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Page 1: Environment of Care News Nov 2009

Apatient lies in his hospital bed,trying to ignore the pain thatradiates from the tumor that

threatens his life. He’s frightened andlonely, and as he waits for the caregiverto administer the pain relief he needs, hefeels isolated from his family and friends.But across from him is a painting thatshows a waterfall surrounded by lushgreen plants and a cascade of colorfulflowers. Dozens of times each day, hiseyes travel to that serene scene, and eachtime it brings him a measure of relief.

This is the world that art can createin health care facilities. A 2002 study1

showed that the interior design featuresin a hospital have a significant effect onhow satisfied patients are with theirhospitalization experience. According tothis study, the hospital environment—including the art in patients’rooms—can improve the quality ofhealth care.

Almost half of all U.S. hospitalsnow have programs for the display and

http://www.jcrinc.com

Contents

Focus on Health Care Facilities Art

1 Art in Health Care

Facilities—Designing Sights for

Sore Eyes

4 CASE STUDY: The End of “Art

for Art’s Sake”—M.D. AndersonCancer Center at the Universityof Texas Medical Center UsesArt to Help Heal

6 EM’S 6 CRITICAL FUNCTIONS:Function 5: Utilities

Management—Avoiding UtilitiesFailure During a Disaster

Visit the EC News blog at http://www.jcrinc.com/Blogs-All-By-Category/EC-News-Blog

Continued on page 2

Healing artwork enlivens new space at Providence Regional Medical Center, Everett,Washington, and is an important part of a design and construction project.

Art in Health CareFacilities

Designing Sights for Sore Eyes

Page 2: Environment of Care News Nov 2009

use of art in their facilities. In 2003, theSociety for the Arts in Healthcare(SAH) and the National Endowmentfor the Arts (NEA)2 analyzed hospitalsaccredited by The Joint Commission.Their aim was to assess the arts inhealth care. In spite of the costs associ-ated with art programs, SAH and theNEA concluded that hospitals use thearts “to create a more uplifting environ-ment” in addition to “create a welcom-ing atmosphere and build communityrelations.”2

The majority of health care art pro-grams dealing with the display of visualart are created and administered by artconsultants, often hired by either thefacility’s architect or interior designer.The hiring process usually involves arequest for proposals issued by a formalart committee. While other characteris-tics can be attractive to hospitals hiringa consultant, the single most importantcredential for selecting an art consultant

seems to be the consultant’s in-depthexperience in health care. Like design-ing a hospital itself, designing and pro-ducing a comprehensive health care artdisplay program is challenging andcomplex, especially because many facili-ties are including evidence-based designprinciples in their projects.

A History of HealingAccording to a white paper titled

“A Guide to Evidence-Based Art,” byKathy Hathorn, M.A., CEO and cre-ative director, and Upali Nanda, Ph.D.,American Institute of Architects (AIA)vice president and director of researchat American Art Resources (AAR), “Artis an integral component of humanevolution, both as a species and as asociety.”3 In fact, as early as 1860, inher famous Notes for Nursing,4 FlorenceNightingale described the patient’s needfor beauty and made the argument thatthe effect of beauty is not just on themind but on the body as well.

“Because of the profound effectthat art can have on healing, it must be

selected very carefully inhealth care settings,”says Nanda. “Art has astrong impact, not juston patients but also oncaregivers.” She notesthat “today there is ashift in practice towardsevidence-based design;in other words, basingdesign decisions on thebest available evidenceand committing toresearch on how design,including art, affectsone’s health care experi-ence.”

A significant bodyof evidence on theimpact of art on healthoutcomes, especiallywith respect to natureimages, is already inplace. Research has

Environment of Care News http://www.jcrinc.com2 November 2009

Art in Health Care(continued)Continued from page 1

Executive Editor: Kristine M. Miller, M.F.A.Senior Project Manager: Christine Wyllie, M.A.Associate Director, Editorial Development: Diane BellExecutive Director: Catherine Chopp Hinckley, Ph.D.

