Reinvigorating Rural Healthcare

reinvigorating rural heathcare Strengthening Hale County Hospital through Community Engaged Design

WRITTEN BY

Nicole Brown Jake Schirmer Ingrid Stahl Kyra Stark

For more information about Rural Studio, please visit ruralstudio.org Published June 2020.

Printed in the United States of America.

For purposes of research documentation. Š Copyright 2020 - Rural Studio *Some images are used under fair use guidelines for educational purposes

Written in collaboration between Nicole Brown, Jake Schirmer, Ingrid Stahl, and Kyra Stark.

Non-distributable SKU:

ii

237-0-00079-529-8

reinvigorating rural heathcare Strengthening Hale County Hospital through Community Engaged Design

iii

“If you want to watch a rural community die, kill it’s hospital” -Lauren Weber

iv

“Over the last year, the Hospital has grown in bright and incredible ways. In reshaping our mission to focus more closely on our ties to the community, we have been able to shift our energy to emphasize more intently on serving our family, friends, and neighbors in high-quality and personalized ways. We have greatly expanded our community outreach, and are working to build a presence in the community that is much more reflective of our mission of truly caring for our neighbors. Though the last few months have been rooted in uncertainty for many, we are incredibly proud of the way we have strengthened our role in Hale County, not only as a community hospital, but as a pillar of this community, dedicated to working with every part of community health�

-Shay Fondren

v

rural health + design

12

chapter 1

14

rural healthcare background a history of why and how health disparities affect rural Americans chapter 2

36

hale county hospital a case study of how rural hospitals can stay resilient chapter 3

enhancing hale county hospital through design how a new courtyard can promote the hospital’s vision

vi

64

how to manual

110

how to

114

a guide to design hale county hospital courtyard 2

know what you don’t know gathering information and conducting initial research how to

148

think like a landscape architect understanding and designing for the cyclical and linear nature of plants how to

156

evaluate design decisions creating our process, collecting feedback, and advancing the design how to

190

communicate ideas presenting to visiting critics and our community partners

appendix

200

vii

viii

foreword Rural healthcare has declined over the past thirty years. This book explores the causes and consequences of that downturn, and how a small rural hospital in Greensboro, Alabama has remained resilient and impactful in a rapidly-changing healthcare world.

ix

about the authors We are four architecture students at Auburn University’s Rural Studio Program whose undergraduate thesis project was the Hale County Hospital Courtyard. We devoted a year of our lives to learning about and living in West Alabama, studying rural healthcare, engaging with the Hale County community, and designing a courtyard with our incredible community partners at Hale County Hospital.

Rural Studio is an off-campus design-build program in the School of Architecture, Planning and Landscape Architecture at Auburn University. Rural Studio has been educating citizen architects in Hale County, Alabama, since 1993 and strives to be good neighbors and friends to the community. Rural Studio emphasizes place, beauty, economy, purpose, and dignity in all that they do, from education to research to outreach.

“Proceed & be bold” -Samuel Mockbee

xi

chapter 1

14

rural healthcare background a history of why and how health disparities affect rural Americans chapter 2

36

hale county hospital a case study of how rural hospitals can stay resilient chapter 3

enhancing hale county hospital through design how a new courtyard can promote the hospital’s vision

12

64

rural health + design BOOK 1

13

14

one

BOOK 1 . CHAPTER 1

rural healthcare background

15

Hill-Burton Act Aug. 13, 1946

WWII Begins

WWII Ends

Sept. 1, 1939

Sept. 2, 1945

57 million rural americans G.I. Bill

Employment Act

June 22, 1944

Feb. 20, 1946

1940 U.S. Census

1939

1940

1941

1942

1943

1944

1945

1946

Rural Health: Post WWII History

CHAPTER

01 SECTION

World War II was a critical turning point for rural healthcare in America. According

01

to the U.S. Census, fifty-seven million, or 43.5%, of Americans were living in rural areas in 1940. Because of America’s victory and economic success after the war, American society became affluent. Public policies, such as the GI BIll of 1944, Employment Act of 1946, and Hill-Burton Act in 1946 greatly improved Americans’ way of life and health.[1] Two months after WWII ended, in May of 1945, President Harry S. Truman gave a speech to Congress, outlining his goals to improve the nation’s health. A major goal was to fund the construction of hospitals and clinics to serve the growing population. On August 13th, 1946, Harry S. Truman signed into law the Hospital and Survey Construction Act, commonly referred to as the Hill-Burton Act after its sponsors, Alabamian Democrat J. Lister Hill and Ohioan Republican Harold H. Burton.

[1]

Higgs, Robert. “Government and the Economy since World War II.” The Independent Institute, 20

Apr. 2005.

16

//

Book 1 : Rural Health + Design

1947

10,748 projects funded

1/3 of all U.S. Hospitals funded

by 1971

National Health Planning &

Public

Resources Development Act

funding ends

(expands Hill-Burton)

1970

1971

1972

1973

1974

1975

1997

1998

Figure 1.01: Timeline of Post-WWII Healthcare Acts

The Hill-Burton Act provided construction grants and loans to build healthcare facilities in communities across the country.

[2]

These facilities would ensure that all Americans had access to decent healthcare, regardless of their location. The main requirement was that communities possessed a minimum population and sufficient financial resources to sustain these facilites after they opened. By 1971, the Hill-Burton Act had funded 10,748 construction projects.[3] These projects included nursing homes, mental health and other specialized facilities, public health centers, and hospitals.

[2]

Schumann, John Henning. “A Bygone Era: When Bipartisanship Led To Health Care Transformation.”

NPR, NPR, 2 Oct. 2016, www.npr.org/sections/health-shots/2016/10/02/495775518/a-bygone-era-whenbipartisanship-led-to-health-care-transformation.

[3]

Thomas, Karen Kruse. “Hill-Burton Act.” Encyclopedia of Alabama, Alabama Humanities Foundation,

22 Jan. 2008, www.encyclopediaofalabama.org/article/h-1439.

Chapter 1: Rural Healthcare Background

//

17

In 1975 when the Hill-Burton Act was rolled into the larger National Health Planning and Resources Development Act, it was responsible for almost one-third of the construction of United States hospitals.

This new act made it necessary to obtain a Certificate of Need in order to construct a medical facility on a state by state basis. The healthcare industry was concerned that the construction of too many hospitals would cause competitors to make up for the decrease of patients by overcharging, or by convincing patients to unnecessarily accept hospitalization. Although the Certificate of Need system requires all health care providers to obtain state approval before making capital improvements, it grants monopoly privileges to already existing hospitals.

As rural hospital closures increased, less Certificates of Need were issued to build new medical facilities. In 1997, the Hill-Burton Act stopped providing funds, but about 140 Hill-Burton clinics and hospitals still exist around the country. These facilities are obligated to provide free or reduced-cost care to patients whose income is at or below the current Federal Poverty Guidelines.[4]

[4]

“Hill-Burton Free and Reduced-Cost Health Care.” U.S. Health Resources & Services Administration,

U.S. Department of Health and Human Services, 24 Apr. 2019, www.hrsa.gov/get-health-care/affordable/ hill-burton/index.html.

18

//

Book 1 : Rural Health + Design

ABOVE: newspaper clipping from 1963, when the Hill-Burton Act funded Hale County Hospital in 1963.*

Chapter 1: Rural Healthcare Background

//

19

Figure 1.02 Mostly Rural or Completely Rural Counties, 2016 Completely Rural Counties (100%) Mostly Rural Counties (50%-99.9%) Urban + Suburban Counties

Source: U.S. Census Bureau

20

//

Book 1 : Rural Health + Design

Chapter 1: Rural Healthcare Background

//

21

Rural Health in 2020

CHAPTER

01 SECTION

The number of people living in rural America has remained relatively consistent

02

over the past century (Fig 1.05). Today, in the United States, about sixty million people, or one in five Americans, live in rural areas (Fig 1.02, p.20). The U.S. Census Bureau defines “rural” as all population and territory outside cities and towns with 2,500 or more people (Fig 1.03).[5]

[5]

Nasser, Haya El. “What Is Rural America?” The United States Census Bureau, U.S. Department of

Commerce, 23 May 2019, www.census.gov/library/stories/2017/08/rural-america.html.

Figure 1.03: What does Rural mean?

URBAN CLUSTER

RURAL 0

URBANIZED AREA

2,500

50,000

Figure 1.04: Percentage of U.S. Population Living in Rural Areas 100

80

60

40

20

Figure 1.05: Distribution of U.S. Population, millions 350

300

250

200

Urban population 150

100

50

Rural population

1910

22

1920

//

1930

1940

Book 1 : Rural Health + Design

1950

1960

1970

1980

1990

2000

2010

Why do people living in rural areas have more health issues?

The difference in quality of health between rural and urban Americans is significant.

According to the Centers for Disease Control and Prevention, rural Americans are more likely to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than their urban counterparts.[6] This trend comes from a variety of issues, including: i. Economic Disparity Rural Americans have higher rates of poverty, have less access to healthcare, and are less likely to have health insurance than urban Americans. In some cases, long travel distances to medical care make a trip to the doctor an all-day experience. This means individuals usually have to weigh the opportunity cost of lost wages before seeking any medical care. Additionally, less leisuretime for physical activity, higher rates of cigarette smoking and obesity also put rural Americans at higher risk. ii. Food Deserts (Fig 1.06, p. 24) Although there are many definitions of what a food desert is, the Healthy Food Financing Initiative considers a food desert as a low-income census tract where a substantial number of residents are more than one mile from a supermarket or grocery store in urban areas, and as more than ten miles from a supermarket or grocery store in rural areas.[7] So how does being in a food desert negatively affect health and lead to obesity?

Groceries sold in food deserts cost an average of 10% more than groceries sold in suburban markets. Also counties with large rates of food deserts tend to have higher per capita fast food restaurants.[8] Consequently, these diets tend to be high in calories and low in nutritional value, leading to obesity and other chronic diseases.

[6]

“About Rural Health.” Centers for Disease Control and Prevention, Centers for Disease Control and

Prevention, 2 Aug. 2017, www.cdc.gov/ruralhealth/about.html.

[7]

Dutko, Paula, et al. Characteristics and Influential Factors of Food Deserts. 140th ed., United States

Department of Agriculture, 2012.

[8]

Chinni, Dante. “The Socio-Economic Significance of Food Deserts.” PBS, Public Broadcasting Service,

29 June 2011, www.pbs.org/newshour/arts/the-socio-economic-significance-of-food-deserts.

Chapter 1: Rural Healthcare Background

//

23

Figure 1.06 No Supermarket within a Mile (Food Desert) >10 percent 5.1-10 percent 2.5-5 percent <2.5 percent

Source: Department of Agriculture, Centers for Disease Control

24

//

Book 1 : Rural Health + Design

Chapter 1: Rural Healthcare Background

//

25

Although these statistics cause great concern for rural communities, the Centers for Disease Control and Prevention, or CDC, recommend the following guidelines for improving rural health: [9] i. Screen patients for high blood pressure and make blood pressure control a quality improvement goal. High blood pressure is a leading risk factor for heart disease and stroke. ii. Increase cancer prevention and early detection. Rural healthcare providers should participate in the state-level comprehensive control coalitions.

Comprehensive cancer control programs focus on cancer prevention, education, screening, access to care, support for cancer survivors, and overall good health. iii. Encourage physical activity and healthy eating to reduce obesity. Obesity has been linked to a variety of serious chronic illnesses, including diabetes, heart disease, cancer, and arthritis. iv. Promote smoking cessation. Cigarette smoking is the leading cause of preventable disease and death in the United States and is the most significant risk factor for chronic lower respiratory disease.

v. Identify additional support for families who have children with mental, behavioral, or developmental disorders. Children with these issues would benefit from increased access to mental and behavioral healthcare, programs that support parents and caregivers, and increased opportunities to learn, play, and socialize. Because children in rural areas with these disorders more often experience financial difficulties, parents struggling with mental illness, and a lack of neighborhood resources, these children need additional support.

[9]â&#x20AC;&#x192;

â&#x20AC;&#x153;Access to Health Services.â&#x20AC;? Healthy People 2020, Office of Disease Prevention and Health Promotion,

www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services.

26

//

Book 1 : Rural Health + Design

vi. Promote motor vehicle safety. Rural healthcare providers should encourage patients to always wear a seat belt and counsel parents and child care providers to use age- and size-appropriate car seats, booster seats, and seat belts on every trip. vii. Engage in safer prescribing of opioids for pain. Healthcare providers should follow the CDC guidelines when prescribing opioids for chronic pain and educate patients on the risks and benefits of opioids and using nonpharmacologic therapies to provide greater benefit.

Chapter 1: Rural Healthcare Background

//

27

Rural Hospitals in 2020

CHAPTER

01 SECTION

Hospitals are an integral part of rural communities. However, an increasing number

03

of rural hospitals are closing each year. Since 2010, The North Carolina Rural Health Research Program has tracked 120 rural hospital closures, and the number continues to rise (Fig 1.07).[10] Unfortuantely, these closures are mainly occuring in communities with higher poverty rates and hospitals in constant financial distress (Fig 1.08, p.30).[11] In most cases, fewer patients seeking inpatient care and reductions in medicare payments have made independent hospital operations too expensive. The resulting increase in emergency medical services, loss of jobs, and increased time and cost of transportation to healthcare services makes healthcare a barrier to vulnerable groups.[12]

[10]

“170 Rural Hospital Closures: January 2005 - Present (128 since 2010).” The Cecil G. Sheps Center for

Health Services Research, The University of North Carolina at Chapel Hill, www.shepscenter.unc.edu/ programs-projects/rural-health/rural-hospital-closures/.

