Healthforward report by HFR Design

2008 - 2015

A QUARTERLY PUBLICATION FROM THE HEALTHCARE DIVISION OF

WWW.HFRDESIGN.COM

healthforward report HFR Perspectives on Health, Healthcare Division Newsletter Vol. 8, #1

New Year, New Beginnings by Ron Franks, President/CEO, HFR Design Part of the legacy of HFR Design is our ability to embrace change and to allow it to refine who we are as a company. 2014 marked our 104th year, and it has been a monumental year for our firm. It’s a year that has brought many changes for HFR: a new office location and company branding, as well as additions to stockholders and staff. We’ve seen an upturn in the economy, including the healthcare industry, and we look forward to seeing continued growth at a national level in 2015. New projects in Illinois include two memory care facilities, a medical/professional building and a freestanding emergency center that includes outpatient support services. In looking forward to the next century of HFR Design, the decision was made to relocate our headquarters and to rebrand the company. Though still based just outside Nashville, TN in Brentwood, the new HFR offices are better suited to staffing and workflow needs. Our new image is clean and straightforward, and makes impactful use of color by utilizing elemental tones of cyan and lime as highlights to slate grey. In modernizing the look and feel of our logo, we have renewed our commitment to produce state-of-the-art, solution-based, comprehensive work while maintaining meaningful client relationships. In October, HFR expanded ownership with the addition of three new stockholders: John Coke, AIA; Martin Franks, AIA; and Don Pierce, AIA. Mr. Coke has over

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20 years of architectural experience, and since joining HFR in 2005 has acted as a project manager on numerous Middle Tennessee engagements, specializing in healthcare, laboratory design and senior housing. Mr. Franks joined HFR in 2007, and has acted as both a project manager and building information (BIM) speR. Franks cialist on several national healthcare contracts. He concentrates on healthcare design and planning for projects that range from small renovations to multi-million dollar replacement facilities. Mr. Pierce, manager of HFR Kansas City, joined the firm in 2000. He has 30 years of architectural experience coupled with an extensive knowledge of the construction industry which allows him to produce enhanced design with an efficient and effective pre- and post-construction approach. These three men have proven their dedication to the success of our firm and continually work towards ground-breaking solutions for our clients. At HFR Design, 2015 brings a renewed focus on the pinnacles of our company — communication, adaptability, technology, integrity, and people. This focus directly relates to the healthcare industry, where trends continually point towards a balance of technology and patientoriented care. A recent project we completed was the design of a state-of-the-art oncology suite as a part of a multi-practice health center. The focus of this project

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THIS ISSUE ... • New Year, New Beginnings • Disruptive Thinking Inside Creative Healthcare Planning • Legislative Value: Advanced Planning and Design for Communities of Tomorrow Copyright (c) 2015 HFR Design, Inc.

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Disruptive Thinking Inside Creative Healthcare Planning by Tom Testerman, NCARB, ACHA, Director of Planning, HFR Design It seems to me that one of the most significant impacts of healthcare reform in our role as planners, programmers and designers is how we rethink our traditional approach to professional services. Historically, we have filled the role of intensive listeners and facilitators to allow our clients to realize their vision Testerman through the talents and skills we bring to a project built around a growth and market share model. There is no argument that listening facilitates understanding and understanding contributes to knowledge. With knowledge and understanding we can offer better results with predictable outcomes. However, if we continue along this track our results are likely to be the same in an environment of rapid change and transformation that demands a fresh approach centered on value. I was enlightened by two recent events. One was an article written by the AB about the evolving role of hospital COOs, and the second was the ACHA conference which explored the three (3) challenges for healthcare architects and designers. The first article described the shift in emphasis of the role of the COO from one of revenue enhancement opportunities to cost shifting/reduction necessities (value based vs. volume based). The second addressed the following three topics: â&#x20AC;˘ Making capital go further â&#x20AC;˘ Creating healthcare settings that produce value â&#x20AC;˘ Creating facilities that deliver meaningful relationships This shifting environment would suggest that not only do we need to be listeners/advocates and facilitators, but perhaps more importantly, we need to be contrarians, challengers and disruptors. This evolving role moves us closer to exploring alternatives and options that otherwise might not be considered and examined. We can already see examples of this disruption in a myriad of different settings. In healthcare, the retail outlets and retail consumer, transparency in payment models, value-based purchasing, clinical integration, big data for analytical feedback that will be the engine to drive new processes and deliver better outcomes. In the area of technology, there is no argument that significant changes are occurring with mobile health applications and diagnostic tools. There are also, within our industry, major game changers with BIM/VDC leading the way for complex analysis of phasing, staging, 2

prefabrication, scheduling and sequencing of construction/ reconstruction work. We now are assimilating convincing case studies to support many of the hypotheses around leveraging technology to provide measurable results and with improved performance metrics. The demands to reduce spending are demonstrated through more emphasis on such things as retro commissioning where we can explore opportunities to improve efficiency, reduce consumption, shorten payback cycle, and trim operating costs. The pace at which this change is occurring will no doubt necessitate transformative thinking and collaborative engagement to seek the highest and best opportunities and leverage the collective wisdom of the larger brain trust that transverses across a wide swath of industry expertise. Effective Planning is Population and Needs Based and When Conducted Effectively, Provides Opportunities for Innovative Change

Legislative Value: Advanced Planning and Design for Communities of Tomorrow - Part I by James G. Easter, FAAMA, MArch, Development Consultant and Joseph J. Hylak-Reinholtz, JD, Attorney The politics of planning has been a topic of interest to many, particularly those of us involved in the rapidly evolving healthcare industry. At a minimum, persons considering a new healthcare construction or modernization project must consider how certificate of need (CON) laws have evolved, the impact a Community Health Needs Assessments (CHNA) might have on the project, and the political implications of lobbying efforts and how the enactment of new laws could impact facility design or the way health care services are rendered. Health care facility planners must also consider, from the onset of a project, how the project’s scope might evolve from the first stage of demonstrating project need, through the CON and licensure application stages, and ultimately the final stage — the operation of the new health care facility. When healthcare-related buildings are constructed or modernized without completing an adequate CHNA, they are often placed in the wrong location, developed without an adequate vision and mission, and typically not packaged with a solid business plan in mind. An adequate CHNA must contemplate the needs of communities with unmet healthcare needs and underserved population groups and consider how a project will affect people living within the project’s service area. If done correctly, the project can open the door to effective gentrification of the community and change the dynamics of the community for generations. Ultimately, planners must consider the current trend toward population-based service delivery, a method which is timely and complementary to improving business practices in the healthcare sector.

Understand the Healthcare Needs of the Community to be Served — Design Accordingly. Before a planner begins any healthcare construction or modernization project, he or she should ensure that they have a complete understanding of the community in which the healthcare facility will be Easter located and the healthcare needs of the people it will serve. The community in question may be a small rural area or an inner city location with similar concerns relating to access to healthcare, but without the means to improve the situation that is presently existing. Access, quality of service, cost of care, and image are key factors to measure along Hylakwith the type and style of care that will be Reinholtz rendered. At the same time, the architecture of change will result in neighborhood and community transformation through urban or rural renewal, new construction and/or building upgrades, and environmental improvements. Gentrification is truly the vision for change that embodies both improved access to healthcare and the economic development we believe can be realized within many communities around the country. Build a Project Team That Understands the Project, the Law, and the Community. Every successful project is rooted with a strong project planning team. From the very beginning the planning team should include, at a minimum, attorneys, consultants, and professionals with extensive experience in the scope of work that they will be responsible for and government relations experts who can address local, state, and federal matters as they arise. The consultants and professionals should be able to provide guidance on project design, financing, reimbursements from government and commercial payors, facility operations, and human resources. Throughout every stage of the project, each member of the team should focus on their given tasks and report to one person identified as the project leader. It is imperative to have experts on the team who thoroughly understand the project and the community it will

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Legislative Value ... (continued from page 3)

serve. An informed policy expert can clarify the legislative agenda, evaluate the national, state, and local situation, and share insights on policies that might enhance the project or clarify how one might draft bills that help fill service and image gaps. Community Health Needs Analysis. The current federal guidelines require that providers of public healthcare services prepare a Community Health Needs Assessment (CHNA) which defines both service needs and methods for filling healthcare service gaps. If there are service needs that have been discontinued or gaps within an underserved population, effective plans will define a path toward filling those gaps. In a recent HFR project, the planning, legal, and design team embarked on a total re-definition of the service plan from inpatient acute care to outpatient, episodic care, and full-service emergency care. The resulting product should equate to improved access to care, better facility design, and happier consumers within a presently underserved community. The completion of the CHNA will typically answer the questions required to meet the needs of the healthcare provider and suggest direction for area-wide affiliations that further enhance the overall project plan. Any partnerships must ensure that they clearly address how the facility’s programs may evolve over time, how services may be adapted to the needs of the local population, and how decision-makers can determine the best course of action for each situation. The CHNA is a thorough report that closely examines the health care needs of people living within a defined service area. The CHNA report will: • Provide an evaluation of the community service area being assessed; • Determine the health needs of the population (compare to other providers); • Administer community survey and capture input/feedback and comment;

• Describe the current health facilities and other resources within the community; • Develop a comprehensive report including the process, analysis, findings, and recommendations for future program expansion; • Clarify ongoing strategies that may link to other providers; and • Define resource limitations and potential roadblocks to effective results. The ability to staff, license, and operate an innovative program is determined by the planning team members and its leader and their ability to structure the operational response to the plan. Staffing is a primary factor as well as the understanding of project’s licensure needs, economic feasibility, and overall program implementation for the market. The ability to adjust to the local situation, establish operational and partnership linkages, and determine the best fit of resource needs to services rendered are critical skills that each team member must possess. (Part II will appear in the next issue of Healthforward)

New Year, New Beginnings ... (continued from page 1)

was the creation of a soothing environment for patients, with attention to natural details and straightforward way finding. As an oncology center, it was imperative that accommodations be made for current and future technology. Medical equipment remains somewhat hidden behind semi-private walls, helping to ease patient stress at check-in. HFR has long welcomed innovation coupled with the art of placing people first, both in design and in company practice. We look forward to the pursuit of these design ideals as we carry on the rich legacy left us by our founders.

Tracing its origins back to 1910, HFR Design continues to enjoy a diverse range of architectural and engineering successes due to an ongoing commitment to customer satisfaction and our collaborative process, which encourages innovative thinking, the sharing of knowledge, and strategic planning. HFR Design offers a broad spectrum of services with technical design expertise in healthcare, commercial, residential, industrial, and parks and recreation. Staffed between three offices in Brentwood, TN, Jackson, TN, and Kansas City, MO, and licensed in over 30 states, HFR’s professional practice of registered architects, planners, interior designers, engineers, and surveyors serve an ever-expanding list of clientele across the U.S. Sammy West Don Pierce, AIA Ron L. Franks, AIA Director, Jackson Office Director, Kansas City Office Director, Brentwood Office swest@hfrdesign.com dpierce@hfrdesign.com rfranks@hfrdesign.com 9237 Ward Parkway, Suite 108 113 N. Liberty Street 214 Centerview Drive, Suite 300 Kansas City, MO 64114 Jackson, TN 38301 Brentwood, TN 37027 (816) 822-8500 (731) 421-8000 615-370-8500

healthforward report HFR Perspectives on Health, Healthcare Division Newsletter Vol. 7, #4

Freestanding Emergency Departments: A Closer Look at the Options by Tom Testerman, NCARB, ACHA, Director of Planning, HFR Design The impact of the Affordable Care Act on emergency services has resulted in the consolidation and closing of a significant number of hospital-based emergency departments creating mergers, acquisitions and network affiliations in recent years. Coupled with this trend is the addition of new emergency department (ED) consumers through the expanding insurance exchanges, the shrinking primary care provider pool and decompression of underperforming hospital based EDs. The need for 24-hour access to urgent and emergent care with more affordable choices in more convenient packaging has opened the door for the development of the freestanding emergency department (FSED). This market response has resulted in the reemergence of the FSED as an expanding option to hospital-based EDs. Initially the FSED was a concept that was launched in the 70s as a model that was designed to serve underdeveloped rural markets. Today, however, the drivers include faster service, better access and the

option of providing the consumer with a choice of care in an upscale patient experience. These are just a few of the things that have separated FSEDs from their traditional hospital-based counterparts. This shifting market has resulted in Testerman FSEDs that have experienced a 65% growth rate since 2006. Information provided by the Advisory Board Company suggests that the FSED represents about 3-5% of hospital admissions with an average length of stay between 60-90 minutes. This trend is in large part due to improved access in fastgrowing, underserved markets with service options that are more streamlined and that mirror most hospitalbased EDs with board-certified emergency trained physicians who are often employed by the sponsoring acute care hospitals. In addition, emergency trained nursing extenders are working closely with physicians and other specialized team members to complement the care delivery model. However, this accelerated growth and expansion raises questions as to their appropriate response to the new market conditions. For the consumer, there can be some confusion between the choice of options offered between a licensed FSED and the less lower acuity options offered through urgent care centers and quick stop clinics in retail and pharmaceutical settings. Considering the annual patient volume of an FSED is typically in the range of 16,000 - 20,000 visits or 35 - 40 patients/day compared to a hospital-based ED, the demographic and market share is more concentrated and focused which drives the facility considerations and strategies to ensure the project performs to business plan. To respond to this market, several hybrid models have emerged including the healthplex or health park which offer a broader base of service offerings. The typical stand-alone ED focuses primarily on urgent and emergency services, with limited lab and imaging

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Design: How It is Measured - Show Me the Evidence James G. Easter Jr., FAAMA, MArch, MArch Healthcare Consultant A number of authors and healthcare specialists have written about the world of evidence-based design. I believe the real evidence comes in phases as architects, engineers, consulting partners, product vendors, builders and, yes, owners prepare for a project. First, the question might be: What type of Easter project does the owner want to built and/or renovate? Is this a new construction project, a renovation, a retrofit of a shopping center or an expansion to an existing building? The evidence, we are told in college — or that we learned through our personal research — begins with the functional programming phase of the engagement. During this predesign phase of development, the architect and/or consulting team member is asked to establish the goals, facts, concepts, needs and clearly identify the issues for the project. The evidence on this topic can be found in the writings of three great architects that this author grew to love during the early years of a robust healthcare specialization practice. The writings of Kirk Hamilton, FAIA, William Caudill, FAIA, and William Pena, FAIA, Founder/Principal of Caudill Rowlett Scott, Inc. (CRS) and author of the book Problem Seeking: An Architectural Programming Primer are noteworthy and invaluable. Mr. Caudill wrote over 1,500 Things I Believe or TIBs and published 217 in the CRSS publication The TIBS of Bill Caudill published in 1984 and still available online. The evidence of all architecture resides in the facts portions of each development phase of a project from predesign programming through final project commissioning and owner occupancy. The more relevant evidence in healthcare architecture resides with the owner and the user of the building in question. This simply means that the facts are assembled (before you start design) and they evolve naturally through the life of the project (accuracy of evidence compilation and comparative assessments is one missing link). How does the evidence impact the ultimate completion of a healthcare project? This is a “moving target” totally contingent upon the context and timing of the answer, for example: A Renovated Healthcare Project Has A History With Much Evidence to Consider: • Age, condition, environmental character, functionality and design character • Size of spaces, location of services, access and egress, code compliance and safety considerations (all the environmental impact and process considerations)

• Infection Control and Risk Analysis (ICRA) Considerations • Functional Use and Future Adaptability to Change and Expansion • Current Performance and Evidence Based Real Time Metrics (Surveys and Simulation) • User Responses to the Spaces and the Existing Conditions • Evidence of Negative or Positive Environmental Impact Issues • Potential Process Changes and Evidence of Opportunity For Improvements • Non-Compliance Evidence (Codes, Standards, Clinical Needs and Consumer Satisfaction Surveys and Findings) A New Healthcare Project Begins With A New Evidence-Based Ranking and Status: • Using the FACTS and Figures obtained in the functional program, evidence defines the direction of the project (a detailed Capacity Analysis must be undertaken). • Using METRICS proven to be reliable through research and publication, CONCEPTS evolve to demonstrate reliable, factual and defendable design recommendations. • Automation (Revit, Onuma, Trelligence, Room-byRoom Programming and Simulation Models) is a primary provider of FACTUAL INFORMATION revealing code complying spaces, ergonomic arrangements, user-based decisions and approved plus tested equipment and systems applications that are adaptable to an environmentally-friendly design product.

Hospitals and airports share some of the same challenges, which obtained evidence and well-planned design can address. continued on page 4

Freestanding Emergency Departments ... (continued from page 1)

capabilities. The typical FSED operates 24 hours a day, 7 days a week with an average of 8-12 beds. On the other end of the spectrum is the health park model, which could include upwards of 15 beds with expanded observation bed options, outpatient imaging services, occupational medicine, physical therapy, rehab services and outpatient surgery services, to name a few potential program enhancements. The opportunity to colocate the FSED in a health park or similar outpatient center with these, and other complementary services, coupled with specialized retail is an option that should be carefully examined and the benefits carefully weighed. This approach could provide a potentially more synergistic solution to the patient experience, including one-stop shopping with proximity to primary care and specialty clinics. This proximity of provider to care center would improve the opportunity for building a larger and more robust referral network. In addition, freestanding emergency departments can potentially provide an effective strategy for a provider to service their market area appropriately with the option to expand upward into a full-service acute care hospital as community needs mature. This approach has been proven effective when the facilities and services are master planned around a solid strategic and operational business plan. There are currently approximately 400-500 FSEDs located in about 16 states. The regulations vary widely by state, as authorities having jurisdiction (AHJs) reconcile license and certification requirements for this delivery care model, further complicating the implementation process. For example, many AHJs view the FSED as an outpatient service under the existing main hospital license; others don’t allow ambulance transfers under any circumstances. It is important to understand these requirements and how they relate to the owner’s operational model. A facility that is strictly an outpatient service, and not under separate license, may be appropriate for an owner who is interested in developing an outpatient health park; but not necessarily a practical means to provide a platform for the development of a future hospital campus. In some cases, this has been an outgrowth of state reviews where the Certificate of Need (CON) programs govern the review and approval process. The 2014 Design Guidelines for Hospitals and Outpatient Facilities has been expanded to include this building type but reference many of the traditional hospital ED functional attributes in the performance guidelines. Program expansion will likely be required to justify community acceptance and longer term need. In addition, several other considerations would include the following:

Facility Considerations: • Ancillary Testing • Heliport Transport Site • Clinical Care Services • Medical Emergencies/Transportation • Hours of Operation • Registrar Work Area Within Treatment Zone • Bedside Registration and Discharge • Urgent/Non Urgent Minor Care • Workflow/Crossover Traffic • After Hours Separate Entrance • Dedicated Walk In/Ambulance Pick Up • Visibility of Caregivers • Pharmacy Fume Hood • Instrument Cleaning/Sterilization • Gyn/Psych/Prisoners/Isolation/Bariatric/ Pediatrics/Geriatrics • Monitored Rooms • Family/Portable Equipment/Universal Room • Offstage/Onstage Zone • Paramedics Backboards/Charting/ Cleaning Equipment • Location/Size Provide for Future Expansion Functional/Operational Programmatic Considerations: • CDU/Observation Decompression Area • Five Functional Zones • Patient Intake • Treatment • Clinical Support • Administrative Support • Building Support • Efficient Staffing Model • EMTALA/Governance • Contracted Services • Specialization and Cross Training • Licensing and Certification • Telemedicine • Technology: Call-Ahead Scheduling/Self Triage • Electronic Health Records • Strategies to Grow Services • Convenient Parking/Entry Point • Heli-Pad Transport Business/Financial Considerations: • Business Plan/ROI/ Salary/Incentive-Based Income/RVUs - Development Lease or Build? - Facility Fee Licensing • Ownership Structure (Hospital/Healthcare System vs. Private Physician/Physician Group and/or Investor Owned) continued on page 4

Design: How It is Measured ... (continued from page 2)

• Applying WORK LOAD DATA based on the evidence of historical use and the contemporary NEEDS ANALYSIS defined in a Community Health Needs Assessment (CHNA), the new project rolls out as workable, cost efficient, high performance and evidence based. • Working carefully within the PROJECT TEAM to carefully analyze, synthesize and compare outcomes to best evaluate design direction and OPTIMUM RESULTS is a preferred approach. At HFR, we believe that contextual design (see Tom Testerman article, Context Centered Design and Functional Programming, Vol. 7, Edition 2, April, 2014) is the best approach to take. The evidence in our world of healthcare architectue is evolving through the design audit trails involving Revit, Onuma and Trelligence software that will help with the benchmark comparisons of design details and outcomes that work effectively, meet standards, and comply with owner and user expectations. It isn’t possible to achieve 100% evidence-based architecture because the owner/client still has the voice of authority on final conceptual approvals and the design architect and engineer have the ability to use persuasion to change time tested + evidence-based methods and design features. We believe the day of the inexperienced healthcare architect is behind us, but there are still projects that begin anew without the benefit of experience, knowledge and true evidential context. Recently the American Institute of Architects (AIA), and the American College of Healthcare Architects (ACHA) hosted national leaders in healthcare at their summer leadership conference in Chicago, IL. Dr. Paul Barach, Principal of J Bara Innovation commented about healthcare environments that produce value: “Once a community normalizes a deviant organizational practice, it’s no longer viewed as an aberrant act that elicits an exceptional response; instead, it becomes a routine activity that is commonly anticipated and frequently used.”

Examples in healthcare might include low compliance in hand washing, safety standards, obesity management, poor acoustical controls, and sound transmission as well as noise reverberation. Despite continuous analysis, product testing and data that offer design-based solutions, Dr. Barach said, “It’s still tough to get clients to pay attention to more evidence-based needs.” He also recognizes the frustration that architects face when value-engineering efforts reduce the incentives for innovation and quality enhancement. In conclusion, we are fortunate to have an active and vibrant quality enhancement effort through the 2014 Edition of the Hospital Design Guidelines for Healthcare and Related Facilities. This document and the evidence provided is the premier tool for better and more reliable evidence-based products.

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• Insurance Contracting • Independent FSED vs. Outpatient ED. All Levels of Care Stabilization/Observation Marketing /Promotional Considerations: • Tailoring the Message • Faster/Convenient/Less Expensive • Aging Population Demographic • Proximity to Physician Offices • Competition/Target Demographic • Population Trends • Cost Escalation/Affordable Lower Cost Options • Referrals/Improve Access to Medical Services Each of these unique challenges are pursued with the ultimate goal of optimizing patient care, while fulfilling the triple aim of healthcare reform - better health, better care and cost containment. Sources: The Advisory Board Company

healthforward report HFR Perspectives on Health, Healthcare Division Newsletter Vol. 7, #3

Health Facilities Can Be A-Maze-ing: What is Wayfinding, Anyway? by Page Onge, AIA, LEED, HFR Design and Janet R. Carpman, PhD, Partner, Carpman Grant Associates, Wayfinding Consultants

HFR Design recently partnered with Carpman Grant Associates, Wayfinding Consultants (CGA) to consider wayfinding issues and related improvements in a large, southeastern hospital. Our first objective was to visit the campus, understand the hospital's goals, and begin discussions relating wayfinding to customer service and patient satisfaction. Some of us remember when hospitals used coloredcoded floor lines to lead patients to their destinations. It doesn't take long to become disoriented in most healthcare facilities. It often starts with arrival at the wrong parking lot, wrong building, or wrong entrance. Once you reach the appropriate lobby or registration area, it only takes a few turns down some nondescript

corridor to start feeling confused about where you are. There is enough stress involved in being a patient or a family member without adding more wayfinding-related anxiety to the mix. Volunteers and considerate staff will often serve as escorts to lead patients and visitors to their destinations. The use of accurate maps, visual cues, logical space planning, clear signage, and even technology will certainly lessen the strain. A comprehensive approach to better wayfinding looks at all these factors and more.

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A dysfunctional wayfinding system results in obvious symptoms: Carpman frustrated patients, late arrivals, missed appointments, and dissatisfaction with the facility as a whole. Unfortunately, poor wayfinding system symptoms are usually treated with "band-aids" — minor corrective measures — rather than comprehensive approaches. When a healthcare facility decides it needs to seek professional treatment for its wayfinding problems, the first step should be to engage an experienced wayfinding consultant. Wayfinding consultants know how to analyze the facilities, circulation routes, signage, patient and visitor wayfinding experiences, managers’ insights, corporate culture and goals, website and on-site directions, staff and volunteers’ wayfinding observations, useful wayfinding technology — and more — and develop a prioritized, pragmatic master plan for wayfinding improvements.

When wayfinding consultants like CGA partner with facility planning specialists like HFR, wayfinding efforts can go even further. In addition to the analyses mentioned above, this specialty team can assess access to the facility from the community, activity volumes which continued on page 4

Project Management in Architecture by John Coke, AIA, CSI-CDT, LEED AP, BD&C, Principal, and James G. Easter Jr., FAAMA, Diplomate In Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design

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The recent presentation to HFR staff on project management (PM) reminded us of its importance in this era of fastpaced design and construction. At HFR — and on healthcare projects in general — the PM represents a vital player in the overall development process. We hear the terms Integrated Project Delivery (IPD) and Building Information Modeling (BIM) and wonder what they have to do with project development.These are the methods and tools we use to complete our work more efficiently, effectively and with a higher level of quality. Time is money and the PM proactively manages both of these resources.

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IPD encourages close attention to both visual and functional details early in the process. IPD involves all the team members — planner, owner, client leadership, users, architectural staff, and contractor — from the onset of the engagement. Some have suggested we might eliminate the Schematic Design (SD) phase and move directly into Design Development (DD) using this approach. Making tough design de-cisions early in the planning and design cycle reduces waste and saves time. The BIM world is here to stay and is grounded in the Revit software which is complemented by both Onuma and Trelligence integrated production software. The 24hour cloud access approach permits convenient access, encourages participation by all stakeholders and minimizes disruptions. Utilizing 3D modeling software we experience improved visual interpretation of space layouts, more accurate programmatic links to summary spread sheets which tie into Revit software. By creating site plans, functionally-integrated space programs, and early master zoning models that link to the building size, room-by-room space needs and service delivery functions we can quickly test budget options and programmatic concepts leading to an affordable project. HFR’s PM approach utilizes these technology tools and manages the most salient aspects of our clients’ development vision. By communicating clearly via telephone, email, Newforma technology and long distance video conferencing we reduce our travel time, expense, and improve communications across the board. We believe the most fundamental attributes of project management include: 2

• Defining the entire project team first and foremost (architect, engineer, consultants, owner, user, equipment/systems, builder/CM, and all agencies having jurisdiction (AHJ) over the project. • Establishing project scope and phasing with an approved functional program. • Confirming the total project budget tied directly to the program. • Preparing a detailed project schedule and phasing plan (day by day, from start to finish). • Conducting regular progress reviews (long distance via Go To Meeting and video linkages). • Project management winning efforts include: - Clarity of project scope, goals and objectives - Standardized owner/architect agreements - Regular electronic minutes with assigned responsibilities - Proactive and timely responsiveness - Availability by all team members (long distance methods preferred) - Clarity of communications and authority - Straight talk with follow-up - A helpful attitude - Truthfulness - Humility - Trust In the final assessment, the best results come from a team of professionals who have a common goal — to complete a quality project on time, maintain the budget, and walk away from the final product feeling that the HFR team exceeded the owners’ expectations. Friendship is built on mutual respect and empathetic understanding. Project management ensures these expectations are met!

Murray-Calloway planning session (photo: Jim Easter).

From Good to Better to Best: A Vision for the Future by Ron Franks, President/CEO, HFR Design Taking the good and making it better … then working a little harder and smarter to make it the best. It’s a simple formula, but it works. It has been the backbone of HFR, allowing it to grow and thrive through the ups and downs of its 104-year history. Communication, adaptability, technology, integrity: hallmarks of a successful company. Important as these are, they are eclipsed by our most valuable resource — our people. HFR has long operated with a family-oriented culture that we strive to maintain. Our future — all of our futures — rely on good people who understand not only their job, but how their role fits within the division and within the company as a whole so we’re all working toward a common goal. With this in mind, communication is key. We’re opening new lines of communication and expanding ones that are already in place. We’ll see more and better intradivision and inter-division understanding.

Adaptability to our fast-moving times is crucial as well. Understanding our strengths, exploring new partnerships, planning creatively and working in unison will give HFR a firm foundation on which to build future business. Integrity can’t be bought. HFR has earned it through its long and rich tradition and we will continue to stress it in the decades to come. Technology is exploding around us daily. Our task is to utilize that which is most beneficial to us and to our clients, yet never losing the all-important human factor … the person-to-person relationships we build with our clients and vendors, even ourselves. We have the rare privilege of welcoming innovation and retaining the best of our distinguished history as HFR makes positive strides into its second century.

From the Advisory Board - Chicago Session by Jim Easter The AB themes of Consumer-oriented Ambulatory Network and the Next-Generation Clinical Integration were superbly presented. Below are the abbreviated Clinical Integration (CI) mandates (paraphrased by the author to suggest a few A/E implications as he sees them): 1. CI on the horizon, systems not adapting well. Architectural implications most likely adaptive assets. 2. CI requiring greater purchaser care value and more risk-based/population-based services. Architecture that helps move assets to convenient locations (master planning). 3. CI leads the transformation via population management (architect must understand this concept). 4. CI requires tighter and more coordinated partnerships and systems (merger mania likely accelerates). 5. CI pressure for system-affiliation to closely link physicians and care partners (growing advanced extender programs while cutting labor budgets to meet primary and urgent care demands). 6. CI carefully assess at-risk populations. Insurance and providers shying away, where manageable, the higher demand consumer groups (chronic disease is more costly to providers). Architecture must take a

moral stand as both designer and business consumer facing potential exclusion as a healthcare consumer. 7. CI demands cost reduction. Architecture must be lean and truly evidence based to survive. 8. CI network membership requires a tailored and accessible product. Creative healthcare design a must to compete on the national stage. 9. CI will re-orient clinical decisions across specialties and care sites. Architecture and planning will respond with better access and more appropriate buildings. Directly relates to clinics, MOBs and free-standing Emergent and Urgent Care programs like the emergenuity model. 10. CI mandates continued IT enhancements, care management via real-time and virtual programs grounded in advanced EMR platforms. Without the system-wide efforts, evidence-based responses will be unreliable. The author is concerned that the capital cost mandates will rule out many providers and create a service delivery debacle. Governmental intervention and capital subsidy will likely be required to meet Medicare and Medicaid compliance and outcome management. Private insurance will find these rigid expectations challenging as well.

Health Facilities Can Be A-Maze-ing ... (continued from page 1)

determine frequency of visit, time travelled, and projected changes in volume over time. Building Information Modeling (BIM) combined with Affinity Trelligence software improve data assimilation and aid in overall building analysis, project pricing, and visual comparisons. After the wayfinding master plan is approved, the next step is to agree on phasing (usually over a few years) and begin detailed planning for a variety of wayfinding elements, such as signs, maps, staff training, and wayfinding maintenance/management. Training architect/engineering partners will be helpful as well, due to their role in site planning, circulation planning, systems, and materials specifications, all of which affect wayfinding. Effective wayfinding makes it easy for everyone — patients, family members, friends, guests, medical and administrative staff, and volunteers — to navigate efficiently. A good wayfinding system includes: • Access to directions and maps on the facility's website and through other technology, including apps. • Signage, cues, and instructions to guide customers to the correct campus, parking lot/garage, building, entrance, registration area, and department. • Reduction of visual clutter. • Landmarks, views, materials, finishes and colors that create memorable places. • Understandable terminology. • Accommodations for people with functional limitations. • Flexibility to accommodate facility upgrades and departmental changes, incremental growth, as well as technological advances. HFR Design, in partnership with CGA (www.wayfinding.com), is committed to working with health facility owners and managers to create effective, stress-free wayfinding for all users. The ROI factors are significant and the consumer benefits overwhelming. We welcome your feedback and the opportunity to learn more about the wayfinding challenges at your facility.

Tracing its origins back to 1910, HFR Design continues to enjoy a diverse range of architectural and engineering successes due to an ongoing commitment to customer satisfaction and our collaborative process, which encourages innovative thinking, the sharing of knowledge, and strategic planning. HFR Design offers a broad spectrum of services with technical design expertise in healthcare, commercial, residential, industrial, and parks and recreation. Staffed between four offices in Brentwood, TN, Jackson, TN, Kansas City, MO, and Louisville, KY, and licensed in over 30 states, HFR’s professional practice of registered architects, planners, interior designers, engineers, and surveyors serve an ever-expanding list of clientele across the U.S. Tom Testerman, NCARB, ACHA Don Pierce, AIA Sammy West Ron L. Franks, AIA Director, Louisville Office Director, Kansas City Office Director, Jackson Office Director, Brentwood Office ttesterman@hfrdesign.com dpierce@hfrdesign.com swest@hfrdesign.com rfranks@hfrdesign.com 214 Centerview Drive, Suite 300 9100 Marksfield Road, Suite 300 9237 Ward Parkway, Suite 108 113 N. Liberty Street Brentwood, TN 37027 Louisville, KY 40222 Kansas City, MO 64114 Jackson, TN 38301 615-370-8500 (502) 425-8505 (816) 822-8500 (731) 421-8000

health forward report HFR Perspectives on Health, Healthcare Division Newsletter Vol. 7, #2

What is Context Sensitive Design and How Does it Relate to Functional Programming? by Tom Testerman, Healthcare Facility Planner, NCARB, ACHA, HFR Design OVERVIEW As healthcare facility planners, conducting a walking tour of an existing facility is often revealing. What was the intended use of the space versus what the expressed use might be will often vary significantly. Balancing the user’s expectations with all the environmental and compliance factors adds complexity to the repurposing and retrofitting process. Utilizing an organized and disciplined process to test the changes and the conceptual fit is key to completing a successful project. Implementing process improvements along with innovative design considerations adds further complexity to engagement. HFR’s functional programming in tandem with automation has proven to be invaluable in reaching rationale and affordable design solutions. WHAT IS FUNCTIONAL PROGRAMMING? Functional programming in its simplest terms is clarifying the questions and defining the problem. Initially, the problem can be framed in terms of scale, magnitude and conceptual responsiveness. The project

scope evolves from these pre-design programming endeavors and sensitive awareness of expectations. Once the scope is established, then additional information will be centered on establishing goals, collecting and analyzing available data and fine tuning the design concepts in the proper context. WHAT IS CONTEXTUAL DESIGN? Context Design is a problem-solving, user-centric design process. It provides methods to collect data about users in the field where their work is performed. Contextual design with user group participation seeks to understand and improve workflow, process delivery, and design solutions that reinforce the intended functions. Contextual Design consists of a series of techniques incorporated into a standard methodology. Contextual Design can also serve as a supporting framework from which additional resource tools/techniques can be added to expand or broaden the data. This is the source of evidence-based metrics and fact-based design conclusions. The contextual design process encourages the development of new models for creating value-driven systems versus less effective re-engineering methods based on dysfunctional and suboptimal systems. WHY IS IT RELEVANT?