Technical Support and Review Provided by Standards Interpretation Group, Division of Accreditation Operations:Patricia Adamski, R.N., M.S., M.B.A., Director; George Mills, M.B.A., F.A.S.H.E., C.H.F.M., C.E.M.,Senior Engineer; Jerry Gervais, C.H.F.M., C.H.S.P.,Associate Director/Engineer; John D. Maurer,C.H.F.M., C.H.S.P., Associate Director/Engineer;Michael Chisholm, C.H.F.M., AssociateDirector/Engineer

Division of Standards and Survey Methods:John Fishbeck, R.A., Associate Director

Contributing Writers: Catherine Rategan, KathleenVega

Editorial Advisory BoardTracy L. Buchman, D.H.A., C.H.S.P., C.H.C.M.,University of Wisconsin Hospital and Clinics, Madison,WIJen Carlson, M.P.H., M.B.A., Loyola University HealthSystem, Maywood, ILDavid P. Klein, P.E., Department of Veterans Affairs,Washington, DCMichael Kuechenmeister, F.A.S.H.E., C.H.F.M., C.P.E.,West Chester Medical Center, Cincinnati, OHJohn W. McKinney III, Atrium Medical Center,Middletown, OHWilliam R. (Bill) Morgan, S.A.S.H.E., C.H.F.M., St. Alphonsus Regional Medical Center, Boise, IDJim Riggs, M.P.A., C.S.P., University Health Systems,Greenville, NCGeorge A. (Skip) Smith, C.H.F.M., S.A.S.H.E.,Catholic Health Initiatives, Denver, COThomas S. (Scott) VanDerhoof, Major, U.S.A.F., M.S.C.,C.A.A.M.A., Air Force Medical Operations Agency,Office of the Surgeon General, Brooks City-Base, TX

Subscription InformationThe 2009 12-issue subscription rates for the UnitedStates, Canada, and Mexico are $319 for both print andonline and $299 for online only; for the rest of the world,the rates are $410 for both print and online and $299 foronline only. Back issues are $25 each (postage paid). Add$25 for air mail delivery. Orders for 20–50 single/backissues receive a 20% discount. Site licenses and multi-year subscriptions are also available. To begin your subscription, call 800/746-6578, fax orders to 218/723-9437, or mail orders to Joint CommissionResources, 16442 Collections Center Drive, Chicago, IL60693. For more information, call 800/746-6578.Environment of Care® News (ISSN 1097-9913) is pub-lished monthly by Joint Commission Resources, 1515West 22nd Street, Suite 1300W, Oak Brook, IL 60523.

© 2009 Joint Commission on Accreditation ofHealthcare Organizations. No part of this publicationmay be reproduced or transmitted in any form or byany means without written permission.

Joint Commission Resources, Inc. (JCR), a not-for-profitaffiliate of The Joint Commission, has been designatedby The Joint Commission to publish publications andmultimedia products. JCR reproduces and distributesthese materials under license from The JointCommission.

E-mail us at [email protected] with your article ideas.Visit us on the Web, at http://www.jcrinc.com.

To contact the Standards Interpretation Group withstandards questions, phone 630/792-5900.

Artwork at Northwestern Memorial Hospital, Chicago

Page 3: Environment of Care News Nov 2009

shown that viewing nature imagesthat contain positively reinforcing fea-tures can reduce stress and anxietyamong patients and staff and canlower the patient’s perception of pain.Research further suggests that natureart (or art with views or representa-tions of nature) will promote restora-tion if “it contains the following fea-tures: calm or slowly moving water,verdant foliage, flowers, foregroundspatial openness, park-like or savan-nah-like properties (scattered trees,grassy undershot), and birds or otherunthreatening wildlife.”

The same research suggests that,in addition to nature art, humans aregenetically predisposed to notice andbe positively affected by smiling orsympathetic human faces. Accordingto Nanda, while these guidelines arean excellent starting point for artselection, it is important to avoid a“one-size-fits-all approach.” Carefulconsideration of the specific patientpopulation and the health care settingare warranted before making decisionson health care art.

An Art PreferenceStudy

In 2006 an art preferencestudy5 with inpatients at St.Luke’s Episcopal Hospital inHouston, Texas, found thatpatients preferred naturescenes and representativeimages to stylized or abstractart—even when the latter wererated as “bestsellers” by onlineart vendors and included clas-sics by artists such as VanGogh, Klimt, and Chagall. Infact, patients made a distinc-tion between pictures theywould like to see in theirhomes and those they wantedto see in their inpatient rooms.Not surprisingly, when thissurvey was conducted withinterior design students, popu-lar art rated higher. Also, therewas a low correlation betweenthe students’ emotionalresponse and their aestheticresponse (or preference) to

http://www.jcrinc.com Environment of Care News 3November 2009

Continued on page 10

The Healing Power of Art Carts

Art carts are now a feature of hospital life in

many health care facilities. Customarily, a hos-

pital employee or a volunteer stacks a rolling

cart with various pieces of art and transports

the art to the rooms of new patients, where

patients are asked to select which art they’d

like to have hung on the walls of their rooms.

This lets patients interact with a caring person

and offers them a sense of control in affecting

their own environment.

When Upali Nanda and her colleague

Kathy Hathorn of American Art Resources con-

ducted a study at St. Luke’s Episcopal Hospital

in Houston, Texas, in 2006, they found several

benefits of using an art cart program. Among

them were the following:

■ Pictures become a means for patients to

interact with volunteers and thus provide

social support.