[11]

Kaufman, Brystana, et al. “Prediction of Financial Distress among Rural Hospitals.” NC Rural Health

Research Program, Jan. 2016.

[12]

Schroeder, Shawnda. “Effects of Rural Hospital Closures .” Rural Health Research Recap, Dec. 2017.

Figure 1.07 Hospital Closures since 2010 Source: Stroudwater Associates, North Carolina Rural Health Research Program

2010

28

//

2011

Book 1 : Rural Health + Design

2012

2013

2014

120

110

100

90

80

70

60

Accumulated Total since 2010 Total Closures, per year

50

Hospital Closures by Type, per year Prospective Payment System Critical Access Hospital 40

Medicare Dependent Hospital Sole Community Hospital Other 30

20

10

2015

2016

2017

2018

Chapter 1: Rural Healthcare Background

2019

//

29

Figure 1.08 Poverty Rate + Hospital Closures since 2010 30+ percent 20-29 percent 15-19 percent 10-15 percent <10 percent Hospital closure (since 2010)

Source: 2013-2017 U.S. Census Bureau, American Community Survey, 2010-2019 North Carolina Rural Health Research Program

30

//

Book 1 : Rural Health + Design

Chapter 1: Rural Healthcare Background

//

31

Why are rural hospitals closing?

Here are some key risk factors that indicate which rural hospitals are at risk of closure: i. Loss in revenue. Rural areas have a high volume of state-funded healthcare with lower reimbursement rates. ii. Difficulty accessing healthcare. Fewer patients seek medical care because of high costs and lack of access. iii. High turnover of physicians. Rural hospitals have difficulty attracting and retaining physicians due to the hospital’s isolated location and limited resources. iv. Lack of Medicaid funding. In 2014, some states expanded hospital expanded Medicaid under Obamacare (Fig 1.09, p.34). Rural areas in non-expansion states have a much higher percentage of uninsured residents.

In states that have expanded Medicaid coverage, people can qualify based on their income alone. If someone’s household income is below 138% of the federal poverty level, they instantly qualify. If a state hasn’t expanded Medicaid, a person’s income is below the federal poverty level, and they don’t qualify for Medicaid under their state of residence’s current rules, then they won’t qualify for Medicaid coverage or savings on a private health plan bought through the Marketplace.[13] When these people become seriously ill or injured and come to the local hospital with no insurance to cover large medical bills, it becomes harder for the hospital to stay in business.

[13]

“How Medicaid Health Care Expansion Affects You.” HealthCare.gov, U.S. Centers for Medicare &

Medicaid Services, www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/.

32

//

Book 1 : Rural Health + Design

It is incredibly important that rural hospitals survive to bring economic prosperity and quality healthcare to its community members. On average, the health sector makes up 14% of total employment in rural communities.[14]

Rural hospitals are typically the largest employers in the area.

The IRS also requires tax-exempt, non-profit rural hospitals to conduct community benefit activities, including a Community Health Needs Assessment every three years. A 2019 report from the American Hospital Association found that rural hospitals on average spent 12% of their total expenses on community benefit in 2016.

Hospitals in rural America do more than just keep people healthy; they help their entire communities. How do we prevent rural hospitals from closing? Learning from successful rural hospitals that have found ways to stay resilient and adaptable is a good first step.

[14]

“Rural Hospitals Introduction.” Rural Health Information Hub, Health Resources and Service

Administration, 31 Mar. 2020, www.ruralhealthinfo.org/topics/hospitals.

Chapter 1: Rural Healthcare Background

//

33

Figure 1.09 States with Medicaid Expansion since 2014 + Hospital Closures since 2010 Adopted Medicaid expansion Not adopted Medicaid expansion Hospital closure (since 2010)

Source: KFF.org Status of Medicaid Expansion, 2010-2019 North Carolina Rural Health Research Program

34

//

Book 1 : Rural Health + Design

Chapter 1: Rural Healthcare Background

//

35

36

two

BOOK 1 . CHAPTER 2

hale county hospital

37

CHAPTER

Introduction to Hale County Hospital

02 SECTION

Despite the increasing trend of rural hospital closures and the increasing challenge

01

of keeping these facilites open, some rural hospitals are able to prosper.

Hale County Hospital, in Greensboro, Alabama, is one of those hospitals. Since a new adminstration took over in 2014, the facility has renewed its commitment to the community and found the formula for ongoing success. Over its almost seventy year history, Hale County Hospital has remained resilient by altering the services it offers and actively engaging in the community.

BELOW: Hale County Hospitalâ&#x20AC;&#x2122;s front entrance

The following chapter will explore how this hospital has found its pathway to success and how it plans to continue this trend into the future. i. Resiliency + Adaptability (p.52). Hale County Hospital is consistently adapting to the communityâ&#x20AC;&#x2122;s medical needs by providing necessary services that are also economically viable for the hospital. ii. Community Involvement (p.56). Hale County Hospital engages with community organizations to serve more residents in the county, expand the hospitalâ&#x20AC;&#x2122;s impact, and market themselves as a progressive healthcare facility.

Figure 2.01 Black Belt region of the Southeast

STATE OF ALABAMA

BLACK BELT REGION OF ALABAMA

27.8%

25.2%

below poverty line

below poverty line

below poverty line

16.9%

HALE COUNTY, ALABAMA

The poverty line is the minimum level of income deemed adequate in a particular county. It is calculated by finding the minimum amount of income that a family needs for food, clothing, transportation, housing, and other necessities. It varies according to the size of the family and their geographic location. In the United States, the poverty line is updated by the U.S. Census Bureau every year. The poverty line indicates if Americans are qualified to receive certain federal benefits and programs such as Medicaid, Food Stamps, Family and Planning Services, and the National School Lunch Program.[1]

[1]

“2020 Poverty Guidelines.” ASPE, U.S. Department of Health and Human Services, 21 Jan. 2020, aspe.

hhs.gov/2020-poverty-guidelines.

40

//

Book 1 : Rural Health + Design

Figure 2.02: Black Belt region of Alabama

Chapter 2: Hale County Hospital

//

41

Figure 2.03 Context map of West Alabama More Dense Less Dense

Tuscaloosa

Hospitals

Tuscaloosa

Bibb

Moundville Centreville

Greene Eutaw

Hale Greensboro

Perry Marion

Demopolis Selma

Thomasville

Marengo

Source: U.S. Census Bureau

42

//

Book 1 : Rural Health + Design

Dallas

ABOVE: various newspaper clippings celebrating the opening of Hale County Hospital*

CHAPTER

History of Hale County Hospital

02 SECTION

Hale County Hospital opened to the public on November 6th, 1963. The hospital was

02

built with federal funds through the Hill-Burton Act contributing $295,000, state funds contributing $60,000, and county funds contributing $136,120, for a total cost of $491,120.

At the time Hale County Hospital was built, Hale County was the second to last county in Alabama to have a public hospital.

Before the hospital opened, Hale County residents had been using hospitals at Centreville, Tuscaloosa, Eutaw, and Marion.[15] According to the U.S. Census, the population of Hale County in 1960 was 19,537 and the population of Greensboro was 3,081.

[15]

Watkins, Ed. “Hale County Gets Hospital of Own.” The Tuscaloosa News, 28 Oct. 1963.

Chapter 2: Hale County Hospital

//

43

N

hw ay ig

Greensboro, Alabama

H

Tuscaloosa St.

Context map of

25

Figure 2.04

Main St.

State St.

1st St.

is

ol

op

.

St

m De

Hale County Hospital 1963

Greene St. looking East

44

//

Book 1 : Rural Health + Design

N

Hale County Hospital was built south of the Bypass Highway, now called State Street (Fig 2.04), across from the National Guard armory. The hospital was designed with colonial columns in keeping with the antebellum tradition of Greensboro.

When it opened, the hospital was one of the newest facilities in the state and “one of the most modern facilities of its type anywhere.”[16] The area surrounding Hale County Hospital has changed significantly since it opened in 1963. Most of the healthcare and recreation buildings are located in the southeast corner of Greensboro, including a dentist office, Hale County Health Department, Hale County Family Planning, Hale County EMS, and Lions Park. The National Guard armory across the street from the hospital no longer functions as an armory. Instead, the gym of the armory is used by the Boys & Girls Club, which opened in 2015 and serves as an after-school program for K-12 kids.

[16]

“Hill-Burton Funds Build Hale Hospital.” The Birmingham News, 17 Nov. 1963.

Boys + Girls Club

Old Armory Building

Rural Studio, 2012

Chapter 2: Hale County Hospital

//

45

Hale County Hospital in 2020

CHAPTER

02 SECTION

As the primary healthcare provider for residents, the Hale County Hospital is

03

a triving part of today’s community. Hale County Hospital also serves people living in neighboring Perry County because their hospital closed in 1988.[17]

Hale County Hospital is the second largest employer in the county with 142 employees.

The staff at Hale County Hospital are committed to their community and many of them have worked in the hospital for the majority of their career. The hospital’s Chief Executive Operator, Shay Fondren, began her career as a nurse in 1993. She has dedicated her life’s work to Hale County Hospital and been a crucial leader in implementing and expanding the hospital’s vision.

The hospital is overseen by an advisory board, which is made up of nine local members who meet quarterly. As residents of Hale County, the board members are dedicated to improving the health and well-being of their fellow community members. They are committed to Hale County Hospital’s fundamental belief in neighbors helping neighbors and work to strengthen and improve the hospital.

[17]

46

//

United States, Congress, Kusserow, Richard P. Hospital Closure: 1988, March, 1990.

Book 1 : Rural Health + Design

Hale County Hospital Mission Here at the Hale County Hospital, we seek to pursue and promote healing, improved health, and improved quality of life of the residents of Hale County and surrounding communities. Our focus is on relationship and community-centered healthcare complemented by programming, activities, and community partnerships that support improved health and quality of life and builds on our mission of caring for our neighbors.

In addition to our role of caring for our community, we also seek to prepare medical, health professions, and other students to carry forward the humanistic and community focused standard we aspire to in our own community and to prepare community health leaders for our region, state, and nation, with a special focus on rural and under-served communities.

[1]

[1]â&#x20AC;&#x192;

â&#x20AC;&#x153;Mission.â&#x20AC;? Hale County Hospital,

halecountyhospital.com/new-page.

Chapter 2: Hale County Hospital

//

47

Hale County Hospital Evolution

CHAPTER

02 SECTION

The following timeline illustrates the various additions and expansions of Hale

04

County Hospital over the last seventy years.

1963 Hale County Hospital opens to the public

1967 Patient Care addition adds 4 patient beds

Hill-Burton Act Aug. 13, 1946

1945

48

1946

//

1962

Book 1 : Rural Health + Design

1963

1964

1965

1966

1967

1968

1979 East wing addition adds 8 new inpatient beds + offices

1998 Clinic opens to the public

1978

1979

1980

1996

1997

1998

1999

2000

Chapter 2: Hale County Hospital

2001

//

49

2004 Patient care addition upgrades all patient rooms

2003 Clinic addition

2003 Rural Studio renovates hospital courtyard

2002

50

2003

//

2004

Book 1 : Rural Health + Design

2005

2006

2007

2008

2010 Maintenance building is completed

2009 Home Health department office addition

2015 Physical Therapy department opens to the public

2008

2009

2010

2011

2013

2014

2015

2016

Chapter 2: Hale County Hospital

2017

//

51

Resilency + Adaptability

CHAPTER

02 SECTION

Understanding Competition

05

Hale County Hospital has been able to remain successful because they are aware of their competition. They make decisions about which markets they can compete in, while also offering services that best serve the community. i. High-tech medicine vs. personalized care The academic hospitals in Tuscaloosa and Birmingham (Fig 2.05) treat patients using high-tech equipment. These medical technologies successfully heal patients but doctors have to treat so many individuals that they struggle to provide personalized care. In contrast, Hale County Hospital prides themselves on being able to offer incredibly personalized care. Their doctors and nurses become very familar with their patients and have the time to check in with them.

Hale County Hospital was the only hospital in West Alabama to receive a four-star rating from Medicare.gov, while the highest rating in the region was two-stars.

[18]

ii. Economically viable and in-demand services The hospital has been aware of which services best benefit the community while also analyzing their economic viability. The result is that the hospital has chosen to remove some low-volume and high-cost markets like labor or surgery.

Patients are instead transferred to larger facilites in the region that are better equipped to handle those procedures. Consequently, the hospital is able to use that valuable space for high-volume, low-cost markets such as physical therapy and imaging.