Reliable contextual planning is a methodology that clarifies how users conduct their work and develops a framework to promote the most efficient work product for the future. This approach maximizes efficiency and measures productivity. It provides insights into how activities are performed and ways to streamline those activities with a lean methodology that eliminates or reduces: • Redundancy • Duplication • Repetition • Waste and Over Production • Inefficiency and Fragmentation It also reveals opportunities for: • Consolidation of Functions • Optimization of Procedures and Methods • Performance Enhancements continued on page 3

Contextual Design Process The contextual design process is comprised of seven (7) parts organized into a sequence of steps: I. DATA COLLECTION Includes both contextual inquiry which is the qualitative data based upon observation and interpretation as it relates to understanding users’ fundamental intents, challenges and drivers in their normal work environment and quantitative planning data is defined as data including historical volumes, capacity, demand analysis, market forecasts and projected market share. II. INTERPRETATION Process of analyzing and synthesizing the data captured to understand the key issues and insights in order to understand how the pre-design data collected can influence the design process. Detailed work models are developed to understand key aspects of the work. The five (5) work models of contextual design include, for example: • Flow model - roles/responsibilities of staff and their interaction within the work environment. • Sequence model - series of activities in process required to accomplish work. This is developed through process and value stream mapping. • Cultural model - personal/social and structural norms/influences and pressures which impact the orderly and logical execution of the work. • Artifact model - represents the documents/tools and equipment necessary to perform and/ or structure the work • Physical model - work environment obstacles/barriers that encourage or require work arounds III. DATA CONSOLIDATION AND ASSIMILATION Organizing, analyzing, synthesizing and interpreting data to reveal common patterns and affinities in a structured hierarchical format. Establishing what common similar elements are and what are distinct elements related to concerns, details and key issues. IV. VISIONING Uncovering and testing concepts with cross functional teams based on key issues and opportunities. Using team building and group interface endeavors to ascertain the overall vision for the client and the key stakeholders. V. PROCESS MAPPING/STORYBOARDING Designing process workflow diagrams based on an agreed upon concept for process improvements. This gaming methodology permits informal concept development with all the pre-design research in place and fully assimilated. VI. WORK ENVIRONMENT/ ENVIRONMENT OF CARE (EOC) Develop a conceptual functional plan that supports the new and/or improved processes. Sometimes this

requires a cultural adjustment and policy/procedural improvements along with the functional adjustments. VII. PROTOTYPING Test conceptual functional plan through development of prototype model for iterative design interface with users. a. Test and refine prototype model with users. b. Test environmental factors aligned with the changes (furnishings and equipment). c. Test the systems applications and new innovations that may enhance the overall environment. What trends are influencing contextual design approach? Healthcare reform has introduced opportunities for more creative approaches to address growing concerns with healthcare delivery. A few of these include: • Value-based vs. volume-based purchasing in clinical care delivery • Consolidation vs. expansion of clinical service lines • Outmigration toward ambulatory care sites from the hospital campus • Patient Centered Medical homes and Population Health Management • Well Care programs and Sick Care programs • Highest and best use of real estate assets • Reconfiguration of space from clinical to administrative and support services resulting from vacating and rebuilding new clinical service platforms • Re-alignment of services to accommodate fewer steps, less travel time and more convenient operational objectives Driving the need for better planning models that support Strategic Facility Initiatives: • Forecasted Future Growth Models • Shell /Vertical/ Horizontal Expansion Capability • Loose Fit Design for Flexibility • Adaptable /Convertible Space - Acuity Adaptable Rooms/Universal Rooms • Robust Utilities/HIT and Systems Interface (Continuity) • Plug and Play Infrastructure • Environmentally Sustainable Solutions • Departmental Integration and Re-Alignment (Better Functional Zoning) • Transitioning from Legacy Care Models to Emerging Practice Models • Use of Robotics, Automation and Innovative Movement Systems (Vertical and Horizontal)

The Master Plan is the Road Map by James G. Easter Jr., FAAMA, Diplomate In Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design At this same AAMA conference, a number of guests attended the Friday closing sessions on healthcare master planning presented by Jim Easter and Tom Testerman (full presentation available from JEaster@HFRDesign.com). The presentation centered around the work-up on a healthcare facility as compared to that of a patient by a physician. It is apparent that the traditional MP has changed and the next generation product will cover the following (at a minimum): • Situation and Context • Cultural Work Up • Asset Work Up • System Intervention (Services, Human Resources and Assets) • User Perspectives and Expectations • Consumer Perspectives and Metrics (Quality and Efficiency Are Mandatory) • Size, Time, Money and Evidence-Based Priorities and Outcomes • Debt Capacity and Operational Proformas by Service Line • Decisive and Action Oriented Outcomes (Focus On Effective and Measurable Results)

These are possibly new terms and new methods to many A/E/C partners. Over the next few months we will explore a few of these new innovations beyond the expectations of the past. As one compares the traditional MP to context sensitive design it becomes clearer how the process improvements and methods are evolving.

What is Context Sensitive Design ... (continued from page 1)

• Outcome Improvements - Patient Safety and Reduction of Medication Errors • Vibrant /inspiring/Uplifting/Experiential Environments • Image/Character/Branding and Improved Way finding • Systems and Furnishing Innovations Linked to Both Space Use and Operation HOW IS IT USED? Traditionally, healthcare planners and programmers conduct on-site interviews with departmental directors and/or managers based on standard questionnaires related to departmental service lines and functions. The questionnaires provide insight into space needs based on current functional criteria. They are intended to improve the overall performance of the programming and planning effort. WHAT IS THE PROCESS? Defining the proper process for a project can differ depending on several variables, including scope, time, objectives, intent and pre-determined expectations. By targeting and studying problem areas significant insight can be gained into how people currently perform their work and what improvements might be considered.

This is evident as you explore how space was intended to be used versus how it is ultimately utilized. Understanding how the work practice unfolds enables you to physically structure the work environment to support work processes. Data needed for design has to be collected with an understanding of work practices. Your information will result from on-site visits and interviews, collecting field data, participating in process-related tours and realtime observations. Photography and video analysis are frequently preferred media to collect and analyze existing circumstances. The focus is planning and designing facilities based on sound decisions. Key considerations include: • Scope of work and timeframe for completing assignment • How the facility is intended to work once it is occupied • Current and projected space needs • Establishment of codes and standards and/or design guidelines • Aligning goals of constituent groups and stakeholders • Phasing - sequence of work • Availability of resources

Emergenuity Gains Momentum by James G. Easter Jr., FAAMA, Diplomate In Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design The recent presentation by the HFR/Emergenuity Team at the AAMA National Meeting in Las Vegas was overwhelmingly successful. Some 50 + guests attended the pre-conference educational session headed by members of the research team chaired by Dr. John Wheary and Tom Testerman. The session focused on trends in Emergency Medicine as outlined by Sruit Nataraja, MPH, Practice Manager for The Advisory Board Company (obtain full report summary from J. Easter at HFR Design). Her topic, “Hub of the Enterprise: Transforming the ED’s Role in Delivering Agile and Coordinated Care,” was summarized in four key transformational areas (paraphrased by author from AB presentation): 1. Efficient Care: a. Manage ED Length of Stay b. Collaborate With Inpatient Staff On Patient Flow c. Recognize Down Stream Aspects of The Continuum 2. Quality of Care: a. Achieve Strong Performance on Reported ED Metrics b. Collaborate to Reduce Readmissions c. Partner With Ambulatory Care Providers To Improve Care Transitions d. Emphasize IT/Systems Interfaces 3. Patient Experience: a. Improve Time to Physician and LOS Performance b. Eliminate/Reduce Waiting Times c. Educate Staff on Responsiveness d. Consider Clinical Pathway Enhancements

4. Appropriate Utilization: a. Reduce Unnecessary Tests b. Route Non-Emergent Patients to Clinically Appropriate, Lower Cost Settings of Care Added to these very important transformation clues is the mandate to improve the functional layouts and the contextual design of each existing ED in existing healthcare settings. The process improvements and functional enhancements must be addressed environmentally to ensure the highest and best use of capital dollars, costly staffing and overall economies of scale. A creatively designed and arranged ED is a one-time cost that pays back continuously over time. In our next issue we’ll discuss the free-standing ED and how it will impact the future of urgent and emergent care in the most appropriate settings with creative design and process enhancements. Jim Easter, Tom Testerman and John Wheary presented the Emergenuity process to the Graduate Architectural Class at Kent State University recently. It was a truly enlightening webinar with active participation of students, faculty, physicians and HFR architects.

Tracing its origins back to 1910, HFR Design continues to enjoy a diverse range of architectural and engineering successes due to an ongoing commitment to customer satisfaction and our collaborative process, which encourages innovative thinking, the sharing of knowledge, and strategic planning. HFR Design offers a broad spectrum of services with technical design expertise in healthcare, commercial, residential, industrial, and parks and recreation. Staffed between four offices in Brentwood, TN, Jackson, TN, Kansas City, MO, and Louisville, KY, and licensed in over 30 states, HFR’s professional practice of registered architects, planners, interior designers, engineers, and surveyors serve an ever-expanding list of clientele across the U.S. Tom Testerman, NCARB, ACHA Don Pierce, AIA Sammy West Ron L. Franks, AIA Director, Louisville Office Director, Kansas City Office Director, Jackson Office Director, Brentwood Office ttesterman@hfrdesign.com dpierce@hfrdesign.com swest@hfrdesign.com rfranks@hfrdesign.com 214 Centerview Drive, Suite 300 9100 Marksfield Road, Suite 300 9237 Ward Parkway, Suite 108 113 N. Liberty Street Brentwood, TN 37027 Louisville, KY 40222 Kansas City, MO 64114 Jackson, TN 38301 615-370-8500 (502) 425-8505 (816) 822-8500 (731) 421-8000

healthforward report

The Patient Centered Medical Home Model and Healthcare Reform by Tom Testerman, Healthcare Facility Planner, NCARB, ACHA, HFR Design ®

Many of us by now are aware, with the stuttering launch of the healthcare exchanges, of the impact of healthcare reform and the Affordable Care Act (ACA), or “Obamacare.” In addition to its impact on healthcare insurance reform, there is also significant movement in the area of clinical service reform through clinical care redesign.

Accountable Care Organizations An ACO is a group of providers, including physicians, hospitals and other post-acute organizations, who are collectively responsible for the total cost and quality of care provided to a panel of patients over a period of time. Several strategies are necessary for successful ACO implementation, including:

As healthcare planners and architects, we find ourselves • An integrated physician in the conundrum of trying network to permit to sort out the impact of the resource sharing and clinical care redesign modjoint contracting. els that are emerging and • A network integrated on how our role in providIT patient information ing professional services system. will evolve and likewise be • A streamlined acute care transformed in this rapidly and comprehensive changing environment.This ambulatory network. is particularly relevant as • Standardized care we come to understand the pathways with greater impact of the Patient emphasis on primary Centered or Primary Care care, care transitions, Medical Home (PCMH) and and improved patient how this service delivery activation. model will evolve, from the • Payor partnerships with perspectives of both hospiThe author (at left) talks with hospital officials about value based and incental-based inpatients and the impact of the medical home model on facility design. tive-based compensation ambulatory care outpafor improved population health management (e.g., tients. payment bundles, shared savings, global risk). The PCMH can be viewed as one subset of two other Clinically Integrated Networks common strategies being explored around population health management: Accountable Care Organizations One key strategy of clinical care redesign involves clini(ACOs) and Clinically Integrated Networks (CINs). cal integration (CI). CI relates both directly and indirectly to the PCMH and the ACO, both as stand-alone conTo understand the role of the PCMH, it is important to cepts as well interdependent, connected approaches. first understand its relationship in the broader context of Each of these concepts has its own unique definition ACOs. The ACO models are transforming the approach to the traditional delivery of care. and purpose.

This Issue ... • Medical Home Model

• Effective Healthcare Delivery • Expanding Definition of Healthcare

Healthcare systems with clinically integrated networks (CINs) negotiate collectively for commercial payer contracts. Joint contracting would support investment (of both time and resources) in performance improvements as well facilitating cross-referrals among participating providers. CIN programs are generally multispecialty in continued on page 4

Developing An Effective Healthcare Delivery System by James G. Easter Jr., FAAMA, Diplomate In Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

We’ve all heard the phrase, “a sense of place.” But why is “place” important? When all the systems work, the staffing is at its best, and the continuity of care working to perfection, it is the place that counts most. Is the chair, bed or recliner properly oriented? Is the room cold or warm? Do the physician and nurse have room to work? Is the care appropriate and will the outcomes matter? The architecture and design of the place is our connection with spiritual, emotional and physical healing. Yes, how we arrive and how we depart remain key aspects of the process, but without the caring in healthcare, all other aspects suffer. Our sensory responses to our destination tell the story. Architecture, art and science blend to give meaning to the phrase “healthful caring from cradle to grave.” In a recent discussion about our research into emergency medicine and ED design, someone noted: Privacy, yes that’s important; sound attenuation and noise transfer, yes, that’s a concern; but what does the staff need? Design details must reflect the function, care team expectations and access to technology. It’s a tremendous challenge for the architect, learning to think like a nurse and design as though you were the caregiver. But it’s essential that the healthcare architect think that way.

quality. The question that remains unanswered in most systemwide situations has to do with the term “integration” and how that can be implemented in a “fragmented service delivery” world. There are a number of public and private systems that have approached this integrated service delivery model with various methodologies and diversified strategies. It would appear to us that the constants would include: • Primary Care Linkages (Physicians Talk) • Special Care Linkages (Physicians Respond) • Extenders and Nurse Practitioners Expand Their Skills (Gain Stature) • Effective Management of Assets (Spaces Work and Feel Good) • Optimum Service Locations With Expansion Space (Expandability) • Continuity of Care Through Pre and Post Initiatives (Early Start Home to Hospital Care) • Staffing And Operational Efficiencies to Optimize Space and Time (Efficiency) • Sustainable and Expandable Programs (Code Minimum But Operationally Innovative) • Benchmarks for Comparative Purposes (Learn From The Winners) • The Master Plan (Vision With Action) • The Strategic Plan (Time, Resources and ROI) • The Place (Good Health and Quality of Living)

The trends continue to move toward “physician friendly” and “fully integrated” services that combine advanced It is our vision that all healthautomation, process care architecture would be improvement and readily responsive to people, producEmergency Department staff members at St. Elizabeth Hospital in accessible, real-time services, tivity and process — first and Florence, Ky., review planned ED improvements with HFR Design’s a tall order in a changing foremost! This is a “fast care Tom Testerman (seated, at right). industry where home-to-hosgeneration,” and we will need pital and home again count most! As noted in the to step up the pace to reach the optimum level! Medical Home Model outlined by Tom Testerman in this edition, this would be the “ideal response” to healthcare Contact Mr. Easter by email at jeaster@hfrdesign.com delivery. Affordable care should respond to those or by calling (615) 424-3642. phrases from our past: accessibility, affordability and

Why Hospitals Should Expand Their Definition of Providing Healthcare Expanding health responsibilities beyond medical facilities by Brandon M. Harvey, Associate AIA, CDT, Intern Architect/Planner, HFR Design ®

Healthcare, generally defined, is prevention and intervention for the improvement and maintenance of physical and mental wellness. Healthcare, altogether, is an amalgamation of medical services, medical insurance, and the medical facilities that house its delivery, and is currently a system being critically evaluated and forcibly transformed by the Patient Protection and Affordable Care Act of 2010 (PPACA).

The CHNA is a requirement for charitable hospitals, and was established to meet the needs of the specific communities those hospitals serve, while complying with a transparent assessment process.

PHM is not a new concept, and, like the “Value Agenda,” its primary objective is to provide data-based, practical guidance for hospitals to shift their focus from patient volumes to improved patient-centered outcomes. Thus, the aims of both the CHNA and PHM are patientIn 2006, Harvard professor Michael E. Porter, co-author centered, and it can be argued that both charitable and of Redefining Health Care (Porter/Teisberg), introduced for-profit hospitals are being urged to embrace the the concept of the “Value Agenda” or value-based, goals of this transition away from fee-for-services per patient-centered healthcare delivery-versus supply-drivphysicians’ medical specialties. Hospitals en, physician should expand their definition of providing specialtyhealthcare to reflect this transition. Providing focused Providing healthcare should be defined healthcare should be defined as providing healthcareas providing medical intervention for medical intervention for patient and commuand described nity health through an optimal connection patient and community health the then with high-value medical resources. healthcare through an optimal connection system as “on with high-vvalue medical resources a collision The underlying efforts in all ongoing healthcourse with care-transforming agendas are aimed at patient needs eliminating clinical and non-clinical barriers and economic that disconnect patients from high-value medical reality.” Currently, the PPACA has mandated that the resources. From a community health perspective, healthhealthcare delivery system shift its focus towards achievcare is just as much a part of the community as decent ing the absolute best value for patient outcomes at the and suitable housing, a great educational system, and lowest costs. The ugly truth about America’s healthcare accessibility to other necessities essential to growth, susdelivery system is that its central focus has been maintainability, and survival. By expanding their definition of taining patient volumes for profits rather than improving providing healthcare, hospitals will gain the public trust value for patients. that the healthcare system will work for them and not solely for itself. The PPACA-mandated Community Health Needs Assessment (CHNA) and the re-emergence of Contact Mr. Harvey by email at bharvey@hfrdesign.com or by calling Population Health Management (PHM) are two health(615) 370-8500. care-transforming trends that align with hospitals shifting their focus towards maximizing value for patients. Hart Freeland Roberts (HFR Design) is a 104-year-old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets nationwide from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA, ACHA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

The Patient Centered Medical Home Model and Healthcare Reform ... (continued from page 1)

nature, and involve several standard components, including: • Performance improvement goals centered around clinical and administrative metrics. • Selective physician membership committed to advancing those goals. • Physician performance monitoring system around those goals. • Physician Performance-based payment incentives based on achieving goals. • A physician integrated IT patient information infrastructure network. • Physician services joint contracting with commercial payers/employers. Patient-C Centered Medical Home The PCMH is a healthcare delivery model centered on primary and preventive care to mitigate risks and manage high-risk patients with chronic diseases. The PCMH model is a team-based care concept with a designated primary care provider. The PCMH is a redesigned approach to primary care that strengthens the relationship between the patient and the primary care provider through a patientcentered care model. The foundational characteristics of a PCMH include: • Improved/expanded patient access. • Enhanced comprehensive care coordination with the primary care team. • Holistic care. • Comprehensive/proactive chronic disease management/registry utilization. • Comprehensive care including preventive care and chronic disease management. • Active patient engagement. • Cross-continuum care coordination. In a PCMH, the primary care provider is supported by a comprehensive care team, comprised of both clinical and non-clinical support staff, such as health coaches, peer mentors, and care managers who work at the top of their licenses to deliver care to the full extent of their skills and training. The PCMH model seeks to improve coordination, enhance patient engagement, and improve outcomes. Collective Relationships The CI, ACO and PCMH relate to each other conceptually in general terms: • PCMH focuses on primary care service improvement. • CI focuses on specialty physician practice improvement. • ACO focuses on patient population care improvement.

Each model has both independent as well inter-related goals, which when taken together are complementary in nature. For example, the CI can serve as the physician platform for building an ACO, offering a way to align a large group of independent and employed physicians around goals for standardization, coordination, efficiency, etc. Likewise, many CI programs also support PCMHs as part of the performance improvement efforts for their participating PCPs. The CI program can help fund this transition through its jointly negotiated contracts. A hospital-led ACO must have an aligned physician platform to achieve its goals for standardization, coordination, patient engagement, etc., but CI is not the only approach. Extensive employment of physicians is an equally effective approach to integration. A CI program can function successfully outside of an accountable care environment, delivering adequate efficiencies with traditional fee-for-service contracts that support the physicians’ investment through higher base rates or basic pay-for-performance bonuses. Although in this case the CI program must generate quality and efficiency improvements to justify its joint contracting behavior. It doesn’t need to take on the full spectrum of care coordination and population health management functions to succeed under accountable care payment models that place providers at greater financial risk for outcomes. While most CI programs contain a significant base of PCPs who focus actively on improving care for chronic conditions, not all CI programs support those practices in a PCMH model. As for PCMH, it too can exist without the support of a larger CI network. The medical home model itself can also be used to improve practice profitability enough to achieve financial stability in fee-for-service, even without outside reimbursement. An ACO is the only truly dependent relationship in the bunch. While the PCMH program can, as with the CI comparison above, exist outside an ACO environment, the converse is not true. Given the importance of chronic disease management, patient engagement, and improved care coordination to managing population quality and cost, ACOs will be hard-pressed to succeed without a heavy emphasis on primary care redesign and support, with PCMH representing the main model here. In summary, depending on the healthcare organization’s long-term strategic goals, the PCMH can be developed separately or in conjunction with CI as foundational building blocks for an ACO, offering potential strategies to help manage population-level quality and cost management. Contact Mr. Testerman by email at ttesterman@hfrdesign.com or by calling (502) 425-8505.

healthforward report

When to Hold ‘Em, When to Fold ‘Em Dealing with outgrown and outdated buildings by Page Onge, AIA, HFR Design ®

Your master planner has shown you the wisdom of building new rather than trying to renovate an outdated, undersized, underperforming and hemmed-in old hospital. So you did. You love your new hospital. It’s efficient and in a great location with room for growth. But what are you going to do with the vacated building? Since the building was not practical to renovate, it is not likely a candidate to sell. You don’t want to leave it as an unattractive nuisance and liability. So, if you decide to demolish it and free up the land, how do you make that happen?

asbestos abatement program. You need to take into consideration fluorescent light fixtures with mercury in the lamps and PCBs in the ballasts, lead-based paint, thermostats containing mercury, radioactive-contaminated areas and onsite toxic chemicals. You also need a Phase 1 environmental assessment, which researches the history of the site to see if there is any reason to suspect hazardous contamination. If so, you will need a Phase 2 environmental assessment that involves actual sampling and testing. Is your building considered historically significant? That could be an obstacle as well.

3. The third step is to get bids on removing all the 1. First you need to decide hazardous materials, what the probable future of demolishing the building the property will be. Does and preparing the site for the city want a park there? the next chapter in its life. Are developers interested in The extent of demolition building on the site? Does below grade will depend a nearby university desperon the future use of the ately need some growing site. There is a significant room? Can the resale help difference in cost if you offset your abatement and totally remove everything demolition costs? Is there a below grade rather than “revert clause” whereby if Long before demolition begins, many important issues must be resolved. just taking the building’s the site is no longer used basement walls down to for a hospital, the ownerfour feet below grade and breaking the basement floor ship reverts back to the city or county? You need a team slabs to drain before importing suitable fill to re-conexperienced in demolition that includes you, your facility tour the site. The architect and civil engineer will define engineer, your board, legal counsel, real estate adviser, the scope of the work to help ensure consistency of proarchitect, civil engineer and a construction manager. posals. Demolition costs may be significantly reduced if The team will help you decide the best future for the the demolition contractor can get the salvage value out site. of certain materials in the building. Hospitals have some very valuable metal. However, some may be 2. The second step is to find out what you have. The impractical to salvage if it is covered with asbestos insuteam will help you coordinate this. You will need an lation. Also, if concrete slabs are to be recycled, any updated site survey, locating all of the buildings, paveflooring/adhesive containing asbestos must be removed ment, walks, significant trees, utilities, drainage feabefore recycling. tures, contours and underground storage tanks. You need a hazardous materials assessment of the building 4. The team will review the proposals to help verify that — an assessment that goes far beyond your ongoing the selected abatement and demolition contractors understand the scope and are qualified to do the work. This Issue ... Coordination and scheduling are critical. There are • Dealing with Obsolete Buildings • Cultural Awareness and Architecture • ACHA Certification Benefits

continued on page 4

Cultural Awareness and Architecture (Part Two) by Valarie D. Franklin, NIHD, Project Designer/Illustrator, HFR Design ®

(Part two of a two-part article previously published in its entirety in the journal of the Tennessee Society for Healthcare Consumer Advocacy.) Author’s note: Last year I had the pleasure of attending a seminar presented by Betty Gregg, RN, of East Tennessee Children’s Hospital in Knoxville, speaking as a member of the Tennessee Society for Healthcare Consumer Advocacy. The topic was “Appalachia: Developing Advocacy Through Cultural Awareness.” Listening to Betty, it became apparent to me that cultural awareness should be in the consciousness not only of healthcare providers, but also of architectural designers. I feel that the responsibility of the designer is to understand that cultural identities must be maintained and valued in the design of a structure or planned community. In Part One of this article, we examined the importance of human interaction, the inclusion of social support in the patient’s care and recovery, and architectural design that is conducive to health and healing. In this conclusion to the article, we take a look at the remaining Planetree concepts and suggested design solutions that relate to Betty’s address and their relevance in creating healthcare architecture that is conducive to healing. Emphasizing the nutritional and nurturing aspects of food... Betty mentioned that the Appalachian people, especially the women, love to cook and that the mother or mammaw of the family often expresses her love through preparing meals and favorite foods. Recently in the world of healthcare design, the idea of the “small kitchen” has been introduced. The “small kitchen” is located in close proximity to patient rooms so that the patients are exposed to aromas such as baking bread or cookies. This type of aromatherapy enhances the patient’s mental wellbeing as it pertains to being hospitalized. The goal here is to utilize all of the patient’s senses in making the patient feel like they are in a home environment, thus, making them feel more comfortable.

discussion. She expressed the importance of the caregiver not having a condescending tone (“talking down to”) the patient because of their perceived educational level or knowledge of the affliction that they have. A knowledge of Appalachian medical terminology is essential, says Betty. An Appalachian patient may come in complaining that their “sugar” is acting up or that they have the “vapors”. Healthcare providers need to know that they are referring to their diabetes and respiratory problems respectively. Sensitivity to, and the knowledge of, their medical dialect is crucial and can be a matter of life and death if misunderstood. As a designer, translating this aspect into building design can be vague; however, I feel that this is where the idea that every building can and often must obtain the qualities of a museum comes into play. Museums are educational buildings, and their form and functions all cater to that educational aspect. I envision an Appalachian patient or family member walking down a patient corridor in a healthcare facility feeling like they are in a museum because the hallways are flanked by informational graphics and pieces of Appalachian-related folk art that educate them on the diseases that ail them. I could even see some of Mammaw’s remedies being explained and validated such as the example that Betty gave about the lamp oil and spider webs. This would further promote pride in the Appalachian heritage and provide a helpful base of learning for those who may have limited knowledge of the Appalachian culture. The importance of spirituality in the healing process… As Betty informed us, the Appalachian people are devoutly religious and hold strongly to their Christian beliefs. Spirituality has always been an important part of the physical recovery of patients especially for those who look to higher beings in times of distress. The inclusion of “spiritual” spaces into the design of the building can

Empowering patients through information and education… Communication with, and the education of, the Appalachian patient in regard to their condition and care were key components of Betty’s continued on page 3

be achieved by the use of large windows in patient rooms that look out to landscaped spaces, making the room-bound Appalachian patient feel as if they were outdoors and closer to their source of inspiration. The “Healing Garden,” often included in Planetree projects, is a landscaped garden area accessible to patients and family members. The Healing Garden is usually filled with the soothing sounds of flowing water provided by water features, as well as fragrant scents from the garden foliage. Another design feature that can be utilized is the inclusion of a Chapel room into the hospital for those seeking spiritual comfort. Often the room is filled with religious-themed symbols and artwork on which the patient or family member can quietly reflect and meditate. The healing effects of human touch… The inclusion of complementary therapies (such as aromatherapy and massage)… A soft touch on the shoulder and sometimes, if appropriate, hand holding, are human interactions that a caregiver can use to effectively communicate with a patient and in turn aid in that patient’s healing. Human touch is a very powerful tool, and Betty touched on the subject during her discussion. No pun intended. She stated that most Appalachian people are very responsive to intimate (one-on-one) conversations, and will respond very well to human gentleness and kindness expressed by touch. The inclusions of spaces that provide that type of therapy are becoming more prevalent in healthcare environments. Spa, massage, aromatherapy, and even hair salon’s are some of the types of areas that can be designed to encourage this type of human interaction. Providing the patient access to arts and entertainment… It is always a positive to be surrounded by sights, smells, and even sounds that remind you of home when you

are hospitalized. Betty described the Appalachian people as having a very multi-talented culture. She, being a very talented storyteller herself, told us of how the children loved gathering around Mammaw to listen to her stories, and how they would sit there and listen quietly for hours. The Appalachian people also enjoy listening to and playing folk music. Spaces within the facility can be designed to accommodate and showcase these types of activities/entertainment. In a children’s hospital, for example, a “Storytelling/Theater” room would be a very positive force in uplifting the spirits of a sick Appalachian child. The importance of community involvement… The Appalachian community is an extremely close-knit one in which distrust of outsiders can be found, resulting in limited interactions with those outside the culture, as Betty expressed. The Planetree concept that community involvement enhances one’s life journey is a very true and profound one. In the case of the Appalachian people and their reluctance to “deal with” anyone outside of their culture, I feel that it is up to the healthcare institution to reach out to the Appalachian community even before an individual gets sick. This way of thinking/care transforms the hospital’s role from just treating illness to preventing illness. It would also transform the Appalachian way of thinking that the hospital is “where you go to die”. Community involvement and education would help to develop trust. Hospitals can reach out to the Appalachian community by sponsoring various themed “kids camps”, culturally-based dance classes, community gardens, culturally-aimed wellness presentations paired with live folk music, folk art exhibits, or storytelling. Betty notes that the church continues to be a very important avenue of communication with the extended community and that the opportunities for festivals, homecomings, and community days should continue to be explored as positive sources of interaction. The idea of improving the healthcare conditions of the people of Appalachia while maintaining cultural sensitivity and respect is a challenging one; however, with some creativity and ingenuity, I am confident that we can find solutions that will keep their way of life fully continued on page 4

Hart Freeland Roberts (HFR Design) is a 103-year-old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets nationwide from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA, ACHA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

HFR Design’s Harrett and Testerman Achieve ACHA Certification

Bob Harrett

Architect Bob Harrett, AIA, NCARB, ACHA, and healthcare planner Tom Testerman, NCARB, ACHA, of HFR Design’s Louisville office, have earned their Board Certificates in healthcare architecture from The American College of Healthcare Architects (ACHA). Harrett serves as managing principal of HFR Design’s Louisville office. Testerman is a senior healthcare planner and design architect with the firm.

Harrett and Testerman recently passed an accredited examination that assesses the knowledge and understanding of architects who practice as healthcare specialists. They join fewer than 500 ACHA colleagues who have received this important architectural credential from around the USA. The American Institute of Architects’ Tom Testerman (AIA) Academy of Architects for Health (AAH) is the sister organization to ACHA and represents a national membership of architectural practices specializing in healthcare design and planning. HFR has been active on this committee since its inception, with leadership provided by Ed Houk, Sam DiCarlo and Jim Easter. Jim was founder of the Academy Journal and currently serves on the Editorial Board. He is a former member and recipient of the AAH Graduate Design Fellowship (currently Arthur N. Tuttle Fellowship Award). Over the years the AAH and ACHA have served as partners to promote the “added value to clients” of healthcare specialization within an ever-changing industry. ACHA provides Board Certification for architects who practice as healthcare specialists. The organization’s membership includes healthcare architects throughout the United States and Canada with specialized skills and proven expertise. Before earning the ACHA Board Certificate, healthcare architects must document their experience and demonstrate their skills through a computer-based examination. ACHA requires its certificate holders to work towards the improvement of healthcare architecture on behalf of the public, to practice in an ethical manner, to maintain high standards of specialized continuing education, and to add to the body of knowledge. The organization stresses the fact that it offers healthcare providers experienced, independently certified healthcare architecture specialists; confidence that certified healthcare architects know current healthcare

issues, trends and regulatory requirements; and the knowledge that they have added a team member that “speaks their language” and understands their programmatic and design needs. Dealing with Obsolete Buildings ... (continued from page 1)

many rules, regulations and associated permits and paperwork. These include federal and state in addition to local government agencies. 5. If you are in a hurry, you may be able to have the demolition contractor follow behind the asbestos abatement contractor as buildings or portions of buildings are phased. However, there is risk that paperwork, unforeseen additional asbestos and labor issues may delay the abatement, causing the demolition contractor “down time” or demobilization and remobilization costs. It may be better to wait until the asbestos abatement is complete before starting the demolition work. Demolition also can inadvertently interrupt utilities if not carefully staged. The demolition process will likely involve soil erosion protection and photographic documentation of the existing condition of adjacent properties. The owner doesn’t want to pay for pre-existing damage that people may say was caused by the demolition seismic vibrations. On the positive side is the community entertainment value of watching how quickly the building comes down. Artifacts can be donated or given as gifts. Recycling efforts as well as the benefit that a new park or a new modern building will bring to the neighborhood can create positive press. So even though the process may seem daunting, it can be a good public relations opportunity. Contact Mr. Onge by email at ponge@hfrdesign.com or by calling (615) 370-8500. Cultural Awareness and Architecture ... (continued from page 3)

intact. It is up to healthcare providers and designers to embrace and educate themselves on all cultures and realize that each is relevant and has made substantial contributions to our American history. The ageless mandate to “treat everyone how you want to be treated yourself” is held onto firmly throughout every culture. It is a concept that is worth its weight in gold in the field of healthcare; and it is an ideal that is at the very foundation of our common heritage, humanity. Contact Ms. Franklin by email at vfranklin@hfrdesign.com or by calling (615) 370-8500.

healthforward report

Cultural Awareness and Architecture (Part One) by Valarie D. Franklin, NIHD, Project Designer/Illustrator, HFR Design ®

(Part one of a two-part article previously published in its entirety in the journal of the Tennessee Society for Healthcare Consumer Advocacy.) In October 2012 I had the pleasure of attending the Tennessee Healthcare Association conference held at the Gaylord Opryland Hotel in Nashville, TN. From a healthcare designer’s perspective, the entire experience was very enlightening. One of the educational seminars that I had the opportunity to attend was hosted by the Tennessee Society for Healthcare Consumer Advocacy, and the topic was related to Cultural Awareness. Cultural awareness refers to the recognition that not all people are from the same cultural background. It also recognizes that people have different values, different behaviors and different approaches to life. People of different backgrounds also tend to utilize specific goods, services, and activities based on their cultural upbringing. I feel that the responsibility of the architectural designer is to understand that cultural identities should not be discarded or ignored but rather maintained and valued even in the design of a structure or planned community. Because architecture or “functional art” as I like to call it, has a profound impact on the environment and humanity in general, architectural design has the unique opportunity to pay respect and homage to the substantial contributions that have been made by the diverse cultures that make up our American History. This is why the idea of the “museum” is so effective. You will notice that any museum that is a monument to a particular cause or people is much

This Issue ... • Cultural Awareness and Architecture • Healing Design Puts the Patient First

more than four walls to encase artifacts. The buildings themselves are part of the exhibit. More precisely they are part of the “experience.” Architectural designers have the opportunity to treat every building that we design as something to be experienced. The topic of discussion at the seminar was “Appalachia: Developing Advocacy Through Cultural Awareness,” and as the topic suggests, the focus of the discussion was to highlight the culture of the Appalachian people and to explore how healthcare providers can effectively communicate with them on various levels in order to create a positive healthcare experience. I Shown here is the feel that my job as an author’s sketch of architectural designer is to a patient room layout that would make sure that the built help meet the needs environment fosters, nurof the typical tures, and reinforces Appalachian patient. patient advocacy to create a positive healthcare experience on every level whether it is a hospital, doctor’s office, or assisted living facility. The focus in the remainder of the article will be on how to improve the healthcare experience of the Appalachian people through the built environment. Speaker Betty Gregg, RN, of East Tennessee Children’s Hospital in Knoxville, who is of Appalachian and Cherokee descent, covered many aspects of Appalachian life and the challenges that the people of Appalachia face. Betty is an excellent storyteller (which is largely a cultural trait) and had her audience captivated by the first 5 minutes of her presentation. She detailed that the Appalachian people are a proud, hardworking, and very much family-oriented people. They are extremely patriotic; however, many refuse to rely on the government for assistance even though they could justifiably do so. They hold very strong Christian religious beliefs, which are the basis for many aspects continued on page 3

Healing Design Puts the Patient First by Wendy Tennis, Planetree Coordinator, Valley View Hospital ®

Nestled in the heart of the Rocky Mountains of Glenwood Springs, Colorado, Valley View Hospital is one of 18 facilities nationwide to earn repeated recognition as a “Planetree Designated Hospital.” Planetree is an organization that champions patient-centered care initiatives, and Valley View has been a Planetree member since 2000. The philosophy of creating and sustaining a healing environment from the patient’s perspective has been the driving force behind all designs by the esteemed architectural firm of HFR Design. The firm has been working with Valley View since 2003 and has incorporated the Planetree concepts of humanizing, personalizing, and demystifying the patient experience into their work on all projects. Most recently, the Calaway-Young Cancer Center at Valley View Hospital opened last September and has received accolades from patients, families, community members and staff. Utilizing the beauty of the surrounding mountains, HFR Design brings a “high-end ski lodge feel” to a place designed to heal. The experience begins before the patients enter the building, with the healing garden. This carefully chosen space provides outdoor seating, a custom water feature, and indigenous plants to further integrate with nature’s splendor. Approaching by car, patients access the main entrance under a welcoming canopy and are greeted by our valet staff who park cars in the underground parking reserved for patients only. A volunteer greets and escorts patients to the elevator just a few steps away. Before going upstairs, patients may wish to linger by the fireplace in the seating area adjacent to the elevator. The elevator takes them up one floor to the reception desk and waiting area. Ample seating and natural light flow in through the expansive windows that allow a view of our healing garden from the inside. Soft music can be heard from our sound system, again selected for its relaxation and healing qualities.

work and two fireplaces in the waiting area. Highly trained, compassionate staff members take each patient through the treatment process, because we believe that comprehensive care comes through a relationship with the mind, body and spirit.

The environment created for treatment is a delicate balance between human interaction and state-of-the-art technology. The Calaway-Young Cancer Center brings these two essential elements together in perfect harmony to support the patient fully during the treatment process. The medical oncology unit offers patients a choice of where they wish to receive their chemotherapy infusions. Four private rooms and eight communal bays are available, each with comfortable seating for both patient and family members. Televisions and artwork adorn the walls in a pleasing manner for patients to enjoy during the long hours of infusion. Radiation oncology patients experience similar amenities, with carefully selected art-

Adjacent to each reception area is the Grand Lobby. This two-story space features a double-sided fireplace where patients and guests can relax in several cozy seating areas. Surrounding the fireplace, patients will find the Connie Delaney Medical Library, Marianne’s Boutique, and Integrated Therapies. Empowerment through information is essential for all patient engagement, so our library offers a variety of publications. Additionally, our medical librarian assists patients in selecting from the many resources available, both print and online, so they may learn more about their diagnosis and course of treatment. Marianne’s Boutique offers an array of products and consultation services specifi-

The HFR-designed Calaway-Young Cancer Center at Valley View Hospital conveys a “high-end ski lodge feel” in keeping with the Planetree philosophy and the hospital’s beautiful mountain setting.

continued on page 3

cally chosen for the cancer patient. Finally, our Integrated Therapies professionals offer massage, acupuncture, yoga, tai chi, HeartMath, aromatherapy and other treatments to move the patient successfully through the healing process. Just around the corner from Integrated Therapies, guests will find our chapel. This space, designed to enhance quiet reflection, is quite versatile. The walls are filled with peaceful, backlit stained glass murals created especially for the space by a local artist. The furniture is movable to accommodate many gatherings. The chapel is easily accessible to both hospital and cancer center guests as it is located just off the Emergency department waiting area and adjacent to the Grand Lobby.

