Innovations in the Rural Health Environment: KU Institute for Health and Wellness

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Innovations in Institute For Rural Healthcare Health + Wellness Environments Design

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TABLE OF CONTENTS 3

FOREWARD

4

THINK TANK

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Designing a Rural Hybrid Community Hospital

STUDIO 808 2015

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PROJECT 2: Rural Hospital Prototype: Redesigning Philips County Hospital

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INTERNATIONAL RURAL HEALTH

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Designing Prototypical Rural Healthcare Facilities PROJECT 1: Smart and Connected Health: Cerner Healthy Village

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An Exploration of Innovation in Rural Healthcare

Kenya’s Tenwek Orthopedic Hospital

POST OCCUPANCY EVALUATION Comparing Past and Present Medical-Surgical/Special Clinics Units

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Editor: Hui Cai Faculty Advisors: Hui Cai, Frank Zilm, Kent Spreckelmeyer Graphic Designer: Jonathan Crookham

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UNIVERSITY OF KANS SCHOOL OF ARCHITECTURE DESIGN AND PLANNING

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HEALTH+WEL

FOREWARD

An increasing body of evidence is demonstrating the importance of environment on health and wellness. The balance between aesthetics, technical requirements, and effective patient care makes design in this field one of the most challenging, and rewarding, areas of architecture. The creation of the Institute for Health and Wellness Design represents a major commitment by the University of Kansas School of Architecture, Design, and Planning to support focused healthcare education, research, and service. The examples provided in our first publication illustrate collaboration between the Institute, practice, and the healthcare community to improve the base of knowledge regarding healthcare facilities and to push the envelope regarding creative approaches to major building needs. It highlights the “Innovations in Rural Healthcare Environment” Think Tank that brings together experts from health policy, rural hospital associations, rural hospital administration, health IT, architecture design and construction. It also showcases student projects exploring innovative prototypes for rural hospitals of the future during Arch 808’s 2013 and 2015 studios. The curriculum for students pursuing healthcare design at KU is unique in the United States. The balance between traditional academic course studies and professional practice internships introduces the delivery of good design to our students. The ability to link our faculty with affiliated firms for research provides value to both, and hopefully to healthcare throughout the world. The example projects demonstrate how combining structured research with “real world” case studies has produced new knowledge. Over the coming years we plan to expand our research initiatives into other areas of healthcare design and into issues affecting the delivery of effective professional service. We greatly appreciate the support of this program by our affiliates and other members of the design and healthcare communities. Sincerely,

Frank Zilm,D.Arch, FAIA, FACHA Chester Dean Director of the Institute for Health and Wellness Design 3

Challenges of Rural Health: An Interdisciplinary Think Tank

Think Tank Explores Innovations in Rural Healthcare Environments By Hui Cai Large segments of the population throughout the Great Plains and agricultural Midwest are facing a crisis in maintaining, upgrading, and replacing aging healthcare facilities. Most rural hospitals, which were built during the post WorldWar II period under the Hill Burton Act, have reached the end of their useful lives. Meanwhile, the increasing elderly population keeps adding pressure to the

existing healthcare system. Rural healthcare facilities also face challenges in relation to energy access and efficiency, especially because buildings in this sector are the second most energy intensive building type. More importantly, rural hospitals play a major role in the economic vitality of small cities and towns, serving as critical sources of employment and acting as economic engines within their communities. In addition to its regional

and national impact, research on rural healthcare design has strong global relevance. Many developing countries such as China, India, Southeast Asia, and Latin America share similar challenges in their rural healthcare systems and facilities. This is the context that formed the central focus of a one day think tank titled “Innovations in Rural Healthcare Environments� at the University of Kansas in Lawrence in March, 2016.

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The symposium brought together more than 100 healthcare providers, policy makers, and designers to outline specific research issues about how innovative design solutions can improve the efficiency and effectiveness of rural healthcare systems. The organizers will use the information collected during the day to form research collaborations and funding partnerships over the next two years to study the issues in detail

and provide information to the design, healthcare, and policy communities. The panel discussions during the day were focused on three topic areas: healthcare system challenges and opportunities; policy implications for rural healthcare; and the role of innovation and technology in rural healthcare. The first panel session discussed the ways that healthcare providers will need to adapt to changing practice models and

constricted economic conditions in rural settings in the future. Decreases in service lines of care and in the number of solo practices will continue to put pressure on rural providers in isolated and remote healthcare environments. The concept of “stealthhealth facilities” was presented by Michael Pulido, chief administrative officer of Mosaic Life Care, as a possible way to blend traditional medical environments into the fabric

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of the surrounding communities they serve. In this model, the local gas station, not the critical access hospital, may be the appropriate rural setting to initiate primary care healthcare discussions. A major theme that emerged from the second panel on policy was the likelihood that the traditional critical access hospital model would be replaced in the near future by a facility type that concentrated on primary and outpatient services, community based health maintenance programs, and information technology rather than bricks and mortar. This new rural healthcare environment has been variously called the “community outpatient hospital,” “primary health center,” and “integrated rural clinic.” Rural healthcare environments will likely be viewed as “community organizers” rather than freestanding and independent institutions in this new model, and medical services will be delivered outside the confines of traditional settings. Brock Slabach, senior vice president for member services at the National Rural Healthcare Association, reminded designers to be much more attuned to the realities of “form follows finance” in an era that includes Medicaid expansion, resultsbased reimbursements, and financial rewards for improving population health. The final panel discussed the roles of technology and design innovation in rural healthcare environments. Building

on the previous panels, the narrative of this session focused on finding ways to use environmental quality to improve the rural community’s wellbeing. A common theme shared by the panel was the concept of the healthy village, where the hospital was only part of the equation for community health. “Eat well, stay well, get well” was proposed as an approach for the continuum of healthy living. The panelists also highlighted the importance of population health and partnerships with the local community. Future rural healthcare designs should recognize the root causes of community health issues and also address individual uniqueness. Big data could support the understanding of the holistic patient profile, but Erik Gallimore, director of rural health at Cerner Corp., also stressed the importance of designers listening to the individual stories within rural communities. The keynote address was delivered by Marci Nielsen, chief executive officer of the Patient Centered Primary Care Collaborative. She focused on the shifting emphases in American medicine from illness to health, from the provider to the patient and family, and from inpatient to outpatient services. She challenged the audience to conceive of a rural healthcare system that sustains itself through local community values and strength, and to recognize that there was not a uniform definition of “rural healthcare,” but rather a continuum of

healthcare needs in rural settings. Many of the issues that were discussed throughout the day were illustrated by design proposals presented by students in Professor Hui Cai’s Health & Wellness graduate studio. Prototypes of healthcare facilities for Phillips and Harper counties in Kansas were reviewed by the audience and provided a range of design options that addressed the ways that traditional inpatient hospitals could be repurposed and refocused. For instance, Erin Hoffman, Erica Hernly, and Connor Crist’s design explored an alternative model of “community outpatient hospital” (COH) that eliminated the inpatient unit of a critical access hospital. The COH focuses on the role of rural hospital as community hub and education center for healthy living and preventive care. In another project, Rachael Wotawa and Briana Sorensen’s group developed a master plan for Cerner Harper County Healthy Village with a full range of health and wellness services, including hospital, nursing home, assisted living, independent living, retail, apartments, educational building, intergenerational activity space, and community center. They also proposed a universal care room to replace the traditional med/surg inpatient room, which could serve as an observation bed for the emergency department and a transitional care bed. Their design considered the implementation of health

IT and telehealth throughout the health village, which would support holistic care and the family involvement and bring stateoftheart care close to home. “Innovations in Rural Healthcare Environments” was organized by Professors Hui Cai, Kent Spreckelmeyer, and Frank Zilm from the School of Architecture, Design and Planning’s Health & Wellness Graduate Program and Professor Mario Medina from the School of Engineering. It was supported by the University of Kansas, Office of the Provost, Level II Strategic Initiative Grant. The organizers would like to thank David Engle from Philips County Hospital; Jessica Hunter and Jim Chromik from Cerner Work Group; and Jody Gragg from Via Christi Health for their support to student projects. A podcast and more information are available for download at https://ruralhealthenv.wordpress.com/photogalley/.

