MedConference 2012

Michael Street:

I have to say that this is the first time I spoke at a conference that doesn’t have a lot of architects, but certainly I have never spoken between a neuroscientist and a clown. Buildings don’t heal patients, but buildings get in the way. About thirty years ago there was a reawakening in design of healthcare facilities. The goal at that time was to create healing environments that are patient centered. Something that provides dignity for the patient.  A whole holistic care system that cares for the patient mind, body, and spirit. The Healing environment. That’s what I am here to talk to you really about today. I am going to talk to you about the Healing environment. Some evolving drivers, things that are changing the healing environment today and for the future. And if I have time I want to talk a little bit about evidence base design and the ramifications it has on the whole healthcare profession. A healing environment can be defined as a place to heal the mind, body and soul, with respect and dignity, supportive care through all stages of life and death, while promoting the best possible patient outcome. Well for me there are many different ways of saying this and many organizations say it differently but really for me the biggest most important word is outcome. What we want to do as healthcare architects is create space that allows the patient to heal better and staff to work better and ultimately make the best outcome for the patient. Now this can be done in many ways, the physical environment that we build for the patient can affect patient directly but it also can affect them indirectly by affecting the staff that care for them.  The direct impact on outcomes are privacy and dignity, reduced patient stress (and that’s one of the most important ones in the healing environment), and then improving safety. Now if you look at the typical semi-private room that we have in the United States, you never know what you’re going to get for a roommate, and then when you are going up to register at an out-patient clinic or talk to some staff, before HIPPA, you really don’t know who else is listening in on your conversations. So privacy and whole dignified experience through a hospital are very important. So, what we do is we’ve shifted as a nation really, we are really one of the only nations in the world that really has gone to fully or 95% private rooms, I’ll say, in hospitals and new constructions. And the rest of the world has arguments against that for various social and economic reasons. But within the United States it really creates the best opportunities for room flexibility, it creates opportunity for maintaining high occupancy rates and not having to deal with different sexes, it also helps minimizing patient transfers, and a lot of other aspects. Not to mention the fact that having an annoying roommate that could have a lot of family members there visiting can raise the patients stress. There is actually proof that with a private environment a patients stress is lower, they sleep better, they use less medicine and the length of stay in a facility is less.  To reduce stress we look at all the senses. Smell and taste are more indirect, they’re done through various methods of the food service program. But sight and sound are really the key from the built environment standpoint, the presences of color and the appropriate color is used within the healing environment is all about calming and reducing stress in the patient and giving them positive connotations of positive memories they have. Now  ________________________________________