The Calaway-Young Cancer Center at Valley View Hospital has chosen to partner with HFR Design, and together they continue to set the standard in Healing Design. By listening to the patients, staff, physicians and community, they have created an environment that accommodates healing of the mind, body and spirit. As one guest noted, “If you walk into an atmosphere that is designed to be warm and comforting, you melt a little bit. The patient is at ease and is likely to have a better outcome.” Contact Ms. Tennis by email at wtennis @vvh.org or by calling (970) 384-6640. Above: The Connie Delaney Medical Library (at right) within the Calaway-Young Cancer Center features a medical librarian who assists patients in selecting from the many resources available so they can learn more about their diagnosis and course of treatment.

Cultural Awareness and Architecture ... (continued from page 1)

of their daily life. She explained to us that the Appalachian people much prefer “Mammaw’s” (Grandma’s) medicine to going to a doctor. She went on to detail a story about how one time she stepped on a nail that nearly went completely through her foot, so much so that the nail created a tented projection on the top of her foot (threatening to go completely through). She immediately went to Mammaw who fervently prayed for her and proceeded to go to work on her foot. Her mammaw poured lamp oil into the wound and then packed the wound with spider webs! The next day her mammaw told her to hop out of bed. She obeyed her mammaw and to her surprise her foot felt as good as new! Later in her nursing career she discovered that lamp oil has astringent properties and spider webs are a blood coagulant! So Mammaw knew what she was doing all along, even if she did not know the exact science related to why her remedies worked. Another issue facing the people of Appalachia is the distance from their homes to a medical facility. This is because after God and Family, the only other thing they value is land. Their land is passed down from generation to generation which makes them reluctant to sell to outsiders; thus, presenting a challenge to developers

who consider building in the area. Sadly, Betty noted that due to their lack of confidence in modern medicine and the idea that hospitalization is a last resort to Appalachians, by the time an ambulance is called the person may be far too ill to be adequately helped. So the challenge for healthcare providers (and designers as well) is how to effectively improve the healthcare experience and conditions of the Appalachian people while maintaining respect and sensitivity for their culture while we find solutions that won’t completely destroy or compromise their way of life. During my tenure at HFR Design, I have had the opportunity to implement the goals of the Planetree concept into our healthcare projects. Planetree is a philosophy of care with objectives to personalize, humanize, and demystify each healthcare experience from a patient’s perspective, which, in turn, fosters a healing atmosphere between the patient and the caregiver, as well as between the patient and the patient’s environment. The Planetree concept embodies 10 goals that are intended to lead to a positive, culturally sensitive, patient-centered healthcare experience. Betty, without knowing it, continued on page 4

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA, ACHA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Cultural Awareness and Architecture ... (continued from page 3)

touched on every aspect of this concept during her educational discussion.

such as getting out of bed to go to the bathroom or showering.

The importance of human interaction... Betty emphasized the importance of “eye contact” during interactions with Appalachian patients. She suggested that the caregiver should take the time to sit with the patient (if the patient is seated) and discuss their care. This will communicate to the patient that there is a genuine interest in getting to know them, which makes the patient more open to what the caregiver is trying to convey. This type of interaction also aids in dispelling any perception that the caregiver is superior to the patient, which is of great value since Appalachians in general do not feel that any one person is superior to another. An architectural solution to this Planetree concept is to provide an area within the patient room for the caregiver to sit and speak with the patient, preferably bedside in the event that the patient is not mobile.

Architectural design that is conducive to health and healing… As a designer this concept seems like a “no-brainer,” but upon further inspection is more complex and multifaceted than one would initially think. Betty in her discussion alluded to the fact that the Appalachian people in general prefer casual, natural environments such as the outdoors opposed to rigid formal spaces. “Sunday Dinner on the ground,” in which the morning church service congregation would gather outside after the service to enjoy an afternoon meal together in the open air, is evidence of this preference. Many Appalachian people continue to work their farmland and have a great appreciation for and enjoyment of nature. An architectural solution to this concept would be to provide large windows from patient rooms looking out on

The author’s sketch of a proposed medical office building located in the Rocky Mountain range of Colorado.

The inclusion of social support (family and friends) in the patient’s care and recovery… If Mammaw is sick and hospitalized, you better believe that the whole family will be there to support her. Betty says that caregivers need to be aware that when an Appalachian family member is in the hospital, you can expect an increased volume of traffic in and out of their hospital room. This is a direct effect of the “tight-knittedness” of the Appalachian family unit. As a designer, this can be accommodated by creating larger patient rooms with a dedicated family nook near the patient’s bedside. This will allow the patient the convenience of having family members present in the room, while not hampering healthcare operations within the room due to increased traffic. Planetree concepts recognize that the presence of family members is an integral part of the patient’s recovery as well as having the potential to take some of the workload off of the nurses. This is because family members can help patients with tasks

to exterior garden spaces to make them feel as if they were in an outdoor space and not in a hospital room. The architectural style of the building could also reflect the rustic nature of the Appalachian culture. This can and has been beautifully done in the Mountain style of architecture where natural materials such as wood and stone are the main construction materials used on the buildings. The architectural forms of the Mountain style also mimic nature and farmhouse architecture, allowing the Appalachian patient to feel more comfortable in the environment, which aids their healing process. (Part Two of this article, featuring the remaining seven design goals and solutions, will be presented in our October issue.) Contact Ms. Franklin by email at vfranklin@hfrdesign.com or by calling (615) 370-8500.

healthforward report

Emergency Department Innovation Using the RAU Model by Page Onge, AIA, HFR Design ®

Emergency Department (ED) waiting rooms are notorious for long waits. It is no fun to wait and worry. Did they forget me? Am I invisible? What if what I have is really serious and I don’t get seen in time? I wonder how many diseases I am catching being exposed to these other sick people? I wonder if that agitated person has a weapon? HFR Design has been fortunate to have found a more effective innovation in Dr. Todd Warden’s Rapid Assessment Unit (RAU) model. Dr. Warden’s company, Emergenuity, Inc., has developed a model for an efficient, effective, successful emergency department. This model has been tested, and the results prove that this innovation is truly effective in very important metrics, including:

So, how does the RAU model work? First, we have to eliminate the bottlenecks! We all know that classic triage is a bottleneck. Two triages help slightly, but not enough. The RAU model takes the patients immediately from the ED waiting room to the Rapid Assessment Unit. For a 50,000-patients-per-year ED, that would be a suite with about 10 exam rooms. This is the “Triage” Suite. The design does provide for maximum HIPAA compliance. In the RAU, the Intake Team goes to work. The patient sees a nurse for five minutes, a registration person for five minutes and then a doctor for five minutes. Obvious tests are ordered, immediately. This takes less than an hour. From there the patient is discharged, sent to the Internal Disposition Area (IDA) or admitted to the Acute Suite of the ED.

• Reduced Wait Time (Reduce Door-to-Provider Time from1.5 hrs to less than 20 Minutes, The IDA contains chairs, 70 percent of the time) recliners and a couple of • Fewer Patients Leaving exam/treatment (E/T) Without Being Seen/ rooms. The IDA is where Treated (Tenfold Decrease) patients go while they wait • Higher Patient Satisfaction for test results or if they Emergency Department staff members at St. Elizabeth Hospital in (Press Ganey Scores need further observation Florence, Ky., review planned ED improvements with increased from 38th to before it is determined if HFR Design’s Tom Testerman (seated, at right). 99th percentile) they should be discharged • Improved Outcomes or transferred to the ED • Reduced Square Footage of ED = Capital Cost Acute Suite. The IDA allows more patients in a smaller Savings (2x capacity of Traditional ED) area, because they are capable of sitting in chairs or • Higher Staff Satisfaction = Better Staff Retention recliners. The intent is to keep vertical patients vertical. and Recruitment This allows additional seating for family and friends, • Increased Flexibility and Efficiency = Operating and takes up much less square footage than having Cost Savings these patients in beds in E/T rooms.

This Issue ... • Emergency Department Innovation • GIS Mapping Advantages • Buildings Changing Healthcare

The two E/T Rooms in the IDA are for situations when there is a reason that a patient in the IDA may need an exam that is best performed on a bed. This allows the patient to not have to leave the IDA. Patients directed to continued on page 4

Maximizing Your Facility Takes Masterful Planning by LeeAnne Denney, Executive Vice President, iVantage Health Analytics ®

In today’s hospital environment, it’s no longer about building buildings — it’s about facility use and maximizing resource allocation. Whether assessing a new building project or repurposing existing space, the new mantra is patient care and population health planning. It’s less about physician convenience and all about meeting patient care needs and engendering patient satisfaction and loyalty. As hospitals tackle managing a population, they are increasingly asking the question, “Are my assets in the right place to deliver the right care at the right time?” Managing a population of patients requires us to think beyond placing the MOB near the hospital; it means analyzing where patients live and putting resources close to those locations, whether it’s a new MOB, outpatient surgery center, urgent care facility or partnering with public health organizations. Determining the right mix of services to deliver the right care at the right time is vital for strategic development.

sions that have a ripple effect; clinical decisions affect operating decisions, which in turn affect capital decisions, and on and on. How do you take all the disparate information throughout your organization and get mission-critical “I have planners with lots of information to good information — now with ensure your continGIS technology I can take that ued viability? You data and interact with it to see need to answer key all my market dynamics. It gives questions such as: me the power to make better decisions, faster.” • Where are my Mark Anderson, D.Sc., MSHHA assets currently Chief Administrative Officer, located in relationShands Jacksonville North ship to my current and prospective patient populations? • What new facilities do I need and what, if any, modifications need to be made in existing facilities? • Which providers should we partner with to ensure we have the required continuum of care needed to meet population health demands?

Analysts have used mapping tools in the healthcare industry for years. The difference Finding the answers with traditional planbetween traditional ning tools would make this task daunting mapping products at best. Sophisticated GIS technology comand sophisticated bined with data integration applications Geographic elevates your current information into a Information strategic decision tool. Using that tool Systems (GIS) mapallows you to set yourself up to examine ping is the ability options by taking definitive steps toward to see detailed more effective planning. relationships. Inventory your market: Your medical staff Traditional mapping typically rosters, urgent care locations, clinics, allows you to place homeless shelters, nursing homes and static icons identiother providers in the market are all fying specific important in determining the best strategic GIS technology allows you to see employed physician offices locations on a approach to patient delivery. Make the in relation to local urgent care centers. map, and that investment in organizing the information. map can be printed or screen-shot into a PowerPoint Align your data: Most hospitals have current investpresentation. ments in data and applications that silo information. GIS mapping is dynamic and interactive. It reveals preGIS allows disparate data sets to be integrated, unifying viously unseen relationships by organizing very detailed the data through the map for strategic analysis. Placing data that can be displayed by clicking the icon, layering information such as physician office locations and outdata to see multiple pieces of information together on patient surgery centers, then overlaying relevant patient the map, and interacting with that data to quickly and demographics, you can begin to draw the picture of easily develop sophisticated “what-if” scenarios. care needs and care delivery. With the new demands health reform is placing on providers, you will inevitably be faced with making deci-

The two important steps above open a whole new world of interactive visual planning opportunities.

continued on page 4

Buildings That Are Changing Healthcare by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

We are seeing some major “accountable architecture innovations” that aren’t really new ideas, but they are moving to the “front burner,” in part due to accountable care and the imminent impact of federal budget cuts. We are referring to the changes that occur as population and needs-based programs evolve. What are the facility factors impacting these pressures? First, it appears that reliable campus master planning and programming are mandatory to give building developments a “business and needs-based justification,” and second, it appears that the fundamental drivers of these pressures boil down to accountability and affordability. In that regard, accountability requires the following ownerdriven research: • Population Characteristics • Market Dynamics • Consumer Needs and Expectations • Financial Status and Potential • Service Needs and Priorities • Physician and Care Team Structure (Medical, Extender and Technical Service Levels) • Clinical Pathways and Specialties • Accessibility and Transportation In the context of affordability, we must address those capital asset and human resource factors that add to the cost of start-up and operation of those future buildings, for example: • Types of Service Centers (Short Stay and Ambulatory versus Acute Care and Hospital) • Process and Integrated Delivery Tools (IT, EMR, Communications and Operations) • Service Methods, Operational Procedures and Manageable Human Resources • Shifts in Clinical Pathways to Reduce Operational Costs • Shifts in Locations to Improve Access and Convenience • Shifts in Design Character to Complement Reductions in Capital Costs

• Appealing Programs and Services That Consumers Will Choose to Use and Pay For • Results-Oriented and Positive Outcomes • Right-Sized Planning and Design These two “a” variables set the scene for healthcare today and in the future. The role of the medical office building (MOB) in supporting these changes has never been more important. These expanding outpatient and ambulatory care programs will augment the efficiency and process improvements of the hospital. Clinics will move closer to the hospital to accommodate the “access needs,” and those newly employed physicians will have a convenient place to work. The mandate to reduce costly inpatient stays and treat patients in “less acute environments” rings clearer as we evaluate how to respond to tighter budgets. The continuation of the physician and extender care team members will grow

Staff members review MOB spaces with HFR Design’s Martin Franks at a facility in Ohio.

continued on page 4

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Emergency Department Innovation Using the RAU Model ... (continued from page 1)

Buildings That Are Changing Healthcare ... (continued from page 3)

the Acute Suite of the ED are then either discharged or admitted as an inpatient.

the demand for hospitalists, intensivists and campusbased ambulatory care. Components of “patient-centered medical home” services fit comfortably into the MOB setting. Education, outpatient-oriented care, specialized testing, clinical studies and office-oriented services all work best when sited in the MOB.

But it isn’t just the floor plan that needs to change to make the RAU model work. Proper staff and physician buy-in and training are also required. For continued success, and to stay on track, there must be continuous tracking, cheerleading, and a mindset to always look for ways to improve. Critical ingredients are strong leadership and a LEAN management coach. On those rare occasions when the ED receives an unusually high number of patients in a short amount of time, the RAU model uses a multi-step escalation protocol. As the number of patients shifts up or down, the protocol procedures step up or down to the next level accordingly. When the number of patients is very high in a short amount of time, the triage is similar to a MASH Unit: Most acute/critical and likely to benefit are first to be examined and treated. Ideally, the full RAU model is implemented. However, when that is not feasible, renovations can be made to existing EDs to allow for incorporation of certain elements of the RAU model. When that takes place, it should include training staff and physicians in the “process,” so that the ED can take advantage of as many of the benefits as possible. Sometimes, in spite of the best RAU plans, the “downstream bed availability” holds up our throughput. This, too, is a challenge. HFR Design has embraced the RAU innovation, and is incorporating it into several projects in several states. It’s not difficult to imagine that many EDs may benefit from this innovative marriage of process and design. Contact Mr. Onge by email at ponge@hfrdesign.com or by calling (615) 370-8500. Maximizing Your Facility Takes Masterful Planning ... (continued from page 2)

Be open to new technologies and to looking at data through a different prism. Interacting with your data in an easy-to-understand visual presentation allows you to engage more stakeholders and to get the necessary buy-in for new strategic directions. Click the link to see GIS in action: http://productpreviews.ivantagehealth.com/ enVision_Product_Overview/. Contact Ms. Denney by email at ldenney@ivantagehealth.com or by calling (615) 298-4011.

Within the service area, we will see the growth of professionally credentialed and branded programs that offer community-based alternatives to those programs traditionally housed in the acute care setting, for example: more healthpark, healthplex, integrative medicine, urgent, emergent care and creatively packaged service delivery centers. Will these function as the “doc in the box” alternatives we’ve observed heretofore? No, they will not, but they will do the following: • • • •

Have a Brand Name That Is Tied To Quality Demonstrate A Patient and Family First Delivery Effort Offer Convenience in A Non-Acute Setting Complement Marketwide and Integrated Care Programs • Address First Costs and Longer Term Capital Costs Related to: - Site Selection and Program Development - Project Master Plan and Functional Program - Project Design and Construction - Project Operation and Sustainability - User Access - User Need Well, we’ve gone full circle — from “need back to need.” Why is this so important in an accountable and population-based environment? It’s important because we each have the responsibility to ask the relevant questions from the very beginning. It is also important to underline the fact that quality and performance go hand-in-hand to deliver effective healthcare. The final assessment of one’s success is grounded in good design that works efficiently and effectively. To make this work, one must plan, price strategically and build smarter for the future. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642.

healthforward report

ue esign Iss D b a L l Specia

New Forensics Lab Provides Morale-Boosting Environment Nashville’s new Wilma Rudolph Sports Testing Laboratory, owned by Aegis Sciences Corp. and designed by HFR’s Ed Houk, AIA, and John Coke, AIA, features a design that not only facilitates the important work done there, but that also provides an environment beneficial to the human needs of employees. It’s a far cry from the cramped, windowless labs of old. At this latest HFR-designed Aegis lab, natural daylight and carefully selected recessed indirect lighting augment an open design where the testing equipment and lab tables can be reconfigured as needed. The 10,000-square-foot lab, resulting from renovation of an existing warehouse, was completed in June 2012. The interior designer for the project was Robin’s Nest Interiors of Hendersonville, Tenn. HFR also contributed ideas that were incorporated into the interior. While sports performance enhancing drug testing is the lab’s primary function, other types of forensics toxicology testing are continued on page 4

This Issue ... • Forensics Lab’s Great Work Environment • Creative Funding for Capital Projects • Four Trends Changing Lab Design

The Wilma Rudolph Sports Testing Laboratory in Nashville was the third forensics lab designed by HFR Design’s Ed Houk and John Coke for Aegis Sciences Corp., and since then two more have been designed and are now under construction.

Right: A stunningly beautiful lobby greets visitors to the Wilma Rudolph lab. Below: Aegis Sciences Corp. stressed the need for spaces that would be inviting and comfortable for both employees and visitors.

Creative Funding for Capital Projects by Bob Harrett, AIA, Principal and Director, HFR-Louisville ®

It appears that, even in a tough lending economy, you can still conduct viable real estate developments on university campuses if you know what mechanisms are available and how to use them. The key is making the development mutually beneficial to all parties involved, including owner, developer, local and state governments, and prospective tenants. Serving as a good example of innovative thinking, the University of Louisville, a state-supported university, has been able to do what I just described. When the university set out to develop a science-andresearch park on its Shelby Campus in Louisville, the hope was that it could be done with the smallest possible capital investment. The original RFP for the first phase of development leaned heavily towards the least amount of burden being placed on the university, with the school basically offering the land as its major contribution to the project. It appears, however, that the selection of the final developer came with more “balanced terms” of both short- and long-term risk.

amount of occupational and property tax a property “generates” for government and the amount of tax revenue generated after the development. The taxing entities continue to receive the “base tax” while the “tax increments” are used to fund public costs of development; i.e., “growth is used to fund growth.” To help fund the planned development of its downtown Belknap Campus, The University of Louisville filed with the Kentucky Economic Development Finance Authority to create a TIF district of more than a square mile on its urban properties. According to Business First of Louisville, over $700 million in public infrastructure costs are expected to be recovered through the TIF over the 15- to 20-year development plan. Teaming with willing developers is key

Teaming with developers to create offbalance-sheet developments is not a new idea; however, the developer taking the “lion’s share” of the risk is seen much less in today’s lending and development environment. At the U of L Shelby Campus, office building develThe value of land opments are a 50-50 venture with the developer and the representative uniTypically, one of the most costly eleversity affiliate, U of L Development ments of any development project is Co., LLC, sharing the development land. The University of Louisville’s costs. Fifty-one percent of revenue from Shelby Campus, located in a suburban leases goes to U of L, with 49 percent business-retail sector in the city’s East going to the developer. There are also End, had 108 acres of relatively undecost benefits of design and construction The University of Louisville used an innovative veloped land. That land has now been that can happen when the developer funding approach when creating an broken into parcels, creating an officebrings the architect to the table, includoffice-research park on one of its campuses. research park that was intended to ing development of a prototype buildhouse research lab tenants to complement the educaing that can be applied over various phases of the tional functions of the university. Phase one is developdevelopment. Developers are also energized to develop ing the first 20 acres along North Hurstbourne Parkway, a campus master plan that permits incremental growth a major activity spine. in phases. This development was not without significant infrastructure investment costs: $10 million-plus total, shared with the Commonwealth of Kentucky, with $4.3 million the responsibility of the university. Taking advantage of creative tax incentives

Many municipalities promote redevelopment through public-private partnerships using tax incremental financing (TIF). A tax increment is the difference between the

Contact Mr. Harrett by email at bharrett@hfrdesign.com or by calling (502) 425-8505. (This article includes information derived from published reports in Business First of Louisville.)

Four Trends That Are Changing Lab Design by John L. Coke, AIA, Project Architect, HFR Design ®

The design of laboratories has evolved rapidly over the past 20 years, with two of the most notable concepts being openness and versatility. But as we progress through the second decade of the 21st century, four trends continue to influence further change in lab design: security concerns, the advent of smaller equipment, changes in chemicals and flammables, and owners’ desire to attract top talent via an attractive and accommodating workplace. Security concerns

Smaller, but more, equipment The miniaturization and sensitivity of equipment continues to evolve. But while the individual footprint of benchtop and floor-mounted equipment may shrink, researchers’ demands for results have not. This has led to the desire to obtain more diverse equipment that can achieve results faster through robotics and automation. Ironically, smaller equipment doesn’t necessarily create more open lab space. In many instances, equipment rooms are getting larger in order to accommodate tried-and-true equipment plus the latest technology to come along.

Owners are demanding more security. Electronic access control devices supplement keyed locksets. Security Smaller quantities of chemicals cameras both inside and outside the lab provide a visual record of who is As advancements in technology continue to entering and leaving make equipment more sensitive and efficient, trends in research indicate that the quantity of various areas. Cameras, card readers and perchemicals used in the lab for research has sonnel are often been reduced. Lab operators can do more arranged to provide a with smaller quantities, which means they layered series of security don’t need to store large volumes of chemithat can be increased, cals, something fire marshals are pleased to based on restrictions. see. Design-wise, this leads to a reduction in This allows the owner to the need for fire barriers and can possibly Natural light and openness are two of the elements that help make for satisfied lab workers. monitor people, equipincrease the square footage of the lab unit in ment and materials control areas. Designs are including fewer visually and by card reader, thumbprint or iris scan. A and smaller designated storage cabinets and rooms for flammables. bar-coded chain of custody becomes a record of materials and samples that can be reviewed if the need arisAttracting top talent es. Naturally, certain functions such as tissue cultures, radioactive material labs, microscope rooms and wash Owners’ desire to attract top-notch talent is also changrooms necessitate a closed space for air ventilation and containment reasons as well as security. Having individing lab design. For example, labs that lend themselves ual closed rooms adds another layer of security within a to collaborative and social interaction present an attraclarger lab or stand-alone building. tive option to prospective workers. New generations of researchers don’t want to be closed off from their colcontinued on page 4

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

New Forensics Lab Provides Morale-Boosting Environment ... (continued from page 1)

conducted there as well, along with research and development. The second and third levels of the building are devoted to office space. The design includes an area for nursing mothers, a meditation room and break areas for employees on the first and third floors. An elevator was replaced, a portion of the floor was lowered, and existing office areas were renovated and reconfigured.

Electricity, gases and data are fed through quick-disconnects/ twist locks at ceilingmounted service panels.

Tennessee native Wilma Rudolph became the first American woman to win three gold medals in track and field events at a single Olympics, achieving that feat in 1960 at the Olympic Games in Rome. She was a student at Tennessee State University, located not far from the site of the new lab bearing her name, and later worked as a teacher and track coach.

Looking from the interior of the lab toward the lobby through windows artistically adorned with sports scenes.

Aegis Sciences Corp., headquartered in Nashville, is the largest independent sports, forensic and clinical toxicology testing laboratory in the U.S., providing a variety of scientific services and programs to Fortune 500 corporations, professional sports leagues, leading colleges and universities, state and local government agencies, pain management physicians, medical examiner systems, courts of law and the food industry.

The lab features an open design with mobile, modular, height-adjustable lab tables and base cabinets on casters, allowing workstations to be easily reconfigured, depending on requirements.

Four Trends That Are Changing Lab Design ... (continued from page 3)

leagues or the outside world. Collaborative work centers are essential in translational research, where multidisciplinary teams document and debate their work. Glass walls dividing labs allow sensitive research to take place securely, while providing a sense of openness. Natural light is always key as well. Simply being able to connect with the outside occasionally not only

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has psychological and morale benefits, but also leads to more efficiency via happier workers. Throughout facilities, artwork, quality finishes, good flooring and other touches help make for an inviting workplace and one in which both owner and employee can take pride. Contact Mr. Coke by email at jcoke@hfrdesign.com or by calling (615) 370-8500.

healthforward report

Membership Has Its Privileges: A New Approach to Healthcare Delivery by Tom Testerman, NCARB, HFR Design-Louisville ®

I returned recently from a business trip, and when I tried to refuel my rental car before returning it, I was declined at the gas pump for “unrecognized customer loyalty.” I had inserted my credit card ahead of my “loyalty brand card.” When I returned home and flipped on the TV, a commercial for a well-known credit card company was running, boasting that, “We have no customers, only members.” I paused to think: Is this the future of healthcare? No more inpatients and outpatients, only members of organizations that manage the care of its members in a manner that affords the highest and best care available in the marketplace by delivering measurable, successful outcomes? Efficiency, performance improvement, member engagement — this “membership” approach embraces behaviors that focus on health and wellness, nutrition, smoking cessation, weight management and chronic disease management by leveraging patient information and medical technology.

As we think about how other types of companies are attracting and retaining their members, are healthcare providers not also evolving into this practice model in a similar manner? We are beginning to see and feel the impact of healthcare reform resulting from the Affordable Care Act (ACA), health information exchanges (HIEs), patient-centered medical homes (PCMH), meaningful use (electronic health records), chronic disease management and patient (member) centered care. At the same time, healthcare providers must look to reduce expenses and boost revenues through data-driven performance monitoring, standardization of staffing models and by leveraging technology, as members will be given the opportunity to shop for their own coverage.

As this retooling and repurposing approach to care unfolds, it presents a range of opportunities and challenges for healthcare facility planners and designers. We find ourselves beginning to think less towards institutional and hospitality design approaches, and more towards customized and Healthcare marketing today is personalized design with the focused not only on traditional amenities and elements that supapproaches that build physician port needs and expectations, referrals and consumer loyalty, enhance members’ attitudes and Architects, engineers and planners meet with the Kansas City but also on member engageelevate their experience. These Chapter of the AIA to plan for change in healthcare design. ment. As health clubs have programs for design will not only trainers to coach and mentor include traditional medicine, but their members, so are healthcare organizations recruitalso will embrace holistic, complementary and alternaing chief experience officers to assume new roles in eletive choices. Duke Integrative Medicine is but one vating member engagement/care management and example; it’s a model that offers a portal to the vast self-management through Internet tools, including spectrum of scientific advances at Duke Medicine, and online communities. In addition, call centers are being an open door to each member’s innate healing power. repurposed to engage patients in post-care follow-up by partnering with each member in an effort to solidify Knowledge, choices and member spirit together form member loyalty. the catalyst for transforming health and healing — care medicine that treats the entire person: body, soul and spirit.

This Issue ...

• New Approach to Healthcare Delivery • Trends in Patient Room Design • Space Standardization

continued on page 4

Current Trends and Issues in General Patient Room Design by Rodney W. Calvin ÂŽ

Mr. Calvin is a recent graduate of the University of Tennessee College of Architecture and Design, where he received a Master of Architecture degree.

The design of the patient room within a healthcare facility continues to be a topic that receives a great deal of attention in the design community. The design of the patient room directly affects the outcome of the patients as well as the caregivers themselves. With the room being the center of interaction between patients, family members and caregivers, it must also meet the needs of each of those individual groups. This means special consideration must be given in the design phase to addressing the issues that affect the relationships between the aforementioned parties.

fall-risk patients. This design, however, also limits the amount of window space for natural light and makes the family zone smaller. In a midboard design, there is a large family zone, full visibility, natural light and significant views, but travel distance for nurses in the corridor is increased. This configuration is also less economical, due to the fact that the rooms do not work within a standardized patient model. There is no clear choice as to which design is best, but staff preference should not be ignored when selecting a configuration.

Infection Control No other issue in healthcare design has affected the change in patient room design more than infection control. Over the past few years there has been an increasing awareness and emphasis on controlling and preventing hospital-acquired infections (HAIs). Hand hygiene is a very important component in the prevention of HAIs. Yet, while most healthcare workers realize this, recommended hand-washing procedures occur only about 50 percent of the time, according to recent studies. With the advent of new technologies, radio frequency identification can now help keep track of handwashing habits throughout the healthcare facility and keep staff aware of their ability to spread infection. Another promising approach - still being tested - is the application of a paint-like coating to walls, surgical masks and other objects in the healthcare facility to help reduce the spread of MRSA (Methicillin-resistant Staphylococcus aureus.) These new technologies will have a direct impact on the design of the patient room in the future.

An inboard toilet limits the caregiverâ&#x20AC;&#x2122;s view of the room from the corridor, but allows for a larger family zone.

An outboard toilet room configuration lets nurses see the patient and the room fully.

Location of Toilet Room A key issue that must be addressed when designing an inpatient room is the location of the toilet with respect to the patient and the staff. Each configuration has a different effect on the perception and use of the patient room. An inboard toilet usually limits the caregiverâ&#x20AC;&#x2122;s view of the room from the corridor; however, it also allows for a larger family zone and provides the most natural sunlight and views to the outside.

Insights from a Post-O Occupancy Evaluation

In an outboard configuration, full view of the patient and the environment is achieved from the corridor, allowing for optimum surveillance when dealing with

The recent case study conducted by HFR Design at Hugh Chatham Memorial Hospital in Elkin, N.C., shed some light on staff perceptions regarding patient room

A large family zone, natural light and significant views are afforded by a midboard design, but travel distance for nurses increases.

continued on page 4

Space Standardization and Overall Geometry by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

The functional programming of rooms in a healthcare facility is a very important and a sensitive concern. Some planners and architects have used a “random space analysis” process that doesn’t relate to the geometry of the room, the functionality of the space or the relevance of “standard room types.” When spaces are repeated by service line — staff offices, exam/treatment rooms, procedure rooms, inpatient rooms, etc. — it is important to seek common ground on the length, width and height of these spaces. Using the “Guidelines For Design and Construction of Health Care Facilities” is a superb starting point. We believe the design should meet and exceed the minimum standards (published by the Facility Guidelines Institute with assistance from US/DHHS). When the geometry is properly established, and the interior functionality determined, one can gain significant value in terms of same-handed layout, continuous safety measures, handicap compliance, optimum size, equivalent equipment arrangements and common environmental attributes by service line. The sensitive study of these standardized areas leads to “optimum functionality” and functional zoning.

Visual impact.

Architect review of geometry and suite.

Over time, this method of “functional” programming saves space, improves efficiency and encourages the safest approach to space use. The acoustical elements, sound transmission between rooms and exterior lighting (windows and skylights) become key design and performance standards that lead to the “most appropriate” final design. Other features of the process will lead to design layouts that can be zoned in “modular” and customized arrangements to more effectively provide improved flow patterns, standardized structural and mechanical systems, and, most importantly, the enhanced opportunity to offer simplified wayfinding and streamlined flow pat-

Site factors.

terns. This is one of the most common areas of concern when conducting campus master planning on larger, more complex medical campuses. continued on page 4

Hart Freeland Roberts (HFR Design) is a 102-year-old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets nationwide from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

A New Approach to Healthcare Delivery ... (continued from page 1)

Just as our shopping behavior trends toward organic food products without traditional additives and preservatives, so also will our healthcare choices reflect these new attitudes and opinions. Will the exclusive “healthcare clubs” that offer these consumers choices emerge as the industry leaders? Let’s face it, membership has its privileges. Contact Mr. Testerman by email at ttesterman@hfrdesign.com or by calling (502) 425-8505.

Current Trends and Issues in General Patient Room Design ... (continued from page 2)

design. Regarding the location of the toilet room, many of the staff members preferred the outboard configuration because of the optimum visibility, which provided the opportunity for quick observation of the patient environment and better safety for the patient. The outboard configuration also allowed for the shortest travel distance from bed to toilet, thereby reducing the probability of a patient fall. The addition planned and designed by HFR for this hospital utilizes the same-handed patient room concept, and the impression from staff regarding this design was very positive. This concept allows for supplies and materials to be in the same place in every room. It seems that the more efficient the workplace, the better the attitude of those who work there. This helps alleviate unwanted stress and helps keep morale high. This may also help decrease nursing turnover, which can be very costly. When you have nurses who genuinely care about the patient’s well-being, are more efficient and less stressed, the hospital becomes a more effective institution. ••• All these issues are key when making decisions regarding the design of the patient room. They should be examined from a variety of perspectives, keeping in mind that what works for one facility may not work for another. The philosophy of the healthcare facility and the preferences of the staff and patients must be taken into account as well. But no matter which patient room design is selected, it will definitely have a direct effect on the efficiency and quality of care provided.

The Advisory Board’s Fred Bentley Speaks on ACA’s Impact Fred Bentley, Senior Director for The Advisory Board Company, recently gave his perspective on the Affordable Care Act to HFR principals and invited guests at HFR Design headquarters in Nashville. The occasion was a special session preceding the HFR Healthcare Division's annual strategic planning conference. Bentley presented an overview of the current issues of greatest importance to the healthcare industry, with special emphasis on how the various provisions of the ACA are expected to impact healthcare providers. He fielded a wide variety of questions from the audience, which included numerous highlevel healthcare executives. An expert in the fields of health policy and service line strategy, Bentley’s research efforts focus on the economic, political and technological innovations that are transforming the U.S. healthcare delivery system. The Advisory Board Company is generally considered to be America’s most respected healthcare research and guidance organization. Space Standardization and Overall Geometry ... (continued from page 3)

In addition, functional programming with space standardization (when appropriate): • Offers a cost savings based on rational ratios of “need to demand.” • Promotes awareness on the part of clinical and operational professionals, helping them see the value and price the components. • Assists in “clustering” and re-zoning inefficient “specialty” programs and designs. • Permits service alignment and re-alignment (in cases of existing facility upgrades) by specialty mix. • Works well with engineering and utility services that are less costly when packaged and designed collaboratively around a modular system, with process, volume and cost in mind. But don’t forget: While it’s true that establishing standard sizes results in efficiencies and economies of scale, and while modular and standardized layouts are certainly here to stay, it’s important that “rubber stamping” not occur. A modular or prototype design does not “fit all locations,” and it is important to balance modular buildings and components with innovative, creative design. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642.

healthforward report

Same-Handed Room Design: What We Learned by Page Onge, AIA, NCARB, LEED A.P., HFR Design ®

Last time in healthforward report, we presented some of the traditional arguments for and against same-handed patient room design. As we said we would, we later interviewed users at an HFR-designed hospital that features same-handed rooms, in order to get comments and opinions from the perspective of people who work in and manage these rooms on a daily basis. Our investigation took us to Hugh Chatham Memorial Hospital (HCMH) in Elkin, N.C. A few years ago, HFR Design completed a campus master plan for this facility and designed a major expansion. As part of that expansion, it was decided that inpatient rooms would be configured with the same orientation — “same-handed” — the idea being that doctors, nurses and others who deal with patients would instantly know where things are, no matter which room they were in.

the ICU. (Our design at HCMH did apply to Med/Surg Inpatient Nursing Units, but wasn’t carried out in Emergency and ICU due to location constraints.) Staff members distressingly commented that they wished we had found a way to apply the concept in the ICU. “Consistency of location is more efficient and reduces errors and critical delays.” There was general agreement that it is beneficial to have uniformity in the location of equipment and supplies. When the staff automatically knows where things are, there is easier and faster access to supplies, plus less chance of supplies being inadvertently located incorrectly, duplicated or missing. Other benefits cited included ease of checking restocking needs, fewer mistakes and quicker access when time is critical due to an emergency/urgent type situation. Various staff members offered the opinion that there is opportunity for safety, security and infection control advantages as well via same-handed design, related to flow, patient/family/clinical zones, and use of the bathroom and shower.