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ARCH 808 Rural Health Design Studio 2013 Impacting the Health of a Rural

Community by Designing a Hybrid Community Hospital

Studio Professor: Kent Spreckelmeyer

Impacting the Health of a Rural Community by Designing a Hybrid Community Hospital By Kent Spreckelmeyer and Tom Trenolone The University of Kansas School of Architecture, Design & Planning and HDR Architecture-Omaha Introduction Access to clinical preventive services and healthy environments can improve overall health outcomes and promote human well-being, although Americans

report receiving only half of the recommended preventive care they need. This lack of adequate healthcare services is made more acute in rural areas because of geographic and economic challenges and an aging population base. This study will create a model that suggests alternative healthcare facility designs to improve health outcomes in rural communities. The study recognizes that a range of environmental, cultural,

Above: Critical Access Hospital Locations in the Continental U.S.

and socioeconomic factors are involved in making progress in helping people improve diet, increase physical activity, and other lifestyle changes. Hence, the study plans to concentrate on strategies that support environments where people can engage in outdoor social activities that resonate with the identity of that small-town community; encourage and support mobility for all people regardless of functional ability; increase the delivery

of clinical preventive services; and increase economic and cultural activities. There are approximately 2,000 rural community hospitals in the United States serving one-fifth of the total US population. Approximately two-thirds of the sub-county municipalities in the US have populations of less than 2,500, although these communities account for less than two percent of the overall population. Since 1997 more than 1,300 of the smallest of those 2,000 rural communities have been served by critical access hospitals (CAHs). CAHs are healthcare facilities that provide inpatient and primary-care services to communities that would otherwise be underserved and remote from essential medical resources. They are established by regulation to receive reimbursements from Medicare sources to serve communities more than 35 miles from adjacent medical facilities. CAHs must have less than 25 inpatient beds and maintain a 24/7 emergency room. There are concentrated heavily in the “Grain Belt� from the western Gulf coast to the upper Midwest. Small rural communities served by CAHs face two major healthcare and environmental challenges. The first is providing healthcare services to an aging population, and the second is reviving the economic vitality of small towns with populations of less than 2,500. The hospitals in these communities are

important economic assets, and the basic assumption of the project is that the healthcare system can play a major role in revitalizing the commercial core of the town. The focus of this project is to create social connectedness, economic prosperity, and community-clinical integration for the delivery of preventive services along with critical care access by designing a Hybrid Community Hospital (HCH). A Case Study Eighteen students in the Health & Wellness Master of Architecture graduate program in the School of Architecture, Design & Planning at the University of Kansas, in collaboration with HDR Architecture-Omaha, created a model for an HCH using a small town in the western Great Plains as a case study. The 25-bed CAH has served the community since the 1940s, and its current facility was constructed in 1965. The project explores the relocation of the hospital to the heart of the downtown, and the goal of the project is to design a facility that provides not just healthcare, but attracts people living in the surrounding communities to other commercial and educational services. The hospital is the largest single employer in this community of 950 people, accounting for 16% of total employment, and represents a significant generator of economic activity in the core of the town. When combined with the consolidated school district in town, these two

employment sectors represents a quarter of the daily working population and have the potential to bring an influx of people to the downtown every day, which could in turn help grow other businesses and community services. In addition to this one case-study town, approximately a dozen towns with CAHs and populations of less than 2,500 throughout the plains states were analyzed to find commonalities in the economic, demographic, environmental, and cultural lives of these communities. What the students were attempting to create throughout the project were not only multiple design solutions for a single small town but prototype proposals that could be applied to a multitude of rural communities. The students’ analyses of these communities confirmed a general pattern of healthcare facilities found throughout rural America. In comparison to residents served by urban healthcare systems, the rural population is older and less likely to be insured, more prone to chronic medical conditions, more dependent on CAHs for long-term and skilled nursing services, and more reliant on primary and outpatient diagnostic and treatment services because of remote locations from teaching or tertiary-care facilities. CAHs operate in older and technically less sophisticated facilities than their urban counterparts, and the economics of reimbursement practices often disadvantage rural healthcare systems.

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What emerged from this analysis was a general set of principles that the students used to inform three distinct design solutions for a hybrid community hospital. These principles were: •Consider the new CAH as a community focus for the social, economic, and environmental as well as the medical health of the community. Define “health” in the broadest terms possible. •Bring life to the heart of the town, and integrate the CAH into the fabric of the exiting physical context of the community. Create an intensity of use that will build on the strength of the existing main street activities. •Use the most current construction and medical technologies to integrate economies of scale, flexibility, and quality of outcomes in the design process. “Master Hub” Designers: Chelsea Campbell, Cole Giesler, Chinonso Ike, Kathy Kim, Ashley Lawrence, and Sarah Moser Networks come in many forms – biological, mechanical, electronic – but they all exhibit similar properties in their ability to transmit information, materials, or people through efficient and elegant patterns. The key element of any network is a central node that collects the strands of the disparate components of the

system and directs their movement to the appropriate adjoining areas. These “synapses,” “switches,” or “routers” are the organic nerve center of any successful network, and they provided the inspiration for this team’s design concept. They took this organizing principle as a way to add density to the community’s resources and provide a strong physical identity to the town. Their research of the social and healthcare systems in the community indicated they were being diluted by the necessity of travelling significant distances to larger towns for medical specialties, consumer goods, education, and entertainment. They also discovered that the primary vehicular route connecting the town to the major highways bypassed the town center, which provided little incentive to focus critical activities in the heart of the community. They proposed that the center of the town become the primary node of a new network – what they called the “master hub” – that would concentrate all the essential components of a new healthcare facility in a revitalized town square. In their analysis of the existing community resources, the design team found that the CAH to the west, the school and community center to the north, and the commercial area to the south of the historic town center were all within walking distance of each other. The state highway meant to link these activities, however, was located a block east of what

should have been the major north-south axis of the town. The team rerouted the highway to provide a continuous path from the school to the commercial center and placed the primary entrance to the new CAH equidistant on this route. This master hub became visually and functionally the new center of the town, located in such a way that would cause traffic to slow and bend around the CAH entry. The new hospital lobby, situated next to the historic city hall, would become an unavoidable feature of a new community network that celebrated rather than hid the hospital’s front porch. In a symbolic way, this design decision was meant to knit together what had previously been a disjointed and dispersed set of critical community assets. At the same time, the activities the team envisioned for the entry would consolidate services and amenities – the community center, school art program, restaurants, outpatient clinics – that gave purpose to reoccupying and revitalizing the town core. Most communities that are served by a critical access hospital struggle to create a density of social and physical assets to maintain a vibrant and commercially stable main street. In their analyses of the case study CAH communities, the studio found that even in those that had a viable downtown, most lacked a strong focal point or an essential function that would anchor the environment or prevent the eventual hollowing-out of the town

center. The question posed by the studio was “Why can’t the community hospital be the social, economic, and physical nerve center of the town it serves rather than an asset remote from the historic heart of the main street?” Can the CAH foster the health of a community center by creating a hub of activities that extend beyond the medical services provided by the traditional rural hospital?

Above: Existing Community Resources

“Small-Town Synergy” Designers: Lauren Amos, John Barnthouse, Chang Liu, Eman Siddiqui, Mahzad Talaei, and Dana Wellman The most consistent finding of the students’ research was the fact that the economic and social anchors of CAH communities are the healthcare and consolidated school systems. Often

times accounting for more than a third of the employment opportunities, the hospital and school provide the bedrock on which the town’s survival depends. These two institutions also provide critical ancillary services to small towns in the form of housing for aging residents, social services for young families, and community identities. The school and hospital are always open, regardless of the vagrancies of the economic cycles that sustain rural

Above: Consolidation in “Master-Hub” 15

communities. These towns are alive on football and basketball nights, daily meals are made and served in both cafeterias, and the life cycles of the residents are literally and symbolically centered on the hospital. This design team began with the idea that the synergy created by the activities of the hospital, the school, and the town center should focus the way the community changed and evolved over time. The primary architectural device that organized this idea was the creation of an open campus that linked the existing CAH with the main street of the town. The concept was evolutionary because it recognized the healthcare system was no longer a monolithic “hospital” as much as a series of social supports. In the initial phase, for example, the long-term care and rehab functions of the hospital were linked to the main street buildings and clustered around what was envisioned as a common lawn and recreation landscape. In subsequent phases of the design, incremental additions of medical, educational, commercial, and residential activities began to create a campus that tied together all aspects of the town’s life. In the final phase, the old hospital site is cleared and occupied by the school’s athletic fields. At the same time, the main street that connects the school and the town center was reconceived as a pedestrian concourse that created a ceremonial and visual link between the healthcare, residential, and

Above: Evolution of Community Synergies

educational functions of the town. The ultimate goal of this scheme was to leverage the innate and deeply-felt qualities of the two most important institutions of the community into a comprehensive vision of how the town as a whole could be seen as a “campus for a healthy community.” “Modular Duality” Designers: Rachel Keeven, Hannah Kramer, Nicole Mater, Lizzy Nikoonamesh, Phillip Perkins, and William Weiner The third design team recognized that even though the CAH towns shared many economic, social, and healthcare commonalities, each was a unique and independent entity. Some towns may thrive and grow in the future, while others will contract and decline. The team labelled this the “duality” of the natural life cycle of a community’s development. What all the communities possessed, however, were a historic dependence on agricultural technologies, highly developed rail and highway networks, and a culture of self-reliance. This team began with the assumption that the design of the healthcare system should be as much about process as final product. They conceived an approach that utilized automated and decentralized modular fabrication technologies to provide a facility system that could expand or contract. They coupled this idea with the fact that much of what now occurs within the confines of a healthcare facility is

Above: Clinical Module System 17

being replaced by digital diagnostic and treatment technologies. Their design thinking, therefore, began not at the town or site level, but at the scale of discrete human activities – the medical exam, a surgical procedure, an inpatient bed. They then proceeded to expand this basic activity module to include those spaces that exist within the town outside the CAH – residential bedrooms, cafés, offices. The most provocative question they posed in this design was “Can a community that has always relied on its own mechanical ingenuity and was connected to the outside world by an integrated rail and truck network use digital technologies to design, build, and transport components of a sophisticated healthcare facility?” In a part of the country where agriculture is being transformed by GIS-driven tractors, where wind turbines are now as ubiquitous as oil derricks, and communication is virtual, it seemed natural to assume that these communities are well-positioned to construct – or deconstruct – their physical environments as conditions demand. The modular system they devised utilized off-the-shelf technologies and materials that could be incorporated in the local implement dealership, the metal shop, or the grain elevator.

Above: Community Module System

Conclusion

design share many commonalities.