[18]â&#x20AC;&#x192;

â&#x20AC;&#x153;Medicare Hospital Compare Results.â&#x20AC;? Medicare.gov, U.S. Centers for Medicare & Medicaid Services,

www.medicare.gov/hospitalcompare/results.html#dist=100&loc=36744&lat=32.6726733&lng=-87.5988876

52

//

Book 1 : Rural Health + Design

Figure 2.05 West Alabama Hospitals and Healthcare Facilities Public Hospitals Private Hospitals Physical Therapy Clinics

Tuscaloosa

Nursing Homes

Tuscaloosa

Bibb

Moundville Centreville

Greene Eutaw

Hale Greensboro

Perry Marion

Demopolis Selma

Thomasville

Dallas

Marengo

Chapter 2: Hale County Hospital

//

53

Services Offered It is important for Hale County Hospital to identify which services are needed by the community while also being economically viable for the hospital. Currently, the services they offer are (Fig 2.06): i. 24-hour emergency room. The department responsible for the immediate provision of medical and surgical care to patients. ii. Full-service laboratory. The department where clinical pathology tests are carried out to obtain information about the health of a patient to aid in diagnosis, treatment, and prevention of disease. iii. Radiology + Imaging. The service that uses imaging technology to diagnose and treat disease. iv. Primary care. This service is day-to-day healthcare at a basic rather than specialized level. It is intended for people making an initial approach to a doctor or nurse for treatment. v. Medical inpatient care. This service is the care of patients whose condition requires admission to a hospital. Inpatient care tends to be for more serious ailments and trauma that require one or more days of overnight stay at a hospital. vi. Home health. This program supports patients who have difficulties with mobility or need more regular care in the comfort and familiarity of their own homes. vii. Swing bed rehabilitation. This extended stay service provides physical, speech, and occupational therapy to patients during a longer term stay with the goal of living independently. viii. Outpatient physical therapy. Therapy has become a critical focus for the hospital. The current program accounts for nearly half of all patients per 24-hours, and they would like to expand the program in the future.

54

//

Book 1 : Rural Health + Design

24-HOUR EMERGENCY ROOM

MEDICAL INPATIENT CARE

PHYSICAL THERAPY

patients per 24 hours

patients per 24 hours

patients per 24 hours

4

24

OUTPATIENT

INPATIENT

29

Figure 2.06 Hale County Hospital Patients per 24 hours MEDICAL OUTPATIENT CARE

15

patients per 24 hours

An important part of physical therapy is allowing patients to practice their exercises in an outdoor “real life” environment.

Within Greensboro, there are only two physical therapy competitors; a nursing home and a small, part-time clinic downtown. Both of those facilites lack the available exterior space that Hale County Hospital offers in their courtyard. Having this amenity could ensure the future success of the physical therapy department.

Chapter 2: Hale County Hospital

//

55

Community Engagement

CHAPTER

02 SECTION

Hale County Hospital has remained resilient through their commitment to

06

community involvement and being present in their local community. In recent years, Hale County Hospital has expanded its outreach to serve more West Alabama residents.

The hospital opened the Moundville Medical Clinic in 2016. This clinic provided much needed primary care to residents of northern Hale County and established more of presence where residents primarilty use Tuscaloosa facilities.

Project Horseshoe Farms Project Horseshoe Farms, a local non-profit organization, works to improve the health and quality of life for community members. The organization was started by Hale County Hospital’s Chief of Medical Staff, Dr. John Dorsey, in 2007. The twelve fellows in Greensboro partake in a “gap year” fellowship where they run Health Partner, Youth, Community Center, and Housing Programs. The Project Horseshoe Farms fellows are an essential part of strengthening local education systems, health systems, and the Hale County community.

From 2019 to 2020, two Project Horseshoe Farm fellows worked at the hospital daily, promoting the facility, collaborating with executives, and organizing outreach programs throughout the county. Those programs include: i. Newbern Library Weekly Program. This program builds support amongst community members and teaches them health and wellness tips. ii. Weekly “From Shay’s desk” local newspaper articles. These newspaper articles improve Hale County Hospital’s visibility in the Greensboro community and showcases the great work and talented medical staff at the hospital.

56

//

Book 1 : Rural Health + Design

Figure 2.06 Hale County Hospitalâ&#x20AC;&#x2122;s Community Outreach Programs

Tuscaloosa

Tuscaloosa

Bibb

Moundville

Moundville Medical Associates

Centreville

Greene Eutaw

Hale Greensboro Hale County Hospital

Newbern

Newbern Library

Perry Marion

Demopolis Selma

Thomasville

Dallas

Marengo

Chapter 2: Hale County Hospital

//

57

ABOVE: the completed mural.

BELOW: the process from left to right: painting the background, applying the stencil, and adding color.

58

//

Book 1 : Rural Health + Design

ABOVE: freshly rebranded items for the Hospital, including letterhead, business cards, and staff ID cards.

Rebranding Hale County Hospital also recently rebranded in 2019 to promote their presence in the community. As part of the rebranding, a new logo was designed to help the hospital market themselves externally to attract new patients and staff. This logo was unveiled to the public as a bright new mural painted on a building alongside a highly trafficked highway through Downtown Greensboro. Internally, the logo has been incorporated onto new business cards, letterhead, banners, and ID badges.

While many rural hospitals find it difficult to recruit doctors to work in rural areas, Hale County Hospital hired two new family doctors, who are expected to arrive in the summer of 2020. The hospital is also increasing the number of Project Horseshoe Farm fellows from two to four. This increase in fellows will enable Hale County Hospital to expand their weekly health programs to Marion, located twenty miles east of Greensboro in Perry County.

Chapter 2: Hale County Hospital

//

59

Signage Hale County Hospital also asked the Rural Studio team to assist in developing a new signage strategy. Previously, the only signage pointing patrons to the hospital site were two blue ‘H’ signs along State St. in Greensboro. Through collaboration with the client team, we identified the following needs for signage: i. Appearance in the Community. This phase involves making the community aware of Hale County Hospital’s prescence through simply getting the logo out into the wild. The mural in downtown Greensboro is an example of this. ii. Wayfinding by Car. Once patrons are aware of the hospital in their community, they should be able to find it easily. This phase involves directing vehicular traffic to the hospital site and the closest parking areas. iii. Wayfinding by Foot. After patrons have reached the hospital, their next task is finding the correct entrace and department within the building. This is done through smaller exterior signage, entrance labels, and room tags throughout the building.

The signage mockups below highlight a look and feel that reinforces the brand of Hale County Hospital. It combines the familar red brick of the hospital facade and lightens with die-cut metal on tongue-and-groove wood siding. This illustrates the “neighbors helping neighbors” image and allows the signs to evolve with the hospital.

BELOW: Rendering of large Wayfinding by Car sign on State St. (directing patrons to hospital site)

60

//

Book 1 : Rural Health + Design

ABOVE: Signage has the ability to use elements of the entire logo and still belong to the same brand.

BELOW: Renderings of smaller â&#x20AC;&#x2DC;Wayfinding by Carâ&#x20AC;&#x2122; signage on 1st St. (directing patrons to parking)

Chapter 2: Hale County Hospital

//

61

Rural Studio Another local program Hale County Hospital partnered with is Auburn Universityâ&#x20AC;&#x2122;s Rural Studio, an off-campus program that teaches teams of architecture students to design and build projects in West Alabama. Rural Studio educates its students to be citizen architects who interact with their communities in a direct and personal way. The students serve a practical purpose in the community and are committed to the place and its people. Rural Studio has built over 200 projects in West Alabama since it started in 1993.

In 2006, Rural Studio renovated the hospitalâ&#x20AC;&#x2122;s courtyard creating a peaceful space for staff and visitors to relax away from the high-stress hospital enviornment.

More recently, the hospital thought of plans to incorporate housing onto their property. First, these units would replace existing doctor-sleep rooms and free up valuable inpatient rooms. Secondly, they could be converted to house patients who do not require full admittance, but need a degree of assisted living.

Additionally, the studio saw an important first step of re-imagining the hospital courtyard to maximize the usage of the space.

Growing the partnership between Hale County Hospital and Rural Studio will allow the hospital to expand to housing, improve their courtyard, and design resourceful solutions.

62

//

Book 1 : Rural Health + Design

Residential:

20K Bobby’s Home

20K Sylvia’s Home

2014 - Hale County, AL

2014 - Perry County, AL

Hale County Animal Shelter

Lions Park Shade

2006 - Greensboro, AL

2015 - Greensboro, AL

Boys and Girls Club

Perry Lakes Pavilion

2012 - Greensboro, AL

2002 - Marion, AL

Community:

Chapter 2: Hale County Hospital

//

63

64

three

BOOK 1 . CHAPTER 3

enhancing hale county hospital through design

65

N

66

N

//

Book 1 : Rural Health + Design

N

N

N

N

N

N

CHAPTER

Introduction To The Project

03 SECTION

Hale County Hospital Courtyard 2 is a student design-build project aimed at

01

improving rural health through community-oriented design. Good design can improve peoplesâ&#x20AC;&#x2122; daily lives and enhance a flourishing rural hospital. The original project brief was a re-making and re-envisioning of the existing Hale County Hospital Courtyard. The hospital had a vision to support their growing program by expanding physical therapy into the courtyard.

Through a deeper understanding of the Hale County communityâ&#x20AC;&#x2122;s needs, the project evolved into a relaxing space for staff and visitors to get away from the high-stress environment of the hospital. The courtyard encourages people to take a break, get some fresh air, and go outside. Hale County Hospital Courtyard 2 is not the answer to fix rural hospitals, but an example of how designing with intent, beauty, purpose, and inclusivity can have a broader social impact.

BELOW:

view of the secondary lobby of Hale County Hopsital

Design Concepts and Intentions Hale County Hospital Courtyard 2 was designed with a set of concepts and intentions that drove the decisions and pushed the design process forward. Overall design concepts included: i. Unifying the space. All elements and structures of the courtyard were designed as one cohesive space. ii. Discovery. The design creates contrast between the interior and exterior iii. Accessibility. The courtyard should be accessible to all mobility levels.

The design of the courtyard follows the same successful formula as Hale County Hospital: i. Resiliency and adaptability. The project is part of the hospitalâ&#x20AC;&#x2122;s effort to be resilient by expanding their growing physical therapy program. The focus on maintenance and programmatic flexibility makes the courtyard adaptable. ii. Community engagement. The courtyard promotes community engagement by providing a large space where people can gather outside together.

BELOW: the courtyard of Hale County Hospital in 2020

Communication and Relationship

CHAPTER

03 SECTION

The relationship between Hale County Hospital and Auburn University Rural

02

Studio is not like a typical architect-client relationship. The “client” of Hale County Hospital is referred to as the “community partners” because both parties work together towards a shared project goal. This partnership drives the project that not only gives students a hands-on educational experience, but also allows them to serve the community.

How can this courtyard best benefit the future of Hale County Hospital?

The Hale County Hospital community partners involved in the courtyard project included: Shay Fondren, Chief Executive Officer.

Shay is a visionary leader for the hospital. She has worked at the hospital for over twenty years so she understands how to push it to adapt and remain resilient.

Tammy Weeden, Chief Nursing Officer.

Tammy gives insight to what it is like to work at Hale County Hospital and how the courtyard could best benefit the staff.

LaCretia Edwards, Head Physical Therapist.

LeCretia’s understands how the hospital performs for therapy patients and how physical therapy can expand into the courtyard. She is attentive both to the details of physical therapy and the unspoken needs of her patients.

Billy Brannon, Head of Maintenance and Life Safety.

Billy wears many hats. He runs the different maintenance systems in the hospital and courtyard. He is knowledgeable about the systems put in place during the first Rural Studio courtyard.

The Rural Studio students on the Hale County Hospital Courtyard 2 team were self-selected in October of 2019. The student team included Nicole Brown, Jake Schirmer, Ingrid Stahl, and Kyra Stark, and was advised by Rural Studio Director, Andrew Freear.

72

//

Book 1 : Rural Health + Design

ABOVE + BELOW: community partner conversations

Chapter 3: Enhancing Hale County Hospital Through Design

//

73

BELOW: existing conditions of the courtyard

Chapter 3: Enhancing Hale County Hospital Through Design

//

75

BELOW: proposed design of the courtyard

reâ&#x20AC;&#x201C;imagining existing conditions

Courtyard Overview: Hale County Hospital Courtyard 2 is designed for a variety of user groups and activities, so everyone has a place to get away and relax by themselves or enjoy the company of others in group settings.

The Lawn The lawn is the most open social space and is intended for large gatherings, games, or other activities. It unifies the space by tying together all other spaces of the courtyard.

Staff Break Room The staff break room is located along the back entrance of the courtyard where many of the nurses park and enter the hospital everyday. It is also located near the primary outdoor route that staff have been using for years. The ground plane is hardscape pavers so staff members can bring out tables and chairs to take a break, eat lunch, or visit with friends under a shaded grove of trees.

Physical Therapy Porch The porch offers shade and protection for all users. It is designed especially for physical therapy patients. The patients can either easily walk on the paved ground plane or practice walking on nearby gravel or grass surfaces. Patients can do their physical therapy exercises against the porchâ&#x20AC;&#x2122;s fin-like columns while resting on the bench.

Relaxation Garden The shaded gravel space surrounding the fish pond is multifunctional. It hosts small gatherings, therapy activities, or staff break space.

Private Nooks The nooks in the low planter wall are for individuals or small groups who want some privacy. People can watch the activity happening in the courtyard without having to partake.

78

//

Book 1 : Rural Health + Design

BELOW: different courtyard spacial zones

N

Chapter 3: Enhancing Hale County Hospital Through Design

//

N

79

N

Initial Courtyard: left-over space from hospital additions no visual boundary to courtyard

2004 The initial courtyard shape was the result of additions to the hospital. The shape has no boundary to the north, resulting in a courtyard that is only partially enclosed.

80

//

Book 1 : Rural Health + Design

N

N

Initial Rural Studio Courtyard design

Maintenance

filled in the hospital’s “doughnut” shape

shed built

2006

N

2010

Rural Studio used a dense planting strategy with bamboo, to complete the doughnut-shape circulation of the hospital. These plantings created a visual barrier to the north and allowed the southern portion to be active space.