■ Having choice in artwork gives patients a

sense of control.

■ Patients explore the narrative scope in

artwork and make stories around the pic-

tures to discuss with friends and family.

This is true for caregivers as well.

■ Patients appreciate the service, which

they perceive as a pleasant surprise, and

they comment positively about the quality

of care at the hospital.

Volunteers have their own unique meth-

ods of approaching patients and selecting art-

work. This selection is largely sensitive to

patient preferences; however, an orientation

session about the reasons for the art cart pro-

gram could be helpful. On occasion, patients

have had extreme reactions to a picture they

don’t like, such as covering it with a newspa-

per or a cloth. Mostly, however, they appreci-

ate the artwork and welcome the change and

the choice offered by the art cart. Landscapes,

nonthreatening animals, and flowers are popu-

lar with patients and volunteers alike.

“We found that an art cart program,

although a relatively small intervention,

embodies the principles of supportive design,”

says Nanda. “It’s a positive distraction that

offers patients a sense of control and a source

of social support.”

Artwork at Prentice Women’s Hospital, Chicago

Page 4: Environment of Care News Nov 2009

The M.D. Anderson CancerCenter believes in evidence-based art. “To us, that means

art that supports the healing environ-ment and produces an unambiguouslypositive experience for both patientsand staff,” says Lynn Bouchard, thecenter’s senior facilities design plan-ner. But that wasn’t always the case.First the center had to re-evaluate itsapproach of “art for art’s sake.”

More than 10 years ago, the cen-ter formed an art committee staffedwith representatives from various dis-ciplines within M.D. Anderson. Thefollowing year, a working groupdecided that the hospital’s policy ofchoosing art for its own sake neededto be replaced with a broader andmore compelling philosophy: Artshould help improve patient out-comes. The first tasks of that workinggroup were as follows:1. Identify characteristics of the kind

of art that contributes to the quali-ty of the environment

2. Develop a policy regarding acquisi-tion and display of art

3. Develop guidelines for selection ofart

4. Define where the art will be placed

The Art CommitteeThe M.D. Anderson working

group was made up of members whohave other jobs in the organizationand for whom the art committee wasan extracurricular responsibility. Forinstance, the current chairperson isthe executive director of Volunteer

Services, andamong theother membersare employeesfromDevelopment,FacilitiesManagement,InstitutionalDiversity, andPublic Affairs.“We all agreethat a broad-based commit-tee representingthe breadth ofthe organizationis key,” saysBouchard.“This allows usto tap intothose resourcesto answer ques-tions as theycome up.”

The artcommitteedrafted aneight-page policy statementand thenengaged an artconsultantthrough a request for proposalsprocess to advise on which artworksto acquire and where to place them.The committee works closely with theart consultant and reviews art that theart consultant recommends for acqui-sition. Since 2002, the center’s con-

tracted art consultant has beenAmerican Art Resources (AAR) inHouston, Texas, which uses the cen-ter’s art policy as a guide in recom-mending artwork for acquisition. Asite survey is done of the pieces thatgo in, a budget is formulated, and the

Environment of Care News http://www.jcrinc.com4

The End of “Art for Art’s Sake”M.D. Anderson Cancer Center at the University of TexasMedical Center Uses Art to Help Heal

November 2009

“The Tree of Life” sculpture at Mays Clinic, M.D. Anderson CancerCenter, symbolizes hope.

CASE STUDY

Page 5: Environment of Care News Nov 2009

artwork is purchased and installed.“We also look to AAR for theirexpertise in deciding which donationsto accept,” says Bouchard.

Art at WorkMuch of the artwork M.D.

Anderson has chosen in the pastdecade graces the walls of the MaysClinic, an ambulatory outpatienttreatment and research center, whichopened in 2005. “Once we completedthe installation of art in that buildingand added the right furniture andlighting, our consultants were able tobegin documenting the premise thatartwork contributes to the healingenvironment,” says Bouchard. “Whenwe completed our post-occupancyevaluation, we learned that ourapproach is achieving the effect wewant.”

Bouchard believes fervently inknowing as much as possible aboutthe populations that the art must sup-port and keeping in mind thethoughts, feelings, and needs ofpatients and staff. As an example,Bouchard relates the story of an artcommittee member who is also a can-cer survivor. The committee memberpointed to aslide in a pres-entation, not-ing that itshowed “a pieceof fine art,something youmight see in amuseum.” Theartwork incor-porated fourviews of thesame piece offruit. But by thelast section ofthe artwork, the image depicted sim-ply the core of an apple. “To a cancerpatient, that image could signify aprocess of wasting away,” the commit-tee member explained. Bouchard

notes that thiscomment “reallyhighlighted for therest of us on thecommittee the dif-ferent viewpoints ofour patients.”

