DANI KOLKER FINAL DOCUMENTATION ARCH 600 - EVIDENCE BASED DESIGN IN HEALTHCARE FACILITIES PROFESSOR - HUI CAI
SEATTLE CHILDREN'S HOSPITAL - PSYCHIATRY AND BEHAVIORAL MEDICINE UNIT | CASE STUDY AIA Academy of Architecture for Health | Research Initatives Committee
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Literature Review
Pediatric Inpatient Facility Design INTRODUCTION A pediatric inpatient behavioral healthcare facility, also known as a psychiatric ward or mental health institution, are hospitals specializing in the treatment of serious mental disorders, such as anxiety, addiction, major depression disorder, schizophrenia and bipolar disorder. Pediatric inpatient settings involve an overnight or longer stay in a psychiatric hospital or a psychiatric unit of a general hospital. The design of pediatric psychiatric hospitals can be organized in various ways. Mental and behavioral healthcare facilities have unique requirements, most of which are a balance of creating a space that is extremely safe, welcoming, healing and comforting. According to Youth.gov, “about 49.5% of youth in the unites states have mental health diagnoses that require treatment. Significant numbers of adolescents receive inpatient psychiatric services, yet little is known about their particular experiences (Moses, 2011). Previous research on adolescent satisfaction of inpatient services has often relied on the responses of doctors, nurses and families. It is hard to determine to what extent the reporting accurately represents the satisfaction levels of youth themselves, with developing research telling wide discrepancies. In order to make contributions to the emerging body of knowledge in Evidence-based Design, I conducted a literature review regarding all user’s perceptions of inpatient psychiatric healthcare facility design and the impact it has on children with a behavioral health diagnosis. Key themes that emerged included perceptions of natural light/nature, colors, furniture, ward atmosphere and space. The following are my findings from the literature reviews.
FINDINGS FROM LITERATURE REVIEW The findings from literature review are illustrated by 5 specific categories.
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AIA Academy of Architecture for Health | Research Initatives Committee Literature Review Prepared By: Dani Kolker
Natural light and views of nature from psychiatric ward are shown to improve psychological wellbeing and reduce stress in pediatric inpatients. For this category, research findings illustrate that the incorporation of natural light and views of nature from psychiatric inpatient wards impact human health and performance. Light impacts human health and performance by improving performance of visual tasks, controlling the body’s circadian system, affecting mood and perception, and by enabling critical chemical reactions in the body. Studies showed that higher light levels are linked with better performance of complex visuals tasks. When you control the body’s circadian system, light impacts outcomes in inpatient behavioral healthcare settings by reducing depression among patients, decreasing length of stay in hospitals or psychological wards, improving sleep, improving the circadian rhythm in the human body and easing pain. Along with natural light, incorporation of nature and views of nature from inside pediatric inpatient treatment facilities has shown to have a positive psychological impact on patients. There exists a great amount of literature about this topic. There were two quantitative studies done that evaluate a conceptual model that advocates for nature as a ‘restorative environment’ in its ability to reduce stress, provide a calming effect therefore ‘replenishing our emotional and mental processes’ (Sherman, 2005). There were numerous studies that identified multiple windows with views of nature as a valuable design feature in pediatric inpatient facilities. It is stated that views of nature can reduce psychological distress and recovery time while also enhancing staff functioning and job satisfaction. For children, large and low windows have the ability to improve sensory abilities and reduce delirium and paranoia. Laminated safety glass in group rooms help to open up the interior and can provide a visual connection to the outside. Outdoor gardens and other elements of nature can serve as “positive distractions” to patients. It is also stated that exposure to nature reduces stress and fatigue and can help facilitate recovery (Karlin & Zeiss, 2006). Another study highlighted that children’s needs in respect to a garden may differ depending on both their state of mental health and their age.
Literature Review
Pediatric Inpatient Facility Design mental health and their age. It found that young children, ages four to five years old, seek places where they can run, hide and jump (active play) whereas older children, six to ten years old, requested structured play areas that provide creative things to do (manipulative play) (Sherman, 2005). Lastly, a prospective controlled study of pediatric psychiatric inpatients and non-patient groups have found that viewing nature reduced psychological and physiological stress, while also diminishing anger in persons exposed to anger provoking stressors (Brown, 2013). Overall, it is clear that research on the impact of natural light and nature in pediatric inpatient facility design is shown to have positive psychologic impacts on patients exposed to natural light and nature. The literature was rich in information how bring daylight in and providing views of nature out of behavioral healthcare spaces can be extremely beneficial in the healing process for patients. Color is a powerful tool that can be used to signal action, influence mood and even influence psychological and physiological reactions. Color is another one of the architectural principals for which data is more frequently available than other architectural aspects. There is consistent research on the impact of different colors on psychological health. Several authors recommend the incorporation of colors in the interior design of pediatric inpatient hospitals. Majority of the studies claimed that monochromatic, bland color schemes and fashionable or trendy palettes or pastels should be avoided. Brighter colors may be preferred for patients with depression, but they could be overstimulating for highly agitated patients. Warm blue tones tend to have a soothing or sedating effect, seemingly because of their shorter wavelengths. These are suitable for the calmest areas of the hospitals. Using closely related colors of the same value and intensity also were reported to have a calming effect. A study was done to elicit children and young people’s views on color and thematic design. Three color spectrums were explored: blue-green,