Chapter 3: Enhancing Hale County Hospital Through Design

//

81

N

Bamboo is

Current courtyard condition

removed

Maintenance shed is new visual edge

2015

2020

The edition of the maintenance shed in 2010 created a new visual boundary for the courtyard. The visual extents of the space now extend to the shed, rather than stopping at the hospital walls .

82

//

Book 1 : Rural Health + Design

N

N

N

Hale County Hospital Courtyard 2 unifies the space with a lawn

future Even though the maintenance shed visually encloses the courtyard, the design of the space itself does not extend to the courtyard. The new design seeks to tie together the full extents of the space with one unifying element: a lawn.

Chapter 3: Enhancing Hale County Hospital Through Design

//

83

Courtyard Design Concepts in 2020

CHAPTER

03 SECTION

Unify the Space:

03

In order to unify the courtyard into one cohesive space, we created a set of guidelines to make it possible. i. Extend the boundary of the courtyard to the maintenance shed. ii. Make the courtyard feel like another world that exists outside of the hospital environment. iii. Connect all entrances to make the entire courtyard accessible. iv. Intersect the staff and patient zones. v. Limit the number of ground plane materials. vi. Use of one type of tree throughout the entire courtyard.

BELOW: key for diagrams N

84

//

Book 1 : Rural Health + Design

N

N

i.

ii.

iii.

iv.

v.

vi.

Chapter 3: Enhancing Hale County Hospital Through Design

//

N

85

RIGHT: physical model showing different elements in courtyard

Accessibility: Gravel to provide entry transition Unifying space: Lawn

Unifying space: Deciduous trees to provide shade in summer and sun in winter

Accessibility: Concrete pavers for ADA compliant circulation

Discovery + unifying: Vine screens to disguise hospital walls

Accessibility: Porch to provide shelter and shade

Discovery: Pond to create soothing noise

Unifying: Brick screen to block mechanical noise

86

//

Book 1 : Rural Health + Design

N

Chapter 3: Enhancing Hale County Hospital Through Design

//

N

87

Discovery: The courtyard is hidden both within the community and the hospital; it is a place to be discovered. The small windows in the doors are the only glimpses visitors get before entering the relaxing courtyard environment (Fig 3.01, p.90).

BELOW: interior circulation experience

The project was conceptualized as a secret but that when discovered could be seen as a billboard for the hospital. The courtyard has the potential to amplify Hale County Hospitalâ&#x20AC;&#x2122;s presence in the community and become a strong asset that attracts visitors, new medical staff, and patients. Hale County Hospital Courtyard 2 is designed to welcome all members of the community it serves.

BELOW: exterior circulation experience

Chapter 3: Enhancing Hale County Hospital Through Design

//

89

1

4

Entrance from the west

Exit from the patient care lobby

2

Vending room near lobby

3

Doctor sleep room

5

Patient room

6

Exit between wings

ABOVE: restricted views into courtyard OPPOSITE: double loaded corridor causing restricted access to courtyard

90

//

Book 1 : Rural Health + Design

Figure 3.01 Views from the interior of the hospital

N

1

6

5

4

3

2

N

Accessibility: It was essential that Hale County Hospital Courtyard 2 be accessible for all people to enjoy, while also creating elements of surprise. The courtyard connects the many entrances that lead to it (Fig 3.02), creating different walking routes and shortcuts. Because of the courtyardâ&#x20AC;&#x2122;s L-shape, there are many spaces that are not visually accessible (Fig 3.03). This encourages people to walk around and explore the different areas of the courtyard. People have the opportunity to discover new things every time they turn a corner.

The courtyard is fully physically accessible without being fully visually accessible.

BELOW: fully accessible surfaces from every entrance and exit

N

N

N

N

Figure 3.o2 Entrances to the courtyard

92

//

Book 1 : Rural Health + Design

ABOVE: physically accessible but not visually accessible BELOW: existing corners in courtyard create surprises

N

N

N

N

Figure 3.o3 Entrances to the courtyard

Chapter 3: Enhancing Hale County Hospital Through Design

//

93

BELOW + OPPOSITE: perspectives showing hidden views around corners

94

//

Book 1 : Rural Health + Design

Chapter 3: Enhancing Hale County Hospital Through Design

//

95

Courtyard Design Intentions

CHAPTER

03 SECTION

Resiliency:

04

The courtyard can be used for physical therapy specific activities but that is not the exclusive purpose. For the courtyard to be resilient, all aspects of design need to be multi-functional. For example, the long covered porch that runs east-west has separate bays that allow patients to do their therapy session in semi-privacy (Fig 3.05, p.98). The fin-like columns can be used for wall exercises during a therapy session, but they also create a threshold into the open shaded gravel zone.

BELOW: relationship from interior physical therapy

96

//

Book 1 : Rural Health + Design

room to exterior physical therapy porch

Figure 3.04 Expansion of Physical Therapy space

N

950 SF ABOVE: increase in total PT square footage

N

850 SF

exterior physical therapy space

interior physical therapy space

1800 SF combined

Chapter 3: Enhancing Hale County Hospital Through Design

//

97

98

//

Book 1 : Rural Health + Design

Figure 3.05 Physical Therapy activities

Chapter 3: Enhancing Hale County Hospital Through Design

//

99

100

//

Book 1 : Rural Health + Design

ABOVE: perspective of the physical therapy porch

Chapter 3: Enhancing Hale County Hospital Through Design

//

101

The variety of ground surfaces not only provide physical therapy patients different surfaces to walk on (Fig 3.06), but also creates zones in the courtyard for people to do different activities. The handrails are not only a requirement to have alongside steps; they also assist therapy patients who need to practice walking.

ABOVE: section of different porch bays BELOW: section of ramp for physical therapy exercises

102

//

Book 1 : Rural Health + Design

Figure 3.06 Routes + Surfaces short fully ADA route short multi-surface route long fully ADA route short multi-surface route N

Chapter 3: Enhancing Hale County Hospital Through Design

//

103

N

Adaptability: The intention of adaptability in Hale County Hospital Courtyard 2 is exemplified through the focuses on maintenance and programmatic flexibility. Billy Brannon, Head of Maintenance and Life Safety, typically has three workers who assist him with the maintenance around the hospital.

Billy and his team excel in keeping the lawn and shrubs well trimmed. In order for the plantings in Hale County Hospital courtyard to survive, they need to be easily maintained and not depend on one person’s skills or knowledge of upkeep.

When selecting trees for the courtyard, it was necessary to think about an appropriate scale that provided ample shade but was not too large. A strong understanding of Hale County Hospital’s maintenance capacity will result in a strategic maintenance plan that ensures the continued growth of any new plantings. As Hale County Hospital continues to adapt, so can the courtyard.

Figure 3.07

15’

Growth and Maintenance of Trees

8’

0–5 years

104

//

Book 1 : Rural Health + Design

trim every year to shape growth

20 years

ABOVE: gaggle of trees create dynamic space BELOW: grid of trees create static space

Chapter 3: Enhancing Hale County Hospital Through Design

//

105

Community Engagement: When studying how Hale County Hospital Courtyard 2 can engage the community, it became clear that the project has a variety of needs specific to its different user groups: i. Staff. The staff need spaces to relax away from their high stress work environment and patients. ii. Patients. The patients need spaces to do physical therapy in individual and group settings. iii. Visitors. Visitors desire a space to visit comfortably with their loved ones. visitors

visitors

In response to these many programmatic needs, the courtyard design has a variety of spaces to gather as a group or have individual respite.

BELOW: perspective looking south

staff

nurse

open spaces for community events

Chapter 3: Enhancing Hale County Hospital Through Design

//

107

The courtyard design is resilient, adaptable, and promotes Hale County Hospitalâ&#x20AC;&#x2122;s community engagement efforts. The project brings together the hospital and itâ&#x20AC;&#x2122;s neighbors. Hale County Hospital Courtyard 2 is an amenity for the hospital as they continue to offer impactful services and expand their community outreach.

108

//

Book 1 : Rural Health + Design

Good design is like good healthcare: everyone deserves it.

BELOW: perspective looking east

Chapter 3: Enhancing Hale County Hospital Through Design

//

109

how to

114

know what you donâ&#x20AC;&#x2122;t know gathering information and conducting initial research how to

148

think like a landscape architect understanding and designing for the cyclical and linear nature of plants how to

156

evaluate design decisions creating our process, collecting feedback, and advancing the design how to

190

communicate ideas presenting to visiting critics and our community partners

appendix

110

200

how to manual

BOOK 2

a guide to design hale county hospital courtyard 2

111

112

foreword The decision-making process of architecture is chaotic and messy. This book explores the people, community, and work that made this collaboration possible.

It documents our understanding of context, working as a team, and posing as landscape architects.

113

114

how to

BOOK 2 . CHAPTER 1

know what you donâ&#x20AC;&#x2122;t know?

115

About the Hospital

CHAPTER

01 SECTION

Hale County Hospital is located about a mile southeast from Downtown Greensboro

02

(Fig 2.04, p.44). Trying to find the hospital proves to be difficult if you are not familiar with the town. When driving down State Street, there is only one road sign that signifies there is a hospital nearby. Hale County Hospital is located in a primarily residential neighborhood and does not have clear signage on its premises to indicate to visitors where to enter.

The approach to the hospital from State Street brings visitors to the back of the hospital. Once you find the front of the hospital, the large parking lot frames several entry doors underneath a large colonial portico. The main entry has a staffed waiting room where patients can check in. The side entry is primarily used for Physical Therapists and physical therapy patients because it is closer to the therapy check-in desk.

The interior of the hospital is sterile, bright, and a constant seventy-two degrees fahrenheit. The waiting rooms have several seats for visitors or patients. The hallways of the hospital are double loaded corridors, which allows all of the administrative rooms and patients rooms to have a view outside.

We found most blinds to be shut during the day no matter the weather outside.

Keeping the blinds shut offers privacy but blocks views outside and good natural light. Weâ&#x20AC;&#x2122;re unsure about why exactly this is, but our best guesses would be: i. Privacy. The hospital is only one story, so anyone walking by would be able to see in if the blinds were open. ii. Energy efficiency. Windows in direct sunlight make small rooms warmer. iii. Distractions. Some employees find the outside activity distracting from their work. iv. Overwelming artificial lighting. The hospital is already very bright from the fluorescent lights, so some employees preferred to not add daylight.

118

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

ABOVE + BELOW: images of the staff of Hale County Hospital

Chapter 1: How To Know What You Donâ&#x20AC;&#x2122;t Know?

//

119

CHAPTER

About the Site

01 SECTION

An important first step of understanding Hale County Hospital Courtyard 2 was

01

gathering information about the site. In 2006, Rural Studio designed a courtyard for the hospital. Unfortunately, due to many maintenance factors and unforeseen circumstances, many parts of the courtyard were in disrepair. The hospital also had a new vision of using the courtyard for program-specific activities.

The 2006 design sought to complete the circulation loop of the hospital; therefore, the southern portion of the courtyard is utilized for activies. The courtyard was then divided into “rooms” with different qualities. However, the success of the overall design was contingent on the spaces staying well-maintained. When the plantings died and the “rooms” failed, so did the overall design.

BELOW: the courtyard around 2015 (Image by Timothy Hursley)

N

ABOVE: diagram of the previous courtyard design BELOW: the bamboo forest of the courtyard around 2015 (Image by Timothy Hursley)

N

Plantings Many of the planting strategies of the 2006 design became maintenance burdens on the hospital and some of the plants did not survive: i. Vines. The vines in the marble planters were too difficult to trim because they were lifted four feet off the ground and became overgrown. This overgrowth created a visual wall that blocked the space under the trellis from the rest of the courtyard. ii. Tall grasses. The tall grasses near the fishpond, created sheltered spaces to sit around the fishpond, but were mowed down because they attracted snakes. iii. Tree. The lone tree that provided shade became infected and died, and was cut down to its trunk. iv. Bamboo. The bamboo in the planters was the biggest maintenance burden of all. Because the bamboo was so dense, it became infested with black birds.

The bird droppings caused a severe hygiene issue for the hospital, and all of the bamboo had to be cut down.

BELOW: the courtyard in 2020

1

Another issue of the existing courtyard is the lack of accessibility. Many of the paths in the courtyard are made of pea gravel, which is not ADA accessible. The paths that are paved with hardscape are aggregate concrete. This concrete is too rough and uneven for people with walkers to walk on. Most of the courtyard is underutilized because it is difficult for patients with limited mobility to move around.

1

2

ABOVE: the pea gravel (left) and aggregate concrete (right).

BELOW: the bamboo forest in 2020

2

Climate Data Currently, the lack of shade in the courtyard makes it very uncomfortable to be in during the summer months. In order to study thermal comfort in the courtyard, we set up two Accurite weather stations. One station is in the courtyard and one station is behind the hospital in order to compare the microclimate in the courtyard to the general climate of Greensboro.

We planned to use this data to gain a better understanding of the local climate and specific thermal comfort conditions in the courtyard. However, our goals shifted from centering heavily on thermal comfort and instead proved most useful for correlating rainfall totals with drainage issues.

Drainage Another maintenance problem the hospital currently faces is flooding. When the hospital experiences very heavy rains, the courtyard fills up and water floods into the hospital under the doors. We surveyed the site to understand the overall topography and found that the hospital was at a high point, so the water naturally flows out of the courtyard to the tree line. After speaking with our civil engineer consultant, we compiled a list of the potential flooding causes (Fig A.01, p.126): i. Blocked french drain. The pipe at the end of the french drain does not daylight.