Contributers:

The final products of this studio exercise were three visions of how the design of a new rural critical access hospital can contribute to the health and human well-being of the small community it serves. The designers from HDR Architecture-Omaha had explored this concept in a dense, urban context, and their charge to the studio at the University of Kansas was to explore if this concept and way of seeing the healthcare system had relevance in a different environmental context. Medical centers in the under-served areas of American cities face challenges as severe as those described above in rural communities. The prevalence of “food deserts,� lack of opportunities for recreation and community assembly, and access to basic primary-care health services characterize many urban sectors of this country. These problems primarily affect the young in urban settings, whereas healthcare systems in rural areas affect to a greater degree the elderly. Although many of the most disadvantaged in the cities live adjacent to the most sophisticated medical centers in the world, they often remain just as remote to those they should serve as the most isolated rural communities. What the studio discovered was that, although the contexts and cultures of rural and urban environments are distinct, the opportunities for improving community health and wellness through healthcare

The image below is a vision of what a hybrid community hospital might look like in the case-study community. It shows the entrance to the new healthcare facility on the main street adjacent to the city hall. It imagines the festivities associated with a school homecoming or a harvest celebration at its front door. It presumes that the health of the town is as much about the ways the hospital tends to the economy, the social life, and the environment as it does its patients.

Kent Spreckelmeyer, D.Arch., FAIA, Paola Sanguinetti, Ph.D., and Faria Islam (University of Kansas Faculty)

Originally Published by AIA Design + Health in June 2014

Tom Trenolone, AIA, Matthew Goldsberry, Matthew Stoffel, and Ian Thomas (HDR Architecture-Omaha) Lauren Amos, John Barnthouse, Chelsea Campbell, Cole Giesler, Chinonso Ike, Rachel Keeven, Kathy Kim, Hannah Kramer, Ashley Lawrence, Chang Liu, Nicole Mater, Sarah Moser, Lizzy Nikoonamesh, Phillip Perkins, Eman Siddiqui, Mahzad Talaei, William Weiner, and Dana Wellman (University of Kansas Graduate Students)

Above:Prototypical Vision for a Hybrid Community Hospital 19

ARCH 808 Rural Health Design Studio 2015

Studio Professor: Hui Cai

Access to high quality healthcare services and environments is essential to improve overall health outcomes and promote human well-being. However, this vital service is more challenging in rural areas. Rural hospitals provide health services for a large portion of the US population, especially in the Midwest. The 95 small rural hospitals in Kansas represent 75% of the 127 community hospitals in the state. Most rural hospitals, which were built during the post-World War II period under the Hill-Burton program, have reached the end of their useful lives. Meanwhile, the increasing elderly population keeps adding pressure to the existing healthcare system. More than 16.5 percent of rural Americans are age 65 or older, which is a higher proportion than in the rest of the country. Elderly patients have limited access to large urban healthcare centers because of their lack of mobility and distances to be travelled. It is therefore very important that health care settings and facilities in rural areas be renovated, expanded, or replaced. Rural healthcare facilities also face challenges in relation to energy access and efficiency, especially because buildings in this end-use sector are the second most energy intensive building type. The reduction of energy consumption is essential for their financial health, especially in rural areas. Just as important, rural hospitals play a major role in the economic vitality of small cities and towns. They serve as main sources of employment and act as economic engines within their communities. However, CAHs are at a critical time due to rapid changes in economics, rural demographics, and healthcare policy. Since 2010, across 23 states, 55 rural hospitals–shortterm, general-acute, non-federal hospitals outside a metropolitan country have closed. Others are suffering from maintaining bottom line and retaining health care work force. The studio takes on the challenge by inviting students to vision innovative approaches towards more efficient rural health care. The studio will embrace the understanding of rural healthcare design from a holistic approach, which integrates prevention and healing, environment and local context, technology and human experience, and process efficiency and care effectiveness into an integrated design solution. Innovations can vary from disruptive to incremental, from entire replacement to renovation and expansion. As a reflection of different spectrum of innovations, students will choose from two rural health related projects, each will last a semester long.

ARCH 808: RURAL HEALTH RESEARCH

RURAL HEALTH SYSTEM CRITICAL ACCESS HOSPITALS

having no more maintaining an annual average length of than 25 inpatient stay of no more than 96 hours beds for acute inpatient care

emergency care

acute-care patients

0 0 0 0 3 5 being located in a rural area, at least 35 miles drive away from any other hospital or CAH (fewer in some circumstances)

offering 24-hour, 7-day-a-week

Diagnostic/Treatment

SNF care

swing bed agreement: a hospital can use its beds, as needed, to provide either acute or Skilled Nursing Facility (SNF) care

RURAL HOSPITALS

CRITICAL ACCESS HOSPITAL provide a high provides percentage of care in inpatient care outpatient settings, such as home health, skilled nursing, and assisted living

RURAL HOSPITAL

offering 24-hour, 7-day-a-week emergency care

RURAL HEALTH CLINIC

Omaha, Ne.

Lincoln, Ne. Kearney, Ne.

located in areas with less than 1,000 people per 2.6 mile radius

provides long-term care

RURAL HEALTH CLINICS

St. Joseph, Mo.

Denver, Co.

Manhattan Salina

Hays

Topeka

provides outpatient care

must be staffed required to use a team approach of at least 50% of the time with a nurse practitioner, physicians working physicianassistant, or with non-physicians certified nurse midwife

Garden City

Kansas City

Hutchinson Pratt

Wichita Pittsburgh

Springfield, Mo. Joplin, Mo.

U.S. HIGHWAY

Bartlesville, Ok.

INTERSTATE HIGHWAY Tulsa, Ok.

located in areas with less than 1,000 people per 2.6 mile radius

must provide basic laboratory services

CRITICAL ACCESS HOSPITAL RURAL HOSPITAL SUPPORTING REGIONAL HOSPITAL

Oklahoma City, Ok.

CHALLENGES IN KANSAS RURAL HEALTH Obesity Rates (%) 45 40 35

36.9

38.8 35

34.9 30

30

31.3

36.3 33.3 29.1

30.8

30.5

28.5

25 20 15 10 5 0 All

Men

AVERAGE AGE

Rural

Urban

UNITED STATES KANSAS

OBESITY RATES (%) RURAL

NATIONAL

URBAN

KANSAS

National

Women Kansas

KANSAS URBANIZATION RURAL POPULATION URBAN POPULATION

PERCENT RURAL PERCENT RURAL

PERSONAL CONSUMER EXPENDITURES

23

EDUCATION: HIGH SCHOOL INSURANCE: CITIZENS FOOD DESERTS geographic area where affordable and GRADUATES WITHOUT HEALTH INSURANCE Anutritious food is hard to obtain, especially 90.0 - 99.0%

80.0 - 85.9%

86.0 - 89.9%

45.0 - 79.9%

Nearly 60% of rural hospital gross revenues come from Medicare and Medicaid.

22.0 - 50.2%

13.0 - 16.7%

16.8 - 21.9%

0.0 - 12.9%

those without access to a vechical. Urban = 1 mile radius, Rural = 10 mile radius.

RANKINGS IN HEALTHCARE OUTCOMES

WORKFORCE SHORTAGES: MEDICALLY UNDERSERVED Ranking Factors: Length of Life, Quality of Life, Health Behaviors, COUNTIES Clinical Care, Social & Economic Factors, Physical Environment http://www.countyhealthrankings.org/app/kansas/2015/overview

77-101

26-50

51-76

1-25

Cheyenne

Rawlins

Sherman

Thomas

Decatur

Norton

Phillips

Sheridan

Graham

Rooks

Osborne

Smith

Gove

Trego

Ellis

Russell

NOT RANKED Jewell

Republic

Washington

Marshall

Brown

Nemaha

Doniphan

Atchison

Cloud Mitchell

Pottawatomie

Clay

Jackson

Riley

Jefferson

Leavenworth

Ottawa

Wyandotte

Lincoln Wallace

Logan

67 % of critical access hospitals reported experiencing shortages in physicians and IT staff. Retaining staff is also a crucial challenge.

Geary

Shawnee Wabaunsee

Dickinson

Topeka Douglas

Johnson

Franklin

Miami

Kansas City

Saline Ellsworth

Greeley

Wichita

Scott

Lane

Ness

Rush

Morris

Barton McPherson

Rice

Osage

Lyon

Marion

Chase

Pawnee Hodgeman

Finney Hamilton

Reno

Edwards Gray Stanton

Grant

Coffey

Anderson

Woodson

Allen

Greenwood

Bourbon

Butler Ford

Sedgwick

Pratt

Wilson

Kingman

Kiowa

Haskell

Neosho

Stevens

Seward

Meade

Clark

Comanche

Barber

Harper

Sumner

Cowley

Chautauqua

Montgomery

Wichita

Crawford

Elk

Morton

Linn

Harvey

Stafford

Kearney

Labette

Cherokee

FINANCIAL IMPACT OF RURAL HEALTHCARE Not Ranked

THE MULTIPLIER EFFECT

1-25

26-50

51-76

77-101

BENEFITS TO THE COMMUNITY

IMPACT OF A CRITICAL ACCESS HOSPITAL RURAL AMERICA 5-YEAR PERIOD

A hospital with 100 EMPLOYEES

Supports an additional 50 EMPLOYEES through their spending in local businesses and industries.