red-pink and orange yellow. Although some children (aged 11 years old) preferred the darkest range of blues and a range of mid, warm yelloworanges, bold pinks, silver and black, overall the mid blue-green colors were the most popular. None of the colors chosen were bright vibrant colors, instead, pale to mid-color ranges were often chosen. This study also looked into themes of rooms or buildings. The general concept of having a theme was popular and choices of themes (such as the sea, nature, animals) were not dependent on gender, but rather age. For example, children aged 3-5 years preferred the sea ‘to be almost cartoon-like’, whilst children aged 6-10 years viewed the sea more as an ‘idyllic holiday scene’ and the adolescent group, aged 11 years and older often viewed the sea more ‘conceptually in waves, patterns, and abstract-like designs” (Coad, 2008). Having themes for buildings or rooms allows children to have a better understanding of spaces and locations. Room themes are a great way to enable wayfinding, which in turn gives children a better sense of independency. Children are very small and sensitive creatures that may react to any stimulant that is created in their environment. Through research done on the topic of color and its impact on children’s psychological state, it is clear that there is sufficient research showing that color can influence both psychological and physiological reactions. Color plays a very important role in the learning and development of children and should be thoroughly thought out when being placed in pediatric inpatient behavioral healthcare facilities. Furniture plays a role in both safety and comfort in inpatient psychiatric facilities and hospitals. Furniture influences virtually every design directive related to patient care, aesthetics, and safety, helping to set the tone for the facility environment. It serves as a major component of the complete design package, which also included carpeting, wall coverings, art and lighting. Historically, healthcare furniture has had more of an institutional feel due to the materials and manufacturing processes that are used to produce it. Each piece usually PEDIATRIC INPATIENT FACILITY DESIGN | LITERATURE REVIEW AIA Academy of Architecture for Health | Research Initatives Committee
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Literature Review
Pediatric Inpatient Facility Design looks the same and, as a result, healthcare furniture gained the stigma of being cold and sterile. Today’s healthcare facility design movements are more towards creating a supportive environment that is both nurturing and comforting to patients and their loved ones. Healthcare facility aesthetics are give a better feeling of comfort and security of a home. This residential design directive brings with it exciting opportunities for creative expression among healthcare facility design and furniture design. Healthcare furniture goes beyond just looks and feel and can have a psychological impact on patients, specifically pediatric patients. One of the most consistent recommendations in all of the bodies of literature on pediatric psychiatric hospital design is the importance of reducing the institutional feel of the facility and incorporating a homelike environment whenever and wherever possible. This type of atmosphere has been associated with enhances emotional and intellectual well-being and improved patient behavior (Karlin & Zeiss, 2006). Uncomfortable furnishings are often described as ‘cold and rock hard’ which is correlates to many as an unfriendly, and therefore anxiety provoking environment (Notron-Westwood, 2011). A lot of research stated that patients rooms should have a familiar tone. The research found that children prefer familiar rooms over very decorative or stylish rooms. Upholstered furniture should be included whenever feasible. Although furniture can be used as a weapon and should therefore not be easy to lift or throw, it should not be too heavy in order to allow for easy movement. Flexible design for interchanging pieces and resistance to damage are also important for longevity of the furniture (Karlin & Zeiss, 2006). Overall, physical environments that display welcoming features and warmth, rather than “hospital” or “prison like” features, provide a nurturing environment to promote the developmental needs of children (Bailey, 2002). This same study states that the use of quality materials and furniture can also help give children a sense of importance, dignity, and acceptance (Bailey, 2002). Although there was not a ton of evidence on this particular category, it is clear that furniture design in pediatric inpatient treatment facilities is
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AIA Academy of Architecture for Health | Research Initatives Committee Literature Review Prepared By: Dani Kolker
an important aspect of design to consider. They way that furniture feels and also how it makes the overall room atmosphere feel is very critical psychologically in making children feel both safe and comfortable. The overall hospital atmosphere and noise can impact the behavior and psychological state of patients. The overall atmosphere of a pediatric inpatient healthcare facility has the ability to impact patients both physiologically and psychologically. There are many factors that can make up the atmosphere of healthcare facilities. Most of the literature that relates to this topic of overall atmosphere focuses on the impact of noise and other sensory things. Noise is an environmental stressor that is known to have behavioral and mental effects. The human body responds to noise in the same way it responds to stress and overtime can impair health. Research shows that hospital noise levels exceed noise level recommendations and has the potential to increase complications in patients. Excessive noise can impact patient’s ability to rest, heal and recover, and has been linked to hospitalization induced stress, increased sensitivity, high blood pressure and poor mental health. According to a Child-Adolescent Mental Health study, sound plays a key role in patients’ treatment. As highly reverbent spaces can play a trigger role, emphasis on quality and properly specified mechanical and electrical systems needs to occur during the design process. With research recommending that environments should avoid echoic spaces, organizations should also avoid spaces such as long corridors, as they can lead to patients’ perceptual distortions (Karlin & Zeiss, 2006). Additional environmental factors such as irritating noise can directly contribute to aggression in adolescents (Dietz & Rada, 1982). Comfortable and inviting environments, whether for treatment or otherwise, engages all the senses – sight, sound, smell, and also touch (Bailey, 2002). Along with noise, air and odor quality can impact patients directly, as both measures often play a role in physical comfort, affecting mental stability. Air quality should include good ventilation with as much exposure to fresh air as possible as
Literature Review
