Linking Long-Term Care and Healthcare Facilities: Examining Typologies, Culture Change and Common Design Features, 2006

LINKING LONG-TERM CARE AND HEALTHCARE FACILITIES: Examining Typologies, Culture Change and Universal Design Features.

Erin K. Peavey Fall 2006 Independent Study Advised by Dr. Susan Rodiek College of Architecture Center for Health Systems & Design Texas A&M University

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ACKNOWLEDGEMENTS : Texas A&M University

Kirk Hamilton, FAIA Associate Professor, Associate Director, Center for Health Systems & Design George Mann, AIA

Professor, Architecture Ron Skaggs and Joseph Sprague Endowed Chair in Health Facilities Design.

Susan Rodiek, Ph. D., NCARB Assistant Professor, Architecture Ronald L. Skaggs Endowed Professor in Health Facilities Design Ronald L. Skaggs Roger S. Ulrich, Ph. D. Professor of Architecture, and Landscape Architecture & Urban Planning. Julie and Craig Beale '71 Endowed Professor in Health Facilities Design.

Photo & Illustration Sources

The author expresses appreciation for the sources from which photos and other illustrations have been taken. As this is an academic project, sources are not cited separately in this paper.

HKS Inc., Dallas, Texas

Craig Beale, FAIA, FACHA, RIBA, CHE, CHC. HKS executive vice president and director of the HKS Healthcare Group. Debajyoti Pati Ph.D., AIIA HKS Director of Research, Inc. Ronald L. Skaggs, FAIA, FACHA, FHFI, Chairman of HKS, Inc. and founder of the HKS Healthcare Practice. Joseph G. Sprague, FAIA, FACHA, FHFI, HKS Senior Vice President and Director Health Facilities Other Sources

Elizabeth Brawley, AAHID, IIDA, CID President, Design Concepts Unlimited, Sausalito, California Margaret P. Calkins, Ph.D., President, I.D.E.A.S. Inc., Kirtland, Ohio I extend special thanks to Susan Rodiek for providing me with the opportunity to work with her, under such unique circumstances, and for coaching me through my personal and professional edification. Additionally, I thank Joe Sprague for his time and guidance.

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LINKING LONG-TERM CARE AND HEALTHCARE FACILITIES CONTENTS:

1. FROM THE BEGINNING: HISTORY & BACKGROUND ON ARCHITECTURE FOR HEALTH 2. HEALTHCARE AND LONG-TERM CARE TYPOLOGIES:

Healthcare Typologies: General Hospitals Ambulatory Care Community Medical Facilities Mental Health Facilities Specialty Care Centers

Long-term Care Typologies: Independent Living Assisted Living Skilled Nursing Dementia Care Continuing Care Retirement Communities (CCRC)

3. APPLYING COMMON BUILDING DESIGN FEATURES:

Wayfinding & Circulation Lighting Nature Views & Garden Design Single-Occupancy Rooms Residentialism

4. CULTURE CHANGE: LEADING TOWARD THE BETTER BUILDING MOVEMENT

Patient and Resident-Focused care Staff Satisfaction and Retention Models of care The Green-house concept The Planetree Model

5. REFERENCES

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Linking Long-term Care and Healthcare Facilities:

Examining Typologies, Culture Change and Universal Design Features.

“Our environments can and should be agents for transformation, providing what is

needed to balance the human spirit- support, nourishment and peace of mind.”

- Barbara Crisp, author of “Human Spaces:

Life-Enhancing Designs for Healing, Working, and Living”, 1998.

The goal of this project is to explain the way in which healthcare (HC) and long-

term care (LTC) facilities share significant attributes and are evolving on parallel

paths. A review of the literature reveals a lack of documentation recognizing the

commonalities of HC and LTC facilities. This paper will call attention to the

similarity between HC and LTC facilities by reviewing facility types and examining

design features common to both. Additionally, it reviews the major factors that tend

to influence how the culture of these facilities is changing. This paper is limited to

what appear to be the most important and diverse aspects that link the HC and

LTC facility design fields.

Numerous texts tangentially address the subjects of HC and/or LTC facilities.

Among these texts are Design innovations for aging and Alzheimer's: Creating

caring environments, wherein Elizabeth Brawley discusses LTC culture change

and design features, with a minimal emphasis on HC culture change. In Hospital

and healthcare facility design, Earl Swenson focuses on HC facility types, implying

that LTC facilities are a completely different type of facility. Because literature

addressing the similarities between HC and LTC facilities is currently almost

nonexistent, this paper will serve as preliminary research upon which others can

build. Literature from the HC and LTC fields is used to show the common elements

that both fields exhibit.

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The way our country cares for people, and the facilities in which it cares for them, is

in the midst of a monumental shift. This change is focused more on the individual

receiving care, and less on the financial bottom line. Numerous care specialties

and care facility types exist that offer the best care for a given patient/ resident’s

needs; yet, there are many common design features that any type of facility should

include. These features tap into psychological and physiological needs, to reduce

stress and increase user satisfaction. By doing this, one is able to create a facility

that acts as an agent of care.

There are changes in the organizational structure of care facilities, changes that

the physical environment can facilitate, in which better care actually costs less.

Designers must be aware of these changes in order to create designs that serve

users of HC and LTC facilities. Architecture for health has come a long way and

continues to be in a constant state of evolution. Designers must understand HC

and LTC design history in order to make future changes effective and

advantageous.

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1: FROM THE BEGINNING: A BRIEF HISTORY OF ARCHITECTURE FOR HEALTH There has been a “dramatic social, technological and architectural transformation

of hospitals during the final decades of the twentieth century.”

- Stephen Verderber and David J. Fine,

Healthcare architecture in an era of radical transformation, 2000.