We dug up the end of the pipe and found pea gravel, which is too small to let water drain through; number fifty-seven rock is the proper size. However the hospital has not flooded since we exposed the pipe, so the improper end of the pipe may be the problem. ii. Damaged pipe. When the maintenance shed was built, it may have accidentally crushed some of the pipe and caused a blockage. iii. Drain inlets. The drain inlets in the courtyard are too high off the ground and are not located near all of the gutters. iv. Cork in the bottle. The concrete ground surfaces and bamboo planters block any natural flow of water out of the courtyard.

OPPOSITE-TOP: Tyler excavating the end of the french drain OPPOSITE-BOTTOM: the team removing the end of the drainage system

124

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Figure A.01: Drainage

126

//

1

2

3

4

5

6

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

N

1

2

3 5

4

6

N

Designing for a Community

CHAPTER

01 SECTION

When designing for a community, identifying all of the members that the project

03

will impact is key. Although we worked with four community members at Hale County Hospital to make decisions, the number of people we talked to and thought about while designing was much larger (Fig A.02). The user groups we identified at the hospital were patients, visitors, and staff.

Patients When understanding patients’ needs, it’s important to point out that inpatients and outpatients have very different experiences at Hale County Hospital. Inpatients stay at the hospital for up to thirty days and spend most of their time in bed.

Patients who stay at the hospital for inpatient therapy have sessions during the day and typically have low mobility. Inpatients need a relaxing courtyard that they can easily access with a walker, cane, or wheelchair.

Although outpatients typically have more mobility than inpatients, they also need an accessible courtyard. Most of Hale County Hospital’s outpatients come for physical therapy.

Visitors Visitors include family and friends of patients, family and friends of staff, or community members who want to attend events put on by Hale County Hospital.

Some visitors will want a quiet space where they can talk to their loved ones, while others might want to partake in outdoor activities or let their kids run around.

The array of user groups makes Hale County Hospital Courtyard 2 complex, but enables the project to flexibly accomodate various needs. Listening to all voices during the design process is essential for ensuring the project includes all members of the community.

128

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

professors Mason admin Eric

visiting architects

Rural Studio staff

hospital visitors

Emily K. David

consultants

Hale County

Emily M. Adele

Tyler

community

Micheal Janis

Dr. Dorsey

horseshoe farms

Hale County Hospital Courtyard 2 inpatient

outpatient

patients

Lacretia

community partners Shay

Billy

physical therapy

admin

Tammy

lab

nurses

doctors

staff maintenance

security

Figure A.02 Community relationships

Chapter 1: How To Know What You Donâ&#x20AC;&#x2122;t Know?

//

129

Staff The hospital staff comprises: doctors, nurses, administration, Physical Therapists, Occupational Therapists, lab technicians, security, and maintenance.

Currently, the staffâ&#x20AC;&#x2122;s interactions with the courtyard ranges from not knowing it exists to interacting with it on a daily basis. In order to create a place that serves the staff, we observed how they interact with the hospital and the courtyard. We followed the head Physical Therapist, LaCretia Edwards, around for a day (Fig A.03).

Figure A.03 Day-in-the-Life of LaCretia

8 AM

9 AM

She arrives at work.

10 AM

She does paperwork at her desk.

11 AM

She typically sees four patients in the morning.

130

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

12 PM

LaCretia Edwards Head Physical Therapist.

LaCretia does not have a place to take a break or eat lunch. She often resorts to walking around the exterior of the hospital or eating lunch at the nearby nursing homeâ&#x20AC;&#x2122;s picnic tables to get some fresh air and a change of scenery.

1 PM

2 PM

She sometimes eats lunch in her car.

3 PM

4 PM

She typically sees four more patients in

5 PM

She leaves all happy as can be.

the afternoon.

Chapter 1: How To Know What You Donâ&#x20AC;&#x2122;t Know?

//

131

Hello!

Please return to the Physical Therapy desk by end of day Tuesday (Dec. 17), thank you!

This survey was created by the Rural Studio students working on the redesign for the Hale

from the

County Hospital Courtyard. We would like to learn more about how you (the staff) use the

Hale County Hospital Courtyard Team

courtyard now and how you would like to use it in the future. The front page focuses on how the courtyard is used now, while the back side provokes some imagination about how

(Nicole + Jake + Ingrid + Kyra)

you think the courtyard could be used in the future.

What is your job title?

1

Part-Time

Full-Time

2

When do you usually work? (Check all that apply) Weekdays

During the day

Weekends

Overnight

We intend to design a space that can be used by staff,

Design Ideas:

How do you use the courtyard TODAY? patients, and visitors for a wide variety of activities. Below

A covered space that provides protection from the rain.

are some questions that could help us better understand Add new surfaces that make the courtyard more accessible 8 Do you walk through the courtyard to get to work?

What is your favorite part of the courtyard? the people for whom we’re designing. To the right are some for wheelchairs, hospital beds, walkers, etc.

3

Yes, everyday.

Sometimes, 2-3 times a week

Under the metal awning that connects the inpatient Planting trees to provide some shade and vegetation. and ER wing

design goals that we’re intending to provide.

Under covered in vines How could you use the courtyard inthe thetrellis FUTURE?

No, almost never.

The open grassy space by the stage

11 As a staff member, do you think the staff needs a How often do you go into the courtyard?

The fish pond separate space from patients in the courtyard?

4

Very often, everyday.

16

Sometimes, 2-3 times a week Rarely, almost never.

I’m not sure.

9

If the walls of the courtyard could be any color, which color would you prefer?

I don’t go into the courtyard.

Yes, I would love some privacy.

Other: No, I don’t mind some interaction.

Yellow

Red

Purple

Blue

White

Gray

Green

Black

Beige/Tan

What is your least favorite part of the courtyard?

Other:

How much time do you typically spend in the Under the metal awning that connects the inpatient 12 Which would you prefer to walk through on your courtyard during a visit, as it is now? and ER wing 17 Which environment would you prefer in the courtyard? way to work? (Check all that apply)

5

I don’t go into the courtyard.

Grove of trees

5 minutes

30 minutes

10 minutes

45 minutes

15 minutes

60 minutes or more

Colorful flowers Hedges or bushes Other:

Under the trellis covered in vines Grassy lawn The open grassy space by the stage Series of vines The fish pond Vegetable garden I don’t go into the courtyard.

Comforting silence; it’s my only chance for peace and quiet.

Soothing background noise (like the fish pond) The sound of action (people conversing, moving around).

All of the above, I would enjoy a mix of all of these!

Other:

Other:

Are you ever in the courtyard when it is dark outside?

13 If you were to eat lunch in the courtyard, which 10 What do you do in the courtyard as it is now? (Check Very often, everyday.

18 If you could change one thing about the courtyard as would you prefer? all that apply) Sometimes, 2-3 times a week it is now, which would you do first?

Lots of activity; I like to people-watch but have my own

6

Rarely, almost never.

private space.

Get some fresh air

Go for a walk Peace and quiet; it’s my time to get away.

Do you ever go outside into the courtyard when it Take a smoke break I usually eat with friends, so I would like a place big is raining?

Take patients outside enough for a few of us.

Very often, I stick to my routine.

Make a phone call

7

Sometimes, if I have to.

Rarely, I’d rather stay dry!

14

Eat lunch or a snack

Which would you prefer to experience from inside Other:

Exercise classes Add some shade.

Gatherings or celebrations Add some comfortable seating.

Gardening Add a covered roof to protect me from the rain.

Socialize with family/friends Create new walking surfaces that are smoother.

Find some peace & quiet Plant some new vegetation (trees, flowers, etc.).

Go swimming in the fish pond Other:

the hospital, looking out in to the courtyard?

I always keep the blinds open and would love to see what’s happening/who’s in there.

15

19

What would you like to do in the courtyard? (Check

Flip the page over for a few more questions about how you

all that apply)

imagine the courtyard could be used in the future.

I would probably have the blinds closed unless it’s a nice day.

Get some fresh air

Exercise classes

The blinds are always closed; I like my privacy.

Go for a walk

Gatherings or celebrations

Take a smoke break

Gardening

Take patients outside

Socialize with family/friends

Every single day; the weather has no effect on me.

Make a phone call

Find some peace & quiet

When it’s warm/cool enough, especially if it had heaters/fans.

Eat lunch or a snack

Go swimming in the fish pond

I don’t expect to use the courtyard.

Other:

When would you most likely use the courtyard?

Thank you for your time completing this survey! If you have any other comments, questions, or concerns, we would love to hear them. Send us an email!

Nicole Brown ndb0012@auburn.edu

ABOVE: staff survey to learn more about the hospital’s population

We wanted to check our conclusions with the rest of the staff’s experience so we sent out a survey inquiring how the staff currently uses the courtyard and how they could envision using the courtyard (Fig A.04). We learned the most beneficial spaces for the staff would be ones where they could get respite from their day to day routine while having comfortable seating and ample shade.

132

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

HALE COUNTY HOSPITAL

130

Figure A.04: Staff Survey results

employees

RESPONDED TO STAFF SURVEY

32

employees

Chapter 1: How To Know What You Donâ&#x20AC;&#x2122;t Know?

//

133

CURRENT USES

FUTURE USES

How do you use the courtyard now, and 5

10

15

20

how would you like to use it in the future?

get some fresh air

go for a walk

take a smoke break

take patients outside

make a phone call

eat lunch or a snack

exercise classes gatherings or celebrations gardening

socialize with family or friends

find some peace and quiet

134

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

LEAST FAVORITE

FAVORITE

Which elements of the courtyard are your 20

15

10

5

favorite? Least favorite?

fish pond

the lawn

trellis with vines

awning between wings

15

10

5

If you could change one thing, which would you change first?

add some shade

add some comfortable seating

add a roof to protect from the rain

create new, smoother surfaces

plant new vegetation

Chapter 1: How To Know What You Donâ&#x20AC;&#x2122;t Know?

//

135

About Physical Therapy

CHAPTER

01 SECTION

Since a crucial part of Hale County Hospitalâ&#x20AC;&#x2122;s therapy expansion plan was to

04

implement therapy in the courtyard, we needed to study how the hospital practiced therapy. The hospital offers three types of therapy: i. Physical therapy. A form of therapy that treats conditions such as chronic or acute pain, physical impairments, or injury. It mainly focuses on recovering muscle strength and alleviating pain. ii. Occupational therapy. Therapy that encourages rehabilitation through performance of activities required in daily life. iii. Speech + Cognitive. A form of therapy that trains people with speech or language problems to speak more clearly and regain cognitive function.

BELOW: some of the tools used for Physical Therapy at Hale County Hospital.

136

//

Steps + Stairs

Variety of Hand Tools

Resistance Bands

Cones

Washer + Dryer

Free Weights

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Because Hale County Hospital approaches therapy in a more hands-on way and try to not exclusively utilize high tech equipment, we created a catalog of the hospital’s therapy tools. The catalog helped us identify frequently used tools that could be brought and stored outside.

To learn what a typical therapy session looks like, we shadowed multiple Physical and Occupational Therapy sessions. Some conclusions from shadowing these sessions were: i. Equipment. Therapy utilizes the same highly-mobile tools such as balls or rubber bands or common objects like chairs and cones for multiple exercises.

The only machines they currently use are two bikes; however a treadmill could be beneficial. ii. Sessions. Typical sessions last about an hour. Due to Medicare policy, occupational and physical therapy patients must be separated indoors but may share an outdoor space. iii. Patient attributes. Therapy involves patients with a wide range of motion ranging from walking with a slight limp to struggling to walk fifteen feet with a walker. iv. Patient experience. Most patients would enjoy the encouragement of group therapy. Making the physical therapy environment more visually interesting elevates the exercises from a level of monotony and provides distraction from discomfort. Patients also need places to sit and rest to recover after exercises.

In order to understand how the rest of the world practiced therapy, we interviewed Janis McCullough, a Professor of Physical Therapy at University of Washington (p.141). She explained that many therapy centers build an outdoor environment on the interior because simulating a “real” exterior environment helps patients better return to their daily life. Most of these centers do not have the space or resources to invest in creating a place for therapy outside.

Chapter 1: How To Know What You Don’t Know?

//

137

Figure A.05 Typical Physical Therapy Session

1 min Ball toss exercises

5 min Seated shoulder pulley

10 min Warm up on Exercise Bike

0 minutes

138

//

5

10

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

15

20

4 min Horizontal lifts

3 min Stretches

6 min Ball rolling exercises

20

25

30

35

Chapter 1: How To Know What You Donâ&#x20AC;&#x2122;t Know?

40

//

139

Getting Outside Help

CHAPTER

01 SECTION

Consultants are key to getting some expertise on technical parts of the project. They

05

help give you a check point against your assumptions. After speaking with many consultants who helped us along the way, we gathered some key takeaways. i. Janis McCullough, Physical Therapy - p. 141 ii. David Hill + Emily Knox, Landscape Architecture - p. 142 i. Emily McGlohn, Climate Analysis - p. 143 i. Michael Gibson, Climate Analysis - p. 144 i. Adele Schirmer, Civil Engineering - p. 145 i. Tyler Hochstettlet, Excavation - p. 146

140

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Janis McCullough University of Washington

Area of Expertise:

Physical Therapy

Janis McCullough is a physical therapist and a teaching associate in the Department of Rehabilitation Medicine at the University of Washington. She has 15 years of clinical experience in outpatient orthopedic settings. We met with Janis during the beginning of our physical therapy research to learn how therapy is typically practiced around the country, what equipment is commonly used, and how having therapy outdoors can benefit patients.

Ingrid: “Doing therapy in an exterior environment is critical to assisting patients on getting back to their normal lifestyles.”

