RESEARCH & PUBLICATIONS
In this month's HCD Magazine, E4H is reinventing the hospital dining experience at Heart Rock Café located in the Baylor Scott & White Health - The Heart Hospital Plano.
"Having a culinary dining experience is very different from a cafeteria experience; we want all guests and visitors to have a true oasis from the busyness and high stress that can be prevalent in hospitals." - Julie Martinez, AIA, Lean Green Belt Read the article
Neighborhood Medicine and Modular Pre-Fab Construction, A Recipe for the Future of Healthcare. The design of new hospitals has been driven by recent trends towards smaller, more comprehensive medical facilities. Most of these facilities target one specific department around which to build their hospital, while minimizing other core department requirements. This has created multiple hospital concepts tailored to specific entities and locales.
Futuristic technologies such as telemedicine, personal diagnostic services, and cloud based medical applications are gaining new focus in the delivery of healthcare. These new practices have the potential to shift treatments from larger, centralized medical facilities to outlying locations such as the local clinic, neighborhood hospital, and even directly into patient’s homes. A facility that can keep up with these changes, integrate new technology, and adapt seamlessly to the future of medicine and healthcare delivery will be a key factor in meeting the advancing and changing needs of patients in the years to come.
At the heart of these smaller medical centers is one of their core concepts: the desire to bring higher acuity healthcare to the local neighborhoods and rural enclaves, thereby bringing medicine to the patient rather than the patient into the hospital. Medical advances that are already in use in outpatient facilities and clinics have started to make this treatment model a reality and allow multiple treatments to be done at home or a nearby facility, keeping it in the family, so to speak. The concept of the neighborhood hospital can take medicine to the next level by delivering traditional inpatient services with trained staff to a “corner store” location. Advances in design, materials, and technologies allow hospitals to appear as any building type; no longer simply large monolithic masses from the past. In today’s healthcare environment, they can now have features and amenities desired by current healthcare consumers.
As the spread of internet and cell phone technology has taken place, physicians and care givers have been brought together from across the world. This allows for robust collaboration surrounding treatment plans and modalities in areas that were previously inaccessible. As our lives become more saturated with the internet and web-based media technology, it has never been more crucial to have reliable network infrastructure in modern healthcare.
In an expanding and rapidly changing technology environment, today’s facilities must maintain an increasingly higher level of service with broad connectivity and easy upgrade accessibility. Without up to date technology, the hefty repository of online knowledge that is available for physician consultation and research can be lost. Indeed, the more connected medical caregivers are the better able they are to treat their patients.
Modern options in prefabrication techniques offer ways to accommodate this ever-changing technology component and allow for adaptation to ideas that have not yet been invented. Utilization of pre-fabricated headwalls, composite modular wall panels, vacuum plumbing systems and demountable partitions allow facilities to both allow for rapid incorporation and adaptation to new technologies as they are developed into both new and existing projects.
When major utilities are installed above ceiling spaces, treatment spaces and patient rooms can be developed as a modular component. Prefab enclosures standardize room layouts and utility connections, and adjustments can be made as needed to create new spaces or connect new medical gas, power and plumbing systems.
The utilization of systems such as these allows a facility to quickly change the acuity of a treatments space or rapidly add to the functional program as needed to fit local conditions; all while expediting construction on renovations and limiting operational downtime. Limitations of space in smaller neighborhood hospitals previously required tradeoffs in facility programming and forced choices about which departments on which to focus limited resources. Conversely, the use of modular universal treatment spaces, designing key infrastructure for expansion, and utilization of premanufacturing technologies allows for facilities to adapt to multiple types of procedures, and create a chassis that can be instantaneously modernized or redeveloped as new treatments and techniques are created.
One example of this is the utilization of prefabricated custom wall panel systems in an Operating room, procedural room, pharmacy, lab or sterile instrument processing facility. These panels allow for the ultimate enhancement of flexibility in any environment, creating a clean, hygienic and durable wall surface that can accommodate a wide range of current technology and infrastructure needs, and adapt to future advancements seamlessly.