The beginnings of architecture for health are seen as far back as the “ancient

Egyptians, Greeks, Middle Eastern and Eastern cultures” (Verderber, 2000 p. 10).

Much of the force that brought about the incredible change from the ancient Roman

model and previous unsanitary conditions originated with the efforts of Florence

Nightingale. Nightingale, a nurse during the Crimean War, was able to convince

the British government to clean up its hospitals in order to help British armed

forces. She did so by using statistical evidence and meticulous record keeping to

show that improvement of sanitary conditions would lead to a decrease in mortality

and morbidity rates. Her new ward design, known as the “Nightingale Ward,” was

modular for easy and cheap construction, and it had increased focus on improved

ventilation. Although Nightingale wards are no longer being built in the United

States, Florence Nightingale paved the way for future healthcare reforms.

The largest healthcare facility reform was set into motion by the Hospital Survey

and Construction Act, also known as the Hill-Burton act, which was passed in

1946. This act, proposed by President Truman, provided federal grants and loans

to be used in the physical improvement of the hospital system. The purpose of this

act was to assist the construction and modernization of public or other not-for-profit

medical facilities, and to promote research and the advancement of general public

health (Schiller Institute, 2001).

It was only in the twentieth century that a dedicated typology of architecture for the

aged emerged. In the past, hospitals often housed the elderly along with those with

chronic illnesses. But, as Verderber said, “by the mid-1960s, it was a widely held

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assumption that regardless of cultural, political, or economic factors in a particular

country, a certain percentage of the elderly population would be in need of a

continuous level of healthcare services most efficiently provided within a long-term

institutional setting” (Verderber, 2000, p. 223). Sociologists and gerontologists

called for humanizing these facilities by giving long-term care facilities a more

residential aesthetic. Likewise, healthcare facilities have become increasingly

influenced by the hospitality aesthetic.

In late Twentieth century a movement called “evidence based design” (EBD) began

to influence HC architecture. EBD came from the medical field of evidence based

medicine which describes the medical practice’s attempt to apply scientific

evidence to aspects of medical practice. Designing with evidence has allowed

architects and designers to base their design on scientific evidence. The major

areas of design research have been conducted in hospitals and other health

facilities, as well as long-term care facilities. Evidence has led the way for designs

that speed healing, reduce the need for medication, and reduce psychological

distress.

As designers embark on the new millennium, it is increasingly important for HC and

LTC facilities to act as agents of care, rather then storage of those individuals in

need. It is important that buildings, where humans spend the majority of their time,

are conducive to living. This will be discussed further in the universal design

aspects portion of the paper. Although much change has already occurred,

Healthcare and long-term care are in the midst of a large cultural change and a

shift towards evidence based, patient/resident centered care.

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2: HEALTHCARE AND LONG-TERM CARE TYPOLOGIES One of the reasons for the various HC and LTC typologies is the realization that

traditional one-size-fits-all facilities were inadequate to meet patient/resident needs.

To solve this problem, large general hospitals are divided by program to offer

specialized services such as specialty care facilities, a multitude of ambulatory care

facilities, and mental health facilities. LTC facilities are categorized by level and by

the type of care a resident needs. Many of these separate typologies actually

share many characteristics and services. It is important to see HC and LTC facility

typologies as flexible categories, rather than rigid definitions, because these

facilities vary greatly depending on location, ownership, and date of construction.

Healthcare Typologies: Healthcare typologies are as diverse as the patients they

serve. These facilities include general hospitals,

ambulatory care facilities, community medical facilities,

mental health facilities and specialty care centers of

different types.

General Hospitals General hospitals have traditionally provided primarily

inpatient services, consisting of critical care, emergency

services and nursing units. General hospitals offer primary

care; as such, user demographics of a general hospital

characteristically depend on the area in which the hospital

is located (unlike more specialized facilities discussed

later). In recent years, general hospitals have been

broken apart by program and often turned into multiple

ambulatory care facilities (discussed below).

General hospitals are divided into departments such as

emergency, surgery and radiology. These departments

each have specific capabilities and limitations, and a

Figure 2.1: Rebecca and John Moore UCSD Cancer Center. La Jolla, California. Architect: Zimmer Gunsul Frasca Architects

Figure 2.2: Clarian Methodist Hospital: CCCC Unit. Architect: BSA Life Structures

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patient may be moved to different departments in order to

meet their specific and changing needs. General hospitals

include obstetrical facilities, diagnostic and treatment

locations, and service areas, such as a dietary facility,

pharmacy and areas for material management and

maintenance (such as soiled linens, cleaning and waste).

One staple of the general hospital is that it offers acute

care. Acute care includes a variety of critical care units

such as the medical intensive care unit, acute cardiac care

unit, or surgical intensive care unit. In critical care, visual

nurse-to-patient access is required by guidelines that were

adopted in 2006 (The Facilities Guidelines Institute, 2006).

This access is vital to the safety of patients. In addition, it

is important for the privacy of patients that there is little to

no visual access from one patient room into another.

Critical care units should be located within convenient

proximity to the emergency, laboratory, surgery and other

vital departments. In discussing other healthcare

typologies, it is important to remember that the attributes of

general hospitals are common to most hospitals, some of

which are discussed below (Facility Guidelines 2006, p.

37).

Figure 2.3: This pod-like layout provides high visual accessibility to critical patients. ICU floor plan. Lynchburg General Hospital. Lynchburg, Virginia.

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Ambulatory Care Ambulatory care centers are freestanding facilities, staffed

by one or more health care professionals, that provide

services on an outpatient basis (West Virginia Healthcare

Authority, 1992). The 2006 Guidelines identify the primary

users as “patients capable of traveling into, around, and

out of the facility unassisted” and, as such, these facilities

should be easily accessible by public transit (The Facilities

Guidelines Institute, 2006, p. 189).