Among those with whom we spoke were: Susan Briscoe, CNO; Don Trippel, CFO; Melissa Bryant, Assistant Nurse Manager of the Inpatient Medical Floor; Vicky Cassell, Assistant An interior view at Hugh Chatham Memorial Hospital in Elkin, N.C. “As long as the rooms are all Nurse Manager of the (photo by www.SkySiteAerial.com) the same, whether they are Inpatient Second Floor; and right-h handed or left-h handed doesn’t matter.” The curTrish Harold, Nurse Manager of the ICU. rent school of thought is to have the patient’s right side Below is a summary of what our interviewees had to toward the door. Hugh Chatham, however, is set up say: with the patient’s left side toward the door. According to our survey group, the hospital has not noticed any “Same-h handed rooms are better.” The consensus was issues that would make right-handed rooms more that same-handed room design is definitely preferred. favored than left-handed. They concluded that choice of The group felt that it was even more important in quickwrist for ID bracelets, choice of hand/arm for IVs, rightaction areas such as the Emergency Department and handed patients reaching for things and signing things are not significant enough reasons to have the patient’s right side toward the door. IVs are put in the best This Issue ... hand/arm vein and do not necessarily favor a side. • Same-Handed Rooms: What We Learned

• Future of Service Delivery in an Outpatient World • Going Tankless in Steam Boilers

continued on page 4

The Future of Service Delivery in an Outpatient World by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

HFR Design and the HFR Healthcare Division have been busy this past quarter with active project work and collaborative involvement with three associations: the American Academy of Medical Administrators (AAMA), the American College of Oncology (ACOA) and the Kansas City Chapter of the American Institute of Architects (AIA). Participating in these sessions were your author along with Don Pierce of HFR’s Kansas City office. The AIA/KC session was an example of professional sharing of ideas relating to “The Future of Healthcare Delivery In An Outpatient Environment.” During this session, Don and I shared planning and design experiences from recent projects that involved both the design of free-standing ambulatory care centers and the growing world of high-volume cancer care. Approximately 25 participants — specialty architects, engineers, contractors, developers and guests — took part in the session and focused on WHY and HOW we should research the planning for innovative ambulatory care in the future. Our host was the Menorah Medical Center (a wonderful example, in itself, of great architecture embracing the users, patients and families). The WHY question relates to the growing expectations of change in healthcare delivery in America. As we all know, The Supreme Court has ruled on the status of accountable care and insurance reform laws. There are sure to be more challenges to the law, but this was a monumental decision. At a recent national meeting of the Health Care Advisory Board in Chicago that I attended, the topic was about “transitioning the healthcare business in a value-based economy.” I’m optimistic that change is healthy and that we are moving in a meaningful direction in America. Facility planning, operational enhancements and design will play a role in this change. HFR Design is going to be proactive; our work will complement the changes in America. Ambulatory and short-stay care generally boil down to process improvements (people drive the process), which are both service- and staff-oriented and impacted by the design of the building. The building is a key factor in the cost of care, starting with the initial capital outlay and continuing through the life of the program. The location, design features, tenant mix and infrastructure continuously impact the services for an average of 30+/- years. Herein resides another aspect of the “why” question. The initial capital investment is small, the long-term operation costs are monumental!

Architects testing the pieces to see how they fit on the site.

Drawing the components to scale on the site; teamwork reaches the best solution.

Our host for the Kansas City session, Menorah Medical Center, sets a good example with an excellent campus master plan.

continued on page 4

Going Tankless in Steam Boilers A North Carolina hospital finds a cost-efficient solution When individual homeowners replace old water heaters these days, many opt for a tankless water heater rather than a regular storage water heater. The tankless models heat water fast, and makers claim they cut energy costs. Hugh Chatham Memorial Hospital (HCMH) in Elkin, N.C., decided to do something similar, but on a much larger scale, when it came time to upgrade their steam boilers. It should be noted that Hart Freeland Roberts master-planned and designed a $25 million expansion and renovation of this hospital, located about 45 miles west of Winston-Salem. “After construction was finished on the expansion of the hospital in 2010, we had no redundancy in our boilers,” says HCMH Plant Operations Director Brent Slate. “We were running our three boilers at 100 percent capacity all winter. We knew something had to be done.” The hospital’s boilers serve its sterilizers, domestic water and kitchen steam tables, and provide heat throughout the facility.

Miura’s gas-fired, on-demand LX Series models were selected to replace Hugh Chatham’s outdated boilers. Two LX-150s and one LX-100 now handle the hospital’s needs with capacity to spare, providing a total of 400 horsepower versus the 300 horsepower of the previous boilers. Whereas the old boilers required water tanks of about 2,000 gallons each, the new models have chambers that hold only 50 gallons. That’s due to the fact that the Miuras don’t require a “reservoir”; the water is heated as it passes through the heating chamber. Miura claims that, based on today’s fuel costs, its boilers offer an average dollar savings in steam production of approximately 20 percent over other designs. The company also touts reduced energy consumption and reduced greenhouse gas emissions. In addition to a savings in energy, the improvement in performance of the new HCMH boilers has been dramatic. The new boilers can go from cold to steam in five minutes; the old boilers — if they had been off long enough to get cold — required at least 45 minutes to an hour to get up to steam.

The new boilers can go from cold to steam in five minutes. To help alleviate the boiler problem, HCMH assigned Duke University intern Erin Shawn the task of researchThe efficiency of not having the heat loss from a big ing the various types and makes of steam boilers on the reservoir of hot water translates into a return-on-investmarket to see which offered the most reliability, cost ment of about four years. If energy prices go higher, the efficiency, energy savings and reduced environmental ROI gets even shorter. Meanwhile, Slate estimates a impact. She determined that Miura Boiler, a Japanese savings of $50,000 to $95,000 a year in gas, water company that is one of the world’s largest boiler manuand electricity. facturers, might offer products that would best fit the hospital’s needs.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Same-Handed Room Design: What We Learned ... (continued from page 1)

The Future of Service Delivery in an Outpatient World ... (continued from page 2)

“There is no advantage to having a percentage of rooms opposite-h handed to accommodate patients with medical issues that would be on the far side in the typical room orientation.” Some argue that it is good to have some rooms that are opposite-handed, so that when there is a patient with a broken arm, for example, that patient can be placed in a room that allows the broken arm to be toward the door. This allows the medical staff to directly examine and care for the medical issue without having to go around to the other side of the bed. The HCMH managers we questioned indicated that if they had such a patient, the opposite-handed rooms might already be occupied, and they said that it is not a problem for the staff to go around to the opposite side of the bed. They agreed unanimously that the benefits of same-handed rooms outweigh any benefits that might be derived from having a percentage of opposite-handed rooms.

The HOW question relates to the architectural methods used for master planning and programming the components of this mixed-use ambulatory care development. Below is the approach our AIA architecture/engineering/builder/developer team used in planning the optimum outpatient healthpark and cancer center. The “key drivers” of the process included:

“Same-h handed room design should include consistency of light switches and electrical receptacle locations.” The healthcare professionals we interviewed at Hugh Chatham not only preferred the same-handed room concept, as we have seen, but actually went beyond the typical design considerations in their advocacy of it! Perhaps architects and engineers — as well as healthcare facility owners and administrators — can benefit from this revelation. It does seem that from a construction and maintenance perspective, having intakes, vents, switches and other surface features in exactly the same place in every room could enhance efficiency. ******* What we learned from our visit to Hugh Chatham Memorial Hospital certainly can’t be labeled definitive as it applies to patient room design. We simply talked with several users at one facility that features samehanded rooms. The subject warrants further study. But if one can extrapolate from the comments we received, it would seem that user consensus points toward the same-handed room concept, and that, over time, the design may produce more effective positive outcomes. Contact Mr. Onge by email at ponge@hfrdesign.com or by calling (615) 370-8500.

• Pick the Right Site for the Right Reasons (Access, Quality, Cost, Growth Over Time): - A Major Intersection - Views To and From the Site - Land Areas Suitable for Other Healthcare Partners and Expansion Over Time - Appropriate Neighborhood with Convenient Consumer Access • Program the Services to Meet the Need - Accurate Service Categories - Correct Quantity and Size of Spaces - Revenue-generating Areas Balanced With Community Need - Service Types Complementing the MultiSpecialty Mix of Physicians - Proper Building and Room by Room Sizes • Master Plan the Service Components to Maximize Flow and Convenience • Create an Identity and Image Reflective of Quality and Care • Involve the Service Leaders in the Process • Run the Pro Forma For Each Venture and Service Venue • Benchmark the “What If” Scenarios • Benchmark the Design Against Other Winning Solutions • Listen to the Consumers and Stakeholders Our AIA Work Group conducted the site planning and concept developments in about four hours of very intense work. We had worked in advance, of course, using Google Earth and demographic factors to select a “strategic site,” and we involved the experts in our group in helping program the elements, testing the zoning of each element and preparing a conceptual master site plan that was very nice and worked effectively. Your author had prepared a “benchmark design” in advance, and we compared the two to achieve our “learning objectives.” Yes, architecture by team is possible, and all of us can learn each day from each other. Good job, AIA/KC, our Menorah Medical Center host, and thanks to those in our audience who remain committed to the new world of outpatient care and specialty niches that embrace us with better design and improved care. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642.

healthforward report

Same-Handed Room Design: The Jury is Still Out by Don Pierce, AIA, Director, Kansas City Office, HFR Design, and Page Onge, AIA, NCARB, LEED A.P., HFR Design Pierce

Onge

There have been many discussions — and many articles written about — the same-handed patient room concept versus the more standard mirrored room concept. (The same-handed concept, by the way, doesn’t apply just to med/surg patient rooms, but also to rooms accommodating a higher patient acuity, such as ICU rooms, ED treatment rooms and ORs.) The basic reasons for choosing between the two concepts have to do with staff efficiency, crisis reaction time and patient care versus initial construction cost. It is generally accepted that mirrored patient rooms cost less to construct than same-handed patient rooms, due to plumbing and electrical service run lengths and the economies of a “shared support wall” between two rooms. It is also generally accepted that same-handed rooms improve staff workflow, efficiency and ultimately better patient care. However, there is little empirical data to support either concept. It is important to note that construction cost is a comparatively much smaller proportion of overall costs of the operation of a healthcare facility. Often decisions to save some money on construction cost cause detrimental impacts on such things as staff efficiency and injuries, patient care quality and outcomes, utilities consumption costs, maintenance and replacement costs, and patient and staff satisfaction. The costs of these items may easily negate the construction cost savings in a very short time. Those who argue in favor of same-handed design typically point out the following attributes: • The door and bathroom are always in the same location. • Nurse, MD and student always work from the same left/right location. • Headwall items never shift. • Orientation to foot of bed and headwall places items in the same spot in every room.

This Issue ... • Same-Handed Rooms • Heart Center Planning • Profitability Through Design

• The ceiling is continuous and AC/electrical and infrastructure are always the same on each unit. • Risk of disorientation is eliminated via modularity. • Patients can be oriented so their ID bracelet is always on the right-hand wrist and always on the side toward the door. Likewise, right-handed patients can easily reach for things and sign things if their right side is oriented toward the door. continued on page 4

Those who favor same-handed room design, illustrated here in a typical floor plan and room rendering, say it benefits both patient and caregiver.

Toward a New Concept in Heart Center Planning by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

The American College of Cardiovascular Administrators (ACCA) recently came together in Chicago to share, learn and improve their leadership skills. Having been involved in the ACCA and the many worthwhile programs hosted by them over the years, I was especially honored to be invited to speak on the subject of “Heart Center Planning: Bundling Services, Architecture and Fees.” I’ve learned that this is a topic of great interest to the industry. But why, one might ask, would administrators, owners, operators and managers of healthcare programs want to know about this? Actually, there are numerous reasons. For example, any one of us could have a serious physiological complication leading to a “breakdown” of our cardiovascular system; respiratory and cardiovascular diseases rank near the top in the world of “most common killers” (with heart disease and cancer, respectively, first and second).

ing heart centers. But guess what? The future is about to offer us new and cost-efficient ways to “bundle” our heart care while bundling the expense and coverage. What I see on the horizon is this: a continuum that is more efficient, less expensive, more humane, more appealing architecturally and ultimately more successful than ever before. I’ve written and spoken many times about the various aspects of cost, affordability and care outcomes. I’ve written about “care with people in mind” and “care with heart.” Those topics are extremely important, but so is this: The art and architecture of specialty centers is effectively provided by the Leonardo da Vincis, Rembrandts, DeBakeys and Frists when we follow some clearly defined rules: (1) Never engage a planner or an architect who has never designed a healthcare facility or a heart-related center; (2) Never shortcut the fees that apply to the pre-design planning, programming and functional analysis; (3) Never develop a heart center, cath lab, pulmonary clinic, vascular center, special care bed area or shortstay center without involving the departmental director, nurses, technical staff and a patient or two.

Anyone who has been afflicted by heart disease recognizes that you encounter the buildings, systems and technology as you move through the curative phases of the disease that you have suddenly encountered or have lived with all your life. At the same time, you’re required to face the rigSomeone once asked me, “If ors of registration, insurance you’re planning a new heart coverage, fear of demise, center, why can’t you just delong walks from the parking sign it and not involve the Seen here are two slides from a presentation by the author garage, waiting in the waiting physician, nurse and patient?” at the recent ACCA leadership conference in Chicago. room and, possibly, outpatient My answer was, “Well, you can, treatment, cardiac catheterization, MRI/CT or US, invabut I can practically guarantee you won’t like the resive or minimally invasive surgery, recovery and long, sult.” Next time I’ll discuss how the participatory design wearisome hours of post-operative or post-interventionprocess offers value in a world where time is money! al rehabilitation. We ACCA members call this the “full continuum of care,” and discuss it intently when planning and design-

Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642.

Profitability Through Design by Sammy West, Director, Jackson Office, Hart Freeland Roberts ®

These are tough economic times, and the healthcare industry is not immune to these forces. The number of uninsured and underinsured patients is growing; insurance and particularly Medicaid reimbursement is shrinking. In this economic environment, all industries are looking closely at the bottom line, and extreme measures are often contemplated to increase profits, lower expenses and generally control costs.

also allows more profitable services to be added or enhanced. As more and more records become electronic, reducing the need for large amounts of storage space for these files, an opportunity to pick up revenueproducing space is presented. Utilizing space to its maximum productivity is a goal to which designers and planners can contribute significantly.

Have you considered how design can help with these issues? Accounting While not as much a design issue as an accounting “trick,” utilizing products that can be purchased as fixtures, furnishings and/or equipment — as opposed to being built-in — can help with the bottom line. These products can be depreciated over Hospital interiors that incorporate Planetree principles, such as this example at HFR-designed Valley View Hospital in Colorado, a shorter time frame, contribute to greater patient satisfaction and ultimately a healthier bottom line. (Photo by Scott Dressel-Martin) providing tax benefits that will affect budgEnergy Efficiency ets positively. The designer would know about the available products and how best to incorporate them. Utilities are a major line item of hospitals’ budgets as well as those of most other healthcare facilities. Plan Flexibility Incorporating green technologies and LEED principles Designing for adaptability in the floor plan can reduce can mitigate these expenses. Lower-wattage lighting, square footage, thus saving money on a construction high-efficiency HVAC, better-insulated building budget. This flexibility of space allows non-profitable continued on page 4 services to be reduced, eliminated or outsourced. It Hart Freeland Roberts (HFR Design) is a 102-year-old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Same-Handed Room Design: The Jury is Still Out ... (continued from page 1)

• Toilet elements and design are the same for each room. • Exterior windows are always the same. • Nursing traffic patterns to the room remain the same. • From the cost standpoint, the same interior components are purchased, which lends itself to modularity. However, one of the few studies conducted, at the University of Texas Arlington’s Smart Hospital and outlined in the Herman Miller Healthcare research summary 2011, found that same-handed rooms have minimal positive effects on staff workflow. Other components of the patient room have a greater impact in increasing staff efficiency and service, such as standardized headwalls, IV location and overall view of the room upon entering. This study concentrated on med/surg patient rooms and used nursing professionals in the research process. Yet, one must consider the advantages of same-handed room design in high-acuity patient areas. Familiarity with the room and its accessories is one of the advantages of same-handed room design with regard to staff efficiency. This becomes more important in rooms such as ICU, ED treatment areas and ORs, because in urgent situations, staff should not have to search for material and equipment to treat a patient. Thus, having everything in the same location becomes a “safety and standardization” measure. In defense of mirrored-plan patient rooms, there are some advantages in addition to construction cost savings. If a patient is left-handed, that patient can be placed in a room where his or her left side is toward the door. In the case of surgery or a broken arm, the patient can be strategically steered to a room where the affected side would be toward the corridor door, thus eliminating the need for medical care providers to go around the bed. HFR Design has two projects that were designed using the “same-handed concept”: a small Critical Access Hospital and a larger, acute care hospital. Both facilities have been operational for about two years. We are comparing the results and will report our findings in the next issue of healthforward report. Contact Mr. Pierce by email at dpierce@hfrdesign.com or by calling (816) 822-8500. Contact Mr. Onge by email at ponge@hfrdesign. com or by calling (615) 370-8500.

Profitability Through Design ... (continued from page 3)

envelopes and similar efficiencies reduce consumption and lower utility costs. Some utility providers offer credits and incentives to offset the costs of implementing these improvements. Staff Productivity Labor costs are one of the largest expenses in most budgets. Through proper planning and design, healthcare professionals can be more efficient, productive and content in their jobs. This eases their workload, reduces stress and improves performance. Incorporating durable materials that require little upkeep reduces the number of custodial and maintenance personnel needed, meaning it may be possible to achieve similar or even better results with fewer employees. Patient Experience While it may not be as evident as some of the other suggestions above, providing an attractive facility that incorporates the Planetree philosophy can have a profound effect on the bottom line. Integrating these patient-centered principles contributes to greater patient satisfaction and shorter length of stay, and a patient who is pleased with his or her treatment is much more likely to recommend the facility to others. These same principles can also help attract and retain physicians, nurses and other staff by giving them a comfortable work environment, thus providing the organization with the most qualified professionals. It will also reduce the time and effort spent training new hires. If you are looking to improve the bottom line, the first place to turn may not necessarily be the accounting or personnel departments. Architects, engineers, facility planners, interior designers and other design professionals have many of the answers to improving profitability, and the solutions they offer may, in fact, be more sensitive, compassionate and long-range than many of the immediate, drastic measures being contemplated today. Contact Mr. West by email at swest@hfrdesign.com or by calling (731) 421-8000.

healthforward report

Project Development Costs: Finding the Right Answers

Take the Time to Get It Right

by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design

by Rodney L. Wilson, PE, President, HFR Design ®

The pricing of a project begins with the facility master plan and is refined in more detail during the functional program ming phase. During a recent master planning discussion, the HFR consulting team investigated project cost distribution and found that the one area healthcare providers should not cut expenses in is the very early programming phase of a small project’s life. The fee expended by the owner for this phase of “business analysis” through effective programming is less than two percent of the total project cost. On a $2.5 million project, saving 100 square feet is worth $26,000. What if the savings in square footage were combined with reductions in equipment purchases (possibly lease vs. purchase), reduced site improvement expenses (reduced excavation expenses) and reduced utility expenses through energy conservation. The savings would be significant, achievable and logical! What are the factors that come into play during the planning of a healthcare project? The responsible planner/architect/ engineer will assist with the assessment of these initial costs combined with the return on investment (ROI) for savings over time, for example: • Defining From the Outset the “Reasonable” Needs for the Project: - Outcomes From the Asset - Revenue Enhancers vs. Expenses Incurred - Efficiency Measures and Added-Value Attributes - Optimum Space Needs • Assessing the Site Location, Preparation and/or Site Improvements: - Parking - Utilities and Hidden Infrastructure Costs - Site Preparation and Phased Improvements - Security, Safety and Convenience Factors • Comparing New Construction and Renovation Expenses: - Square Footage Occupied - Building Utilization and Space Efficiency - Energy Utilization and Life/Cycle Costs - Infrastructure Expenses and Code Compliance • Considering Medical Equipment, Furnishings and Furniture Carefully (ROI Factors) • Information Systems, IT and Electronic Medical Records • Time Savings In Project Duration/Early Completion Incentives (Inflation Possibly $161/Day+) continued on page 4

This Issue ... • Project Development Costs: Finding the Right Answers • Programming and Designing for Disaster Planning • Working with Local Government: 10 Keys

Things are really getting exciting, because you’ve narrowed the project down to a site or even a few sites for your new building. Seems most times this narrowing is based on very obvious factors such as land costs or proximity to your target market. But before you execute that contract, take the time to consider the many potential additional costs for land development that may come into play with that particular site or sites. Zoning restrictions/requirements, subdivision and land development requirements, stormwater management (quantity/quality) requirements, parking requirements, landscaping requirements, site adjacent utility capacities, off-site utility improvement requirements, poor soils, filing fees, special inspection fees ... the list goes on and on. Site development costs could range from a minimal percentage of the total project cost that could be absorbed by traditional building per-square-foot estimating to in excess of 20% of the total project construction cost — or even more. On top of the cost of these accessory site improvements for a new building project, the engineering fees associated with these improvements and the potential legal fees for zoning and land development should be considered. The land development process for sites can vary greatly with regard to the costs of land development and the time required for approvals to bring a project to fruition, even just across the street. So make sure that you have asked yourself, “What are the potential land development costs beyond the cost of the building itself?” Remember, infrastructure is costing more than ever before as sites become less desirable for development and regulations governing land development become more stringent. There is good news: There are engineering consultants familiar with all of these frequently hidden or overlooked issues, and it’s almost certain that whatever engineering fees you incur for these early site selection/evaluation services, the odds are high they will be more than made up in savings on the ultimate project. You may not want to hear the consultant’s findings, especially if you like everything about the site, but it’s much better than receiving some really costly surprises later on. Contact Mr. Wilson by email at rwilson@hfrdesign.com or by calling (615) 370-8500.

Working with Local Government: 10 Keys to Making Sure Everyone Wins by Page Onge, AIA, NCARB, LEED A.P., HFR Design and Kyle Dunn, Client Service Specialist, HFR Design ®

In fulfilling our leadership duties and responsibilities in a healthcare facility, we are going to come into contact with local and state government officials from time to time. It may be as innocuous as chatting with the mayor prior to a ribbon cutting, or it may be interaction with a regulatory official who has the authority and right to cause drastic changes in the way we do things — and possible headaches for us and our staffs. How well we communicate and interact with government officials significantly affects the ease, cost and schedule of the project. The myriad of technical requirements in codes and regulations often can be interpreted in different ways. We are all human and therefore imperfect. Good communication, respect and appreciation smooth out the process of project approval and help make a better project. Below are 10 important things to keep in mind: 1. Do your homework. Find out who the people are and what the regulations are. Meet with them to confirm that you aren’t missing anybody or any regs. Include these regulatory officials in all correspondence and emails that are generated. 2. Show everyone involved respect. This cannot be overemphasized. To get respect, you have to show respect.

Onge

Dunn

6. Share their goals of following the regulations to create better, safer buildings and communities. Don’t try to get away with doing less than what is required. Generally speaking, the regs are the minimum. 7. Don’t argue. Instead, ask questions. Tell them you don’t understand and ask if they can explain. Or say you thought it was this way, but you may be mistaken. There is never a dumb question, and they’d much rather have you ask and then get it right. 8. Allow them to be part of the project team. Typically, government officials aren’t supposed to offer design solutions, but there are ways for them to indirectly suggest solutions to be designed by the A/E. Keeping them on the team makes for a smoother-running project, because everyone stays informed as to the project’s progress and can be involved in solutions as problems and opportunities develop. In addition, everyone has a desire for a successful project, because when they are invested in it, they tend to put more energy and effort toward its success. 9. THANK THEM! The more you thank people, the more likely they will be to want to help you again. It has been our experience that if you thank someone for responding quickly, for example, they will try to top their response time at the next opportunity!

3. Get to know them. Getting to know local officials helps pave the way for a cordial working relationship. It’s amazing how accommodating people can be when you are friends and have some common 10. GIVE THEM CREDIT! If they were part of the team, connections. Those connections always exist; you just have they deserve part of the credit for a successful project. They to find them. Some questions about them and their backdon’t get enough of that! Every individual responds posigrounds will help reveal those connections and build that tively to hearing his or her name mentioned and having friendship. Find out about their background, where they some time in the spotlight. are from, what college they attended. ~~~~~ 4. Don't waste their time. While you do want to get to Whether or not you commit the 10 keys to memory, there’s know them, you don’t want that process to become bura simple, underlying key that will always stand you in good densome to them. So be careful regarding No. 3 above. stead when dealing with a government official: Think Play it by ear. It’s a balancing act. about how you like to be treated, and treat that person the same way. The Golden Rule really does work! 5. Do the necessary paperwork, even if it’s the thing you dislike the most. If you want to get the result you want, you Contact Mr. Onge by email at ponge@hfrdesign.com or by calling must give them what they ask for! (615) 370-8500. Contact Mr. Dunn by email at kdunn@hfrdesign.com or by calling (615) 370-8500.

Programming and Designing for Disaster Planning by John R. Potter, Jr., AIA, Senior Vice President and Project Architect, Healthcare Division, HFR Design ®

Whether nature unleashes a natural, pandemic or manmade disaster, or an act of war, disaster planning for such is in the forefront of most healthcare facilities. It will happen when you least expect it, that event that triggers a mass casualty healthcare emergency. Your plan is in place, you have rehearsed and trained for an event, and use the facility to the best of your ability. After the event and debriefing, and the resulting afteraction report, was it determined that the facility design facilitated the event response? If it didn’t, then was a mass casualty healthcare emergency part of the planning, programming and design of your facility? If it wasn’t, should it have been? Many facilities are being proactive on this front to make preparations to allow expanded services during a mass casualty event or other restricting event. We have seen a positive response from medical facility staff to try to identify

circumstances, events and potential time periods that could aggravate or increase the mass casualty load. The problems include the obvious: weather-related events such as hurricanes, tornadoes, snow and flooding; massive range and forest fires, rock slides and volcanic eruptions; as well as aircraft, traffic and industrial accidents that isolate and disrupt transportation. The threat of biological, chemical and nuclear weapons just adds to the list. The challenge is to identify the potential threats and to evaluate the level, probability and length of time that the event may last. For each of the threat items, these variables will vary based upon the location and other evaluations. These will all require probability-and-risk-analysis studies. For example, a volcanic eruption in Washington or Oregon — in addition to causing a great deal of destruction — continued on page 4

This floor plan for a portion of HFR-designed Valley View Hospital in Glenwood Springs, Colo., shows the relationship of the emergency department to the special procedures area, providing a quick expansion option in case of a mass casualty emergency.

Hart Freeland Roberts (HFR Design) is a 102-year-old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Don Pierce, AIA Director, Kansas City Office (816) 822-8500 (816) 520-0529 dpierce@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Project Development Costs: Finding the Right Answers ... (continued from page 1)

Many of these cost factors should be developed as a “yardstick” for measuring the affordability of a project. A responsible program measures function, form, economy and time balanced against the owner’s goals; facts plus evidence; efficiency concepts and rational functional needs. The “economy” goals, objectives and outcome measurements are crucial these days, with access to capital dollars being a major concern for all our clients. The “ideal functional program” includes a project budget that links to the “size of the project” and its added-value attributes. As those square-foot savings are identified, costs go down. If space increases, targeted “revenue enhancements” that support the “bottom line” should be considered. This is another justification for “iintegrated healthcare networks” that maximize resources, relocate services to centralized locations, and redistribute capital assets to provide the right services that are right-sized for the right reasons in the right locations. It is worthwhile to consider hiring consultants who are cost-conscious and willing to spend the time to determine what is most appropriate in the very early stages of project development. The ROI “fee factors” will prove invaluable to the informed consumer of planning services. By the way, that $26,000 savings was more than the fee charged for the pre-design services, and the space reductions were far greater than 100 square feet. It appears the payback was worthwhile and sustainable! Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642.

Programming and Designing for Disaster Planning ... (continued from page 3)

could isolate parts of eastern Oregon and Washington along the Columbia River, causing extended disruption in the supply of utilities and basic goods. There are areas along I-70 in western Colorado that pass through canyons and gorges that can be blocked or closed due to rock slides, snow or vehicular accidents, resulting in major delays in the delivery of supplies and goods. The memory of Katrina is still fresh in everyone’s mind: Facilities were knocked out of operation or ran out of backup supplies or fuel. The possibility of any of the events described above might suggest that additional emergency fuel capacity and basic goods storage be provided. The most probable event is a highway accident involving a bus or multiple vehicles, which could create a mass casualty event. What is a facility to do, since it is not reasonable to just build extra space to accommodate such an event? Careful consideration should be given to departmental adjacencies, to allow for cross-utilization of space if the need should arise. For example, by designing an outpatient surgery and minor treatment facility adjacent to the emergency department, the quick use of the area for a mass casualty event is facilitated. Other outpatient facilities, such

as cancer centers and sleep labs, can also be used to provide expanded treatment areas. With the current national trend of physician and physician groups becoming hospital employees, multiple opportunities are presented to quickly mobilize and augment the hospital emergency team. The additional use of their offices at the hospital site to treat minor injuries after a triage could greatly expand the treatment spaces, but could also create more demand for backup power, heating and cooling systems. Finally, it’s important to keep in mind that the hospital is not alone in trying to prepare for catastrophic events. Joint planning with local, state and regional governmental emergency management agencies is required to help evaluate the hospital’s responsibilities and risk assessment as it relates to the continuing operation of the facility during a disaster or mass casualty event. Contact Mr. Potter by email at jpotter@hfrdesign.com or by calling (615) 370-8500.

healthforward report

Why Involve Users?

Healthcare facility designers need their input by Scott Corbin, AIA, Vice President, Principal, Healthcare Division, Hart Freeland Roberts ®

Most people wonder how architects design buildings. I have been asked that question myself a few times over the years. And sure, we could just work in a vacuum and create. But realistically, that only works for your own buildings or house. The minute your spouse sits down next to you, the other user gets involved and must be listened to with polite smiles and affirmative nods of the head. It’s really the foolish architect who doesn’t involve the user, and that is especially true in healthcare design. Hospitals are a moving target. The technology of the healing environment today is advancing exponentially. Couple that with psychological advances in healing, such as the Planetree philosophy, and one begins to realize just how complex today’s healthcare design issues are, compared to yesterday.

The St. Joseph ICU project is a good example of why and how to involve users. The design has no central nurses’ station. It used a breakaway medical column that traveled with the patient to surgery and back, for example. The in-room toilet for the patient was concealed when not in use. The windows were very oversized to promote circadian rhythm by allowing large amounts of sunlight into the room. This kind of design comes from the involvement of users — staff, spouses, family members — plus a little research into the subject. It won’t happen by designing in a vacuum. My first ideas on a state-of-theart, “same-handed” patient room were crafted with input from the Director of Nursing and her staff at Hugh Chatham Memorial Hospital in Elkin, N.C. Their rooms were grossly undersized and shared with other patients. Through numerous sessions with the nurses about exactly what it was they did every day inside the patient’s room, I was able to design a private room that caters to patients, families and the nursing staff. The design takes advantage of evidence that told us that medical errors in the patient room would be reduced if all rooms were exactly alike, versus the old combination of left-hand and right-hand rooms the staff had to work in.

I always learn when I begin a new design. The genesis of the award-winning Intensive Care Unit at St. Joseph Medical Center in Kansas City started with focus groups and a fresh, new pad of lined paper to take copious notes. The first group interviewed was former patients. I was eager to learn Hugh Chatham Memorial Hospital ICU nurse Carolyn Hall reviews plans for what their experiences had the hospital’s new ICU with lead designer Scott Corbin, AIA, of HFR Design. been and how the design could benefit from what they had to say. However, it turned out they were unconscious most of Users offer a tremendous wealth of knowledge that really should the time they had been in the hospital, and therefore didn’t and must be used — especially in healthcare design. As science remember much. I saved a lot of notebook paper on that. impacts medicine and healing, we are realizing that the knowledge of healing is advancing in a manner that requires that the The second group to be interviewed was the spouses and family buildings housing healthcare-related activities be adaptable. They members. Oh my goodness! That was a goldmine of information. must allow for rapid change to meet quickly changing market And they became the real clients. With that group, I needed extra conditions and pressures. What was a cardiology department last notebook paper. year may have to change to become additional emergency department space today. All of that requires meaningful input in the design phase from a team of users. The best healthcare facilities of today and tomorrow will reflect that input when they are This Issue ... constructed. • Why Involve Users?

• Lessons in Looking • Accountability Beyond ACOs

Contact Mr. Corbin by email at scorbin@hfrdesign.com or by calling (816) 822-8500.

Lessons in Looking Gaining a New Perspective on Your Facility by Marjorie Moody, Registered Interior Designer (NCIDQ Certificate #015604), and Leonard Lutche, Registered Interior Designer (NCIDQ Certificate #016482), Interior Design Department, HFR Design ®

You spend the majority of your time working at your facility and probably know it like the back of your hand. But there may be things you no longer notice that instantly give a patient or visitor one of their first impressions of your facility — and that impression may not be positive. An important concept of design is the concept of design continuity: continuing a single concept or multiple design ideas with a common thread throughout an entire project. Design continuity can be achieved by something as simple as base and trim color or a type of wood, or something more complex, such as an architectural design style. If you’re fortunate enough to be starting off with a completely new facility or renovating/expanding a department within your existing facility, there are finishes that require less periodic repair and maintenance. They may have a higher initial cost, but will cost less to maintain and will look better over the long term. Accent colors can provide continuity of design, and if used truly as accents, rather than dominating/overwhelming a space, they will also help your facility look good, and not dated, longer.

If signage is used as the “accent” color, you may be locking yourself into working with a dated color longer. Signage is rather expensive to completely upgrade throughout a facility, but a dated color can be improved in increments. A more timeless, neutral color can be used within newly expanded and renovated departments. But even more important than updating the aesthetic appearance of your signage is updating the information it conveys, which should be kept current as each renovation takes place.

Rainbow Effect: Continual partial patching and renovation can produce a clashing, rainbow effect. Rather than patching the original turquoise casework, replacing it all with a neutralizing, warm wood-tone laminate would have made the subsequent partial renovations and the accent colors within the department more cohesive.

A hospital is continually evolving. There will always be the need for architectural renovation due to changes in functionality and, hopefully, continued growth and expansion of services. These are necessary and provide a return on investment. However, the value of periodic, aesthetic, interior finish renovations is more difficult to quantify and, unfortunately, may not occur as frequently. The same is true for repair and maintenance of aesthetic items. Just as dated finish materials and colors detract, so can visible disrepair and damaged finishes give a negative impression. Unfortunately, due to renovation, maintenance and repairs, patching of existing materials can’t be avoided. But thoughtful planning of the patch work can make it less obvious and more cohesive with the existing finishes. Whatever the nature of the renovation project, it is imperative that attic stock material be provided for future patching of finishes and that thorough records be maintained of the finishes used throughout. This will help minimize patching with mismatched materials.

Negative Impression: (left) Damaged laminate, peeling wallcovering, stained ceiling tiles, etc. give a negative impression.

You may know exactly how to get from one place to another within your facility and probably don’t even notice the signage along the way, but navigating through a hospital can be like walking through a maze for patients and visitors. It adds to their stress. Directional and room signage needs to be clear, concise and, most importantly, current to enable patients and visitors to get from one place to the next. Another example of something that may appear dated or that may clash with that which has been recently updated is the wall protection. Unfortunately, “it is what it is,” one of those necessary evils that provide a great benefit but typically have an “institutional” look. Since wall protection is not a “design” element, we recommend that it be a neutral tone, rather than an accent color, which will help keep it from becoming dated. Down the road, less has to be updated, and the neutral tone is less likely to be discontinued by the manufacturer.

Too Bold: (above) Strongly colored signage makes future renovations more difficult and costly. Keeping it neutral allows for easier color scheme updates over time.

In a recent tour of a facility, we noticed that several different, mismatched shades of wall protection were used throughout adjacent corridors, most obvious where those corridors intersected. The facility leadership hadn’t previously noticed this, but once it was pointed out to them, replacing the vinyl covers of the existing wall protection was added to the interior finish upgrades so that it would all be one consistent, neutral tone. Many hospitals are embracing a hospitality-driven style of design. It is much more pleasant entering a hospital that is warm and inviting, with natural light, plant life, comfortable seating, simple floor patterns, and design features such as fireplaces. Planters in the lobby finished in the same stone as used on the exterior of the building are one way of creating design continuity from exterior to interior. continued on page 4

Accountability Beyond ACOs (Part 2 of a 2-part series) by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

In “The Impact of Health Insurance Reforms Through ACOs,” presented in our third quarter issue, we looked at the healthcare delivery system from the perspective of how it is being impacted by the Affordable Care Act and Accountable Care Organizations, examining the insurance component of healthcare reform along with accountability in the traditional sense as it applies to individual healthcare providers and design firms. In this final installment, we examine accountability as it applies to functional programming, campus master planning, architectural design, the care team, patient care environment, and sustainable building/resource management. Accountable to The Functional Program

• • • •

What What What What

are the spatial inhibitors to flexibility and change? should be the space needs based on volumes? economic measures can be applied to cut costs? are the energy and sustainability factors?