According to Jason Keith, Partner and Co-founder of mfPhD, provider of the FORTRESS wall system to health systems across the country, the ability to deliver new spaces (whether renovations or new construction) to facilities quickly, with lower overhead and cost of operations, all while allowing development of spaces to continue during and after completion of construction, makes a huge impact on how hospitals serve patients. Prefabricated, custom components such as the FORTRESS system have been widely regarded as an impactful, direct way to provide future flexibility with the lowest impact to service delivery interruptions, adaptability or service provision decisions. Whether a small community hospital, a large urban health system or a neighborhood microhospital; one thing is certain. Change is inevitable and unpredictable. Incorporation of building components that increase a facilities tolerance of these factors is essential.
Instead of building larger facilities with multiple specialty treatment areas and departments, creating a few more universal rooms in a smaller facility with infrastructure designed to adapt and expand as needed, and utilizing prefabrication technologies contributes to a hospital chassis that is well suited to all environments, current and future needs, and is eminently adaptable for whatever healthcare throws at it.
The incorporation of these concepts into smaller, neighborhood hospital programs allows for rapid prototyping of a building and for modifications to the specialties needed to serve a specific population. The creation of a typical chassis that can then be adapted during the phases of the design process to allow for anticipated demand and local factor needs can be scaled to fit any region, type of hospital or associated outpatient facilities. This roadmap would allow healthcare systems and government agencies to spend their development dollars in areas where they can be of greatest benefit, while providing visually pleasing spaces with warm, welcoming green environments that aid the healing process. This would work toward the creation of a new recipe for the future of a hospital concept that everyone in society could benefit from.
Jeff Sudman, AIA, NCARB, ACHA
New modalities of healthcare delivery are emerging, as the nexus of technology, genomics, and personalized medicine impacts healthcare. Translational research is allowing these breakthroughs to reach the patient more quickly than ever before. As architects and designers, we are increasingly challenged to provide a bridge from our current modes of patient care and biomedical research to the future. Both IVF and cancer treatment provide models for care delivery that are being addressed by large healthcare organizations.
According to the Agency for Healthcare Research and Quality (AHRQ) in 2015, 6% of Pediatric Emergency Department visits nationwide were for Mental or Behavioral Health related issues. E4H participated in a multi-disciplinary team of individuals in order to inspect the issues and develop strategies to improve the patient, family, and staff experience in Emergency Departments serving adolescents. Through provider interviews and an extensive research review, the group proposed solutions for the patient experience of adolescents in Emergency Departments supported by best practices. Explorations and suggestions included in-room patient support and companion programs, including trained advocates as part of the care team, offering holistic treatment and therapy for extended stays, technology enabled positive distractions, telehealth psychiatric evaluations, family educational resource packets, and design for behavioral patients including natural light, accent graphics, and sound masking.
Smaller medical facilities have found favor with healthcare providers, are convenient for patients, and might offer opportunities to investors
Micro-hospitals, ranging in size from about 15,000 square feet to 50,000 square feet, are springing up around the United States, in part because they are positioned to deliver care in a more economical and operationally efficient manner than larger-scale facilities. What’s more, they can thrive in urban, suburban and rural areas, and are considered a patient-friendly model of care.
Architect Jason Carney, partner at E4H Environments for Health Architecture, has 15 years of healthcare-facility design experience encompassing a broad range of project sizes and types, including the design and construction of micro-hospitals.
What Is the definition of a micro-hospital?
Micro-hospitals are an affordable, effective way to provide a large variety of big-hospital services in the community, including surgery, radiology, emergency departments and related services. Typically, they are 24/7, small-scale inpatient facilities, roughly 15,000 to 50,000 square feet, with between five and 15 inpatient beds for observation and short-stay use. In some cases, based on market demand, these facilities can reach 50 beds. While micro-hospitals can treat some high-acuity needs when necessary, more are located within 20 miles of a full-service hospital to ensure a seamless transfer process when warranted.
Why are they growing in popularity?
Because not only do they offer a full set of services that are typically found in large hospitals, they provide greater accessibility and convenience for many consumers, as well as affordable market-growth opportunities for providers.
What problem do they solve or advantages do they offer?
Cost, convenience and location are three of the leading advantages micro-hospitals offer. Compared to large medical centers, micro-hospitals can be 90 percent less expensive to build, staff and operate, and the format allows providers to deliver services in locations that, because of population density or other factors, could never sustain a full-size hospital. Micro-hospitals also offer communities a much more robust suite of medical services than you find in a typical urgent-care clinic or outpatient facility. Compared to a standard full-size hospital, however, the smaller footprint makes them feel much more intimate and calm for patients, and makes daily work flow more efficient for physicians, and nurses and care providers.