Artwork ondisplay at M.D.Anderson mustconvey a positiveimage and must befamiliar and com-forting; the mediarange from oils toacrylics and fromphotos to sculpture.The subjectsinclude floral work, urban landscapes,and natural landscapes, and the art-work must have broad-based appealin order to serve the hospital’s diverseand wide-ranging patient group.“We’re not just a regional or nationalcancer center,” Bouchard says. “M.D.Anderson is world-renowned, andpeople come here for care and treat-ment from all over the globe. So westay away from showing only regionalscenes.”

Much of the art at M.D.Anderson isoriginal, whichenables theconsultants tomeet specificcriteria for size,color, material,and subject. Isa piece of artever moved to anew location?“Almost never,”says Bouchard.

“Typically oncewe install the

artwork, it’s there to stay. If the art istaken down for reconstruction orredesign, we do find another spot forit.”

As an example of positive art-

work, Bouchard cites “The Tree ofLife,” a massive two-story sculpturethat conveys a feeling of vitality andthat many patients and visitors use tohelp orient themselves (see the illus-tration on page 4). “The sculpture hasbecome an icon for the clinic itself—an embodiment of our philosophy ofhealing and hope,” says Bouchard.

Positive Responses to Art

There’s little or no difference inthe kinds of art that are selected toappeal to patients with different kindsof cancer, with the exception of theart chosen for pediatric patients. Mostof the artwork on display in the pedi-atric diagnosis and treatment areas isdone by M.D. Anderson patientsthemselves. “We have an outstandingchildren’s art program,” saysBouchard. “The children find it high-ly therapeutic to make art, especiallywhen it shows what they’re goingthrough.”

Each day the center experiencesthe benefits of its artwork in the over-whelmingly positive response fromvisitors, caregivers, and patients them-selves. “Rather than statistical, it’sanecdotal, such as comments that a

http://www.jcrinc.com Environment of Care News 5November 2009

Continued on page 9

M.D. Anderson Cancer CenterProfile

M.D. Anderson is one of the largest cancer centers in the

world, with more than 17,000 faculty and staff members

working in 25 buildings in Houston and central Texas.

The physical plant includes an inpatient pavilion with 507

beds, 5 research buildings, 3 outpatient clinic buildings,

2 faculty office buildings, a proton radiation clinic build-

ing, and a patient–family hotel. In addition, the following

facts describe the center:

■ 90,000 patients are expected in 2009, one-third of

them new.

■ The average number of beds is 510, up 7% over

2008.

■ There are 956,245 outpatient clinic visits a year for

treatments and procedures.

Artwork at M.D. Anderson Cancer Center

Page 6: Environment of Care News Nov 2009

This is the fifth of six articles dis-cussing the six critical functionsof emergency management: com-

munication, resources and assets, safetyand security, staff responsibilities, utilitiesmanagement, and patient clinical andsupport activities. For the previous arti-cles, see the January, March, June, andAugust issues of EC News.

A disaster is bad enough, and ifyour hospital’s utilities fail during thatcrisis, things go from bad to worse.During an emergency, a failure of yourorganization’s utilities can escalate a sit-uation and move it from a small, con-trollable event to a large, multifaceteddisaster. For example, if a hurricanedescends on a hospital during a steamyweek in August, the storm itself maynot represent a catastrophic event. Butif the storm knocks out power andshuts down the air-conditioning systemfor five days, the emergency canincrease in both size and scope.

Utility failures can not only com-plicate emergencies, they can be the

direct cause of emergencies. Duringnormal business operations, utility sys-tems run unnoticed, but if a utility sys-tem fails, its absence is apparent to alland may cause a significant disruptionin patient care. “In order to preventsuch situations from spiraling out ofcontrol, an organization must pro-actively address how it is going to pro-vide utility systems during an emer-gency and continue the level of opera-tions that everyone takes for granted,”says Jerry Gervais, C.H.S.P., C.H.F.M.,associate director, StandardsInterpretation Group, The JointCommission.

The Joint Commission addressesthe topic of preserving utilities duringan emergency in StandardEM.02.02.09. This standard and itsseven elements of performance (EPs)walk the organization through the dif-ferent utilities that must be maintainedduring an emergency and require anorganization to anticipate and preparefor failures involving these utilities. “In

some ways, this is the most specific andstraightforward of the emergency man-agement standards,” says Gervais. “Anorganization must establish ahead oftime how it is going to maintain criti-cal utilities during an emergency andensure that those backup systems willfunction when the time comes.”Although the standard is straightfor-ward, complying with the standardinvolves some careful consideration anddue diligence. The following sectionstake a closer look at the utilities cov-ered within the standard and providesuggestions on how to comply with itsrequirements.