Pediatric Inpatient Facility Design well as maintaining a neutral odor (Karlin & Zeiss, 2006). When a child is ordered to an inpatient mental health treatment program, they are forced to live in a world and atmosphere different than anything they are used to. From the very first step into an inpatient unit, the healing process begins and the environment that surrounds the patient play a very critical role in how they will respond to treatment. There is no one size fits all solution for healthcare design, a successful design for a pediatric psychiatric hospital requires a careful organization of many factors. The spatial layout of a pediatric behavioral healthcare facility should be designed with pediatric behavioral health in mind, as the spatial organization and layout of every room has the ability to impact children psychologically. In addition to children and adolescents psychological and emotional needs when staying at an inpatient treatment facility, research has begun to consider the aspects of the hospital layout and their impact on the patient’s well-being. There were a few themes that appeared in multiple literatures relating to this topic of the spatial organization and over layout design of inpatient behavioral healthcare facilities. A special focus in a few of the studies was put on the organization of the ward to create appropriate assemblies for psychosocial purposes. One study stated that by arranging a psychiatric ward into smaller psychosocial units, there was a reduction in vandalism, stealing and violence in a psychiatric hospital for adolescents (Wilson, 1983). Another important design feature of a psychiatric hospital or unit is maximizing the visual observation of patients from the nurse’s stations. Stephanie Vito, of Cannon Design in Buffalo New York stated that this could be done through a central awareness point. A central awareness point is an area in which a nurse can see every part of the facility from one spot. This allows nurses to always have eyes on all parts of the facility in order to keep everyone safe, while also helping the patients stray away from the feeling of always being watched. Another consideration for design of the nurse stations is that patients tend to gather around it. For this reason,
space should be provided near the nurse’s station for quiet activities such as table games or comfortable seating for reading. Another critical design aspect of behavioral healthcare facility is privacy. Adolescents, who are often at a stage in development where the need for independence and a sense of self is already a struggle, may find any loss of privacy in the hospital even more threatening. Although bedrooms may be classified as designated private spaces in psychiatric facilities, residents are often not allowed free access to bedrooms due to safety concerns. For that reason, it is critical to provide private spaces within facilities are of free use to patients. Gulak’s 1991 article resonated with this finding of adolescent’s desires for private spaces. The need for privacy and sense of personal selfsufficiency is common to all children and adolescents whose minds and bodies are still developing (Csikszentmihalyi & Rochberg-Hlton 1981). Lack of privacy can lead to negative behaviors, especially among adolescents. In Baily’s (2002) literature review, he offers examples of ways to provide children with this sense of privacy while keeping them safe. He states, “Quiet spaces away from the main traffic route, such as window seats or reading nooks, can still provide visual connections with caregivers. Interior glazing and thoughtful lighting provisions can also help patients feel a sense of privacy while maintaining visibility for patient safety” (Thompson 2010). When looking at the layout of behavioral healthcare facilities, it is important to realize that every design decision can have an impact on the pediatric patient. Spaces should be designed keeping in mind that adolescents are still at a developmental phase in their growth process, so they need spaces that allow them to have both privacy and social interactions. Because this is a fairly new type of research, there was not a ton of evidence or case studies on pediatric behavioral healthcare design.
PEDIATRIC INPATIENT FACILITY DESIGN | LITERATURE REVIEWANALYSIS AIA Academy of Architecture for Health | Research Initatives Committee
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Literature Review
Pediatric Inpatient Facility Design THE RELEVANCE OF THE TOPIC The healing characteristics of health care environments is something that has been ignored for a long time. Medicine was seen as a self-sufficient subject in curing the disease. However, new evidence has revealed that other areas, such as hospital design, can also contribute to the healing process. With a growing number of children and adolescents being diagnosed with mental or behavioral health disorders, more and more teams are being called upon to design specialized psychiatric facilities that can treat patients effectively and efficiently.
THE RESEARCH GAP Adolescents are underrepresented in the research on behavioral healthcare design. There are a significant number of adolescents who receive inpatient behavioral health care services, but there lacks decent research and case studies on their personal experiences. The research that does exist about adolescents and their views on how the built environment impacts their behavioral and mental health has strictly relied on responses of other people, like their doctors, nurses and families. It is hard to determine to what extent the research that is out there actually represents what adolescents themselves feel.
THE EXISTING APPROACHES Designing a pediatric inpatient behavioral health facility, unlike a general hospital facility, presents a unique and significant challenge. A successful design for a psychiatric hospital requires careful coordination of a multitude of factors; there is no one size fits all solution. The final design will be unique to the individual facility and its stated goals and philosophies. From my findings in my literature reviews, at the very least, when designing a behavioral healthcare facility, attention should be paid to the following principles:
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AIA Academy of Architecture for Health | Research Initatives Committee Literature Review Prepared By: Dani Kolker
1. Natural Light and Views of Nature 2. Use of Color, Art and Wayfinding 3. Furniture 4. Overall Atmosphere and Noise 5. Spatial and Room Layouts
CONCLUSION Through the literature review, it is obvious that there has been some convincing scientific research done regarding inpatient behavioral healthcare facility design and the impact it has on patients mental and behavioral health, but I think that there is still a lot of research that can be done on the topic. Behavioral healthcare has very unique requirements, most of which involve the balance of creating a space that is extremely welcoming, healing and friendly. As a greater emphasis is placed on mental health treatment and early interventions, this knowledge will allow healthcare organizations to make more informed and confident decisions when creating new environments to provide treatment, leading to better outcomes for patients and their families.
Literature Review
Pediatric Inpatient Facility Design REFERENCES Bailey, K (2002). The role of the physical environment for children in residential care. Residential Treatment for Children and Youth. 20(1), 15-17.
Sherman SA, Varni JW, Roger S. Ulrich, Malcarne V. (2005). Post-occupancy evaluation of healing gardens in a pediatric cancer center. Landscape Urban Plan. 2005;73:167-83.
Brown, J.L. Barton, V.F. (2013). Gladwell Viewing nature scenes positively affects recovery of autonomic function following acute mental stress. Environmental Science & Technology, 47 (2013), pp. 5562-5569
Thompson, J. (2010). Designing for health: Patient and staff safety in behavioral health facilities.