Hospital-based outpatient care often includes central

registration, lab-work, imaging, endoscopy, cardiovascular,

neurology and recovery beds. Some types of ambulatory

care facilities include freestanding birthing centers,

psychiatric outpatient centers, ambulatory surgical facilities

and primary care outpatient facilities. These facilities

typically consist of diagnostic and treatment areas,

administrative and public areas, service areas for waste

and material management, and imaging facilities.

Ambulatory, or outpatient care, is driven by cost

containment and is typically sponsored or supported by a

neighboring hospital. Ambulatory care centers are a

central example of a primary care facility. These facilities

often consist of surgical centers and clinics like community

medical centers, and are used for convenience and ease.

Figure 2.4: Floor plan of Bronson Methodist Hospital, Kalamazoo, Michigan. Architect: Shepley, Bulfinch Richardson and Abbott

Figure 2.5 : Main entry of Bronson Methodist Hospital, Kalamazoo, Michigan. Architect: Shepley, Bulfinch Richardson and Abbott

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Community Medical Facilities Community medical centers offer an umbrella of primary-

care services in a local setting. This facility type is often

the primary care provider for rural populations. As such,

the services provided are typically wide-ranging with a

relatively low volume of specialized care. These services

span basic diagnostic, treatment and prevention needs.

Community medical facilities typically consist of an

emergency room, minor operating or surgery capabilities,

a large ambulatory care unit, a physician’s center, a

wellness center and a nursing component. Some of these

facilities have limited twenty-four hour capabilities.

Figure 2.7: The Hospital at Westlake Medical Center. Westlake Hills, Texas. Architects: Polkinghorn Group Architects, Inc. and McFarland Architecture

Figure 2.8: Partial floor plan for St. Rose Dominican Hospital. Henderson, Nevada. Architect: HKS Inc.

Mental Health Facilities: Mental health facilities are often called residential

treatment centers or psychiatric hospitals. These are

clinics and hospitals designed specifically for the mentally

ill and severely emotionally disturbed. Mental health

facilities provide service for people of all ages and

backgrounds and may serve as permanent residences for

individuals with cognitive impairment and other chronic

disabilities. These services include rehabilitative therapies

such as recreational, vocational, educational, physical,

occupational, child/adolescent, and general therapies.

Figure 2.9: Interior Geriatric and Medical Psychiatry. University of Arkansas Psychiatry Research Institute. Fayetteville, Arkansas. Architect: Albis Turlington Architects LLC

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Important facility components for psychiatric facilities

include observation rooms, drug distribution areas, and

secured areas for detoxification or for treating

schizophrenic and potentially violent patients. Facilities

are divided into units by patients’ ages and diagnoses.

These institutions usually consist of one or more of the

following psychiatric units: general, child, adolescent, and

geriatric; there may also be units for Alzheimer’s (and

other dementia) patients.

Figure 2.10: Southeast Regional Treatment Center. Madison, Indiana. Architects: HOK and Ratio Architects

Figure 2.11: Partial floor plan of Geriatric and Medical Psychiatry. University of Arkansas Psychiatry Research Institute. Fayetteville, Arkansas. Architect: Albis Turlington Architects LLC

Specialty Care Centers There are numerous types of specialty care centers, some

of which include cancer centers, spinal centers, heart

hospitals, imaging/radiology centers, surgery,

rehabilitation, children’s hospitals, and women’s centers.

These centers provide both secondary and tertiary care by

offering specialization in addition to the primary care that

general hospitals and outpatient facilities provide.

Typical users of specialty care centers include a wide

range of individuals who need specialized care, which can

Figure 2.12: This Children’s hospital atrium provides a fun view of the play-space below and provides instant spatial orientation.

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often be provided at a lower cost or in a setting preferable

to the general hospital. Many of these centers utilize

research to maintain the most current and highest level of

care. In-house research units are often incorporated into

the design.

Figure 2.13: This facility offers education, research and minimal clinical services. The Lou Ruvo Brain Institute. Las Vegas, Nevada. Architect: Frank Gehry

Long-Term Care Typologies:

"Good design directly impacts quality of life, and care

environments cry for design that looks beyond the aesthetics and addresses the

more complex needs of physically and often cognitively challenged seniors.”

- Elizabeth Brawley, IIDA, AAHID

As long-term care facility design progresses, there is a trend towards addressing

residents’ needs for increased autonomy and more hospitable living, as well as

healing environments. One of the key attributes of a well-designed long-term care

facility is the ability to balance autonomy with safety. As Carter Williams, a senior

with the Pioneer Network said, “Life is vital and precious until we take our last

breath” (pioneernetwork, 2006). It is important to design facilities that portray this

sense of life’s worth. LTC typologies stretch to meet the varied needs of seniors,

spanning from independent seniors looking for a new home to those in need of

special care for physical or cognitive disabilities. These types include Independent

Living Facilities, Assisted Living Facilities, Skilled Nursing Facilities, Dementia Care

Facilities, and Continuing Care Retirement Communities.

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Independent Living Independent Living Facilities provide a living environment,

often a condominium or apartment, in which the residents

take responsibility for the majority of their care and are

provided with on-site care when needed, yet no twenty-

four hour onsite nursing or medical care is offered.

Resident Seniors are typically healthy and self-sufficient.

Independent facilities often provide services like laundry,

transportation, group meals, beauty shops, libraries,

exercise facilities and a moderate number of social

activities. One thing that all of these facilities have to

offer is a chance to live among peers in a secure seniors-

only community.