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this is very different, I just moved back from San Diego to Connecticut, and I am experiencing my first Fall season in a long time and just seeing the trees just calms me and relaxes me, so I like to think that patients seeing those types of colors and those types of spaces that are filled with those types of natural materials are calmer.  Clutter is a huge problem in many facilities. Basically if you have a cluttered waiting room the patient comes in right away and they have lack of confidence in your facility. They have their stress level go up right away, versus some of the newer patient rooms we are designing in other part where there is a place for everything and everything has its place. Keeping it nice and clean, and raising confidence, and lowering stress.  Natural light is very important as well. We try to bring natural light into as many of the spaces within the facility as possible, you know that many are mandated, we look at studies in key areas like the patient rooms where we need to maintain several levels of light throughout the day but also we need to minimize glare so we are constantly balancing trying to maintain the positive natural environment for the patient. Artificial light is just as important, in procedure areas where you cannot have natural light we look at using artificial light methods to really maintain the calming experience. One of the vendors, Phillips, has recently developed this, were they are actually using an entire customizable patient experience as they go into all their different imaging rooms and interventional rooms. And we even use it in some OR’s, but basically by creating whatever color the patient wants for their calming, some imagery, music as well, and then once a patient is sedated or otherwise, they could switch over to a procedure room for instance to a green light system and so its highly flexible. As well as corridors, how many people have been a patient on their back being pushed through a corridor with a constant rhythm of light coming in their eyes flashing? So whenever we have a patient coming in on their back we like to do a nice soft indirect lighting down the corridor so we are bringing the stress down on that patient. Art is another very important aspect. Many many facilities across the country are doing very inexpensive renovations, putting things on the ceiling of their imaging rooms, or other procedure rooms, or recovery rooms, and that allows the patient to focus. It’s a positive distraction to make them stop thinking about their condition, for even just a moment, to help bring their stress down. Of course art is very variable, everybody has a different taste so you have to be very careful of what art you put in a facility, and in a patient room especially, you don’t want to put challenging art, you don’t want to make them think too much. You want them to see something that is very familiar, very relaxing and calming like a nature scene. You don’t want to give them an abstract piece of art that’s going to raise their stress level.  Healing gardens are another positive distraction. Again we try to make space for patients, staff, and family members to get away, but it could also be used for various activities. It can be a social space for education, it could be gatherings for staff outside, or it can just be a contemplative space where a family member can go, or even a staff member can get away. We try to create as many spaces for rest.  Sound is another important aspect. There are negative sounds and there are positive sounds. We want to use positive sounds like music and create an ambiance to again be a positive distraction. But we want to create spaces with materials that absorb sound so that private conversations are not heard. Overall the ambient level sound is kept low. We found that in environments with hospital corridors for instance, were the light levels are  ________________________________________

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kept down low and the corridor maybe more hospitality looking or carpeted, then people tend to talk quieter in that space. Although carpet is a very controversial material for obvious reasons. In all industries you learn from another industry. The healthcare industry is learning from Disney, so basically the concept of on and off stage, so that when a doctor or nurse or staff member are actually in the patient environment they have to act a certain way. They have to be respectful of the patient, they have to be quiet, they have to respond. And then, in the off stage areas, that’s where they can let their hair down. They can relax, they contemplate their score with the grim ripper. They can do whatever they need to do, they can get the socialization they may not have gotten in other spaces.  We do this in patients rooms or units now. I found that over the past five years we have actually kind of reverted back to what I call the bar, the rectangular bed tower for nursing units. And we’ve done that because it has allowed a central off stage support zone where all the activities that happen all day long all night long, stocking the floor, all the janitorial staff, the materials management staff, slamming of doors of utility rooms, all happens in a center staff corridor where no patient traffic is, and then in the space right across the hall from every patient room is actually this nice artwork or calming lighting space. I mentioned hospitality before, and hospitality has really changed the hospital. You know a lot of hospital lobbies it’s impossible to tell whether they are hotels or not. And that’s really changing the whole arrival experience and how you move through a facility. In cancer care, things like navigators, and in all hospital things like concierge service and valet service are all geared towards the hospitality service.  Waiting rooms we do the same thing. We try to make the soft and quiet and decentralized spaces where family members can sit in clusters and not have to worry about the conversations of others.  The Spa experience is another thing that many facilities, especially women centers and cancer centers, we are creating spaces–when I say we I mean the profession as a whole— we are creating space where everything is about the patient experience, patient sometimes get the terry cloth robe or slippers. They come in, and no more gowns with their butt hanging out, so they’re really trying to change the experience as well as using new materials, very natural calming materials. In the project in Abu Dhabi, for Cleveland Clinic, we really took it to one level further. We created—at first they were coining the phrase seven star, but there’s really only a couple seven star hotels in the world— but we really created a five star hospital environment. Where everything is based on service, there is tea carts for patients and families. If you go into the emergency room and you have to get into a gown, your garments are immediately placed in a garment bag. It’s a totally different experience. As well as the whole VIP and royal and beyond just the general population.  We also need to accommodate family. This a plain tree concept, but the family is critical to the overall success to the patients overall outcome, not only when they are in the hospital but also after they leave. So if you engage the family as an active member in the space, whether it is the out-patient department or whether they are in a patient room, then that person can be more educated and better able to care for them down the road.  They do lead to demands. The room to the left is a NICU, we are looking at creating private NICUs, this is actually a very large one. I couldn’t find a better picture for a more  ________________________________________