The functional program responds to the current situation with a space listing that reflects the realistic needs as compared to the “wants and desires,” and the space listing is linked to a total project budget that adjusts “real time” as these spaces and needs are negotiated for both cost effectiveness and return on investment. A proforma should be run on each service to defend its value, need and timing. Accountable to The Architecture, Design and Operations

It would be relatively easy to skip over the details of this The architecture that responds to the functional program category in lieu of the easier discussions reflecting on and the listing of spaces that have been “right sized” and design theory, conceptual evolution, fully “evidence based” must instill in evidence-based protocols and many the client a sense of confidence that other “warm and fuzzy” topics. the ultimate design is justifiable, funcThe heart and soul of the However, the heart and soul of the tional and flexible. Flexibility includes healthcare planning of healthcare planning of today and the the space layouts and flow patterns in today and the future future reside in this category of functandem with the staffing strategy, new tional programming and campus masand innovative technology, and sysreside in the category of ter planning. We tend to mix and tems that will enhance service delivery. functional programming and match the two without a clear definiThe flexibility features must meet user campus master planning. tion of what they are and how they expectations and permit “healthy work. A truly effective functional prochange” as the building evolves over gram is driven by the following forces: time. Measures that would seem appropriate to consider include the following: • What are the service goals, objectives and strategic The Care Team and Patient Care Environment plans? (very important in the Planetree vision) • What are the existing conditions, sizes and technological conditions? • What are the “quality and outcome metrics” driving • Spaces responding to patient, family and staff (safe, reimbursement? secure, friendly). • What are the current needs, workloads, historical trends • Spaces and places similar in concept to Planetree or and future growth analytics? Greenhouse programs. • What are the clinical service line manager expectations, • Spaces and services delivered beyond the traditional with environment conditions and functional deficiencies? use-centric measures and voluntary support through • What are the technology factors and equipment needs? “ambassador-style” friendly support services. • Where do the staffing efficiencies and innovation measures apply? continued on page 4 Hart Freeland Roberts (HFR Design) is a 100-year-old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts 9100 Marksfield Road, Suite 300 Louisville, KY 40222

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Lessons in Looking ... (continued from page 2)

An open-design main lobby with a prominent reception area that provides easy and barrier-free communication, a desk finished in warm wood tones and very durable, but beautiful solid surface or quartz surface countertops and a mix of comfortable seating invites visitors to wait in comfort. What kind of first impression would people perceive when they step into this hospital? The answer is pretty obvious, and it helps to demonstrate that giving interior design a high priority — and really seeing your facility as others see it — can make a huge difference in how the world thinks and feels about your hospital. Contact Ms. Moody by email at mmoody@hfrdesign.com or by calling (615) 370-8500. Contact Mr. Lutche at llutche@hfrdesign.com or by calling (615) 370-8500.

Accountability Beyond ACOs ... (continued from page 3)

• Integrated service delivery providing options, alternatives and advisory support to help the consumer better understand their potential outcomes. • Services geared toward maximizing resources, assets and programs to achieve the most sustainable outcomes and overall environmental enhancements. • Spaces and services planned and designed to meet the highest technological performance standards, embracing innovative systems, technology and accountability. • Spaces that meet the “time share aspects” of integrated physician practices and the overall shift from traditional to integrated physician practices, as well as the use of hospitalists, intensivists and nurse practitioners. Flexible, Adaptable and Convertible Medical Campus Master Plan (change is the watch word) • Asset and service branding to provide a recognizable image and design character. • Access to the healthcare campus with ease of drop off, parking and safety; clear signage and directional wayfinding, convenient parking, clear portals of entry. • Clear, distinct and direct flow patterns and circulation, promoting immediate reception and check-in plus immediate informational support, with kiosks and public amenities (computer/Internet kiosks), physician and clinical information. • Site plan with distinct separation of service, emergency, outpatient and inpatient traffic, along with designated parking areas. • Building design with expandable options for growth over time. • Building design with modular components and subcomponents easily linked. • Services offered with short-stay emphasis. • Site design with creative master zoning of all components (all levels). • Site design with adaptability to meet diverse site selection criteria. • Site design adaptable to private venture partnerships and development opportunities, such as medical/profes-

sional building, clinics and short stay, rehabilitation, nursing home, assisted living, etc. Sustainable Physical Asset, Building and Resource Management • Staff trained and informed about facility management and technical issues. • Systems that are virtual and real time. • Supportive of wireless communication (new Cloud technology coming fast). • Sustainable and energy management applications. • Systems that help facilitate admission, registration and discharge process. • Building and room design that considers the following: - Room sizes and areas in synch with functional program - Components to maximize ROI and efficiency - Construction parts and components assembled on and off site - Compliance with life/safety and security measures - Compliance with PHAMA, ICRA and AHJ design guidelines - Responsive to innovation in room layout, design, view and bariatric needs - Responsive to staffing, travel times/distances, safety/security measures and nursing views plus critical and routine pathways • Technology sensitive to Integrated Project Delivery (IPD): - Clinical and nursing - Operational - Architectural, engineering, construction and owner

All the players in the business of delivering quality healthcare must be accountable in their individual realms so that the combined effort produces the best possible results and the most reasonable and rational costs. As we can see, “accountability” has a host of important meanings beyond the official definition of “Accountable Care Organizations” and reform measures apparently on the horizon. All the players in the business of delivering quality healthcare must be accountable in their individual realms so that the combined effort produces the best possible results and the most reasonable and rational costs. As in all industries, just like healthcare, the bottom line and the outcome are the key measures. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642.

healthforward report

The Impact of Health Insurance Reforms Through ACOs (Part 1 of a 2-part series) by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

It would seem to this author that “accountability” is a key aspect of everything we healthcare facility planners and architects do. We work with our clients to define their goals, concepts and vision for the future, then craft a product that responds to their vision. When we are permitted, we also evaluate the realistic need and longer-term expectations. In Certificate of Need (CON) states, this is mandatory and stands to reason. This may be a foregone conclusion for the future. Cost containment remains the foundation of reform, time after time. The current healthcare “insurance reform” efforts impact the planning, architecture and ultimately the buildings treating patients. Insurance is a key driver in this movement and requires a close look at the functional appropriateness plus the architecture. From a historical perspective, they go “hand in hand.” If one recalls the CON laws of the mid-70s, the DRGs and prospective payment of the ‘80s and the continued movement toward “value-based purchasing” (bills 3006 and 10301) along with “national payment bundling” (bill 3023), we see the insurance and/or reimbursement reforms continuing.

planning and programming for Mid-Columbia Medical Center (MCMC) in The Dalles, Ore., is an excellent example of a successful process responding to the question of “what can possibly be done?” First, MCMC has committed to informed campus-planning leadership involving external project management, strategic planning, facility planning, facility design and construction pricing support. This team is working in tandem to address these same key questions running parallel to service delivery and market share. MCMC is also evaluating services provided and unbundling the traditional acute care model with more outpatient and short-stay services.

Second, MCMC has recognized that their 49-bed acute care hospital with obsolete buildings averaging around 50 years of age must change over time. These buildings are being masterplanned and replaced in stages to respond to codes, life/safety needs, environmental concerns and operational efficiency (lean planning measures have been adopted). For HFR and our strategic planning partner, Health Strategies and Solutions, it has become a “dual-purpose effort” to determine: What services do we really need to provide? What gives the community and the MCMC “Planetree-driven” programs the most accountable products to serve patients and their families? Staff members at Mid-Columbia Medical Center evaluate

The USA’s economic stability dilemma is perhaps best described in an article published by The Oregonian, “The Government’s Mountain of Debt,” which does a superb job of describing those budgetary line items found in the unsustainable, federally irresponsible and unaccountable debt categories. This is the paradox we face as we measure the pros/cons of USA fiscal accountability. Within this debt looms quietly the $24.8 trillion dollar (approximately $212,500/per household) line item for Medicare. Neither Medicare nor Medicaid can remain intact without aggressive space needs compared to costs. national reform efforts. These efforts then Third, accountable care and “trickle down” to each healthcare consumer, with more money out accountable architecture have traveled “hand in hand” for many of pocket likely! years, but within the healthcare architectural world the forces of “needs vs. wants” became more life threatening in the context of Planners and architects of healthcare facilities need to be cogpatient care and architectural survival. For those architects and nizant of how these federal trends (usually adopted by the facility planners continuing to serve responsible providers of care private sector) indirectly impact buildings. One must look carefully around the USA, there are a few helpful hints that one might at the same, parallel trends of need, justification and costwant to consider within the overall planning, functional programeffective developments. Where does this impact our buildings the ming and design process. This author believes the responsible most and what can we do about it? Our recent campus master consultant who is “wired to the ACO effort” will respond to the design in the following ways.

This Issue ... • The Impact of Health Insurance Reforms Through ACOs • Accessible Patient Room Toilets • ONUMA and BIM — Tools for Healthcare Facility Planners

continued on page 4

Accessible Patient Room Toilets Uncovering the Dirty Little Secrets of ADA Design by David Jann, AIA, Project Manager, HFR Design-Kansas City ®

The design professional can quickly learn the basic assumptions behind accessible toilet layouts by looking at the pictures and illustrations in the accessibility manuals. However, there are usually more challenging questions as to how these rooms are really used, especially when you design accessible toilets for hospital patient rooms. Adhering to the accessibility codes will almost always get you past a codes inspector, but these rules often baffle the owner or intended occupants. Here are some typical responses from owners when accessible design principles are used with patient room toilets: 1. “The toilet room is too small,” or “the 36”x36” shower is too small.” 2. “It is hard for nurses to maneuver the patients to the toilet fixtures.” 3. “It is difficult for a nurse or nurses to work around the patient.” 4. “Water almost always ends up on the toilet floor after showers.” 5. “Lots of extras are appreciated inside the toilet room.” The Reality of First-T Time Wheelchair Users The first challenge unearths a general fact about designing buildings: One must find ways to conserve space, because it is very expensive to build, especially a hospital. So how can use of the toilet’s central space be maximized? Since the accessibility codes require a certain open space in front of each toilet fixture, you might arrange them so that their clear floor spaces overlap each other. You might arrange the fixtures to fit tightly around a five-foot turning radius of a wheelchair. But while these ideas look good on paper, there are consequences when these layouts are used by the hospital staff.

the toilet and shower, so this negates using a layout that locates the toilet facing the shower. Nurses do not like having to endlessly turn wheelchairs in order to get the patient situated. Nurses also help the patients shower, and this is where the minimum shower requirements fall short. The 36”x36” accessible shower space is acceptable for a patient with decent mobility, but it allows for very little space for the nurse to help maneuver the patient. The 60”x30” shower space is much better for both the patient and the nurse. However, the larger shower space has not escaped criticism. Nurses need room to step inside the shower curtain. Because of this, a larger area for the curtain enclosure seems warranted. Instead of having the curtain right at the shower edge, a more useful location may be outside the clear floor space of the shower. Designing for Ease of Movement

The third challenge is helping nurses avoid needless exertion, bumps and bruises in This floor plan of three hypothetical, “same-handed” the course of patient rooms illustrates the author’s thoughts on the their work. ideal design and amenities. Nurses typically work long shifts. Struggling to maneuver a patient into the toilet room The five-foot turning space is good for one person in a is not only no fun, but also could result in injury. One laywheelchair. You assume that the patients can manage their out that works well uses a diagonal entry into the toilet wheelchairs by themselves and that they are familiar with room, meaning the nurse can move slightly left or right day-to-day use of accessible fixtures. The accessibility and get the patient to the required fixture quickly and easiguidelines work well for a savvy wheelchair user. However, ly. And there’s this: Wheelchairs are getting bigger, so the most occupants in a hospital patient room will be first-time standard 36” doorway is probably a thing of the past. users of wheelchairs. Many will not have the strength or Make the doorway 3’-6” wide, minimum. ability to maneuver. This is where the nursing staff enters the picture. The Water Problem Considering Nurses’ Needs A fourth challenge is the fact that water almost always ends up on the toilet floor after a shower, due to the “barThe second challenge is that it can be hard for the nursing rier free” requirement. You cannot have a high threshold staff to help patients into and out of the toilet rooms. to keep the water in. The maximum change in level, for Occasionally they will use a patent lift, but generally a the floor, is ½” beveled. Designers may use a ½”-high wheelchair is used. Nurses like to have a straight shot to threshold at the shower edge to help direct water back into the shower area, but this is not much of a change in floor continued on page 4

ONUMA and BIM — Tools for Healthcare Facility Planners by Tom Testerman, NCARB, HFR Design-Louisville ®

As healthcare facility programmers and planners, we are constantly challenged with the task of leveraging our skill sets to incorporate the latest building information technology into the planning scheme. We simply need the next iteration of software that will launch us in the right direction. In this era of web-based software and cloud computing, it’s “evolve or dissolve.” This is the mantra of one of the pioneers in the emerging field of building information modeling (BIM). Given our continually emerging information technology, the ability to transition information effectively, work efficiently, increase productivity and manage a wide and complex array of data is a prerequisite to working seamlessly through a project. This is necessary in order to navigate through evaluation, multiple design option scenarios and cost/benefit analysis. One must also take into account energy and systems analysis, evaluation of building performance, project staging and phasing, credentialing for LEED certification, codes analysis, prototypes, integration of standards, implementation of best practices, green design principles, simulation modeling and operation efficiencies including lean design principles. Gains in construction logistics present opportunities for document coordination, scheduling, clash detection and prefabrication. Setting up an intelligent database for cataloging this information is essential. The Onuma system bridges the gap between planning/programming/design and three-dimensional modeling with the integration of interoperable software based on IFC standards. The Onuma system moves planning into the digital data arena. The planning study deliverable will no longer consist of a paper report, but instead will exist as a living document that will continue to be useful, long after the initial project is completed, for longer-term facility management purposes. This system provides the ability to cohesively manage data digitally and export it digitally to a variety of programs that provide the tools for more robust development. Much as pencil and paper have been supplanted by digital technology for production documentation, a similar evolution is now gaining traction with programming and design. It is not a cycle with a defined starting and ending stage, such as we were accustomed to in traditional project development. Instead, the project can begin at a variety of points. Whether it be conceptual site analysis, space programming, existing building inventory/analysis, campus block planning or simply conceptual building design, the program is adaptable, flexible and versatile enough to integrate at multiple levels and interface points. continued on page 4

Photograph? No, it’s a 3-D rendering, produced internally at HFR Design, that can show a client precisely how the lab will look when completed.

The Cloud “Cloud computing” has quickly become a buzzword, thanks in part to TV commercials promoting it, but aside from being a trendy new techno-ttool, it has real value in the work world. The idea is that if you’re connected to the Internet, you can store information on a remote server rather than carrying around a device such as a flash drive. Web-b based email provides a very simple illustration of how it works, as those who use it make use of “cloud” email servers. In practice, cloud computing allows you to work with almost no data or software on your actual computer. It’s a way to increase capacity or add capabilities without buying new software.

Hart Freeland Roberts (HFR Design) is a 100-year-old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 425-8505 (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts The Forum III Office Park, Suite 190 305 N. Hurstbourne Pkwy. Louisville, KY 40222

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

The Impact of Health Insurance Reforms Through ACOs ... (continued from page 1)

Accessible Patient Room Toilets ... (continued from page 2)

Accountable to The Customer

height. If the shower curtain is placed near this threshold, water often makes its way out and onto the bathroom floor.

This requires the architect’s full attention to operation, responsiveness to the clinical care team, understanding of patient and family needs, and responsiveness to staffing and board leadership expectations. A sensitive balance of “awareness through campus master planning” creates a “real time workplace” where all members of the team collaborate on issues that impact both services and facilities. It also requires an intelligent client, such as MCMC, that is willing to compare and contrast dated cultural paradigms to new, innovative measures and methods. Finally, it requires some truly painful cost/benefit and ROI discussions leading to accountable solutions. The “customer” of the planner/architect could be described as the following: • Physicians and nurse practitioners • Hospital-based nursing and technical partners • Administration and C-suite professionals (CEO, COO, CFO, CNO, CIO) • Board of directors • Third-party payors • Agencies having jurisdiction (AHJ) over the campus • Patients and family members • Contracting partners • Affiliate entities • Community leadership • Funding agencies and underwriters Why, one might ask, is this list so long, and is it a manageable customer listing? Yes, it is long and manageable, but it requires a sensitive balance of resources and strategic decision-making interface, timing on this involvement and understanding of the healthcare delivery system as we know it today and envision it to be tomorrow. Meanwhile, Oregon’s statewide Accountable Care Organization (ACO) reforms (it doesn’t hurt that the governor is a physician) and the recently announced passage of a bill that creates a government-regulated health insurance “exchange” that will make health insurance both affordable and mandatory in Oregon, do demonstrate progress. The state is responding to ACO legislation to require insurance be provided and carried by all consumers in the state, along with the appropriate federal subsidies that would normally be a part of the historically deficient Medicaid efforts. Is this the only way to provide healthcare? No, but it does represent a responsible and accountable approach that is reasonable, equitable and balanced across all constituent and consumer levels. HFR Design’s Healthcare Division is privileged to be a party to this innovation. We will be there as the strategic plan evolves to respond to the revenue streams, the access and the affordability measures that roll out of this innovative plan. Will it be the “perfect answer”? No, but it will demonstrate progress and a responsible design product. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642. (In Part 2, coming in our fall issue, we deal with accountability as it applies to functional programming, campus master planning, architectural design, the care team, patient care environment, and sustainable building/resource management.)

Nurses often dislike the ½” threshold, because they prefer a smooth transition without a bump when rolling wheelchairs into the shower space. The best way to respond to this design issue is to bring the shower curtain outside the clear floor space for the shower. The current ADA guidelines will permit a clear floor space to have no more than a 1:48 slope (1/4” per 12” slope). This exception would allow a designer to slope both the shower space and the clear floor space towards the shower drain. By bringing the shower curtain outside the clear floor space and sloping the clear floor space toward the shower drain, the potential for water to make it onto the larger floor area of the toilet is lessened. Give Them Functional Accessories A fifth challenge results from the hospital staff’s understandable desire to have the toilets function like a welldesigned hotel room toilet, with plenty of shelves, hooks and towel bars, plus possibly an in-wall bed pan cabinet. These items would seem to be easily accommodated until you find you have no wall space to house them. One solution would be the construction of wing walls to add some wall space. Another design trap is the requirement that wall-mounted objects must not protrude more than 4” into the circulation path or accessible route. One way to address this is to design recessed toilet accessories. Recessed shelving units, which fit inside a stud wall, are also available. ~~~ Careful study of these design issues show that both the patient and the nursing staff should be considered when designing patient room toilets. The placement of the toilet fixtures in the toilet space will always require certain movements by the patient and the nursing staff. Unnecessary turning or reaching should be avoided. Space should be provided for both the patients and for the nurses assisting them, and safety for all is enhanced by keeping the shower water off of the toilet room floor. Contact Mr. Jann by email at djann@hfrdesign.com or by calling (816) 822-8500. ONUMA and BIM — Tools for Healthcare Facility Planners ... (continued from page 3)

A portion of the design professional’s work is standard and repetitive, and therefore benefits from standardization and prototyping elements for adaptive reuse. Templates and resources can be developed within the program that can be transferred and shared in a web-based environment. This is an exciting time in our industry, as we begin to explore new and innovative ways to practice planning through building information modeling. Contact Mr. Testerman by email at ttesterman@hfrdesign.com or by calling (502) 425-8505.

healthforward report

Creating Hybrid OR/Cath Labs in Older Healthcare Settings As the capabilities of modern diagnostic imaging equipment have advanced, so have the complexities of the physical and functional requirements necessary to accommodate these modalities in our healthcare facilities. Designers must carefully balance the functional, operational and spatial needs, which can create multiple architectural and engineering challenges requiring careful consideration. Even more difficult is adapting existing infrastructure to accommodate the many demands of supporting hi-tech medical diagnostic equipment. Designing and constructing a

by Bob Harrett, AIA, Principal and Director, HFR-Louisville ®

safety concerns for the caregivers as large pieces of equipment are moved and rotated about the patient during a procedure. The patient’s location is fixed, which becomes a given. The “variables” are that the staff and portable equipment are not. It is not uncommon to hear of collisions occurring, such as anesthesia machines being knocked over, and, even more serious, techs and nursing staff colliding while assisting with the procedure. This is especially critical when an emergency or code situation occurs. All of these factors increase the size of the procedure room, typically over 700 square feet, significantly greater than basic cardiac diagnostics. Sterile fields and sub-sterile support and equipment supply spaces, required for the operating room function, physically compete for the same spatial relationships required to support the basic cath lab functions of the hybrid suite. This requires careful placement of patient and staff entrances and access points so as not to compromise each other’s functional needs.

This photo of the hybrid OR/cath lab at Maury Regional Hospital in Columbia, Tenn., demonstrates how various pieces of equipment can be integrated in a procedure room.

Hybrid Operating Room and Cardiac Catheterization Suite in such a structure involves a multitude of overlapping design criteria. Functional needs Combining the needs of cardio diagnostics with those of a surgical intervention environment creates twice the concerns and considerations within the same physical space. The surgeon’s and cardiologist’s spatial and functional needs are equally important in creating an environment for the successful delivery of patient treatment. Patient, physician, and staff flow creates multiple “functional overlaps,” which can create

This Issue ... • Creating Hybrid OR/Cath Labs in Older Healthcare Settings • Location, Design and Technology: Smart New Focus • Flying High in a New Era of Healthcare • News and Notes

Physical needs Most demanding are the structural loads created by the large ceiling- and floor-mounted bi-plane armatures and the equipment booms that carry and monitor patient imaging sources. This equipment requires structural support that not only accommodates the increased load capacity on floor slabs, beams and columns, but also minimizes movement, vibration and deflection that can disrupt the equipment’s proper operation. These multiple loads affect not only the floor of the room the equipment is on, but also the ceiling or roof structure above and the ceiling areas of the floor below. Adding this structural support presents physical issues of installing reinforcing while working within confined spaces, to field-install heavy structure steel components. The mechanical infrastructure typically found in retrofit projects would not meet the temperature and humidity requirements of this modality. On a recent project it was necessary to provide total upgrade of the mechanical infrastructure, including replacing rooftop air-handling equipment and primary ductwork and creating two floors of supply and return shafts necessary to reach the procedure and support spaces. This was complicated by the continued on page 4

Location, Design and Technology: Smart New Focus

Neal Dodell

David Rubenstein

by Neal Dodell, of counsel to Weissman, Zucker in Atlanta, where one of his practice concentrations is healthcare real estate and finance, and David Rubenstein, a principal of CresaPartners, a national commercial real estate services firm specializing in tenant representation, where his specialties include healthcare facility transactions. ®

Today’s healthcare industry is in a state of flux. Demographically, the U.S. population is aging, increasing healthcare demand every year. And due to cost constraints and recent healthcare legislation, providers are looking for more efficient ways to deliver care. As a result, the look and feel of healthcare facilities continue to change and modernize. Years ago healthcare providers (physicians, hospital systems and related providers) centered around traditional bed towers that collectively made much of their money on cost-plus, fee-for-service, inpatient procedures. The more complex and expensive the procedure, the more the system and/or physician could be reimbursed by health insurers or Medicare. High occupancies in the bed tower meant high profitability. There was little pressure to actually contain costs, especially given the quality-of-life benefits of medical breakthroughs. Today healthcare providers are trying to cope with completely different reimbursement models. Medicare and managed care have squeezed margins out of traditional pricing models. Providers (whether for-profit or not-for-profit) now have to operate like real businesses, with a variety of discounted and/or fixed pricing models (per patient, per procedure or per covered life). Controlling costs and improving efficiencies are critical to maintaining a positive bottom line.

is occurring away from these hubs. Like retailers strategically locating stores near growing population centers with access to major transportation routes, healthcare providers are taking their services to their prospective customers. Patients and their employers are demanding healthcare delivery close to where patients live and work. Ease of access is important to patients when choosing healthcare providers. The providers themselves are embracing this strategy, as they can more cost-effectively operate a customer-friendly outpatient clinic, lab or imaging center in a suburban office park or a neighborhood shopping area than they can in an expensive bed tower surrounded by congested roadways.

This “decentralization” of healthcare delivery has also created opportunities for entrepreneurs (physicians or otherwise) to provide - at a lower cost structure - more attractive services that were once monopolized by area hospital systems. Hospitals, physicians and forprofit enterprises are now competing Serving an aging population and taking advantage of for coveted healthtechnology that requires very little space are two of the trends care dollars. shaping healthcare delivery today.

Furthermore, under new healthcare legislation, insurers are required to increase coverage while controlling premiums and are, in turn, putting pressure on healthcare providers to provide more services with less reimbursement. As a result, for healthcare providers, fixed costs and daily overhead matter more now than ever before. As is true for most businesses, after personnel costs, real estate expenses typically represent the greatest component of a healthcare provider’s overhead. Whether it is a large healthcare system or a boutique medical practice, “managing” real estate is critical to survival. While locating facilities in large “hubs,” often surrounding a hospital bed tower, is a model that will continue to exist, much of the new growth in healthcare delivery

Design trends have changed dramatically through the years in order to make the delivery of care more efficient. As single- and multi-specialty medical practices have grown in size, floor plans have changed to improve patient flow. Common design features include self-contained pods, racetracks and sub-waiting areas to get more patients checked in, examined, treated and checked out more quickly, minimizing walking distances and distractions for physicians, physician assistants and nurses. As a result, larger floor plates with fewer interior columns are preferred by space planners designing practice space. The traditional hospital structure has also undergone changes. Less space is being allocated for inpatient overnight beds and more for outpatient treatment, recovery and education areas. These and other design continued on page 4

Flying High in a New Era of Healthcare by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

In recent conferences with the AIA and AAMA, and in conversations with our clients, we have compared the value-added aspects of airport planning and design to healthcare facilities. Now, this might be a questionable comparison if you are not a “frequent flyer,” but if you are, there’s much to consider and take note of. For the author, this is certainly a factor, given the number of airports he visits annually on behalf of our healthcare clients around the USA and beyond our borders. What is it about hospitals and airports that seem to have common planning and design attributes, you might ask? • Access, parking and expedient wayfinding right to the gate • Creature comforts and customer expectations • Security, safety and time measured in seconds • Planes, carts, cars, ambulances and buses • Registration, check-in, welcome and waiting (minimal) • Retail, restaurants and recreation • Music, art and entertainment • Time, money and creature comforts • Efficiency • Empathy • Energy

need for computer stations, stand-up work areas and wireless connections grows hourly. Some of the other details include the following: • Airports with artwork and wayfinding tailored for the customer • Walk-in and walk-through convenience for Internet access and cell phones • Sit-down communication chairs • Reclining sleep centers • Perching and kiosk convenience stations • Marketing posters and wall-mounted promotional information for healthcare and other lifestyle improvements

The world’s major airports have made great strides in providing value-added services, a concept that hospitals can and should emulate.

• Flat screens with realtime arrivals, departures and delays • Up-to-date news with timely customer information • Concierge stations for help-needed services • Emergency responsiveness at all levels

These are the key features we keep in mind as we begin the “creative process.” What have been some of the recent innovations we’ve seen? There are many. For example, a private entrepreneur and the governor of Florida are developing outpatient centers in key airport hubs. Why not? We get haircuts, backrubs, shoeshines and meals in airports, so why not check-ups, X-rays and minor procedures? In many international markets, the airport has become a housing site, retail center, mass transit hub and healthcare mecca for the region. The

continued on page 4

Hart Freeland Roberts (HFR Design) is a 100-year old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

NEWS&NOTES HFR Design Chosen by Oregon Hospital For Campus Master Plan Hart Freeland Roberts was recently awarded a contract by MidColumbia Medical Center (MCMC) of The Dalles, Ore., to provide a campus master plan and programming services. MCMC is a Planetree hospital. The non-profit Planetree organization describes its vision as promoting the development and implementation of innovative models of healthcare that focus on healing and nurturing body, mind and spirit. Hospitals that adopt the Planetree model attempt to personalize and humanize the health care experience for patients and their families. “We are being called upon to provide a high-level planning analysis of the MCMC campus,” said HFR’s Jim Easter. “We have some recent and very applicable experience related to this project, as MCMC is a Planetree hospital and has a campus similar to Valley View Hospital in Glenwood Springs, Colo., another Planetree hospital for which HFR Design developed a master plan. MCMC’s mission statement begins with the words, ‘to lead and act as a catalyst in promoting health for all people,’ and the master plan we provide will reflect that mission.” Creating Hybrid OR/Cath Labs in Older Healthcare Settings ... (continued from page 1)

need for temporary HVAC equipment and a phased work plan to keep other key peripheral diagnostic rooms in operation. The scope of what may initially appear to be a relatively compact area of program space can quickly “creep” into multiple phases of renovation over multiple floors. Design tools Computer-aided design tools such as Revit and 3D modeling software were used in the preliminary design stages to look at both physical movement of the equipment within the space and the integration of infrastructure components. These models are critical, not only in analyzing the actual constructability of the project, but also in helping the users understand how well the equipment will function with various positioning and configurations of boom arms, lighting and table placements, for the variety of Shown here is an early 3-D study procedures that will model created by HFR Design occur in this complex using Revit software. diagnostic and surgical delivery setting. Contact Mr. Harrett by email at bharrett@hfrdesign.com or by calling (502) 425-8505.

Location, Design and Technology: Smart New Focus ... (continued from page 2)

changes are geared toward getting people in and out efficiently, providing a higher level of service to more patients for a lower overall cost. Technology is closely connected to location and design trends. It is only because of advancements in medical technology that more services can be performed in a less expensive outpatient setting. Electronic medical records and advanced medical devices allow providers to diagnose and treat patients efficiently in a medical office space instead of a traditional inpatient setting. Whether it means locating computer stations in every exam room or integrating imaging suites and outpatient surgery centers with patient exam space, providers are leveraging technology to lower costs and increase the quality of care. Clearly, the trends in healthcare delivery are evolving. As the business of healthcare continues to change, so will the way providers take advantage of the real estate they utilize. Like most industries, the healthcare industry is embracing cost-effective real estate solutions. Those who are strategic in their location, design and technology implementation will clearly have a competitive advantage over those who do not. Contact Mr. Dodell by email at neal@wzlegal.com or by calling (404) 760-7428. Contact Mr. Rubenstein by email at drubenstein@cresapartners.com or by calling (404) 446-1586. Flying High in a New Era of Healthcare ... (continued from page 3)

(consumers, employees, guests) • Open, visible and convenient flow patterns • Discrete administrative and airport management offices • Valet parking, automobile security and improved convenience factors Why would we make such a comparison? Healthcare is changing, and we see the transition happening in our work daily. This was recently discussed in meetings related to a wonderfully creative “HealthPark” that HFR is master-planning for a client in Georgia. This is the start of “accountable care” and will continue as we improve the case for fully accessible and “integrative medicine.” The world of outpatient, ambulatory and accessible healthcare is here to stay. Yes, the acute and tertiary centers will be with us forever, and they too will become more user friendly, accessible and airport quality. The outpatient centers will embrace all the features of efficiency and the retail accommodations found in our best worldwide transport hubs. What an exciting image for our future! We are on our way. The plane is off the ground, and the trip has begun. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642.

healthforward report

This issue is dedicated to our friend Dick Carota, who lost his life January 12th in a tragic auto accident. He truly understood the dynamics of hospital administration and facility planning. We’ll miss him.

The Questions Most Often Asked by Our Clients by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

We started this topic during a speaking engagement for the ASHE/AIA Professional Development Conference in Phoenix, Ariz., and continued the conversation at the AIA-Tennessee annual meeting in Murfreesboro, Tenn. This writer, along with Clay Seckman of SSR Engineering, led the discussion. Our objective has been to balance the “ever changing” aspects of facility management, planning and operations and bring the engineering concerns to the conversation table early in the cycle. As these questions have evolved, I have observed some changing attributes.

tive medicine and outpatient programs which reduce the demands for traditional inpatient rooms. Older facilities with semi-private rooms and undersized toilets and showers are most likely obsolete.

• Do we need a master plan and functional program? Yes, this is a key variable in the decision-making process. Working closely with the staff, hospital engineering, departmental directors and practicing physicians, one can determine rather quickly the direction the hospital should move in. We compare this process to conducting The number one question we a physical examination of a patient. hear from clients is: How do we The question of “build vs. renovate” get our arms around project cost is answered using the master plan management? (MP) process. The tools that are used are transferable from the on-site fix But to provide a credible answer up to the new-site replacement. The to that general question, several answers in a comprehensive campus other questions must be master plan establish the ground answered, for example: rules for short-term fixes compared to longer-term cures. The cures are • Should we renovate, expand in often much more cost-effective and place or build new? beneficial over time. Skipping the The answer to this is based on MP process and embarking on some key variables that remain piecemeal remedies without the benIn this recent photo, the late Dick Carota, who served as Senior constants in today’s environefit of a rational, longer-term road Planner and Programmer for HFR, studies the zoning for ment: Is the facility presently in map can be counter-productive, Kennestone Hospital and the new patient tower expansion. the right location? Do the buildand, for the leadership team, operaings meet current design stantionally catastrophic - in fact, careerdards? Is the infrastructure salvageable, and is it possible to limiting for the CEO and hospital engineer. The MP will also upgrade and renovate so that the energy and operational apply both “lean principles of operation” and “quality payback can occur within a reasonable time frame? The issues enhancers” that improve operation and awareness of benchof sustainability, code compliance and design character genermark programs that represent success stories from other locaally become the bottom line. Most hospitals over 30 to 40 tions. years old, without modest upgrades, are obsolete. The other concerns address functional efficiency, image/impression, • Can we incorporate technology and innovation into the design process? wayfinding and utilization. If the census is down and the diagnostic and emergency demands are up, then the facility is likeThe question should not be “can,” but “how” and “when.” ly ready for a complete upgrade and/or replacement. Current Without the interface of advanced technological thinking, the trends are moving toward ambulatory care facilities, integraoverall design process loses credibility. The innovation comes from the experience of the architect/engineer/builder team, the knowledge and experience of the client and the service This Issue ... partnerships already in place or soon to be established. • Questions Most Often Asked by Our Clients Where in this process do the questions start? They begin on • The Future of Critical Access Hospital Design day one and will vary, depending, for example, on whether • Blinded by Science: Architecture Should Be More • News and Notes

continued on page 2

The Future of Critical Access Hospital Design by Scott Corbin, AIA, Vice President, Principal, Healthcare Division, Hart Freeland Roberts ®

With the outlook for our country’s healthcare system still up in the air following the midterm elections, the picture remains murky and unclear. Yet healthcare facility design should, and does, continue to respond to current needs and projected future needs despite our inability to fully visualize a workable, governmentally controlled system. We know that some things will evolve and change as we shape a healthcare system for America, and the Critical Access Hospital (CAH) model plan is a fine example of what efficiency in our new system will look like. For example, prefabrication will become even more popular in the design and construction of Critical Access Hospitals. Prefabrication allows construction work to proceed under controlled temperature and humidity, with good light levels and worker comfort. It leads to higher quality construction, more easily inspected indoors. We are already seeing architects designing repetitive rooms, such as patient rooms, with the concept that they will be prefabbed and shipped to jobsites on flatbed trucks. The “product” is delivered “just-in-time” to the construction site, allowing it to be craned off the truck and installed immediately. Within a few weeks, the patient wings are finished. In the nottoo-distant future, we will see prefabrication of emergency departments and ORs as well.

year may not be allowed the next. This will demand that the hospital be extremely flexible in its ability to change and adapt its facilities to varying regulations. Reimbursement is predicated on a department’s square footage, so efficiency is paramount in creative hospital design. Interstitial space above the ceilings that is tall enough for a man to walk upright and more easily change ductwork, lighting, plumbing and wiring would cut remodel time and disruption of daily hospital operations, thus allowing the hospital to respond to changing reimbursement and regulation in a rapid manner. Shorter construction times will become mandatory as costs for this kind of work will escalate with the inflation that is predicted by many. Medical research is already working on the integration of robotic surgery inside the bore of the MRI. This technology, while still in its infancy, would seem to be perfect for the more rural Critical Access Hospital of the near future. Coupled with long-distance telerobotic capabilities, the technology can already perform surgery on soft tissue, as well as suture, dissect, biopsy and cauterize using a surgeon who is remote and sitting in a workstation. So, realistically, how far away are we from seeing that surgeon sitting in a workstation in Boston doing an integrated MRI and robotic surgical arm, image-guided procedure on a patient in a Critical Access Hospital in Bozeman?

Many Critical Access Hospitals will be able to take advantage of wind power as one alternative energy source.

More “green” will start to show in hospitals. Places of healing are making big strides in how they clean, using nonchemical cleaners and making more reasonable use of biologically friendly cleaning agents. Likewise, hospitals are slowly recognizing the importance of using wind and solar power as they strive for responsible use of energy and our natural resources. Critical Access Hospitals, typically being more rural, can more easily make use of innovative windmill design on their campuses. They are also more likely to employ geothermal heating and cooling systems, due to their generally larger land areas, than are medical centers in large, dense urban areas. Governmental reimbursement programs will undergo even more rapid change. What was reimbursed last

Not too far, I think. Contact Mr. Corbin by email at scorbin@hfrdesign.com or by calling (816) 822-8500.

