Design details for health : making the most of design’s healing potential [2nd ed.] 9780470524718, 0470524715

Table of contents :
A List of Checklists and Special Topics. Foreword. Acknowledgments. Part One. Long-Term Care. 1. Assisted Living. 2.Caring for People with Dementia. 3. Home Health Care. 4. Hospice. 5. Subacute Care and Rehabilitation. Part Two. Ambulatory Care. 6. Day Care and Respite. 7. Medical Offices. 8. Wellness Centers. Part Three. Acute-Care Hospitals. 9. Birth Centers. 10. Children's Hospitals. 11. Inpatient Psychiatric Units. 12. General Hospitals. 13. Critical Care. Index.

Citation preview

DESIGN DETAILS FOR HEALTH Second Edition

DESIGN DETAILS FOR HEALTH Making the Most of Design’s Healing Potential Second Edition

Cynthia Leibrock • Debra D. Harris, Ph.D.

JOHN WILEY & SONS

This book is printed on acid-free paper. ♾ Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978–750–8400, fax 978–646–8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201–748–6011, fax 201–748–6008, or online at www.wiley.com/go/permissions. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. For general information on our other products and services, or technical support, please contact our Customer Care Department within the United States at 800–762–2974, outside the United States at 317–572–3993 or fax 317–572–4002. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley products, visit our Web site at www.wiley.com. Library of Congress Cataloging-in-Publication Data: Leibrock, Cynthia. Design details for health: Making the most of design’s healing potential / Cynthia Leibrock and Debra Harris.—2nd ed. p. cm. Includes bibliographical references and index. ISBN 978-0-470-52471-8 (cloth); 978-0-470-926826 (ebk.); 978-0-470-92683-3 (ebk.); 978-0-470-92684-0 (ebk.); 978-0-470-95026-5 (ebk.); 978-0-470-95050-0 (ebk.) 1. Health facilities—Decoration. 2. Interior decoration—Health aspects. I. Harris, Debra D. II. Title. NK2195.H43L45 2011 747’.8551—dc22 2010025491 Printed in the United States of America 10

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To our Christian faith which inspired this book.

CONTENTS A List of Checklists and Special Topics Foreword

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Acknowledgments xv PART ONE

LONG - TERM CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Quality of Residential Long-Term Care 2 Design Intervention 3 Technology 4 Residential Long-Term Care in Other Countries 4 Endnotes 6

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ASSISTED LIVING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Assisted Living in Europe 8 Assisted Living in the United States 12 Planning Public Spaces 17 A Note on Apartments 24 Endnotes 25

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CARING FOR PEOPLE WITH DEMENTIA . . . . . . . . . . . . . . . . . 27 Reducing Distractions 32 Establishing Links with the Familiar, Healthy Past 33

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Providing Sensory Cues to Prompt Memory 34 Eliminating Dangerous Options 36 Avoiding Confrontations 38 Encouraging Successful Social Interaction and Family Participation 39 Releasing Excess Energy 41 Encouraging Independence 42 Endnotes 44

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HOME HEALTH CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Design Demonstration Centers 47 Cohousing 54 Group Homes 57 Independent Living 61 Endnotes 65

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HOSPICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Design Criteria 70 Privacy 70 Comfort 71 Support of Friends and Family 76 Individual Choice 80 Infection Control 81 Security 81 Endnotes 82

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SUBACUTE CARE AND REHABILITATION . . . . . . . . . . . . . . . . . 85 Design of Subacute-Care Facilities 86 Design for Visual Acuity 86 Design to Enhance Hearing 88 Assistive Technology 91 Design for Improved Cognitive Ability 92 Design for Mobility 94 Other Sensory Issues 97 Design of Rehabilitation Facilities 97 Physical Therapy 99 Occupational Therapy 100 Specialized Services 107 Endnotes 112

Contents

PART TWO

AMBULATORY CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Health-Care Cost Containment 114 The Educated Consumer 115 Endnotes 116

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DAY CARE AND RESPITE . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Adult Day Care and Respite 118 Day Care for People with Dementia 128 Child Day Care 132 Endnotes 134

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MEDICAL OFFICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Accessing the Facility 137 Registration and Waiting 142 Examination and Consultation 151 Self-Care 154 Laboratory 155 Specialized Practice 155 Pediatrics 156 Diagnostic Imaging Centers 159 Ambulatory Surgery 160 Oncology and Cancer Care 162 Endnotes 169

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WELLNESS CENTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Transforming Hospitals into Wellness Centers 175 Design Elements 176 Fitness Area 177 Extended Services 181 Locker Rooms and Wet Areas 182 Swimming and Aqua Therapy Pools 187 Comprehensive Services 189 Endnotes 191 PART THREE

ACUTE-CARE HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . 193 Endnotes 195

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BIRTH CENTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Innovations in Birth Centers 197 The Birth Room 200

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CHILDREN’S HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . 207 Efficacy 208 Comfort and Safety 212 A Sense of Belonging 215 Positive Distraction 218 Endnotes 225

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INPATIENT PSYCHIATRIC UNITS. . . . . . . . . . . . . . . . . . . . . 227 Patient Independence 229 Integration of the Family 231 Public and Social Areas 231 The Mind-Body Connection 234 Endnotes 237

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GENERAL HOSPITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Critical Trends and Issues in Acute-Care Design 240 Cooperative Care and VIP Suites 261 Cooperative Care Model 261 VIP Suites 264 Endnotes 274

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CRITICAL CARE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Emergency Departments 277 Intensive Care Units 281 Specialized Intensive Care Units 286 Cardiac Intensive Care Units 286 Neonatal Intensive Care Units 288 Family Waiting 294 Endnotes 295 Index

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A LIST OF CHECKLISTS AND SPECIAL TOPICS Carpeting 21 The Seven Basics of Housing for Home Health Care 46 Strategy for Safe and Comfortable Aging 51 Security 54 Windows 59 Universal Kitchen Design 64 Building Approach 69 Doors 74 Door Hardware 76 Eliminating Glare 87 Color 89 Universal Lighting 90 Grab Bars 95 Universal Kitchen Cabinets 101 Universal Kitchen Counters 102 Universal Controls 104 Universal Faucets 104 Universal Sinks 105 Electrical Switches 105 Receptacle Outlets 106 Kohler Demonstration Project 108 Seating 126 Upholstered Seating 127 Parking and Curb Ramps 138 Passenger Loading Zones 139 Elevators 140

Drinking Fountains and Water Coolers 144 Room Dividers and Wall Systems 150 Computer Stations for All Abilities 150 Showers 183 Toilet Stalls 185 Lavatories 185 Toilets and Urinals 186 Validating Acoustic Guidelines 201 Flooring 203 Accessible Routes for Children 210 Accessible Bathrooms for Children 212 Therapy as Play 222 Outdoor Play Areas for Children with Disabilities 224 Pattern, Texture, and Contrast 236 Planning a Healing Garden 246 Accessible Signage 250 Environmental Wayfinding and Orientation Cues 253 Ramps 258 Stairs 259 Handrails 260 Tables 271 Patient Beds 272 Bathtubs 273 VIP Patient Bathroom Amenities 274 Wardrobes and Dressers 286

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FOREWORD

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he physical environment is made up from two basic elements: the natural environment and the built environment. We can thank Mother Nature for providing us with such a remarkably functional and supportive natural environment. Interestingly, much of the built environment is the consequence of specific decisions that design professionals have made on our behalf. How do they know what is really best for us? What research can be drawn upon to support the decisions that designers make, to increase the likelihood that their built solutions will be both functional and supportive? Fortunately, Cynthia Leibrock and Debra Harris have developed a vitally important reference that provides practical answers to these questions: the second edition of Design Details for Health. Here, they draw upon and compile a rich source of evidence that supports the application of specific research-based details for particular health-related settings. In this regard, it is instructive to note that the actual purpose of applying these design details is all in the service of improving health through a knowledge-based decisionmaking process that transcends the boundaries of mainstream “health care.” This distinction is a subtle but crucial one, since many of these applications do also, coincidently, support clinical and/or organizational improvements within the healthcare setting. It must be stated that this book represents a quantum leap into the future, and the authors are to be applauded for their invaluable contribution to mainstream practice, both the broad practice of design professionals as well as the practice of all health-related practitioners. Eleven years ago, when I wrote the foreword for the first edition, evidence-based design was in its infanthood. Between then and now, the awareness and utilization of evidence-based design has snowballed as an extension of two foundational precedents: the supportive work of both the Environment–Behavior (E-B)

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pioneers as well as the practitioners that embrace the evidence-based medicine movement. From the E-B pioneers, who believe that design of the environment can influence behavior, the leap was not that dramatic to postulate that design of the environment could also improve health, healthcare, and well-being— which, of course, we now know that it does. From the evidence-based medicine movement practitioners, it was also a natural stretch to suggest to the health-care-based decision makers that a similarly sound rationale could be used to argue on behalf of certain design features . . . and here we are today. I can only speculate that, within the coming decade, that this progressive approach to designing the built environment for health, health care, and well-being will only accelerate—and that the next logical extension of this knowledge base will actually be of the scale of an entire encyclopedia. I wholeheartedly encourage Cynthia and Debra to buy a big box of pencils, and start writing now. Dr. Wayne Ruga, AIA, FIIDA, Hon. FASID Founder and President, The CARITAS Project

ACKNOWLEDGMENTS

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his book is enriched by the many individuals and organizations who generously contributed their knowledge, time, and images, without which this publication would not be possible. We would like to thank the following design firms, hospitals, manufacturers, photographers, and individual professionals and academics: Adventist Behavioral Health, Affinity Health System, Menasha, Wisconsin, Aktivitetscentret Sophielund, Anita Rui Olds, AZPHOTO Houston, Barrier Free Environments, Ben Carter, Bennington Project Independence Adult Day Care and Rehabilitation, Benny Chan/Fotoworks, Bon Secours St. Francis Cancer Institute, Bradley Jones, Brian Fritz, BSA Design, Caritas Good Samaritan Medical Center, Centerline Architects, Chambers Lorenz Design Assoc., Chas McGrath, Clarian Health, Colin McRae Photography, Condell Medical Center, UCLA Medical Center, Dean Birinyi Photography, Delawie Wildes Rodrigues Barker & Bretton, Dell Children’s Medical Center of Central Texas, Desert Samaritan Medical Center, Dronning Anne-Marie Centret, Earl Swensson Associates, Inc., Easy Access to Health, LLC, Eckert & Eckert, Ed Jacoby, Ellerbe Becket, Esto Photographics, ETV arkitektkontor AB, Eva Maddox Associates, Inc, Evan Terry Associates, Flad Architects, Florida Hospital Celebration Health, Fran Brennan Photography, Frank Guillani, Gail Collins, Gruppbostäder i Sverige AB, Guynes Design, Inc., H + L Architecture Ltd., Hafele America Co., Healthcare Environment Design, HEWI, Inc., Hilliard Photographics, Inc./Joe Hilliard, Hospice of Lancaster Co., Jain Malkin Inc., The Office of James Burnett, James F. Wilson, James Halsted, Ltd., Jason Cheng, Jim Semlor / Semlor Image, John Bertram House, John Durant Photography, Jud Haggard Photography, Kai-Yee Woo & Associates, Karlsberger Architects, KI, Kieran Reynolds Photography, Kohler Co., Koyama Photographic, Land Design Partners, Inc., Laura Bauer, Louis

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Acknowledgments

Feinstein Alzheimer’s Center, Mallary Morbant, Marc Swendner/ photographer, Mark Johnston, Mary Beth Rampola, Mary Jean Thompson, Max Plunger, Maxwell MacKenzie/Photographer, Memorial Hermann Hospital, Memorial Hermann Memorial City Heart & Vascular Institute, Memorial Hermann The Woodlands, Mid-Columbia Medical Center, Moore lacofano Goltsman, Inc., Morris Architects, Inc., NBBJ, Niels Gjerstrup, Odell Associates, Inc., Ohlson Lavoie Corporation, Orcutt/Winslow Partnership, OWP&P Architects, Paul Docktor, MD, Photographer, Paul Schlismann Photography, Pei Partnership, Perkins+Will, Philip Prowse Photography, Pratt Design Studio, RAD Consultants, RBB Architects, Reese, Lower, Patrick & Scott, Ltd., Rehabilitation Institute of Chicago, Rick Gardner Photography, Robinson Design, Roger Whitehouse, Sanford Health, Scott McDonald, Scottsdale Healthcare’s Breast Health Center, Scripps Ambulatory Surgical Center, Seccombe Design Associates, Sekisui House, Ltd, Seton Family of Hospitals, Shepley Bulfinch Richardson and Abbott, Skyline Art Services, Spector Group with Guenther Petrarca, St. Anthony Summit Medical Center, St. David’s Women’s Center of Texas, St. Vincent’s Hospital South Tower, Stanley-Senior Technologies, Steinkamp Photography, Steve McClelland Photography, Steve Rosenthal, Stichting Humanitas Rotterdam, StudioSIX5, Susan Rodiek, The McGraw-Hill Companies, The Mohawk Group, The S/L/A/M Collaborative, Timothy Doyon, Photographer, TRO/The Ritchie Organization, Watkins Hamilton Ross Architects, Wayne Ruga, The CARITAS Project, and Zimmer Gunsul Frasca Architects. This book is better for the contribution of guest authors, experts in their field. We are especially grateful to Laura Bauer; Elizabeth Brawley; Louise Carter; Julia Child and RISD; Sarajane Eisen; Kirk Hamilton; DAK Kopec; John Marsden; Keith Diaz Moore; Mary Beth Rampola; Jane Rohde; Mardelle Shepley; Margie Snow; Jo Solet, Orfeu Buxton, Jeffrey Ellenbogen, Wei Wang, and Andy Carballiera; Ruth Tofle, Benyamin Schwarz, and SoYeon Yoon; and Robert White, M.D. We would also like to thank our publishers, John Wiley and Sons, Inc., our editor, John Czarnecki, and our editorial assistant, Sadie Abuhoff. A special thanks to those who really made this project possible—our families and friends, for their support and understanding as we have labored to complete this manuscript, which we hope is a valuable contribution to the field of healthcare and senior design.

P A R T O N E

LONG - TERM CARE

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he Census Bureau data released September 27, 2007, showed that 7.4 of those 75 and older lived in nursing homes in 2006. However, that is down from 10.2 percent in 1990. Today 4.4 percent (1.57 million) are still living in institutionalized settings according to the U.S. Department of Health and Human Services Administration on Aging.1 In addition to those living in institutional settings, it is estimated that 95.5 percent of older persons may be in need of varying levels of long-term care services. These services vary across the states and many in need fall through the cracks in the system.2 Many residents of long-term care facilities are moved several times through what has been termed the “spectrum of long-term care” as the resident’s condition changes or requires more care. A resident may move from independent living, to assisted living, and then on to a nursing home when the resident requires 24-hour medical care and perhaps hospice services. The continuing care model does not minimize the relocations, but restricts those relocations within the community. However, “aging in place,” a concept whereby the management of long-term care services provide a much needed opportunity for older people to live independently in their communities, can be supported by design that contributes to independence, providing safe and comfortable homes to live out the rest of their lives. The number of Americans 85 years and older is expected to increase from 4.2 million in 2000 to 5.7 million in 2010 and then projected to increase to 12.9 million by 2020. This will represent over 23 percent of the elderly.3 Unfortunately, only 9 percent of the 3.7 million older persons enrolled in Medicare received care from service provider agencies. Most rely on families and friends to provide necessary caregiving.4 Statistics like these underscore the importance

of making long-term care services available and providing design interventions to age in place and avoid institutionalization. Furthermore, the number of children and adolescents with severe long-term health conditions and adults with physical and developmental disabilities continues to grow. Of people 6 years and older, 11 million needed personal assistance with one or more activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Among people aged 65 and older, 51.8 percent had a disability; and about 36 percent had a severe disability.5 Among the population 15 years and older, 3.4 percent had a visual impairment; while an estimated 3.4 percent of people aged 15 and older had a hearing impairment.6

QUALITY OF RESIDENTIAL LONG-TERM CARE Research has shown that emotional stressors may influence the immune response to bacteria, thereby making the resident vulnerable to disease.7 High-quality home care may prevent the need for institutionalization and the associated stressors. Geriatric evaluation and diabetic assessment services provide in-home assessment and referral to community services. These services are offered in the home by some geriatric physicians, registered nurses, home health aides, medical social workers, and therapists. Home therapies are becoming commonplace, including provision of pain management, dressing and wound care, ventilation therapy, and phototherapy for jaundice. Physical and occupational therapy account for about 10 percent of the services in the home. Technology also supports activities of daily living. Examples include heart monitors and

Long - Term Care

glucometers; active devices that perform therapy on users (home dialysis systems, perfusion pumps, drug delivery systems, and oxygen systems); and general assistance and monitoring devices such as fall detectors and pill-minders. Another important component supporting home care is home modification. This may include nonmedical equipment for lifting, mobility, special chairs, rails, ramps, adapted toilets, showers and baths, beds, and adapted kitchen design. Through housing design and supportive technology, individuals can function with a higher level of independence, and the demand for staff assistance may be reduced.

DESIGN INTERVENTION Consumers are increasingly demanding more options for senior housing and residential care. In most communities these choices are limited to (1) independent living, (2) assisted living, and (3) skilled nursing care. CCRCs integrate all three, moving residents from independent living to assisted living when activities of daily living become challenging, then to skilled nursing when significant medical challenges require fulltime care. In contrast, aging in place allows the resident to stay in the same place and have services delivered to the resident. However, the choice for residential long-term care is a personal one, a decision made by the individual or with family members and their medical professionals to determine the level of care needed and the type of residential living that is appropriate. Such choices might include: 1. Community-based group homes 2. Foster homes

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Supervised apartments Shelters Housing with live-in roommates Host homes where the resident becomes part of the family Boarding houses Shared homes Semi-supervised apartments (without live-in managers) Subsidized support programs where individuals receive payments to follow a plan for self-sufficiency (or discounts on insurance for healthy houses and healthy habits)

These choices support all ages and financial abilities. A team of professionals can help with a seamless transition by providing a “needs assessment,” modification when necessary, and assisting devices. The team may include an occupational therapist, social worker, architect, and interior designer The design of a residence can significantly affect care. Many long-term care services can be eliminated by making changes in a person’s dwelling.8 In addition, studies show design elements influence the ease with which long-term services can be provided in the home.9 For older people, design improves ability to adapt to and recover from stressful activity. It also maximizes the use of existing mobility as well as the auditory, visual, and tactile senses. Forty percent of deaths from injuries to people 65 and over result from accidents at home. Tripping, fire safety, handrails, lighting, hot water temperature, HVAC (heating, ventilation, and air conditioning), kitchen safety, and security are issues that become critical for long-term care. Research confirms that the most important issues for older people involve health and security. A survey of 500 southern California

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seniors (over the age of 65) showed that the most requested features were 24-hour security on the premises, an arrangement with the local hospital, an attendant on the premises trained in cardiopulmonary resuscitation (CPR), emergency call systems, and a television security system in the building.10

TECHNOLOGY Communication tools are truly important for those with decreased mobility. Audiovisual and communication devises can connect residents to family and friends, preventing loneliness and a connection to care providers to provide a safe feeling. Commonplace technologies like personal computers with a camera and sound can also be used by providers to monitor patients and to improve diagnosis and treatment in the home. It can provide patients and their families with access to records, and the best medical expertise and information on specific illnesses. Smart technologies help older people and people with disabilities live independently in their homes by offering services to aging in place residents including safety monitoring, social alarming, sensor alarming (smoke, CO, housebreaking), medical monitoring (telemedicine), functional management of comfort (remote operation of lights, curtains, doors, etc.), energy management, and multimedia and entertainment.