78 JOBS LOST HEALTH EDUCATION AND PREVENTATIVE CARE

INCREASED EMPLOYMENT AND INCOME

ATTRACTS AND RETAINS OTHER BUSINESSES

$1.7 MILLION IN INCOME LOST $452,100 IN RETAIL SALES LOST $9,100 IN SALES TAX REVENUE LOST

TECHNOLOGY & TELEMEDICINE

+

Healthcare + Hospitals

+

Wireless Devices + Technology

Remote Signal

TELEMEDICINE

The World Health Organization has adopted the following broad description: “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”

DESIGN CHANGE:

HOMEHEALTH CHALLENGES

Population Demographics & Health

Lack of Scale & Limited Staffing

Inadequate Infrastructure & Data HOW DO WE DESIGN A SPACE PROGRAM AND SERVICE LINES TO ADDRESS UNIQUE NEEDS OF THE RURAL COMMUNITY?

Finacial Pressure

HOW CAN WE ATTRACT/RETAIN WORKFORCE IN RURAL AREAS?

OPPORTUNITIES: Federal Financial Assistance

Integration of Services

Strong Community & Patient Relationships

HOW CAN WE PROVIDE UNIQUE COMMUNITY SOLUTIONS WHILE STANDARDIZING DESIGN?

HOW CAN WE IMPROVE EFFICIENCY TO INCREASE FINANCIAL PROFITS?

25

ARCH 808 Rural Health Design Studio

Project One Smart and Connected Health: Cerner Healthy Village

Driven by a personal tie and compassion, Neal Patterson, the CEO of Cerner is committed to support rural community at Harper County to reimagine a new model of health care delivery. The project is to design a “Cerner Healthy Village” as an innovative replacement project that support Harper and Anthony counties explore partnerships in delivering care. The intention is to design a rural system with access to almost all of the care standards and specialty skills of a large national integrated health system – a system that helps right decisions to be made with the right skills at the right time, with the support of information and medical technologies. This project will serve as a prototype for future technology-driven rural healthcare model the focuses on community and population health. The design challenges are: •

Identify potential site for merger (40 acres) through demographic analysis

•

Evaluate proper service lines and develop space programs accordingly

•

Develop master planning for “Cerner Healthy Village”

•

Vision how smart and connected health can transform rural health and wellness center

Harper County Healthy Village: A Rural Healthcare Prototype By: Andrew Borkon, Andrew Jablonski, Joshua Kirkman

NE 30 RD

Our goal is to create a healthy village that breaks the mold of the existing healthcare campus model, through sustainable design features, evidence based design, community engagement, and EMR. Our model is centered around the concept of connectivity of wellness, intergenerational living and activities that are available to the surrounding community. This village is about the wellness of the individual, not only the physical aspect of health, but also the mental aspect of wellness. This concept is intended to promote a shift in lifestyle choices. Preventative check ups and education become the front line of health and wellness. In order to accomplish this we chose a site that can bridge the two cities of Harper and Anthony. We chose to place our hospital and wellness center along Route 2 to give it visibility to the road.

7

5

PATTERNSON BOULEVARD

Above: Harper County Health & Wellness Campus Site Plan

10

PA

F

CES : 2 54 SPA

P OF RO

GENT UR

CA

E

RE D

ED /

SUPPLY

NT

E

BU L A N

D

STAFF

RKING

CE

4

AM

NE 30 RD

R A NC

P OFF RO PAT I

R TO

T / VISI EN

C AC ESS

8

T / VISI EN

PAT I

R TO

2

G

C AC ESS

IN

RK

IC

BL

LEARNING CENTER DR

PU

21

PA

ES

:3

C A SP

9

1 PATTERNSON BOULEVARD

G PARKIN STAFF ES : 2 C 55 SPA

6

C AC ESS

PAT I

11

R TO

T / VISI EN

PUBLIC PARKING

PUBLIC PARKING

124 SPACES : 5

188 SPACES : 7

3

29

The facade design is based upon the structure of a mitochondrion. This decision was based upon Cerner’s new Continuous Campus with their facade based upon a DNA chart. We wanted to take their vision and make it our own with an element that embodies our design. We chose the mitochondrion because it is the power plant of the cell and is responsible for respiration. Also it is comprised of layers within its construction

Above: Main Kansas Public WindEntry Power Exterior Rendering

and so is our campus. Each layer of our campus is based upon bringing people to the campus and breaking the current view of a hospital. We wanted to give the community a place they can be proud of and a place that they would want to come to. In bringing people to the campus we want to change their day to day lives in the name of wellness. In changing and educating people’s view of wellness we will create an overall healthier

community that will have less health risks. This is a multi facaded design that will better the community as a whole.

In the design of the lobby we wanted to create a multifunction space that would give something to the community. We designed the space with hosting events in mind, such as wedding receptions, using a monumental stair case and a decorative chandelier. Within the design we made a technology center around the columns with computers and charging stations. Along with the atrium space we designed in breakout

areas that will give an escape from the function of a hospital. These areas include hanging gardens between areas of our specialty clinic, occupiable greenroofs through out the campus, a chaple, and a healing garden for the staff offering them a place to unwind and get away from the stress of their work.

Above: Wellness Center Atrium 31

At the core of our campus we included a learning center. Withing the learning center we have included a health professional training center meant to educate the health professional working at the campus with new technologies and techniques of healthcare. This principle is to eliminate “rust out� within the healthcare profession. The learning center also include a technology retail with the idea of selling wearable technology so that overall health can be monitored. Within the learning center is an educational space to teach people how to use their devices. Also, within the fitness center is a monitoring center so that the date collected by the wearable devices is analyzed and used to better people’s overall health and wellness. The mixed used that we created is displayed in the lower picture. The intent of the mixed use is to offer health food choices to the community through a grocery store and a restaurant. The apartments above the retail and restaurant is intended to promote the growth of young healthcare professional. We saw these apartments as a place for new healthcare professionals to live and a place where they would want to live.

Above: Learning Center

Above: Mixed-Use (Grocery, Restuarant, Commercial Kitchen, 18 Apartments)

Within our program we included assisted living and skilled nursing. We designed these around the emerging green house model. The overall look of the assisted living is taking materials found in Kansas, The glass is an abstraction of the mitochondrion found on the wellness center and the wood is intended to mimic the out buildings found on Kansas farms, We also included independent living. We designed these in clusters offering a central courtyard between four units. These are intended to give more housing to the community and give housing options to healthcare professionals and their families. Three units are centered around an engineered wetland giving a beautiful view as well as direct access to the trail that we created. Also in mind with the independent living is the easy access to the learning center where the day care is located which is just one action we are taking to create a multi-generational campus.

Above: Assisted Living/Skilled Nursing

Above:Independent Living 33

Harper County Healthy Village: A Rural Healthcare Prototype BY Brianna Sorensen and Rachel Wotawa With rural populations on the decline, small town main streets that once thrived with businesses and pedestrians have become vacant ghost towns in major disrepair. We see this current situation of many rural towns as an opportunity to create a healthy village prototype that could revitalize rural American towns such as Harper, Kansas. This prototype would provide quality primary care, promote healthy lifestyles, and educate residents of all ages.

35

After analyzing the vacancies and major disrepair of many of Harper’s buildings which once thrived, we created a strategy for our healthy village to revitalize this declining community. Our main goals were to provide business and retail services not currently available; foster wellness through lifestyle changes, community involvement, and education; create a place for active aging in a rural community; provide a quality and close-to-

home source of care for all Harper County residents through innovative IT Health solutions; provide a primary care hub for Harper County; provide resources for Family Support for all stages of life; create an engaging environment for children to learn about healthy living; and unify the Harper and Anthony communities. We see these goals coming to life by knitting specific programs into the existing

fabric of Harper. These new buildings and the revitalization of existing buildings would restore Harper and encourage growth. The economic vitality of Harper’s Main Street could be restored by repairing historic buildings, giving back a sense of place, and providing proper business environments for new small business owners.

-HIGHLY VACANT -MOSTLY VACANT -PARTIALLY VACANT -LITTLE VACANCY -NO VACANCY

HARPER, KANSAS | 1950s

HARPER, KANSAS | TODAY

Provide Storefront Retail Windows

Provide Spaces for Social Interaction

Enhance Safety Repair and Character Historic Facades

The master plan for the Harper Healthy Village, which is shown below, includes the phasing of a new hospital, clinic and skilled nursing facility on the site of the existing Harper Hospital District #5. The atrium space of this facility would draw the community in from a large pedestrian mall that faces the existing Harper City Park. The assisted living facility and intergenerational buildings on either side of the pedestrian mall would activate this space at the ground level.

The city park’s existing tennis and basketball courts would be revitalized and a central stage and a 1/4 mile walking trail would be added to encourage a healthy lifestyle for Harper residents. The community pool would be revitalized as well and a new community fitness center would be added adjacent to the pool. Extended stay apartments would provide visiting physicians and out-oftown family members a place to stay

COMMUNITY CENTER MAIN STREET

CITY PARK

and independent living cottages would give aging Harper County residents the opportunity to live independently while taking advantage of the healthy village amenities within a close proximity. Retail and residential mixed use buildings would round out the Healthy village by reactivating Harper’s Main Street as a pedestrian shopping mall.