From a real estate investment standpoint, how do micro-hospitals perform?
We think the overall numbers and continued growth of micro-hospital design proposal requests are the strongest validation of the financial merits of the concept. As of the beginning of this year, 19 different states have at least one micro-hospital in operation, and across the country more than 50 micro-hospitals are now serving patients. These hospitals are particularly popular in parts of the Midwest and certain Western states, notably Arizona, Colorado, Nevada and Texas. Most of the micro-hospitals in operation or under construction are located in states facing the strongest pressures to control the growth in healthcare costs and get the historical overbuilding of healthcare facilities under control.
You have suggested the healthcare industry can learn some design lessons from the hospitality business. Give us some examples.
A great example is E4H’s recent work with a New York hospital to create a long-term space for immune-compromised patients going through a procedure such as a bone-marrow transplant (BMT). The first phase of a BMT— surgery and initial recuperation — obviously must take place in an inpatient hospital setting. But in later phases, when patients are recovering and need mainly to be monitored closely for infections or complications, they do not require a standard inpatient hospital room and can enjoy a much better, less-costly experience in a specially designed, hotel-like space. For our client, we created a space for this in-between population that has private, suite-style rooms; specialized water-filtration systems to protect immune-suppressed patients; and more of a hotel aesthetic. Patients are served by a concierge instead of a charge/ desk nurse. If any of them develop complications, of course, they are quickly detected, and patients can rapidly be brought back into the hospital for treatment. But if their recovery proceeds without incident, they can enjoy the equivalent of a long-term hotel stay, instead of long-term hospitalization, after their BMT. We find that these lessons are also relevant for those serving rural populations. Patients and families who must travel great distances for healthcare will often seek out options that provide a balance of the best patient care and the most comfortable experience for family members during the stay. Providing a comfortable, welcoming space that accommodates family members at the patient’s bedside adds important practical and emotional support to the patient experience. The availability of family support improves outcomes.
Laboratory architects have introduced innovative ideas to the biotech marketplace as the next generation of research and researchers continues to mature.
Today’s workplaces have been strongly influenced by the trend to provide modern comforts to employees. For example, architects are adapting plans to accommodate increased access to daylight, more flexible spaces that encourage idea sharing, and a variety of environments that can accommodate different personalities in the workplace.
Some of these trends are finding their way into the biotech workplace—enhancing the work environments of the front office and lab space at the back—while maintaining regulatory compliance.
Of the many design innovations architects are bringing to biotech offices and labs, one of the most impactful is the ability to provide transparency between non-classifi ed spaces (offices, corridors) and research and product manufacturing. By bringing researchers and scientists forward to the “front of the house” and making them visible, venture capitalists, investors and regulators can observe work being done and witness breakthroughs occuring. Glass walls around research spaces can also be a positive solution for giving regulators and auditors access to observe laboratory operations—without the need for them to gown up every time they want to inspect or review highly secure spaces where research is underway.
It’s not a perfect analogy, but in many ways, this change in biotech company work spaces mirrors changes in restaurant design, where today, more high-end eateries make chefs and their crews visible for patrons. Diners take pleasure and inspiration in seeing where their meals come from, who is preparing them and how.
We see that same sense of excitement from biotech stakeholders who today can visit a prospective portfolio company and witness researchers and technicians harvesting cultures, working with raw materials and using automated technologies. It’s one thing for a company executive to tell investors about progress on a new autoimmune disease treatment: it’s more powerful when the CEO can tour guests through a facility showing what researchers may be looking at in real time through the lens of a microscope. This is science in action.
The stakes are very high when it comes to transparency and allowing access to sensitive information. It has to be done carefully and is not for every biotech or pharmaceutical company. There are limits, of course, to how much companies can safely expose to public view, particularly in this era of heightened concerns about intellectual property protection.
Maximizing real estate spend
Another trend driving innovation in biotech space design is the steadily increasing cost of real estate, particularly in the research hubs where the best talent and the best companies want to be, such as Boston, New York, Seattle and San Francisco. Whether it’s renovating an old urban structure or building new, biotech companies are looking to architects to help manage and maximize their real estate investment.