RESIDENTIAL LONG-TERM CARE IN OTHER COUNTRIES The argument for home care is strong. It prevents or postpones institutionalization, promotes healing, allows for freedom of the individual, and

home care is personalized, tailored to meet the specific needs of each individual. The aim of home care is to meet health and social needs of individuals with high-quality home-based health care and social services. This may include formal and informal caregivers and the use of technology when appropriate. In Europe, home health care is practiced differently around the region. Because of this, evidence about the appropriateness and effectiveness of home care is diverse and complex, making it difficult to gather and analyze data to make informed decisions. Improvements in public health to identify noncommunicable diseases have contributed to the demand for home care, especially for treatment of mental illness, dementia, and Alzheimer’s disease, and chronic illnesses more people are living with such as diabetes, heart disease, respiratory disease, stroke, and cancer. According to the World Health Organization (WHO), with the appropriate and targeted support, these illnesses could be effectively and efficiently taken care of at home.11 Home health care in France had an early start but is limited in its development. Since 1957, when home health care was an experiment to reduce the pressure on hospital beds, it has been an option, but mostly considered secondary rather than an alternative to hospitalization.12 Patients with mental illness, infectious diseases, and chronic respiratory or renal failure are not eligible for hospitalization at home. However, 60 percent of all elderly people utilize home care services either through a nurse’s aide or household help. In France, patients have direct access to national funding authorities and some control over service delivery. In Ireland, boarding-out has been explored. Patients are placed with nonrelatives in private homes. The client and the state split the

Long - Term Care

costs. However, most of their elder home care is focused on formal and informal care, but needs regulation and a framework to govern key areas of access, financing, and quality. Demographics in Japan suggests that by 2014, the increase in the older population will reach 32 million (25 percent of the total population), creating a tremendous market for long-term care design services. In Japan today, 16 percent of the population is 65 or older, but more than 50 percent of all health-care dollars are spent on these older Japanese.13 For this reason, the government already provides preferential interest rates on universally designed homes that prevent institutionalization. Since elders live longer lives with more disabilities and require more care, older Japanese are demanding residential longterm choices offering independence, personal growth, and support for activities, security, privacy, and dignity. Sweden boasts world’s largest proportion of citizens over 65 years of age and the largest proportion of people over 80 years of age. Many are in good health and lead active lives. Nearly 94 percent live in their own homes. According to the Swedish Institute, Sweden invests 2.8 percent of its gross domestic product providing public care services for the elderly. Although about 90 percent of all elderly care is provided by the government in Sweden, the elderly are allowed to choose whether they want their home care or senior housing to be managed by the public or private sectors. The goal of the government care provision is to ensure that older people and those with disabilities are able to live independently. This system advocates for living at home for as long as possible. The support includes home meal delivery, help with cleaning and shopping, safety alarms, and a transportation service.14

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Sweden and Denmark have moved many health services to residential environments. Sweden has been reducing nursing home beds by about 900 beds per year.15 Existing nursing homes are viewed as subacute facilities where only the most severely impaired patients belong. In Europe, much of this care is delivered in sheltered-care houses, which are typically smaller than U.S. assisted living facilities. In Sweden, five to six people may each live in their own small apartment grouped around a large living area and kitchen. At a minimum, each apartment has a separate bedroom and small kitchen. Couples frequently have two bedrooms, which offer the flexibility to hire live-in help at a later date. Some units are equipped with passive systems that summon help if the toilet has not been flushed or if the refrigerator door has been left open. Motorized windows sense rain and close automatically. Toilets have built-in rinse and dry features. Sinks tip forward to ease hair-washing from a seated position. The Swedes have found that design intervention is less expensive than staff intervention and that care in the home is less expensive than institutionalization. Grants are provided for adapting homes to meet the needs of the elderly and persons with disabilities. If a grant is awarded, the government pays the entire cost of the renovation, equipment, and furnishings needed to make the home adaptable. Denmark is considered the most advanced country in Europe in terms of social policies for older people. Services are typically brought to people in their independent living units until that becomes impossible. Then, every attempt is made to find long-term care within the immediate neighborhood of the individual. Housing complexes often offer intergenerational care, integrating children and seniors while still offering privacy. Considerable effort is made

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to blend these facilities into the neighborhood. Commercial restaurants, rather than dining rooms, are located within the facility. Day care and therapies are offered to the public by the facility, encouraging community interaction. In Denmark, disabled people have a legal right to continue living at home. Very extensive modifications to existing houses are paid for by the government. It is considered good economic housekeeping to empower a disabled person to

continue living at home. Legislation requires all ground-floor flats to be accessible. As general housing in Denmark has become accessible, the need for special housing for people with disabilities is reduced. Design demonstration centers are in place, allowing citizens to learn about their choices. These centers also help in the development of new equipment, providing consumer feedback to designers and manufacturers.

Endnotes 1. S. Greenberg,. A Profile of Older Americans. (Washington, DC: U.S. Department of Health and Human Services Administration on Aging, 2008). 2. Institute of Medicine of the Academies, Improving the Quality of Long-term Care. (Washington, DC: National Academy of Sciences, 2000). 3. Ibid. 4. Ibid. 5. M. Brault, Americans with Disabilities. Current Population Reports: Household Economic Studies, no. 2008, 2008. Retrieved September 11, 2009, from www.census.gov/prod/2008pubs/p70-117. pdf. 6. Ibid. 7. T. Breivik, P. Thrane, R. Murison, and P. Gjermo, Emotional Stress Effects on Immunity, Gingivitis and Periodontitis. European Journal of Oral Sciences 104:4, 327–334 (2007). 8. R. Stuyk Current and Emerging Issues in Housing Environments for the Elderly, in America’s Aging: The Social and Built Environment in an Older Society, Committee on an Aging Society (Washington, DC: National Academy Press, 1988). 9. Ibid.; S. Newman, Housing and Long-Term Care: The Suitability of the Elderly’s Housing to the

10. 11. 12. 13.

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Provision of In-Home Services. Gerontologist 25:1, 35–40 (1985); Noelker The Impact of Environmental Problems on Caring for Impaired Elders in a Home Setting, paper presented at the 35th Annual Scientific Meeting of the Gerontological Society of America, Boston, 1982. V. Regnier and J. Pynoos, Housing the Aged: Design Directives and Policy Considerations. New York: Elsevier, 1987. R. Tarricone and A. Tsouros, Home Care in Europe: The Solid Facts. Copenhagen, Denmark: World Health Organization, 2008. B. Charles, Home Health Care in France. Pharmacy World and Science 12:1, 23–25 (1990). Hiroko Machida, “Why Housing Coordinator(s) for the Elderly,” paper presented at International Conference of Living Environment Health and Well Being for the Elderly, Izu, Japan, March 1997). Swedish Institute (2007). Elderly Care in Sweden. Retrieved September 11, 2009, from http:// www.sweden.se/upload/Sweden_se/english/ factsheets/SI/SI_FS8p_Elderly_care_in_Sweden/ Elderly_care_in_Sweden_FS8p_Low.pdf. Gilbert Dooghe and Lut Vanden Boer, Sheltered Accommodation for Elderly People in an International Perspective (Amsterdam: Swets and Zeitlinger, 1993), p. 64.

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he future of assisted living is lifetime care in one location. It is not the continuing care concept where residents are moved from independent living to assisted living to skilled care units. The best of assisted living provides the independence and dignity of a home, individual assistance with daily activities, and physical medical care for life in the same apartment. Traditionally, assisted living is defined as a housing model offering support for unscheduled needs,1 including assistance with ADLs, personal care, and some health care. Skilled nursing is defined as 24-hour medical intervention. However, it is important to note that, in regard to health-care services, the lines are blurred; many residents view the trip to skilled nursing as the last stop, but often, as residents regain their health status, they are moved back to assisted living for rehabilitation. Health care is now portable; many interventions can easily be brought to patients and their families with advancements in home health care. In addition, most assisted living complexes offer transportation to ambulatory care. Many have nurses on call, if not on the premises, 24 hours a day. Some complexes have two-tier call systems that let residents choose between minor assistance and emergency help. Prevention is a priority—nutrition, exercise,

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social activities, security, and safety (see Checklist: Security on page 54) are part of an integrated program of services managed by the provider. In the United States, a shift has occurred over the past 10 years, shaped by consumer demand. Assisted living has been the fastest-growing sector of housing for seniors. However, it is important to note that this industry is serving fewer and fewer low-income residents, often not accepting government financial support programs like Medicaid. Therefore, those with money have access to housing options driven by consumer demands, while those with limited resources have limited choices. Because of financial limitations, many older people who simply need assistance are residing in substandard skilled nursing facilities that are supported by government resources. Also, due to policies, either state mandated or provider driven, many residents are forced out of their assisted living situation when they begin to need more assistance, limiting the opportunity for aging in place. This is not true in much of Europe, where a distinct separation is maintained between housing and health-care facilities. Rehabilitation, emergency assistance, and 24-hour skilled nursing are available at home, but fewer Europeans actually live in health-care facilities. The United States has the largest percentage of people living in nursing homes of all developed countries in the world.2

ASSISTED LIVING IN EUROPE In 1996, the Humanitas Bergweg apartment for life project was completed in Rotterdam (see Figure 1–1).3 The Dutch concept was to create a housing and service system that supports older frail people in a normal apartment. What started out as the “Apartment for Life” philosophy of care has burgeoned into a multigenerational community accessible housing complex that provides apartments for 250 residents—rich and poor, healthy and sick, and young and old live in a noninstitutionalized setting. Though the average age is 80, the age range is 55–96; another twenty-five younger individuals with developmental disabilities live there. They will not be moved along the continuum of care from independent living to assisted living to skilled nursing. Humanitas Bergweg residents can now live with their spouse of any age, even a spouse with Alzheimer’s disease. They can have their children stay overnight in the apartment, and develop friendships with their neighbors without fear of being moved out of the neighborhood into a health-care facility. This project has literally returned

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Figure 1-1 Lifetime care without moving. Courtesy of Stichting Humanitas Rotterdam.

life to residents who were previously subsisting in semiprivate (which means almost public) rooms in nursing homes. The complex consists of 195 lifetime apartments, each with two or three rooms averaging 750 square feet. The apartments are not only accessible to people in wheelchairs; they are accessible to people in hospital beds as well (see Figure 1–2). Even bedridden residents can be bathed on a gurney in the privacy of their own bathroom (see the Kohler Demonstration Project Expert Focus on page 108). The apartments are built over an ambulatory health-care facility (see Figure 1–3) offering skilled nursing to one third of the residents, assistance to another third in the apartments while the remaining third receive no services and live independently. Instead of moving to a nursing home, nursing care is delivered by a home care provider. Many apartment residents, however, need therapy and rehabilitation, which is available within the complex or within the neighborhood. Each apartment overlooks an atrium whose glass roof provides yearround protection from the elements. Atriums are appreciated by older people with concerns about safety and security (see Figure 1–4). Even though the Humanitas Bergweg atrium is located on the second floor, a stream runs through it. Sculpture, trees, and plants are all bathed in daylight, a

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Figure 1-2 Gurneyaccessible apartment to support aging in place. Courtesy of Stichting Humanitas Rotterdam.

Figure 1-3 Geriatric rehabilitation in an apartment building. Courtesy of Stichting Humanitas Rotterdam.

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Figure 1-4 Atrium provides security and protection from the elements. Courtesy of Filo Laken, Stichting Humanitas Rotterdam.

major contribution to a healing environment. Surrounding the atrium is a 20,000-square-foot shopping mall that is not just for the elderly—the entire community uses the shops, restaurants, hairdressers, kiosks, and so on. Next to the elevator, an escalator from the street invites walk-in traffic and community interaction with the residents (see Figure 1–5). In addition to serving 195 apartments, the ambulatory health-care facility provides day care for 20 community residents and is staffed with occupational therapists, physical therapists, a full-time general practitioner, a dentist, and a massage therapist. Its offices open to the street, encouraging community use. The entrance to the facility is also on the street level, well away from the apartment entrance. There is clear separation between housing and health-care facilities. Humanitas Bergweg is a truly integrated complex offering shopping, dining, and health care to the entire community in a mode sensitive to the security and dignity of the older residents. This housing model is emerging in many countries in northern Europe. Increasingly, Europeans are not required to move out of their homes into a health-care facility. If a resident does not function well in an apartment, other housing choices are available (e.g., group homes for people with advanced stages of Alzheimer’s; see

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Figure 1-5 An escalator to attract visitors. Courtesy of Stichting Humanitas Rotterdam.

Chapter 2). But many older people can receive services in their own apartments for life, even if they lose ambulatory ability and are confined to bed. Although the apartments are constructed over a geriatric rehabilitation clinic (see Chapter 5), the separation between the place in which one lives and the place in which one receives health care is well defined. If necessary, one can receive treatment all day in the clinic and still have the dignity of returning to one’s own apartment at night. Residents are expected to perform at their highest level to save staff time and maximize independence. For example, therapy equipment is displayed in visible public areas to encourage residents to exercise without staff reminders. Residents are actually expected to exercise to maintain ability and elevate self-esteem. The units are much larger than those in a typical nursing home, yet the costs are about 35 percent less. The management attributes that savings in part to the peripatetic approach to care giving that characterizes this philosophy. After all, the whole system is operating on only 90 full-time employees.

ASSISTED LIVING IN THE UNITED STATES Much of U.S. assisted living design was built by former nursing home administrators and is still based on a nursing home model. This model is the result of the social programs of the 1960s and 1970s, when the federal government

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became the principal payer for care of elderly residents in nursing homes. Government reimbursement drives nursing home design and staffing, dictating such details as square footage per patient. Reimbursement is dependent on government approval through the certificate of need (CON) process and state inspections. There is little change in revenue when these inspections determine that quality of care exceeds the level required by regulations, and every incentive exists to maintain minimal care. Design improvements are discouraged by lengthy waiver, conditional-use permit, and variance processes. On the other hand, the best designers overcome the challenges and still manage to build innovative models. Theirs is the work that raises overall quality levels. Theirs is also the work that gets published and becomes the latest standards of good design. For example, when assisted living is combined with historic preservation, requirements can be modified to preserve the historic significance of the project (see Figure 1–6). One restoration was able to hide sprinkler heads in cornices and visual alarms under chair rails, retaining their function but eliminating the institutional appearance they convey. Many licensure codes, however, would need to be changed to construct affordable Scandinavian lifetime models in the United States.4 Scandinavian fire codes for long-term care are less stringent than those in the United States, allowing fireplaces in skilled nursing homes, reduced separation requirements, and natural (flammable) materials. The Scandinavian Living Center is an assisted living community in the Northeast that has focused on environmental attributes that provide a high quality of life while providing the care and support that seniors require. While this facility does not have fireplaces, it does have large windows in each unit to provide natural light in an apartment living environment; and a design that encourages independence, community, and fitness (including walking, stretch and yoga classes, massage therapy, and physical therapy on site). What are the program requirements of an assisted living model? In addition to transportation, the model must include optional assistance with the ADLs. These activities include housecleaning, daily bed making, linen service, personal assistance (e.g., bathing, dressing, and medication), meals, and health monitoring (e.g., pulse rate, blood pressure, and weight).5 Some of these services can be provided by family members, reducing costs as much as 40 percent and encouraging family participation with the resident.6 Residents should also be encouraged to help one another to bolster self-esteem, reduce dependence on staff, and reduce costs. A case manager must track volunteer involvement and ensure that all needs are being met. This ten-story condominium complex is located in San Mateo, California. It offers 65 condominiums that can all be converted to assisted living.

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Figure 1-6 Historic preservation in the assisted living setting. Courtesy of John Bertram House, Assisted Living Residence.

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Figure 1-7 A comfortable library with natural materials creates a homelike public space. Courtesy of Seccombe Design Associates, Inc. © Chas McGrath.

This is one of the few complexes in the United States licensed for both independent living and assisted living in each residence. Amenities include hotel services; a concierge keeps treats on hand for the many pets. Design details include an electronically controlled entrance, a library (see Figure 1–7), and an enclosed swimming pool. A nice option is offering choices in dining: elegant restaurant-style dining (C-1), private dining rooms, and perhaps a chef ’s bar for a quick meal (see Figure 1–8). The Stratford plan includes a lifetime medical program, including an on-site physician for consistency of care (see Figure 1–9) and a fulltime registered nurse. Transportation is provided to all medical and dental appointments, and medical insurance forms are processed by the staff. The wellness program includes health education (in the penthouse lecture room overlooking the bay), fitness classes, and nutritional consultation. An alternate model for lifetime care is been offered on many college campuses—Cornell, Iowa State, Indiana University, University of Connecticut, Dartmouth, Duke, University of Washington, Stanford, Princeton, and Lehigh, to name a few. Assisted living apartments are provided on campus, offering all of the perks of college life with none of the course requirements. Residents can attend classes, parties, free concerts, and collegiate games.

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Figure 1-8 A restaurant, not a congregate dining hall. Courtesy of Seccombe Design Associates, Inc. © Chas McGrath.

Figure 1-9 Exam room in a condominium complex. Courtesy of Seccombe Design Associates, Inc. © Chas McGrath.

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Sophisticated medical care is often available on these campuses and there is a strong emphasis on rehabilitation. Although skilled nursing is not generally offered in the apartments, most schools have a fine record of getting residents out of nursing homes and back on their own.

PLANNING PUBLIC SPACES The best of assisted living apartments provide environmental layers to allow residents to gradually enter social situations. A deck overlooking the entry permits residents to screen visitors without making a social commitment. The deck can also be used as a place for residents to smoke away from the entry. The first impression at many complexes is an entry littered with cigarette butts and a group of smokers as the official greeters. Entry landscaping must be carefully planned with no place for an intruder to hide. Even in safe locations, older people may perceive danger lurking in a highly landscaped entry. Night lighting contributes to the perception of safety and empowers the many older people who have trouble with night vision. Landscaping should offer distinctive layouts for each entry. Courtyards assist residents with orientation by spatially differentiating exterior landscaping. Parking lots should also be small and clearly differentiated (see Checklist: Security on page 54). To maintain a residential environment, delivery vehicles should not use the main entrance. They should deliver close to the staff kitchen, perhaps through a residential garage. As in any apartment building, the public spaces of assisted living complexes should be homelike and inviting but not at the expense of clear spatial definition. Forty percent of assisted living residents have some degree of dementia, and they may become confused in unfamiliar spaces like large congregate dining halls. Interior spaces should be small, intimate, and clearly defined. Interior social layers can be created by half walls, balconies, window seats, greenhouse enclosures, and atriums. Glassed-in porches can provide the dual benefit of a social layer as well as access to nature in a safe environment for socialization. Exterior views of nature keep residents alert to the weather and to seasonal changes (see Figures 1–10 and C-2). An exterior swimming pool offers an opportunity to exercise, spend time outdoors, and socialize. Tables with umbrellas can define personal space in the pool area and create another social layer. A swimming pool also offers an excellent opportunity to invite the community into the complex for exercise classes or an afternoon of family fun.

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Figure 1-10 Sitting on the porch provides access to fresh air, views of gardens, and activity in the neighborhood. Courtesy of Susan Rodiek.

EXPERT FOCUS Design Features that Contribute to Homelike and Inviting Spaces JOHN P. MARSDEN, PH.D. Provost and Vice President for Academic Affairs, Mount Mercy College

According to the National Center for Assisted Living (NCAL),1 more than 900,000 Americans currently live in assisted living communities. Three-quarters of residents are women, and the typical resident is 86 years old and needs assistance with approximately two activities of daily living. Although older women are the primary occupants of assisted living, family members are often the key decision makers when selecting a community. The most influential family members are daughters between the ages of 45 and 55.2 What physical features of assisted living communities are important to older adults and family members? Which characteristics contribute to homelike and inviting public spaces? I have found, through a series of photographic surveys with several hundred older adults and family members, that familiar housing cues, references to nature, scale, and accessibility are important in varying ways to these two distinct groups.3 In my studies, both older adults and family members responded favorably to symbols associated with the house, including porches, porticos, sloped roofs, gables, window shutters, fireplaces, and residential furniture as well as familiar spatial patterns and well-defined spaces that promoted understanding. Unfamiliar housing cues such as the porte-cochere, the windows of uniform shape and size, and the information desk with a large built-in counter often evoked images of hospitals and funeral homes. Direct references to nature through interior plants, natural light, and landscaping were desirable. Indirect references provided by window views and building materials such as wood and brick were also desired by both older adults and family members.

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The two groups differed with respect to scale. Older adults tended to favor lower ceilings in public spaces and one-story building heights that appeared more manageable. They preferred changes in rooflines, setbacks, and materials that helped to reduce the overall massing of buildings. They responded favorably to smaller bookcases rather than wall units and preferred windows with panes to humanize interior spaces. The two groups also differed with respect to the accessibility of spaces. Older adults experience the environment through sensory modalities that have been altered by aging. In particular, a decrease in visual acuity, an increase in sensitivity to glare, hearing decline, and reduced touch sensitivity may impact older people’s ability to interpret the environment and respond appropriately. As a result, older adults desired features such as indirect lighting provided by clerestory windows and cove lighting, furniture and flooring with matte finishes, furniture with padded but firm seating, and adequate spacing between furniture that facilitated independence. In contrast, these features were not salient in family members’ perceptions. When input from potential consumers—older adults and family members—is taken into account, designers may be more likely to create humane assisted living communities that support expectations, understanding, and effective functioning. And when consumers are satisfied, well-being and market appeal may be enhanced. 1. National Center for Assisted Living. Resident profile. www.ahcancal.org/ncal/resources/Pages/ResidentProfile.aspx; accessed March 11, 2010. 2. G. Dixon, P. Parshall, D. Pratt, J. Solinger, and D. Young., “The Foundations of Marketing: Referral Development and Successful Strategies,” in K. H. Namazi and P. K. Chafetz (eds), Assisted Living: Current Issues in Facility Management and Resident Care (Westport, CT: Auburn House, 2001), 65–76. 3. J. P. Marsden, Humanistic Design of Assisted Living (Baltimore, MD: Johns Hopkins University Press, 2005).