Independent living facility types include senior

apartments, retirement communities, and low-income

housing. Some of these facility types may include central

dining, in addition to resident apartments/ living quarters

(such as the one shown in Figure 2.14), activity areas,

and recreation/exercise facilities and greenscape such as

healing gardens and walking paths. Independent living

apartments typically contain a living room, full bathroom,

kitchen, one or more bedrooms, and often a washer and

dryer.

Figure 2.14: Mary's Woods at Marylhurst. Lake Oswego, Oregon. (architect unknown)

Assisted Living Assisted living facilities (ALFs), should act as “supportive

residential environments” that foster family and

community involvement (The Facilities Guidelines

Institute, 2006). These facilities combine residential

housing, personalized support, and assistance and

Figure 2.15: Remington Park Assisted Living Community. Baytown, Texas. Interior Design: Studio Six5

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healthcare services while maximizing independence.

Essentially, these facilities are similar to independent

living, but include twenty-four hour care and assistance

with activities of daily living (e.g. eating, bathing, dressing,

toileting, and ambulation). In these facilities, the residents

are typically moderately healthy and relatively active with

most of their cognitive functions. The auxiliary services

that supplement ALFs often consist of home health,

dietary, storage, pharmacy, and linen and laundry. They

should always be barrier-free environments. ALFs should

be designed to “provide a supportive residential

environment that is conducive to day-to-day activities,

consistent with the cultural, emotional and spiritual needs

of individuals who need assistance” (The Facilities

Guidelines Institute, 2006).

Figure 2.16: Bathing spa at Wells of Bainbridge. Bainbridge, Ohio. Architect: Dorsky Hodgson+Partners

Skilled Nursing Skilled nursing facilities offer the highest level of acute

and twenty-four hour care for their residents. Daily health

services including treatment, care, and medications are

provided by trained medical staff and supplemented by

on-call physician services. These facilities offer

assistance with activities of daily living, which typically

include eating, bathing, dressing, getting to and using the

bathroom, getting in or out of bed or chair, and mobility.

Skilled nursing facility residents are typically physically

frail and unable to perform these activities (Senior

Housing Network, 2006). Seniors can be there for

temporary rehabilitation or for long-term care.

Much like ALFs, these facilities must provide for dining,

indoor and outdoor recreation, and living areas for their

Figure 2.17: Harbour House. Greendale, Wisconsin. Architect: KM Development Corporation. Interior design: Mithun, Inc.

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residents. In addition, the facilities require support areas

such as equipment and supply rooms, soiled utilities, staff

storage, work and break areas, and nourishment areas.

Skilled nursing facilities and the amenities that are offered

therein should be designed to provide barrier-free,

supportive housing to return a degree of autonomy to

their residents.

Figure 2.18: Floor plan of Edgemoor Skilled Nursing Facility. San Diego, California. Architect: Ashen-Dyer

Dementia Care Dementia care facilities provide for the changing stages of

Alzheimer’s and other diseases that cause chronic mental

deterioration. These facilities provide twenty-four hour

comprehensive care, which is important for residents who

often have difficulties throughout the night. The typical

resident has moderate health but needs a high degree of

nursing care and health services (Senior Housing

Network, 2006). Cleaning and laundry services are

provided, and there is a moderate amount of social and

community activity. The auxiliary services in dementia

care are facilities similar to those in assisted living

communities.

Security is vital in these environments since residents can

become disoriented and wander from the facility. In order

to provide security, dementia care facilities allow minimal

personal freedoms. Some general nursing and assisted

living facilities have secure units specifically designed for

individuals with dementia and varying degrees of

cognitive impairment.

Figure 2.19: Outdoor common space. Hearthstone at the Esplanade. White Plains, New York.

Figure 2.20: Chapel. Hearthstone at Heights Crossing. Brockton, Massachusetts.

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With regard to interiors, the patterns, fabrics and designs

are chosen with restraint to reduce disorientation and

agitation. Dementia Care facility components, and the

services provided therein, are similar to skilled nursing,

but the care objective is different.

One aim of dementia care is to maximize awareness and

orientation of residents to their social and physical

environment (Cohen et al., 1987). One way of making the

social environment understandable for residents is to

cluster resident rooms in order to create a number of

smaller units in which the members are able to better

connect with each other. One design element that has

been found to have strong research backing is

camouflaging exits in order to reduce elopement

attempts. Other design elements include creating

residential-like common spaces, walking paths with nodes

of activity, and healing gardens. The goals of which are

to increase privacy and In a correlation study, John

Zeisel, Nina Silverstein and others found a link between

specific environmental design elements and measures of

behavioral health in a study of Alzheimer’s residences,

implying that the environment may ameliorate symptoms

of Alzheimer’s (Zeisel et al., 2003). While these attributes

are discussed here in relation to Alzheimer’s facilities,

they are also successfully applied to other long-term

facilities.

Figure 2.21: Building exterior of Hearthstone at Heights Crossing. Brockton, Massachusetts.

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Continuing Care Retirement Communities Continuing care retirement communities are sometimes

called congregate care facilities (CCFs) or life-care

communities. These facilities are campus-like and

provide a full spectrum of services including independent

living, assisted living and skilled nursing, rehabilitative

care, hospice care, and dementia care (Senior Housing

Network, 2006). Residents in these facilities may fall

anywhere on the independence-dependence continuum

of long-term residential care, from independent care to

highly dependent care such as skilled nursing and

dementia care. It is typical of these residences to have a

large population of independent living residents.

This array of living choices is designed to allow a senior

to flow seamlessly from one area of the community to

another as needs change. CCRCs are able to provide

the basic services that all of the aforementioned facilities

provide.

Figure 2.22: Bishop Gedsden Episcopal Retirement Community. Charleston, South Carolina. Architect: HKS Inc.