Coad J, Coad N. (2008). Children and young people's preference of thematic design and colour for their hospital environment. J Child Health Care. 2008;12(1):33-48.
Wilson, M. R., Soth, N. & Robak, R. (1983). Managing disturbed behavior by architectural changes: Making space fit the program. Milieu Therapy, III (2), 15–24.
Csikszentmihalyi, M. & Rochberg-Hlton, E. (1981). The meaning of things: Domestic symbols and the self. New York: Cambridge University Press. Dietz, P.E. & Rada, R.T. (1982). Battery incidents and batteries in a maximum security hospital. Archives of General Psychiatry. Gulak M. (1991). Architectural guidelines for state psychiatric hospitals. Hospital Community Psychiatry, 2, 705-707. Karlin, B., & Zeiss, R. (2006). Environmental and therapeutic issues in psychiatric hospital design: Toward best practice. Psychiatric Services 57(10), 1376-1378. Norton-Westwood, Deborah. (2011). The ability of environmental healthcare design strategies to impact event related anxiety in pediatric patients: a comprehensive systematic review. JBI Database of Systematic Reviews and Implementation Reports. Moses, T. Psychiatr Q (2011) 82: 121. https://doi.org/10.1007/s11126-1019151-1.
PEDIATRIC INPATIENT FACILITY DESIGN | LITERATURE REVIEW AIA Academy of Architecture for Health | Research Initatives Committee
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Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA
SQ FT 34,000 SF
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OWNER/AFFILIATION Seattle Children's Hospital
AIA Academy of Architecture for Health | Research Initatives Committee Case Study Prepared By: Dani Kolker & Samantha Eichhorn
ARCHITECT(S) ZGF Architects
Image Sources: ZGF Architects
COMPLETION DATE May 2015
Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA
Family and Visitor Map
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4540 Sand Point Way Springbrook #1 Seattle Children’s Adolescent Medicine Prenatal Clinic
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Site Location
ABOUT | DESIGN INTENTIONS The Seattle Children's Hospital serves the largest population of any pediatric hospital in the nation. The 34,000 SF Psychiatry and Behavioral Medicine Unit (PBMU) split between levels 4 and 5 treats a pediatric population made up of children ages 3 to 18 years who experience complex mental health issues. The design
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team created a space focusing on integrating patient and staff safety into the design with an emphasis of a life-affirming attitude. The process of design development involved a children's leadership and design team that worked together to create an environment that provides for patient population in a positive
way. The program designed creates a variety of space choices that the patients can utilize outside of their in-unit treatment. The goal was to create spaces that provide a nurturing and supportive environment using both natural and playful design elements, rather than being designed strictly for function.
SEATTLE CHILDREN'S HOSPITAL - PSYCHIATRY AND BEHAVIORAL MEDICINE UNIT | CASE STUDY AIA Academy of Architecture for Health | Research Initatives Committee
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Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA
GUIDING PRINCIPLES
LEVEL 4:
DIGNITY AND RESPECT HOPE AND COMPASSION CREATE COMMUNITY OF RESPECT FOR SELF, OTHERS AND THE ENVIRONMENT
DESIGN DRIVERS NORMALIZE THE ENVIRONMENT PROVIDE PATIENTS WITH VARIETY AND CHOICE REMOVE BARRIERS AND GIVE SENSE OF CONTROL APPEAL TO ALL AGES DURABILITY AND MAINTENANCE INFECTION CONTROL PUBLIC AND STAFF SAFETY INTERGATED WAYFINDING SUSTAINABLE DESIGN CELEBRATE BRAND IDENTITY
UNIT DESIGN The inpatient unit on Level 4 houses 16 beds, with bedroom clustered into two pods, one to each side of a central nurses' station, with a seclusion room in proximity. The perimeter zone houses a classroom and group room. Functions located in the inboard side of the floor consist of staff support, a family lounge, counseling offices, and a communal kitchen/dining room
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AIA Academy of Architecture for Health | Research Initatives Committee Case Study Prepared By: Dani Kolker & Samantha Eichhorn
Image Sources: ZGF Architects
Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA
SIZE
LEVEL 5:
PHASE 1 20,300 SF PHASE 2 13,700 SF TOTAL 34,000 SF PHASE 1 BEDS 25 beds PHASE 2 BEDS 16 beds TOTAL BEDS 41 beds
COST CONSTRUCTION $12.3 Million
UNIT DESIGN On level 5, 25 beds are deployed in two configurations: a linear grouping consisting of 8 beds, and in two clusters of four beds positioned to either side of the dayroom/living room/dining space. The beds on this level are arranged nearly the same as those on the level immediately below. Both levels have seclusion and 'chill' spaces. PATIENT CARE MODEL:
Low Acuity.
High Acuity Patients
1. Check in at reception 2. Wait to be called to triage 3. Preliminary screening in triage 4. Patient sent to appropriate trreatment area
1. Arrive in Ambulance 2. Taken directly to trauma bays for treatment
SEATTLE CHILDREN'S HOSPITAL - PSYCHIATRY AND BEHAVIORAL MEDICINE UNIT | CASE STUDY AIA Academy of Architecture for Health | Research Initatives Committee
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Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA RECEPTION
RECEPTION
LIVING ROOM
PATIENT ROOM
DINING ROOM
The welcoming reception area provides a place for parents and caregivers to check in, greet visitors or take a break. Secure storage is provided for items not allowed in the unit.
LIVING ROOM The living room serves as a space for children to hang out with friends and family.
PATIENT ROOM Patient rooms include flexible, damage free, mobile furniture; two beds - one for the atient and one for the parent/ caregiver; a mirror and outlet for grooming; a communication board and locked storage drawer. All rooms have large windows to allow natural light and views to the outdoors. All patient rooms are private, and depending on room orientation, have large windows overlooking either trees, the medical campus, or a nearby neighborhood.