Utilizing Smart Facility Design principles, architects can maximize workflow and create environments that are economically and environmentally sustainable. One leading example is the transition from stick-built, drywall-and-stud construction to modular environments, where prefabricated structures are created offsite and assembled quickly at their destination. For example, creating a modular cleanroom in a controlled shop, testing its systems and pre-commissioning it before bringing it to the site for installation provides cost and scheduling efficiencies. It allows builders to adhere to timelines, and bring in painters and floor installers as modular rooms arrive. Studies by Research and Markets project that modular construction for pharmaceutical and biotechnology facilities will grow by an annualized rate of about 9 percent between now and 2030—doubling every eight years on average. More than 80 percent of this modular construction will go to serve biologics manufacturing, 5 percent for other manufacturing, and 12 percent for research and development spaces. R&M predicts that 65 percent of modular/prefabricated construction for biotech/pharma will be to create new facilities, the other 35 percent expansions of existing sites.
In addition to modular construction, real estate spends are being maximized by designs that incorporate adaptable and multi-use spaces. Instead of creating rooms and areas that are dedicated to a sole function, many companies are opting for spaces that can serve multiple purposes.
Multiple spaces for multiple personalities
When it comes to office space, it’s no secret that there’s an ongoing debate about open floor plans versus traditional office layouts. However, it’s important that amidst the trend to attract millennial talent with open floor plans and foosball, architects do not lose sight of the unique culture of each biotech company they design for. Design needs to account for the many types of personalities in an organization. Some executives and scientists perform better in quiet space with doors that can close. Others prefer flexible spaces for spontaneous collaboration, and still others want to gather in a “corporate living room” to have an informal conversation. Ultimately, architects should look to the company founders for inspiration and to ensure the culture they created and seek is captured in any new design. A workspace that caters to many different personality types will help invigorate and retain talent.
What I’ve learned as an architect is: one size does not fit all. It’s critically important before we even begin to draw schematics that we do the work to understand the culture of the companies and organizations we are building for. The workplace has to work for all workers, in all generations, and for both extroverts and introverts. An obsessive insistence on an open workplace makes no more sense than does an obsessive insistence on making sure every employee has an office with a door that closes. The reality is, we need a mix of both, and almost all people working in a biotech environment will want and need both public and private spaces at different times in their work week.
The pace and promise of innovation in biotechnology have never been as exciting and challenging as they are now. For architects and designers, it’s a great time to work with biotech laboratories and researchers as they move toward the next generation of research.
Indianapolis Business Journal recently published a story on microhospitals. It includes a quote from Rod Booze, AIA, ACHA, Partner, “Tiny hospitals project hefty earnings”.
“They can bring health services closer and closer to a consumer, in a convenient setting,” said Rod Booze, an architect and principal with E4H Architecture in Dallas, which has designed 28 micro-hospitals in Arizona, Colorado, Texas, Louisiana, and Ohio. “They’re usually not in a congested urban area.”
Rod will be speaking at the 2017 November HCD Conference in Orlando.
Healthcare organizations are facing increased pressure to provide easy access to care, quickly, and through innovative healthcare delivery processes. E4H presents Ambulatory Design for the New Market, an insight on trends in ambulatory facility planning and design. Kevin Neumann, AIA, Partner, and Regan Henry, PhD, AIA, LEED AP, LSSBB, present case studies to provide an understanding of how various healthcare organizations are adapting their physical spaces to keep up with market demands and changes.
Shifts in patient demographics have implications on the design of healthcare facilities and how services are rendered. Architects and other project team members will need to rethink their planning and design strategies to address patients’ changing mobility requirements, minimize falls, and improve caregivers’ abilities to monitor at-risk patients. Read the article by Regan Henry, PhD, AIA, NCARB, LEED AP, LSSBB.
Renaldo Pesson, NCIDQ, IIDA, AAIA, Associate Partner, discusses how lighting design influences optimum health care and better performing facilities.
Mercy Medical Center's $15M Sister Caritas Cancer Center consolidated outpatient cancer care programs in one 26,000SF comprehensive and collaborative space.
E4H and IrisVR seek to provide a solid foundation of the understanding of virtual reality in this research presentation. The team explores various ways healthcare professionals and design teams can use VR to achieve maximum benefit throughout both design and construction. Watch the Video.
The Healthcare Associated Infections Organization (HAIO) was started in Boston to bring together hospitals and designers with the common interest of exploring how design, materials, and operations can impact hospital acquired infections in the inpatient setting. MorrisSwitzer is an active member of the group and recently participated in the HAIO Patient Room Challenge.