Electricity (EM.02.02.09,EP 2)

“The electrical systems are to anorganization what the central nervoussystem is to the human body,” saysGervais. “And as with the human body,a failure in such systems can have far-reaching consequences.” Most, if notall, health care organizations have anemergency electrical power system inplace that will turn on in the event of apower failure. Often, this power systemconsists of one or more diesel-poweredgenerators or something similar. “Thekey element to meeting this require-ment is not that you have an emer-gency electrical power system—becausemost organizations do. Instead, focuson what equipment and systems arepowered by the emergency power sys-tem and whether all the appropriatesystems are covered,” says Gervais.

The Joint Commission requiresthat certain systems and equipment bepowered by the emergency power

Environment of Care News http://www.jcrinc.com6

FUNCTION 5: Utilities ManagementAvoiding Utilities Failure During a Disaster

November 2009

Utility failures can easily escalate an already dangerous situation.

EM’S 6 CRITICAL FUNCTIONSCommunications / Resources & Assets / Safety & Security / Staff Responsibilities / Utilities Management / Patient Clinical & Support Activities

Page 7: Environment of Care News Nov 2009

system. These include fire alarms, exitroutes and signage, emergency commu-nication systems, life support systems,and so on. (A complete list of whatThe Joint Commission requires can befound in Standard EC.02.05.03.)“Although meeting these requirementsis important, they only scratch the sur-face of what an organization should becovering with its emergency backuppower systems,” says Gervais. “Forexample, covering heating, cooling, andair-conditioning (HVAC) systems viaemergency backup power is notrequired by the standards. However, ifa prolonged power failure occurs dur-ing extremely hot or cold temperatures,your organization is going to have areal problem if the HVAC system isoffline. Not only could everyone’s com-fort be affected, but so could the orga-nization’s ability to maintain thepatient isolation that relies on con-trolled air flow. If an organization can-not maintain patient isolation, thedynamics of an emergency can getmore complex, and the ability torespond to the emergency can becomemore limited.” Ofcourse, the HVACsystem requires a sig-nificant amount ofpower, so organiza-tions will need tothink carefully abouthow much of thesystem they want toplace on emergencypower and how toreduce the amountof energy the systemuses.

The Joint Commission does notrequire computer systems to be coveredunder emergency power, but if yourorganization uses an electronic medicalrecord, placing that system on emer-gency power is important. In somecases, an organization may want toconnect its computer systems to anuninterruptible power source.

“Typically, when normal power is inter-rupted, there is up to a 10-second lagbefore emergency power kicks in,” saysGervais. “This may not seem like along time, but it’s enough to bringdown an entire computer system.Depending on what the system is beingused for, your organization may wantto overcome the 10-second delay bykeeping computer systems on batterypower.” During normal business opera-tions, the battery would be continuous-ly charged by regular power, and dur-

ing emergencies,the battery wouldbe charged byemergency back-up power.

Another system that anorganizationshould considerincluding onemergency back-up power is thevertical trans-portation system.

“Although Standard EC.02.05.03requires an organization to have oneelevator on emergency backup power;if you are working in a large hospitaland plan to continue providing patientcare during a power outage, you willneed more than one elevator working,”says Gervais. “In this situation, it is notrealistic to work just within the con-

fines of the requirements; instead, youshould look at how your organizationwill operate during an emergency andensure that you have enough elevatorsavailable and functioning.”

Different organizations have differ-ent emergency backup power needs, soit is important to determine what yourneeds are and verify that your backuppower is covering all systems relevantto your organization’s performance. Todetermine what should be coveredunder emergency power, the JointCommission recommends that anorganization conduct a gap analysis.Such an exercise allows an organiza-tion’s leaders to examine which systemsand equipment are currently coveredby emergency power and which sys-tems should be covered by that powerbut are not. Depending on the resultsof the gap analysis, your organizationmay have to reevaluate its emergencypower system and add more capacity.(See the Joint Commission’s SentinelEvent Alert #37, at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_37.htm, formore information on gap analysis.)

Water (EM.02.02.09, EPs 3 and 4)

Water is a critical resource for everyhealth care organization, and everyorganization uses two types of water:

http://www.jcrinc.com Environment of Care News 7November 2009

Continued on page 8

Make sure you have enough clean water for emergency use.

“During an emergency,a failure of your

organization’s utilitiescan escalate a

situation and move itfrom a small,

controllable event to alarge, multifaceted

disaster.”