DINING ROOM Warm, natural materials are used to aid in wayfinding and create a calming environment. Image Sources: ZGF Architects
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AIA Academy of Architecture for Health | Research Initatives Committee Case Study Prepared By: Dani Kolker & Samantha Eichhorn
Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA
NURSES STATION
GROUP ROOM
NURSES STATION Views from the nursing station offer a direct line of sight to enhance safety. The nurses' stations are partly shielded in a manner that facilitates direct communication with patients and their families, while not compromising staff safety.
GROUP ROOM The group room is a space for patients to imagine, create and work on coping skills.
REC ROOM REC ROOM
CLASSROOM
Community plays an important role in the healing environment. Wayfinding is enhanced using landmarks in the form of color-accented walls, signage, furnishings, and varied lighting effects.
CLASSROOM ROOM Natural wood paneling; colorful, curvilinear furnishings with rounded edges; and natural light contribute to a significantly deinstitutionalized aesthetic throughout compared to before.
SEATTLE CHILDREN'S HOSPITAL - PSYCHIATRY AND BEHAVIORAL MEDICINE UNIT | CASE STUDY AIA Academy of Architecture for Health | Research Initatives Committee
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Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA DESIGN PLAN The design was completed in two phases, the first of which was completed in the Fall of 2014. This phase features 25 beds, a dining area, comfort rooms, group rooms, a classroom, recreational facilities, and a designated area for the Autism Spectrum Disorders Program. The patient rooms featured large windows that were to optimize natural light in each unit as well as provide views to the outdoors that was intended to maximize healing. The new facility design incorporated natural and warm materials that were intended to connect patients with nature and aid in way finding. The second phase, which opened in the Spring of 2015, included a total of 41 beds on two levels. The central stair served as the connection between the two floors of this particular unit, and provided patients with the freedom to move between the two floors and the ability to access all of the community spaces. The overall goal was designed using Lean strategies that were intended to minimize waste, optimize operational efficiencies, and enhance patientcentered care within a strict budget and an accelerated construction schedule.
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INTEGRATED DESIGN EVENTS
NEW FACILITY FOCUS
The overall design goals were considerate of the hospital function while also still focusing heavily on the function, program, and patient experience. Some primary goals were to minimize waste, improve the staff's efficiency, and patient outcomes. The information gathered to drive the design was taken from four Integrated Design Events that brought together a diverse team of staff, board members, patients, and patient family members to provide the designers with the evidence used to drive their design.
The unit design prior to the renovation was operating at 98% capacity in 2013 and 192% capacity in 2014. This was during a time in which the facility did not support the optimal model of patient care most importantly in terms of privacy. The new facility was intended to create a sense of community that enhances the patient's overall sense of well being while also increasing staff efficiencies.
AIA Academy of Architecture for Health | Research Initatives Committee Case Study Prepared By: Dani Kolker & Samantha Eichhorn
Image Sources: ZGF Architects
Seattle Children's Hospital - Psychiatry and Behavioral Medicine Unit Seattle, WA, USA
DESIGN ACHIEVEMENTS - Increased bed capacity to 41 - Decreased inpatient and staff injuries by 40% - Decreased restraint use by 50% - Decreased building repairs by 50%
Image Sources: ZGF Architects
- Increased family survey results by 50% - Increased staff engagement by 10% These design achievements were established using a lean approach, which is to maximize value while simultaneously minimizing design inefficiencies. Lean planning considers all facility functions while placing an equal focus on function, program and experience. This particular lean approach minimized waste and inefficiencies and maximized patient
outcomes. PROJECT SUMMARY: Project: Seattle Children's Hospital - Psychiatry and Behavioral Medicine unit Project location: Seattle, Washington Owner/Client: Seattle Childrens Hospital Architect: ZGF Architects SEATTLE CHILDREN'S HOSPITAL - PSYCHIATRY AND BEHAVIORAL MEDICINE UNIT | CASE STUDY AIA Academy of Architecture for Health | Research Initatives Committee
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Operational Modeling and Data-Driven Programming Pediatric Inpatient Unit BACKGROUND
TYPICAL SPACES
Jonson County has a total population of 591,178 residents. Of this total population, 27.14 percent are under the age of 20. This provided us with our baseline population of 160,446 residents.
Typical spaces in a pediatric inpatient unit, outside of their patient rooms, include:
Some of the key challenges are related to the set inputs that the program has. One challenge is the fact that the age limit can only be in increments of 5. The typical adolescent age range is 0 - 18, but the progam only allows us to account for ages 0 - 20. Another challenge is that the baseline population input only allows for increments of 100's of thousands. Because the baseline population of adolescents in Johnson County is 160,446 residents, the program creates a margin of error of 40,000 residents, which is 25% of our baseline population.