Water aerobics (followed by a sauna or spa) can provide significant pain relief. Swimming pools must be planned for users in wheelchairs as well as those with reduced hearing and vision (see Chapter 8). An interior pool may be a good place to increase sensory stimulation by adding live butterflies and the relaxing sound of falling water. If the pool is located in the basement, provide access to daylight and extra attention to acoustics. The concrete surfaces may reflect sound, making therapy and instruction difficult. Consider an instruction pit, a sunken area next to the pool that keeps the instructor dry and at the same level as the swimmers. Instruction and treatment areas should be acoustically isolated from the rest of the complex to prevent sound transition. Access to natural elements may also be provided by large windows that open onto protected interior gardens and invite exploration. Double-loaded corridors (with rooms off both sides) offer few opportunities for window placement. A corridor that circles an atrium or patio tends to have shorter horizontal stretches and offer more articulation. When this design is not

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possible, the corridor can be deconstructed with jogs or curves. Corridors can be planned to encourage chance encounters and excuses to meet people. Resting places should be provided and supportive handrails visually integrated (see Checklist: Handrails on page 260). Details define a residential environment. Seating breaks up long walks; kiosks offer snacks and drinks. Conversely, the design formula for an institutional environment is uniformity and lack of detail. Shiny beige vinyl composition floor tile and unfamiliar spaces like dayrooms are institutional clichés (see Checklist: Flooring on page 203). Rooms should be planned with clarity of purpose. Keep spaces understandable, with public spaces very public and private spaces very private. Residents do not understand a living room with 50 chairs in it. Spaces and finishes should anticipate behavior and physical limitations, particularly dementia and incontinence. Most assisted living residents experience some degree of memory loss. Familiar details like a fireplace, a case filled with books, and a china cabinet can trigger long-term memory and serve as important way-finding cues (see Figure 1–11) (see checklists: Environmental Way-Finding and Orientation Cues on page 253). Fragrances like baking bread and morning coffee are also important cues. Music can be used to bring back long-term memories and cue the start of daily events, maintaining a sense of order. Public space in assisted living can and should retain familiar, homelike qualities. Residents can be offered supervised options, like participating in laundry and cooking. A vegetable garden, aviary, greenhouse, aquarium, and liberal pet policy also allow the residents to express personal interests.

Figure 1-11 Comfortable furnishings and a warm fireplace have a homelike appeal. Courtesy of studioSIX5.

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Secure displays of personal collections offer important way-finding and orientation cues. Residents feel more in control when designers humanize interiors with such elements as bay windows, mullions, balconies, and carpeting (see Checklist: Carpeting on page 21). Human scale should be maintained, especially in areas frequented by residents. Entries, porches, and transition spaces may include windows with small panes and doors with details on a traditional residential scale.

CHECKLIST Carpeting • Light-colored carpeting increases light quantity throughout the space without increasing glare (see Figure C-3). • Hard-surfaced floors are not safer than carpet for controlling fungal or bacterial growth in health-care environments.1 • Hard-surfaced floors may hinder walking efficiency and confidence. In a study of 58 elderly hospital patients, carpeting significantly improved mean gait speed, step length, and walking confidence.2 • Carpet used with wheelchairs, carts, and gurneys cannot exceed ½-inch pile height, and a ¼-inch height offers less resistance to rolling traffic. • High-cut pile may pull a wheelchair, gurney, cart, or stroller in the direction of the nap. Use an uncut or tip sheer in a high-density pile for an easy traverse. • Carpeting with an antimicrobial system prevents microbial growth and resulting odors. • For people with dust allergies, hard-surfaced flooring is a better choice than carpeting, which can harbor dust and dust mites. • People with incontinence may associate cold, hard floors with going to the bathroom and thus will appreciate carpet. • Carpet reduces the incidence of falls and cushions falls that do occur. The carpet should have a pile height of ¼–½ inch; the pile should be of a high density. A carpet surface that is too soft is easy to sink into and may cause loss of balance. Large loops can catch on braces, canes, and walkers. • For people with hearing difficulties, reduce electrical interference with hearing aids by installing static-resistant carpeting. • For people with incontinence, seal concrete slabs with an acrylic polymer before installing carpeting. If the concrete flooring is hydrophilic, it absorbs liquids and their odors as it expands and contracts. Continued

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CHECKLIST Carpeting (continued) • Area rugs should be permanently installed to prevent tripping. The small wheels of wheelchairs, gurneys, carts, and strollers may cause loose area rugs to gather in front of the user. People in power wheelchairs may also be immobilized, and rugs may become tangled with the mechanism. • Borders can be used to blend carpet colors from room to room, but keep the contrast to a minimum so that a border is not mistaken for a step. • It is often difficult to spot a slight elevation in floor level. Single steps, thresholds, carpet tack strips (especially across corridors), and the edges of area rugs all cause tripping. Use a bevel when changing from one floor surface to another if the change is between ¼ and ½ inch. Use a small ramp if the change exceeds ½ inch (see Checklist: Handrails on page 260). • Metal carpet strips between rooms may pose a tripping hazard. Sew carpets together at doorways or use graduated transition strips. • For the easiest wheelchair ride over carpet and for a stable surface offering sure footing, eliminate padding in the carpet installation. A glue-down installation also prevents rippling caused by wheelchair or gurney use. 1. Center for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health-Care Facilities (Atlanta: U.S. Department of Health and Human Services CDC, 2003). 2. M. Wilmott, “The Effect of a Vinyl Floor Surface and Carpeted Floor Surface upon Walking in Elderly Hospital In-Patients,” Age and Aging 15 (1986): 119–120.

Entries, reception lobbies, and elevators require increased lighting levels, up to 100 footcandles for close work like reading instructions or signs7 (see Checklist: Universal Lighting on page 90). Redundant cuing should also be provided in the elevator, and an emergency elevator phone should be connected directly to the building manager and receptionist (see Checklist: Elevators on page 140). This phone cannot replace the elevator alarm system required by the Americans with Disabilities Act (ADA). Lighting is also used to reinforce the change from public to private space. Increased lighting levels at apartment entrances offer control, security, and clarity. Differences in detail, materials, and size can accentuate the transition, providing a unique apartment entrance as part of the way-finding plan. The entrance can also serve as an important place to people-watch from a wheelchair or to charge a power wheelchair. For this purpose, plan a special outlet and ventilation from the odors caused by recharging. For ambulatory residents, provide a place to sit down to remove boots and overshoes before entering the apartment.

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EXPERT FOCUS Senior Living Sustainability Guide (SLSG) JANE M. ROHDE, AIA, FIIDA, ACHA, AAHI, LEED AP JSR Associates, Inc.

The Senior Living Sustainability Guide will be available online and will consist of the following four sections or modules that may be utilized in tandem to develop sustainable senior living communities.

Resident Quality of Life Perception of life quality changes as physical and mental abilities decline. Many seniors measure quality by how close the lifestyle is to that of active elders living in their own home. Therefore, the primary goal of a senior community will be to provide the opportunity to continue basic activities of daily living and special interest activities. As resident support and care needs increase, the challenge is to compensate for the physical and mental losses as much as possible through environmental supports. The guide shall utilize indicators of quality of life based upon resident-centered care. For example, privacy is an important tenet of resident quality of life. The following would be indicators of privacy: • Operational policy in place that includes staff knocking on a resident’s door prior to entering their private space. This includes in-service training for the staff. • Private rooms that include personal controls at bedside for lighting and window blind control. • Organizational commitment to provide private resident rooms, but with the flexibility to accommodate couples and situations that may benefit from the sharing of a room (due to diagnosis or level of dementia).

Organizational Values and Vision Sustainability of the organizational values and vision is essential for developing and maintaining organizational momentum and effectiveness. Accomplishing this requires that the governance body/owners of the community define: (1) the core values that guide all governance and operational decisions and actions, and (2) a vision of the desired state of being of the persons served after their interaction with the organization. Progress toward the vision is the primary measure of organizational success. While the means to achieve the vision will change over time as the external environment changes, the means used will always uphold the values and the outcome of a high quality of life for residents. The Organizational Values and Vision process holds true for both new development as well as for repositioning projects.

Operations Achieving sustainable operations is dependent upon selecting, developing, and retaining the appropriate staff, including top leadership. Having a focused, innovative, efficient, effective, and consistent organization is dependent on having the right organizational culture. Since the CEO or executive director is the primary determinate of the culture of an organization, and since the values of an organization are expressed daily through the culture, the selection by the governing body of this leadership position requires the individual to live the values to maintain operational sustainability. Continued

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EXPERT FOCUS Senior Living Sustainability Guide (SLSG) (continued) The establishment of a functional program identifies each staff and resident area, including the activities and services that will take place in all locations. This information includes not only how a space shall function and operate, but also addresses equipment and storage needs, appropriate access by residents based upon the level of care, integration of the outside and the interior including access, and the need for certain spaces to relate to one another. Each function should be reviewed completely, including personal care services, food preparation and serving, laundry services, medication distribution, housekeeping and maintenance processes, communication services, and all other planned processes. It is the responsibility of the CEO or executive director to achieve sustainable operations and continuity of the functional program by providing the resources and training for all staff.

Physical Setting The physical space program and adjacencies have to be based upon the functional program supporting resident quality of life and operations. This integration provides a setting for resident-centered care. A sustainable building design is flexible, having the potential for adaption and remodeling to meet changing needs. The building also supports future developing technologies, and allows for evolving care models. To reduce the environmental footprint of a building, consideration must be given to energy and water consumption. Recycling and reuse of materials and resources must also be considered together with the safe handling of chemicals and use of products with low volatile organic compounds. Lighting and acoustics also play a role. All of the building design decisions must be made in a manner that does not compromise the other dimensions of sustainability—resident quality of life, organizational values and vision, and operations.

Conclusion The Senior Living Sustainability Guide is the result of passionate individuals who desire to sustain the ability of elders to have a high quality of life regardless of the changes that the aging process inherently brings, and to do it in a way that sustains our world for future generations.

A NOTE ON APARTMENTS Apartments are private; facilities are not. When people are shuffled from level to level, possessions must be eliminated and physical territory is reduced. The value of privacy and independence increases dramatically. The apartment represents a place to maintain independence when, through aging, all forces seem to lead to less control. An individual’s home allows that person to stay in touch with the person they were in the past. It provides a place to accumulate memories. As we age, each change can represent a loss of territory and possessions. Symbols of life like a flower box, a mailbox, a doorbell, a clothesline, and holiday displays become increasingly important. Residents need to remain

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connected with others, but through windows, doorways, and porches that permit the choice of privacy. Chapter 3 is filled with universal design detail that should be integrated into apartments. As a closing thought to this chapter, please consider that social spaces and bedroom spaces are culturally incompatible. At a minimum, apartments should offer separation between sleeping areas and living areas. Endnotes 1. M. Kalymun, “Toward a Definition of Assisted Living,” in Optimizing Housing for the Elderly: Homes, not Housing (New York: Hayworth Press, 1990), 97–132. 2. House of Representatives Select Committee on Aging, Housing for the Frail Elderly: Hearing, May 4 and July 26, 1989 (Washington, DC: GPO, 1989): SD cat. no. Y 4Ag 4/2:H 81/26. 3. V. Regnier, Design for Assisted Living: Guidelines for Housing the Physically and Mentally Frail (New York: John Wiley & Sons, 2002). 4. V. Regnier and D. Hoglund, “Expanded Housing Choices for Older People: Building Codes Impact on the Environment of Older People,” paper delivered at the American Association of Retired Persons White House Conference on Aging, Mini-Conference, August 1995, Tab 700, 69. 5. American Institute of Architects, Guidelines for Design and Construction of Health Care Facilities (Washington, DC: American Institute of Architects, 2006). 6. V. Regnier, Assisted Living Housing for the Elderly (New York: John Wiley & Sons, 1997). 7. E. Brawley, Design Innovations for Aging and Alzheimer’s: Creating Caring Environments, (New Jersey: John Wiley and Sons, 2006).

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CARING FOR PEOPLE WITH DEMENTIA

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locked nursing home is not appropriate housing for people with dementia. It is also not appropriate for people with dementia to be isolated in their own homes. A group home with trained staff in a residential neighborhood is often the better solution. Hundreds of these homes have been constructed in northern European countries. This movement started in 1985, when six older people with geriatric dementia were moved to the Baltzargarden group home in Motala, Sweden. This lovely ten-room home was used as a demonstration project for the care of people with Alzheimer’s disease. Most were moved from institutions; all of the residents were incontinent and heavily medicated. Within three months, none of the residents required diapers, sleeping medication, or psychopharmaceuticals. Aggressive behavior, wandering, anxiety at night, and periods of screaming came to an end. The residents became happier and more outgoing and started to take notice of their surroundings and their fellow human beings. These remarkable results were achieved by Barbro Beck-Friis, the worldrenowned Swedish physician and gerontologist who founded this movement. According to Dr. Beck-Friis, people in advanced stages of geriatric dementia “should be cared for in a group home of no more than six to eight

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people and in an environment that is as homelike and secure as possible.”1 In the United States, the National Institute on Aging confirms that housing for a small number of individuals is less confusing and less stimulating than larger groups.2 Small scale encourages activity and mobility. Dr. Beck-Friis’s successful demonstration of this concept opened the doors of group homes to over 7000 Swedish residents.3 Attendants in these homes help residents to care for themselves using “active participation” in such tasks as grocery shopping, cooking, and folding laundry. Care is individually tailored to the needs of each resident. When compared to those in an institutional environment, residents in group homes experience marked improvement. Medical experts from many countries have traveled to Sweden to receive training in this model of care provision. The method of care at Baltzargarden is designed to strengthen residents’ self-esteem and reinforce their remaining healthy resources and brain functions. Resident care is highly individualized and is based on positive contact; the staff is encouraged to express praise, warmth, appreciation, happiness, and laughter, reinforcing positive behavior. Therapy includes the use of music, and some residents who were unable to speak can now sing songs fluently. All of the senses (sight, hearing, taste, smell, and touch) are activated to trigger long-term memory. Residents even grow their own food, which they eventually harvest and consume. Design intervention at the group home incorporates familiar way-finding cues, like hearts on the floor leading to the bathroom. Lighting is also used in way finding, including a night light so residents can find their way to the toilets (see Checklist: Universal Lighting on page 90). Furniture and carpets from the 1940s, and 1950s are used to trigger memories. Familiar objects like chamber pots are used by residents who were used to them. Program repetition, familiar surroundings, and set routines with the same staff contribute to memory reinforcement. In Sweden, care in group homes for people with dementia costs 30 percent to 40 percent less than nursing home care for the same population.4 Nursing homes are viewed as subacute facilities where only the most severely impaired residents belong. The quality of care in group homes is viewed as superior. Even though the work is exhausting, it should be noted that a higher degree of staff work satisfaction was found in group homes than in nursing homes.5 Group homes unite the best parts of institutional care with the quality of life at home. They are often located close to senior centers offering a wide variety of programs and services. As the movement has grown, the housing models have been finetuned to truly serve the needs of older people with dementia. A typical

Caring for People with Dementia

plan includes six apartments, each with a living room, safe kitchenette, and bedroom alcove. The L-shaped building reduces the perceived length of the corridors. Residents can view both corridors from the central space, a boon to way finding (see Checklists: Environmental Wayfinding and Orientation Cues on page 253). The common space includes a small living room, a family dining room, and a large kitchen designed for resident participation. The central kitchen table and window seat are used by residents during meal preparation. Staff members dine with the residents, which encourages a sense of family. Dining with others stimulates the appetite and prompts the use of appropriate table manners, a fact confirmed by research. In one interesting U.S. study, residents with psychogeriatric disease, including dementia, improved their eating behavior when dining in groups around tables (compared to those eating from trays in chairs along corridor walls).6 Every 70 seconds, an American is diagnosed with Alzheimer’s disease. An estimated 5.3 million Americans have Alzheimer’s disease. Over the next decade, the baby boomers are projected to add 10 million people to these numbers, with a total estimated prevalence of 11–16 million people. The cost implications related to Alzheimer’s disease and other dementias include an estimated $148 billion in direct/indirect costs and an additional $94 billion in unpaid services provided annually by an estimated 10 million caregivers.7 Many others suffer from dementia caused by stroke, AIDS, Parkinson’s disease, or vascular disease, sometimes in combination with high blood pressure and diabetes.8 Unfortunately, funding for the long-term care of people with dementia is seldom based on the medical diagnosis of the resident; it is most often based on the location of their care. Although people with dementia seldom require 24-hour medical intervention, many are forced to move into nursing homes by Medicaid reimbursement policies. An appropriate setting, like a group home specializing in their care, is generally funded by private pay sources. As a consequence, people without private pay sources end up living in nursing homes. Eighty-five percent of older people plan to age in place, never even considering other living choices like group homes (see Chapter 3). But too much privacy can be dangerous to one’s health; elderly people who live alone consistently have longer stays in the hospital and fewer discharges than people living together.9 When dementia forces a move, most Americans can choose only between nursing homes or assisted living facilities specializing in this care. Minnesota offers other options.

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Reimbursement drives design. Minnesota has experimented with reimbursement based on the health of the residents rather than the place where they receive the care. Individuals can receive the same amount of reimbursement whether receiving care in a skilled nursing facility or in a group home. Minnesota has used a Medicaid waiver process based on 12 levels of care assessment, not on the facility offering the care. This unique process has encouraged design innovation. One of the first American group homes for people with dementia was built in Buffalo, Minnesota. Four cottages, each housing six residents with dementia, are located in a wooded residential neighborhood. The homes were designed to be converted to individual apartments if the reimbursement pattern changes. Each cottage offers a common area with a living room, dining area, and family kitchen. Daily chores are shared by the staff and residents. They dine together around a kitchen table, and staff is required to eat the food they prepare. When a demonstration project pushes the envelope, codes become problematic. Even though these cottages are sprinkled, fire code requires some exits to remain unlocked, a real danger to residents unless the perimeter of the property is secure. Fortunately, it is easier to monitor these exits with only six residents per cottage. Outside each open exit, a gate is installed with a difficult latch as well as a soft bell to warn staff. Locked doors are visually integrated so residents are not tempted to try them. Residents who are cognitively capable of using them have keys to the locked doors. Simple details to minimize unwanted noise include felt on the feet of chairs and a phone equipped with a soft chime rather than a disturbing ring. The kitchens have diffuse tungsten track lighting that conveys a more residential ambience than fluorescent lighting. Handrails are installed in the halls. The Bergweg model (discussed in Chapter 1) has also pushed the envelope in care for people with dementias. The newer complexes in Holland feature day-care centers for people with Alzheimer’s. Couples can remain together with good life quality even if one develops this devastating disease. The author interviewed one spouse who had lost her husband to Alzheimer’s disease. She was able to stay with him for life because of the choices offered at Bergweg. When she needed to leave during the day, she could utilize the services of the on-site day-care center. With fifteen minute checks all night, she could get her sleep, even with her husband’s variable wake/sleep cycles. She was living with a person with Alzheimer’s and had great life quality.

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EXPERT FOCUS Designing for Dementia ELIZABETH BRAWLEY, AAHID, IIDA, CID Designing for Alzheimer’s Disease: Strategies for Creating Better Care Environments

Good design planning may take more time initially. It involves more people and requires asking some tough questions. How can design result in settings that function for individuals with Alzheimer’s disease? How can it avoid costly redesign? Any health-care professional who has worked with the frail elderly and individuals with dementia will tell you we don’t have all the answers. We are still learning. The foundation for creating better environments that support a more fulfilling aging experience rely on exploring practical, innovative ideas based on the results of current research studies, flexible design, and the clear intention to accommodate change over time.

Plan Before You Do! 1. Assess the situation: It is important to define the characteristics of the users, programs, and schedules, and to understand the stages of Alzheimer’s disease. It is equally important to understand normal age-related changes in vision, hearing, touch, smell, strength, and mobility as well as changes related specifically to the disease. 2. Research and information gathering: It is increasingly common for design professionals to work with behavioral scientists to explore special needs and design solutions. The foundation for design is to keep people active and find the best ways to support the issues of the frail aging individual and the difficulties of Alzheimer’s disease. 3. Define the problems and challenges: Good solutions require identifying challenges and potential problems. Persons with dementia have special needs. To find solutions, it’s essential to know and understand the problems. Good planning can produce a very positive effect on both their ability to function and on their quality of life. For example, the environment can contribute to optimizing fitness and encourage exercise, motion, and mobility. Possible solutions might include access to safe, secure outside areas, chairs that rock, and level walking paths with a destination. 4. Establish a priority of needs; set goals and objectives; develop a plan: Develop a written statement that recognizes the unique needs of an elderly individual with dementia. Varying degrees of interaction are appealing and valuable to both the alert and the impaired, to the capable and the frail. Define your most important goals and develop a plan.