The Questions Most Often Asked by Our Clients ... (continued from page 1)

we are talking about development of a new, innovative health park, expansion of an emergency department or the addition of a new bed tower. If we were to use the bed tower example, the following issues would need to be addressed: - How many beds do we really need and what category of patient care do we serve (special care, acute, sub-acute, observation, short stay or other)? - Should our rooms be private, same-handed and possibly universal in concept, or should we plan for mirrored rooms with in-board or out-board toilets? - What nurse-to-patient ratio will we achieve, and what are continued on page 4

Blinded by Science “Integrated medicine” is a buzzword that has been used in the healthcare industry for several years now. The term is often defined as a practice that combines conventional as well as complementary and alternative medicine (or CAM) treatments for which there is evidence of safety and effectiveness. The Integrative Medical Model involves a holistic approach to healthcare, calling for services that address not only the physical and biological requirements of the patient, but also the social, psychological and spiritual needs as well. This is especially interesting from an architectural standpoint because of arguments espoused during my years as an architectural student in college. Is architecture an art or a science? Maybe medicine is going through a similar questioning. This is a very healthy (pardon the pun) discussion.

by Sammy West, Director, Jackson Office, ®

intuitive and ethereal aspects are needed. This relates to the CAM side of the integrated healthcare argument. Daylight, fresh air and the incorporation of other natural elements can help bring the enriching and deeply satisfying experience of being in the great outdoors into the built environment. This can greatly reduce the effects of “cabin fever,” especially for long-term patients, aiding in the healing process.

Colors, textures and materials are artistic elements that enrich the experience of a building. Subdued lighting and muted colors can be used to relax and calm patients, whereas direct lighting and bright colors might stimulate activity. Through the In architecture school we play of light and dark, lighting learned that architecture is can evoke emotions within the certainly more than just the human soul. In much the same science of putting a building way that a sense of awe and together. Sound engineering inspiration can be evoked by principles are necessary to an ancient cathedral, similar make the building stand, to feelings can be induced provide adequate lighting and through dramatic lighting in power, and for proper climate any facility. All of these elecontrol. These elements relate ments can combine to to the conventional medicine decrease stress levels, encourside of the integrated healthage interaction, ease the psyDaylight, natural elements and carefully chosen colors, textures and care argument. Of course materials bring a welcoming warmth to HFR-designed Valley View Hospital che and otherwise make the the physical and biological facility a more attractive, in Glenwood Springs, Colo. (photo by Scott Dressel-Martin) aspects have to be there: vibrant and restorative place. correct diagnoses, proper treatments, prescriptions, surgery, etc. But is there more to healing than just the sciAlong with the aspects highlighted above, the incorpoence? Are there less tangible aspects that can aid in the ration of green technologies and alternative energies health and well being of individuals and society? Can can greatly benefit healthcare facilities. The standards the built environment play a part in the healing set forth by LEED (Leadership in Energy & Environmenprocess? tal Design) and the U.S. Green Building Council address better air quality, cleaner water, utilizing nonI think most architects agree that it takes more than just the science to make good architecture. Other, more continued on page 4 Hart Freeland Roberts (HFR Design) is a 100-year old architectural and engineering firm offering architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets from offices in Nashville, Kansas City, Louisville and Jackson, Tenn.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

NEWS&NOTES HFR’s Jim Easter Honored With 2010 AAMA Chairman’s Award James G. Easter, Jr. FAAMA, director of HFR Design’s Healthcare Planning Department, was recently awarded the 2010 Chairman’s Award by the American Academy of Medical Administrators (AAMA). The award recognizes “an individual who has contributed significantly to the strength and vitality of the Academy and to its service to members.” Easter

In 2005, Easter served as Chair of the AAMA Board of Directors. Since then, he has continued to actively support the Academy, its colleges, conferences and members. He currently serves on the IT Task Force, regularly contributes to the AAMA Foundation, participates in the member recruitment program and has written for the Academy’s e-publication, AAMA Executive Online. AAMA describes its mission as “advancing excellence in healthcare leadership through individual relationships, multidisciplinary interaction, practical business tools and active engagement.” HFR is an AAMA Strategic Partner.

Building of America Network Honors HFR-Designed Medical Office Building The GPFB Medical Office Building in Columbia, Tenn., has been selected as a Building of America award winner. The award honors innovative, unique and challenging projects that are particularly noteworthy and/or that give back to their respective communities. “Our ultimate goal was to provide the clients with a building that would serve to boost their overall image in the community as providers of exceptional medical care underscored with a personal, caring touch,” said Kevin Caudle, AIA, LEED AP, project manager for HFR Design and the project’s architect. “We felt image, access and overall convenience were extremely important to our ‘number one’ customer — the patient and his or her family.” A case study of the project can be found at www.buildingofamerica.com.

The HFR-designed GPFB Medical Office Building was recently honored by the Building of America Network. (photo by Tom Gatlin)

The Questions Most Often Asked by Our Clients ... (continued from page 2)

our operational goals and objectives (walking distance, sight lines, access concerns, etc)? - What evidence will we use to determine the room performance (infection rates, acoustics, patient movement, lifts, falls, safety measures, etc)? - What criteria will we evaluate to compare and contrast support systems: medications, housekeeping and linen, electronic medical records, nurse and physician charting, soil utility systems, dietary objectives and support services? - What about the family, the caregivers and the interface with the patient? - What about short-term and longer-term growth of unit needs and service support? - What about robotics and patient monitoring systems? • Time is money: How can we speed up the process? The answer resides in the selection of the team. Having an experienced consulting team that is willing to respond quickly and is aware of the steps required to move forward will certainly help. Second, having an owner willing to make decisions and cooperate with the expedited process is very important. We also feel the Integrated Project Delivery (IPD) process has merit for today’s project delivery and will serve to move projects forward more effectively than the traditional process. This requires the combined expertise of architect, engineer, planner and contractor working in a seamless and efficient manner. This is particularly true when applied to larger, complex renovation and expansion projects in which one must address disruption avoidance, safety measures, ICRA compliance and complex details of accessibility, phasing and daily distractions that could potentially impact the operations of the hospital. While the above are some of the most important questions, they are by no means all the questions that should be answered. We will deal with others in future issues. We believe the answer to the question of “results” resides in the track record of the team. In all cases, the best test is experience, past performance and measurable outcomes. Patient and staff opinions are the bottom line! Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 424-3642. Blinded by Science ... (continued from page 3)

toxic and sustainable building materials, reducing pollution, energy conservation and efficiency, and recycling. Incorporating these ideals is advantageous not only to an individual or a single facility, but also has far reaching consequences for the health and well-being of our communities and ecological system at large. Of course a healthcare facility can be a cold, sterile, functional box for the treatment of a person’s malady. But is that enough? The answer is no, not if we take into account the totality of what makes us human beings. Contact Mr. West by email at swest@hfrdesign.com or by calling (731) 421-8000.

Celebrating 100 Years

1910 - 2010

healthforward report

Integrated Project Delivery and Integrative Medicine by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design, and Tom Testerman, NCARB, HFR Design ®

Integrated Project Delivery (IPD) is rapidly becoming a mainstream methodology for design and construction services. This seems both timely and appropriate given the federal initiatives to reduce healthcare costs, streamline service delivery, improve accessibility and enhance quality. In the IPD world, we are witnessing the integration of all stakeholders involved in a development program into a singlepurpose project delivery team. The owner’s representative, architect, engineer, builder and program manager are all working as an integrated team to deliver the project on schedule and within budget, without sacrificing quality.

from a fault/negligence-based agreement to a relational form of agreement. This encourages collaborative/innovative thinking that ultimately serves the mutual interests of all contracting parties. What makes IPD work A few of the features integral to IPD are:

• Building Information Modeling (BIM) to streamline production • Project scheduling and construction logistics • Open door and open book cost estimating, material costing and product pricing • Creative modular and This process involves shared risks standardized systems and rewards, which are integrally • Reduction of errors, elimination woven into measurable project of redundancy and streamlining outcomes. When all parties work of the process together collaboratively under a • Embedding requests for informateam governance format with tion (RFI) into the BIM software project-focused incentives, the • Encouraging collaboration and Turner Construction Co. execs Randy Keiser (left), vice president result is efficiently managed reduction of waste of Turner Logistics, and Russell Alford, business manager, projects with creative solutions • Elimination of “silo mentality” and discuss integrated project delivery and construction logistics that optimize cost/benefit outenhancement of client objectives at a recent session at HFR headquarters. comes. • Creation of building information exchange, with integrated By being incentivized to optimize capital spending on projects, management tools for seamless data access we are motivated to move beyond less efficient traditional Applying the tools models, leveraging assets with creative thinking to improve ultimate results. The evolving integrated agreement forms include single-purpose entity, multi-party and a number of During a recent meeting at HFR, members of the HFR customized hybrids that attempt to integrate insurance prodHealthcare Division and guests from the construction industry ucts with shared-risk allocation. The intent of the agreement is discussed the leveraging of IPD tools. Items addressed includto unify efforts by shifting the structure of the agreement form ed:

This Issue ... • Integrated Project Delivery and Integrative Medicine • What is HFR Design’s “Sustainable Design Policy”? • The Advantages of Open, Flexible Labs • New Book Tells Story of HFR Design’s 100 Years

• Single-source, incentive/performance-based agreements supported by the industry (AIA, contractors, owners) • Computer, IT/LAN support and Building Information Modeling (BIM) continued on page 4

What is HFR Design’s “Sustainable Design Policy”? by Page Onge, AIA, NCARB, LEED A.P., HFR Design ®

Is it “green,” is it “sustainable” or is it semantics? Either of the first two is fine. They are used interchangeably. You’ll also hear a lot about “LEED,” Leadership in Energy and Environmental Design. Unless you’ve been isolated in a fallout shelter, you can’t help but see every person, company and organization getting involved in “going green.” So what does it mean and what is HFR Design’s policy on the subject? Green, or sustainable, means making an extra effort to: 1. CONSERVE — reduce the use/waste of limited natural resources. 2. PROTECT — reduce and eliminate the contamination of, and damage to, the environment. 3. THRIVE/ENJOY — improve the physical and mental environment so that where we live, work and play becomes more healthy. We also include cultural resources and environment in the definitions above. The intent is to improve our current quality of life and to ensure future generations the same or better (sustainable) quality of life.

Silver, Gold or Platinum. The LEED rating is accomplished by documented compliance with enough sustainability criteria from a list that gives “points” to different options. The total points achieved determine the rating level. It is not a perfect system and does involve substantial fees; at the same time, it is popular and does proffer bragging rights. However, some “points” are more costly to achieve than others and may not reflect a correspondingly higher level of sustainable benefit. In fact, the benefit may be less. This is where HFR can help. In Responsible Sustainable Design, we analyze your options and help you direct your limited resources where they will have the most positive effect. It’s not about getting points, but about getting the most results from your financial resources. If you want and need a plaque, our LEED accredited professionals can help you get the LEED rating. If you had rather put that money into making your building “greener,” we can help you with a design that maximizes the beneficial impact on sustainability without registering for the LEED rating. In evaluating the impact of choices in the design, we look at the “life cycle”: What was the effect on the natural resources, environment and the users from where and when the materials were mined, grown or obtained? How was the item manufactured, transported, retailed, installed, used, removed and discarded? What was the cost to the environment and the monetary cost while it was in service? It is counterintuitive that something made of plastic may be considered “green,” but if it lasts four times as long as something made of wood, it may have a more positive impact when the “life cycle” is considered.

HFR Design’s policy is to not only be practitioners of sustainable design, but also to be leaders in the promotion and advancement of the Working together, healthcare facility owners and architects can movement. To do integrate sustainable design principles even when resources are limited. this we have made an ambitious effort to stay educated and trained in sustainable design, staying on top of trends and evidenceIf you desire to help make a positive difference in the based corrections in methodology. By evaluating which green/sustainable design movement, HFR Design would efforts result in the most benefit for the time and money like to help you maximize your contribution. Because we invested, we can help owners maximize their contribuapproach the evaluation and decisions thoughtfully, we tion to the sustainability movement. We call this consider ourselves leaders in responsible sustainable “Responsible” Sustainable Design. We practice this and design. educate others in getting the most benefit for their dolContact Mr. Onge by email at ponge@hfrdesign.com or by calling lar. (615) 370-8500.

Many of our professionals are LEED accredited. LEED is a system developed by the U. S. Green Building Council through which you can register the design of a new building or renovation and achieve a rating of Certified,

The Advantages of Open, Flexible Labs

Labs should easily adapt to technological and functional changes by Ed Houk, AIA, Senior Vice President, Principal, Hart Freeland Roberts ®

During the past 25 years of experience in the design of more than 150 medical clinical, biomedical research, and forensics/crimes testing labs, we have learned that regardless of the type, labs are always in a state of change.

• In many cases, the existing HVAC is not of adequate size to offset the heat gain generated by new instruments and equipment. • Existing gas supply systems typically cannot be easily modified to add new or additional gases and/or air.

New testing technologies are constantly emerging. Tests become more equipment/instrument-driven, rather than people-driven. Increasing numbers of tests are becoming automated. A process or test which only a few years ago might have taken 12 months of work by several lab techs can now be accomplished overnight by a robotic instrument.

Flexibility can be achieved by first allowing the lab designer to work closely with those who will use the lab. This allows the designer to determine and define the users’ needs and then provide for those needs with the appropriate spaces, benches, base cabinets, HVAC, electrical, data, lighting, etc. that will allow for the everchanging needs of the lab.

As technology develops and/or improves, more and more instruments become available to enable labs to become more efficient and more accurate than could have been achieved previously by hand in the same time frame. Yet, while the availability of instruments has increased, the physical size of those instruments generally has continued to diminish. In some cases, an instrument that only a few years ago might have filled an entire room now is easily accommodated on a bench.

The use of mobile, modular tables and base cabinets with color-coded coupled fittings at the ceiling for electrical, gases and communiSeen here is a portion of the HFR-designed lab at cation connecHugh Chatham Memorial Hospital, Elkin, N.C. Unfortunately, the design of most labs is tions serving the such that advancements in technology mobile tables are not easily accommodated: and equipment below helps facilitate flexibility. As newer floor-mounted instruments become available and • Most have fixed casework that does not easily allow are purchased, tables can be moved or removed. The for adding new floor-mounted or bench-mounted heights of the tables can be adjusted as needed to instruments or equipment. accommodate new bench-mounted equipment. • The existing electrical and data connections are usually not adequate in location, capacity and type to In addition, the well-being and comfort of lab techniaccommodate new instruments. cians must not be ignored. Locating noisy, heat-produccontinued on page 4

Hart Freeland Roberts (HFR Design), which celebrates its 100th anniversary this year, offers architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets nationwide.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Integrated Project Delivery and Integrative Medicine ... (continued from page 1)

• LEAN principles of planning, design and construction: -Proper functional and space programming (right sizing of space requirements) -Proper flow and circulation assessments (meeting patient handling and movement assessment (PHMA) standards) -Collaborative communication between all parties, built on mutual trust and respect -Integrated productivity and quality standards -The institution of uniform standards -Energy performance and environmentally renewable products/protocols -Optimization, standardization and prefabrication opportunities -Streamlined processes

-Educational workshops that encompass physical, spiritual and emotional care -Individual coaching, health plan development/guidance and orientation We visualize a future in which Integrated Project Delivery and integrative medicine go “hand in hand” to improve services to our communities across the U.S. and around the world. This holistic approach builds bridges that are easily accessed and crossed by consumers to care centers where architecture, engineering, construction and service delivery meet. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 4243642. Contact Mr. Testerman by email at ttesterman@hfrdesign.com or by calling (502) 425-8505.

Design assist/support benefits All involved benefit from inherent IDP principles that include: • Budget/cost-sensitive measures • Long lead/early purchase • Major trades on board early (MEP) • Team decision making enhanced and streamlined • Contractor and prime subcontractors work toward reliable GMP pricing • Reduction of material waste Service delivery also evolving At the Duke Integrative Medicine Center in Durham, N.C. (recent winner of the AIA Academy 2010 Design Award), the master plan of the campus and the design of the project enhance the total patient care experience. It’s a prime example of how healthcare service delivery is shifting toward a higher level through integraThe arch form that distinguishes tive medicine programs such this walkway is reiterated in the as the one at Duke. Services interior architecture at Duke delivered in the future will Integrative Medicine Center. need to meet holistic, curative outcomes, be fully accessible and offer advanced and creative healthcare alternatives: • Understanding and dedication to physical, spiritual and emotional well-being • Enhancing the person’s state of wellness and disease prevention • Educational and advisory tools to support recovery and healing • Approaches and tools to manage chronic illness (diabetes, heart disease, depression, etc.) • Personalized healthcare planning and comprehensive support • Selective program components can include: -Medical, therapeutic and restorative care -Integrative case discussions incorporating patient-centered care models

New Book Tells the Story of HFR Design’s 100 Years Hart Freeland Roberts has unveiled its new hardback “coffee table” book, Hart Freeland Roberts: 100 Years. The 356-page book, with hundreds of photos, chronicles the personalities, designs and philosophy that have shaped and guided the firm since its beginnings in 1910. Persons interested in purchasing the book, available for $49.95 plus sales tax and shipping charges, should contact the Accounting Department at HFR Design, (615) 370-8500, or accounting@hfrdesign.com. The book is also available at Davis-Kidd Booksellers in Nashville, (615) 385-2645, or www.daviskidd.com. The Advantages of Open, Flexible Labs ... (continued from page 3)

ing hoods, refrigerators, freezers, etc. in alcoves near the lab benches can greatly improve the working environment, as can the use of indirect lighting, natural lighting and resilient floor materials. Since many lab workers are cross-trained, it is possible for some labs to be housed in open spaces that allow for expansion and contraction of various functions as needs change. Glass can be used to physically separate labs as needed, while at the same time allowing for not only more supervisory control but also greater utilization of lab techs. Thanks to the greater visibility plus the crosstraining, it is easy to see which lab area may need additional workers and which may have excess workers. It has been our experience that lab needs seem to change about every five years. Therefore, it is economically wise to design and build a lab that allows for flexibility and ease of reconfiguration. Contact Mr. Houk by email at ehouk@hfrdesign.com or by calling (615) 370-8500.

Celebrating 100 Years ®

1910 - 2010

healthforward report

Planning and Designing for Mental Health and Psychiatric Facilities (Author’s note: The following article was developed from an abstract prepared for the recent SECAD conference in Nashville, in conjunction with Debbie Gregory, RN, BSN, who is co-founder of the Nursing Institute for Healthcare Design and Senior Clinical Consultant for Communications and Technology Planning for Smith Seckman Reid Engineering. Also instrumental was a conversation with Virginia Trotter Betts, MSN, JD, RN, FAAN, Commissioner of the Tennessee Department of Mental Health & Developmental Disabilities.) There is a great need for communication and collaboration between senior mental healthcare leadership, hospital designers and the clinicians who work daily in these healthcare environments. Knowledgebased initiatives and advanced design principles apply in the mental healthcare setting as well as in acute and long-term care housing. Nurses, mental health professionals, architects and engineers working together results in superior healthcare environments for this mental health/developmentally disabled (MHDD) population.

by James G. Easter, Jr., FAAMA, Diplomate in Healthcare Administration, SVP, Principal, Director of Planning and Programming, Healthcare Division, HFR Design ®

principles play a major role. For example, unlike the more “open” acute care environment, the psychiatric facility imposes varying levels of constraint, protection and security that must be balanced with the needs of the resident and care team. Respect is a key variable, balanced with the use of materials, finishes, furnishings, doors, windows and spaces that serve as places of respite, care and small-group therapy. The facility must also provide more normalized environs as the resident recovers over time.

The most appropriate environment for each mental healthcare patient is determined by the individual treatment plan. The grouping of patients, the patient-to-staff ratio and the flow of residents must be carefully crafted, with all the sensory responses taken into conPictured here are (l-r): Debbie Gregory, RN, BSN, co-founder of the Nursing sideration. Design concepts Institute for Healthcare Design and Senior Clinical Consultant for must respond to age, sex, Communications and Technology Planning for Smith Seckman Reid Engineering; accessibility, therapeutic Virginia Trotter Betts, MSN, JD, RN, FAAN, Commissioner of the Tennessee milieu and physical needs. Comparing notes on accessibilDepartment of Mental Health & Developmental Disabilities; and Sensitive interior design must ity, building design and the HFR Senior Vice President James G. Easter Jr., FAAMA, address wayfinding within the interface of short stay and Director of Planning and Programming for HFR’s Healthcare Division. facility, the color and texture community-based outpatient of materials and finishes, care with the more complex acoustics and the scale of the program. The environment must needs of mentally ill and developmentally disabled populations provide adequate exercise, play and work therapy, and these is key to effective service delivery. The marriage of clinical prospaces often become the pathway back to the community. tocols, compassionate care and creative design can produce remarkable results. Individual Empowerment and Supportive Rehabilitation Architectural Design, Sensory Design and Functional Balance As the care team develops, the architectural space plans, interior design concepts, layouts and furnishings evolve. Ideally, We envision a continuum of care that covers all stages of menthese spaces and places are creative, warm and inviting, with tal healthcare needs, and in that future, planning and design clear respect for safety of both residents and staff. The environment allows the resident to experience both personal This Issue ... • Planning and Designing for Mental Health and Psychiatric Facilities • The Master Plan and What’s Behind It • HFR Design Celebrates 100 Years of Service!

continued on page 4

The Master Plan and What’s Behind It The hospital master plan is one of the architectural tools that clearly establishes the “road map” for ongoing success in healthcare facility design. The design of the hospital can be an asset or a detriment to effective operations; a master plan can help make sure the design is an asset and one that accommodates future growth. Owners, architects, engineers and builders are now seeing significant opportunities to establish “Integrated Project Delivery” (IDP) teams that work together under one contract in a disciplined and harmonious manner to complete complex healthcare projects, using advanced Building Information Modeling (BIM) and “collaborative contracting” methods. This innovative process and the superior results it can produce can only be achieved through client and consultant partnerships in which the goals are clearly defined and the concepts articulated from the very beginning. Those actions are central to an effective master plan. Yet, there should also be a basic healthcare philosophy guiding the plan. In best practice, the decisions reflected in the master plan must be grounded in an overall vision of what the hospital wants to be, how it defines “healthcare” and how it wishes to be perceived. Having this underlying philosophy — if it can be put in writing and understood by all involved — is of immense value to the planner and architect in developing the master plan. When it comes to establishing a philosophy of healthcare delivery and communicating it clearly, no one has done it These renderings show interior and exterior views of the new HFRdesigned Cancer Center at Valley View Hospital, Glenwood Springs, Colo.

by John R. Potter, Jr., AIA, Senior Vice President and Project Architect, Healthcare Division, HFR Design ®

more successfully than Planetree, the internationally recognized nonprofit organization that promotes a patientcentered, holistic approach to healthcare. Hospitals that are members of the Planetree Alliance adopt the principles of the organization and put them into practice. Needless to say, the concept of “patient-centered” or “patient-friendly” healthcare is not unique to Planetree. It’s just that Planetree has gone to great lengths to spell out exactly what the concept means and how it can be put into practice. One of the basic tenets of the Planetree philosophy, as stated in its “Vision, Mission and Beliefs,” is that “physical environments can enhance healing, health and wellbeing.” Therefore, the Planetree model stresses the importance of architectural and interior design in the healing process. This writer can state from experience that having Planetree’s well-articulated philosophy to guide a master plan, combined with the shared vision of all involved, has helped make the success of one uniquely challenging project much more achievable. In the case of Valley View Hospital in Glenwood Springs, Colo., the HFR design team developed a long-range, six-phase master plan that is allowing the hospital to replace and enlarge the existing facility on-site, in other words, creating an “in-place replacement hospital.” The facility has remained operational as the phases have been implemented. The final phase of the project — a new cancer center, hospital administration, food service, physician offices and other support spaces — is currently being implemented. The master plan and design of the replacement hospital embody the core values of the Planetree Alliance, as evidenced by Valley View receiving the Spirit of Planetree Award for Architectural Design, among other honors. At the same time, the planning and design have produced excellent operational efficiency and space utilization. The sensitive balance of form, function, economy and time, which are the fundamental aspects of healthcare design, are best achieved through a master plan that is guided by a comprehensive healthcare philosophy. Contact Mr. Potter by email at jpotter@hfrdesign.com or by calling (615) 370-8500.

HFR Design Celebrates

100 Years of Service! ®

Hart Freeland Roberts (HFR Design) is celebrating its 100th anniversary this year. The company was founded in 1910 by architect Russell Hart, who was joined a few years later by engineers Eugene Freeland and Martin Roberts. The three men established a reputation for excellence in design and unsurpassed client service, principles that continue to guide the 100-year-old firm. Today, HFR Design is one of the nation’s leading designers of healthcare facilities large and small, providing architectural design; interior design; master planning and programming; market research and feasibility studies; civil, transportation, structural and environmental engineering; and project man-

agement. Looking toward its second century, the firm continues to excel in the planning and design of acute care hospitals, critical access hospitals, senior living facilities, medical office buildings, labs and other healthcare-related facilities. In addition to its Nashville headquarters, HFR Design maintains offices in Kansas City, Louisville and Jackson, Tenn. In connection with its 100th anniversary, HFR Design is producing a hardback “coffee table” book detailing the firm’s history and presenting interesting facts about the architectural and engineering professions. Numerous images, from late 19th century photographs to futuristic renderings, are included.

Old and new: A notable HFR project from the 1920s (left) was the permanent reconstruction of Nashville's exact replica of the Parthenon (photo by Bruce Gore); Gibson General Hospital in Princeton, Ind., is a recent example of the firm's 21st century expertise in healthcare facility design (photo by Chris Phebus, www.phebusphotography.com).

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Planning and Designing for Mental Health and Psychiatric Facilities ... (continued from page 1)

spaces as well as structured group encounters defined by creative clinical support teams. To maximize support, rehabilitation and overall care, designers should create a place where non-institutional characteristics prevail. A residential style of housing is encouraged. This may vary from the “softer spaces” designed for senior care and geriatric patients with dementia to more protective environments for younger adults suffering from schizophrenia. In all cases, the quality of the care plan interfaces with the space and place of care to maximize the features of nature, loving expressions, places of warmth and sensory responses designed to facilitate rehabilitation, re-orientation to family and recovery. Family, Friends and Social Support It takes a cohesive family support system to survive and recover from mental health-related problems. This is a pressing concern in a world adept at war, fractured by family upheaval and economic stress, and pressured by sexual addiction, alcohol, drug and related chemical abuse. The treatment environment of the future will likely require higher volume and more creative ambulatory care with broader home-based treatment that maximizes resources but improves access (through use of telemonitoring, real-time AV linkages and routine home-based and/or outpatient visitations). Expanded remote assessments, intervention and informational continuums are a must. How this mental health and developmentally disabled “call center” is designed and developed will evolve over time, but meanwhile, it is important to recognize that knowledge is power and that this interventional measure is crucial to a care plan that is manageable, effective and affordable. Spiritual, Emotional and Intellectual Support The great thinkers that we associate with health and healing have always possessed a keen sense of creativity, time and space. All have been gifted people with the uncanny balance of right- and left-brain thinking that permitted their seeing the world through sensitive and compassionate eyes while allowing design to motivate their creative energies. They also had the gift of salesmanship, intense competitive spirit and a passion for training and development. These traits are found in many people in our society today, but with the added characteristics of Internet overload and huge volumes of information. The environment is expanding MHDD interventional demands exponentially. Finding a sense of self-worth, belonging, peace and personal pride may be one of our greatest needs. How we address the spiritual and inner psyche of our most vulnerable citizens with a sensitive respect for normalcy is challenging. Human Touch and Sensory Stimulation The caring environments that seem most effective respect the personal space of residents, show empathy for both the patient and family, and assist with treatment by giving of

themselves. This “giving process” resides in the MHDD work as well, and in best practices which are integral to each patient’s emotional state of mind. For many the perspiration of exercise, the heat of a sauna or the warmth of a shower offers both therapeutic and clinical relief. “Sensitive doses” of touch and TLC respond to the need for caring, compassion and confidence. Healing Arts and Sensory Responsiveness The healing arts have progressed to levels well beyond the traditional MHDD and psychiatric arenas. We will soon see the value of art, music and science as they become a part of the continuum of care that balances traditional therapy with new ways of thinking, treating and responding to the needs of the human mind. What would a new style of therapeutic responsiveness look like and what programs might be introduced that advance beyond the status quo into the next generation of mental healthcare? Complementary Therapies MHDD professionals are recognizing the need to balance the groups and recreational endeavors with the rehabilitative and occupational needs of family. There is a willingness to explore new concepts of human interaction, responses to addiction and untested reactions to space and environment (mental illness, mental retardation, developmentally disabled, substance abuse, dementia, etc). The complementary therapies involve concepts from the past that mental health programs abandoned but may likely revisit in the future. These include the importance of animals, gardening, creative crafts, design/sculpture/arts, educational intervention, home-training and day care at all levels (respite for families and creative day care for children). The balance of art and science with music, reading and storytelling all fall into this category. The current transition into the “graying generation of baby boomers” is rapidly impacting MHDD demands (linkages to assisted living, geriatric psychiatry, secondary care, skilled care and long-term care are necessary). Healthy Communities (Youth + Aged) The path leading to a healthy community is often much like the pathway through a hospital or down a busy street in an unfamiliar city. The ability to “find one’s way” is often impacted by poorly defined pathways, inclement conditions, self-serving distractions and insensitive vendors. In a healthy community, there are milestones, visual cues, symbolic images and environmental factors that make the trip more meaningful. In a building, this might be described as “pleasurable or experiential wayfinding”; creative interior design and architecture make the travel an enjoyable and educational journey. A healthy community is both internal to the family unit and the social network of the population served, and is “lived out” through socialization of the MHDD resident admitted to an appropriate treatment program. Access to information, crisis intervention, medication, physical therapy, rehabilitative support and family-focused care are vital attributes. A healthy community doesn’t discriminate or create barriers to change and growth. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 4243642.

healthforward report ®

Why Plan During These Austere Times? Looking back over the past 30-plus years, one can see that we have been in this austere financial situation before, more or less on the brink of economic disaster in America. Are we broke? Not yet, but it appears that many individuals and various states are nearing financial collapse.

healthcare is the heart and soul of productivity, the essence of service delivery at many levels, and a dynamic force in the country’s overall economic profile. by James G. Easter, Jr., FAAMA, Principal, Director of Planning and Programming,

Healthcare Division, HFR Design Yet, the healthcare business seems to survive during these Healthcare is said to downturns, and, through sheer “staying power,” adjusts to the be the second most forces at work: Certificate of Need (CON) programs, influential economic Prospective Payments (PPS), Diagnostic Related Groups (DRGs), force in America, just behind the defense budget. According Capitation, Critical Access Hospitals (CAH), the Balanced to the American Hospital Association, hospitals employ more Budget Act (BBA) initiatives, Medicare and Medicaid reform, etc. than 5 million people and are the second largest private secEach phase of change within the American healthcare delivery tor employer, with only restaurants employing more. system returns to “serve another day,” When one looks at the approximatehaving survived ly 5,700 hospitals in America, the another round of academic health science centers, what appears to be universities, research programs, feda predictable push eral sector healthcare components, toward cost containpublic health departments, outpament and reimtient centers and allied health probursement reform, grams, the full extent of healthcare’s in lieu of systemic economic influence becomes apparreform. As Vanderent. When you add in the public and bilt University Vice private insurance systems, one Chancellor for begins to sense the overpowering Health Affairs Jeff influence healthcare has on society. Balser noted recently An aging population, longer life in a presentation to spans, advances in scientific metharchitects, this lack ods and information technology add of systemic reform is both fear and optimism to our emoa big part of our tional state of mind. Along with overall “reform reimbursement pressures through Planning healthcare facilities has reached new levels of precision and problem.” We must entitlement programs comes the sophistication thanks to Building Information Modeling (BIM). expand the agenda added stress of increased utilization beyond “change” to within our emergency departments. incorporate delivery alternatives. Why Plan Now? Healthcare and the Economy Why plan during these austere economic periods? Because Along with religious expression, freedom of speech, quality planning is a way to begin the corrective actions necessary to education and the entrepreneurial spirit, healthcare remains fix the healthcare delivery system in America. It is not about near the top of the list of crucial services required to provide a community forums and discussion groups, although they are reasonable quality of life in America. Why is healthcare such an politically helpful when the agenda for the conversation is emotional force in society? Why do we grow anxious when the based on “real actions and real facts.” Healthcare is both a subject is discussed? The answers can be found in the fact that service and a science which must be addressed with a high degree of sophistication, much as one would address the ®

This Issue ... • Why Plan During These Austere Times? • Wayfinding Requires Comprehensive Vision

continued on page 2

Why Plan During These Austere Times? ... (continued from page 1)

physician’s surgical plan for hip replacement, the CEO’s budget plan for the yearly operation of his or her hospital, or the master plan for the hospital or health science center campus. Each partner on the care team utilizes a high level of sophisticated planning, programming, analysis, synthesis and evaluation, with a closure revealing logical and calculated actions. These actions are based on goals, facts, concepts and needs, and are balanced against form, function, economy and time. As we were taught in architecture school and later in life: “Form follows function, follows funding and yes, often follows political forces and paradigm shifts.”

plays out in the suburban and urban areas of America as well, and results in the changes we are seeing nationwide: the proactive shift toward ever higher volumes of outpatient care, the expansion of retail medicine, the rapid move back to home-based initiatives, virtual connections for remote patient care monitoring, and higher volumes of patient throughput based on improved efficiencies of care. Hospital architecture is a vital part of the solution. Hospital of the Future The hospital of the future will emulate the CAH model, with much more emphasis placed on appropriately sized buildings and portals of entry, along with cost-justifiable building design products and supportive technologies that are carefully measured against the care plans, staffing availability and clinical pathways. The marriage of the city, county and community will be re-consummated to provide “family care” in the most gracious manner possible, and Americans will again comprehend continued on page 4

A Dozen Crucial Questions Planning is a hands-on experience with board members, community leaders and the voting public: HFR’s Scott Corbin (right) is a frequent leader of such sessions.

Identifying areas in which efficiencies and cost savings can be realized is a major benefit of healthcare facility planning.

In the world of healthcare architecture and hospital planning, we are forced to make decisions and promulgate actions on the basis of a realistic step-by-step process. When we address the needs of a small community, we understand the market forces and the services that are required. When we work with a Critical Access Hospital (CAH) in rural Kansas or Illinois, we understand the dynamics of the community, the economy and the availability of professionals to carry out the healthcare tasks at hand. We collaborate and connect around the “rules of the CAH program,” and we plan our facilities accordingly. This

It is important to our healthcare delivery system that the providers, consumers and payers meet along the pathway toward economic recovery and address some very fundamental questions: 1. Should healthcare be available to everyone in America, and, if so, what is the ideal healthcare continuum, from cradle to grave? 2. Should healthcare be delivered in the same way it has been for years? 3. Can America sustain three or four levels of care (public, private, investor owned, federal sector)? 4. What service delivery and systemwide improvements should we consider? 5. What demographic and market forces should we address first and foremost? 6. Is healthcare sustainable as both a business and a service? 7. What are the universal measures of success, productivity and outcome that society will embrace? 8. How can we improve healthcare delivery modalities and clinical pathways? 9. How can we improve access to care with efficiency and virtual, systemwide integration? 10. What is the best formula for society to invest in their future healthcare needs? 11. What hard assets should we fix first and who helps with this transition process? 12. Why are buildings and technology a vital part of the solution? When we answer these questions, we progress along the path to real and lasting healthcare reform.

Wayfinding Requires Comprehensive Vision by Bob Harrett (left), AIA, Principal and Director, HFR-Louisville, and Tom Testerman, NCARB, HFR-Louisville ®

Hospital leadership said: “We need to evaluate our wayfinding system to determine what improvements and changes need to be made in order to aid our patients, visitors and guests in navigating their way through our buildings.”

changes included the addition of a women’s health center and ambulatory surgery center, campuswide parking, circulation additions and numerous site improvements. In aggregate, these additions resulted in a labyrinth of pathways that traverse departments, creating a wayfinding nightmare for patients and visitors attempting to reach destination points in the medical center. In addition, the hospital was experiencing a significant increase in emergency room visits, which necessitated a study to decompress this area plus predict the growth of this service along with space-planning improvements. These accumulated factors and ongoing changes have left the navigation through the center with several deficiencies.