Kyra: “Therapy is conducted similarly across the entire United States, some places may choose to use high-tech equipment, but it’s not a necessary thing to provide quality therapy services.”

Nicole: “I was utterly sick with a kidney infection so sadly I cannot say I have a takeaway but the team learned lots! “ Jake: “The opportunity and commitment of the hospital to devote exterior space to physical therapy is very rare, and is very smart by Hale County Hospital. Exterior space is almost always preferred to interior space for physical therapy”

Chapter 1: How To Know What You Don’t Know?

//

141

David Hill + Emily Knox Auburn University

Area of Expertise:

Landscape Architecture

David Hill and Emily Knox are both Landscape Architecture Professors at Auburn University. Along with leading a Rural Studio fifth-year workshop in September, they made a special visit to lead our team in courtyard design charrettes in January.

They taught us how to use the tools we have as architects to think spatially and apply that to the landscape. The workshop also helped us come up with overall design schemes and move our process forward.

Ingrid: “Plants have a huge impact on creating an environment in a space.”

Kyra: “Learning how to talk about landscape architecture in a more spatial way influenced the way we designed the courtyard.”

Nicole: “Having a clear design language in which to communicate a larger idea is key; layer trace! Layers of landscape architecture help define the complexities that are different from the way drywall and interior conditions are drawn on the same layer.”

Jake: “Landscapes offer a completely different tool set for affecting space. In the same way, they can’t be explained with traditional architectural diagrams. For example, a central path doesn’t have to be just circulation, it can do more.”

142

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Emily McGlohn

Area of Expertise:

Climate Analysis

Auburn University Rural Studio

Emily McGlohn is the current third-year studio professor at Rural Studio. She is a Rural Studio alum and spent two years working on the Alabama Heritage Center and three years working as Clerk of Works. Her professional experience after Rural Studio and Master of Architecture from University of Oregon enabled her to specialize in building performance and climate analysis. Emily helped us identify what factors we wanted to analyze while collecting thermal comfort data and how to make that data presentable to others.

Ingrid: “Pick your battles. Thermal comfort could be an entire dissertation” Kyra: “When presenting data to people, find frame of reference they can relate to.”

Nicole: “Narrow our scope, aim for three factors; we can’t solve everything: radiant temperature, mixed humid climate, thermal comfort.”

Jake: “Passive comfort is a thesis within itself, and hundreds of people have been trying to answer that question. Focus on what you can control, and do it very well.

Most other factors will result from just altering shade, and airspeed.”

Chapter 1: How To Know What You Don’t Know?

//

143

Michael Gibson Kansas State University

Area of Expertise:

Climate Analysis

Michael Gibson is an Assistant Professor of Architecture at Kansas State University. He teaches design studios, digital design and fabrication, construction technology, and environmental systems. One aspect of Michael’s research is environmental performance, so he was extremely helpful in teaching us about climate analysis. He taught us to use data to identify what we could control and where our focus should go.

Ingrid: “I don’t remember this conversation at all. Something about micro-climate.”

Kyra: “Use data to learn what you can control and where your focus should go.”

Nicole: “Define a scope on how we want data to help us; use research to support argument and justify claims of design that the courtyard is unbearable during summer season.“ Jake: “There are many ways to explain climate data, and the least effective is what architects traditionally model it as: the psychrometric chart. Explore different ways to layer data on a chart that is easy to digest.”

144

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Adele Schirmer

Area of Expertise:

Civil Engineering

City of Social Circle

Adele Schirmer is the City Manager of Social Circle, Georgia. She has a degree in Civil Engineering and worked as a stormwater management specialist for thirty years.

Adele worked with us on site to identify potential causes of the courtyard flooding.

She also helped us identify next steps of how to find the drain blockage and taught us how to build a proper french drain.

Ingrid: “Civil engineering 101: always direct water away from the building.”

Kyra: “When making a french drain, use large number fifty-seven gravel at the end, not tiny pea gravel left over from the courtyard.”

Nicole: “Underground drainage systems must have day-lighted junction connections in case there is a clog to access. The previous courtyard design did not have junction access points.”

Jake: “She’s the most wonderful consultant the studio has ever had and has the most wonderful son in the world. Also she knows her stuff.”

Chapter 1: How To Know What You Don’t Know?

//

145

Tyler Hochstettlet

Area of Expertise:

C & T Excavating

Excavation

Tyler Hochstettlet is an Excavating Contractor who works on projects throughout West Alabama. He is an expert in septic tank installation and repair as well as excavation. Tyler came on site to excavate the end of the courtyard drainage pipe so we could identify what was clogging it. He also explained the practicalities of excavating the soil in the courtyard planters.

Ingrid: “Know when to put down the shovel and let the big guns take over.”

Kyra: “ Even the pros have to do a bit of guesswork when digging on site.”

Nicole: “What took us hours took tyler thirty minutes, having working machinery is worth it.“ Jake: “Why dig for hours only to go down 18 inches, when Tyler can come in and dig eight feet in thirty minutes.”

146

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 1: How To Know What You Donâ&#x20AC;&#x2122;t Know?

//

147

148

how to

BOOK 2 . CHAPTER 2

think like a landscape architect

149

Basics of Landscape Architecture

CHAPTER

02 SECTION

When pretending to be a landscape architect, know the lingo! Here are some words

01

that will give David Hill a heart attack: Dirt: use soil Bush: use shrub Landscaping: just donâ&#x20AC;&#x2122;t say that. Ever Designing space as a landscape architect is all about using layers to shape space.

Because of Hale County Hospital Courtyardâ&#x20AC;&#x2122;s smaller scale, the layers we worked with were the understory, the shrub layer, and the ground plane.

Understory The understory shapes space up to about twenty-five feet. It uses trees to create overhead planes in spaces. There are several different ways to organize trees. i. Lone wolf. The lone wolf is a stand-alone tree usually in fields and spaces much larger than the hospital courtyard. ii. Gaggle. The gaggle is when trees are interspersed in a space. Gaggles can create compression and release by intentionally clumping and gapping trees. iii. (in)Grid. A grid arranges trees in grid patterns. They tend to suggest walkways and specific views. If one tree in a grid dies, then the courtyard would look like it is missing a tooth. iv. Hip-hop row. The irregularlly spaced rows are called hip-hop rows. We found that the courtyard was too small for a hip-hop row to exist without it looking like it was a grid row that had lost teeth.

Shrub Layer The shrub layer ranges from three to twelve feet. The shrub layer shapes the space that a person interacts with on a human scale. It can shield, divide, and filter between spaces. The shrub layer is tricky from a maintenance stand point. Plants in this layer may be seen as weeds and are easy to accidentally mow over. They may also attract snakes or wild life.

150

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

canopy

understory

shrub layer

ground plane

Figure B.01: Landscape Layers

Ground Plane The ground plane involves many different material textures. Material can be pulled up or down to create transitions between spaces. Manipulating the topography is an important means of creating small transitions in the courtyard. However, pulling up the ground plane too high will turn small transitions into blockade walls.

All of these layers work together to give space different energies.

Dense planting strategies create perceptions of protection, shade, shelter, and enclosure. Less dense planting strategies with lighter leaves and plants that are spaced further apart act to dissipate energy. These less dense areas give levels of transparency and complexity to space. Keep in mind that these spatial energies will change through the seasons and over time.

Chapter 2: How To Think Like A Landscape Architect

//

151

Changing Medium A significant difference between designing as a landscape architect and designing as an architect is that the elements you design with are constantly changing with the seasons and growing over time. You can use the changing nature of plants to your advantage. There are two main aspects of plant change to consider: how plants change through the seasons and how plants grow over the years.

Changes through the seasons: i. Both evergreen and deciduous trees will shed leaves or needles at some point, so make sure that debris will not cause maintenance issues. ii. How will the changing colors of the tree affect the spatial atmosphere? iii. Deciduous trees will shade in the summer but let in the sunlightâ&#x20AC;&#x2122;s warmth in the winter.

Changes over time: i. Shrubs may need to change from sun-loving to shade-loving once trees grow large enough to shade a space. ii. Consider the speed that a tree grows. You may need to plant fast growing plants and slow growing plants at the same time so that the space does not initially look sparse. iii. What happens if one plant dies? Will the entire design fail?

Make sure that your planting strategies do not become a burden on the maintenance team. In our case, Billy and his team had a lot of ground to cover. Maintenance is just one facet of Billyâ&#x20AC;&#x2122;s job and he is working with an ever-changing team.

A planting strategy relying heavily on thinning trees or shrubs over time may be too involved.

There are also important cultural connotations in West Alabama attached to plants.

Tall grasses may not be seen as beautiful spatial dividers, but rather as weeds that will attract snakes. People pride themselves on lawns that are always freshly mowed. Shrubs are meant to be trimmed and shaped.

152

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

ABOVE: landscape changes throughout the seasons and years

(courtesy of Auburn University - Masters of Landscape Architecture Program)

Chapter 2: How To Think Like A Landscape Architect

//

153

Modeling Landscape Tips for modeling landscape designs: Trees: Do: A. Use black wire. Cut several pieces roughly the same size, bunch them together, fold in half around a pencil, twist together, pull apart top strands to look like a tree.

Shrubs, not bushes, remember?: Do: E. Cut up a broom and hot glue the pieces to the model. This will take forever, but you can reuse the shrubs on future models.

Ground surfaces: Do: G. Topography: make the rough shape from stacked cardboard and then paper mache over the top.

Do for client presentations: H. Gravel: spray paint low grit sandpaper.

I. Grass: paint sandpaper green.

154

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Don’t: B. Make the canopy from stacked cardboard circles. They will look too solid.

C. Make the canopy from crumpled trace. These just look like Dr. Seuss trees.

D. Use silver wire; it looks too reflective in pictures.

Don’t: F. Use black pipe cleaners: they are the fast way out but your model will look like it’s full of black sheep.

Don’t: J. Use shades of brown for different materials because

it

makes

them

impossible

to

differentiate.

Chapter 2: How To Think Like A Landscape Architect

//

155

156

how to

BOOK 2 . CHAPTER 3

evaluate design decisions

157

hale county hospital courtyard 2

research

existing elements?

meet with clients

site

what goes where?

design community provoke thoughts of expansion

check underestanding

where to put porch?

Figure C.01: Design Process Mind Map

158

fresh perspectives

make design decisions

gather information

use materials?

material bank

find main idea

zoom out without constraints of previous semester

identify five promising designs

how do you evaluate designs? main idea strength

design charrettes

combine design aspects

circulation

maintenance

series of tests

lenses

use info gathered

meet with clients

what is exciting?

program

hospital resiliance

climate

program

PT, staff needs

narrow down to two designs

meet with clients

what is exciting?

can we maintain it?

further one design

study material bank think about demo operations

highest material quantity: soil

spatial qualities

check scale of space

energies of space?

limit elements

create a system with parameters

maintenance

159

Design Process

CHAPTER

03

So, this is a complex community project. Where do you even begin?

SECTION

01

Gather information (see previous section) and filter!

We went over all the information we gathered in the previous section. We want to spare your eyes and not repeat it all here.

Conversation with clients The design process began with a lot of research and initial conversations with our Hale County Hospital community partners. i. Confirm research. We wanted to make sure that our understanding of the hospital, its history, and its services were correct. ii. Introduce ideas. We wanted to introduce the ideas of a covered porch in the courtyard and provoke the potential of switching rooms around in the future so that therapy could have direct access to the courtyard.

The community partners agreed that physical therapy could greatly utilize a porch in the courtyard. Because Hale County Hospital plans on moving doctor sleep rooms to future houses, they were also interested in moving physical therapy closer to the courtyard in the future. Because the hospital is state funded facility, Rural Studio can not take on the liability of construction on the physical hospital building. We still wanted to show our community partners at Hale County Hospital the potential they had to expand physical therapy in the future.

160

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

hale county hospital courtyard 2

gather information

research

existing elements?

meet with clients

site

what goes where?

design community provoke thoughts of expansion

fresh perspectives

make design decisions

check underestanding

use materials?

material bank

where to put porch?

Chapter 3: How To Evaluate Design Decisions

//

161

What do you do with the existinging courtyard?

Our initial response to the elements in the existing courtyard was to decide what to keep, what to demolish, and what to repurpose. The “Dope and Nope” list explained what aspects of the courtyard were “dope” or working well, and which parts were a “nope” or needed to be demolished.

Decem

ber 3,

DOP

2019

E NO

PE

December 3, 2019

DOPE NOPE ber 3,

Decem

2019

DOPE

NOPE

ge

e sta D th

pond e fish A th A the fish pond

A th e fis h

C

D the stage

pond

D th e st

age

D

C

der B un

D C

A

B

B

B un de

r the

F D

along

E

B

ll

uth wa

the so

llis

the tre

under the trellis

E

along the south wall

trellis

B

A

E

alon

g the

A

sout

h wal

l

F

E E

F

E

putting

+ green

trellis

g

nin r the aw

F

de C Un

C U nd

er th

C Under the awning

e aw

F

ning

F

putting green + trellis

putt

ing gr een

+ trel

lis

ABOVE: examples of our “Dope and Nope” chart

However, we found the value of these elements was very subjective; reviewers each “liked” different elements and had their own opinions on what to keep. Our sketches and charrettes reflected our uncertainty on what to keep and resulted in very piecemeal designs that had no overall strategy to them.

162

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

This road block led us to the realization that in order to do what was best for the hospital, we needed to be unattached to the courtyardâ&#x20AC;&#x2122;s existing elements.