Figure 2.23: Capital Manor CCRC. Salem, Oregon.

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3: COMMON BUILDING DESIGN: FEATURES IN PATIENT CENTERED CARE

Within healthcare and long-term care settings there exists a countless array of design

features that determine the success and care-potential of a facility. These features are

shared by the two facility types: wayfinding, lighting, single-occupancy rooms, nature views,

and residentialism. Each of these features contributes to better quality of life (QOL) for the

individuals living and working within the facility. This QOL is evidenced in improved stress

levels and indicators of health. Although HC and LTC facilities may be quite different, they

are similar in what they provide the individual. Strategic use of building design features is

beneficial to patients/residents and can be financially lucrative as well (Berry et al., 2004).

By decreasing hospital stay time and staff- turnover rates, one is reducing the strain on

government funding. In addition, by increasing patient satisfaction, healthcare facilities can

hope to attract loyal patients. Wayfinding & Circulation Careful consideration of wayfinding and circulation is critical

for facilities in which the patrons are infirm and naturally

disoriented. Key components in wayfinding include proper

signage, place-markers and thoughtful facility layout.

Another means of providing wayfinding is to create views of

the outdoors and multi-story openings, such as atriums.

These building features allow occupants to anchor

themselves to the building and orient to the exterior

environment. The larger the facility, the more important

wayfinding becomes. One study of a major tertiary-care

hospitals calculated the annual cost of their wayfinding

system to be more than $448 per bed each year (Zimring,

1990). Most of the cost was incurred through staff hours lost

because of time spent directing visitors and patients.

In healthcare facilities, signage and the size and spacing of

the signs carry great potential for guiding or misguiding,

Figure 3.1: The red beams serve as markers for the three entrances. Christus Santa Rosa Medical Center. San Antonio, Texas. Architect: RTKL Associates Inc.

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patrons. As such, it is important to have proper signage to

direct the patients and visitors. It is additionally vital to place

signage at all major intersections or “decision points” along a

given route (Carpman et al., 1986). In addition, “you are

here” maps play a crucial role in navigation through large

facilities, medical or otherwise. Figure 3.2 shows the

importance of having a clear drop-off and pick-up in

navigating healthcare facilities.

Although signage is a great wayfinding tool, it is

inappropriate for the majority of long-term care facilities. As

such, it is important to use clear and obvious place-markers

and indicators of space. For instance, a central atrium can

serve as a landmark, or different areas may be painted

according to function. Having themed or differently colored

wings/corridors differentiates the space, creating landmarks

to help confirm that one is in the correct location.

Healthcare and long-term care facilities take different

approaches to ensure effective wayfinding but the overall

effect is the same. Both use interior landmarks such as

color, architectural detail, artwork, murals, and lighting, in

order to highlight areas of importance and to facilitate

wayfinding. In addition, the building’s overall form plays a

critical role in understanding the space. By having exterior

windows and interior courtyards, individuals are able to

anchor themselves. Wayfinding is crucial to the

effectiveness of a facility’s floor plan.

Figure 3.2 : This image, diagrams the wayfinding sequence to get from ones home to an appointment at a healthcare facility(Carpman et al., 1986, p.35).

Figure 3.3 : Unique spaces, such as this one at O’Connor Hospital, offer memorable land-marks for wayfinding. O’Connor Hospital. San Jose, California.

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Lighting Lighting has the potential to heal by improving sleep,

depression, agitation and stress, and also by reducing

medical errors. Both natural and artificial lighting are

important factors in creating a facility that acts as a

component of care. Sara Marberry asserts that “lighting is

the most important part of the interior environment,” (2006).

One can achieve proper daylighting through numerous

methods such as skylights, room windows, and corridor

windows.

Daylighting is an essential component in achieving patient/

resident, staff, and visitor satisfaction. Appropriate natural

lighting can decrease depression, pain, and hospital stay

time, while concurrently improving sleep and patient/resident

and staff satisfaction (Joseph, 2006). Evidence supports

that increased daylight exposure, especially morning light in

patient rooms, reduces depression and pain (Ulrich, 2006).

This reduction of pain perception has monetary impact

through the amount of pain medications and length of

hospital stay for patients with dementia and seasonal

affective disorder (Ulrich et al., 2004).

Light regulates a person’s sleep/wake cycles through its

ability to increase or inhibit the body’s production of

melatonin. Melatonin is a hormone that is responsible for

sleep cycles. Sleep disturbances are a major problem for

elderly; sixty-five percent of individuals 65 years or older

suffer problems sleeping, and forty-five percent of

individuals with Alzheimer’s (who are particularly deficient in

melatonin) experience restlessness and wander at night

(Marberry, 2006). As such, it is important to have a design

that encourages residents to receive sun-exposure.

Figure 3.4,3.5 : Whimsical lighting features, like those in RTKL’s Indiana Heart Hospital, offer a great alternative to traditional ceiling lights. This type of lighting is particularly important for corridors holding patients on gurneys. Indiana Heart Hospital. Indianapolis, Indiana. Architect: RTKL Associates Inc.

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Evidence supports that increases in exposure to bright light

in a dementia unit stabilizes the circadian rhythms of

patients with sight (Van Someren et al., 1997). One study

found that patients exposed to increased levels of daylight

experienced less perceived stress, less pain and had a 20

percent reduction in pain medication cost, compared to

those without increased exposure (Walch et al., 2005).

Increasing the overall level of indoor illumination is also

important. Brighter light levels have been shown to improve

indicators of health and help with loss of visual acuity in

aging eyes. These lighting strategies influence safety and

mental health in healthcare and long-term care facilities.