Functional Programming Programming is the critical phase when information about needs and preferences is obtained before preliminary design begins. This data is typically used for analysis and then to make recommendations for the preliminary design phase. Programming for elderly living settings is more complicated because of the broad spectrum of needs. Architects and designers gain an understanding of these needs through programming and are then able to translate that information into designs that support abilities and help individuals maintain their independence Continued

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EXPERT FOCUS Designing for Dementia (continued) For architecture to respond to the comprehensive needs of older people, a clear understanding is needed of the people and the many ways they use an environment. Programming is the essential part of the design process that identifies the overall characteristics of the environment. For example, programming defines the residential quality, and the relationships between spaces, such the adjacency of toilets to kitchen or dining spaces, den or family rooms, and bedrooms. The process also evaluates the sensory setting—lighting and the need for increased light levels, acoustics and excessive noise, and the interior finishes and furnishings. A balanced design addresses various impairments and varying levels of impairment, as well as the interaction of impairments. Individuals with cognitive impairment most likely also have vision and/or hearing impairments. Some may have mobility impairments. One of the most important challenges of environmental design is dealing with the interaction of multiple impairments. The solutions are typically complex. What sets Alzheimer’s special care design apart is the emphasis placed on the social, psychological, and physical needs of the individual. The need for mobility, for example, to easily sit and rise from a chair, carries more weight than a designer’s need to select a chair for the aesthetic appeal, but causes the individual to need assistance in order to get up.

REDUCING DISTRACTIONS Some patterns are distracting and visually confusing; even light patterns from blinds may be disturbing visually. A heavily patterned tablecloth may even prevent a resident from concentrating on eating.10 High-contrast squares on the floor may look like things that need to be picked up or like holes. Noise is a major distraction for all of us, and ambient noise levels should be reduced. Eliminate the public address system; use vibrating beepers instead. Constant music may also be distracting and certainly adds to the ambient noise level. Periodic use of nostalgic tunes may serve as an important memory cue, however, and music may be used to announce events like dining or special activities. Keep in mind that older people with hearing loss have a hard time accurately identifying most sounds, including announcements, and responding appropriately. Startling sounds, like sudden vacuum cleaner noise, may contribute to falls. Prevent doors from slamming (using a closer that requires less than 5 pounds of force to open). Use a chime on the telephone. Eliminate the doorbell or buzzer; in a group home, a knock on the door will suffice.

Caring for People with Dementia

ESTABLISHING LINKS WITH THE FAMILIAR, HEALTHY PAST People with dementia need design that stimulates interest and curiosity, especially in mastered skills. Residents should be empowered to perform familiar tasks; they should be encouraged to dress themselves, even if it takes an hour for them to do so. Provide a place to arrange clothing each day in order of use: underwear first and socks and shoes last. Everyday tasks should be performed in familiar spaces and everyday events should take place in rooms with clarity of purpose. Without meaningful activity in familiar space, residents may focus on inappropriate activities, like raiding a neighbor’s room. The resident’s personal space may present the best opportunity for establishing links with the past. It’s not easy for any of us to adjust to communal living, and personal possessions help with the transition. A personal photo (redundantly cued with a nameplate) can personalize the entrance, distinguishing it from similar doorways in the corridor. A collection can be displayed at the room entrance, secured under glare-free glass and recessed in the wall. A protruding Plexiglas box with sharp corners is a hazard and an institutional cliché. The resident’s room should feature a place to display prized possessions including crafts, photo albums, and furniture from home. Institutional built-in furniture is certainly not as recognizable as freestanding personal display pieces. Valuables can also be displayed on a plate shelf out of reach of other residents. Each object must be permanently attached in earthquake zones. Personal treasures can also be securely displayed in public spaces. Serving as landmarks, displays should be planned for every 20 feet; personal cues are 50 percent more effective than traditional signage. For example, a model ship made by a resident is more effective in way finding than a banner, plant, or other impersonal cue. Antique pocketknives, bows, combs, handkerchiefs, woodworking tools, and kitchen utensils can be displayed to stimulate conversation and trigger memories. Hat racks with a variety of caps, helmets, and scarves can stimulate the imagination. Resident art should be displayed in a variety of frames to improve differentiation. Picture books and magazines are so popular with the residents that shelving often must be added. A library is recommended, not only for the residents, but for family members who are seeking information about dementia.

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PROVIDING SENSORY CUES TO PROMPT MEMORY A crackling fire in the fireplace, the fragrance of bread in the oven, a hot cup of coffee in the morning, a warm room filled with daylight, the touch of a loved one—these are the memories of home (Figure 2–1). A home that appeals to the five senses can improve orientation and reduce loss of memory. Family life often revolves around the kitchen. Provide aprons to encourage participation. Textural activities like supervised cooking and dining stimulate the sense of touch. Finger foods, touchable objects within reach, pleasant fragrances, and the warmth of the oven are all available in the kitchen. The kitchen should be planned to encourage resident participation, although this can get out of hand; sometimes one resident will take over the kitchen and not let others in. Perhaps residents can grow some of their own food in an adjacent garden. Pulling weeds, raking, and digging in fragrant earth can be practical therapy to a gardener. Sunlight is also healing; insufficient exposure to daylight disrupts circadian rhythms and often results in sleep disorders and seasonal depression. Other outdoor activities can include hanging clothes on a clothesline, feeding and exercising a pet, and sweeping the sidewalk;

Figure 2-1 Comfortable living area with fireplace creates a home-like environment. Courtesy of studioSIX5.

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Figure 2-2 Social gathering spaces provide opportunities for families to share time together. Courtesy of studioSIX5.

even a trip to the ice cream store shared with family. These familiar routines bring back memories (see Figure 2–2). Plan a healing garden accessible to residents (see Checklist: Planning a Healing Garden on page 246), who will truly value the freedom to go outdoors at will. Even a view of the garden can help with day-night orientation and awareness of seasonal changes (Figure 2–3). A bird feeder in the garden can provide lively entertainment. Plants can be selected to attract butterflies (C-4). For comfort, plan partial shade or filtered light, a feature often requested by families and residents.11 Staff is often encouraged to use eye contact, tenderness, closeness, and loving physical touch, but too often a high-touch environment is overlooked. Big, cuddly bath towels in bright colors, textural wall hangings, and soft bedspreads just ask to be touched. Encourage participation in arts and crafts; the process of painting allows memories to surface. Color preference can often be deduced from the colors residents select for paintings or projects. Residents may be encouraged to help with the color selection in their rooms. Often the colors of the 1940s or 1950s are popular. Clear color, devoid of gray and black, is most easily seen. Maintain midrange values. Some older people have more difficulty

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Figure 2-3 Resident enjoying the outdoors. Courtesy of Susan Rodiek.

discriminating between cool colors, like blue and green or blue and violet, than between warmer tones, like orange and yellow.12

ELIMINATING DANGEROUS OPTIONS Ensure that interior design delivers the right message. Windows can tempt residents to escape from the home. Plan windows that open into secure interior gardens to invite exploration, not escape. Reduce visual access to people getting in and out of cars, a scenario that may encourage residents to leave. Residents are drawn to light; a poorly designed window can be used as an unsupervised exit. Exit strategy can be reduced to “out of sight, out of mind.” Visually offset exits. Locked doors to janitorial closets, stairway landings, and other hazardous areas may be disguised by a mural or painted to match the surrounding wall. Residents are frequently frustrated by attempts to open locked doors. To keep door controls out of sight, some residences have received permission to place an automatic door control around the corner and paint it to match the wall. Wristbands containing microchips are also available to automatically lock the doors for some residents and open it for others (Figure 2–4). Unless the doors are visually concealed, however, this process may be frustrating to many.

Caring for People with Dementia

Figure 2-4 Resident safety management system for exit control. Courtesy of Stanley-Senior Technologies.

Dangerous items should be stored out of sight in visually integrated locked cabinets. Kitchen appliances can be equipped with a control lockout feature, timer switch, or remote control for staff use. Magnetic induction cooktops cannot heat when the pan is removed and they stay relatively cool during the process. Only the pan is heated, eliminating red-hot elements. The flat cooking elements offer more stability for pots and pans than do raised burners.

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AVOIDING CONFRONTATIONS Many symptoms of Alzheimer’s trigger confrontations. People with the disease may easily become suspicious, blaming others for stealing things that have only been misplaced. Fighting and hitting may occur, often because residents are defending themselves from something they don’t understand. Inappropriate sexual behavior can be a real test of compassion, patience, and understanding. Some people with Alzheimer’s disease deal with the same changes experienced by many older people: reduced mobility, visual impairment, auditory changes, and incontinence. People with Alzheimer’s disease may hallucinate; shadows and glare can further distort perception13 (see Checklist: Eliminating Glare on page 87). A wall of mirror produces startling and confusing images each time a resident walks by. A shadow turns into a demon and glare becomes the headlight of an approaching train. Appropriate design intervention calls for even illumination using high lighting levels without glare. Confrontation and resulting frustration can often be avoided with minor environmental modifications. A medication cart can trigger a showdown; hand out medications from a basket instead. Specify twin size or double beds; dormitory beds are too narrow for people with Alzheimer’s (who may have difficulty adjusting to an unfamiliar size). Don’t expect people with dementia to learn to use high-tech devices like movable counters and adjustable cabinets. High expectations may lead to disappointments for residents, families, and staff. Bathing is often a source of much frustration for both residents and staff. A private bathroom can help to alleviate many problems. When residents’ privacy is not respected or when they are overstimulated by having too many people in the bathroom, they may act out. Residents may behave badly because they are cold or are surprised by a sudden spray of water. Install a pressure-balancing feature on the faucet control to prevent surges of hot water. A carefully controlled handheld shower can cause less agitation than a standard shower. Noisy whirlpools are overstimulating and even threatening if the water rises close to the head of the resident. Bathing can be less difficult, if not enjoyable, with the addition of fragrances and bubble bath, but oils may make the tub too slippery.14 Environmental cues can reduce incontinence and make toileting easier. In each resident’s room, plan the space so the toilet is clearly visible from the bed when the private bathroom door is open. In public bathrooms, leave stall doors open so toilets are in view when the outer door is first opened. Increase the number of public bathrooms, shortening the trip required by the resident. When planning, allocate space on both sides of the toilet for a two-person

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Figure 2-5 Recessed sink providing clear floor space for the toilet. Courtesy of Evan Terry Associates, P.C.

transfer. To reduce the size of the bathroom, recess the sink or shower in these spaces (Figure 2–5). Provide soft paper towels for cleanup, hidden under the countertop or over the toilet. A chamber pot or container may need to be installed under the toilet seat to catch objects residents drop in the toilet. Thoughtful prevention and creative staff intervention can resolve many confrontations. Sometimes inappropriate resident behavior can be redirected by a favorite food or another enjoyable activity. At other times, an individual away space may be necessary. A private room or a quiet place in the garden may suffice. Staff must constantly supervise residents without hovering. Low dividers, interior windows (if not confusing), and vision panels or sidelights in doors can be used for this purpose. A vision panel can also be used to create a social layer, a transition between spaces that allows the resident to become oriented before entering a room. The panel must not generate glare and must be usable by shorter residents and those in wheelchairs. In summary, people with Alzheimer’s disease need a supportive, calm, consistent environment, not a climate of constant change. Relocating a resident is particularly difficult. Every attempt should be made to keep the resident in one location (and one room or apartment) for life, not requiring a move to a nursing home or to other space within the residence.

ENCOURAGING SUCCESSFUL SOCIAL INTERACTION AND FAMILY PARTICIPATION When a new residence opens, it is helpful to have everyone move in at the same time. Residents in the early stages of dementia will be more tolerant of familiar neighbors as they work together to cope with the changes of aging.

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Tolerance is difficult in a residence for people with dementia. From the point of view of the resident, much of the social interaction is negative. Precious possessions are stolen by the other residents. Sleep is disturbed by a noisy neighbor. Much of the behavior of other residents is distracting at best and threatening at worst. Some residents may cry for long periods. Others perpetually wander. Some may engage in public sexual behaviors. It is no wonder that the reactions of residents are sometimes catastrophic, especially late in the day. But sundowning (increased agitation at sunset) is not the fault of residents. Most cannot control the reaction or fake agitation for attention. It may be possible, however, to reduce this behavior by design. Research has shown that bright light exposure can reduce agitated behaviors in people with advanced Alzheimer’s disease. Increased exposure to light may also help to regulate variable wake and sleep cycles.15 Every effort should be made to reset residents’ internal clock. If these efforts fail for some, the residence must support dining, sleeping, bathing, and wandering at will. For safety, consider wiring the night-light to be activated by a motion sensor in the resident’s room. Maintain an even lighting level in the corridors. Keep juice, fruit, and rolls out at all hours. As an added benefit, a breakfast bar becomes a destination where people can stop and socialize at any hour, as well as an invitation for friends and family to drop in for a visit. Family members often view moving a loved one to a long-term care setting as a failure, and each visit is a painful reminder. An institutional environment filled with noise and odor may tip the scales against the decision to visit. The residence must be warm and welcoming, encouraging family and friends as well as the residents. Visitors should be allowed to room in occasionally. The resident’s room or apartment may include a daybed or window seat that makes into a bed. Bedding can be stored underneath the window seat as long as a clear kick space is planned: 8¾ inches a.f.f. (above finished floor) by 6 inches deep. To rise from the seat, older people may put their feet back into the kick space and lean forward to redistribute body weight. The residence must also be planned to accommodate children and pets. Perhaps a play area could be included for children. Art, music, exercise, and dance classes offer opportunities for child involvement. Pet therapy can be a wonderful activity to share. Pets offer unconditional love, and permanent pets can be included in many settings.

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RELEASING EXCESS ENERGY People with dementia need meaningful activity and plenty of exercise. A well-designed walking path in a secure setting offers an opportunity to release excess energy, stay in shape, get some sunshine, and explore. An exterior walking path should incorporate two basic design criteria: the path should circle back to the beginning, and this point should be clearly cued and visible from most points on the path. The cue can be a canopy over the door to the residence, a change in the landscaping, or a tall sculpture. The path should be designed to create a safe surround without the feeling of confinement. A fence can be hidden within the foliage; a black chainlink fence is nearly invisible when covered with foliage. Fencing must be high and secure, located well away from architectural elements and trees that could be climbed. Plant trees that will not drop fruit and foliage on the walking path; provide plants with blooms and fruits that are safe to eat and sturdy enough to take some abuse. Shallow water features may be used as barriers to reduce access to more fragile plants. The garden (see Figures 2–6 and C-5) can feature raised beds so that residents can grow their own vegetables and flowers or just release energy by digging. The path through the garden must be stable, firm, and slip-resistant; a covered pathway is necessary in many climates. A boardwalk or pressure-treated

Figure 2-6 Garden with a slip-resistant path, a place to rest, and elevated planters at water elements. Courtesy of Susan Rodiek.

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lumber is a good choice; asphalt, dark concrete, and fine decomposed granite may also be used. Gravel is unstable, and people with Alzheimer’s disease have been known to eat it. Light-colored concrete reflects light, causing glare. An interior courtyard with daylight is an ideal location for a walking path and can also serve as an extension of the indoor path. This path should accommodate industrious activity (the need to stay busy) and searching behaviors (e.g., looking for home). Searching behaviors can be accommodated by providing displays along the way, perhaps recognizable objects from home. “Window shopping” is a popular and familiar activity. Collections can be exhibited on rotating shelves or in recessed shadow boxes. Consider an aquarium or an aviary filled with interesting birds. Offer a wide variety of activities. A place to snack provides a popular destination and encourages socializing. Cabinets along the way can be planned for exploration, perhaps with interesting hardware and drawers for rummaging. The laundry can include a place for residents to fold towels; the living room may offer pillows to fluff and furniture that rocks, bounces, or swivels safely. A rocker stimulates the vestibular canal, which provides a calming effect.16 Platform models provide better stability. Encourage a safe adventure along the interior walking path. Resting areas and bathrooms should be provided along the way. As with the outside path, interior walking paths must be circular, bringing residents home again. Way finding to accommodate dementia differs from standard practice. Color-coding corridors, for example, doesn’t help most residents. Alzheimer’s disease combined with visual impairment limits the ability to recognize color and to attach significance to it.17 Residents rely on tactile cues, like actual objects or air currents, for orientation. The interior path must be a slip-resistant level surface. Even though standards permit a ¼-inch change in elevation,18 a change of 18 inch would be less of a tripping hazard for older residents, who shuffle and drag their feet. The interior path can be defined by furniture arrangements and other movable items, but once defined; these items should remain in place. Change is disorienting.

ENCOURAGING INDEPENDENCE The Swedish philosophy of care for people with dementia literally translates into “sitting on the palms of your hands.” Staff members are required to take a handsoff approach, encouraging residents to do for themselves and to maintain their skills. Most residents prefer private rooms, although shared rooms are available for those who want the companionship and security of a roommate. Resident

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Figure 2-7 Memory care social area provides an intimate setting for patients with dementia. The Legacy at Willow Bend. Courtesy of studioSIX5.

rooms should include simple storage systems that are clearly defined—socks stored in one drawer, underwear in another, and so on. The smallest detail can make the difference between staff dependence and independence. Residents can more easily maintain control in small spaces that are clearly differentiated. Large spaces are disorienting and sometimes noisy. Each small space should have clarity of purpose; flexible space planned for multiple uses is confusing to people with dementia. Keep public zones very public and private zones very private. Dining, for example, should take place in a small, private dining room for a small number of residents, not in a noisy dining hall. Select furniture and accessories that are familiar and easy to use (Figure 2–7). Well-meaning designers often specify accessible products that cannot be used by people with dementia. Furniture with contrasting edges may be visually confusing to some. Levers may be unfamiliar; knobs are more difficult to use but may be more recognizable. Many older people experience some degree of memory loss as part of the natural aging process. All benefit from sensitive and thoughtful interior cuing planned to reinforce memory. One fascinating Japanese apartment was designed around a familiar childhood fable, cuing the pleasant memories of youth. Design cues include a constellation in the headboard, a bamboo chandelier lined in gold, a copper moon with a patina that improves with age, and a cornice engraved with a hundred “Y”s bequeathing at least a hundred years of life.

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Endnotes 1. Barbro Beck-Friis, At Home at Baltzargarden (Orebro, Sweden: Libris, 1988). 2. P. Sloane and L. Matthew, “The Therapeutic Environment Screening Scale,” American Journal of Alzheimer’s Care and Related Disorders and Research, vol. 5 no. 6 (November 1990 ): 22–26 3. J. Pynoos and P. Liebig, eds., Housing Frail Elders: International Policies, Perspectives and Prospects (Baltimore: Johns Hopkins University Press, 1995). 4. A. Wimo, J. Wallin, K. Lundgren, E. Rönnbäck, K. Asplund, B. Mattsson, and I. Krakau, “Group Living, an Alternative for Dementia Patients: A Cost Analysis,” International Journal of Geriatric Psychiatry 6 (2004): 21–30. 5. Gilbert Dooghe and Lut Vanden Boer, eds., Sheltered Accommodation for Elderly People in an International Perspective (Amsterdam: Swets and Zeitlinger, 1993). 6. I. Melin and K. G. Gotestam. “The Effects of Rearranging Ward Routines on Communication and Eating Behaviors of Psychogeriatric Patients,” Journal of Applied Behavior Analysis, 14 (1981): 47–51. 7. Alzheimer’s Association, “Alzheimer’s Disease Facts and Figures,” Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association 5(3) (May 2009): 234–70. 8. Barbro Beck-Friis, At Home at Baltzargarden (Orebro, Sweden: Libris, 1988). 9. B. Soldo and C. Longino, “Social and Physical Environments for the Vulnerable Aged,” American’s Aging: The Social and Built Environment in an Older Society, in Committee on an Aging Society (Washington, DC: National Academy Press, 1988). 10. E. Brawley, Designing for Alzheimer’s Disease: Strategies for Creating Better Care Environments (New York: John Wiley & Sons, 1997), 163. 11. Ibid., p. 206; A. Cronin-Golomb, R. Sugiura, S. Corkin, J.H. Growdon, “Incomplete Achromatopsia in Alzheimer’s Disease,” Neurobiology of Aging 14 (1993): 471–477. 12. Victor Regnier, Design for Assisted Living: Guidelines for Housing the Physically and Mentally Frail (New York: John Wiley & Sons, 2002), 106. 13. Brawley, Designing for Alzheimer’s Disease, 102. 14. Ibid., 200. 15. S. Ancoli-Israel, J. L. Martin, P. Gehrman, T. Shochat, J. Corey-Bloom, M. Marler, S. Nolan, and L. Levi, “Effect of Light on Agitation in Institutionalized Patients with Severe Alzheimer Disease,” American Journal of Geriatric Psychiatry 11:2 (2003): 194–203 16. Brawley, Designing for Alzheimer’s Disease, 102. 17. Margaret Calkins. Design for Dementia: Planning Environments for the Elderly and the Confused (Owings Mills, MD: National Health Publishing, 1998).. 18. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG.) (Washington, DC, 2002), retrieved September 22, 2009, from www.access-board.gov/adaag/ADAAG.pdf.