Patient Care Unit Reception Area - Waiting (160 NSF) - Interview Room (120 NSF) - Public Toilet (60 NSF)
Patient Care Unit Patient Area - Isolation Room (80 NSF) - Seclusion Room (80 NSF) - Exam Room (120 NSF) - Consult Room (120 NSF) - Quiet Room (120 NSF)
Patient Care Social Spaces
- Dining Room (360 NSF + 15 NSF per patient bed greater than 24) - Day Room (675 NSF + 28 NSF per patient bed greater than 24) - Group Room (225 NSF) - Nourishment Station (70 NSF)
Patient Care Unit Operations
- Storage (60 NSF + 2 NSF per patient bed greater than 24) - Laundry Room (90 NSF) - Utility Room - Clean (80 NSF) - Utility Room - Soiled (80 NSF) - Medication Room (80 NSF) - Data & Tele-Communications Room (120 NSF) Information Source: VA Space Planning Criteria
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AIA Academy of Architecture for Health | Research Initatives Committee Space Program Prepared By: Dani Kolker, Samantha Eichhorn and Nadia Laytimi
Operational Modeling and Data-Driven Programming Pediatric Inpatient Unit TYPICAL SPACES Typical spaces in a pediatric inpatient unit, outside of their patient rooms, include: Patient Care Unit Staff and Administrative Area - Nurse Station (300 NSF) - Nurse Workroom (120 NSF) - Conference Room (300 NSF) - On-Call Room (80 NSF) - Head Nurse Office (100 NSF) - Workstations (56 NSF) - Staff Locker Room (80 NSF) - Staff Lounge (80 NSF)
Educational Area
- Office, Residency Program Director (100 NSF) - Team Room (240 NSF) - Training Room, Resident (300 NSF)
SPATIAL RELATIONSHIPS Spatial relationships are extremely critical in pediatric inpatient units. It is important to have the nurses stations positioned in close proximity to the patient rooms, shared support spaces and dining/ activity rooms.
Image Source: VA Space Planning Criteria
OPERATIONAL MODELING AND DATA-DRIVEN PROGRAMMING | ANALYSIS AIA Academy of Architecture for Health | Research Initatives Committee
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Operational Modeling and Data-Driven Programming Pediatric Inpatient Unit
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CASE 1
CASE 2
CASE 3
INPUTS
INPUTS
INPUTS
Baseline Population: 200,000 Market Access : 15% Anual Days of Operation: 365 Optimum Utilization : 85%
Baseline Population: 200,000 Market Access : 20% Anual Days of Operation: 365 Optimum Utilization : 85%
Baseline Population: 200,000 Market Access : 25% Anual Days of Operation: 365 Optimum Utilization : 85%
Service Line: Mental Health
Service Line: Mental Health
Service Line: Mental Health
Inpatient Unit
Inpatient Unit
Inpatient Unit
For the state of Kansas, in the year 2025, the catchment area is to have a population of 200,000. With a targeted market access of 15%, the target population is 30,000. The facility is to cater to all genders between ages of 0 to 19 years and is to be operational for 365 days in a year with a target utilization of 85%.
For the state of Kansas, in the year 2025, the catchment area is to have a population of 200,000. With a targeted market access of 20%, the target population is 40,000. The facility is to cater to all genders between ages of 0 to 19 years and is to be operational for 365 days in a year with a target utilization of 85%.
For the state of Kansas, in the year 2025, the catchment area is to have a population of 200,000. With a targeted market access of 25%, the target population is 50,000. The facility is to cater to all genders between ages of 0 to 19 years and is to be operational for 365 days in a year with a target utilization of 85%.
RESULTS
RESULTS
RESULTS
Psych Patient Bed - 1 Bed: 16 Psych Patient Bed - 2 Bed: 4
Psych Patient Bed - 1 Bed: 21 Psych Patient Bed - 2 Bed: 5
Psych Patient Bed - 1 Bed: 26 Psych Patient Bed - 2 Bed: 6
Total Beds: 24 Beds
Total Beds: 31 Beds
Total Beds: 38 Beds
AIA Academy of Architecture for Health | Research Initatives Committee Space Program Prepared By: Dani Kolker, Samantha Eichhorn and Nadia Laytimi
Operational Modeling and Data-Driven Programming Pediatric Inpatient Unit
CASE 1 SPACE PROGRAM Program Spaces
Patient Bed - 1 Bed Patient Bed - 2 Beds Reception Dining Room Group Room Day Room Nurse Station Isolation Room Exam Room Conference Room Consult Room Storage Data and Tele-Com.
PATEINT BED - 1 BED
Area (SF) Required key driver count Total area required (SF) 200 300 160 360 225 675 300 80 120 300 120 60 120
16 4 1 1 1 1 1 1 1 1 1 1 1
3200 1200 160 360 225 675 300 80 120 300 120 60 120
PATEINT BED - 2 BEDS OPERATIONAL MODELING AND DATA-DRIVEN PROGRAMMING | ANALYSIS AIA Academy of Architecture for Health | Research Initatives Committee
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Post-Occupancy Evaluation Research Proposal TOPIC
BACKGROUND
The impact of wayfinding in pediatric inpatient unit's on patient’s stress and experience.
Mental health is a silent killer. It is hard to come to terms with, especially among children and adolescents. About 75% of mental illness appears before the age of 24, and left unaddressed, can heave a substantial negative effect on the healthcare system and society at large. Behavioral healthcare facilities themselves are extremely important healing environments. Facilities are increasing recognizing how difficult and challenging it can be for patients and visitors to find their way around the facility, and the impact this can have on patient stress and experience. Multiple aspects of wayfinding systems – signs, maps, terms, site, floor layout – can all influence how a patient feels within a space. The motivation for this study is to look at how these wayfinding design features impact patient’s psychological well-being and enhance the feeling of home, safety and healing.