With an emphasis on “patient and family first” care, the medical center was finding, through patient satisfaction surveys, that patients attempting to travel to and from their destinations were frustrated and expressing significant dissatisfaction. In addition, hospital employees were devoting a noticeable percentage of their day to assisting patients, visitors and guests with directional instructions, not to mention wasting their time walking through circuitous hallways. The goal of the assessment was to evaluate targeted opportunities for improvement in the areas We began our assessment process with an initial walking of image, orientation, pathways tour of the hospital, cataloging and signage messaging. areas where gaps and messages This was the challenge presented were absent, confusing and/or to HFR Design recently by a inconsistent. We queried volunregional tertiary care health cenAt the new HFR-designed Memorial Hospital in Carthage, Ill., it could be ter in southern Georgia. A sigteers to determine quality and nage program had been institut- said that wayfinding starts miles away, thanks to the signature clock tower. consistency of instructional directions along pathways to destinaed more than five years earlier, tions. Next, we provided questionnaires focusing on pertinent with the vision of upgrading the image with a hospitality theme. The system put into place was effective, but needed to categories of wayfinding systems and conducted interviews be revisited given the changes that were taking place. Those with clinical department managers who were most impacted

continued on page 4 ®

Hart Freeland Roberts (HFR Design), which traces its roots to 1910, offers architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment programming and space planning. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets nationwide.

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Wayfinding Requires Comprehensive Vision ... (continued from page 3)

by patient and visitor wayfinding challenges. From this data, we formulated a “top 10” ranking of priorities requiring an action implementation plan: 1. Develop a comprehensive master facility plan for the campus for a fully integrated approach. 2. Complete a comprehensive inventory of wayfinding signage to identify amendments/corrections/augmentation recommendations. 3. Establish a hierarchy and placement of marquee and directional components. 4. Develop criteria/recommendations for cosmetic/community image enhancements. 5. Develop wayfinding orientation/instruction material and protocols. 6. Integrate wellness enhancements with wayfinding recommendations. 7. Develop a universally understood methodology for updates/changes and modifications. 8. Develop orientation features through design that enhances understanding and navigation. 9. Explore opportunities in other industries that are translatable to the healthcare model. 10. Introduce technology enhancements that provide a more seamless approach and improved continuity. Medical centers are continually evolving and repurposing and repositioning themselves to adjust and adapt to the ever changing forces that define them and the manner in which they offer their services to the community. They are comprised of a myriad of complex structures and systems. Just as a medical center needs a comprehensive plan for the logical and intentional mapping of forecasted positive or negative growth, the wayfinding system should also be approached with a comprehensive vision to facilitate this change. In these final months of 2009 and throughout 2010, we will move forward, as decisions are made by the hospital mentioned above, in implementing the actions required to establish a first-rate wayfinding system for this facility. In doing so, we will continue to accrue knowledge that will help us provide solutions in the future.

(Above) Ideally, wayfinding assistance starts as soon as one enters the campus and continues along the way to the destination. (Right) What a relief: Discovering a campus wayfinding map that points you in the right direction.

Always looking forward with planning in mind is one aspect of healthcare delivery that we all should agree is mandatory. Contact Mr. Harrett by email at bharrett@hfrdesign.com or by calling (502) 425-8505. Contact Mr. Testerman at ttesterman@hfrdesign.com or by calling (502) 425-8505.

Why Plan During These Austere Times? ... (continued from page 2)

the contribution of healthcare to overall quality of life and the local economy. We cannot afford to let this important business/service/healing commodity go unattended any longer. In addition, the statewide planning initiatives for healthcare (former comprehensive planning agencies and hybrid statewide healthcare development councils) must be revisited and redefined to address what is right for each county and municipal district on a case-by-case basis. This is not a mandate to bring back CONs, but rather a request to reconsider systemwide service delivery awareness and rational solutions. A payment plan and healthcare delivery protocol must be put in place in partnership with an areawide network partnership.

This network may be public, private or religious, but it must have a disciplined structure to meet well-defined and benchmarked standards. The standards can be set by our healthcare leaders and administered judiciously and fairly. If we adopt a “no play, no pay” rule in America without a definition of the game plan, service plan and asset plan, we face a tumultuous outcome, and the consumers lose in the long run! It is about access first, quality services second and cost third - in that order! Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 3708500.

healthforward report

Benchmarks For Improved Cancer Center Design Architects who design hospitals have a responsibility to compare and contrast the attributes of healthcare facilities and obtain “evidence-based” feedback from the user groups (staff, physicians, patients, etc.) regarding their design decisions. We believe these post-occupancy assessments should include staff feedback along with that of the patients and families. Fulfilling this responsibility with action recently were HFR architects Sam DiCarlo (one of your co-authors) and Jack Potter, who toured eight cancer centers around the country. Their research efforts coincide with three additional cancer center projects already on the drawing boards at HFR. The range of observations and discussions during the tour varied from design features and details to equipment selection, operational and efficiency measures, and outcomes impacted by quality design. We believe the designs we produce in the future will benefit from these discussions, as we have gained insight into what works best and experienced the outcomes of others decisions. We were also gaining insight into client perceptions of a start-up cancer center program, with these being the issues they most wanted to talk about:

The authors felt that the most prevalent by Sam DiCarlo (left), AIA, Senior Vice President, start-up challenges and James G. Easter, Jr., FAAMA, related to having Director of Planning and Programming, expert guidance Healthcare Division, Hart Freeland Roberts from the beginning: consultants willing to listen, ask probing questions, record answers, seek out common operational and design themes, and “think outside the box.” There was also the suggestion that the team visit Planetree programs, which have a very high environmental, family-focused, sustainable and design-related philosophy. This was helpful in that Planetree centers, by their very mission, understand the value of sensitive design and typically do not cut corners, avoiding major shortfalls after opening. The Planetree projects were excellent examples of wayfinding, natural light, color, materials and finishes. Also deemed highly important in a start-up was preparation of a comprehensive “shopping list” of services and functions that could be compared from site to site and ultimately used for master zoning of the “building blocks” that become the foundation of a new center. This functional-program-plus-master-zoningplan instrument became the roadmap now being used by HFR for cancer center design projects.

• Start-Up Goals and Objectives • Initial Hurdles plus Planning and Design Challenges • Staffing Strategies • Equipment and Furnishings Once the program and • Budgetary Concerns and master plan have been Planning a successful cancer center requires careful consideration of funding methods, agreed to, it is time to Funding Methods design features, equipment selection and much more. • Design and Construction crosscheck the potential Pitfalls cost of the project in • Windows of Opportunity order of magnitude. This is easily completed using the agreed • Things One Would Not Want to Repeat to program and master plan drawings to compare and contrast the projected sizes of spaces, their location and disposition in terms of renovation, new construction and develop-

This Issue ...

• Benchmarks For Improved Cancer Center Design • Protecting Access to Capital Through Competitive Planning • Powerful Branding: A Breast Health Center With Digital Imagery

continued on page 4

Protecting Access to Capital Through Competitive Planning Access to capital is crucial to implementing an organization’s competitive strategy. However, the current economic climate is complicating hospital performance, resulting in bond downgrades and reduced access to capital. In a recent industry forum, Fitch Ratings projected twice as many bond downgrades as upgrades for 2009. And this new trend was demonstrated in Moody’s recent downgrade of 18 hospital systems’ ratings in OctoberNovember, 2008. As a result, organizations are giving additional scrutiny to how they are being rated. Bond rating agencies’ evaluations typically fall into four broad operating categories: financial reserves, debt structure, core operations and strategic position. Historically, hospital management teams have focused on performance in the first three evaluation categories. However, the fourth category, strategic position and related market strategy (i.e. competitive planning), needs to be given additional attention, since it is a key predictor of long-term sustainable operations. Raters and underwriters understand this.

by Rich Miller (left) and John Miller, Miller Consulting

These agencies look for the hospital executive team to clearly articulate their organization’s competitive plan and give evidence that the plan is (1) being followed, (2) producing the desired results and (3) being updated to reflect new realities and opportunities. The bottom line is that management needs to demonstrate that a culture is in place to ensure opportunity identification and realization. Such a culture needs to produce candid evaluations of an organization’s strategic position and a competitive market strategy with sufficient organizational commitment to implement. But, too often, organizations find this difficult to achieve. Here’s why: Competitive planning often takes too long to develop, tends to result in “big bang” rather than incremental change programs, and replicates the linear engineering approach of requirements definition, solution specification and build. Recognizing the need for quick responses to market changes, the competitive planning process is changing. It is becoming action-oriented and operations-focused. It has begun using pilot tests to replace exhaustive analyses, third parties to objectively address politically charged issues, and phased implementation to drive early results. It is moving from linear to multi-thread development. Such an approach moves competitive planning from a once-every-three-years exercise, separated from day-to-day operations, to an activity that is an integral part of the organization’s ongoing business processes. (See accompanying illustration.) By adopting this approach to competitive plannning, organizations are responding to changing market needs, building excellent customer relationships, achieving superior financial performance, securing bond ratings and maintaining needed cost-effective access to capital.

Competitive planning is fast becoming an integral part of the regular business process for many healthcare organizations.

(Contact Mr. Rich Miller by email at rmiller370@aol.com or by calling (843) 821-2148. Contact Mr. John Miller by email at jmillerv@bellsouth.net or by calling (404) 307-9925.)

Powerful Branding: A Breast Health Center With Digital Imagery People today increasingly make their healthcare choices as active consumers. That means individual providers of healthcare must let potential patients know exactly what they offer and in which areas they excel. It’s about differentiating themselves from other providers in a decisive and clear-cut way, what we’ve come to call “branding.”

by Beverly Reagan, BS, RT, AAMA Consultant

For hospital owners, women’s health is a crucial component in overall success. Therefore, branding that attracts female patients — backed up by excellent services that win their loyalty — should be a major focus. And not only do women represent a large percentage of the market as patients. Studies have shown they make the vast majority of all healthcare purchasing decisions. In other words, win over the women, and you’ve won much more than half the battle. Some healthcare systems are attracting women by making names for themselves in women’s heart care, some in other areas. Breast health can generate a strong brand, as well, and for many women is a gateway to other services. In establishing a breast health center, or enhancing an existing one, technology is key. Women want — and deserve — the utmost accuracy in testing, along with comfort and a specialized staff they believe in and trust. Therefore, when it is time to plan your new breast health center, you will want to plan for all-digital imaging. Branding that attracts female patients — who make most healthcare purchasing decisions — makes a lot of sense for hospital owners.

A small percentage of medical professionals argue that film mammography is just as accurate as digital mammography in detecting breast cancer for the general population. However, those who have adopted the digital method believe without doubt it is superior. It seems all agree that women who are pre- or perimenopausal or who are younger than age 50 may benefit from having a digital exam, rather than a film/analog mammogram. HFR worked with Maury Regional Hospital (MRH) in Columbia, Tenn., in planning a state-of-the-art Women’s Center. According to MRH Women’s Services Coordinator Dana Salters, “Digital imagery is superior to analog hands down. We definitely increased efficiency after going with all-digital imaging. There is a decrease in radiation dose, along with shorter exam times for the patient, and virtually no need for retakes.” continued on page 4

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

Benchmarks For Improved Cancer Center Design ... (continued from page 1)

ment phases that may occur in a staged fashion over time. The projected project costs become a key element of the pro forma, which must include many of the income revenue and expense items along with the anticipated payback period for the entire venture. Many questions have been asked about the reimbursement factors for both the RT and Chemo/IV aspects of cancer care. This must be researched carefully by the provider to ensure that third-party and private payment expectations have been met and that the market share will permit a viable program, given the location, population demographics and staffing plans. Another concern was: What options do we have in radiation therapy (RT) and megavoltage equipment? We learned that there are not a lot of choices in RT equipment, with Varian, Elekta and Siemens taking the lead. It is very important to involve key clinical and nursing support professionals in the technology phase of the discussions, and to have vendors share their perceptions and experience with both the healthcare delivery team and the design consultants. Getting input from those who will actually deliver the care and from those whose business it is to stay attuned to the needs of cancer center owners will go a long way toward establishing a successful program. Contact Mr. DiCarlo by email at sdicarlo@hfrdesign.com or by calling (615) 370-8500. Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 370-8500.

Testerman Joins HFR-LLouisville Tom Testerman, NCARB, has joined the Louisville office of HFR Design, where he will be involved in healthcare and senior living facility planning, design and project management. He brings 30 years experience to the firm. Testerman

Healthcare Facility Symposium & Expo HFR healthcare facility planner Jim Easter and architect Bob Harrett, along with Daryl Weaver, CEO of King’s Daughters Hospital in Yazoo, Miss., and architect Richard McCarty of The McCarty Co., will speak on Operations, Strategy, Planning and Design Keys to Rural Hospital Success at Healthcare Facilities Symposium & Expo, Sept. 30 - Oct. 2 at Navy Pier in Chicago. For complete information and to register, visit www.hcarefacilities.com. Early bird pricing through July 31.

Key Design Considerations When Planning a Cancer Center • Identifiable entryway, drop-off and convenient parking • Views and natural lighting (carefully placed glass, skylights and pleasant views) • Healing spaces and materials (water, stone, sculpture, artwork) • Clear and tasteful signage • Warm, pleasant public spaces (library, Internet, discussion, conference) • Discrete examination, clinical and consultation spaces • Segregated chemotherapy spaces (some open and some closed areas) • Non-threatening megavoltage spaces (soft finishes, hidden technical spaces, warm colors and materials to mask the heavy equipment) • Open and playful hallways that don’t look like traditional hospital hallways • Taller ceilings with non-institutional lighting designs • Discrete work areas segregating staff work and consult from patient waiting and holding • Innovated gantry and entryways for radiation therapy (heavy doors are very threatening) • Acoustically buffered areas to reduce noise transfer and ensure privacy • Discrete spaces for staff learning, work and team meetings Powerful Branding: A Breast Health Center With Digital Imagery ... (continued from page 3)

Jonathan Sanders, director of imaging at Mt. Graham Regional Medical Center in Safford, Ariz., cites statistics showing that for every five positive cases found through analog mammography, a digital system found a sixth one. “Unfortunately, I didn’t know at the time of her exam that one of the lives we might have saved with digital mammography was that of my aunt,” says Sanders. Dr. Casey Hines, radiologist at Murray-Calloway County Hospital in Murray, Ky., says his facility had three film/analog mammography units and replaced all with one digital unit. “We were following certain patients with calcifications on the analog system and can now see even more calcifications on the same patients with the digital breast mammography system,” says Hines. “The additional calcifications were there all along; we just could not see them on analog/film.” Regarding the potential implementation of a digital mammography system, this writer has heard concerns voiced such as: “Is this the best solution for the patent?” “Can the time and cost in planning a digital breast health center be justified?” “Will it really make a difference when women are choosing where to have an exam?” When one becomes familiar with the facts, though, the question should be: “Can I afford not to plan a digital breast health center?” Contact Mr. Ron Franks by email at rfranks@hfrdesign.com or by calling (615) 370-8500.

healthforward report

Good Healthcare Design Is About Listening What is “good design” as it relates to healthcare architecture? The answer depends on whom you ask and what their criteria are for evaluating good design. A patient would probably place high value on the finishes, amenities, ease of use and the design subtleties that promote a warm, friendly, comforting environment. An administrator might view efficiency and reasonable construction cost, along with patient friendliness, as hallmarks of a good design. A doctor, nurse or technician would have yet another set of standards, based on their daily interaction with the facility. Ultimately, it is the architect’s role to listen carefully to these sometimes disparate design goals and then produce a design that takes them all into account. That is what clients expect us to do. So, in a sense, they rely on the architect to tell them what good design is, as applied to their particular facility. Someone once said that “good design is free,” meaning that any solution might deliver what the client is asking for, but that good The grand lobby in this HFR-d designed Colorado hospital amply demonstrates the maxim that interior architecture is the heart and soul of a building.

design goes beyond mere deliverables, achieving a success that shows understanding and caring about the client’s needs. In other words, this part of the service goes beyond the contract, producing what can truly be called “good design.” Here are a few specific concepts that, depending on how they are handled, can often make the difference between good design and ordinary design: Clarity A consistent approach to all aspects of a project reveals the clarity of the design. For example, a hospital lobby may be filled with beautiful materials, but if the space has awkward proportions, the original intent of the design is defeated.

This Issue ... • Good Healthcare Design is About Listening • The Whitfield Building: Assisted Living at the Meadows • Deploying an eICU Program in Challenging Financial Times

Site Design The first impression of a hospital is from by Rob Bryant (left), AIA, Project Architect, the road. The site and John L. Coke (right), AIA, Project Architect, layout leads the Hart Freeland Roberts patient and visitor, easing the transition into the hospital. Among other items, site layout is dependent on topography and existing infrastructure. Is patient and visitor parking an endless expanse of asphalt? Would a parking structure bring people closer and reduce travel distances? The emergency department should have an entrance that isn’t tucked around the corner. It is desirable to locate delivery entrances and loading docks in the back of the house, but efficiency and ease of use affect the internal workflow. Way-ffinding Good way-finding design helps alleviate anxiety for patient and visitor alike. Can one find the appropriate parking lot, delivery or loading area, ED, outpatient, etc.? Site signage should have a clear and simple theme that is consistent with the design and mission of the hospital, inside and out. Interior Architecture Interior architecture is the heart and soul of a building.To make it so requires a design interface of exterior, interior, technology and systems. It’s often difficult to manage, but it’s wonderful to experience the final product. And the interface of these disciplines opens the door to a holistic design focused on vision instead of program. continued on page 4

THE WHITFIELD BUILDING: Assisted Living at The Meadows Designing for the Senior Generation of the New Millennium

by Valarie D. Harris Project Designer/Illustrator Hart Freeland Roberts

There is a growing consensus that the “senior generation” of the new millennium is more affluent, healthier, and has higher expectations in general than their counterparts of previous generations. Thanks to modern medicine and a rise in general health consciousness, “baby boomers” typically do not feel or even look “old,” and they certainly have no intention of retiring to an “old folks home.” On the contrary, they are looking to retire in a place comparable in comfort and style to the homes they will leave behind. Architects and designers in the field of assisted living — and healthcare in general — have the task of rising to this challenge. One school of thought in dealing with the issue is to gain knowledge from the hospitality industry, in which the goal is to create spaces people will enjoy living in for an extended period of time, comfortable environments that feel like “home.”

An assisted living facility that resembles a fine hotel: The proposed Whitfield Building at Lakeshore Meadows in Nashville caters to the tastes of today’s senior generation.

The design for the proposed Whitfield Building, to be situated on the existing Lakeshore Meadows “aged living” campus in Nashville, aspires to answer that call. The two-story building will consist of 46 generously sized apartments and 16 apartment units for residents who require memory care support services. At first glance, the building could be mistaken for an upscale hotel or resort. The dramatic approach to the over scaled and craftily articulated porte cochere, an element almost exclusively found in hotel design, is a main contributor to this aesthetic. This assisted living facility, designed in the Arts and Crafts architectural style, is clad in an artistic medley of residential materials such as stone, brick and fiber cement lap siding. Exterior building materials are used on the interior of the building as well to help facilitate the transition of the architectural style to the interior and to create a visually cohesive design. The Whitfield Building contains a number of intimate interior and exterior spaces planned to create an environment that gives a sense of comfort and home to the residents as well as their visitors. Residents of the 69,000-square-foot facility will have 24-hour/seven-days-a-week access to entertainment and amenities such as restaurant style dining, café /soda shop, intimate parlor and living areas, media/theater room, library, beauty salon, business center with Internet access, mini pharmacy, on-call medical care, laundry facilities, luxurious garden/patio/gazebo areas, a thought provokingly designed wandering courtyard for memory care residents, and a graciously sized two-story main lobby area that will serve as a central hub of activity and interaction. The main lobby is open to a secondfloor balcony and boasts a custom-designed water fountain with attached seating and an ingenious two-story, walk-through fireplace complete with craftsman-style monumental staircase. continued on page 4

Deploying an eICU Program in Challenging Financial Times The severe recession, complicated by the simultaneous credit and liquidity crises, has seriously disrupted capital projects across the healthcare spectrum. Many hospitals have suspended building programs. Others have delayed major IT purchases and upgrades. Every day, hospital staff is impacted by hiring freezes, pay cuts, even layoffs. Under these constraints, deploying an eICU program — even considering doing so — seems counterintuitive. But is it? For those new to the concept, the eICU program is an intensivist-led, multi-professional care team and infrastructure supporting the care of critically ill patients across a healthcare system or region. It uses advanced, scalable telemedicine technology, decision support capabilities, and proven workflows, all integrated with bedside teams across ICUs, EDs and other high-acuity care areas, to deliver improved clinical and financial results. Recent statistics show an average 30 percent reduction in hospital mortality of ICU patients, severityadjusted ICU length-of-stay reduction of 29 percent, reductions in variable costs of care and risk spend, and increases in hospital and professional fee reimbursement.

by Joel S. Gochberg Regional Director Philips VISICU

With its proven clinical and financial results, an eICU program investment is a smart decision in any economy. It improves patient care as well as staff satisfaction. But more importantly, it has been demonstrated to be accretive to earnings. Recent experience has shown that a health system deploying an eICU program can achieve a rapid return on investment — in some cases just months after activation. In addition to these tactical benefits, the eICU program offers the host organization a strategic advantage in the region it serves. Nationwide, a severe shortage of intensivists limits critical care quality. But the eICU-enabled health system more easily attracts and retains this scarce resource. Optimal utilization of ICU beds positively impacts ED throughput, volume of surgery and overall capacity management of medical/surgical beds. The program increases quality of care while simultaneously improving efficiency, resulting in an increase of inbound referrals as well as hospital and ICU throughput. In these tough times, most cannot invest in bricks and mortar. But at a fraction of the cost, an eICU program is the virtual equivalent — creating increased capacity with the beds and staff already in place, and providing a compelling, sustainable competitive differentiator. As with any investment, there are costs. In the first year, the major spend components of an eICU program include construction of an eICU hub facility, installation of technology at the ICU bedside, computer hardware and software, and implementation of consulting and training. The principal operating expenses are payroll of the eICU clinical staff and support services from the vendor.

Even in challenging economic times, a case can be made for investing in an eICU program.

The collapse of real estate prices has moved beyond residential properties into the commercial sector. While unfortunate, this creates an opportunity to secure eICU hub space at a reduced cost. Typically, using existing space at an inpatient facility is not recommended due to its high demand and higher remodeling costs. But continued on page 4

Contact: Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Sammy West Director, Jackson Office (731) 421-8000 (731) 695-2902 swest@hfrdesign.com Hart Freeland Roberts 113 N. Liberty Street Jackson, TN 38301

ASHE Session Focuses on Key Questions

Good Healthcare Design is About Listening ... (continued from page 1)

At the recent Health Facility Planning, Design and Construction Conference in Phoenix, sponsored by the American Society for Healthcare Engineering (ASHE) in conjunction with the AIA Academy of Architecture for Healthcare, key questions often asked by hospital administrators, engineers and facility managers were fielded by Easter a panel that included HFR’s Jim Easter, FAAMA, and Bob Harrett, AIA, along with Clay Seckman, PE, of Nashville-based Smith Seckman Reid Inc. engineering, and Rex Mason, JD, AIA, of Phoenix.

Efficiency This is determined in part by the volume of patients and the duration of their stay. The time a patient spends waiting can be reduced by designing the space so that various functions are adjacent or near to each other, meaning the patient isn’t required to circumnavigate the hospital to receive an image or prescription. Ease of use by visitors also determines the efficiency of a hospital.

Attendees heard a discussion of proper planning for healthcare facilities and many of the engineering and infrastructure issues hospitals face daily. Seckman discussed infrastructure and engineering aspects of building design and development, emphasizing that every plan should begin with a “work-up” of the mechanical, plumbing and electrical systems. He also described how voice, data and communications systems are integral threads in the fabric of operations. The panel answered questions from the audience related to topics that included cost management, infrastructure, contingency planning, consultant selection and pre-qualification, plus ways to implement projects effectively. Easter concluded the session with 10 steps to follow in a campus master plan. “Well over 200 people attended,” notes Easter, “and we got extremely favorable feedback from the audience following the presentation.”

Louisville Office Designing Mississippi Hospital

Harrett

HFR Design-Louisville is designing a replacement, 35-bed hospital for King’s Daughters Hospital in Yazoo City, Miss. The new, 75,000square-foot critical access hospital will be built a few miles from the present facility. Bob Harrett, AIA, director of the Louisville office, is architect of record.

“We chose HFR to design our replacement hospital because of their experience in planning and designing critical access hospitals,” said Daryl W. Weaver, CEO of King’s Daughters. “Hospitals of this type have unique operational needs, and HFR demonstrated a full understanding of the functional efficiencies necessary for a successful design.” The Whitfield Building: Assisted Living at The Meadows ... (continued from page 2)

In a very real sense, this planned senior living facility accurately represents the type of environments for retirees we’ll be seeing more and more of as the 21st century progresses. Both baby boomers and senior generations of the future will be able to relate to this type of living as a natural extension of the environments they’ve known and loved in their youth. Contact Ms. Harris by email at vharris@hfrdesign.com or by calling (615) 3708500.

Visitor Amenities Certain visitor amenities, often small gestures, go a long way toward delivering hospitality and patient care. Chapels, private family/doctor consult spaces, gift shops and gardens may carve precious square footage out of the hospital, but can be incorporated in lobby spaces with minimal impact. Competence in these areas, of course, is only the first measure of good design. Architects must constantly be aware of current design trends, deliver solutions based on a genuine enthusiasm for what they are doing, and, above all, show genuine concern for their clients. Contact Mr. Bryant by email at rbryant@hfrdesign.com or by calling (615) 3708500. Contact Mr. Coke by email at jcoke@hfrdesign.com or by calling (615) 370-8500. Deploying an eICU Program in Challenging Financial Times ... (continued from page 3)

an eICU hub can be located anywhere. In fact, a health system may already own underutilized space that could be converted for eICU hub use, providing a facility that is comfortable and effective without being extravagant. Many hospitals already have made investments in the patient monitoring and IT systems necessary to feed information into the eICU hub. Although some servers, network and audio/video equipment are necessary to support an eICU program, their cost is modest compared to major IT investments. Software licenses, implementation, training, support and upgrades can be amortized over multiple years, reducing the upfront investment. Based on research conducted by the Advisory Board Company, chances are an existing intensivist staffing model costs more than an equivalent eICU physician staffing model. In a typical intensivist model, one physician supports up to 20 patients. With an eICU program, one intensivist and two critical care nurses can support more than 100 patients. In 2008, at least $4.5 million in grants was awarded by major insurers and the federal government to support program development and outreach. Plus, with the recently passed financial stimulus package, dollars will be made available for healthcare IT projects, which may include eICU program deployments. With a smart approach to licensing, bargain hunting for space and a combination of funding sources, an eICU program can be within the reach of a health system, even in the midst of this challenging time. Contact Mr. Gochberg by email at joel.gochberg@philips.com or by calling (931) 233-0479.

healthforward report

Hospital Beds, Planning and Housing Needs Addressed by TEAM HFR HFR’s Dick Carota recently spoke at the American Academy of Medical Administrator’s (AAMA) annual meeting in San Antonio, Texas. His presentation addressed the topic: “Hospital Beds ... How Many and What Kind?” The session was well attended with representation from both the AAMA federal and private sector membership. Utilizing actual planning case studies, Dick illustrated how historical use data and new service delivery initiatives may be utilized to forecast future bed needs. Methods for projecting future workload volumes were highlighted along with unique factors that can affect the volume outcomes. A number of evidence-based design and planning scenarios were illustrated. Attendee responses and questions addressed issues such as: “Does the increasing use of private rooms impact the number of beds and their utilization?” “How has the obesity factor impacted design and quantities of rooms?” And, “How do you see the architecture of the inpatient rooms changing in the future?” Feel free to contact Dick Carota with questions at (615) 424-3642 or rcarota@hfrdesign.com.

improved management outcomes”: Hugh Chatham Memorial Hospital in Elkin, N.C., (featured in the October by James G. Easter, Jr., FAAMA, 2008 edition of healthforDirector of Planning and Programming ward report) and DeKalb Healthcare Division, HFR Design Medical, a major force in mother and infant care in Decatur, Ga. Through photos and descriptions, a history of very successful management, planning and design was revealed. Questions were numerous, including “Does good design cost more?” and “How can we convince our board of directors to hire creative planners and designers?” Questions concerning this presentation can be addressed to Jim at (615) 424-3642 or via email to jeaster@hfrdesign.com. Meanwhile, at the Annual Tennessee Governor’s Conference on Housing in December, this reporter, along with HFR’s Kyle Dunn and Tom Phillips, outlined the steps one should follow in preparing a housing needs assessment. HFR Affiliate Partner and Senior Consultant Tom E. Phillips, AICP, is also Principal of Phillips & Associates, Manhattan, Kan., and authored an article in the July 2008 healthforward report.

Also at the San Antonio conference, your author, a past chairman of AAMA, spoke on “Asset Management and Administrative Services: Form Follows Function Follows Funding,” addressing the importance of comprehensive master planning, program The program also included Presenters at the recent Tennessee Governor's Conference on Housing analysis and functional intepresentations by housing included (left to right) Jim Easter, HFR Design; David Fox, University of gration of patients, staff and leaders and a legislative Tennessee College of Architecture and Design; Tom Phillips, Phillips & Associates; family into the planning and update by Tennessee and Kyle Dunn, HFR Design. design process. How eviCongressman Jim Cooper, dence-based design impacts “hands-on care” of patients and who described societal, planning and service delivery chalhow “branding and benchmarking” of assets improve access, lenges. David Fox, AIA, a professor at the University of quality and ROI were also included in the presentation. Tennessee College of Architecture and Design, along with one of his students, presented examples of their work from a proDesign illustrations for future inpatient rooms were presented, gram that involves students in the design and construction of along with two HFR case studies illustrating how “good planlow income housing for Tennessee communities. Afterwards, ning plus good design equals better business practices and they answered questions concerning program start-up, funding and ongoing efforts.

This Issue ...

• Hospital Beds, Planning and Housing Needs Addressed by TEAM HFR • Healthcare Facilities Benefit From LEED Certification • Project Spotlight: Energy Efficient AND Within Budget

continued on page 4

Healthcare Facilities Benefit From LEED Certification Sustainability, broadly defined, means using a resource so that the resource is not depleted or permanently damaged. Sustainable design, more commonly referred to these days as “green design,” means designing the built environment to comply with this principle. Green design is an integrated design process within architectural design. In addition to concern for outdoor environmental pollution, green design also focuses on indoor air quality: the air our physicians, patients and staff breathe, day in and day out. In 1998, the U.S. Department of Energy grasped the significance of this problem in healthcare and funded the Leadership in Energy and Environmental Design (LEED) program in an effort to promote sustainable building design and reduced energy costs. The LEED program develops and enforces sustainable design standards for several construction project types: new construction, heavy renovation, interiors and shell space. Each LEED rating system offers levels of certification according to the number of credits completed: Certified (26-32 pts), Silver (33-38 pts), Gold (39-51 pts) and Platinum (52-69 pts). All credits are grouped into one of six sections, based on the following types of sustainable design: 1. Sustainable Sites (SS) - ecosystem preservation, building location, heat island and light pollution control - 14 points possible. 2. Water Efficiency (WE) - decrease potable water usage in building and landscaping - 5 points possible. 3. Energy & Atmosphere (EA) - promote green power usage and decreased use or elimination of ozone-depleting chemicals 17 points possible (2 required for certification). 4. Materials & Resources (MR) promote use of recycled and regional materials - 13 points possible. 5. Indoor Environmental Quality (EQ) - improve healthy indoor air quality and thermal/lighting comfort for users - 15 points possible. 6. Innovation in Design (ID) - encourage creativity and exemplary performance in green design - 5 points possible.

by Emily R. Mowry, LEED-AP Assistant Specifications Writer Hart Freeland Roberts

The U.S. Green Building Council has compiled a list of benefits for LEED design, including reduced energy costs, a decrease in employee sick days, increased staff productivity and improved education on environmental standards. Designing a building for LEED certification does add some upfront cost to the project budget; however, many owners of LEED-certified buildings have seen this initial investment repaid over time through a decrease in energy and labor costs. These ROI factors are tested with the owner during the architectural, planning and programming phase of development. Owners with stringent budgets can choose to design their buildings with “LEED-like” elements. Both scenarios are possible with the help of a LEED-accredited professional assisting with the programming and design process. In order to gain this accreditation, candidates must pass an exam that covers LEED credits, project team, procedures and calculations. The end result of LEED certification is a built environment that is healthier for the users and less costly to operate over time. People who enjoy their working environment have greater motivation to excel, which improves company morale and productivity. Sustainable environments are here for the long term, and the certification process ensures added value for the building user. Contact Ms. Mowry by email at emowry@hfrdesign.com or by calling (615) 370-8500.

The use of solar power and other forms of green energy helps build credits toward LEED certification.

PROJECT SPOTLIGHT

Energy Efficient AND Within Budget Many healthcare facility owners, along with their architects and engineers, have considered solar and geothermal energy to dramatically reduce a building’s energy usage. Additionally, it’s “just the responsible thing to do.” But, all too often, those efforts are dashed when design cost estimates quickly point to those options as budget busters. However, there are attainable alternatives, all too seldom used, that easily avoid the budget ax.

by Scott Corbin, AIA, Vice President, Principal, Healthcare Division, Hart Freeland Roberts

For the design of the new Ringgold County Hospital in Mt. Ayr, Iowa, HFR worked with the owner, the owner’s rep and the power company to design a building that performed above the norm and returned energy cost savings to the owner through design. We worked closely with a consulting firm charged with the goal of integrating energy conservation concepts into our design for a high-performance hospital envelope. The design also included daylighting of the building. Hospitals are, by their very nature, energy-intensive structures. Large areas are often in a cooling mode, even in the dead of winter, due to their 24/7 operation, required lighting levels, constant equipment usage and the intense use of each room in the building. But there are some simple, no-nonsense design decisions that can and will reduce energy use daily. They include: • Windows of low E clear glazing in a thermally broken aluminum frame. • Occupancy sensor lighting controls in rooms such as offices, restrooms, storage rooms, locker rooms, conference rooms and lounge/waiting spaces. • Dual level switching of lights. • Manual dimming of lighting in rooms such as conference and board rooms. • Premium efficiency supply and return fan motors. • Structural precast concrete panels with an integral insulation core. • Premium efficiency pump motors. • Variable frequency drives on supply and return fan motors and chilled water pumps. • On-demand hot water heaters. • R-30 roof insulation. • High efficiency gas boilers. • Sensible heat recovery system design. All of these measures are then computer modeled to arrive at informed design choices by weighing construction costs of the measures against the potential energy cost savings over time. Precast concrete panels with an integral insulation core are part of the energy-efficient design at Ringgold County Hospital.

Finally, by designing large, daylighted public spaces such as the lobby area, the need for artificial illumination is minimized. Coupled with accent lighting, the room uses minimal daytime power for lighting. continued on page 4

Contact:

Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrkc.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

David Jann Becomes a Licensed Architect David N. Jann of HFR’s Kansas City office recently became a licensed architect in the state of Missouri, having passed the Architectural Registration Exam. David, a project manager, joined HFR in January 2000. He is a 1992 graduate of Kansas State University, where he earned a Bachelor of Architecture degree. Programming, design, construction documents, and construction administration are his main areas of expertise. David has been mostly involved in healthcare projects, the most recent of which were replacement hospitals in Carthage, Ill., and Falls City, Neb. He served as project manager on both. Past HFR-KC projects on which he has worked include replacement hospitals for Cameron Regional Medical Center, Cameron, Mo., and I-70 Medical Center, Sweet Springs, Mo.

Medical Equipment Specialist Joins HFR as Consultant Beverly Reagan, an executive diagnostic imaging equipment consultant and medical equipment planner, has contracted with HFR as a consultant in the Healthcare Planning Department and will be based at HFR headquarters. Reagan comes to HFR with a background in executive consultative business development, medical equipment planning of major and minor medical facilities, educational consulting, plus nursing experience and coursework. Her education includes a bachelor’s degree in radiology education and health administration.

Louisville Office Honored

advertising.

HFR Design-Louisville, headed by Bob Harrett, AIA, was recently selected for a Best of Louisville Award in the Engineering & Architectural Services category by the U.S. Local Business Association (USLBA), a Washington, D.C. based organization whose purpose is to promote local business through public relations, marketing and

The award program recognizes companies that the USLBA identifies as having achieved exceptional marketing success. Winners are determined based on information gathered by the USLBA and data provided by third parties.

Hospital Beds, Planning and Housing Needs ... (continued from page 1)

The HFR team’s housing needs assessment steps included: Step 1: Establish a housing plan steering committee. Step 2: Survey the current situation and conduct on-site constituent interviews and property assessments (housing condition survey and visual assessment of existing housing). Step 3: Collect relevant housing, population, demographic and economic data. Step 4: Present draft findings for comment and feedback. Step 5: Conduct citizen focus group sessions and present priorities for joint ranking and comment. Other “change agents” described by city planning specialist Tom Phillips and this writer included: • Collaborative leadership • Utility and infrastructure • Staged program funding • Neighborhood “health index” • Constituent sounding boards • Incentives to grow the local economy • Reinvestment in private dollars • Creating new housing opportunities near the university • Flexible planning and zoning regulations • Code enforcement and incentive measures • Community planning through shared vision • Facilitating economic growth within the area Two case studies completed by HFR Design in 2008 were presented: a housing and human services engagement for the city of Pittsburg, Kan., and a recreational, wellness and fitness study completed for Fayetteville, Tenn. Both demonstrated the linkages between human services, housing, recreation and quality of life. For questions concerning this presentation, call Jim Easter at (615) 424-3642 or (615) 370-8500 or email jeaster@hfrdesign.com, kdunn@hfrdesign.com or tphillips3@cox.net.