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any of us have had to institutionalize a loved one and we wonder if we will we become dependent on the care of our children or be permanently moved to an institution because there is no other choice. The good news is that we don’t have to. As the powerful baby boomer population segment ages, there is an increasing realization that services and housing must be in place to protect their rights to independence, efficacy, and aging in place. Currently, there is real demand for home health-care services and increasing awareness of the need for universal design to accommodate equipment and mobility devices. Demand is also growing for universal design in the second home and retirement housing markets. Enlightened boomers who can afford to do so are already building second homes for future retirement and using them today as recreational retreats. There are sound economic reasons for doing so. In addition to meeting requirement needs, accessible housing facilitates home health care. Selfcare at home can be a viable economic means to contain health-care costs. Insurance payments and tax incentives already encourage the use of home health-care services, covering a wide variety of therapies that are offered at home. Accessible housing can be considered design intervention, replacing

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staff intervention as consumers care for themselves. In this housing situation, patients can increasingly make their own health-care decisions, retaining responsibility for their own health. This trend will further reduce the responsibility (and liability) of practitioners. The basic requirements for accessible housing can be found in the 1988 Fair Housing Amendments Act requiring accessibility in multifamily housing projects with four or more units. Although there is no compliance requirement for private homes, consumers who wish to age in place should plan for their future living needs, considering the guidelines offered by this act (see Checklist: The Seven Basics of Housing for Home Health Care on page 46). The latest version of The Fair Housing Design Manual is available online at www.huduser.org/publications/destech/fairhousing.html.1 CHECKLIST The Seven Basics of Housing for Home Health Care 1. An accessible entrance on an accessible route. Include access to the street (and public transportation), a covered transfer space adjacent to the vehicle, and an accessible route into the dwelling, preferably not exceeding a 1:20 grade or an abrupt change in elevation in excess of ¼ inch. Ramps should only be used as a last resort. 2. In public housing, usable common areas. Public bathrooms, for example, should be in compliance with ADA Accessibility Standards (see checklists for showers, toilets, urinals, and lavatories on pages 183, 185). 3. A clear width of 32 inches at all doors. A clearance of 36 inches is preferable, to allow clearance for the open door and elbow room to the wheelchair user. Each door to the master bath and master bedroom should have a side panel that can be opened to provide a clearance of 44 inches. This extra width is necessary to move the bed into the living room or to transfer a patient on a gurney from the bed to the bath. 4. A 36-inch-wide accessible route throughout the dwelling. Hallways should be at least 42 inches wide, with doors swinging out of the hallway. To accommodate wheelchairs, greater widths are necessary if doors swing into the hallway. 5. All controls in accessible locations. Install controls at a minimum height of 15 inches and a maximum height of 48 inches and provide a clear floor space of 30 inches by 48 inches. Pay special attention to the location of switches, outlets, thermostats, and breaker panels (see Checklist: Receptacle Outlets on page 106). 6. Reinforcement in bathroom walls. (Use ¾-inch plywood from floor to ceiling around the bathroom perimeter. This will secure towel bars grabbed in an emergency and support the addition of grab bars or a shower seat as needed.

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CHECKLIST The Seven Basics of Housing for Home Health Care (continued) 7. Usable kitchen and baths. A 60-inch turnaround space can be used for a T-turn or U-turn in most wheelchairs and provides space for those using walkers, canes, or assistants. This clearance can include space under the counter and sink. Removable cabinets can be used to clear the space for access by a wheelchair user.

Figure 3-1 Removable cabinets. Source: USDHUD.

Housing choices must return control to the consumer, with features to improve independence, safety, and security (see Checklist: Security on page 54). Universal housing must adapt to specific diseases and disabilities. To be a sustaining success, it must be integrated within the community rather than isolated in centers for older people or those with disabilities. Design demonstration centers in neighborhoods support this integration, offering an opportunity to try products and design ideas before purchase.

DESIGN DEMONSTRATION CENTERS One such model is Sophie’s Home in Horsholm, Denmark, a prototype for independent living. The demonstration center is part of a complex for all ages that features 650-square-foot apartments and a day-care center serving 100 residents. The center provides training in the use of products like adjustable nightstands, remote controls used to operate doors, adjustable counters, lights, draperies, television, call systems, and lifts from the bedroom to the bathroom (see Figure 3–1).

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Figure 3-2 Sophie’s House lift. Courtesy of Aktivitetscentret Sophielund.

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The service house model of northern Europe has succeeded in maintaining older frail people in adjacent individual units as well as in the surrounding neighborhood. The model is similar to that of senior centers in the United States, with the addition of health and rehabilitation services. Most such houses offer physical and occupational therapy as well as home health-care services and personal assistance. As in U.S. senior centers, these models also offer meals, day care, and social activities to prevent isolation. Green Mountain Ranch is a U.S. demonstration project featuring over 200 ideas installed to demonstrate the complementary aspects of green and universal design (see Figures 3–3 and 3–4). The project is proactive, using design elements to prevent injuries and to encourage a lifestyle that leads to health and longevity. The house accommodates wheelchair users and is adaptable to tall and short users, to people with low vision and low hearing, to those who want to do rehabilitation at home, and to those requiring a caregiver. All features are visually integrated, not advertising age or disability. For additional information, see www.AgingBeautifully.org/ranch.html. For many, taking on the project to modify their home to meet their needs as they age in place seems to be a daunting task with considerable investment. Some improvements require little investment and can be done easily and quickly (see Figures 3–5, 3–6, and 3–7); providing time to plan for more expensive and time consuming projects to be part of a more extensive remodeling effort (see Checklist: A Strategy for Safe and Comfortable Aging in Place on page 51).

Figure 3-3 Exterior view of demonstration home, Green Mountain Ranch. Green Mountain Ranch, www.agingbeautifully. org/ranch. Courtesy of Paul Docktor M.D. [email protected].

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Figure 3-4 Interior view of demonstration home, Green Mountain Ranch. Green Mountain Ranch, www.agingbeautifully.org/ranch. Courtesy of Paul Docktor M.D. [email protected].

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CHECKLIST A Strategy for Safe and Comfortable Aging in Place Do It Now 1. Tape down rugs. 2. Add handrails with extensions to both sides of the stairs. 3. Add grab bars to your shower (see Figure 3–5). 4. Reorganize your kitchen around the tasks you perform. 5. Add offset pivot hinges to narrow doors. 6. Replace your showerhead with a handheld shower on a vertical grab bar. 7. Do an energy audit. (We generally need higher ambient temperatures as we age.) 8. Add task lighting to improve visual acuity. 9. Be proactive about your health—reorganize your house to encourage you to make it fun to exercise and to cook healthy meals. Try steam cooking; a portable steamer costs less than $100. Keep your house cleaner with a place to remove shoes upon entering. 10. Remodel the inside of your cabinets. Add pop-up shelves, lazy Susans, pull-out racks, and lighter colors, for example. 11. Add warning systems: smoke detectors, CO2 detectors, and driveway alerts. 12. Replace difficult controls with door levers and cabinet “C” grips, not knobs; use pressure switches, touch controls, and rocker switches on lamps. To test what works, try to use all controls with a closed fist. Then try to use all of them with one hand.

Figure 3-5 Add grab bars. Green Mountain Ranch, www.agingbeautifully. org/ranch. Courtesy of Paul Docktor, M.D., [email protected].

13. Replace your cookware for safety. Look for stay-cool handles and nondrip edges, for example.

14. You may need a new phone. If you have trouble hearing on your phone, replace it with one that amplifies high frequencies, not one that just increases the volume. If you frequently dial wrong numbers, find a phone with a large, lighted touchpad. Continued

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CHECKLIST A Strategy for Safe and Comfortable Aging in Place (continued) 15. Use your house to reduce stress. Add a small fountain that produces the relaxing sound of running water. Keep relaxing music playing at all times. Add speakers that don’t require wiring. 16. Buy a comfortable chair that is easy to access and exit, with arms well forward and space to put your feet back so you can lean forward and push off. 17. Increase your security. Add deadbolts to all doors. Block sliding-glass doors when not in use. Consider the many options in security systems.

Figure 3-6 Invisible grab bars utilizing a Hafele fold-down grab bar with connection hidden behind wall tile. Courtesy of Kohler Co.

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CHECKLIST A Strategy for Safe and Comfortable Aging in Place (continued) Do It Later: Adaptable Solutions 1. Install the wall reinforcements, not the grab bars (see Figure 3–6). 2. Install the track and wiring, not the $10,000 stair lift. 3. Add that study or den now and use it later for a live-in caregiver. 4. Install wiring for an automatic door opener in a tight hallway, and add the opener later. 5. Wall-mount cabinets so they can be lowered or raised later. 6. If the laundry is downstairs, wire and vent a closet on an upper floor so you can add a small washer-dryer at a later date. 7. Stack closets on multiple floors to form a shaft for an elevator at a future time.

Do It as You Remodel 1. If you are putting in a wood floor, recess that area rug. 2. Use a nonslip finish on the wood floor. 3. Use a drop-down door bottom instead of a threshold (which is a tripping hazard). 4. Plan 4-foot hallways, 5-foot turnaround spaces in each room, and clear floor space for walkers, wheelchairs, strollers, and scooters. Use anthropometric measures to evaluate the route by walking through your house with elbows out to a 3-foot width. 5. Add more windows and skylights with low-E thermal glass. This will increase ambient light levels. We may need a fivefold increase in ambient light as we age. 6. Replace your cooktop with a safe and fast induction model (see Figure 3–7). 7. Build a seat into your shower. 8. Replace your oven with a safe, side-hinged model. Add a pull-out shelf below. 9. Replace your washer and dryer with elevated, front-opening models.

Figure 3-7 Renovation images before and after completion of a universal kitchen at Green Mountain Ranch. Courtesy of Cynthia Leibrock, www.agingbeautifully.org/ranch and Paul Docktor, M.D.

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COHOUSING In the United States, cohousing communities are often clustered around a common house, similar to the Scandinavian service house, but without staffing. This space is shared by the entire community, not just the older residents. The common area often includes a kitchen, dining room, workshop, children’s day-care area, and perhaps a laundry room. The community often dines together, sharing cooking and maintenance responsibilities. Cohousing works well for older people who want an intergenerational setting. One older resident commented, “We aren’t Sun City types. It’s nice to be with a group of people who don’t spend all of their time talking about health and money.” Another resident noted, “Children need to appreciate that people get older and may not be as physically able, but that doesn’t mean they have to be isolated or waited on.”2 In cohousing, residents often try to live simply, cutting down on space and sharing responsibilities. Residents may pick up the mail for their neighbors, tend a community greenhouse, or house guests at the common house. The community may share some possessions, including tools, snow blowers, and camping gear. Cohousing is not a commune, however. Homes are individually owned and income is not shared. This style of living offers the advantages of community support without the problems of a commune. Neighbors watch the house while you are away. Some may put out a colored flag before they leave for the grocery store, inviting people to drop off their shopping lists. Many communities focus on conservation of energy and resources, and the residents contribute to the cost of landscaping and maintenance. CHECKLIST Security • At least four types of security systems are available: ultrasonic motion detectors, pressure mats, passive infrared photoelectric sensors, and switch sensors. Each type can be powered by batteries or direct wiring. • Ultrasonic sound motion detectors in the security system can interfere with hearing aids. Use pressure mats, passive infrared photoelectric sensors, and switch sensors instead. • For a private residence, consider an electric locking system for the entry door coupled with an intercom system. When a noise is heard, the lock can be checked by remote control from anywhere in the interior. The doorbell can be answered and the door unlocked without having to move to the entry.

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CHECKLIST Security (continued) • A video monitor can also be added to the system, giving a clear picture of visitors at the front door. • Outdoor lighting is an essential part of this system. An entry light that comes on automatically at night is another good choice. • With any electrical security system, plan for backup if power is lost. • Proximity to the call system becomes a critical issue in the event of a medical emergency or security breach. Many portable alarm devices enable the use to call for help with the push of a button. • It may be important to include an emergency call system in the bathroom. A touch system could be installed on the baseboard, for example, so that a person could call for help after a fall to the floor. A redundant system should be available higher on the wall. • In less critical situations, a telephone or intercom in the bathroom may be sufficient. Most intercoms can be monitored in other rooms when the channel is left open, so a call for help can be heard throughout the house. • A commercial call system may be as simple as a buzzer or as involved as a video teleconferencing device. • An automatic garage door opener makes an essential contribution to security. The garage door system should include an automatic light with at least a 15-second delay to allow time to drive into the garage. Some systems are equipped with touch pads, smoke detectors, carbon monoxide detectors, and burglar alarms for added security.

Figure 3-8 Baseboard call system. Courtesy of RAD Consultants with illustration by Laura Bauer.

Continued

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CHECKLIST Security (continued) • For security purposes, bay or bow windows provide a more complete view of the surroundings. Glass windows can be more easily broken than plastic and do not provide intruder protection. Wired glass can also be used, but it has an institutional appearance. • Look for windows with pins that extend into the frame to prevent the window from opening even if the lock is breached. Locate the lock as far away as possible from the glass on windows and doors. • Use a quick-release combination lock on doors to potentially dangerous areas, such as the head of a stairway or the entrance to a furnace room. • A metal door and frame provides the best security. Wooden entry door frames (even with a dead bolt) can be forced with a well-placed kick. • Add screws to the top of existing sliding glass doors to prevent them from being lifted out of the frame. • Add a peephole with a scope that can be viewed by a child, shorter person, or wheelchair user. • To increase response time to a fire, specify flame-retardant fabrics, furnishings, and carpet. For window treatments, modacrylic or fireresistant polyester fabrics drape well. Although fiberglass is flameproof, it does not drape well and can cause skin irritations. Furniture should comply with California Technical Bulletin 133, which tests the entire piece rather than the individual components; the most flameretardant carpet should also be selected. • Every kitchen should be equipped with a fire extinguisher. Specify a multipurpose ABC model to combat electrical and grease fires Figure 3-9 Door scope. Photo courtesy of Evan Terry Associates. as well as ordinaryå combustibles. • In a residence, smoke detectors should be installed adjacent to each bedroom and at the top of the stairway. Another smoke detector should be installed in the living room if it is more than 15 feet away from a bedroom unit. A third should be installed in the basement. Other possible locations include the kitchen and furnace room. Be sure to consider location in relation to air supply and air return registers. • A gas leak detector may also be required. Select a model with photoelectric and ion chamber detection to warn of both smoke and heat. • The detector should sound a warning when the battery needs to be replaced. • Some localities allow use of a smoke detector that activates a recorder that in turn dials the nearest police or fire department.

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CHECKLIST Security (continued)

Figure 3-10 Placement of smoke detectors in residential units. Source: USDHUD.

One cohousing community offers disabled people of all ages the opportunity to assist one another. It began with a critical need: affordable housing and assistance for people faced with institutionalization because older family members could no longer provide care. It culminated in a demonstration project offering a common house for shared activities and 32 accessible and adaptable units. Each resident received 60 hours of training in maintenance and project management to ensure user autonomy.

GROUP HOMES Group homes offer independence to people who require assistance with bathing, toileting, mobility, grooming, medication, or meal preparation. Group homes have also been used successfully to accommodate mentally frail people who become confused and lost, even in familiar surroundings

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Figure 3-11 Five-bedroom Swedish prototype. Courtesy of Gruppbostäder i Sverige AB.

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(see Chapter 2). Most group homes in the United States serve people with developmental disabilities. Innovative models that serve other populations are found in northern Europe. In one such model in Sweden, four to eight people may live in their own small apartments grouped around a larger living area and kitchen. This model offers more dignity and autonomy than the typical group home, where residents live in a bedroom. The European group homes may even offer twobedroom apartments so that couples may stay together, sleeping in different rooms if necessary. The second bedroom may also accommodate live-in help. The Scandinavian governments have found that design intervention is less expensive than staff intervention. The Swedish government has paid for passive energy systems that summon help if the toilet has not been flushed or if the refrigerator door has been left open over a programmed period. Motorized windows sense rain and close automatically and manual controls are designed for independent use (see Checklist: Windows on page 59). Toilets have built-in rinse and dry features. Sinks tip forward to ease hair washing from a seated position. This technology has been added to reduce staffintensive programs and the need for institutionalization. These strategies and others are examples of what is possible using smart home technology. In a Swedish group home, individual apartments are typically grouped around two public spaces (see Figure 3–11). One of these spaces is shared as a great room and the other is used for staff, including a work space and two small bedrooms for the night shift. The great room has a large kitchen, dining table, and living area. The apartments also feature a kitchen, dining, and living space separate from the bedroom and private bath. All spaces have a private patio, including the staff area. For a comprehensive discussion of northern European group homes, see Assisted Living Housing for the Elderly.3 CHECKLIST Windows • Both the design of the window and the location of the controls should be accessible by children, shorter people, and wheelchair users. Casement, sliding, hopper, and awning windows with controls on the bottom are easier to reach. • Latches should be operable with a closed fist. • Corners of sills must be rounded to prevent injury. • Double-hung windows can drop unintentionally, are difficult for everyone to open, and are often too high to be reached from a wheelchair. Add a crank control to an existing double-hung window. Continued

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CHECKLIST Windows (continued) • An awning window is easier to reach and open than a double-hung installation. An awning window can also be installed inside an open double-hung window. • Many crank-type casement windows are easier to use than sliders, although a slider with ball bearings may also be easy to operate. • A longer crank or lever arm multiplies the force. Place levers so that they can be operated with the strongest hand for greater power. • Casement windows with levers do not require as large a range of motion as do horizontal sliders and pivoting sashes. • Casement windows and horizontal pivot sashes are easier to clean than are other types. The window lock should be installed within reach of wheelchair users and shorter persons. • A sliding window panel or shutter on a track may be easier than a hinged panel to operate from a wheelchair. The top panel of a double-hung shutter is often higher than 48 inches and not reachable from a wheelchair. • For safety, choose windows and shutters that won’t drop unintentionally or swing in the wind. • People with limited circulation often need higher ambient temperatures, yet people in wheelchairs or on gurneys must operate in the lower, often colder, part of a room. For these clients, heat loss and solar gain become critical issues. Reduce the header or window height and create an overhang to reduce solar gain. • Double-glazed sliding windows conserve energy but may be too heavy for many people to operate. For people with strength limits, specify a double-glazed power window with a breakout feature for emergency exit in a power failure. • Window treatments mounted within the window frame block some of the light and view but free extra wall space for storage within reach of children, shorter people, and wheelchair users. • Keep wands on blinds a maximum of 48 inches a.f.f. (above finished floor) and ensure that cords on roller shades are no higher with the shade rolled up. • Wall-mount cords on blinds and draperies to keep them handy and within reach. Do not mount cords over counters, where they are difficult to reach. • Consider electric drapery rod controls. Wands on blinds and shades can also be operated electrically by switch or remote control. Remember that all electrical devices require additional maintenance.

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INDEPENDENT LIVING Most people with disabilities would choose to live independently, caring for themselves with the support of a universally designed home. Much of the design intervention takes place in the kitchen and bath. The balance of this chapter discusses innovative kitchen and bath design. (Comprehensive coverage of universal design is available in Beautiful Universal Design.4 Additional discussion on kitchen and bathroom design can be found in Chapter 5.) In Japan, the Sekisui House, Ltd., has constructed hundreds of accessible homes and demonstration projects, including the Mitaka Model Home for independent living5 This unique installation showcases a ceiling-hung lift offering direct access between the bedroom and the toilet area (see Figure 3–12). This product alone could delay, if not prevent, institutionalization, supporting home health care with minimal assistance. In the bathroom, the toilet features a heated seat, automatic flush, a wash-dry feature, and an internal odor exhaust system. The track extends into the bathing area to a transfer seat and wooden tub (see Figure 3–13). No comfort was spared; even the quarry tile floor is warmed by heating coils. Sekisui studies lifespan housing in a huge research and development facility near Nara, Japan. Consumers are encouraged to tour this facility as well as the adjacent model homes and to participate in sensitivity training on the mobility and sensory changes of aging. For more information, see www. sekisuihouse.co.jp/company/data/current/document-423-datafile.pdf. In the United States, the Rhode Island School of Design has conducted extensive universal design research, resulting in production of model kitchens displayed at the Smithsonian (see Figure 3–14 and Expert Focus: Universal Kitchen Project on page 64). While these innovations offer a glimpse of the future of universal design, many universal design ideas are already in common use to support health care at home. Lever controls, side-by-side refrigerators, and C-grips are invisibly integrated into most of our homes, accommodating people of all sizes and abilities. Many larger cities offer mobile hospitals, interactive cable, and sophisticated computer systems to support home health care (see Checklist: Computer Stations for All Abilities on page 150). Increasingly, home health-care services and technologies are prescribed by teams of therapists, designers, and social workers dedicated to helping residents cope with changes in ability as they remain at home.

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Figure 3-12 Remote-controlled lift. Courtesy of Sekisui House, Ltd.

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Figure 3-13 Smooth transfer to a wooden soaking tub. Courtesy of Sekisui House, Ltd.

Figure 3-14 Universal kitchen. Courtesy of RISD—Universal Kitchen, Mini and Maxi. Photography: Mark Johnston.