Proper task lighting reduces medical prescription errors and

decreases frustration among those with impaired vision

(Ulrich et al., 2004). It does so by increasing light levels,

which reduces eye strain. For patients/residents with

dementia, poor lighting can be particularly agitating. Proper

lighting throughout a facility may help reduce in-facility

injuries such as patient falls. It is important to control how

daylight enters a building, especially in senior facilities

where residents with poor vision may become disoriented by

sharply contrasting light levels. To ease transitions between

interior and exterior spaces, one can use clerestory and sky

lights which introduce natural lighting.

In both HC and LTC settings, there are high levels of stress,

sleep problems and depression; by maximizing both bright

light and sunlight, a facility can reduce these problems.

Figure 3.6: This waiting area uses a variety of lighting systems to create a proper lighting levels for a mixture of area activities.

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Single Occupancy Rooms Asa S. Bacon made the first recorded recommendation for

single occupancy rooms in 1920, but it was not until the

1970s that research confirmed his hypothesis regarding the

benefit of single patient rooms. Single occupancy rooms

have been shown to reduce patient/resident stress; increase

ability to sleep; greatly reduce nosocomial (hospital

acquired) infections; create less noise; provide better patient

confidentiality; improve patient-staff communication; provide

better accommodation for family and visitors; and increase

overall satisfaction with the quality of care provided (Ulrich et

al., 2004).

Private rooms in long-term care are vital to keep one’s

sense of self. A Pioneer network resident said, “I like a

private room so you can go to the door and invite people in,

so you don’t have to have someone walk in unannounced”

(pioneernetwork, 2006). Residents, often used to living

alone, find it uncomfortable to share close proximity to other

residents. For this reason, it is important to allow for ample

person-space, while creating a layout that is sociopetal

(fosters social interaction). Powell Lawton suggested years

ago that the need for privacy increases with age. In order

for residents to preserve their dignity, they must be given

privacy (Brawley, 2006). Individuals in HC and LTC settings

lack control of the environment, meal choices, and even

their health. Giving individuals a private room grants them a

sense of privacy and control.

Research shows evidence that single-occupancy rooms

lower average infection rates. The reasons for this decrease

include reducing airborne transmission (through moderation

Figure 3.7: The home-like atmosphere offered by this single occupancy room provides a healing space. The Hospital at Westlake Medical Center. Westlake Hills, TX. Architects: Polkinghorn Group Architects, Inc. and McFarland Architecture.

Figure 3.8: Resident Room. The home-like atmosphere offered by this single occupancy room provides a healing space.

24

of ventilation systems and air-quality) and reducing contact

with contaminated individuals and surfaces. In addition,

single-bed rooms are significantly easier to decontaminate

after the infected individual is discharged (Ulrich et al.,

2004). In LTC settings, the areas of most concern are those

in which one roommate easily infects another.

Nature Views & Garden Design Although most people instinctively know that incorporating

gardens and views of nature is important, many designers

struggle to understand what makes some greenscapes work

and others fail. Nature serves as a positive distraction by

providing soft-fascination, the ability to gently refocus an

individual’s attention elsewhere, in this case, to nature (Bell

et al., 2001). By addressing the principles of nature views

and garden design, stress can be reduced through design.

Views of nature serve as a positive distraction, which have

the power to ameliorate the negative effects of being non-

ambulatory and being in physical and psychological distress.

Laboratory and clinical studies show that viewing nature has

stress reducing and restorative benefits which are

represented in self reporting and physiological measures

(Ulrich et al., 2004). This has the effect of reducing patient

stay by up to three days, which translates into cost savings

for the hospital and the patient.

Gardens are important attributes to HC and LTC facilities.

The primary benefits of gardens in these settings are

improved mood and restoration from stress to the individual

(Barnes; Cooper-Marcus, 1995) (Whitehouse et al., 2001).

Visits to the garden are an excellent way to receive bright

Figure 3.9: This image illustrates an outdoor seating environment that provides options for group conversation or solo-people watching. This option allows the space to be used to its fullest potential.

Figure 3.10: In some cases, especially when dealing with older facilities, windowed nature views are unavailable. In these circumstances, screened images (above) offer an alternative source for the beneficial effects given by views of nature.

25

light exposure thereby increasing levels of vitamin D and

regulating levels of the hormone melatonin which governs

sleep-wake cycles. The most utilized gardens have an

abundance of paved walking paths, various seating options,

and ample shade. Many gardens in LTC facilities provide

activities and a sense of usefulness to residents. Residents

may even be able to cultivate fruits and vegetables and

maintain the garden. Studies suggest that there are health

benefits which result from spending time outdoors. The

possible reasons include increased physical activity,

exposure to bright light, and social interaction.

Nature views and outdoor gardens have a symbiotic

relationship. Window views of nature help to pull individuals

outdoors and into the gardens, while the views of the

gardens help increase the power of the window as a positive

distraction. These two facets work together in reducing

stress, increasing health, and bettering the healing

environment.

Figure 3.11: Spaces like the one above provide a sheltered area for residents and patients to enjoy gardening and the suns warmth.

Residentialism Due to the nature of HC and LTC facilities, they often act as

temporary or permanent homes. As such, they should instill

a sense of normalcy and reassurance. It is, therefore, only

natural for HC and LTC buildings to seek an aesthetic that is

reasonably residential in character. Residentialism is the

shift to creating facilities that are more residential in

character in order to reduce the negative association of a

starkly institutional setting. Making spaces more residential

or home like is an obvious step for long-term care facilities

due to the length and permanence in resident stay;

consequently, healthcare facilities are realizing the positive

Figure 3.12: Good Tree Assisted Living. Stephenville, Texas. Architects: Polkinghorn Group Architects, Inc.

26

effects of residentialistic design.