ABSTRACT Where am I? What can I do here? Where can I go from here? How do I get out of here? Consciously or not, we ask these questions everyday as we navigate places and spaces of our lives. The term wayfinding refers to what people perceive, what they think about, and what they do to find their way from one place to another. Wayfinding involves five deceptively simple steps: knowing where you are, knowing your destination, knowing and following an effective route to your destination, recognizing your destination upon arrival, and finding your way back or on to your next destination (Carpman, 1991). Unfortunately, many healthcare environments are not designed for easy navigation by unfamiliar patients, visitors, and staff. Healthcare settings are large, complex environments that for many are visited infrequently, and often in times of physical or emotional stress. In particular, designing an inpatient behavioral healthcare facility for pediatrics is challenging. The goal is to create an environment that reduces stress, promotes healing, feels like home and encourages a sense of normalcy. There are numerous wayfinding factors which influence these conditions including floor layouts, signs and colors. In their book published in 1992, Wayfinding: People, Signs, and Architecture, authors Paul Arthur and Romedi Passini concluded that good wayfinding designs not only are instrumental in helping people navigate built environments with ease, but that they actually promote good health. Their reasoning was that well designed systems provide patients and visitors with the kind of control and empowerment that is necessary in reducing anxiety and fear, stressors that prevent healing. My research will explore how wayfinding in pediatric inpatient behavioral healthcare facilities impacts patients stress and experience.
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AIA Academy of Architecture for Health | Research Initatives Committee Research Proposal By: Dani Kolker
LITERATURE REVIEW Currently, there is very minimal evidence that links wayfinding in pediatric inpatient behavioral health care units to the level of stress and overall experience of patients. Mental and behavioral healthcare facilities have unique requirements, most of which are a balance of creating a space that is extremely safe, welcoming, healing and comforting. According to Youth.gov, “about 49.5% of youth in the unites states have mental health diagnoses that require treatment. Significant numbers of adolescents receive inpatient psychiatric services, yet little is known about their particular experiences (Moses, 2011). Previous research on adolescent satisfaction of inpatient services has often relied on the responses of doctors, nurses and families. It is hard to determine to what extent the reporting accurately represents the satisfaction levels of youth themselves, with developing research telling wide discrepancies. Specific to wayfinding in behavioral health settings, most of the existing data relates to how staff and visitors perceive things, not the patients.
Post-Occupancy Evaluation Research Proposal
In order to make contributions to the emerging body of knowledge in Evidence-based Design, I conducted a literature review regarding all user’s perceptions of wayfinding in pediatric inpatient behavioral health care facility design. Overall, the healthcare-built environment plays a distinct and complementary role in defining patient satisfaction and wellbeing, in addition to affecting other health-related outcomes such as length of stay, pain, medication intake, and stress (Huisman, 2012). Other key themes that emerged included perceptions of spatial layout, degree of differentiation and degree of visual access. One characteristic that is likely to affect wayfinding is complexity of spatial layout. This variable is difficult to define concisely, but it is related to the building/unit size, the number of possible destinations and routes within a unit, and whether the routes intersect at right angles or not. A simple layout should facilitate both the formation and execution of travel plans by making it easier to choose destinations and routes, to maintain orientation, and to learn about the environment (Evans, 1984). A simple layout can also increase the possibility of creating good visual access. According to one study, stress brought about by disorientation may lead to anger, hostility, discomfort, indignation, or even panic. Disorientation felt by those visiting a facility may surface as a generalized hostility toward the organization (Berkeley, 1973). Another key characteristic of wayfinding is the degree of differentiation. This is the degree to which different parts of an environment look the same or different and can affect people’s ability to recognize places. In turn, this can affect both newcomers an more experiences user’s spatial orientation and wayfinding in a particular environment. Differentiation can be achieved by varying size, form, or architectural style. (Evans, 1984). When different parts of an environment are clearly differentiated from one another by any or several of these means, spatial orientation and wayfinding will be enhanced.
Lastly, degree of visual access can aid in wayfinding. This variable refers to the extent to which different parts of the unit can be seen from other parts. Both recognition and the localization of distant destinations should be enhanced if parts of the environment are visible from many vantage points. Empirical evidence indicating that visual access facilitates spatial orientation and wayfinding is available (Garling, 1983). Generally, wayfinding is the process of solving spatial problems while navigating from one point to another. It encompasses 3 mental operations: information processing, decision making, and decision execution (AbuGhazzeh, 1996). The process is facilitated through occupant’s mental perception and cognition, which are in relation to perceptions of spatial layout, degree of differentiation and degree of visual access. Overall, stress brought about by disorientation may lead to anger, hostility, discomfort, indignation, or even panic. The implementation of wayfinding can help lower these feelings of disorientation, in turn lowering stress levels in building occupants. Although there is information and data on wayfinding, there lacks data on the adolescent age range in relation to wayfinding and the impact it can have on adolescent patients psychologically.
BEST PRACTICE ANALYSIS The Seattle Children's Hospital serves the largest population of any pediatric hospital in the nation. The 34,000 SF Psychiatry and Behavioral Medicine Unit (PBMU) split between levels 4 and 5 treats a pediatric population made up of children ages 3 to 18 years who experience complex mental health issues. The design team created a space focusing on integrating patient and staff safety into the design with an emphasis of a life-affirming attitude. The process of design development involved a children's leadership and design team that worked together to create an environment that provides for patient population in a positive way. The
POST-OCCUPANCY EVALUATION | RESEARCH PROPOSAL AIA Academy of Architecture for Health | Research Initatives Committee
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Post-Occupancy Evaluation Research Proposal
program designed creates a variety of space choices that the patients can utilize outside of their in-unit treatment. The goal was to create spaces that provide a nurturing and supportive environment using both natural and playful design elements, rather than being designed strictly for function. As it pertains to wayfinding and patient experience, some of the main design drivers in this program include: normalize the environment, provide patients with variety and choice, remove barriers and give sense of control, appeal to all ages, durability and maintenance, infection control, public and staff safety, integrated wayfinding, sustainable design and celebrate brand identity. Wayfinding is enhanced using landmarks in the form of color-accented walls, signage, furnishings, and varied lighting effects. Warm, natural materials are used to aid in wayfinding and create a calming environment.