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EXPERT FOCUS Universal Kitchen Project

A Collaborative Project by Julia Child, Rhode Island School of Design and Cynthia Leibrock6 The Rhode Island School of Design has restructured kitchen standards and developed prototype kitchens that adjust to meet the needs of a full range of users. Time-motion studies revealed that over 400 steps are needed to prepare a simple dinner in a standard kitchen; this number has been greatly reduced by these unique designs. Instead of an interrelated work triangle in one work area, three separate major work areas were identified: the food preparation area, the cleaning area, and the snack area, each with their own sink. The research also identified a comfort zone on the countertop that is 16 to 18 inches deep. Two small refrigerators are placed in this zone, one in the food preparation area and one in the snack area. Redundancy throughout the kitchen reduces the reach, mobility, and time required for each task. The research also identified a need for seating in the food preparation area. Communication problems and environmental concerns were also addressed. One kitchen recycles gray water through a waste channel. A continuous wet surface drains into this channel, encouraging a clean-as-you-go work style. Three kitchens were developed, including a standalone mini-kitchen that is perfect for dormitories, hotels, assisted living, and independent living models (see Figure 3–15). The mini-kitchen cabinets unfold to reveal a standard kitchen that contains everything needed to make a moderately complex meal for two. Appliance components are interchangeable with storage components, and the disappearing doors on both do not sweep over the countertop.

Figure 3-15 Mini-kitchen. Courtesy of RISD—Universal Kitchen, Mini and Max. Photography: Mark Johnston.

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Endnotes 1. Department of Housing and Urban Development, Fair Housing Act Design Manual: A Manual to Assist Designers and Builders in Meeting the Accessibility Requirements of the Fair Housing Act, 2009, retrieved September 23, 2009, from www.huduser.org/publications/destech/fairhousing.html. 2. Colleen Kelly, “Older Residents Find Way Back to Community,” Spectrum (October 1993): 6. 3. Victor A. Regnier, Assisted Living Housing for the Elderly: Design Innovations from the United States and Europe (New York: John Wiley and Sons, 2004). 4. Cynthia Leibrock and James Evan Terry, Beautiful Universal Design (New York: John Wiley and Sons, 1999). 5. Sekisui Housing “Nattoku Kobu Studio,” in Sekisui House Comprehensive Housing R&D Institute Guidebook (P9 “Lifetime Home Zone”), Kyoto, 1997. 6. Rhode Island School of Design, The Universal Kitchen: Research, Analysis and Design. Paper presented at the Universal Kitchen Project Advisory Board Meeting, Providence, 1997.

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merican hospice service started with the Connecticut Hospice in March 1974. In 1980, this facility was licensed as an inpatient hospice. Hospice is a program designed to facilitate end of life care by maintaining and managing the patient’s quality of life for the terminally ill, usually with a life expectancy of six months or less. According to the National Hospice and Palliative Care Organization (NHPCO) there are, at present, over 4,700 hospice programs and 2,800 hospice facilities in the United States, with more than 1.4 million Americans seeking hospice care in 2007.1 According to the National Hospice and Palliative Care Organization, in 2007 42 percent of hospice patients received care and died in a private residence; the remaining 58 percent received care and died in a health-care facility where hospice and palliative care was provided. Inpatient hospices are part of the continuum of palliative care. Facility types range from nursing, long-term care, and hospice inpatient care facilities; or acute care hospitals. The growing numbers of people choosing hospice services demonstrates that awareness of choices that are available have grown, creating a demand for hospice services and places where services may be provided. How should we view the process of dying? The philosophy of hospice maintains that we should enhance the life that remains. Hospice emphasizes

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palliative care, controlling pain and other symptoms but not necessarily prolonging life. At the end of life, time must be measured by quality instead of quantity as stated in Einstein’s Dreams, authored by Alan Lightman in 1993.2 Each moment takes on greater importance, each sensory experience a special meaning. A window is not just an opening for light and air; it frames a vista of the last sunrise. A door is more than a functional entrance; it brings in friends and family members. Design details in hospice are selected to improve life quality, not necessarily for their healing attributes. Detailing goes beyond problem solving to plan the setting for a wide choice of comforting scenarios. The key is choice, providing the hospice patient access to positive experiences. For example, patients should be offered choices in music, dining, fragrance, and tactile experiences. Design detail must be flexible and easily adapted to the desire of the patient. Hospices are not designed for the average user; they must be planned to adapt to individual needs of patients and their families. The hospice must be easily personalized and controlled, even by users with reduced strength, coordination, and mobility. In addition, details must be visually pleasing and appealing to all the senses. Space planning can also support life quality. Short travel distances should be planned between spaces, especially to bathrooms (see showers, toilet stalls, and lavatories checklists on pages 183 and 185 and the Kohler Demonstration Project research abstract on page 108). In general, spaces should be small and clearly differentiated to aid in way finding and orientation (see Checklist: Way-Finding and Orientation Cues on page 253). The environment must also be visually pleasing and appealing to all the senses through choices in music, dining, fragrance, and tactile experiences. The entrance to a hospice should welcome the patient. Patients should not be required to use the institutional entrance for staff and consultants; they should have their own dignified entrance. The approach should be designed to accommodate a person on a gurney or anyone using a wheelchair or walker (see Checklist: Building Approach on page 69 and Checklist: Passenger Loading Zone on page 139). The building should offer a residential ambience. This can be established by reducing larger elements to a human scale. Dormers and window boxes can be added to the exterior. Seen from the inside, window boxes serve as a garden at bed height. Interior scale can be reduced through the use of multiple windowpanes, trim in the hallways, and handrails on stairs. Institutional scale can also be reduced by space planning. Four to six private rooms can be clustered around an intimate shared living area (see Figure 4–1), providing space for social support.

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Figure 4-1 Clustered bedrooms. Courtesy of Hospice of Lancaster Co. Designer: Reese, Lower, Patrick & Scott, Ltd.

CHECKLIST Building Approach • Plan smooth, firm, and stable sidewalks with good traction. Brick, sand, and cobblestone surfaces are examples of textures that are difficult for many people. • Abrupt edges and drops in the sidewalk pose a tripping hazard and a barrier for people in wheelchairs. Specify adequate drainage and sidewalk sub-base construction to prevent settling and the resulting changes in level. • Ramp existing changes of level exceeding ½ inch. Bevel changes of level between ¼ inch and ½ inch (see the Checklist: Handrails on page 260) as dictated by ADAAG (2002).3 Continued

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CHECKLIST Building Approach (continued) • Where an accessible route crosses a curb, provide a curb ramp built to ADA Accessibility Standards in slope, location, width, and surface (see Checklist: Ramps on page 258) as dictated by ADAAG (2002).4 • Curb ramps should not reduce the width of the level accessible route. When a curb ramp is cut into the level accessible route, the resulting slope can pull people in wheelchairs into the street. • Specify flared sides on curb ramps, because steep sides can pose a tripping hazard to pedestrians. • Plan a covered exterior route for emergency escapes. Such a route usually consists of a covered sidewalk around the perimeter of the building. For security and safety, the sidewalk should be well lighted. It should be adequately drained yet free of gratings, which could catch on wheels and crutches. • Gratings used in other areas should have spaces no greater than ½ inch wide, as dictated by ADAAG (2002).5

At the end of life, basic human needs do not necessarily change, yet people with terminal illness are often isolated from friends and family, enduring painful treatment and an unending procession of providers. More than ever before, they are in need of privacy, comfort, and the support of friends and family.

DESIGN CRITERIA Privacy As death approaches, privacy seems to become more elusive. Interruptions by staff become more frequent. Family and friends may visit more frequently. A private room offers the patient more control, especially if visitors and staff enter by patient permission only. Some patients prefer a roommate, so double rooms should be available, but generally a private bedroom and bathroom offer patients greater control over their personal space and privacy. The private bedroom can also be used as a viewing room after death. In hospice, the bedroom is often larger and more private than a hospital patient room. Privacy is ensured with acoustical design planned to absorb ambient noise and prevent transmitted noise. According to Pascale

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Carayon, editor of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety (2006), the Environmental Protection Agency (EPA) recommended guidelines for continuous background noise in hospital patient rooms are 45 decibels (dB) during the day and 35 dB at night.6 As an example, during the day, 45 dB equate to the level of noise in a quiet office or perhaps a living room; 35 dB at night would sound more like a library or a quiet whisper. At this time, there are no recommendations specific to hospice care settings.

Comfort Comfort is the major provision of hospice. It involves more than relief from pain; comfort comes from pleasant memories, hours spent in the garden, the sound of a crackling fire, soothing music, appealing fragrance, and a loving touch. Hospice provides these final pleasures; hospice design strives to evoke pleasant emotional responses. Norman Cousins states in The Healing Heart: Antidotes to Panic and Helplessness (1984), that memory is where the proof of life is stored.7 Patients in hospice often spend time reviewing their life, looking for meaning as they become reconciled to death. Personal possessions and family photographs can trigger comforting memories. Windowsills should have plenty of room for personal treasures. A bathroom shelf can house personal photographs as well as grooming items. A trunk could be placed at the end of the bed, offering a surface on which to display cards and photographs as well as a secure place for storage. Familiar furniture brings back memories, and patients should be encouraged to bring their own furnishings. Storage for existing hospice furniture should be planned to make room for the patients’ own furniture. In public spaces, elements of home like a piano, a grandfather clock, a game table, and French doors can evoke pleasant memories. Nature is comforting to many, and access to the outdoors is important (see Figure 4–2). A garden provides a comfortable place to visit and produces flowers to adorn the patients’ rooms (see Figure 4–3). Even short exposures to nature, as short as three to five minutes, evoke psychological/ emotional and physicological changes, reducing stress.8 Bring the natural elements of light, water, and fire indoors through the use of skylights, fireplaces, and fountains. Special care should be taken with the hearth of the fireplace, which may be viewed as the heart of the hospice. This is an appropriate place to display personal photographs of the staff and their families.

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Figure 4-2 Bedrooms with private gardens. Courtesy of Hospice of Lancaster Co. Designer: Reese, Lower, Patrick, and Scott, Ltd.

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Figure 4-3 Flowering gardens. Design: Delawie Wildes Rodrigues Barker & Bretton, 616/299–6690. Photography: David Hewitt/Anne Garrison.

Bring nature in by providing sufficient space in patient rooms to place the bed close to a window with a comforting view. Studies (conducted by Cooper and Barnes; and Whitehouse et al.)9,10 have shown that, in addition to reducing stress, views and access to nature and gardens can significantly increase patient and family satisfaction with the caregiver and the overall quality of care. The bed must be adjustable (see Checklist: Patient Beds on page 272), and the window must be easily operated to offer the patient access to fresh air. Orient the window to provide good sunlight without glare, even in the late afternoon. Soft sheers on the window produce lovely shadows. Designer bed linens are a relatively inexpensive extravagance that adds a comfortable residential touch. Choose linens with a high thread count for softness and comfort. Leave enough space around the bed for a patient to receive care and comfort; extending the bed diagonally from the corner of the room does not provide sufficient space for family and caregivers at the head of the bed. Comfort and reassurance come from human touch. Provide clear floor space for a portable massage table. Integrate touchable textures in upholstery and floor covering. With proper specification, fabric and carpet can be used in patient bedrooms, bathrooms, and other high-maintenance areas (see Checklist: Flooring and Checklist: Carpeting on pages 203 and 21).

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The warmth of a soaking tub or a soothing whirlpool bath can also be a great source of comfort. Some tubs have doors that swing up or open out for easy access. These doors are tightly sealed and can be used with a whirlpool bath. A tub with a swing-up door can be ordered for a left or right approach, allowing full use by a person with hemiplegia. The strong side of the body can be used while transferring and accessing tub controls. Make sure that drain controls are within reach. Since the patient must wait for the tub to drain before exiting, a high-volume drain allows the tub to be quickly emptied before the patient gets chilled. Family comfort must also be considered. Provide a private place for the family to grieve and a private telephone for their use. This room could also be used for counseling and meetings with providers. It could even double as a guest room with the addition of a fold-down bed or sofa sleeper. Other comforting family options include a place to nap and a children’s day-care area. A coffee shop is a great place for a quick break, and it could be open to the community to encourage integration and acceptance of the hospice. CHECKLIST Doors • French doors are often specified for wheelchair access, but it is difficult to open both doors at the same time from a wheelchair. One leaf must offer at least 32 inches of clearance. • Eliminate the vertical strip between French doors, as it is often not detected by blind people who use canes. Doors that open at an angle into high-traffic areas may also be hazardous to people using canes. Plan sliding interior doors to eliminate this problem. • For people who must spend part of the day in bed, use wide French or atrium patio doors that allow the bed to be moved outside. Wide doors also facilitate moving large pieces of furniture into the room. • Sliding glass exterior doors can be difficult to operate because of the width and weight of each door. Also, the accumulation of dirt in the door track can render the doors inoperable. Consider a hinged glass door as a replacement. • For people who are autistic or prone to seizures and falls, use tempered glass in doors. Glass doors should be protected from wheelchair abrasion by a kick plate. • Pocket doors often solve space-planning problems, but the recessed hardware is often difficult for many to use. An outside-mounted sliding door can eliminate the need for recessed hardware. • Dutch doors are problematic, as the top half of double-hung doors often is not detected by a blind person using a cane.

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CHECKLIST Doors (continued) • To operate swinging doors, people in wheelchairs must often reach, grasp, pull, back up, turn, and go around. Sliding interior doors that stack out of the way are the best choices for wheelchair and gurney access. • Folding doors also work well, but it is easy for children and others to pinch their fingers in them. If these doors are on a track, make sure the track is recessed and not an obstacle for entry. Accordion-folding doors and draperies also work. • Sliding top-hung doors with bottom guides may be easier to move than those that slide on a bottom track. Choose nylon wheels or roller bearings with selflubricating metal tracks. • Solid-core doors prevent transmitted noise but require more strength to open and close than hollow-core doors. Maintain a minimum width to keep doors light and easy to open. • To measure the force necessary to open a door, attach a spring scale to it, then open the door slowly and evenly. Many people cannot open exterior doors that require more than 8.5 pounds of force (lbf). Interior doors and all sliding doors should require less than 5 lbf as dictated by ADAAG (2002).11 • Doors that stick or drag require needless effort. The problem can often be corrected by oiling the hinges or removing the old paint on the edges of the doors. If this does not work, remove the door, plane and sand the edges, shim the hinges, or hang the door on new hardware. • Sand leading edges of doors to eliminate a sharp edge and minimize possible injury. • If allowed by code, specify an oil finish on doors for easy touch-up. • In commercial spaces, specify alternative doors or gates adjacent to revolving doors and turnstiles. Some doors feature an extra panel that can be opened when wider access is necessary. • People with reduced vision are often injured by swinging power doors or sliding doors with malfunctioning motion detectors. Air curtains and manually operated doors are better choices. • Whenever possible, specify 34 inches (instead of the required 32 inches) of clearance in the door frame. This allows wheelchair users 2 extra inches for elbow clearance.

The aroma of fresh coffee signals break time for many, a time to relax with friends and family. The sense of smell may trigger more memories than sight or sound because of its strong link to the limbic system, the brain’s emotional center. A study conducted by Louis and Kowalski12 measured responses of 17 cancer hospice patients and linked the use of aromatherapy

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using lavender oil to short term benefits including a positive change in blood pressure and pulse, pain, anxiety, depression, and sense of wellbeing. Another study of 42 randomly selected hospice patients, conducted by Soden, Vincent, Craske, Lucas, and Ashley,13 used lavender oil for aromatherapy massage to look at long-term outcomes. The study was unable to demonstrate significant long-term benefits for improving pain control, anxiety, or quality of life; however, sleep scores improved significantly and depression scores were statistically reduced. Other positive distractions like music and emotionally positive artwork, and environmental complexity can reduce stress and pain, as discussed in The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity.14

Support of Friends and Family At the end of life, social rituals and celebrations of life have great value. The rituals of dining are small pleasures that add immeasurable quality to hospice life. Patients may prefer to dine in bed or at a table with family and friends. A small table set with beautiful linen and tableware in the bedroom is a nice touch. A choice of dining areas and cuisine is preferable. The meal could be served in individual courses with hot food storage available to give the patient time with each course. Although most patients do not prepare their own food, a family kitchen offers them this option as well as a place to find a quick snack (see the Universal Kitchen Project research abstract on page 64 and checklists pertaining to universal kitchen components and design on pages 101 and 102). It can also be used by families to prepare a favorite meal. A dining table in the family kitchen provides the patient one more place to spend time with family and friends.

CHECKLIST Door Hardware • Door accessories for wheelchair use include levers, door closers, thresholds, protective plates, vision panels, and hinges. • A door can be equipped with double-action hinges so it can swing in both directions. Be sure the action of the door does not interfere with foot traffic. • If an existing door is too narrow for wheelchair use, try removing the doorstop for added clearance. Offset pivot hinges can increase the width of an open doorway by 2 inches.

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CHECKLIST Door Hardware (continued) • In case a person loses consciousness behind a locked door, specify rising pinbutt hinges for easy door removal. Be sure interior locks can be opened with a screwdriver. This is especially important on the bathroom door. • A rising pin-butt hinge can also be used to elevate weather stripping from floor surfaces. Maneuvering over interior thresholds may be difficult for people in wheelchairs and walkers. Thresholds are also a significant tripping hazard for people with ambulatory limitations. • Interior thresholds often serve no purpose and should be removed. If exterior thresholds cannot be eliminated, they should be no higher than ½ inch. Bevel thresholds to a vertical slope no greater than 1:2.5. • Exterior thresholds should be of a contrasting color to the floor. • To totally eliminate the threshold on swinging doors, use movable mortise-type weather stripping that lowers to the floor when the door is closed. • Limit the height of doormats to ¼ inch and secure them to the floor with beveled metal trim or tape. They can also be recessed but may require a drain. A recessed carpet mat should not exceed ½ inch in pile height. • A pneumatic door closer can offer convenience for people in wheelchairs who have the strength to operate it. It is also useful for people with vision limits because doors left open at an angle into traffic areas may present unexpected problems. • A power door opener can be activated by a remote control, a floor mat sensor, a wall switch, or a photo cell. If mounted on the pull side of the door, the sensor or photocell must open the door before the user reaches the sweep area. This is not an issue with folding or sliding power doors. • A wall button or switch may be used if mounted within reach, close to the door or on the push side (but not in the frame). The button must be a minimum of 3/4 inch in diameter, be flush mounted (not recessed), and require 5 lbf or less to operate. Make sure automatic doors have a breakout feature in case of power failure. Force required must be no more than 15 lbf as dictated by ADAAG (2002).1 • A delayed-action door closer helps to keep the exterior door from blowing closed during use. Automatic doors must remain open to a full 90° for 20 seconds to allow wheelchair passage. Rising pin-butts are not sufficiently reliable as door closers. • To close the door without a door closer, add a C-grip handle mounted on the hinge side of the door. Again, this requires strength to use, but it does offer convenience. Continued

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CHECKLIST Door Hardware (continued)

Figure 4-4 Hinge-side C-grip. Courtesy of Barrier Free Environments.

• To protect doors from abrasion, consider a high kickplate (16 inches) on manually operated doors. Extend the plate the full width of the door on the push side. The corners of metal plates should be filed or bent toward the door to avoid possible injury. A plate is preferable to projecting rails, which could catch on a wheelchair or gurney. • A metal bar or decal over a sliding glass door makes the door more visible and can prevent accidents. • Vision panels in doors (with the bottom of the panels no higher than 3 feet) allow a child, shorter person, or a wheelchair user to see and be seen. On an exterior door, a vision panel helps to monitor visitors. On an interior door, the panel lets the person become oriented to ongoing activities before entering a room. Be aware that people with reduced vision can mistake panels that extend to the floor for door openings. • Levers (mounted at a height of 36 in) on both interior and exterior doors are convenient for people in wheelchairs, children, and anyone with reduced strength as dictated by ADAAG (2002).2 They are much easier to use from a seated position than doorknobs are. Horizontal levers require less operating force than vertical levers do.

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CHECKLIST Door Hardware (continued) • Levers should turn toward door hinges for easy access. They should have a slight return to keep them from catching on clothing. • It is easy to trip over a floor-mounted doorstop. Use wall mounted doorstops long enough to protect walls from door levers (but not protruding more than 4 inches). Choose one that doubles as a hook for clothes. • Paddles on doors can be specified if they can be easily maneuvered with one hand. Avoid doorknobs; never specify a knob on one side of the set and a lever on the other, because the spring of the lever is too strong for the knob. • Avoid door hardware requiring simultaneous two-handed operation. One example is a lock that requires the user to turn the key with one hand and pull with the other. Specify a pushbutton system that can be operated with one hand. • If a dead bolt is used, specify a set that disengages both the dead bolt and the door latch with one motion. For people who don’t have the strength to operate the dead bolt, a slide bolt provides nearly the same amount of security and is easier to handle. • Doors without latches should have a C-grip on the pull side and a push bar on the push side. Doors with C-grips on both sides give the misleading message that both sides should be pulled. 1. U.S. Architectural and Transportation Barriers Compliance Board (Access Board) (2002). Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG.) Washington, D. C. Retrieved June 8, 2009, from www.access-board.gov/adaag/ADAAG. pdf. 2. Ibid.