Energy Efficient AND Within Budget ... (continued from page 3)

All of this effort early in the design phase to save utility cost dollars is, of course, contingent on the construction management team carrying out the work properly. In addition, the end user must be on-board with policies that minimize energy use in order to achieve the cost savings goals of the design. Contact Mr. Corbin by email at scorbin@hfrkc.com or by calling (816) 8228500.

HFR Attains Silver Level as AAMA Strategic Partner HFR Design has been recognized by the Board of Directors of the American Academy of Medical Administrators (AAMA) as a sustaining and supportive member of AAMA and elevated to Silver Level Strategic Partner. “This is one of the highest honors that could come to a corporation,” said James G. Easter Jr.,

FAAMA, Director of Healthcare Planning and Programming for HFR Design. “We make a priority of being actively involved with this fine organization.” AAMA’s Strategic Partners program recognizes the major role that leading corporations play within the Academy and its specialty groups.

healthforward report

Hospitalist Programs Expand Beyond Large Hospitals [Editor’s note: Mt. Graham Regional Medical Center, a 59-bed general acute care hospital in Safford, Ariz., recently contracted with Mark Tozzio, FACHE, Senior Healthcare Consultant for HFR, Inc., to assist with the design and implementation of a new hospitalist program.] The development of dedicated hospitalist programs is spreading rapidly at hospitals large and small. Since 1995, the number of full-time hospitalists has grown from a handful of practitioners to over 23,000. Higher costs and lower reimbursement for primary care physicians (PCPs) have accelerated adoption of the programs to care for inpatients and allow PCPs to focus on seeing patients in the office.

• Improved utilization of intensive care beds. • Increased PCP office capacity. • Improved patient and physician satisfaction scores through constant involvement of the on-site hospitalist.

Increased Office Capacity and Revenue Flores also discovered that a hospitalist program can contribute to increased PCP office capacity and generate more revenue for referring physicians that use hospitalist services. She estimates that the average PCP can see an additional six patients per day by avoiding two hours of daily hospital rounding, which can amount to a “net daily replacement income” of about $275, or incremental annual net income of over $23,000.

According to industry surveys, 49 percent of hospitalists are salaried and 34 percent receive a salary plus performance incentives. Generally, they earn about 15 percent more than their general practice internal medicine colleagues, with base salaries ranging from $180,000 to $220,000.

Key Elements Dr. Shawn Morrow, a six-year hospitalist veteran and medical director of Mary Black Inpatient Physician’s Group in Spartanburg, S.C., believes there are several fundamental elements that should be incorporated into a hospitalist program start-up process:

Benefits The benefits of a well-run hospitalist program are both tangible and intangible. Research by consultant Leslie Flores of Nelson/Flores Associates LLC, La Quinta, Calif., indicates that the main attributes of a hospitalist program include: • Cost avoidance and reductions. • Increased admissions (particularly unassigned patients from the ER). • Increased procedure volume. • Enhanced case-mix severity of illness. • Reduction in ALOS. • Improved bed availability. • Better utilization of ancillary services. • Improved discharge timing.

This Issue ... • Hospitalist Programs Expand Beyond Large Hospitals • An Interview with Dr. Allen Lawhead of AWCC • Project Spotlight: Master Planning, The Business Perspective

by Mark Tozzio, FACHE Senior Healthcare Consultant Hart Freeland Roberts, Healthcare Division

• Medical staff buy-in, particularly FPs and surgeons associated with the hospital. • Administrative support that covers all of the parameters of the operations: staffing, clinical and financial support. • A referral mechanism that incorporates patient follow-up (participants in the post-discharge program must take all patients, not just their own or insured patients). • Program coverage that includes a minimum 12 hours during the daytime; evenings can be covered by rotation of on-call status for emergency cases. • A fair compensation methodology. Having hospitalists care for inpatients while primary care physicians focus on seeing patients in the office is a rapidly growing trend.

continued on page 4

An Interview with Dr. Allen Lawhead, Director, Atlanta Women’s Cancer Care

Interviewed by James G. Easter, Jr., FAAMA, Director of Planning and Programming Healthcare Division, HFR Design

It is often challenging for physicians to address both the “heart and soul of caring” in tandem with the “business of healthcare delivery.” Allen Lawhead Jr., MD, FACS, FACOG and Director of the Atlanta Women’s Cancer Care (AWCC) at DeKalb Medical, chose to begin this interview with these responses to Jim’s questions. DeKalb Medical is a long-standing and respected client of HFR Design. Jim Easter and Dick Carota have worked with DeKalb on a number of specialty programs ranging from ambulatory surgery, to women and infants, to heart center care, emergency medicine and cancer care. JE: How would you describe the “business” of cancer care? AL: The cancer care for patients at DeKalb Medical has one very important business objective: deliver responsive, excellent patient care and clinical support to cure the patient and return them to normal life. What had been missing from this vital premise was the service delivery aspect of the business. Everyone on the AWCC team understands that responsive service is far greater than the “dollars and cents.” In today’s environment, everyone is sensitive to limited resources, cost reduction measures and management of time. Immediate responsiveness to fear is comforting. From the first contact, through treatment, recovery and follow-up, our collective business objective is positive, professional and personal care. Our industry (yes, healthcare is an industry) has not totally delivered the highest return on the healthcare dollar of investment. This will change. Excellent care is much more about efficiency, turnaround time in a professional fashion and continuous service volumes over time. The AWCC program is proud to be personal, professional and profitable. We focus on service quality first, and the business just thrives. JE: Regarding the human and clinical aspects of cancer care, which do you consider the most significant? AL: The golden rule of all medicine is curative: Treat others as we would treat ourselves. We live this fundamental principle here at AWCC, and we place the care above teaching, research and scientific advancement. We do place emphasis on an educated patient and their family. This is the secret to patient empowerment, a curative partnership that works miraculously. They become partners with our team on the road to healing and recovery. We are always factual and personal in our clinical world. Our team understands, and the successes demonstrate the added value. JE: What do you consider the primary issues today for your healthcare delivery team? AL: Today and every day the AWCC team is focused on taking care of each patient in an optimal fashion, being prompt, seeing the patient on time, treating them professionally and educating them through the very best service delivery obtainable. What differentiates us is the absolute passion we possess for the care for each patient. That passion is empowering and curative. We are truly revolutionizing the patient care in our system. It is the human element that counts first and foremost. We believe the number one strategy is to provide all aspects of patient care through a synergistic and dedicated team in a comprehensive “one-stop environment” for both inpatient and outpatient services. There is a harmony and balance that results with this approach to care and caring. (Following the interview, Dr. Lawhead described a phone call he received the previous evening from a husband asking about his wife’s condition. “She was in my office upon my arrival this morning,” Dr. Lawhead said. “Being there is everything. Our patients have our phone number!”) Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 370-8500.

PROJECT SPOTLIGHT

Master Planning: The Business Perspective Several valuable aspects of a hospital master plan (MP) often go unmentioned, for example, organizing all existing plans so that one knows present locations and conditions; understanding the existing topography, traffic flow, parking and access; gathering the existing workloads for diagnostic and treatment areas; and assessing bed utilization, history and future needs. Putting all this information into a manageable package expedites decision-making regarding construction of priority projects. Once the sizes of the new programs have been confirmed, testing locations (internal to existing buildings, adjacent to existing or even vertical expansion, nearby or offsite), fit and design considerations come into the picture.

by Scott Corbin, AIA,Vice President, Principal, and Page Onge, AIA, Healthcare Division Hart Freeland Roberts

1. Yes, even though it would be somewhat disruptive, emergency could expand in place and be designed to meet projected volumes while staying in operation. The new design will improve access, functional arrangements and overall efficiency. 2. Yes, the lab could move to available shell space within the existing hospital, helping facilitate completion well ahead of renovation in place or more expensive new construction. 3. No, the present inpatient bed areas would not work as they were originally constructed (for either acute care private rooms or intensive care and congested observation). We must move walls to meet new space standards and handicap accessibility.

Because these original rooms had been designed in an era when angular walls and small toilets and showers were the norm, it was apparent that redesign would be required in order to meet We began the MP for HCMH with three Hugh Chatham Memorial Hospital ICU nurse Carolyn Hall current design guidelines, consumer formidable questions on the table: reviews plans for the hospital’s new ICU with lead designer demands and ADA handicap accessibility standards. For these reasons, a Scott Corbin, AIA, of Hart Freeland Roberts. new bed tower was planned for acute 1. Could we expand the emergency care and ICU/special care phase 1, thus freeing up space for department ASAP, and how big should the service be profuture renovations of the older areas. grammed? 2. Where should we place our very congested and outdated hospital lab? 3. Is it possible to make our private When we reviewed the added value of the MP in a business rooms work without moving walls and making major engineerand management context, we realized the following: ing changes to the building? Many of these goals and issues were addressed by HFR Design for Hugh Chatham Memorial Hospital (HCMH) in Elkin, N.C.

The answers became apparent as we evaluated the facts and compared the existing conditions to work load volumes, bed needs and reasonable projections into the future.

1. Construction projects are often developed in an “opportunistic” manner without considering the “big picture,” such as flow patterns, parking needs, ease of wayfinding, operational concontinued on page 4

Contact:

Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrkc.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

Master Planning: The Business Perspective ... (continued from page 3)

siderations and optimum service delivery for both staff and patients. It would have been easy to address only the “big 3” questions and not review the other concerns on campus. This piecemeal approach was not what the hospital leadership team desired, and the staff supported this objective 100%.

3. By creating the MP, one creates a “road map” into the future with a phasing plan designed to minimize disruption. This MP can then be revisited routinely as funds and functions come together over time. Balancing affordability with service need is a challenge in today’s healthcare environment. Making sure revenue-generating services are not overlooked, or unwisely delayed, is essential to staying in business and remaining competitive in a consumer-driven world.

2. The MP also took into account key service factors relating to longterm parking needs, potential medical office space, rehabilitation services and the disposition of cancer care Hugh Chatham programs by asking Memorial Hospital has additional relevant set the bar very high. In this aerial perspective view of Hugh Chatham Memorial Hospital, questions, such as, They are true role modthe existing hospital is shown at left (white), new bed tower addition is center “Should we stay on els for healthcare servand planned parking garage (grey) is at right. ice delivery and quality campus or move these care within this region. important services to other nearby sites?” We reached the appropriate answers Contact Mr. Corbin by email at scorbin@hfrkc.com or by calling (816) 822through consensus and ROI comparisons. 8500. Contact Mr. Onge by email at ponge@hfrdesign.com or by calling (615) 370-8500.

Hospitalist Programs Expand Beyond Large Hospitals ... (continued from page 1)

• Effective communication with referring doctors and ER physicians. • Evaluation of the program’s effectiveness at least semiannually. Proceed With Caution When establishing a new hospitalist program, management must take into account a potential “love/hate” relationship between the medical staff and hospital-based internal medicine practitioners. Some PCPs feel strongly that it is important to care for their own patients in both the office and hospital. This writer’s experience indicates that a formal “letter of understanding” between the hospitalist program and referring physicians is advantageous to all. This helps clarify expectations and outlines pre- and post-discharge processes for participating physicians, avoiding misunderstandings that can compromise the program’s effectiveness. Failure to send the patient back to the referring PCP and provide important follow-up information is the “death blow” of a positive relationship with referring PCPs. Positive Impact A hospitalist program can positively impact a hospital and its physicians by: • Providing a seamless process for caring for unassigned and other patients being admitted through the ED.

• Supporting PCPs and surgeons in the care of patients assigned to the care of the hospitalists. • Improving patient management. • Enhancing patient access to inpatient services. • Increasing the availability of IM specialists in the community. • Providing timely oversight and management of critical care patients. Patrick Peters, CEO of Mt. Graham Regional Medical Center, states: “We are confident that our new hospitalist program is designed to benefit our patients, many of our busy physicians, and enhance medical services in our growing community. Any cost savings for the hospital will be an added bonus.” Overall, this writer has found that a well-thought-out hospitalist program can generate a positive contribution margin in two to three years. Contact Mr. Tozzio by email at mtozzio@hfrdesign.com or by calling (918) 521-7468.

Sprinklers to be Required for ALL Nursing Homes All nursing homes in the U.S., not just new or rehabilitated facilities, must have full sprinkler systems in place by the year 2013 in order to serve Medicare and Medicaid beneficiaries. This results from a new regulation to be issued by the Centers for Medicare and Medicaid Services. To be compliant with the new rule, nursing homes will be required to have sprinkler coverage in all areas. The systems will have to meet the technical specs of the National Fire Protection Association.

healthforward report

Hospitals as Community Components by Tom E. Phillips, AICP Principal, Phillips & Associates Affiliate Partner and Senior Consultant, City Planning, Hart Freeland Roberts

City design, according to author Kevin Lynch, deals with the spatial and temporal pattern of human activity and its physical setting, taking into account its socioeconomic and psychological effects. The design of new or expanding hospital environments needs to be compatible with city planning principles and local planning policies. Understanding and coordinating with the larger city-planning framework is critical.

Working together can be mutually rewarding for hospital planners and city planners, who share many of the same goals.

What role does the design of a hospital play in creating good city design? The author believes an important aspect of hospital design is the contextual and physical relationships that exist between a hospital and the city and neighborhood within which it operates. To strengthen and enhance the ways in which a hospital contributes to the livability, aesthetic quality, social fabric and built environment of a city, the basic concept of hospital “project design” needs to be broadened to include the spatial arrangement and activities of that city. Hospitals operate within defined geographic boundaries, which are typically set by ownership patterns or expansion into nearby neighborhoods. Hospital designers are well equipped to master plan a formal framework for individual buildings on a medical campus, typically including in their plans key elements such as wayfinding signage and on-site circulation for the general public, the goal being to create a user-friendly environment. However, focusing on the interface beyond the boundaries of the hospital - the larger urban context - is often neglected, to the detriment of the hospital and the community atlarge.

This Issue ... • Hospitals as Community Components • Toward a Better Chemotherapy Treatment Room Layout • Project Spotlight: Functionality Key in New Emergency Department Design

Presented here are some examples of urban design/planning principles that represent the logical interface between city planning and hospital project planning: Community Access/Connectivity A hospital represents a significant “development node,” and in many instances generates nearby private development in housing, office or commercial space. How the community gains access to a hospital is critical to both hospital designers and community planners. Transportation facility planning is necessary to successfully serve the hospital, the community, and new development opportunities that arise. A holistic approach is needed to evaluate street capacity, roadway widening, traffic calming measures and highway infrastructure. How well pedestrians, bicycles, autos and public transit are accommodated, how strong the various linkages between hospital and community are, how effectively local business and living environments are supported, all contribute to livability and to the success of a hospital. Park/Open Space Hospitals, by their very nature, bring concentrations of people together to provide or receive medical care or conduct research. A collaborative design approach between hospital continued on page 4

Toward a Better Chemotherapy Treatment Room Layout [Editor’s note: Emily Mowry, Jim Easter and members of the HFR Planning and Healthcare Design Department helped teach the class referred to in this article, with Hart Freeland Roberts serving as sponsor of the 2007 chemotherapy room project and the 2008 CAH inpatient room project.]

As cancer centers continue to grow in the U.S., patient comfort becomes a more important factor in choosing where to seek treatment. Poor flow patterns within a hospital department can decrease treatment quality and efficiency as well as increase patient discomfort. But what would the ideal chemotherapy chair and treatment room layout look like? A group of biomedical engineering (BME) students at Vanderbilt University School of Engineering may have come up with the answer. During their senior year, BME students at Vanderbilt are required to complete a design project, usually in teams of three to four individuals. Engineering faculty accumulate a list of sponsors from academia and industry, each of which has reallife problems that need to be solved. Traditionally, biomedical engineering (BME) students focus on projects applicable to medical research, such as implant devices or data processors. However, one recent group took on the challenge of designing the perfect chemotherapy treatment room and patient chair. To begin, the students took a firsthand look at the current room layouts in Vanderbilt University Medical Center’s Ingram

by Emily R. Mowry, BE Programmer, Planning, Healthcare Division

Cancer Center, then interviewed clinical staff there. In talking with staff members, they learned that lack of room circulation, especially around the patient infusion chair, was the most common complaint. It was also pointed out that there was not a designated space for family members in the room and that nurses often had to reach over patients to dispose of needles or other biological waste. The design team created a 3D layout of a treatment room that outlines three “zones,” for patient, clinical staff and guests. The patient has full view outside a window in the room, while the charting station is located close to the door. The L-shaped configuration creates small alcoves to place chairs or sofas for family members to wait. The reclining patient chair also includes moveable side tables on which patients can place laptops and other portable devices. In 2008, a senior design group is focusing on inpatient care, specifically the inpatient room as applied to critical access hospitals (CAH). CAHs require a different planning and design approach because they are limited to 25 staffed acute-care beds. These hospitals must make the most of their limited space and dollars through creative design, while also meeting the demand for a higher quality patient care environment.

With this in mind, the students are researching room designs that meet AIA guidelines, but which also incorporate a creative component that transforms the traditional “hospital room” into a comfortable “hotel room” for patients and family members. In this treatment room layout created by biomedical engineering students at Vanderbilt University, blue represents the patient, magenta the clinical staff and yellow the guests.

In the past several years, HFR has completed replacement hospital designs for several CAHs in the Midwest. We anticipate great results from this year’s student team and look forward to incorporating those results into our future CAH patient room designs. Contact Ms. Mowry by email at emowry@hfrdesign.com or by calling (615) 370-8500.

PROJECT SPOTLIGHT

Functionality Key in New Emergency Department Design So, you need an elevator, a stairwell and a mechanical penthouse moved? No problem--it’s all in a day’s work, so to speak, for the design team at Hart Freeland Roberts (HFR), and that is precisely what was required in order to maintain the functionality of design of the new 22,000-square-foot emergency department for Maury Regional Hospital (MRH) in Columbia, Tenn., a client we have served for nearly 25 years. Making such changes would be a costly exercise, but MRH was determined that there would be no compromise to staff/patient flow and appropriate adjacencies, and HFR was dedicated to meeting those expectations.

by Ron Franks, AIA Chairman Hart Freeland Roberts

cant grade change. While the design team’s initial solution complied with codes, a number of patients and their families were intimidated by the length and steepness of the ramp. HFR ultimately decided that it should be torn down, redesigned and rebuilt, and in addition helped to pay for the rebuilding. In an effort to help obtain the best construction manager fees and services available, Maury Regional Hospital assigned Hart Freeland Roberts the task of soliciting proposals and qualifications from construction managers. HFR’s design team then went about developing a comparison matrix for this purpose, and MRH finally selected the firm that historically handled most of the hospital’s work.

In addition to making functionality a top priority, construction phasing was Opening its doors in mid-2007, the also a critical issue, and during this new, state-of-the-art Maury Regional stage it was business as usual in the Hospital emergency department now existing emergency department while provides separate entrances for both the new addition was being constructwalk-in patients and ambulances, a ed. Once completed, the ED relocated Both staff members and patients have expressed great to the new addition in order for existing central core surrounded by multi-pursatisfaction with the improved flow, functionality and areas to be renovated. All of the addiaesthetics of the new HFR-designed emergency department pose exam rooms, and a shelled space at Maury Regional Hospital in Columbia, TN. tion and renovation had to be specififor future expansion and underground cally designed to meet high-rise code parking for physicians. standards, as the new design broke down a fire separation barrier that kept the high-rise patient tower separate. I’m happy to report that staff and patients alike have expressed a great deal of satisfaction with the improved flow, functionality One unexpected challenge that arose during the course of the and aesthetics of the new emergency department at MRH--a project was the construction of a ramp (designed to bring hospital recently recognized as one of the top 100 hospitals in patients to the curbside for discharge), which involved a signifithe nation.

Hart Freeland Roberts (HFR Design), which traces its roots to 1910, offers architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment procurement, and move management. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets nationwide.

Contact:

Ron L. Franks, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0898 rfranks@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive, Suite 300 Brentwood, TN 37027

Scott D. Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrdesign.com Hart Freeland Roberts 9237 Ward Parkway, Suite 108 Kansas City, MO 64114

New Digs for HFR-LLouisville

NEWS NOTES ... • Advanced Cardiovascular Leadership Workshops, sponsored by the American College of Cardiology, will be held Aug. 21-22 at The Fairmont Hotel in San Francisco and Nov. 6-7 at Heart House, ACC headquarters, in Washington, D.C. Full information is available at www.acc.org. • The American College of Surgeons’ 94th Annual Clinical Congress, “Leading the Way to Quality, Safety and Excellence,” will be held Oct. 12-16 at the Moscone Convention Center in San Francisco. The complete program planner, including online registration and hotel reservations, is available at www.facs.org.

HFR’s Louisville office has a new address, and Bob Harrett, AIA, says he could not be more pleased with the move. “Having a larger space with a better layout is already paying dividends in terms of greater efficiency, plus we’re now closer to more of our core market,” says Harrett, an HFR Associate and Director of HFR-Louisville. The office provides healthcare facility planning, design and interiors. The new address is The Forum III Office Park, Suite 190, at 305 N. Hurstbourne Pkwy. in Louisville. Bob can be reached at (502) 425-8505 or bharrett@hfrdesign.com.

• The American Society of Anesthesiologists will hold its 2008 Annual Meeting in Orlando Oct. 18-22. The deadline for online registration and ticket purchases is Oct. 8. For more information, visit www.asahq.org. • The American Board of Medical Genetics has announced that November 28, 2008, is the application deadline for the 2009 Certification Exam. Questions concerning the examination program should be directed to abmg@abmg.org. HFR-Louisville has gotten squared away in new office space.

Illinois Hospital Celebrates Major Milestone A groundbreaking ceremony was recently held at the site to be occupied by the new Memorial Hospital in Carthage, Ill. HFR not only provided master planning and design services for the replacement hospital, but also worked with hospital officials on a CON, funding, negotiations with the city and land acquisition. Memorial is headed by CEO Ada Bair. Members of the design team included: Scott Corbin, AIA, Principal in Charge; Jim Easter, Senior Programmer and

Planner; David Jann, Project Manager; Brad Athey, Project Coordinator; Marjorie Roysdon, Interior Designer; Brian Crump, Structural Engineer (all of HFR); John Fleming, PE, mechanical/electrical engineering, KJWW Engineering Consultants; Terry Knoke, PE, and Doug Seeber, PE, civil engineering, Poepping, Stone, Bach & Associates; John Kennedy, kitchen planning, Santee/Becker Associates; and Bob Yancy and Matt Short, medical equipment planning, MEMdata.

Hospitals as Community Components ... (continued from page 1)

and community planners can lead to innovative ways to incorporate a public park or open space capable of serving both the users of the hospital and the surrounding neighborhood. A team approach can bring into sharper focus the spatial relationships between the layout of the hospital buildings, the surrounding neighborhood and the transportation corridors that link the hospital to the larger community. Streetscape/Civic Space The term “streetscape” describes all the elements that are visible from the street, plus the space from the front of a building to the street edge. Elements of streetscape design include street lighting, trees, changes in sidewalk texture, safe and convenient pedestrian movement, street furniture, transit shelters, business signage, hospital directional signage, overhead utilities, landscaping and parking areas. While all these elements

are primarily the responsibility of city leaders and community planners, they clearly have a direct impact on hospital design. The images that people have about the pathways leading to a hospital help define the meaning they attach to visiting that hospital environment. Therefore, attention to civic space leads to ensuring a positive engagement between the person and that environment. A good streetscape provides a sense of orientation that communicates a sense of identity, thereby contributing to the creation of a recognizable and engaging environment for the hospital, differentiating it from other locations and contributing to neighborhood livability. Hospital planners and city planners share many of the same goals, almost all of which relate to creating environments that help make human activity more efficient, rewarding and enjoyable. It’s time they got to know each other and started working together. They’ll find it mutually rewarding. Contact Mr. Phillips by email at tphillips3@cox.net or by calling (785) 537-2867.

healthforward report

First Quarter 2008

A Changing Healthcare Consumer Base = A Changing Healthcare Architecture

by James G. Easter, Jr.

As we read current healthcare publications, a number of provocative titles jump out at us: “When We’re 65 … Few Are Looking Ahead at How to Care For a Coming Horde Of New Seniors” “Will There Be Enough Doctors?” “Alarming VA Problems - Questions Continue Over Quality of Vets’ Healthcare” “Longer Life, Less Healthy - Community Outreach Needed: Experts” “Uncompensated Care Spikes by 8.3%: AHA - Medicare losses at General Hospitals Also up 20% to $18.6 Billion, Association Says” The demand for healthcare services continues to escalate while the cost of care increases at a disproportionate rate, much faster than the general economy. Some have suggested high costs are the fault of the delivery system; others say the solution rests in the hands of the consumer.

• Prescribed medications • Emergency medicine for urgent, emergency and traumatic injury • Outpatient and ambulatory care • Elective care for routine medical needs and personal choices • Senior care for rehabilitation and crisis intervention • Infant, pediatric and children’s care • Wellness and fitness care • Assisted living and nursing home care • Psychiatric and mental health care • Home care • Long-term and hospice care

Obviously, we have a growing demand for a wider variety of healthcare services due to the Baby Boom spike, longer life expectancies, wartime posttraumatic shock syndrome, emotional illnesses, obesity, addictive behaviors and other conditions common to the early 21st century. At the same time, there is a never-ending list of healthcare solutions and portals of entry to the system.

Many suggest that healthcare isn’t really an “industry” at all, but instead an inalienable right, a societal obligation along with safety, security and freedom of speech. This sentiment is the reason for entitlement programs such as Medicare and Medicaid, both of which are currently in a state of panic, with resources being cut daily while demands increase. Over consumption of these programs has resulted in major problems. Medicaid challenges at the state level have created budgetary dilemmas that are bankrupting certain individual states. If over consumption without adequate funds to cover the costs is the problem, let’s examine what healthcare consumers typically consume:

James G. Easter, Jr., FAAMA, Vice President, Director of Planning, Healthcare Division, Hart Freeland Roberts

A growing demand for healthcare services is due in part to longer life expectancies.

This Issue ... • A Changing Healthcare Consumer Base = A Changing Healthcare Architecture • An Adaptive Patient Room for Critical Access Hospitals • Project Spotlight: HFR Designing Replacement Hospital in Iowa

It is the author’s opinion that there are three major issues to address within the healthcare delivery system: access, quality and cost. Having access to the system is a special blessing for those who can pay. The greatest concern is affordability and the ability of the USA to determine how to manage accessibility while balancing service delivery in a truly unmanageable twotiered system (those who can pay and those who can’t).

Years ago, the answer was Health, Education and Welfare (HEW). Many will remember that acronym and its ultimate demise. The biggest complaint was in the “welfare” portion, which remains our greatest challenge today. How can a society like America manage the needs of consumers who have limited resources, compromised lifestyles and limited to zero incomes? How can society manage continued on page 4

An Adaptive Patient Room for Critical Access Hospitals by Scott Corbin

Critical access hospitals (CAH), by their very nature, must be flexible in order to do as many things as possible in a limited amount of space. Being the community hospital of the new century, they are expected to do a lot of things very well without having the specialty units seen in tertiary facilities. By now, we are all well aware of the concept of the three zones of the private patient room: Scott Corbin, AIA Vice President, Hart Freeland Roberts

• The Caregiver Zone • The Patient Zone • The Family Zone

And by now we are somewhat familiar with the concept of the same-handed room. Both of these concepts result from the desire to achieve a more “universal” patient room, that is, a room designed to house the LDR patient and baby, the bariatric patient, the telemetry patient in need of closer monitoring but not quite an ICU candidate, and the orthopedic patient, i.e., an all-things-to-all-people room design. The Caregiver Zone Even prior to entering the room, the nurse should be able to roll a computer on wheels up to the view window just outside the room. From there, the electronic medical record of that patient is accessed for review, and the patient is observed. This is done from a distributed caregiver workstation located off the corridor in an alcove. Good design would have one of these for every two rooms, with every other alcove used for necessary medical equipment and thus parked outside the mandatory eight feet of clear space. In the past, the room would have a four-foot-wide door, but with the emergence of the bariatric patient as well as the need to transport patients tethered to bigger and bigger machines, a five-foot opening is becoming the norm. A nurse server accessed from the corridor for stocking purposes keeps interruptions to the patient and family to a minimum. From inside the room, the nurse is able to pull stock specifically supplied for that patient. Soiled linen is housed out of the way in that unit and removed on the corridor side by housekeeping staff. Inside the room, the caregiver has a sink, countertop and additional wall cabinet for supplies kept out of sight, such as latex gloves and sharps containers. Available close to the patient’s side is a privacy curtain that affords cover for the patient from the open door to the corridor. This privacy issue from the corridor seems to be the biggest determinate in selecting an inboard or an outboard patient room design, but there is no one right answer here, merely preference. The Patient Zone Incidences of falling have led designers to position the head of the bed on the same side of the room as the bathroom door, with a handrail from one to the other. However, family members typically want to sit where they can watch TV along with the patient. Both can be in the same area as long as the chair is on wheels. Providing patients a wide view through an oversized window is very desirable as well. There is now considerable medical research into the healing power of such a view, even though it is difficult to quantify as evidence. Along the footwall is a whiteboard with day, date and names of the caregiving team, along with a clock, flower shelf, artwork, corkboard for get-well cards and comforting personal items from home such as framed pictures of loved ones. The TV is located above the wardrobe unit built into the cabinetry. continued on page 4

PROJECT SPOTLIGHT

HFR Designing Replacement Hospital in Iowa

Sam E. DiCarlo, AIA Director, Healthcare Division Hart Freeland Roberts

by Sam E. DiCarlo

HFR’s Kansas City office was recently awarded the contract to design a new 60,000-square-foot Critical Access Hospital to replace the current, 57year-old, Ringgold County Hospital in Mount Ayr, Iowa.

ment due to the unique design of the two areas of the building. There will also be a number of shared support spaces along with a circular lobby/waiting room for the hospital itself as well as the clinics.

Construction is scheduled to start this spring and is expected to be complete by summer 2009. Gordon Winkler serves as CEO of the hospital. Yanik Companies of Minneapolis is the Owner’s Representative for the project, with John Curran as Project Executive.

Renal dialysis, physical therapy and cardiac therapy will be organized along the front wall of the building so that patients can park in the parking lot designated just for them and go directly into those departments from the outside. “This will be much like HFR’s Scott Corbin (center) and Emily Mowry (right) discuss interdepartmental relationships with Ringgold County Hospital executives. the configuration of The Medical Mall HFR, which has extensive experience at St. Joseph Medical Center,” said in Critical Access Hospitals, will provide full architectural and Corbin, referring to a Kansas City project that he designed several engineering design services. In addition to the hospital, the buildyears ago. ing will include the existing Mount Ayr Clinic, and the Visiting Specialists Outpatient Area will serve as an extensive outpatient In addition to the architectural services provided by HFR of services center. Kansas City, KJWW Engineering Consultants of Des Moines will serve as the consulting mechanical/electrical engineers. Lead architect Scott Corbin, AIA, said the plan calls for sharing Contact Mr. DiCarlo by email at sdicarlo@hfrdesign.com or by calling (615) 370-8500. staff between the medical/surgical unit and the emergency depart-

Hart Freeland Roberts, which traces its roots to 1910, offers architectural design, healthcare master planning and programming, market research, feasibility studies, interior design, civil and structural engineering, environmental engineering, project management, office furniture and equipment procurement, and move management. The firm serves the healthcare, education, municipal/civic, commercial/retail, industrial, parks/recreation, religious, corrections, transportation and environmental markets nationwide.

Contact: Sam E. DiCarlo, AIA Director, Healthcare Division (615) 370-8500 (615) 347-0598 sdicarlo@hfrdesign.com Hart Freeland Roberts 7101 Executive Center Drive Suite 300 Brentwood, TN 37027

Bob Harrett, AIA Director, Louisville Office (502) 689-2159 bharrett@hfrdesign.com Hart Freeland Roberts P. O. Box 436883 Louisville, KY 40253

Scott Corbin, AIA Director, Kansas City Office (816) 822-8500 (816) 868-6766 scorbin@hfrkc.com Hart Freeland Roberts 9237 Ward Parkway Suite 108 Kansas City, MO 64114

Rex E. Mason, JD, AIA Director, Phoenix Office (602) 387-5096 (928) 713-0195 rmason@hfrdesign.com HFR/MASON 2375 E. Camelback Road Suite 510 Phoenix, AZ 85016

NEWS NOTES ... • The American Society for Healthcare Engineering presents the 2008 International Conference and Exhibition on Health Facility Planning, Design and Construction March 10-13 at the Gaylord Palms Hotel & Convention Center in Orlando, FL. Online registration will be accepted through March 8. • The American College of Healthcare Executives presents its 2008 Congress on Healthcare Leadership, “Redefining the Healthcare Landscape,” March 10-13 at the Hyatt Regency in Chicago. Seminars, networking opportunities and career development programs are offered. Online registrations will be accepted through the week of the congress. • The American College of Cardiovascular Administrators, a specialty group of the American Academy of Medical Administrators, will hold its 19th Cardiovascular Administrators’ Leadership Conference, “Getting a LEG up on the Competition - CV Services Leadership, Execution and Growth,” March 26-28 at the Westin Michigan Avenue in Chicago. Early registration is encouraged. • The American College of Oncology Administrators, a specialty group of the American Academy of Medical Administrators, presents a Cancer Program Planning Conference June 19-20 at Vanderbilt University’s Frances Preston Cancer Center in Nashville. Sponsors also include Vanderbilt and Hart Freeland Roberts. Details available at www.aameda.org. • The American Academy of Pediatrics will present its 2008 National Conference and Exhibition Oct. 11-14 at the Hynes Convention Center in Boston. Attendees are reminded that special events occur one day before the official start date. A Changing Healthcare Consumer Base = A Changing Healthcare Architecture ... (continued from page 1)

those who are underinsured, ill informed or undereducated? It is through the awareness of disease prevention and early intervention that a large proportion of illness is managed. It is through knowledge that access to the system works best. There are answers to these questions, and they reside in the structure of the “non-system” and how access, quality and cost are managed. Some solutions derive from taxation, some from medical savings accounts, some from information technology, some from insurance portability, some from deregulation and some from tort reform. One part of the equation involves the willingness of Americans to share some of the profit from the proprietary systems with the not-for-profit public systems. Last, but definitely not least, is the need to redesign and re-engineer many of the capital assets within the system. This means new styles of buildings, better information technology, transitional continuums of care, cost-effective service delivery models driven by outpatient and ambulatory care, plus new health and wellness communities. Sounds pretty easy. Time to get rolling! This author will demonstrate how this works in future editions of healthforward report. Get ready, change is just around the corner and architecture is a very big part of the solution! Contact Mr. Easter by email at jeaster@hfrdesign.com or by calling (615) 370-8500.

An Adaptive Patient Room for Critical Access Hospitals ... (continued from page 2)

The headwall is an example of the effort to deinstitutionalize the hospital. It is cabinetry that conceals medical gases and the equipment hooked to the headwall. Sliding wood panels reveal the equipment on the wall, and, once hooked up, the panels are slid back in place, allowing the hoses and cabling to drop straight down from the headwall in a less obtrusive manner. The ceiling above the patient bed can have an illuminated scene of serenity to help create the healing environment. The bathroom (why do we constantly refer to it as a toilet?) is fully handicapped-accessible and contains a shower with a fold-down, wall-mounted seat. Rather than being just a portion of the open floor, which is becoming more common due to space constraints, the shower is within a three-sided area. This contains the water better, reducing falls. The sink is in a stone counter that has plenty of room for personal hygiene items, which can also be kept in the medicine chest in the wall. It is also possible to have a small window above the sink to allow natural light into the bathroom. The Family Zone Inpatients today are sicker than ever before, thus family in the room is of even greater value. Rather than a sleeper/sofa that could cause back injuries to the nursing staff who deal with them, a window seat with built-in nightstand for books, purses and keys is preferred. Pillows and linens are stored underneath in large drawers. A reading light with dimming capabilities is located above the head of the sleeper/seat. An Internet connection at the visitor desk means visiting family members can stay in touch with the rest of the family and their office. Finally, a reclining lounge chair next to the patient allows both to watch TV together. A change in floor finish to a softer, noninstitutional finish is a nice change from the faux wood floor of the rest of the room. Lighting on this side of the room can be darker, and the room itself is best when using darker colors such as natural blues and greens that foster a quieter environment. No matter what the final layout, it is highly recommended that a mock-up room be constructed early on to test the results. Creating a CAH patient room that can serve a wide variety of patients while also serving caregiver and family needs is absolutely achievable, and facility owners can enjoy the bottom-line benefit of being able to do more at less overall construction cost. Contact Mr. Corbin by email at scorbin@hfrkc.com or by calling (816) 822-8500.