MAIN STREET LOFTS

INDEPENDENT LIVING COTTAGES

ASSISTED LIVING FACILITY

INTERGENERATIONAL BUILDINGS

ENERGY PLANT

EXTENDED STAY

CLINIC SKILLED NURSING FACILITY

HOSPITAL

N

W. 14TH STREET

Above: Healthy Village Master Plan 37

The program of our healthy village consists of nine main building types. The Community Center includes a gym, fitness center, aquatic center, track, teen center, mental health center, and community meetings rooms. The Assisted Living Facility includes twenty-four assisted living units, dining services for the residents, a game room, library, and several resident gathering spaces. Two Intergenerational Buildings

encourage community relationships by programming a joint adult and child day care, an art studio and gallery, a music studio, a coffee shop, a market with a demonstration kitchen, a hydrotherapy spa, and a health retail education center. The extended stay apartments house ten one-bedroom and ten two-bedroom apartments. Forty-eight independent living cottages provide twelve one-

bedroom and thirty-six two-bedroom homes to aging Harper residents. Two skilled nursing buildings house twelve units each in a neighborhood style, which includes a kitchen and central gathering area. The Main Street Lofts provide ground level retail and loft-style apartments to Harper’s Main Street. The village buildings total: 254,900 BGSF.

THE INTERGENERATIONAL

THE INTERGENERATIONAL

THE COMMUNITY CENTER

THE ASSISTED LIVING FACILITY

BUILDING 1

BUILDING 2

THE EXTENDED STAY

THE COTTAGES

THE SKILLED NURSING FACILITY

THE MAIN STREET LOFTS

The Health Center includes a two-level clinic, a hospital, and an atrium that has amenities for patients as well as the public. The first floor of the Clinic houses a Rehabilitation Facility that includes physical therapy and occupational therapy spaces as well as private and group therapy rooms. Also, on the first floor is an Urgent Care Center with ten typical exam rooms and two familysize exam rooms. On the second floor there are three clinic spaces--each with consultative care rooms and exam rooms-that can be rented by different specialty providers. An infusion center is also located on the second floor, which has both private and public bays for patients.

PHARM. INFUSION/ SPECIALTY CLINIC

INDOOR GARDEN

REHAB/ CLINIC

ATRIUM

CAFE CENTRAL REG PATIENT FINANCE LAB

SURGERY

CENTRAL STERILE SERVICES

MATERIAL MGMT. STAFF ATRIUM SUPPORT

IMAGING ADMINISTRATION

EMERGENCY

Patient Entry

Staff Entry

Service Entry

Health Center Departmental Plans (Level 2 on left and Level 1 on right)

With a focus on outpatient services and procedures, the hospital has full-functioning surgery, imaging, and emergency departments, as well as an in-house lab and pharmacy. To make up for a lack of inpatient beds, we have included four universal care rooms within our emergency department, which are a hybrid of an observation room and a typical inpatient room. At the center of our health center is a twolevel atrium space with amenities such as a cafe, gift shop, and an indoor garden that is located on the second level.

Health Center Main Entrance 39

We have developed twenty consultative care rooms that are incorporated into all three of our specialty clinics in the Health Center. Since we see our facility as a place for conversation, education, and preventative care, we felt that it was important to develop a space where conversations could happen between providers and patients. These consultative care rooms feature views to central light wells with mirrored glass for privacy, a mediascape table for teleconferencing and access to electronic medical records, a white board, a couch for additional family seating, and a pocket door that provides quick access to a traditional clinic exam room. The consultative care rooms provide spaces for families to comfortably gather and be educated through a one-on-one conversation with their provider. The mediascape table provides groups of patients to hear medical insight from specialty care physicians in surrounding support hospitals.

Within our Emergency Department we have developed four universal care rooms, an innovative alternative to the traditional inpatient care unit. After learning about the low patient volumes that are consistent across inpatient units in rural hospitals, we decided to include these universal care rooms within our ED for patients that require longer recovery periods after surgery as well as for the births of Harper County’s newest citizens. By placing these rooms in the ED, they can easily be tended to by the ED nurse staff. Each universal care room includes various amenities to help aid in the comfort and healing of each patient. These amenities include a bed that monitors patient movement, a TV on the patient headwall that displays data of the patient’s vitals, and a mobile tele-conferencing station that allows physicians to provide care remotely from other hospitals. Each room also has a dedicated staff zone that can be converted into a monitoring station in the case of an ICU patient as well as couches for additional family seating.

TOILET 60 SF

UNIVERSAL CARE ROOM 407 SF

41

ARCH 808 Rural Health Design Studio

Project Two Rural Hospital Prototype: Redesigning Philips County Hospital

As a typical Kansas Rural CAH, Phillips County Hospital, has an outdated Hill-Burton era facility that hardly meets the needs to support community healthcare delivery. The CEO of Philips County Hospital, Dave Engle, are interested to invite our young creative minds to identify the challenges they are having with their older building and think about innovative solutions for a more efficient new facility. Options should be explored both in terms of renovation, expansion and replacement. For new replacement facility, they have secured a 96 acre location at the NE corner of 183 hiway and Sante Fe road. There is 20+/- acres that is flat that would provide an ideal location.

Students should also use the opportunity to explore alternative model to CAH. KHA Rural Health Visioning Technical Advisory Group has proposed a primary health center (PHC) model as an alternative for low volume rural hospitals who are challenged to maintain either a Critical Access Hospital or a small PPS hospital. It is imperative to understand the implications of transforming into the PHC model in rural hospitals and how physical environment can support the new model.

The design challenges are: •

Evaluate existing facility and identify challenges in care process, spatial layout, and community health needs

•

Evaluate proper service lines and develop space programs accordingly

•

Develop options for renovation or replacement and evaluate pros and cons of each option

•

Design to support full or partial adoption of the PHC model

Phillips County Health & Wellness Center By: Chris Meier, Jimmy Sgroi, Devan Swiontkowski

Mission Statement: Critical Access Hospitals are notorious for functioning under a set of lower standards than a traditional healthcare facility. Our main goal is to recognize the inefficiencies for patients and staff, and provide appropriate solutions for both the present and future status of the hospital. This means providing separate routes of circulation and allowing for flexibility and growth of major departments within an efficient floor plan. Aside from the typical healthcare modalities, we seek to provide a sense of place for the community in a common public core. This area will not only provide a friendly face and simplify way-finding, it will also provide a common ground for members of the community to interact and collaborate with one another and learn about healthy habits. All of the departments have access from this core, with one side serving predominantly outpatient and one side serving inpatient and diagnostic functions. Individuals can see all the way through this hearth space to the outdoors.

Above: A front entrance render of proposed hospital

Above: Nurse Workstations

AMBULANCE DROP-OFF & STAFF PARKING

STAFF

PUBLIC

STAFF

H

DINING + EDUCATION + DAYCARE

ADA

ADA

T IEN PAT

MAIN HOSPITAL

REHAB+ DIALYSIS

A AD

PATIE NT

PATIENT

FF STA

AMB./STAFF

OUTPATIENT INPATIENT, ED & URG. CARE

EMERGENCY & URG. CARE

Above: Site Plan 45

While we believe that interaction between staff and public is important, we wanted to make circulation throughout the hospital to be very clear and efficient. This diagram shows how we were able to separate public and staff circulation to help with way finding and staff efficiency. We have carefully considered the sustainability of our design as well. We oriented our building to maximize use of the daylight from the south. The public views to the exterior exist in the hearth atrium along the public concourse waiting areas on the south. Staff views of the exterior are provided via skylights in the clinic work area and a courtyard in the back of house staff zone on the diagnostic wing. PV panels and geothermal energy are also incorporated into the design to capture on-site renewable energy.

STAFF PUBLIC

Above: Circulation Diagram This hospital is designed for both the present and the future. We have carefully designed departments around this central hearth in order to allow for simple expansion to the departments in the future. Departments are also configured based on a 32’ x 32’ grid, which allows for future flexibility of use for the rooms themselves.

While we were considering efficiency in terms of staffing, we also considering it in terms of building and energy efficiency. We divided the hospital into three “time zones.” The areas that are in use 24hrs are the Emergency Department/Urgent Care and the Inpatient Unit. Areas of extended business hours are a portion of the outpatient unit and the hearth space. Areas that are used during business hours are imaging, lab, surgery, supplies, a portion of the outpatient, rehab, daycare, and administration. Above: Time Zone Operation Diagram

24 HOURS EXTENDED HOURS BUSINESS HOURS

We organized our hospital into a two-story plan to reinforce our efficient space programming. The out-patient and in-patient wings are separated by a central community hearth space. The hearth space has been programmed with high activity level spaces flanking it. This allows for the hearth space to be fully activated at all times of day and make it a strong commu-

nity hub. Some of these programs are a community daycare center, gift shop, dining space, chapel, rehab, Pharmacy counter as well as central registration. The Out-Patient clinic has been place in its own wing close to central registration with easy access to rehab and dialysis. The diagnostic side of the hospital was design to allow a connection for the

Emergency Department/Urgent Care to Surgery and Imaging. The material support is broken into two locations, with the main hub being closest to the diagnostic department and a smaller satellite hub near the clinic and rehab. This allows for materials to be accessed by all department at all times of day without having to transport materials through the public space during business hours.

MECHANICAL MATERIALS

2500 SF

3991 SF KITCHEN 1772 SF

DINING/CAFE 1551 SF

EDUCATION CENTER

GIFT SHOP STAFF

1748 SF

735 SF

DAYCARE

375 SF

4100 SF STORAGE

SURGERY

166 SF

9018 SF

COURTYARD

STAFF 1108 SF

STAFF 475 SF UP

STAFF CIRCULATION

TOLIETS

4751 SF

661 SF

CHAPEL 741 SF

UP

PUBLIC 12570 SF REHAB

LAB 991 SF

4158 SF

ADMIN 1009 SF

IMAGING 6009 SF

ED/ URGENT CARE 8641 SF

REGISTRATION PHARMACY ADMIN

901 SF

579 SF

MECHANICAL 442 SF

MATERIALS 344 SF

673 SF DIALYSIS/INFUSION 663 SF

CLINIC 12610 SF

Above: Level 1 overall plan 47

The second level of our hospital plan is comprised of our In-Patient wing as well as our upper level administration. The In-Patient wing was located directly over our diagnostic area to allow for quick and easy access when those services are necessary. There is a secure patient elevator that goes from the In-Patient wing down to a restricted corridor near the Emergency Department and Imaging. We also

designed a shell space of the In-Patient wing for future expansion if necessary. To activate the hearth space below even more, we designed two “pod� bumps out that overlook the space. There is one in the In-Patient waiting area as well as a one in the administration zone that acts as a conference room.