Page 8: Environment of Care News Nov 2009

Environment of Care News http://www.jcrinc.com8 November 2009

1. Potable water—that which is fit fordrinking or use in health care procedures.

2. Nonpotable water—that which isused within the organization’s clean-ing systems, boilers, bathrooms, andso on.

“Organizations often focus onensuring that there will be enoughpotable water during an emergency.This is very important, but it’s alsocritical to ensure that there’s enoughnonpotable water,” says Gervais. “Infact, to function effectively during anemergency, an organization will proba-bly need more nonpotable water thanpotable water.” Nonpotable water isnecessary to flush toilets, operate theboiler, and perform other critical activi-ties. Not having enough nonpotablewater can quickly lead to sanitaryissues, heating and cooling issues, andother problems.

To be adequately prepared for anyemergency, an organization should seekemergency sources of both potable andnonpotable water. As with other sup-pliers, your organization should ensurethat water suppliers can access yourorganization during an emergency andprovide sufficient supplies.

In addition to water, your organi-

zation may want to ensure that it hasaccess to steam during an emergency.Many organizations use steam to steril-ize medical equipment and supplies,wash dishes, and prepare food. If steamis not available during an emergency orif the quality of the steam is compro-mised, the safety of patients and theenvironment can be negatively affected.

Fuel (EM.02.02.09, EP 5)The requirements related to emer-

gency management have always focusedon ensuring enough fuel to operateemergency backup power and otherbuilding systems during an emergency.Recently, however, the JointCommission added requirementsregarding another aspect of fuel man-agement: transportation services. “Ifyour organization remains open duringan emergency, you will need fuel tooperate any vehicles you use as part ofoperations—such as ambulances andother transportation vehicles,” saysGervais. “This is particularly importantduring an evacuation situation, whenyou want to ensure that you haveenough fuel to operate the vehicles thatwill transport your patients off site.”

In addition to operating your owntransportation vehicles, suppliers com-ing to the facility during an emergencymay have only enough fuel to get tothe organization and may require

refueling before they depart.Consequently, organizations must haveenough fuel to address the potentialneeds of their suppliers.

There are two ways to make surethere is adequate fuel during an emer-gency. One is to stockpile fuel at thefacility, although this is not very practi-cal. The other is to make arrangementswith a local supplier—such as a nearbygas station. “It’s important to remem-ber that gas stations often don’t haveemergency power generators and thuswill not be able to operate their fuelpumps during a power outage,” saysGervais. “Because of this, your organi-zation may find itself in the difficultposition of being near a fuel source butnot able to access it.” To overcome thisproblem, your organization shouldwork with the gas station to determinehow you can obtain gasoline during apower outage. This may involve sup-plying the gas station with a generatorduring emergency situations. “Whenseeking fuel sources, it is not enough tosign a memorandum of understanding(MOU) and forget about it. Yourorganization must probe into how thesupplier can get fuel and take owner-ship of investigating that capability,”says Gervais.

Medical Gas andVacuum Systems(EM.02.02.09, EP 6)

As with the other utilities dis-cussed in this article, organizationsmust make sure there is access to med-ical gas and vacuum systems during anemergency. Per Standard EC.02.05.03,such systems must be connected toemergency backup power. Althoughthe backup power will allow the med-ical gas and vacuum systems to keepfunctioning during an emergency, thesesystems are known to malfunction andbreak down. “In order for your organi-zation to be confident that medical gasand vacuum systems will continue to

Function 5: UtilitiesManagement (continued)Continued from page 7

You’ll need fuel if you have to transport patients off site. Continued on page 9

Page 9: Environment of Care News Nov 2009

patient or nurse would share,” saysBouchard. Some of the comments areshown in the box “Artwork DrawsPraise,” on page 9.

The center has commissioned somepieces for use in highly visible areas,and an attempt is made to use at leastone piece of art in every exam room,where posters are sometimes used, espe-cially if they have high impact. The artcommittee is responsible for placing artnot just in the Mays Clinic butthroughout the hospital, except in theback of the house and in the staff areas,where staff members can bring in theirown art. “We’re quite careful aboutwhere we place the art and where wespend our dollars. We keep in the fore-front of our minds the need to be goodstewards of the institution’s assets.”