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realistic room. But basically putting space in there for the parents to stay the night so they can really be a part of their child’s early life. And then in intensive care units there is a floor plan graphic of the NICU in Cleveland Clinic, where they have the nursing zone at the top of the room and then there is an entire family zone for large numbers of the family to really stay in the room and be part of the patient care.  We also are accommodating various needs for the family, we’re looking at TVs, separate TVs for family, and Internet access. In Korea on the right–this is not the final project— this is what they had before. Even in wards they have cots underneath each hospital bed that roll out at night so a family member can sleep. So if you picture where you have three feet between one bed or between one stretcher from another, you’ve got the nurse is only limited to one side of the patient during the night because there is a family member sleeping there.  Going back to Cleveland Clinic, we included a lot of amenities, they like to bring in food, bring the patient the food they’re used to having so they have refrigeration and warmers for family supplies and for them to bring in home cooked meals.  Patient safety from falls is a huge problem in all the facilities. One of the interventions, as we call it, is on the left, where we are looking at using actual little hand rails built from the head wall side so the patient can navigate their way to the bathroom, which is also right there. There is some argument against it, claiming that empowering the patient to get up is actually more damaging than making them sit in a place where they can’t possibly get up without help and require lifts and other things. Lifts are everywhere now, in every space, I am finding it hard to find procedural rooms to patient rooms and projects now that don’t have ceiling lifts built-in.  Well those are all direct things, now from an indirect standpoint, staff have the stress too, so we want to create the same types of spaces for staff. We want to use the on stage and off stage model from Disney. And we want to create efficiency for staff. So that they can spend more time with the patient. Ultimately, in my mind, in a hospital administrator’s mind, staff efficiency might be about bottom line, but the health care architects mind and many of the nurses I’ve dealt with, it’s about spending more time with the patient. So if we make the nurse more efficient, they can spend more time with the patient. So, how do we do that? The biggest trend right now, and probably in the past 10 years, is to decentralize nursing stations. It’s highly controversial but we’re finding that demographically, as the younger generations of nurses come up, they’re more independent and they rely on things like social media and texting. So they are used to actually communicating in different ways. Actually, it’s easier for them to work in decentralized environments. But that puts them right at the patient rooms. In addition to the decentralized nursing stations we are looking at bringing back, in many projects, the old nursing server. Basically, it’s a caster cabinet that has supplies, linens, and even possibly a med-locker for each patient so that all the supplies are right there at hand. And really what this is about, is minimizing travel distances. The top diagram is typical nurse traffic, were the nurse is going all day long to different utility rooms, to different patient rooms, the central nursing station, versus the bottom diagram where it’s all compacted and the supplies are at the bedside almost–we don’t want them at the bedside in the room because that gets in the way, but we want them outside the room  ________________________________________