ADMIN 2031 SF

PUBLIC OPEN TO BELOW

DN

STAFF CIRCULATION SHELL 3620 SF

Above: Level 2 overall plan

83 SF

INPATIENT 15667 SF

1436 SF

OPEN TO BELOW DN

The circulation of our site plan was designed to create a clear path for both patients, visitors and staff. The public all enter through one main drive located on the south edge of the site. They have the option to park near either wing of the hospital, depending on what they are arriving at the hospital for.

The ED and Urgent Care entrance is separate but still accessible from the main public entrance. Clear building and monument sign-age direct visitors where to go. Separate staff parking and service vehicle circulation allows for easy access by visiting medical professionals.

spaces that can be accessed by patients, visitors and guests. These areas are clearly denoted on our plans. The materials that we chose for our building, which are expressed below, are zinc and terracotta panels with accents of limestone and timber

The site also features two outdoor

Above: Aerial rendering

Above: Backside rendering facing Phillipsburg 49

Our central hearth space is the community hub of the hospital. It is a large open and light filled space that has been given a natural aesthetic through the use of timber columns and beams, limestone planters and column bases as well as other wood accents throughout. The hearth space of our building is the main hub and public gathering space of our design. We wanted to create a large open space that was filled with daylight and could be used for a multiple range of programs. We chose to bring some of the exterior materials into the hearth to create a consistent transition from outside to inside. We also believe these elements give a natural aesthetic to the overall space and create a calming environment for patients, visitors and staff.

Above: Render of Hearth space from the dining area

RESTROOMS

Above: Cross section of the central hearth space.

Level 2 15' - 0"

Level 1 0' - 0"

DIALYSIS/INFUSION 576 SF PROCEDURE 1 192 SF

JANITOR 95 SF

EXAM 1 123 SF

NURSE MGR 190 SF

EXAM 2 123 SF EXAM 3 123 SF

DIRECTOR OFFICE 233 SF WORK AREA 404 SF

EXAM 4 123 SF

STORAGE 195 SF

SOILED 75 SF

EXAM 5 123 SF

CONSULT 101 SF

EXAM 8 123 SF

EXAM 6 123 SF

EXAM 7 123 SF

CLEAN 86 SF

EXAM 9 123 SF

STAFF LOUNGE 298 SF

ALCOVE 21 SF

EXAM 10 123 SF WORK AREA 360 SF

EXAM 11 123 SF

EXAM 15 123 SF

DATA/ELEC. 251 SF

EXAM 14 123 SF

CONSULT 96 SF EXAM 13 123 SF

EXAM 19 123 SF

EXAM 12 123 SF

SHARED OFFICE 401 SF

EXAM 18 123 SF

ALCOVE 21 SF

EXAM 17 123 SF

STORAGE 275 SF

EXAM 16 123 SF

WORK AREA 392 SF PROCEDURE 2 191 SF EXAM 22 123 SF

CONSULT 89 SF

EXAM 21 123 SF

EXAM 20 123 SF

Above: Enlarged Plan Outpatient Clinic

DN

INPATIENT REHAB 372 SF CRITICAL CARE 349 SF

CRITICAL CARE 346 SF

PATIENT ROOM 279 SF

DN

PATIENT ROOM 279 SF

PATIENT ROOM 279 SF

PATIENT ROOM 279 SF

PATIENT ROOM 279 SF

PATIENT ROOM 279 SF

PATIENT ROOM 284 SF

EQUIP 36 SF

NURSE TOUCHDOWN

The inpatient rooms are canted from the center hallway to maximize daylighting and views from the room towards nature. This also places the patient’s headwall directly adjacent to the bathroom entrance in order to provide stability when moving from the bed to the bathroom. This layout also creates a clear separation of space between the care providers and the family allowing easy circulation throughout the room.

MATERIALS 326 SF

SOILED 103 SF

CLEAN 111 SF

MEDS 182 SF

STAFF 165 SF

NURSE STATION 233 SF

BATHING 115 SF

CLEAN 188 SF

SOILED 188 SF

DICTATION 168 SF

MEDS 134 SF

RN MANAGER 137 SF

NURSING 233 SF NURSERY 130 SF

Bariatric/LDR 497 SF

NOURS 60 SF

Bariatric/LDR 419 SF

PATIENT ROOM PP 279 SF

PATIENT ROOM PP 287 SF

NURSE TOUCHDOWN

The Out-Patient clinic was place in it’s own wing and near registration to make it easy for patients to move in and out of the hospital. The clinic is broken into three pods that are designed with their own color and number, as seen below in the render. The colors and numbers are used to help patients with way-finding when they are directed to which waiting pod to go to after checking in. We chose to create a double entrance exam room design. We chose to do this to help create a clear separation of “public” and staff space. Since efficiency of staff was a high design priority for us, this model allows for the doctors to enter and exit an exam room easily and without running into patients in the hallway. The back of house workstations also allows for collaboration of doctors and nurses and hopefully a more comprehensive health model for the patient.

NOURS 106 SF

PATIENT ROOM 287 SF

PATIENT ROOM 286 SF

PATIENT ROOM 286 SF

PATIENT ROOM 286 SF

PATIENT ROOM 286 SF

PATIENT ROOM 286 SF FAMILY 227 SF

Above: Enlarged Plan: Inpatient Unit 51

PHILLIPS COUNTY HEALTH & WELLNESS CENTER By Connor Crist, Erica Hernly, and Erin Hoffman

Existing Hospital

Outp a Clin tient ic

The current healthcare facilities available through the Phillips County Hospital are outdated and consist of a number of problems. We began the design process by addressing these six challenges:

Spec

ialt

Outpatient Clinic and Rehab separate from the rest of the building.

y Clin

ic

DESIGN CHALLENGES 1

Inefficient departmental adjacencies

2

Departmental functions do not meet needs of patients and providers

3

Inpatient unit only uses 1 of the 15 rooms per day, which wastes time and resources

Surg

ery

Lab ED Ima

gin

Community members don’t support the existing hospital

5

Difficult to find main entrance and parking

6

Lack of outdoor green space

After touring the existing hospital, we found that hospital staff had major problems with walking distances and core service layouts. For example, in order to get to the imaging department, hospital staff had to walk through the emergency department, which not only interrupted emergency services but also created longer walking times for the staff. Corridors in both departments were also far too narrow, and staff complained of poor turning radii for stretchers.

M als

g

Inadequate ED, Imaging and Lab layout.

nt

me

e ag

an

teri

Ma

4

Materials Management far from all other services. Accessible by elevator only.

Inp

atien

Approximately 1 bed used per day.

t Un

it

Inpatient space takes up 20% of total building.

Reg

.

Reg

.

Reg

.

Three different main registration points with unclear marking. Minimal green space not visible to patients.

Above: Existing Hospital Main Issues Axonometric

Our proposed solutions address each of the six challenges through innovative and collaborative design ideas:

2

Adequate departmental layout and size based on analysis of Philipsburg demographics

3

Welcoming community space and local business collaboration

5

Clear main entry from exterior

6

Inclusion of healing garden, natural light, and calming interior design

PA TI

REHAB

PORT SUP AL C

URGENT CARE

LAB

UPPORT GS IN

OUTPATIENT CLINIC

MATERIALS /ENGIN.

PHARM

Removal of inpatient unit to save resources

4

SU

BUI LD

Revised adjacencies for stronger departmental relationships

T EN

CL IN I

1

CO M M

PROPOSED SOLUTIONS

ORT UPP S Y IT N U PPORT

WAITING/ REGISTRATION

IMAGING

ED

CSS ADMIN SURGERY

Through our adjacencies and site analysis, we were able to develop an initial program layout. Our materials management is located centrally beneath the building, and can therefore be easily accessed by all departments of the hospital through a large service elevator. For our patient support areas, the outpatient facilities are separate from the emergency department so our hospital can close down the outpatient side without affecting the operations of the emergency services, which will need to remain open 24/7. The clinical support areas are centrally located between the outpatient and emergency departments so both facilities have easy access to them. Lastly, we wanted to encompass the patient services with a large, welcoming community face.

re

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en ati

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ING

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Y

ER

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ou

tpa t rinient g

T IEN AT TP NIC OU CLI

T.