A favorite image is bluebonnets, aflower that’s indigenous to Texas. “Ifsomeone asks where to find art similarto that, we refer them to the art con-sultant,” says Bouchard. Artwork is dis-played without labels or plaques show-ing the names of the artists. Butrequests sometimes come from patientsand/or visitors for the names of certain

artists so they can acquire some of theartists’ work. “In those instances, we

will provide the names of artists,” saysBouchard. EC

NEWS

http://www.jcrinc.com Environment of Care News 9November 2009

The End of “Art for Art’sSake” (continued)Continued from page 5

Artwork Draws PraiseThe response to M.D. Anderson Cancer Center’s artwork has been overwhelm-

ingly positive. The following are just a few of the comments that Lynn Bouchard

at M.D. Anderson received via American Art Resources:

■ “The artwork lifts your mood when you get into the lobby after fighting the

traffic. Art reminds me that there is a future. Sometimes you get bogged down

by the details of your situation—and then you look at the art. I think it’s

stunning.”

—Breast imaging patient

■ “The artwork takes you away from the pain and your mind off the treatments

and puts a smile on your face.”

—Outpatient MRI patient

■ “The art demonstrates what M.D.

Anderson is about: patient care to the

maximum, and a continuing search

for a cure for the disease.”

—Nursing staff member

■ “The artwork is the main reason why

the Mays Clinic doesn’t feel like a

hospital. Whenever friends or family

visit me, I make a point of having

them tour the artwork in this building.”

—Patient services staff member

Artwork at M.D. Anderson CancerCenter

operate during emergency situations,your organization should have a supplyof parts on hand to fix the equipmentif it breaks,” says Gervais. “Obtainingparts during an emergency is nearlyimpossible, so it would be beneficialfor your organization to identify criticalparts and ensure that you stockpilethose before an emergency occurs. Thisis not only true for medical gas andvacuum systems but also for any utilitysystems that need to continue func-tioning during a disaster.”

Taking a ProactiveApproach to UtilitiesManagement

As previously mentioned, compliance with this standardrequires organizations to carefullyexamine what utility systems they willneed during an emergency and deter-mine how they will provide those systems. “Many health care organiza-tions have not done a complete analy-sis of which utility systems they willneed during an emergency, particular-ly during a protracted one,” saysGervais. “Without such planning,organizations may be in for some

unpleasant surprises during emer-gency situations.”

Advance planning not only helpsavoid surprises, it also allows anorganization to make effective deci-sions about evacuation. “Utility sys-tems can be a driver in determiningwhether an organization can stay inits facility during an emergency orneeds to evacuate,” says Gervais. “Ifthe organization has done some goodadvance planning, organization leaders can make well-thought-outdecisions about evacuation and ensurethe best possible care for theirpatients.” EC

NEWS

Function 5: UtilitiesManagement (continued)Continued from page 8

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Environment of Care News http://www.jcrinc.com10 November 2009

different pictures, whereas for patientsthese two were highly correlated. Thisindicates that designers may prioritizeaesthetics at the cost of the emotionalwell-being of patients and reinforces theimportance of rigorous research toinform decisions on art selection forhospitals.

Nanda states that the maxim “first,do no harm” holds true for art selectionin health care environments because ofthe vulnerability of patients and care-givers. Research by Roger Ulric et al.6

showed that viewing abstract art withangular forms worsened outcomes inintensive care unit patients recoveringfrom surgery. In a recent study withpsychiatric patients, Nanda and her col-league Sarajane Eisen, M.D.,7 foundthat on days that an abstract art pieceby a renowned artist was displayed onthe walls, there was an increase in thePRN medication requested, as com-pared to days when a realistic natureimage following the guidelines was dis-played. A previous study by Ulrich8

shared anecdotal reports of an increasein aggressive behavior in a psychiatricward in response to abstract art pieces.More research is warranted before thefinal word is given on abstract art,including considerations of elementssuch as color, composition, forms, andso on. However, designers must be cau-tious about selecting art for hospitalsbased on personal preference or pureaesthetic merit. Nanda reminds us ofthe major differences in the emotionalstates of someone visiting a museumversus a patient anxiously awaiting aprocedure or recovering from an ail-ment or a hardworking caregiver whodeals with life and death each day.

Nanda believes that, in the currenteconomic environment, a strong busi-ness case can be made for an evidence-based approach to art. A landmarkstudy by Ulrich in 19849 showed thatmerely viewing nature from the windowsignificantly reduced the length of stayof patients. The reduction in PRNmedication previously mentioned alsohas a financial implication. Reducedpatient anxiety and stress affect the timeand success of procedures and the over-

all productivity of staff, which in turntranslate directly into cost savings.

A post-occupancy evaluation of anevidence-based art program at M.D.Anderson Cancer Center in Houston,Texas, showed that the artwork con-tributed to the patients’ perception ofthe overall quality of care, which in turnhas significant financial ramifications.

Selecting and Placing Art

To maximize the impact of art,designers and art consultants mustselect and place it carefully. The follow-ing aspects of art discussed in the whitepaper by Hathorn and Nanda areimportant in healing environments3:■ The location of artwork. Locate the

artwork where it will be the mosteffective in enhancing the physicalenvironment and developing a heal-ing atmosphere.

