-the-art operating rooms, 76 preoperative and postoperative bays, a new waiting room with technology to keep families apprised during the surgery process, plus other amenities, according to Banner Good Samaritan CEO Larry Volkmar.

In outlying areas, construction is underway at what will be called Florence Hospital at Anthem northwest of Florence, says Gilbert Hospital CEO David Wagner. Completion of the 96,000 SF building, which will include an 18-bed correctional unit, is targeted for next summer.

Other rural projects include the 75,000 SF Marana Health Center for MHC Healthcare, slated for completion in March, and the $4.2M Superstition Mountain Mental Health Center in Apache Junction.

Meanwhile, USDA Rural Development, an arm of the federal Department of Agriculture, has committed $28.6M, including loans, for Arizona healthcare projects this fiscal year, says spokeswoman Dianna Jennings.

Other projects aided with federal funds are: the Pinal Hispanic Council Clinic in Coolidge, Copper Queen Rural Health Clinic in Palominas-Hereford, and the La Paz Regional Hospital in Parker.

Peterson says the economy is having an impact on the way people approach their own healthcare, and that’s having an impact on new hospital construction.

“Private sector clients are moving ahead with strategic plans for future master planning
and how best to position their organizations in urban areas,” Peterson says. “That’s true in Phoenix and Tucson and a little bit in Northern Arizona. It’s all about capturing the market and having the best possible response to healthcare reform and emerging changes to the economy.”

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AZRE Magazine November/December 2010

Healthcare Reform - AZRE Magazine November/December 2009

How National Healthcare Reform Could Define A Chronic Condition For Valley Construction

Healthcare Reform – Healthy Choice?

Healthcare reform has been a national hot button lately, and with it comes a focus on all related industries, such as healthcare design and construction. With the development of proposed plans, comes the scrutiny of every penny allocated, prompting a public perception that the cost of healthcare facilities drives up the cost of healthcare. Because of this opinion, many healthcare operators are feeling pressure to decrease spending on their facilities to prevent a collective outcry.

Despite the myriad subjective view points on this issue, several facts substantiate that healthcare construction should not cease.

Injecting Capital Into Growth

History has proved that government-provided medicine hinders the development of new healthcare facilities and does nothing to foster innovation or improvement. There have been many newsworthy examples of limited investment in facilities maintenance programs and improvements, resulting in run-down, non-viable centers, which minimize effectiveness of healthcare delivery.

Capital expenditures (facilities and equipment) typically comprise 10% to 15% of a healthcare organization’s budget, while staff costs can total 60% or more. Spending on projects should not be limited, but instead examined to elicit greater efficiencies through planning and design.

Booming Healthcare

The Phoenix and Tucson metropolitan areas have invested in healthcare facilities, but rural areas still lack capacity. The Hill-Burton Act of 1946, implemented “to modernize hospitals that had become obsolete due to lack of capital investment,” caused a surge of rural hospitals to be built in the 1950s and ’60s. Many of these hospitals still exist in almost the same condition today as when they were first built — unable to support current clinical demands and technological needs.

According to a U.S. News and World Report article published earlier in 2009, Phoenix ranks No. 11 on the top 20 list of cities where baby boomers are likely to retire, based on the expected senior population growth. The oldest boomers will begin to retire in 2011, and the Valley is not ready to receive them.

Arizona is short 1.5 beds per 1,000 residents, based on the national average. Because the demand on our statewide facilities will increase, not investing in additional healthcare facilities now will yield a greater shortage in the future. Seventy-six million baby boomers are anticipated to have multiple chronic conditions due to longer life spans (90+ years is the fastest-growing demographic) and will require more in-patient and primary care.

Baby boomers don’t plan to live in traditional nursing homes, as they prefer a community-centered lifestyle. The “old school” model of long-term care won’t suffice, requiring innovative facilities to accommodate the increasing numbers in a supportive manner.

To compound the demographic dilemma, earlier this year the under-20 population, or Gen Y, surpassed the number of baby boomers. This cohort now comprises roughly 28% of the U.S. population and is fast becoming equally as influential as the boomers, but with new expectations. Because this generation is just now beginning to enter its child-bearing years, more women and children’s services will be in demand at the same time boomers’ healthcare needs peak.

Reviving Investment Through Operations

As the healthcare reform debate rages, investment in design and construction of healthcare facilities must continue. Implementing effective planning and design strategies can actually help to reduce operational costs, such as staffing, because of improved efficiencies. Investing in facility updates also emphasizes a focus on better patient care through the creation of quality, healthy environments that take advantage of current technologies and meet best-practice expectations at a minimum.

To help spawn the future success of healthcare in Arizona, it is necessary for design and construction to continue at the high caliber of success it has achieved — and lead the way to providing innovative healthcare programs and facilities for the nation’s aging and future generations.

AZRE Magazine November/December 2009