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because its nearby. And as far as travel distances, instead of walking miles every day it is reduced to just a manageable few hundred feet because everything is right there. Another big argument is: are same handed rooms better? We have many projects where we don’t do same handed rooms but we do mirrored rooms. Where they are the same hand but it’s flipped. So you approach a patient in one room from the right and the other room from the left, but everything else in the room is identical. Same handed rooms put everything in the exact spot. So borrowing from the whole industrial world and lean design from things like Toyota, is to put everything in the same spot and eliminate steps, eliminate wastes in the process, and make everybody as efficient as possible.  We also have a lot of arguments, literally arguments between facilities nursing staff, administration, and physicians about the placement of toilets in the patient rooms. Whether it’s inboard next to the corridor or outboard by the window and what that does. Whether it crowds the entry into the room and creates problems and allow the nurse to have those decentralized nursing stations. Or whether it blocks the natural light if it’s on the outside of the room. So we have a lot of different models. Two of my favorite models are the model that puts the toilet in between two patient rooms. But what this does is it lengths the corridors, because the patient rooms take up more room along the corridors. So they are some negatives to that. Another, is we are trying to find away to have inboard toilets and successful decentralized nursing stations. The bedroom on the right there, is actually one in Saudi Arabia, the team has actually done the patient toilets inboard but because of their nursing ratios, they have very little confidence in their nurses there, so they want the nursing ratios in their intensive care units and step down units to be one to one or more. So because of that we have a decentralized nursing station in every room.  Infection control, as Dr. Fromm mentioned, this is one of my favorite topics and I’m used to arguing a lot with infection control officers but infections are a huge issue and the biggest culprit obviously is you. In 2008 less than 40% of staff followed proper hand washing protocol. And then if you take that one step further, the keyboards that we are touching all over the facility, there is a lot more germs on every keyboard than there is even on that toilet there. But because of that we have some really really aggressive control officers in every facility we are dealing with.  In Humber river, the diagram on the left shows that we have to have, in every patient room, or any room really (a utility room, even some vestibule areas) when you open the door, right inside the door, in that exact spot, there has to be a handwashing sink and it has to be visible to the patient. So in this diagram here, that ultrasound room because of the door has to be opened all the way, that sink is not compliant. I had to move it, so some facilities are getting really picky about it.  We are doing whatever we can to create a hands free environment. We try to use soap dispensers and sinks that are hands free. We use paper towel dispensers that are right above the sink, so there are not droplets of water anywhere else. We put biohazard soil bins and waste bins with openings so that the staff can just wash their hands and toss it and just go right to the patient. So when they come right into the room or leave the room they are always walking by the sink and the patient sees it.  I mentioned evolving drivers, the health care is continually changing from your perspective, but it’s also changing how we do things. The patients are becoming more informed and demanding customers. Whether you like it or not, as physicians, webMD is  ________________________________________

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there, and it leads to patients coming in with their own preconceived notions. But also they’re informed and want to be part of their care process.  The veterans administration, in fact, has created a model called the PACT model, Patient Allied Care Team, and it’s completely revamped how we do outpatient health clinics for the VA. Where we embedded, in every primary care or speciality care clinic, mental health social workers, nutritionist and other staff, and it’s created additional space and additional consult rooms. At the same time they are going to less offices, so we are finding it’s actually making things a little better. But the patients are becoming more demanding, as you know.  We are all getting older. The boomers are getting older and the boomers are going to live a lot longer than their parents. And they are going to have a lot more episodes requiring hospitalization and care, and they are going to have a lot more chronic problems, so we are going to have to deal with that somehow. I don’t know exactly what that means, but all indicators tell us that we are going to find a more use on pushing as much as we can into the ambulatory environment and then hospitals are going to be there for the very very sick.  The growing population is growing in many ways. We are growing outward too. The bariatric design is probably the most frustrating thing for architects. Because everything we’ve known about design spaces, the size of bathrooms, the sizes of patient rooms, exam rooms, utility rooms, everything that could possibly have anything to do with a bariatric patient means our equipment is getting bigger. So we really need to design more larger space and frankly hospitals need to build more space and it cost more money, all to deal with obesity.  Staff shortages: Demographic also lead to staff shortages as the population gets older the nurse get older and there are fewer and fewer younger nurses. So basically, we are trying to find ways to accommodate and support that staff. I mentioned earlier things like decentralized nursing stations make them more efficient, but we are also relying on things like robotics, for all sorts of supplies and very high end magnitude systems. In the Humber River project in Toronto, we actually have AGV’s from Germany, Automated Guided Vehicles, that run all day long delivering supplies to every department in the hospital, they go to the pharmacy, they deliver raw material, they go to the other side of the pharmacy and pick up med carts and deliver them to each floor. Basically, what it’s meant, from an architectural standpoint, is our corridors need to be wider to accommodate these things and elevator vestibules are much larger. In addition, there is obviously laboratory and pharmacy changes in automation that are changing how we design those spaces as well. And generally, even though technology is getting smaller, those spaces are getting bigger and bigger.  Sustainability, is really at the heart of trying to do what’s right, not just for the patient, but for the whole environment. So they are many issues of Green Guide for health care that not only tell us what to do as designers, but tell you what to do as hospital staff and how to maintain the facility. Green roofs are becoming the standard. We are looking at water conservation, in Fort Belvoir we actually have a rain catching roof that collect water and stores it, and its use for landscape irrigation.  This is Cleveland Clinic in Abu Dhabi, in this one we created, because the Sheikh wanted a glass box jewel of the dessert, it’s not really an efficient design for energy, so the mechanical engineers came up with a new really unique idea, where the building  ________________________________________