Design elements supporting socialization may be as simple as a reachable telephone on a usable nightstand and as complex as programming and space planning to support excellent communication. Design details help families to communicate, to come to terms with death. Family members may feel afraid of death or be confused about the situation. They may feel guilty, perhaps wishing they had done more. They may experience unresolved hurt, a feeling that the loved one is deserting them. For family members as well as patients, a place for private contemplation, prayer, and worship is a necessity. According to Design Innovations for Aging and Alzheimer’s, by Elizabeth C. Brawley, indoor and outdoor meditation and prayer areas should be planned.15

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Many hospice activities are quiet and contemplative. A reference library could offer recreational reading material, spiritual support, and research on coping with life’s transitions. Spaces should be planned throughout the hospice for reading, listening to music, playing games, gardening, and watching television. A classroom or auditorium could be used for in-house education as well as community events that encourage community support. A beauty salon could also be open to the public while providing patients and visitors a needed boost in self-esteem. Patients should be able to spend time with visitors in all locations; the entire hospice should be accessible to patients with mobility aids as well as those on gurneys. Since many patients are on gurneys or in bed, plan an interesting ceiling pattern (see Checklist: Pattern, Texture, and Contrast on page 236). Light control on skylights is especially important to reclining patients. Medical equipment should be out of sight to encourage repeat visits. Medical gases can be concealed in the headboard of the bed; and suitable storage should be planned for potentially frightening medical equipment like gastric tube pump feeders, intravenous (IV) stands, and portable oxygen supply.

Individual Choice To meet the needs of a wide variety of consumers, design detail must accommodate a wide range of choices. For example, younger patients may need more electrical outlets for computers, MP3 players, and other electrical devices, but patients in the latter stages of the disease are very sensitive to noise. A slamming door or even the ring of a telephone can be physically painful. Sophisticated acoustical design (see Chapter 10) should be combined with simple solutions like soft phone chimes on the phones and door closers that prevent slamming. Individual control of heating and ventilation is critical. Flexible lighting is also important for adaptation to a variety of needs (see the Checklist: Universal Lighting on page 90). Public spaces require night lighting to accommodate variable wake-sleep cycles. During the day, numerous sources of natural light should be provided. Clients’ rooms should offer visual access to the outdoors, a positive distraction from health problems. Bedrooms need large windows with good window controls to accommodate increased light sensitivity as well as ventilation. For people who spend some daylight hours in bed, use a reflective blackout lining to darken the room for sleeping.

Hospice

Many rooms should provide secure access to the outdoors. A private balcony with sun and shade is especially appreciated by patients who need fresh air but are not well enough to go out in public. Access to nature can also be provided by a greenhouse. This warm retreat is particularly welcome to patients with reduced circulation, who may prefer ambient temperatures as high as 78 degrees. Because hospice care encompasses a variety of services, inpatient hospice must accommodate a large number of visitors. Demand for parking is higher than at other long-term care facilities. Friends and relatives also visit frequently. Rooming-in is common; family members may also request access to exercise areas, the kitchen, and laundry. The kitchen may need a larger freezer than is standard; some patients find relief from nausea by chewing ice and are soothed by a bowl of sherbet or ice cream. A sterilizing dishwasher should also be available for infection control.

Infection Control The terminally ill have an increased susceptibility to infection, though the source may be masked by the appearance of many well-recognized symptoms, as reported by Nicolle, Strausbaugh, and Garibaldi.16 According to Spaulding, an estimated 1.5 million infections occur annually in extended care facilities in the United States.17 Facilities must have a program for detecting, preventing, controlling, and reporting infections. An infectioncontrol program should focus on all elements of care, including design and construction; environmental issues such as food handling, laundry, cleaning, and waste disposal; visitation policies; and direct care practices, for example, hand washing and immunization. Every state and the federal government have regulations relevant to infection control for inpatient hospice facilities and other extended care settings. In addition, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards and Medicare regulations may be incorporated into state licensing regulations, providing a structure for developing and sustaining an infection control and prevention program for the safe care of hospice patients.

Security Security for hospice serves two purposes: (1) control access into the hospice and surrounding grounds; and (2) control potential wanderers from walking off the grounds. Those suffering from dementia are at risk for wandering into the street and out of the neighborhood. A security system for monitoring

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patients who have been identified as wanderers, such as an identity bracelet that sets off an alarm if a wanderer attempts to exit the hospice, will minimize the risk and provide families with the assurance that their loved one is safe. Hospice patients are vulnerable, requiring a security system that not only limits access, but incorporates a monitoring system and visual access of entry points. Twenty-four-hour supervision is required. A sign-in book is a low-tech, nonthreatening way to continually monitor the entry of the hospice. Egress must be limited in some situations but not restricted in case of fire. The accessible route must include doors that expand to 42 inches of clearance for the evacuation of patients on gurneys. This extra clearance also prevents these patients from being confined full time to their rooms, allowing them to be moved on gurneys to social functions and hospice activities. In addition to wide doors, client bedrooms and bathrooms should be equipped with an emergency call system (see the Checklist: Security on page 54). One final detail: When a loved one dies, families frequently cannot find the strength to immediately claim the possessions. As a courtesy for the patient’s family, providing storage for personal effects will support the family in transition. The Bustle of a House The Morning after Death Is solemnest of industries Enacted upon Earth— The Sweeping up the Heart and putting Love Away We shall not want to use again Until Eternity —Emily Dickinson Endnotes 1. National Hospice and Palliative Care Organization (NHPCO), Facts and Figures: Hospice Care in American. (Alexandria, VA: National Hospice and Palliative Care Organization, 2008). 2. Alan Lightman, Einstein’s Dreams (London: Bloomsbury Press, 1993). 3. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG), Washington, DC, 2002, retrieved June 8, 2009, from www.access-board.gov/adaag/ADAAG.pdf.

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4. Ibid. 5. Ibid. 6. P. Carayon, Handbook of Human Factors and Ergonomics in Health Care and Patient Safety (New York: Routledge, 2006). 7. N. Cousins, The Healing Heart: Antidotes to Panic and Helplessness (Boston: G.K. Hall, 1984). 8. R. Ulrich, Health Benefits of Gardens in Hospitals, conference proceeding, Plants for People International Exhibition Floriade, 2002. 9. C. Cooper and M. Barnes, Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations (Martinez, CA: Center for Health Design, 1995). 10. S. Whitehouse, J. W. Varni, M. Seidel, C. Cooper-Marcus, M. J. Ensberg, J. J. Jacobs, and R. S. Mehlenbeck, “Evaluating a Children’s Hospital Garden Environment: Utilization and Consumer Satisfaction,” Journal of the Environmental Psychology, 21 (2001): 301–314. 11. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) 2002, Washington, DC, retrieved June 8, 2009, from www.access-board.gov/adaag/ADAAG.pdf. 12. M. Louis and S. D. Kowalski, “Use of Aromatherapy with Hospice Patients to Decrease Pain, Anxiety, and Depression and to Promote an Increased Sense of Well-being,” American Journal of Hospice and Palliative Medicine 19:6 (2002): 381–386. 13. K. Soden, K. Vincent, S. Craske, C. Lucas, and S. Ashley, A “Randomized Controlled Trial of Aromatherapy Massage in a Hospice Setting,” Palliative Medicine, 18:2 (2004): 87–82. 14. R. Ulrich, X. Quan, C. Zimring, A. Joseph, and R. Chaoudhary, The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity. Report to the Center for Health Design for the Designing the 21st Century Hospital Project., 2004. Available at www.rwjf.org/files/publications/ other/RoleofthePhysicalEnvironment.pdf, accessed August 2010. 15. E. C. Brawley, Design Innovations for Aging and Alzheimer’s, (Hoboken, NJ: John Wiley & Sons, 2006). 16. L. E. Nicolle, L. J. Strausbaugh, and R. A. Garibaldi, “Infections and Antibiotic Resistance in Nursing Homes,” Clinical Microbiology Review 9 (1996): 1–7. 17. L. Spaulding, “The Changing Role of Infection-Control Programs in Long-term Care Management,” Nursing Homes 5:55 (2006), 95–97.

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SUBACUTE CARE AND REHABILITATION

T

he Scandinavian approach to care begins with their philosophy toward aging. They value their elders as precious human beings. Because they place so much emphasis on dignity and independence, their system is more about assisting than institutionalizing older people. They keep people out of institutions by providing “service homes,” which are units designed to maintain resident’s independence for as long as possible. These service homes are scattered throughout apartment complexes of 10 and 50 units per complex. By relying on appropriate technology, residents sustain their independence, reducing reliance on staff and thereby reducing the cost of care.1 For those with recent or current illness or injury, subacute care or transitional care is an option. The care received by patients in subacute care varies considerably, depending on the general or specific focus of the subacutecare facility—there are specialty facilities that focus on heart, orthopedic, cancer, or pediatric care, for instance. Basically, subacute-care programs serve patients who require less intensive care than acute care, but more intensive care than assisted living or nursing home care. Although many patients in subacute care receive rehabilitation services, they are generally not as medically stable as those in rehabilitation hospitals.

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Length of stay at a subacute care or rehabilitation facility may be as long as six months or as short as two weeks. Subacute costs have been shown to be about 30 percent lower than costs in a similar setting in an acute-care hospital.2 Patients in both subacute and rehabilitation facilities often have multiple afflictions requiring a wide variety of treatments.

DESIGN OF SUBACUTE-CARE FACILITIES Regulations governing the design of subacute care include the Americans with Disabilities Act (ADA), the Omnibus Budget Reconciliation Act (OBRA), and certificate of need (CON). ADA prevents disability by design, OBRA addresses restraint-free environments (locked doors, etc.), and CON deals with a range of building issues, including minimum square footage per person. Health department standards regulate call systems and distances to the nursing stations. Building codes and the National Fire Protection Association (NFPA) determine the design of the facility to meet safety and fire codes. The AIA Guidelines for the Design and Construction of Health Care Facilities (AIA Guidelines)3 is a guideline often adopted by municipalities, becoming an addendum to the building code as the primary guideline that incorporates many of the requirements in these other codes and guidelines. The USGBC LEED program is adopted by the facility or system, with the expectation that their building will be sustainable and contribute to the quality of care. 4 All of these requirements are minimum standards and, as designers, we should strive for excellence; however, these standards create a framework from which to build. An example of the minimum standard conundrum is that only 50 percent of skilled nursing patient rooms and baths are required to be accessible under the ADA standards, yet 70–75 percent of the patients are in wheelchairs. If a facility meets a minimum requirement but does not provide adequately for its constituents, does that drive relocation of residents? As mentioned in previous chapters, seniors do better when they remain in place. The physical environment and the medical and social programs must support that intention.

Design for Visual Acuity As we age, our eyes may adjust to light more slowly due to a reduction of elasticity of muscles. We develop an inability to adapt to changing light levels. The result is a dazzle effect called contrast glare that makes it more difficult to focus when moving between light levels. Sensitivity to glare may also be caused by macular degeneration, a deterioration of the central area of the

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retina. One-third of people 70 years old or older have this disease, which produces a spot in the center of the visual field that gradually enlarges until it fills the field. Glare actually increases the deterioration rate of the retina.5 As we age, the lenses of our eyes thicken, making us more susceptible to another type of glare called a veiling reflection, which we experience when trying to read a shiny printed page. In subacute care, veiling reflections may be subtler. Reflections on a shiny floor look like water when perceived through a thickened lens. Older people are immobilized by a fear of falling. A window or door at the end of a shiny corridor can produce enough glare to cause an older person to trip over a threshold or fall down a stairway. These accidents can be easily prevented by design (see Checklist: Eliminating Glare on page 87). CHECKLIST Eliminating Glare • Keep lighting levels adjustable and consistent from room to room. Keep corridor lighting levels low at night. Many people have trouble adjusting to sudden changes from a dark bedroom to a bright corridor. Night-lights in the bedroom can also help. Many falls occur when people try to get out of bed. Install a light under the lip of the nightstand or around the perimeter of the bed. • Gradual changes in light levels are also needed in transition spaces between indoors and outdoors. Create a transition zone, such as a well-lighted entryway or porch, between the outdoors and the interior. Put sidelights at the entrance to a bright room. Sidelights and other accent lighting (instead of flat fluorescent light) can help people to maintain orientation within the room. • Shield all lighting sources to prevent contrast glare. Especially avoid chandeliers without shades because they do not significantly increase light levels, yet they cause glare unless frosted globes are used. Even then, unprotected bulbs have high-temperature surfaces capable of carbonizing dust, a source of irritation to many people with allergies.1 • Avoid directed sources like spotlights. Provide several low-intensity light sources rather than one bright source. Keep all lights high and well diffused over the task area. Wall lighting strips can be mounted 12–18 inches from the ceiling, washing the wall as well as the ceiling with light. Other successful choices include indirect pendant and cove lighting. Under-cabinet lighting can illuminate matte-finished counters without glare. • Control contrast glare at windows through proper placement and treatment. Window glare can be controlled by draperies, blinds, and shades. Dark color schemes adjacent to bright windows can dazzle and make it difficult for people to distinguish objects located near the window. Continued

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CHECKLIST Eliminating Glare (continued) • To reduce dazzle, doors should be placed in alcoves or to the sides of corridors, not at the ends. An open door at the end of the hall causes both contrast glare and veiling reflections down the length of a shiny floor. • Eliminate veiling reflections by specifying low-glare surfaces on counters, floors, furnishings, and walls. 1. Robert J. Kobet, Allergies in Architecture, paper presented at the Regional Conference of the American Association of Otolaryngologic Allergists, San Antonio, TX, May 18, 1987.

Eighty-five percent of older people experience yellow tinting of the human lens.6 The yellowed lens filters out short wavelengths. Cool colors, like blue-green and blue-violet, become grayed. It becomes nearly impossible to see the edge of a blue chair or ottoman situated on a blue carpet, a contributing factor to falls. Yellowing of the lens also reduces the amount of light perceived. In addition, pupil size generally decreases with age, so the pupil lets less light in. Many older people require 4 to 5½ times more light to distinguish a figure from the background (at least 100 footcandles (fc) for reading and close work).7 The light level in a typical nursing home is about 20–30 fc8 (see Checklist: Color on page 89). The Illuminating Engineering Society (IES) recommends at least 30 fc in the bathroom. As the pupil becomes smaller and the lens denser, depth perception may become restricted, potentially causing problems with spatial orientation and mobility. For example, a stripe across a hallway could be perceived as a stair or a change in elevation. Shadows from high-contrast lighting may have the same effect. To prevent the problem, keep lighting levels even (see Checklist:Universal Lighting on page 90). In some areas, high contrast is needed. A lack of contrast may make it impossible to distinguish between the floor and the wall, for example, or between foreground and background. High contrast also helpful to the many older people with reduced peripheral vision. Retinitis pigmentosa and glaucoma both cause this problem.

Design to Enhance Hearing Many older people have difficulty hearing high frequencies, and increased volume may not help. Some amplified phones boost high frequencies and improve clarity. Ambient noise reduction is also important. Background noise

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is often amplified and distorted by hearing aids (see Checklist: Validating Acoustic Guidelines on page 201). Older people have difficulty understanding a conversation when ambient noise levels exceed 30 decibels. It is not unusual to find dining rooms with noise levels at 60–70 decibels.9 Specify products with a high noise reduction coefficient rating (NRC). Low reflective ceilings amplify sound, increasing ambient noise. Long, rectangular rooms increase sound reflection and resulting noise levels. Ceiling light fixtures that reflect sound should be replaced with suspended or wall-mounted fixtures.

CHECKLIST Color • Use intense colors only for accents and for contrast to improve visual organization. Brightly colored grab bars, door frames, levers, and switches, for instance, are easier to find than those that blend into the background. • Yellow color schemes may cause difficulties for people who have yellowing lenses; bright yellow colors can intensify to the point of annoyance and pastel yellows are difficult to distinguish from white (which appears yellow). • With yellowed lenses, blue, blue-green, or violet color schemes may appear gray, especially in daylight or fluorescent light (in a blue color spectrum). Blue tones can be distinguished from other colors more easily at night when lighted by tungsten light. • Yellow tinting of the human lens has little effect on red tones. However, people with color blindness have difficulty distinguishing between green and red. • Texture makes tones appear darker, absorbing important ambient light.1 • Color values that contrast by more than two digits on the gray scale are adequate to increase the imagery of objects.2 (The gray scale consists of ten increments from black to white; it is often illustrated on the back of many printers’ rules.) • A monochromatic color scheme throughout the building may be perceived as institutional. It can become monotonous and boring when viewed for an extended period. It can contribute to sensory deprivation, which leads to disorganization of brain function, deterioration of intelligence, and an inability to concentrate. For those who suffer from a deficiency of perception, plan variety in color, pattern, and texture. • Primary colors (red, yellow, and blue) and strong patterns are pleasing at first but may eventually become tiring. Highly saturated colors may also be too controversial, triggering unpleasant associations.3 • The boundary between two intense colors (for instance, complementary colors like orange and blue) eventually becomes visually unstable.4 Continued

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CHECKLIST Color (continued) • Color can affect perceptions of time, size, weight, and volume. In a space where pleasant activities occur, such as a dining or recreation room, a warm color scheme makes the activities seem to last longer. In rooms where monotonous tasks are performed, a cool color scheme can make time pass more quickly. 1. L. G. Hiatt, ‘The Color and Use of Color in Environments for Older People,’ Nursing Homes 30:3 (1981) 18–22. 2. Hiatt, Long-Term Care Facilities, 200. 3. D. A. Carey, Hospice Inpatient Environments (New York: John Wiley and Sons, 1986), p. 223. 4. L. A. Pastalan, Aging and Human Visual Function (New York: A. R. Liss, 1982), p. 324.

CHECKLIST Universal Lighting • Sufficient lighting is particularly important in areas where concentration is required, decisions are made, or danger is present. Decision areas, like a reception room and entryway, may require increased lighting. A light ceiling color increases the quantity of reflected light. • Many accidents occur in bathrooms; increase lighting levels without glare to prevent accidents. • Stairways and landings, especially the head and foot of the stairs, are potentially dangerous areas (see Checklist: Stairs and Checklist: Handrails on pages 259 and 260). Place lighting (and windows) to throw light toward, not down, staircases. Recessed lighting under stair treads prevents accidents without creating glare. • As lighting quantity increases, be careful to avoid excessive heat by using luminaries with low heat output. • Extra lighting is helpful when using a shower chair or seat. A steam-filled room makes vision more difficult, and high ceiling lights may not penetrate to the level of a shower seat. At a minimum, recess a vapor-proof light fixture in the ceiling of every shower stall. The light can be combined with an exhaust fan to reduce the steam. • Flickering fluorescent lights have been found to trigger epileptic seizures. • Studies have shown that people with Alzheimer’s disease become agitated under fluorescent lighting.1 • Cool fluorescent light emphasizes the blue-green tones that are most difficult for people with cataracts to perceive.2 • When planning fluorescent lighting, keep in mind that a lighting spectrum as close as possible to daylight may reduce depression, fatigue, hyperactivity, and some incidences of disease. The daylight spectrum also may increase calcium absorption

Subacute Care and Rehabilitation

CHECKLIST Universal Lighting (continued) and reaction time to light and sound. This, in turn, may increase staff productivity and patient progress. • A less institutional appearance is achieved when only the light is seen, not the source of the light. With concealed lighting systems, the emphasis is placed on the beauty of the room and its occupants rather than on the light fixtures. • When using wall fixtures, keep controls within the reach of patients. Fixtures must protrude less than 4 inches when placed 27–80 inches a.f.f. (above finished floor).3 1. L. G. Hiatt, “The Color and Use of Color in Environments for Older People,” Nursing Homes 30:3 (1981) 18-22. 2. J. Carpman and Myron A. Grant, Design That Cares: Planning Health Facilities for Patients and Visitors (Chicago: American Hospital Publishing, 1998), p. 223. 3. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) 2002, Washington, DC, retrieved June 8, 2009, from www.access-board.gov/adaag/ADAAG.pdf.

Products with a high sound transmission class (STC) rating reduce transmitted noise that adds to ambient noise levels. Wall construction, double or triple glazing on windows, and placement of doors and windows can also reduce transmitted noise. Stagger interior doors so they do not face each other in corridors. Back-to-back outlets and medicine chests in bathrooms are also sources of transmitted noise that can be avoided. Many people with reduced hearing unconsciously depend on body language and lip reading. For people with hearing differences, plan adequate lighting to allow facial expressions, body movements, and gestures to be distinguished. Lighting is especially important in areas of frequent communication, like nursing stations and reception areas. Avoid backlighting and shadows on speakers and interpreters.

Assistive Technology The mainstream calls it smart home technology and it is marketed as a way to manage your home away from home (such as changing the thermostat to warm up the house at the end of the work day), or manage your music and grocery list within the home (primarily focused on convenience). However, when it is used in conjunction with assistive technology, it can maintain and sustain independence by enabling people with disabilities and aging adults to accomplish daily living tasks, and can assist with communication, education, work, or recreational activities. Coupled with smart home technology, it allows the user to control the

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lights, appliances, telephone, television, thermal comfort, safety (alerts), and other environmental aspects. Additionally, medical information (coordination), remote patient monitoring (fall detectors, health monitors), cognitive fitness and assessment, and social networking are viable assistive measures to enable people to live independently and age in place.10 These technological advances when utilized in the home improve the well-being and independence of older adults while providing the potential for significant health cost savings.