We desired to be respectful of all the work and resources put into the existing courtyard by the 2006 Rural Studio team, but we also wanted to do what was best for Hale County Hospital in 2020. We began to think of the existing courtyard not as full of separate elements but as a material catalogue (Fig C.02, p.164).

We began this new way of responding to the existing courtyard by analyzing the elements as resources. We cataloged all of the existing materials and soil, and then made a graphic comparison to understand the scale of resources (Fig C.02, p.164).

The biggest concern of the existing courtyard design was the amount of soil inside all of the raised planter beds. Digging up soil and hauling it off-site can be very expensive, so we had to be analytical with our decision on how much earth to get rid of. Once we calculated precisely how much soil was in the courtyard, we realized we would have to be keeping a lot of it. We began exploring using soil to ramp the lawn.

Liberating ourselves from the design and materials of the existing courtyard was an integral part of us moving forward in our design process.

Recommended next steps: i. Foundation details. Dig up foundation details of each existing element. ii. Consult Tyler. Evaluate demolition plan and feasibility with Tyler on site. a. How much would it cost to move soil off site? b. Can we move soil into back of site? c. Can we utilize soil in the courtyard to ramp the lawn.

Chapter 3: How To Evaluate Design Decisions

//

163

Figure C.02: Material Catalogue.

Marble blah blah blah about marble. blah blah blah about marble. blah blah blah about marble. blah blah blah about marble.

168 linear feet

Expanded Metal blah blah blah about marble. blah blah

88

blah about marble. blah blah blah about marble. blah blah blah about marble.

ten-foot panels

880 linear feet

Cor-Ten Steel blah blah blah about marble. blah blah blah about marble. blah blah blah about marble. blah blah blah about marble.

52 + 29 eight-foot panels

irregular panels

512 linear feet

164

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Earth

NORTHERN LARGE BAMBOO

122

38

cubic yards

cubic yards

WESTERN MARBLE PLANTER

EASTERN MARBLE PLANTER

17

cubic yards

blah blah blah about marble. blah blah blah about marble. blah blah blah about marble. blah blah blah about marble.

+

SOUTHERN LARGE BAMBOO

+

25

cubic yards

SMALL BAMBOO

14

cubic yards

216 + 13% cubic yards

expansion factor

13 15-yard truck loads

Chapter 3: How To Evaluate Design Decisions

//

165

hale county hospital courtyard 2

Getting Past a Design Roadblock

We hit a roadblock and needed a fresh perspective. In mid-January, Auburn University Landscape Architecture professors David Hill and Emily Knox came down to Rural Studio for a day to pull our heads out of the mud and get our design juices flowing. We spent most of the day charretting ideas for the courtyard, only giving ourselves enough time to get the big idea across.

gather information

make design decisions

We started with an empty courtyard as a constraint and focused on creating an overall strategy for the courtyard instead. research

meet

We realized the necessity of finding a main idea that we could base decisionswith off clients

site

of. By the end of the day, we identified five design schemes with promising overall design strategies, but were all different from one another.

community provoke thoughts of expansion

BELOW: workshop with David Hill + Emily Knox. where to put porch?

check underestanding

what goes where?

find main idea

fresh perspectives

zoom out without constraints of previous semester

identify five promising designs

design charrettes

circulation

existing elements?

maintenance

use materials?

material bank

series of tests

lenses

program

hospital resiliance

climate

narrow down to two designs

meet with clients

what is exciting?

can we maintain it?

further one design

study material bank think about demo operations

highest material quantity: soil

Chapter 3: How To Evaluate Design Decisions

//

167

Evaluating Designs So how do you decide which designs to keep? This next step in our design process was learning how to evaluate designs. i. Overall strategy. We asked ourselves if the designs had a substantial enough overall strategy to support an entire courtyard design. In the process of cutting schemes out of the running, we found that aspects from designs could be incorporated into other schemes that had stronger main ideas. For example, the dense shrub pattern of “The Sheep” was introduced into “The Shard”. ii. Lenses. We evaluated the schemes through lenses of circulation, maintenance, program, shading, and views. These lenses explored how functional the design schemes were. We studied the schemes’ circulation to make sure all connecting entrances to the courtyard were accessible. We thought about potential maintenance burdens and how plantings would evolve over time. iii. Programmatic use. We did a series of studies on how different user groups would use the courtyard throughout the day. We started referring to spaces in the courtyard as “staff zones” or “patient zones” and emphasizing the need for staff to have their own break space. iv. Porch location. Shading studies showed which porch position and heights offered the best shade. These studies explored which scheme created a strong connection between the exterior and interior physical therapy.

With these evaluation tools we were able to go through an elimination process week by week in order to push the strongest couple of designs to delve into details.

As we narrowed down the schemes, we reintroduced the information we had gathered in the fall semester. We began to understand the nature of Hale County Hospital and the need for an adaptable and resilient courtyard space.

168

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

find main idea

zoom out without constraints of previous semester

identify five promising designs

how do you evaluate designs? main idea strength

design charrettes

combine design aspects

circulation

maintenance

series of tests

lenses

use info gathered

meet with clients

what is exciting?

program

hospital resiliance

climate

program

PT, staff needs

narrow down to two designs

meet with clients

what is exciting?

can we maintain it?

further one design

study material bank think about demo operations

highest material quantity: soil

spatial qualities

check scale of space

energies of space?

limit elements

create a system with parameters

maintenance

Chapter 3: How To Evaluate Design Decisions

//

169

Figure C.03: Design Matrix of 5 schemes

170

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

171

ABOVE: community partner meeting to discuss “The Shard” and “The Lawn”

Community Partner Feedback With “The Shard” and “The Lawn” left in the running, we knew we had to get our community partners’ thoughts on design, maintenance, and plantings before moving any further. We built one more set of models and put together boards of both schemes that included perspectives, plans, and material examples.

Both “The Shard” and “The Lawn” were very well received and there were no maintenance concerns about either one. They appreciated that we were using a limited palette of materials such as one type of tree, one type of shrub, only one or two hardscape surfaces. The Hale County Hospital community partners prefered the overall strategy of “The Lawn” scheme, but enjoyed the small pocket spaces inside the shrubs of “The Shard” scheme. We made a collective group decision to move forward with “The Lawn” scheme, but incorporate more private individual spaces into the design.

172

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

ABOVE: the two design schemes and models: “The Lawn” (left), “The Shard” (right).

Chapter 3: How To Evaluate Design Decisions

//

173

Design Development Finally, just one scheme! This next step in our design process was all about developing the design further and getting into the details. i. Spatial Qualities. The feel and energy of the spaces became much more important as we balanced the need for secluded individual spaces and open public spaces. ii. Ground plane. The ground surfaces became more articulated as we thought about paver dimensions and the need for a simple limited palette.

iii. Trees. We looked at how to organize the trees and decided that a grid was much too static, while a gaggle created more dynamic spaces. iv. Porch. We explored the idea of how the ceiling plane could change during the seasons to provide more light in the winter and more shade in the summer. The columns of the porch were made wide enough to create therapy zones where patients could do their exercises on the walls.

174

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

narrow down to two designs

meet with clients

what is exciting?

can we maintain it?

further one design

study material bank think about demo operations

highest material quantity: soil

spatial qualities

check scale of space

energies of space?

limit elements

create a system with parameters

maintenance

Chapter 3: How To Evaluate Design Decisions

//

175

Representation Tools

CHAPTER

03 SECTION

It was important as a team that everyone got eyes on each scheme and drawing, so

02

we often passed them from desk to desk. However, we drew them in the same hand for client presentations and reviews for clarity. i. Diagram. Graphic tool used to communicate the big idea of the design.

176

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

177

ii. Plan. Architectural drawing used to explore spatial organization and layering of ground plane, shrubs, trees, and canopy.

178

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

179

iii. Elevation and Section. Drawings used to explore heights and spatial relationships.

180

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

181

iv. Model. Artifact constructed to visualize a physical scale in reference to the hospital walls and surfaces.

182

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

183

iv. Model. Artifact constructed to visualize a physical scale in reference to the hospital walls and surfaces.

184

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

185

v. Perspectives. Views analyzing the scale and spatial qualities of the design.

186

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

187

Lessons Learned

CHAPTER

03 SECTION

Recognize when youâ&#x20AC;&#x2122;ve hit a road block, and when to take a step back. Donâ&#x20AC;&#x2122;t go

03

down the rabbit hole. Jake did this quite a bit.

Individual lessons: Ingrid: Be sure in your strengths and weaknesses. Learn to recognize how your teammates excel where you struggle. When four people with different perspectives strive for the same goal, the outcome is incredible.

Jake: needed.

Kyra: Stick to your gut and if you have a strong feeling about something say it out loud becuase your teammates probably feel the same way.

Nicole: needed.

188

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Chapter 3: How To Evaluate Design Decisions

//

189

190

how to

BOOK 2 . CHAPTER 4

communicate ideas

191

ABOVE: presentation for Soup Roast, in the Boys and Girls club of Greensboro.

Communicating to Visiting Critics

CHAPTER

04 SECTION

Learning how to present your teamâ&#x20AC;&#x2122;s work is an integral part of a Rural Studio

01

education. In order to be good citizen architects, it is necessary that we can explain design to anyone. We learned how to familiarize starchitects, Rural Studio students and professors, our friends and family, and our community partners with months of work.

Our presentations evolved with our work on Hale County Hospital Courtyard 2.

Each weekly presentation was a reflection of where we were in our process at the current moment and what we understood to be the most important things to share.

An enjoyable part of presenting was showing off the work done at Hale County Hospital. We are so proud of how much the hospital has accomplished in recent years and enjoyed sharing their plans for the future as well.

192

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

ABOVE: presentation for “pre-stress test” in Red Barn.

Our presentations helped us formulate the work we did into a clear argument for the design.

Communicating the project to reviewers enabled us to see the holes in our argument and guide us on where to go next. Although the presentations were always given to someone, they helped us learn as a team.

We learned to filter out information so that our argument could be concise. We didn’t need to explain everything we had worked on, but rather the parts that were essential to the narrative. Sometimes the presentations and reviews went really well, and sometimes they drove us crazy for weeks. We determined what information from the reviewers was helpful, and what we wanted to use to move forward. After getting new opinions every single week, it was essential that we remained firm in our own opinions and thoughts about the project.

Chapter 4: How To Communicate Ideas

//

193

What really helped us with our presentations was the shift from creating a presentation to crafting a narrative. We became critical about what information and research we presented so that the argument for the design would be clear. For each slide we included, we had to ask ourselves if it was truly necessary to present?

Figure D.01: Structure of Soup Roast Review Presentation

history intro

HALE CO HOSP.

outreach

population

evolution

competition

user groups

day in the life organization

services

THE COURTYARD

tools

conclusion

therapy typical session

evolution

dope + nope

then v. now

planting

drainage

maintenance

PROJECT GOALS purpose

function

porch

beauty

climate

usability quality space

196

45

slides

minutes

194

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

SPATIAL STRATEGIES designs

We were no longer presenting information about Hale County Hospital Courtyard 2, we were presenting our decision making process. Since design is subjective, we crafted the narrative around how we were making informed design decisions.

Refining the argument was tedious but gave us confidence in presenting the project.

Figure D.02: Structure of Pre-Stress Review Presentation

organization

resilience

intro

OPPORTUNITY

competition

evolution

services

population history

tools

interior

therapy typical session

patients

audience outreach

staff

staff survey day-inthe-life

site + place

maintenance

then v. now

community

garden

DESIGN + PROCESS

INTENTIONS hospital

schemes

clients

workshop

on the wall

lawn

shard

104

20

slides

minutes

Chapter 4: How To Communicate Ideas

//

195

Communicating to Our Community Partners

CHAPTER

04 SECTION

The purpose of community partner presentations is to check if our information and

02

assumptions are correct and to present design ideas. It is important that we get their feedback on the design and make sure the project is headed in the right direction.

When presenting design ideas to our community partners, we always presented two to three options.

Presenting multiple options encourages back and forth conversations that are critical to the design process.

Tips for communicating effectively: i. It’s not about “us.” We tried to never refer to Hale County Hospital Courtyard 2 as “our project” because it belonged to the community. ii. Who you tryin’ to impress? We avoided using “archibabble” or “archispeak” as much as possible. A good check is to ask, “Would your mother understand what you’re talking about with the words and phrases that you use?” iii. Imagine yourself in the design. We focused less on the conceptual ideas and more on how people would use the design. It was important that we highlight how the design can be an asset to our community partners. iv. Ideas over aesthetics. We asked what aspects they liked about the design, not just which option they liked most.

196

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

Figure D.03: Structure of Community Partner Presentation

organization

evolution

resilience

intro

OPPORTUNITY

competition

services

population history

tools

therapy typical session patients

outreach

audience then v. now

staff

maintenance

staff survey day-inthe-life

THINKING

contrast

experience

INTENTIONS transition

goals

drumroll

on the wall

lawn

shard

96

18

slides

minutes

Chapter 4: How To Communicate Ideas

//

197

We found that physical models and perspective drawings worked best. People without an architecture background typically have a difficult time understanding architectural drawings like plans and sections.

Physical models were successful because our community partners could hold them in their own hands and look into the design. They were color coded to match the material they represented. The physical models made it very easy to visualize the design, and adding people into the models helped them understand scale as well.

Perspective drawings were another helpful tool because they depicted certain views in the courtyard. Adding photos of the existing Hale County Hospital courtyard also improved the clarity of the drawings because they added more context.