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cor

AD

ea

nd

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Above: Adjacencies Diagram and Axonometric

53

The new Phillips County Wellness Center is located just outside the Phillipsburg city limits. With direct access off Highway 183, the new facilities provide separate entrances for supply, patient, emergency department/urgent care and ambulance. Utilizing site topography, the supply route gracefully tucks beneath the surgery department for easy unloading and direct connection to materials management as

well as engineering services. Addressing concerns of visibility and access, the main entrance is centrally located on the building. Clearly marked from the street, a large circle drive and covered entrance allocates space for dropping off limited mobility patients. The main patient parking is located close by on the west portion of the site. Lastly, patients can easily access a combined ED/UC and ambulatory entrance on

Ground Level

N 10

Supply

9 1

Main 2 10

11

ED/UC Ambulance Above: Ground and Basement Level Floor Plans

Basement Level

N 10

12 13

14

4

7 6

100

LEGEND: 1) Out Patient Clinic 2) Specialty Clinic 3) Rehabilitation 4) Surgery 5) Emergency/UC 6) Imaging 7) Lab 8) Pharmacy 9) Daycare 10) Dining 11) Comm. Commons 12) Building Maint. 13) Administration

3

8

40

the South side of the building; with an adjacent parking area on the south side. A separate pull-through frames a simple ambulance access. Additionally, there is direct access to the imaging department for the traveling MRI truck. Lastly, a large helicopter pad is located on the southeast corner for quick access and transferral of patients to/ from the emergency department.

5

H

40

100

Within our departments, we wanted to use innovative strategies to increase efficiency as well as patient and staff satisfaction. In the outpatient clinic, we simplified the patient circulation by starting them at an initial vitals station near the entrance, moving them around the patient loop to the exam room, and then having them leave through a separate door that passes a checkout

station. We also implemented a centralized nursing station that has easy access to our four separate exam room pods, consisting of three exam rooms each separated by a shared consultation room. Because we removed the inpatient unit, we created four observation rooms to be shared by both surgery and the emergency department. These rooms will be used for patients that need to be monitored

Outpatient Clinic

for at least 23 hours during recovery. Although the departments share these spaces, they are still primarily closed off to one another for patient safety and infection prevention. Because the service core for both the emergency department and urgent care is almost identical, we created a shared core that is separated with a triage unit to determine where the patient needs to go. This helps save space and consolidate nursing resources.

Surgery/Emergency

Patient Circulation

Patient Circulation

Lounge Phys. Work Stor. Exam Exam Exam Cons. Exam Exam Exam

Locker Locker Endoscopy

RR RR

NS

Clean

Soil

RR RR

Med.

Central Sterile

Exam

Staff Work

Sub Minor OR

PACU

Vitals

NS

Clean

Soil

Med.

Procedure Procedure

Stor.

Exam

Exam

Exam

Exam

Exam

Exam

Procedure Observ. Room Triage

Lounge Phys. Work Stor. Exam Exam Exam Cons. Exam Exam Exam

Exam

Clean

Exam

Soil

Storage

Staff Circulation

Observ. Room Observ. Room

Tele-Conf. Exam Exam Exam Cons. Exam Exam Exam

RR RR

RR RR

Procedure Procedure

Major OR

RR RR

Reg.

NS

Observ. Room

Trauma Decon. Ambulance Bay Room Room

Vitals Tele-Conf. Exam Exam Exam Cons. Exam Exam Exam

Above: Outpatient and Surgery/Emergency Departmental Layouts 55

2

NON-BUILDABLE ZONE

Site design

1 Utilities

Sustainable site features (passive and active)

3 NON-BUILDABLE ZONE

Community involvement

Above: Site and Phasing Plan

Due to the jumbled combination of the current Phillips County Hospital facilities, our design proposes a unique master plan solution. Consisting of three zones (a wellness, community and assisted living zone) the development largely utilizes the west portion of the site. Additionally, a phased construction coordinated with each zone expansion helps lessen the economic burden on the community.

Above: Site Aerial Render

While developing the site, we kept in mind strong architectural concepts. Emphasis is placed along the future road development and entrance to the hospital by creating two major axes. A preliminary utility diagram of sewage, electricity, and water shows future development connection to the existing city grid. Incorporating one of our main concepts of sustainability, both passive and active features are utilized. Passive features include shaded western facades, pervious paving, compost, a bioswale and a rain garden. We introduced active sustainable features through wind turbines, geothermal heating/ cooling and solar panels. Lastly, the entire northwest corner of the site is dedicated to the community. Major amenities include a community garden, park, outdoor amphitheater and running track in hopes that each could be utilized by partnered local groups.

Above: Healing Garden Render 57

After analyzing a number of local groups, we identified three major categories to partner with including key comunity groups, education facilities and health related stores. The new Phillips County Wellness Center aims to partner with the local Community Center and Phillipsburg Wellness Center to share amenities and increase membership among the local residents. This is also achieved through a communal running track, accessible both inside and outside the facilities; creating interaction between local residents and building users. By partnering with local schools, children can participate in extra curricular activities such as learning in the community garden and preparing healthy food in the new kitchen. Directly adjacent, the community commons area can also be utilized as a multipurpose space for education purposes such as exercise classes and community meetings for lectures or conferences. The new cafe provides a secondary business location for local healthy food stores to sell products. Finally, additional space is provided for local family owned pharmacy’s to expand their businesses.

Above: Community Dining Render

Above: Community Flex Space Render

st St. A St.

B St. 2nd St.

C St.

ICON LEGEND

D St.

COMMUNITY COMMUNITY CENTER

E St.

PHILLIPSBURG WELLNESS CENTER

EDUCATION

F St.

PHILLIPSBURG SCHOOL DISTRICT

State St.

36

G St.

HIGH SCHOOL TRACK & FIELD

HEALTH 10th St.

9th St.

8th St.

7th St.

6th St.

5th St.

4th St.

3rd St.

2nd St.

1st St.

H St.

ELEMENTARY, MIDDLE AND HIGH SCHOOL

HEALTH FOOD FAMILY HEALTH STORE AND WHITE’S FOODLINER PHARMACY

I St.

WITMER REXALL DRUG STORE AND MIDWEST FAMILY HEALTH PHARMACY

Kansas Ave.

J St.

Nebraska Ave.

K St.

Park Ave.

Fish

er D

r.

E. Santa Fe. Rd

183

Above: Phillipsburg Community Services Map 59

Phillips County Health & Wellness Center By: Ashley Meadows, Erin McFarland, and Andrew Kloppenburg Our goal for this project was to create a critical access hospital that would meet the health and wellness needs of the citizens of Phillipsburg, Kansas. We found a critical access case study on the Cherry County Hospital in Valentine, Nebraska. This city is similar in size to Phillipsburg and has a very successful critical access hospital. Another way that the city and the hospital succeed is in promoting both health and wellness. The hospital provides health-related classes as well as health promotion through the school district. Wellness is also promoted through several youth recreation activities as well as the use of their outdoor aquatics facility. We felt that this was a great precedent for us to use to find a way to bring health and wellness into Phillips County and the City of Phillipsburg. So, from our research and programmatic needs we created a mission statement: Our mission is to engage rural residents and promote healthy lifestyles through a facilty that integrates health care services with community-based activites that will unify people of all ages.

Above: Main Entrance (Facing West) of the Phillipsburg Health & Wellness Center

61

We chose to place the main entrance to the hospital on the west side of the site because it is the most visible part of the site in access to the street running north into the City of Phillipsburg. One problem from the existing hospital site is the amount of entrances into the hospital. It created confusing paths and directional traffic flows, which we felt was easily remedied with only one main entrance into the hospital. This allowed for our Wellness Center to be placed on

the west side of the site as well so that it was most visible from the highway that leads into Phillipsburg. The location of the walking trail is also close to the main street for easy access to Phillipsburg and surrounding citizens to use, as it is considered a public walking trail on the site. The Emergency Department entrance is located on the south side of the site. We wanted to separate the main entrance from the emergency to continue on the idea of clear patient paths

N

Above: Phillips County Health & Wellness Center Site Plan (Not to Scale)

throughout the space. The staff parking and entrances are located on both the southern side (Outpatient, Lab/Imaging, Emergency, and Urgent Care staff) and the northwest side (Surgery, Inpatient and additional staff). Again, we wanted to keep a clear distinction between patient and staff paths throughout the hospital so we chose to separate the patient and staff entrances and parking on site.

Our challenge became ‘how do we draw in the community and how do we make all components revolve around wellness?’ By adding a wellness component to the program, wellness activities become integrated with health services, not only promoting healthy lifestyles but also engaging all members of the community. The wellness component consists of a fitness and rehabilitation center, a wellness garden atrium, and an outdoor recreation and leisure park

ZONE: SURGICAL & SUPPORT

all positioned very publicly at the front of the building. After passing through the central garden atrium is the clinical spine, a semi-private zone containing a shared waiting space, inpatient wing, outpatient clinic, and emergency/urgent care department. The rear side of the facility is the private zone which holds the surgery wing, lab and imaging, and various back-of-house health services. This transition from public to semi-private to private is strategic in drawing people

of the community to the site and into the building. In order to keep wellness the focus, the central garden atrium serves as the building’s core in which all other departments radiate out from. As natural light and views to nature help to improve a person’s well-being and to heal quickly, all public and semi-private spaces have views into either the garden, the park, or other vegetated areas.

N

PUBLIC | WELLNESS SEMI-PRIVATE | CLINICAL SPINE PRIVATE | SURGICAL & SUPPORT

Above: Strategic zoning helps to integrate health with wellness and draw in the community. 63

W DRESS 74 SF HYDROTHERAPY 616 SF

Adjacent to the main lobby is the fitness and rehabilitation center, the garden atrium, and several flex spaces (administration, cafe, and daycare). The fitness and rehabilitation center has several public spaces, such as a basketball court, an open fitness space, and an elevated track overlooking the public spaces below. These activities will help to incorporate community members of all ages into one space. The semi-private spaces in the center are for rehabilitation and therapy. These spaces, such as Physical Therapy and Occupational Therapy, are partially enclosed to allow some privacy but remain spatially connected to the public. Similar in zoning, the garden has public gathering spaces, semi-private benches with views to a water feature for relaxation, and a private studio space for intimate yoga or one-on-one rehab sessions. From the garden is access to the outdoor park which includes a walking trail for rehabilitation and all community members, open recreation space, tennis courts, and a small water feature enhancing inpatient and wellness center views.