Interviews Staff, visitor and patient interviews will be conducted through in person interviews, and survey interviews to asses wayfinding experiences related to locating destinations within the unit, entrances, signs, and direction. Staff interviews will assess involvement in giving directions to visitors and patients, how that involvement relates to work commitments, and ideas of wayfinding improvements. Staff from different shifts (day/night) will be interviewed to get a variety of feedback. The visitor interview will test wayfinding experiences related to locating different destinations within the units. Patients wills be interviewed to evaluate their ability to travel throughout the unit comfortably and confidently. It will assess how well they can figure out how to make their way around the unit without the help of staff.
RESEARCH QUESTIONS
Observation of Behavior Over a couple day or week period, researchers will spend time inside the hospital to observe the behavior of staff and patients. These observations will provide an estimate of traffic flow and space utilization throughout the unit. Patients of different stays will be observed to determine the use of wayfinding aids upon entering the unit and upon a long stay at the unit. Observations will also be taken of visitors who enter the unit to identify what wayfinding aids are used within the unit and if they aid in helping visitors find their way around. Data gathered through behavior mapping demonstrates which spaces in the unit are visited most. Spaces with better wayfinding will be used most, as it is easier for patients to find and utilize them.
This research will explore how wayfinding in pediatric inpatient behavioral healthcare facilities impacts patients stress and experience. The age group of adolescents in inpatient facilities is not explored and should be researched to find out how the use and implication of wayfinding designs can affect adolescents psychologically and encourage healing and wellbeing.
RESEARCH METHODS The research data will be collected through a mix of qualitative and quantitative techniques. Literature Review The literature review shall be conducted to provide a historic platform and insight into research on wayfinding in a pediatric inpatient behavioral healthcare setting.
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AIA Academy of Architecture for Health | Research Initatives Committee Research Proposal By: Dani Kolker
Cognitive Maps As a part of daily activities, children will be asked to draw maps showing the route from different spaces in the unit t their own patient rooms. Cognitive maps are known to be limited by the drawing skill of the mapmaker but may provide useful vehicles for revealing where images of places are unclear or distorted.
Post-Occupancy Evaluation Research Proposal
Space Syntax Legibility of spaces is influenced by the degree of visual access. In space syntax, visual information is described as, “the set of all points visible from a given vantage point in space”. A space syntax study can be done to give a visualization of what spaces have a higher relationship to visibility. Occupants are more likely to find destinations that are visible, so using space syntax can measure what spaces have the highest visibility and therefore the highest occupancy and usage.
EXPECTED OUTCOMES The expected outcomes of this study include a better understanding of the impact that wayfinding in pediatric inpatient units has on patient’s stress levels and overall experience. It is expected that wayfinding in this setting will have an overall positive impact on lowering patient stress and increasing the overall patient experience. In turn, this will lead to faster recovery and the total length of stay at the facility will be reduced.
TIMELINE Phase one of this study will consist of collecting previous studies done on wayfinding in pediatric inpatient behavioral health care settings to find relevant and historic research on the implementation of wayfinding in these settings and results of impact on patient psychiatric health. Phase two of the study will allow the professionals to familiarize themselves with the facility through a site visit that will take around one- or twodays in total. Phase three will involve the data collecting part of the study. Research professionals will take part in in-person interviews with both staff and patients to gain knowledge about their experience and feelings towards wayfinding in the unit. Along with in-person interviews, surveys will be given to gain even more information. Research professionals will then spend two to three weeks in the unit observing behavior. Patients will also participate in cognitive mapping exercises. Overall, these three phases will take a total of approximately 12 weeks.
BIBLIOGRPAHY Bowers, D, & Stewart, C. (2011). Impatient violence and aggression: A literature Review. Report from the conflict and containment reduction research program. Institute of Psychiatry, Kings College London.
ANTICIPATED CHALLENGES AND LIMITATIONS Some anticipate challenges and limitations are accuracy of data collected. Because most of the data that is needed to answer this research question relies on adolescents 18 years old or under, there is room for error in level of honesty. Incentives can be given to patients who complete these interviews or surveys to encourage them to answer the questions as accurately as possible. Another limitation is the amount of data needed in behavior mapping. In order to get more consistent and accurate data, behavior will need to be mapped over a long period of time and at different times of the day. This will ensure that the data obtained from mapping provides research professionals with precise and truthful information.
Chapman, J. (1991). Design That Cares: Planning Health Facilities for Patients and Visitors. J-B AHA Press. Book 142 Brown, B., Wright, H., & Brown, C. (1997). A Post Occupancy Evaluation of Wayfinding in Pediatric Hospital: Research Findings and Implications for Instruction. Journal of Architectural and Planning Research,14(1), 35-51. Retrieved from www.jstor.org/stable/43029243 Evans GW, Skorpanich MA, Gärling T, Bryant KJ, Bresolin B (1984) Effects of stress, path configuration, and landmarks on urban cognition. Journal of Environmental Psychology. Gärling T, Lindberg E, Mäntylä T (1983) Orientation in buildings: Effects of familiarity, visual access, and orientation aids. Journal of Applied Psychology. Garling, T., Book, A., & Lindberg, E. (1986). Spatial Orientation and Wayfinding in the Designed Environment: A Conceptual Analysis and Some Suggestions for Post Occupancy Evaluation. Journal of Architectural and Planning Research, 3(1), 55-64. Retrieved from www.jstor.org/stable/43028787 Huisman, E.R.C.M., Morales, E., Vam Hoof, J., & Kort, H.S.M. (2012). Healing
POST-OCCUPANCY EVALUATION | RESEARCH PROPOSAL AIA Academy of Architecture for Health | Research Initatives Committee
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