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breathes. The air that comes out of the building that’s exhausted actually goes across a manifold that actually pre-cools the incoming fresh air. And then that dirty air is exhausted through the exterior double glass wall system. That actually acts like a thermostat to keep the building cooler. So there is a lot of high tech things that are being utilized to take advantage of different environmental situations. Within a space indoor air pollutants are a problem, the smells, the headaches that contribute to patient problems are a big problem. One of the things that I think is going to be a big change in the coming years is displacement ventilation. Basically, providing air at a low level, that is slightly warmer temperature, that’s more efficient, and a little velocity, basically cutting down mechanical ventilation cost by a half to two-thirds, in some instances. And also it’s much more comfortable for the patients, because it’s not this cold blast of air blowing down on them from the ceiling.  In Singapore and other climates like that natural ventilation is the norm for most of their patient rooms. So we’re looking at different models to utilize building pressure, wind flow, to actually draw air through the building and draw it up through what’s called a– basically like a heat stack– and suck the air through the rooms. We also are changing the way the old style wards are looking. This an extreme example, but basically, you can see patient beds that would normally be right on top of each other are kind of pulled apart, to allow that decentralized nursing station to be right at the bottom of the picture there, to see all those patients, as well as have the natural ventilation.  Technology is changing, I can talk for hours about this, but bottom-line is that everyone got an I-phone or some other tablets. We are designing all hospitals now with wows and tows, and even going away from that now, to more tablet orientated designs. So it’s completely changing the computers presence and how we design spaces, as well as patient education rooms.  Economics and politics are going to shape the future. I don’t even know where things are going to go, but obviously these two men have different ideas (Obama and Romney). They both have the best intention we think but reimbursement has changed. The whole reimbursement issue with infections and other hospital injuries not being reimbursed, there is going to be a lot more. No more DRGs, things are going to change. There is a lot more changes coming through legislation. And then finally medical tourism. Medical tourism is why as an architect I have been travelling the world a lot in the past ten year. A lot of third world countries, or developing countries, or wealthy countries, are creating marquee medical centers to draw people from Canada and the UK. Places with socialized medicine, where the waiting list is too long to get a procedure or to not reimburse, so they go overseas. The cost in different countries is up to 75% less than what it will be here. So if our health care system changes, and patients are more dependent on paying their own way then there is going to be a lot more American medical tourism, travelling, doing vacations, and having procedures. Really that’s how the Cleveland Clinic project came to be. Cleveland Clinic, Johns Hopkins, Wooridul from Korea, they are all going to the Middle East. They are all partnering with these developing countries and creating areas.  Well, in the interest of time, I’m going to cut it at that, but basically what I said in the beginning was that the patients are not healed by the building, but the building can contribute radically. It can contribute by lowering their stress, lowering their blood pressure, it can help prevent unnecessary infections, it can make the staff more efficient,  ________________________________________

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make them spend more time with the patient. So if you get to the bottom or the heart of the matter for this conference, really, you can treat the patients’ body, mind, and spirit. You can communicate and educate, work with them and their families, and give them a holistic care. And also you can have the best possible working environment for all, with the lowest possible stress. And they look pretty nice too, everyone wants to work in a nice environment.