In HC facilities, this residentialism often takes a more hotel-

like or hospitality tone. This is achieved through providing

plush chairs for visitors, higher quality linens and

furnishings, plus paintings and cabinetry that disguise the

functional elements of the headwall. The goal of hospitality

design is to create a calm and comfortable setting that is

non-institutional. Rounded walls and columns, carpeting,

and decentralized care-giving stations give way to a warm

and relaxed atmosphere (Buenning & Shepler 2006).

A reorganization and allocation of space called clustering,

may be used to increase proximity to services, benefit

caregivers, and may help both staff and residents socially-

identify spaces. In comparison to the typically

institutionalized floor plans with long straight corridors,

clustering provides a more residential-architecture

appearance. This method is most commonly used in long-

term care facilities due to the longer length in stay but is

recently being used in many hospitals.

When people go to HC and LTC facilities, their needs

change but their desire for a comfortable space, for privacy

and for family, stays the same. Design can act as a steward

of care if it responds to both the needs and wants of the

individual.

Figure 3.13: The Christiana Care Helen F. Graham Cancer Center. Newark, Delaware. Architect: HKS Inc.

Figure 3.14: The waiting area for this medical office building resembles a cozy living room. Texas Diabetes and Endocrinology. Austin, TX. Architect: Susman Tisdale Gayle.

27

4: CULTURE CHANGE: LEADING TOWARD THE BETTER BUILDING MOVEMENT

“Culture change and transformation are not destinations but a journey, always a

work in progress”

–Pioneer Network-

Culture change is driven by goals of increasing staff satisfaction and retention

rates, improving safety and physical health, and decreasing environmental

stressors. These goals cannot be brought to fruition without changing the

organizational culture and the environment of a facility or facility type. Making this

change in healthcare and long-term care practices requires a holistic approach

involving physical environment, organizational environment, and

psycho/social/spiritual environment. This is the movement of the future, one in

which informed consumer society demands better and more thoughtful care. This

demand makes the change financially advisable.

One of the great differences in long-term care and healthcare facilities is

healthcare’s focus on healing. The healthcare model focuses on curing the

ailment. This focused, fix-it model means less patient mobility, a high staff to

patient ratio, and greater diversity in patient population. In this model, patients are

often encouraged to stay in bed and to be passive recipients of care. In contrast, in

LTC facilities, residents are expected and encouraged to be active participants in

self-care. In the LTC model it is important to accept and embrace aging and to help

residents leave their rooms and to be active. The difference in user ability and

circumstance influence the change each facility is able to make.

HC and LTC facilities are demanding of their care staff, staff that is often underpaid

and overworked. It is, therefore, important to facilitate their jobs through design

and organizational change. Each facility must act as a steward of care, embracing

the sickest and the most needing of our society. These are people who, like all of

us, want to maintain community, comfort, and a sense of normalcy. Although these

people’s needs have changed, their vision of what a home or place of care should

28

be is the same. It is the designer’s duty to create HC and LTC facilities that foster

a sense of wellbeing.

HC and LTC are in a constant state of change. By gearing this evolution towards a

higher standard of care and a better experience, one can increase the quality of life

for all individuals who live, work, and visit the facility.

Patient Centered (PCC) and Resident Directed Care (RDC) Patient/resident directed care is about involving, energizing, and empowering

patients/residents. Patient/resident centered care focuses on watching and caring

for the patient/resident. As consumers grow more knowledgeable of available

options, they demand better care. This makes it economically advisable for facility

planners to provide the highest quality of care which bows toward user needs; this

can be provided by PCC and RDC.

Patient-centered care refers to the guiding principle that

care should be centered on what is in the patient’s best

interest. An example of this is found in hospitals with

decentralized nursing, although this plan of construction is

slightly more expensive as it does provide more complete

patient care by increasing time that nurses are able to

spend with their patients. One focus of patient-centered

culture change is delivering care with an emphasis on the

person rather than the task; this allows caregivers to build

relationships with the patient. This type of communication

provides a sense of humanity and normality, and

emphasizes an approach in which all interaction has the potential to be positive

and meaningful.

In the past, long-term care facilities often made most choices for the residents.

RDC empowers residents by putting choice back in their hands. Resident-directed

care refers to a policy of allowing the residents of a long-term care facility to

Figure 4.1: Patient centered care model (Verderber et al., 2006).

29

choose their activities, dining, and care regimen. In this way, facilities are able to

restore the resident’s autonomy and give him/her a greater sense of being at

home.

Directed care is reasonable for long-term care facilities; yet, it is not feasible for

most healthcare settings due to patients’ frequent incapacitation, heavy sedation,

and fragile condition. In these settings, the patient’s family should assist the

physician in the decision-making process. Regardless of the setting, the focus of

care for both models is the resident/patient. In this way, facilities provide the best

and most comprehensive care by shifting their focus from the bottom line to the

bedside.

Re-centering Care: Models for Change Models for culture change are conceptual frameworks in which an organization, or

facility, functions. These models include, but are not limited to, Pioneer Network;

Restraint–Free/Individualized care; The Regenerative Community; The Eden

Alternative; The Wellspring Model; Planetree; and The Green House Project. Planetree and The Green House Project are some of the best-known and most

influential models in their respective fields. Both of these prototypes work within

the conceptual framework of patient/resident centered care.