M DRESS 73 SF

GYM STORAGE 663 SF

STUDIO STOR. 181 SF

STUDIO 1138 SF

PUMPS/STORAGE 173 SF PHYSICAL THERAPY / OPEN FITNESS 4035 SF

TRACK ABOVE

SPEECH THERAPY 149 SF

PT CUBICLE 1 82 SF PT CUBICLE 2 82 SF

CARDIAC REHAB 419 SF

PT CUBICLE 3 82 SF

EQUIP CHECK OUT 147 SF

Basketball 9750 SF

PT CUBICLE 4 82 SF PT CUBICLE 5 82 SF PT CUBICLE 6 82 SF

SHARED OFFICES 557 SF

PT TREATMENT ROOM 120 SF

ADL ADL STATION STATION 1 2

OCCUPATIONAL THERAPY 1321 SF

ADL ADL STATION STATION 3 4

Above: Fitness and Rehabilitation Center Floor Plan

WOMEN'S LOCKER ROOM 752 SF

MEN'S LOCKER ROOM 750 SF

WAITING 506 SF

TRACK ABOVE

Above: Outdoor Recreation and Leisure Park

WEIGHTS 262 SF

CHAPEL 468 SF

During our site visit to the existing Phillips County Hospital, we learned that one of the most utilized areas of the system was the outpatient clinic. Many residents of this rural community visit their primary care physician or specialty physicians in this clinic. We sought to integrate the primary and specialty physicians in common work areas. Benefits of shared spaces include cross-discipline collaboration, more open space for natural light and communication, and reduced walking distances. To achieve the common work areas, we implemented the two-door exam room model. This helps to eliminate the crossing of patient-staff travel paths in the corridors. Additionally, the external corridors look out upon natural or calming areas to reduce patient anxiety and discomfort.

EXAM 3 226 SF

EXAM 4 144 SF

EXAM 5 144 SF

EXAM 6 227 SF

EXAM 2 136 SF

EXAM 11 221 SF

EXAM 7 137 SF

EXAM 12 144 SF

EXAM 10 139 SF

EXAM 15 136 SF

CLEAN 3 120 SF

CLEAN 2 120 SF EXAM 1 135 SF

STAFF AREA 1

EXAM TABLE

EXAM 9 139 SF

EXAM 8 137 SF

EXAM 16 136 SF

STAFF AREA 2

PROCEDURE 2 259 SF

PROCEDURE 1 269 SF

EXAM 17 136 SF

STORAGE 198 SF

SOILED 2 120 SF

CLEAN 114 SF

SOILED 3 120 SF

SOILED 110 SF

EXAM 18 138 SF

EXAM 24 249 SF

PHYSICIANS WORK ROOM 294 SF EXAM 23 143 SF

EXAM 22 144 SF

EXAM 21 144 SF

EXAM 20 144 SF

EXAM 19 145 SF

CONSULT DESK

M LOCKER ROOM 180 SF

STAFF BREAK ROOM 1128 SF

W LOCKER ROOM 188 SF

STAFF ENTRANCE

Above: Outpatient Floor Plan & Enlarged Outpatient Clinic Exam Room OVERNIGHT ROOM 336 SF

OVERNIGHT ROOM 339 SF

TREATMENT 164 SF

STORAGE 149 SF

HSKP 94 SF

CONSULT 191 SF

PATIENT BATHING 190 SF CLEAN 98 SF

DAY ROOM 766 SF

CONFERENCE 167 SF

DICTATION 90 SF

SOILED 74 SF

STORAGE 307 SF

STORAGE 33 SF NURSE STATION 652 SF

The inpatient wing is quite challenging to design given the current trends in rural healthcare. The current Phillips County Hospital only has one inpatient admission per day, so beds are frequently used as skilled nursing swing-beds. We chose to use a canted inpatient room design for several reasons. First, it increases the visibility (shown in blue) of staff into the room. Second, it increases the patient’s ability to see natural views and also see the corridor if needed.

EXAM 14 228 SF

EXAM 13 144 SF

RX ROOM 76 SF

DR OFFICE 104 SF

SHARED DR OFFICE 218 SF

NOURISHMENT 133 SF

DIETARY 191 SF

STAFF ENTRANCE

HSKP 75 SF

W LOCKER 182 SF

DIETARY 1676 SF M LOCKER 153 SF

STAFF LOUNGE 322 SF

NURSERY 265 SF

LDRP 2 366 SF

STAFF GARDEN 1436 SF

LDRP 1 346 SF

ADMIN STORAGE 93 SF

CONSULT ROOM 147 SF

RECEPTION/ADMIN 368 SF VESTIBULE/SUB WAIT 276 SF

Above: Inpatient Floor Plan & Enlarged Inpatient Room 65

INTERNATIONAL HEALTHCARE Tenwek Orthopedic Hospital: Supporting Critical Health Care in Kenya

Professor: Frank Zilm

Tenwek Orthopedic Hospital: Supporting Critical Health Care in Kenya By Connor Crist, Vincent Cunigan, Johann Duran, Erin McFarland, Ashley Meadows, Ariel Peisen, Aaron Rule, Katie Smith, Brianna Sorensen Professor Frank Zilm Tenwek Hospital has been providing critical health care services to the southwestern region of Kenya since its inception in 1937. A broad range of inpatient and outpatient care are currently provided along with medical education and staff support functions. In 2013 Tenwek treated more than 140,000 outpatients for dental care, stomach aches, broken bones, HIV follow-up visits, and other health needs in 2013. The hospital, one of the most advanced in the region, also saw more than 14,000 inpatients and performed over 3,000 major surgeries. The 300 bed campus has experienced dramatic growth in care, with existing facilities reaching capacity. This project seeks to consolidate and expand orthopedic services to the region through construction of a 3,600 square meter (40,000 square foot) building at the west end of the existing campus, directly tying into Casualty and Emergency services, which accounts for 60 percent of the services workload.

Services that will be housed in the building include: • • • •

Four state of the art operating rooms and support functions A CT supporting Orthopedics, Casualty and Emergency services, and other outpatient care. A outpatient clinic with six exam rooms, casting, and treatment spaces. Physical Therapy functions, hydrotherapy, and exercise areas

•

• •

One floor of private and semi-private rooms, accommodate special need patients and possible isolation needs. Two floors of patient ward beds supporting 24 patients per floor. Rooftop exercise and support areas for patients and families.

Level 4 Casualty and Emergency

Level 3 Level 2 Level 1 Level 0

69

Isolation Rooms Semi-Private Rooms Surgery Support

LEVEL 1: Private Nursing, Sugery

Private Rooms

LEVEL 0: Admin, Clinic, P.T.

FLOOR PLANS

Clinic Area

Admin. Area

Physical Therapy Area

LEVEL 3 & 4: Nursing Ward O.R./Sterile Core Waiting/Consulting/Prep Support/Service Spaces Holding/PACU CT

LEVEL 2: Surgery Suite

Casualty & Emergency

71

POSTOCCUPANCY EVALUATION

A Comparative Analysis of a Past and Present Medical-Surgical/Special Clinics Units

E ANALYSIS OF PAST AND PRESENT INP CAL OF CENTER IOWAINPATIENT U SIS PAST- MANCHESTER, AND PRESENT A Comparative Analysis of a Past and Present Medical-Surgical/Special Clinics Units

R - MANCHESTER, IOWA At Regional Medical Center in Manchester, Iowa By Megan S. Davis

f 2016 I conducted an independent attempt at a post Intern at Invision Architects, dical-Surgical/Special Care Unit at Regional Medical Center Waterloo, Iowa gather evidence-based information that can help guide pendent attempt at a post nd, time,Beginning and space staff and patients. in theinfallrelation of 2015 to through Unit at Regional Medical Center the spring of 2016 I conducted an rmation that can help guide al access hospital located a town independent attempt atin a post occu-of 5,000, yet it serves on to staff and patients. nal hospital was built inof1950, whileand the new inpatient pancy evaluation an existing new Medical-Surgical/Special Care pened December 8, 2015. The staff, Unit number of beds, and n a town ofRegional 5,000,Medical yet itcurrent serves Center units, (RMC) in ween theatprevious and allowing the Manchester, Iowa. The purpose was to 0,ing. while the new inpatient gather evidence-based information that The staff, number of beds, and can help guide future design units, allowing thetask timing decisions. dntlocation mapping, of nurses, decibel Areas of focus were sound, time, and of patientspace Press Ganey information, as well as informal in relation to staff and patients.

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I interviewed the nurse manager before and after the move asking her questions about her staff and department. She shared with me the Press Ganey results of the patients from before and after, as well as distributed my online survey to her staff. Talking to her allowed me to get a personal perspective into how they use the space. Before I would UNIT shadow the nurses I would introduce myself and ask them informal questions as to how they were liking and adjusting to the space. This allowed me to gather additional information as to what was working and what would need more of a cultural adjustment. TASK

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The Press Ganey information I received was from 2nd quarter (April 1, 2015 to June 30, 2015) for the past unit, and included an average of 289 patient responses per question. For the current unit I received data from the first quarter of 2016 (January 1 to March 31) and included an average of 76 patient responses per question. There was data available from the 4th quarter of 2015 that would

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