■ The patient’s sightlines. Considerthe patient’s sightlines when placingart in hospital rooms. For example,mammography is done one side at atime, and patients are repositionedaccordingly. This creates limitationsin the lines of sight. Two differentworks of art should be displayed, onefor each line of view.

■ The needs of special patient popu-lations. Evaluate the unique needs ofthe kind of patients who will viewthe artwork. For example, art forpediatrics may differ from art for pal-liative care.

■ The role of demographics in thehealing environment. Consider theethnic, gender, and age makeup ofthe health care population in a givenlocation and choose art accordingly.

The Art BudgetRealistically, a budget for art should

be a line item in the construction budg-et. In the past, hospitals could rely onfunds from operating budgets or fromdonations, but not today. Hathorn andNanda’s rule of thumb for an adequate

Art in Health Care(continued)Continued from page 3

Artwork at St Luke’s Community Medical Center, The Woodlands, Texas

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budget is generally between $1 and $3per gross square foot, or 0.5% to 1% ofthe total construction budget. Items thatare typically covered in an art budgetinclude art, framing and display, instal-lation, specialty lighting, plaques, assetmanagement tools, and consulting fees.“It’s important to create a hierarchyearly in the program developmentprocess in order to set and maintain pri-orities for art in the facility,” saysHathorn. “This hierarchy shouldinclude all art locations and quantitiesand the medium or media consideredappropriate for each area of the facility.”

Forming an ArtCommittee

According to Hathorn, an art com-mittee should be formed early in thedesign and construction process so thatthe organization can bring an art con-sultant on board. This allows an artprogram to be coordinated seamlesslywith the architecture and interiordesign and enables it to focus on factorssuch as art placement, art in architec-ture, lighting, structural needs, wayfind-ing, and so on. The art committee andthe art consultant are also responsiblefor fostering good will, creating positivepublic relations throughout the com-munity, and capitalizing on fund-raisingopportunities.

A group of 5 to 10 people allowsfor fair representation of a cross-sectionof the entire facility. The most effec-tive committees include membersfrom a number of hospital depart-ments, along with representativesfrom the community.

Under the guidance of a knowl-edgeable and experienced art consultantand a dedicated and inspired art com-mittee, evidence-based visual art canenhance the beauty of the healing envi-ronment as it positively affects the well-being of patients and staff.

Editor’s Note: The full text of the white paper “A

Guide to Evidence-Based Art” by Kathy

Hathorn, M.A., and Upali Nanda, Ph.D., a

source document for this article, can be found at

http://www.healthdesign.org/advocacy/adgroups/

documents/Hathorn_Nanda_Mar08_001.pdf .

References1. Harris P.B., McBride G., Ross C., Curtis L.: A

place to heal: Environmental sources of satisfac-tion among hospital patients. Journal of AppliedSocial Psychology 32:1276–1299, Jun. 2002.

2. Wikoff N.: Cultures of Care: A Study of ArtsPrograms in U.S. Hospitals. Washington, DC:Americans for the Arts, 2004.

3. Hathorn K., Nanda U.: A Guide to Evidence-Based Art, 2008. http://www.healthdesign.org/advocacy/adgroups/documents/Hathorn_Nanda_Mar08_001.pdf.

4. Nightingale F.: Notes on Nursing: What It Is, andWhat It Is Not, 1860. http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html.

5. Nanda U., Eisen S., Baladandayuthapani V.:

Undertaking an art survey to compare patientversus student art preferences. Environment andBehavior, 40(2):269–301, 2008.

6. Ulrich R.S., Lundén O., Eltinge J.L.: Effects ofExposure to Nature and Abstract Pictures onPatients Recovering from Heart Surgery. Paperpresented at the Thirty-Third Meetings of theSociety for Psychophysiological Research,Rottach-Egern, Germany . Abstract published inPsychophysiology 30(1):7, 1993.

7. Eisen S.J., Nanda U.: Effect of Art onPsychiatric Patients. Paper presented at theSociety of Arts in Healthcare, Buffalo, Apr.22–25, 2009.

8. Effects of Hospital Environments on Patient Well-being. Research report from the Department ofPsychiatry and Behavioral Medicine, Universityof Trodheim, Norway, 9(55):1–13, 1986 .

9. Ulrich R.: View through a window may influ-ence recovery from surgery. Science224:420–421, Apr. 27, 1984.

10.Nanda U.: Laguna Honda Art Survey: ResearchReport. Paper presented at the Society of Arts inHealth Care, 2008 .

ECNEWS

Artwork at Sacred Heart Medical Center at RiverBend, Eugene, Oregon

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