The Planetree Model (Healthcare) Planetree focuses on enhancing healthcare from the patient’s perspective,

empowering patients and families through information and education. The

Planetree model was founded in 1978 by a patient, Angelica Thieriot, after

numerous traumatic hospital stays (Planetree, 2006). The Planetree model uses

organizational transformation and architectural design to achieve active

collaboration between caregivers and patients in patient-health. The guidelines for

this model come from the following Planetree components:

1. Human interactions

2. Architectural and interior design that is conductive to health and healing

30

3. The importance of

the nutritional and

nurturing aspects of

food

4. Empowering patients

through information and

education

5. The importance of

family friends and social

support

6. Spirituality: the

importance of inner

resources

7. The importance of

human touch

8. Healing arts: nutrition for the soul

9. Complementary therapies

10. Healthy communities

In architectural design, Planetree facilities stress efficient layouts, domestic

aesthetics, and the symbolic messages communicated through design. They focus

on creating an environment that provides opportunities for socialization and

solitude. These facilities offer their staff warm and inviting lounges and sacred

spaces (Planetree, 2006). The Planetree model is predominately used in

healthcare settings. One of its successors, the Green House concept, is

predominately used in long-term care settings. The Green House Concept (Long-term care)

The Green House Concept is progressive because of its integrated model of

design that involves key-players throughout the process. In getting architects,

builders, contractors, neighborhood members, nursing staff and residents to take a

Figure 4.2: Conceptual model of Planetree Program.

(Malkin, 1992, p. 23)

31

personal investment from the beginning, these facilities insure their success. The

Green House concept is a great example of resident directed care: residents

choose what they want to eat and are able to spend time as they wish. In this way,

they are able to keep their individuality and freedoms (Rabig et al., 2006).

There is a semantic-shift in the Green-House that intends to counter the negative

connotations that come with institutional language, such as “staff”. They refer to

their assistants as “Shahbaz”, their residents as “elders”, and the administrators as

“guides” (Rabig et al., 2006).

As part of their “facilitative social model,” Green-Houses provide private bedrooms,

equipped with mechanical assistance such as ceiling-mounted lifts for disabled

residents. This gives independence to infirm residents and greatly reduces staff

injuries. This increase in self-sufficiency is part of a larger trend of returning pride

to residents who have often been limited in activity and autonomy. The Green-

House model creates a home-like setting by eliminating long institutional hallways

and cold materials, and it encourages residents to bring their own furnishings from

home. From the exterior, these assisted living facilities typically look like large

single family homes. Their interiors are consistent with the residential aesthetic, yet

their floor plans reveal an average of 12 bedrooms per house.

Increasing Staff Satisfaction and Retention Rates The current situation in hospitals and long-term care facilities shows a rate of nurse

turnover that cannot be sustained. Nurse turnover rate is 20 percent per year, but

designers can help change that by reducing staff walking, fatigue, and stress (Joint

Commission, 2002). Increasing staff satisfaction is at the top of most lists of care

concerns for both hospital patients and long-term care residents; the quality of

patient/resident care is highly correlated with nurse performance. In the U.S.,

approximately 15-17 percent of hospital nursing positions go unfilled. There are

32

things that designers and administrators can do to change this downward trend; a

holistic approach to this issue allows monumental change.

In long-term care facilities, adequate staffing and stable nurse leadership (with

longer tenure for the nursing director), as well as reward based administrative

climates with open communication, have been shown to increase staff satisfaction

(Anderson et al., 2004). By designing spaces that allow nurses to more efficiently

and effectively perform their jobs, nurses are able to spend more time taking care

of patients.

Designers can also help by making more stimulating and home-like support areas

for staff such as staff lounges, staff toilets, and staff storage facilities (The Facilities

Guidelines Institute, 2006). Design features such as gardens that alleviate patient

stress can also help relieve caregiver stress (Whitehouse et al., 2001). However,

active and retired nurses have reported that although staff lounges are important,

nurses often do not have time to use them. One nurse suggested that facilities

provide windows in heavily trafficked areas in order for the nurses to be able to

pause briefly. According to the attention restoration theory, visual access to nature

allows task-concentration to be restored (Bell, 2001).

By improving staff mood and reducing fatigue, one is able to achieve a higher level

of patient/resident safety. The bulk of nursing staff age-out of the profession, and

organizations must offer more and better incentives to young talent. Maintaining

and increasing the number of skilled caregivers is vital to the health of the

patient/resident as well as the economic health of the organization/ facility for which

the caregivers work. High turnover rates mean that caregivers spend more time

training and less time at the bedside.

It is clear that many ongoing improvements in HC and LTC facilities are on parallel

paths. By examining their individual characteristics, culture change movements,

and their shared necessity for design guided by evidence, one can see that there is

a clear focus on the betterment of the user’s quality of life and of care. The

typologies of HC and LTC set the stage for the design and culture of a facility. For

33

each of these facility types, a different culture and strategy will be necessary to

maximizing each facility’s potential.

An ideology of care sets healthcare and long-term care facilities apart from the

majority of architectural building types. The building is itself a caregiver; therefore,

its design strengths and weaknesses are translated into patient/ resident safety,

healing time, stress levels and overall satisfaction. It is vitally important that

architects design with the keen knowledge and abundant care that one would

extend to a loved one.

It is important to remember that designers and architects are required to work with

the facility owner’s program, and as such, are unable to create these changes

without administration and executive buy-in. The ability to incorporate the values of

different user groups is what makes these models for change so revolutionary in

the design of care facilities. It is important to note that the architect can use his/her

relationship with the client to introduce them to the benefits of new plan models

such as those discussed above.

As our population continues to age, the line between HC and LTC tends to fade.

Yet, what is most important to remember, is the universality of the nature of care.

Each person looks to the surrounding environment for reassurance that one is

safe; it is part of the human condition. In long-term care and healthcare settings,

this need for reassurance amplifies. In both cases, the environment of care has

the potential to save lives and to make life better for those who live and work in the

spaces. As a nurse chooses to care for his/her patient, so should designers show

their care through thoughtful and caring design.

34

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