If we did include architectural drawings in our presentations, we would use material codes and/or color to make them look more realistic. The plans were important to explain the overall organization of the design schemes. It was also important to walk through the drawings with the hospital team to point out what the materials were and other details.

198

//

Book 2 : How To Manual: A Guide To Design Hale County Hospital Courtyard 2

for Architectural Reviews:

for Client Presentations:

Chapter 4: How To Communicate Ideas

//

199

200

appendix

201

APPENDIX

Meet The Team

01 Big thanks to our dear friend Livia Barrett for hosting this interview and spinning up all the emotion!

Question #1: Are you excited for the interview?

Jake: I’m going to do mine in morse code Nicole: I’m going to do mine in Swahili Kyra: Aaaaaaaah I’m EXCITED Ingrid: *thumbs up*

Question #2: What was your team song?

Kyra: What’s the don’t dream it’s over song? That one.

Ingrid: Our song…”Dig It Up” from Holes. YAY DIGGING! Jake: What’s a song that we all vibe to? “Go Your Own Way.” That was our team karaoke song.

Nicole: I would say a Dixie Chicks, Fleetwood Mac, or a Highwomen song. But if I had to pick one song, “Redesigning Women” by Highwomen, which is kind of appropriate since we’re an all girls team.

202

Question #3: Which teammate needed the most attention?

Kyra: I’m going to say Jake off the bat, but really we know it’s Ingrid because we all hide our emotions but she actually shows them Nicole: I would say initially Jake because he is the only guy on the team, but I would say Ingrid because of the amount of attention she actually requires.

Ingrid: *starts laughing* That’s definitely me.

Jake: So one time we were all having a great team discussion, a question was asked and answered, and then we still heard some gibberish like someone was talking. We looked up and Ingrid is talking to herself with her headphones on just having a complete conversation. Everyone else in the room had their headphones in, not listening, and Ingrid was still talking and trying to answer the question. So for that reason I would say Ingrid, but as a libra myself I cannot be completely devoid of attention.

Question #4: In your opinion, what was the most important thing to implement in the hospital courtyard?

Ingrid: Dude it’s hot out there, gotta get rid of that white marble and get some shade in there. It’s hot. Maybe somewhere to sit, to smoke, to relax, comfortably.

Nicole: A space where staff and patients could both intermingle that’s not crazy hot, so a porch.

Jake: We always say that therapy is a very important thing, and it is, but the staff and the people that are there 8-5 every single day that are battling coronavirus as we record this right now, they need a place to sit!

Kyra: Being able to combine the hospital’s patients who want to go outside and for therapy and the staff. The Hale County Hospital staff work really hard every day so they need a place to just chill out and relax. And the staff is so focused on their patients that sometimes they forget that they need to take time for themselves.

203

Question #5: What design element was the most contentious?

Ingrid: We fought about what the lawn was doing, and also putting stuff in the lawn. We had a really long conversation about that.

Nicole: I feel like the lawn plus the porch mixed with shading.

Kyra: Yeah, how open the porch should be. Winter vs. summer shade, like how the porch should dissipate. I think we also struggled with how to create private moments in the space. Things like individual nooks or private spaces against a wall.

Jake: We fought a lot when we thought about putting shrubs in the lawn. I think they give you so much opportunity to do things, but the scale of the courtyard space maybe wasn’t appropriate for it.

Question #6: What do you think would have been the biggest fight between all of you?

Kyra: I feel like it would be something really insignificant on site. It would be like do we use this screw or this screw? And it wouldn’t matter, but the very small decision where either thing would’ve been fine is what Ingrid and Jake would erupt into a huge feud over.

Jake: I would totally agree. I think it’d be something like if we were grading the land at some point and it’s a 2% slope over like 200 feet and then we get to it, Tyler’s graded it, and I’ve said it’s 2.0323% and I’ve said no it’s fine and Ingrid’s like no no no it needs to be exactly 2%. I would say either that or if we had any sort of wall with any permanent typeface on it.

Ingrid: Haha. Jake and I had an argument about captions the other day. We had a zoom call about captions. For like 35 minutes. I was like I tried to mess with Jake’s layout and he didn’t like it!

Nicole: Ingrid would probably fight someone on site if she didn’t have access to her seven meals a day.

204

Question #7: What would you tell the next team to work on this project?

Ingrid: I would say don’t be afraid to make simple interventions that have a great impact. It’s a big project, don’t get overwhelmed. There’s a lot going on.

Jake: I’d build on that and say follow your gut. I think all of us had the same gut instinct when we were deciding what existing elements stay and what elements go. We all had this moment, we just never said it, when we realized that all the stuff in the existing courtyard wasn’t working together. Follow your gut and if it all needs to go, then get rid of it. Don’t be afraid of what people are going to think or whatever. Do what’s best for the people and for the hospital. There’s not a perfect answer, there’s just your answer.

Kyra: I would tell the next courtyard team to talk to as many people as possible. It was really helpful to talk to Shay, Tammy, Lacretia, and Billy, and get our community partner’s feedback. But talking to other doctors, nurses, administrative staff, and the maintenance team was incredibly beneficial. Also embrace your teammates’ differences. We all had different reasons of why we were interested in this project and why we came to Rural Studio. We had different skills, different everything, and that’s what made our team so good.

Nicole: I would say, teammates wise, everyone has their own backgrounds and what they’re bringing in. We all brought in different first impressions of the project. Definitely capitalize on those first impressions because we all had very different ideas of what the project could be. And it all changed into one big idea, but we all had our own outside ideas from whatever we’ve dealt with in life.

205

Question #8: What would’ve annoyed you the most by the end of it all?

Nicole: So, A, my point being and B, my point being. It was A and B. That was it.

A and B. Ingrid, you say A and B a lot. When we were talking to Andrew, you’d be like “so let me get your points being, A you were talking about the porch including the staff and the patients and then B, being the fish were really important with the staff and the patients. So A and B.” We were like, does she notice that she’s doing A and B? And that there was never a C! Ingrid: I stand by my lateness thing because for some reasons that pisses me off.

When I’m late, it stresses me out. It’s the way I am. It was a good thing I started working on the farm because then I had to get up at a time that didn’t involve anyone else so I was like, alright, I’m there when I’m there and it’s my job so it doesn’t matter.

Jake: Listen, mine is directed at Kyra, but it’s not Kyra’s fault, it’s not her fault at all, it is Tim Cook of Apple’s fault, I don’t know if you guys know where I’m going.

It’s just the sound that her keyboard makes. It drives me up the wall. It’s not a big deal, but when I sit across from Kyra and she’s writing a blog it’s mashed potatoes for days. I get so frustrated. It’s not your fault. I just hate the way they made the keyboard sound.

Kyra: Originally I was really annoyed with how late we were to things, but I eventually adapted. It was like, oh Jake’s picking me up in the morning, I’m going to sleep in fifteen more minutes. So I planned, if I knew Jake or Nicole was picking me up I would sleep in at least fifteen more minutes.

206

Question #9: How did you improve as a team?

Ingrid: I realized this after a while, but when Andrew talked during one of our reviews and you guys would just sit there, I could see the wheels turning. At first I was like oh my gosh what are they thinking I don’t know. And my first reaction was like they’re not understanding or they don’t care and I realized eventually, oh they’re thinking about it internally. They don’t have to say it.

Nicole: Ingrid would affirm what Andrew was saying out loud, which was just you making sure that what you understood was correct. And the three of us were doing that in our brains, but we don’t have to do that out loud. It’s just a different way of thinking and understanding. Learning how we all process criticism and feedback was a important for growing as a team.

Kyra: I think we very quickly recognized one another’s strengths and weaknesses and worked to highlight the strengths while improving the weaknesses. I believe it’s what made our design process, presentations, and now creating the book so successful. But to be honest I never felt like we had any huge difficulties, we were kind of lucked out with how well everything fell into place.

Jake: Absolutely! Believe it or not, but each day we got better at communicating with each other, and understanding what we were trying to get to.

207

APPENDIX

Meet Our Fearless Leader

02 Question #1: What were your initial thoughts about the Hale County Hospital Courtyard 2 project?

Andrew: I was really excited to re-engage with the hospital. We had a number of conversations about the housing issue for them at first. I was glad the hospital initially asked us about the housing but then agreed to my proposition that we use the courtyard as a kind of first date. I was pleased that they were going to do the courtyard first because they were still trying to formulate what they were trying to do with the housing issue, which like everything else, itâ&#x20AC;&#x2122;s an ever changing thing.

The other thing that I was really intrigued by was the challenge of dealing with a former project. I have to say I was also pleased with the fact that the original team members were not precious about it. Cause as you can imagine, we did talk to them about it. And they were like whatever the hospital needs, the times have changed, ten years on, stuff happens. So that was all good.

208

Question #2: What makes us an appropriate team for the project?

Andrew: Aside from this COVID star planet that disaligned it all, for me, the kind of planetary alignment of things like the opportunity to do the hospital’s signage, the opportunity to get involved with the graphics, the opportunity to engage with their organization was fantastic. I appreciated the fact that you all were willing to take on those extra curricular things as a way to learn about the hospital community, the administrators, and the needs of the hospital. I was both really pleased that those were offered to you, but also really pleased by your attitude for taking them on. That’s why I’m so disappointed that we can’t keep going. I felt the kind of segway into doing the project through those things was superb.

I had a lot of things on my plate last year, but some of the highlights of my week were coming and sitting with y’all and talking about the project. I always enjoyed a good sense of humor and a good laugh. And the work is serious, but we don’t take ourselves too seriously. I just really enjoyed working with y’all. Simple as that. I think your attitude and the additional work you took on allowed you to be involved in the hospital. Doing things like going and digging holes with Billy, replanting roses, putting together a graphics package for them, all super important things and not many teams have that opportunity and also take that opportunity. And all that also takes time. You could be sitting in the design studio when you’re doing that extra stuff, but in my view that’s equally as important as sitting in the design studio. You might not see that as design-build, but for me that was a design-build project and it’s also an indication of your ethic and willingness. And remember that architecture is not just about building, it’s also about building relationships and pushing ideas and helping where it’s needed and offering skills and capacity when other people don’t have it. You all have a legacy of that thing. It’s great, I mean I can’t blow anymore smoke of you than that, y’all were a lot of fun to work with.

Question #3: Who from the team would win in a mud wrestle?

Andrew: I’ve got to say Shakira. I could just hear Jake screaming as those nails scratch.

209

thank you To our wonderful community partners We were very fortunate to have articulate and opinionated community partners.

Whenever we asked what they liked about a scheme, a porch, or even a planting strategy, they always had an answer. They made it easy for us to move forward in the design process because they knew exactly what they wanted. Our community partners at Hale County Hospital were absolutely incredible, and weâ&#x20AC;&#x2122;re so lucky we had the opportunity to work with them.

Shay Fondren For inspiring us with all of the hard work that you do for the hospital Tammy Weeden For challenging us to explore every option LeCretia Edwards For always telling it how it is Billy Brannon For showing us how to be practical yet creative Our other hospital friends This was the project of a lifetime and we will miss getting to work with you all so much!

To our support network To our fealess leader, Andrew Freear For teaching use how to take our work seriously but never take ourselves too seriously To our parents For being our most consistent supporters even when you didnâ&#x20AC;&#x2122;t know exacly what was going on out in rural Alabama

210

To Johnny Parker For teaching us all the things we didn’t know we needed to know To David and Emily For patiently guiding architects in the world of landscape architecture To Emily, Steve, Xavier, Elena, Chelsea, and Mason For showing us how to be citizen architects To Brenda, Heather, Katherine, and Doris For doing everything behind the scenes to make sure the show runs smoothly To Natalie and Eric For being our rock during difficult times and constant support To Sweetbriar Coffee and the Merc For keeping us caffienated and well-fed To our dear super leftovers of Horseshoe Farm Homes and Horseshoe Farm Courtyard For the support, advice and many laughs that came from our years of knowing and loving you To our not-too-stale leftovers of Moundville Pavillion, Anne’s Home, and MassBreathers For helping Greensboro feel like home To the grandparents, Charlie and Devin For making us feel young and bringing a much needed new perspective To our fellow classmates For helping us not only survive the past five years, but also thrive. Thanks for all the great memories, this place wouldn’t have been the same without y’all!

211

To the most special place There’s something undeniably magical about being a student at Rural Studio. It’s the kind of place that you try to describe to someone, but words just never do it justice. We enjoyed being surrounded by beautiful West Alabama country, building relationships that will last a lifetime, and working for a community that we love with our whole hearts. We’re going to miss driving by sunsets over the catfish ponds, eating meals under the great hall, and having yet another ice cream sandwich at the Merc. Most of all, we’re going to miss the people who truly made this place so special.

Due to the unforeseen circumstances of COVID-19 and wanting to put our community’s safety first, our project was put on hold for a future student team to carry forward our research. Although our experience at Rural Studio wasn’t what we expected, we are so thankful for the time we spent here and the relationship we formed with our Hale County Hospital community partners. Without a shadow of a doubt, each and every one of us would have done anything to have the opportunity to build Hale County Hospital an amazing courtyard. The struggles that we’ve gone through have only made us closer as a team, and the constant love and support we have for one another is something that could never be taken away. This place has helped shape us into who we are today and will always have a special place in our hearts. Although the four of us will be moving miles away from one another, this is by no means the end of our journey together. Thanks for all the memories.

Yours Truly, Kyra, Ingrid, Nicole, and Jake

212

Colophon Adelle PE, designed by JosĂŠ Scaglione and Veronika Burian, 2006.

Geomanist, designed by atipo.

214