The Challenge asked design firms to propose novel ideas to increase infection control in patient rooms. MorrisSwitzer's proposed Bio-Inspired Patient Room centered upon 3 concepts:
- Establish distinct clean and semi-clean environments: The patient bathroom and wet components are removed from the immediate patient care environment to foster a clean zone area around the patient. Housekeeping will be able to access the patient bathroom without disturbing the clean patient environment. Ease of patient access to the bathroom is maintained via hands-free operation of all doors.
- Create a Care Cocoon for the patient which completely envelopes them with patient-care technology.
- Utilize surfaces and curved or coved material intersections that do not allow for the collection and advancement of bacteria. Anti-microbial surfaces would be specified throughout. In addition, flush mount technology, lighting, glazing, entertainments, and storage would be utilized to avoid small corners that would inhibit cleaning.
Hospital based staff from Brigham and Women's Hospital as well as Mass General Hospital reviewed the proposed designs and will incorporate the top ideas into a prototype room at one of the participating hospitals.
St. Joseph's growing internal medicine practices have been consolidated in this new 23,000-square-foot medical office building. The practice is an accredited Patient-Centered Medical Home with both the National Committee for Quaility Assurance and Stage A for Medicaid.
The new addition to Steven & Alexandra Cohen Children's Medical Center of New York is located on the North Shore Long Island Jewish campus. The parcel was bound by campus roadways and the existing children's hospital, which led to the building's angular shape. This orientation also serves to provide greater access to natural light for new and existing patient rooms.
Partner Jennifer Arbuckle, AIA, LEED AP, presented research "Facility Design with the Patients at the Center," with Dartmouth Hitchcock's VP of Community Group Practices, Christine Schon, MPA, FACMPE, at the Medical Group Management Association 2014 Annual Conference in Las Vegas, NV.
The mission of Blythedale Children's Hospital is to improve the health and quality of life of children with complex medical illnesses and conditions. Given the extraordinarily tight site constraints, this design solution had to be limited in its footprint yet provide substantial space for patients and their families, as well as the multidisciplinary staff at the core of the hospital's caregiving approach.
Partner Bill Repichowskyj, AIA, presented “The Healthcare Facility Design Process; the Imperative for Involving Patients and Families” in an educational session at the Vermont Association of Hospitals and Health Systems Annual Meeting with Dawn LeBaron, VP of Hospital Services, of Fletcher Allen Health Care.
This new five-story medical office building is truly an example of innovations in an ambulatory care setting. Completed earlier this year, the 154,00-square-foot multispecialty clinic provides an inspired ambulatory environment that includes urgent care, and improves every patient's access to care, keeping them out of the hospital.
Home to one of its state's busiest Emergency Departments with more than 50,000 visits per year, Central Maine Medical Center (CMMC) is a Level Two Trauma Center and Home base for the LifeFlight of Maine's medical helicopter. To accommodate the growing emergency visit demand, CMMC is undergoing a multiphase renovation and expansion upgrade to its existing facility.
Marked as the largest, single construction project in the history of CVPH Medical Center, the surgery project focused on the numerous departments and areas of the hospital in need of expansion, relocation, or upgrade,. A major component to the project was the renovation of the hospital’s main entrance and lobby. Prior to the renovation, the hospital’s outdated lobby was small, narrow, and worn. Simply put, it did not resemble the quality and level of care for which the medical center is known.
Founding Partner Jerry Switzer, AIA, ACHE, wrote and researched "Can Single Rooms Pay for Themselves? Researching the Evidence." The research was presented at the annual ASHE/PDC Summit March 4-7 in Phoenix, Arizona. The MorrisSwitzer team discussed savings involved in single-bed vs. multi-bed rooms using select criteria.
Eastern Maine Medical Center (EMMC) is the largest comprehensive medical center and primary healthcare provider to the state’s central, eastern, and northern regions. As many surrounding rural hospitals have downsized to Critical Access designation, a significant increase in inpatient acuity and population has generated the need for EMMC to expand and update its inpatient care services with the design of a new state-of-the-art eight-story inpatient tower.
The new freestanding Scarborough Surgery Center for Maine Medical Center was designed to be the premier outpatient surgical facility serving the southern Maine region. This state-of-the-art facility decompresses the surgical volume at their two Portland campuses, bringing outpatient surgical services to a setting that is comfortable and reassuring for patients and their families.