Design for Improved Cognitive Ability Cognitive difficulties in subacute care may range from poor judgment about touching hot surfaces to reduced attention span, depression, disorientation, and dementia (see Chapter 2). Considering the extended length of stay in subacute care, orientation is particularly important. A bulletin/marker board in each patient room can feature family photos. It can also be used for seasonal displays or to post the day of the week. A calendar and clock also help with orientation (see Figure 5–1). For a more comprehensive discussion on orientation, see Chapter 13. Disorientation may also be caused by repetitive elements in the design, for example, doors repeated the full length of double-loaded corridors (corridors with rooms off both sides). Long corridors themselves can be disorienting. Lighting and ceiling treatments can help to visually reduce the length of corridors (see Figure 5–2). Walking distances in corridors can be shortened with seating niches every 20 feet. This seating also supports

Figure 5-1 Clock and marker board with artwork and pinup space for orientation. Courtesy of Skyline Art Services.

Subacute Care and Rehabilitation

Figure 5-2 Design details visually reduce the length of corridors. St. Anthony Summit Medical Center, Frisco, CO. Architect and Interior Designer: Earl Swensson Associates, Inc. (ESA). Photo courtesy of Scott McDonald © Hedrich Blessing.

mobility; without seating in corridors, older people may be reluctant to leave their rooms. Orientation can be improved or reduced by pattern. Eliminate bold patterns, stripes, and undulating patterns in subacute care. Older people may feel more comfortable with patterns from the 1940s and 1950s.11 Orientation can be significantly improved by planning small spaces that are clearly differentiated by finish and size. Visual connection of spaces also improves orientation and offers patients a chance to observe activities prior to entering (see Figure 5–3). Orientation (where you are) differs from way finding (how you get there). Chapter 13 offers a comprehensive discussion on signage and way finding. Lighting can also be used to improve or impede cognitive skills. Some people with concentration differences may experience a shortened attention span triggered by fluorescent lighting. The flickering nature of fluorescent illumination can affect cognitive skills in people with limitations.12 Access to sunlight may help. Research has also shown that access to daylight and nature can make a significant difference in depression (see Chapter 11). Many older people have some degree of depression, and as many as 50 percent of patients in nursing homes are clinically depressed.13

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Figure 5-3 Visual connection between spaces. Courtesy of TRO/The Ritchie Organization. Photography: Edward Jacoby, Jacoby Photography

Design for Mobility Beautiful Universal Design is filled with ideas for people with reduced mobility.14 Most of these accessibility features meet the needs of older people, but a few do not. High toilets for wheelchair users, for example, don’t work for many ambulatory older users. It may be easier to sit and rise, but some older people (and shorter people) have bowel trouble with high toilets. Some even have to use a stool to elevate their legs into a squatting position in order to have a bowel movement. Specify standard-height toilets; an elevated seat can always be added if necessary. Many older people have a fear of falling, and with good reason. Osteoporosis and arthritis may have reduced their bone density and weakened their joints. The weakness may not be bilateral; older people typically are stronger on one side than the other. Unilateral weakness must be accommodated by grab bars on both sides of the toilet and handrails on both sides of the corridors. Handrails should be flat, not round, so the user can slide along using the forearm. A flat oval shape also increases grip strength (see Checklist: Handrails on page 260).

Subacute Care and Rehabilitation

The grab bars required by the ADA seldom meet the needs of older people. Although people with reduced strength often prefer grab bars on both sides of the toilet (refer to Chapter 3, Figure 3–6), people using wheelchairs, walkers, or assistants need one side clear for the approach. To accommodate everyone, install the grab bars required by the ADA and add swing-up assistance bars, wall mounted on both sides of the toilet (see Checklist: Grab Bars on page 95). CHECKLIST Grab Bars • Grab bars, sinks, and towel bars must withstand tremendous force (250 lb/sq.ft.), including bending, shear, and tensile forces.1 To help meet this standard, install grab bars with wood screws into studs, blocking, or plywood reinforcement. Molly bolts, nails, or screws into gypsum board are not adequate. • With prefabricated showers, the blocking or plywood support for grab bars must contact the plastic over the entire reinforced area. • Grab bars should not break or chip. They should have no sharp or abrasive edges, and they must not rotate within their fittings. • An oval design requires less strength to grasp than a circular bar and the flat of the oval can be used to brace the forearm as well. • A grab bar is often used by bracing the forearm between the bar and the wall for support. Install the grab bar no more than 1½ inch from the wall to prevent the entire arm from slipping through the gap. • The color of the grab bars should contrast with the wall to ensure quick and accurate eye-hand coordination in an emergency. Chrome and metallic bars may produce reflected glare or blend in with the wall. Even better, visually integrate the grab bar into a contrasting wainscoting. • Add fold-down grab bars on both sides of the toilet to support ambulatory users. Raise the grab bars for access from a wheelchair. • Textured finishes are available for a sure grip. • A transfer bar may be helpful over the bathtub; it should be installed on a ceiling trolley track or a ceiling eyebolt above the tub (with a minimum capacity of 300 lb/sq.ft). The ceiling may need to be reinforced to install this bolt or track. • Grab bars may also be necessary for transferring to a shower wheelchair. Clients whose doorway to the bathroom cannot be widened for wheelchair use may have the strength to transfer to the shower wheelchair through the doorway. In this case, grab bars should be installed on both sides of the doorway for support in transferring. Continued

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CHECKLIST Grab Bars (continued) • In most showers, grab bars should be installed at a height of 33 to 36 inches on all sides, or just below elbow height. When a shower seat is wall mounted, no grab bar is needed along that wall. Shower grab bars for children should be no higher than 27 inches. • A vertical grab bar at the entrance to the shower may be desirable for a standing user. Vertical grab bars must not conflict with horizontal grab bars for wheelchair use. • For the easiest approach to the toilet, grab bars should be located behind the toilet and on one side. Install them at a height of 33 to 36 inches, depending on the user. The bars should be long enough to allow unobstructed movement. • People with strength differences prefer grab bars on both sides of the toilet, and people in wheelchairs need one side clear for the approach. A swing-up assistance bar can meet both of these needs.

Figure 5-4 Integrated vertical grab bar. Courtesy of HEWI, Inc. 1. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) 2002, Washington, DC, retrieved June 8, 2009, from www.access-board.gov/adaag/ADAAG.pdf.

Subacute Care and Rehabilitation

Edward Seinfeld has conducted interesting research on the needs of older people with disabilities.15 He makes a case for a larger turning radius for older people in wheelchairs, up to 60 inches wide by 72 inches deep. He recommends resting places every 100 feet on the accessible route and an optimal slope of 1:20, even on ramps (see Checklist: Handrails on page 260). In addition, he recommends increasing corridor widths to 48 inches with doors swinging out of the corridor and 60 inches with doors swinging in. Doors to bathrooms should swing out and, in a typical 60 inch by 90 inch bathroom; the door should be on the long wall. In-swinging doors should have 24 inches of clearance on the latch side, not the minimum of 18 inches required by most codes and standards.

Other Sensory Issues As we age, we may experience reduced senses of taste and smell as well as a loss of sensitivity to pain and temperature. Beautiful Universal Design suggests a pressure balancing mix valve in the shower to prevent surges of hot water that can easily burn a person with reduced sensitivity to temperature, reduced circulation, and reduced reaction time.16 Many older people experience all of these changes. In the bath, a temperature control can also prevent burns.

DESIGN OF REHABILITATION FACILITIES Rehabilitation focuses on physical impairments as well psychological dysfunctions like stroke, head injury, cognition, and perception. But it goes beyond mere restoration of physical and mental function to the activities of daily living (ADLs). The key to design for rehabilitation is patient motivation; the facility must provide the incentive for a patient to get out of bed every day, sometimes for months at a stretch, and endure painful and possibly embarrassing therapy. Although most inpatient rehabilitation is completed within three to six weeks, it may involve tedious and repetitious activity for months on end, perhaps playing the same games with the same therapist at the same time every day. The design of the facility can have a positive impact on the patients (and the staff) by providing a treatment facility that goes beyond the typical acute-care facility, both in design and in planning. The therapy gym should provide an environment of care that inspires patients to do exercises that are often painful and require a mental commitment for success. The ADL treatment suite should be well appointed and comfortable; and of sufficient size

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to support assistance when needed, but provide opportunity to build selfreliance and independence. Independent apartments transition the patient to a more autonomous living situation. One rehabilitation therapy model features a large variety of training modules while providing rehabilitation therapists with an assessment tool, a real-life environment in which efficacy can be determined before discharge. Patients gain confidence in their skills and lose their fear of returning to work and home. They also learn to accept their limitations. Patients relearn everything from climbing stairs and ramps to banking. This type of rehabilitative environment offers modules including a grocery store in which the therapist can assess the patient’s ability to read and recognize prices (see Figure 5–5), count change, and stay within a budget. Patients also relearn to ring doorbells, retrieve mail, and use door hardware (see Checklist: Door Hardware on page 76). In addition, patients learn to traverse a variety of floor surfaces, including brick, turf, stone, and broken concrete. They practice getting in and out of a car, operating a parking meter and a gas pump, and walking through a crossing

Figure 5-5 A grocery store setting provides occupational therapists opportunities to integrate real life activities for rehabilitation patients. Courtesy of Guynes Design, Inc.

Subacute Care and Rehabilitation

with a timed traffic signal. This transitional life simulation environment includes an apartment with a bathroom, kitchen, living room, and bedroom. The patient may find a bank, an ATM, and a café. Simulation rehabilitation therapy challenges patients to improve their function and mobility while working on activities of daily living in an environment that is stimulating. The many disciplines in the field of rehabilitation medicine include physical therapy, occupational therapy, speech therapy, therapeutic recreation, physiatry, neuropsychiatry, and social work. Most of today’s facilities are premised on a multidisciplinary rehabilitation philosophy. The physical plant features shared space in which turf battles must be minimized and patient care can be maximized.

Physical Therapy Much of physical therapy is performed on mats with patients staring at the ceiling. Indirect lighting is important (see Figure 5–6). Interesting ceiling detail should also be considered. Many physical therapy areas could easily be planned to resemble an executive health club or spa (see Chapter 8). The spa atmosphere can boost morale for both patients and staff. A fitness center or gym is used by physical therapists to restore function to patients’ major muscle groups. Physical therapy involves a wide variety of equipment, some rather frightening in appearance. Some pieces are very large—apparatus for gait and motion analysis, for example—and storage is always at a premium. It is important to keep such equipment out of sight when not in use, and to isolate treatment areas where patients could be in pain. Recreation therapy space is often combined with physical therapy, increasing the storage needs. Music, games, and exercise equipment are used to support physical and mental therapeutic goals. Outdoor garden areas are common at acute-care hospitals, but a therapy garden has a specific mission—to provide opportunities for therapy outdoors, in a natural setting with natural light and beautiful surroundings. Aside from the areas that may be designed for contemplation or respite, a therapy garden provides a variety of path textures, steps and stepping stones, and bridges to traverse. It may contain an area for gardening, and for those who are limited in movement, a potted garden or raised planting bed that is ADA compliant to work fine motor skills. It is an opportunity to work with physical therapy and occupational therapy patients in a context that provides incentive to keep working through therapy to regain independence.

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Figure 5-6 Indirect lighting above treatment space. Courtesy of Rehabilitation Institute of Chicago. Interior Architecture and Design: Eva Maddox Associates, Inc., 300 W. Hubbard, Suite 300, Chicago, IL 60610; 312/670–0092. Photography: Steve Hall, Hedrich Blessing.

Occupational Therapy The primary goal of occupational therapy is to restore fine motor skills. Occupational therapy may include driver evaluation and training, hand rehabilitation, and a bracing and prosthetics lab. Space needs vary significantly depending on the scope of services. Aside from general fitness needs of those recovering with an occupational injury, tables with proper seating, treatment areas, and additional storage for mobile equipment should be provided.

Subacute Care and Rehabilitation

CHECKLIST Universal Kitchen Cabinets • Plan removable base cabinets with an adjustable counter. Each cabinet can be designed as a freestanding unit that is totally removable, as a unit that folds up in place, or as a unit with a removable front and base. • Base cabinets should be a maximum of 27 inches in height to allow the counter to be lowered for seated users. • Install upper cabinets on heavy-duty commercial shelf brackets between counter height and the high reach limit of users. Cabinets that lower with the push of a button are also appropriate. • An open shelf between a cabinet and the counter increases reachable storage space. • Organize storage by activity; for example, keep the coffee, coffeepot, and filters in the same area. Use high cabinets to store seasonal items and seldom-used equipment. • Use clear plastic shelves or metal racks in upper cabinets to allow easy viewing by children, shorter people, or those in wheelchairs. • A lazy Susan or slide-out rotary shelves also improve access. Half-circled pullout shelves are particularly useful in corners. • Roll-out shelves must have rims to keep objects from sliding off. • Removable bins offer access and flexibility on any shelf. Bins and heavy objects slide more easily on smooth surfaces. • Drawers should be equipped with full-extension roller-type slides, which allow access to deep storage. Pull-out drawers should have one side lowered to allow access from a seated position. • Cabinets with handles should have extra-long C-pulls. Mount handles vertically on upper cabinets as close to the bottom of the doors as possible. On base cabinets, mount the pulls near the top edge of the cabinet doors.

One of the most popular occupational therapy environments is the ADL apartment (see Figure 5–7), which can be used for training the patient and their entire family. It is sometimes used for transitional living between the hospital and home. The activity kitchen has lowered counters so patients may cook while sitting (see checklists pertaining to the design of universal kitchens on pages 64, 101, and 102. A large bathroom is provided for training as well (see Expert Focus: Kohler Demonstration Project on page 108). Increasingly, these apartments offer a wide variety of electronic choices with accessible controls for all users (see Checklist: Electrical Switches and Checklist: Receptacle Outlets on pages 105 and 106.)

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Figure 5-7 ADL apartment with kitchen, bathroom, and living space to assist with the transition to more independence. Courtesy of Dean Birinyi, photographer. Designer: H + L Architecture Ltd., AIA.

CHECKLIST Universal Kitchen Counters • People in wheelchairs, children, and shorter people are faced with an awkward angle when lifting heavy objects off and onto counters. It is easier to drag a heavy pan of water, for example, along the counter. For this reason, provide a consistent counter height on each surface. • Alter counter heights when surfaces change. For example, parallel kitchen counters could be at different heights, and a kitchen island could be at a third height. • Counter surfaces at a variety of heights allow people of all ages, sizes, and abilities to work comfortably. Pull-out breadboards and multiple-height tables should be considered (see Checklist: Tables on page 271). • Adjustable surfaces offer flexibility for people with strength and coordination differences. Counters can be mounted on recessed heavy-duty shelf standards screwed into studs or solid blocking. If only one adjustable-height counter can be installed, place it next to the refrigerator. This improves reach into the refrigerator

Subacute Care and Rehabilitation

CHECKLIST Universal Kitchen Counters (continued) for people in wheelchairs and minimizes the inconvenience of counters staggered at different heights. Specify a finish on adjacent counter ends and cabinets, because these are exposed when the counter is lowered. • Tall people seem prone to lower back pain and may prefer counters up to 42 inches high to prevent bending over tasks. • The minimum clearance required for wheelchair use under the counter is 27 inches. • A counter no more than 2 inches thick allows wheelchair users to work close to their lap, an advantage when kneading dough or performing other heavy manual work. • The ideal height for a standing user to perform heavy manual work is about 10 inches below elbow height.1 Writing and light work can best be done on a work surface 1 to 3 inches below elbow height when standing. • If the counter has a skirt board, recess it a minimum of 12 inches from the front edge to accommodate a wheelchair user. • Specify a heat-resistant counter next to the cooktop to prevent burn marks when pans are dragged across it. Ceramic tile does not burn, but it is more difficult to slide pans over tile joints than over a smooth surface. Smooth, heat-resistant solid-surface counters are available for this purpose. Surface burns, scratches, and cuts can be removed from solid surface counters with a light sanding. These tops are also preferable for people who are allergic to laminate tops adhered to chemically offensive substrates. • Corners are often difficult to reach from a wheelchair. An L-shaped counter design has only one corner, but a person who uses the counter for support may have trouble leaning into it. Add a straightedge to the corner of the kitchen counter for better support and more workspace. • Because people in wheelchairs must rest their arms on the edge of the counter while working, bevel or round the edge for comfort. This also protects those who may fall against the counter. • Elevated rolled edges prevent spills but make it difficult to work directly on the counter from a wheelchair. Rolling out a piecrust, for example, is almost impossible on an elevated edge. Slope the counter slightly to drain toward the sink. This slope also helps people slide heavy pots from the work area to the sink. • Add a rail to the edge of the counter as a safety feature, as many accidents occur in the kitchen. The rail also protects the surface from chipping and can be used by wheelchair users to pull up to the counter. 1. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) 2002, Washington, DC, retrieved June 8, 2009, from www.access-board.gov/adaag/ADAAG.pdf.

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CHECKLIST Universal Controls • Switches can be accompanied by warning lights to show that appliances are on. Redundant cuing like this makes controls more noticeable by all people. • Controls should be large and easy to read. • Specify push bars rather than pull-out buttons, touch controls rather than dials, and controls that can be operated with the palms up rather than down. Test controls to see if they can be operated with a closed fist. • Where greatest accuracy is required, hand and arm motion should be applied rather than foot and leg movements. The hand should be held close to the body at approximately elbow level to maximize accuracy when using a control, for example. Locate controls accordingly. • Avoid controls that can be activated accidentally. Although touch controls are the easiest to use, they are also easiest to turn on by accident. Remember that touch controls can also be easily used by children. • Specify controls that do not require sustained effort. Some push-type faucets, for example, require sustained holding to operate. Also, keep in mind that it is easier to operate controls in front of the body rather than at the side.

CHECKLIST Universal Faucets • Faucets with a single lever can be operated with one hand. Paddles, blades, and push-type mechanisms are easier to use than knobs. To eliminate controls, install faucets that incorporate an infrared sensor to control water flow. • A gooseneck faucet can be used to fill a pan on the counter without lifting the pan into the sink. One innovative faucet design combines a gooseneck style with a pull-out spray on a retractable hose. Both the faucet and the spray can be installed in an existing sink with a single hole. • Faucet controls should be located uniformly on all sinks throughout the home to prevent accidental scalding. Hot water taps are normally on the left, cold on the right. Red and blue color coding can be used to differentiate hot and cold taps, respectively.

Subacute Care and Rehabilitation

CHECKLIST Universal Sinks • Adjustable-height sinks are available in prefabricated models. When customizing an installation, simply change the tailpiece to alter the height. To do so, a flexible supply line must be in place and the trap must be low enough to receive the tailpiece at the lowest position of the sink. • One sink should be no deeper than 6½ inches. From a seated position, the user should be able to place one hand flat on the bottom of the sink. A removable rack can be used to improve reach on deeper sinks. • If the counter is not adjustable in height, consider installing two sinks in the kitchen. If the cook is standing with arms relaxed, the bottom of the sink should be 2 inches higher than wrist height. For children and seated users, add a bar sink on a lowered counter. • Specify sinks with the drain to the back and to one side so that connecting pipes are either to the left or right, not in the center, allowing a closer approach from a wheelchair. With a double sink, only one side needs to be accessible. • It is easier to ease pots and pans out of a sink with a slightly angled side. • A stainless-steel sink must be insulated to prevent leg burns. Stainless steel is thinner and allows a bit more knee clearance than porcelain, and it does not chip, an advantage for people with differences in coordination. • Insulate exposed pipes to prevent burns, or add a nonmetallic panel that can be removed for maintenance. The cover also keeps the pipes out of sight.

CHECKLIST Electrical Switches • Locate light switches at the height of the door lever (36 inches for use by people in wheelchairs and by most small children).1 • In bedrooms, consider a lighted switch that can act as a beacon in the dark. • People with differences in sight appreciate rheostats on each switch to control the quantity of light in the room. A rheostat is also helpful for task lighting. For example, it may be necessary to increase lighting over the kitchen sink or in other areas where detailed work takes place. • Thermostats featuring Braille and high-contrast numbers are useful for people with vision differences. Controls that click audibly between settings can be helpful. • Make sure the main switch box is installed in an accessible area. If the switch box location is not well lighted, attach a magnetic flashlight to the box. Use circuit Continued

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CHECKLIST Electrical Switches (continued) breakers rather than fuses, which may be more difficult for people with arthritis to handle. Label all circuits and keep the top of the box at a reachable height (54 inches) for a side approach in a wheelchair. • Wall-mount kitchen fan controls or install a fan on the counter, placing controls within reach. • Wall-mount the switch for the bathroom light outside the bathroom. It is always helpful to have lighting before negotiating a confined space. • Specify palm toggle switches, which can be operated with the elbow or a closed fist. Pressure- or rocker-type switches are easier to operate than conventional toggle switches. • Projecting switch plates are easier to locate in areas with reduced lighting. Selfilluminated trim for switches and levers is also helpful and should be installed at bedroom, bathroom, and entry doors. Color contrast between the plate and the wall makes the switch easier to see. Contrast between the switch and the plate is also helpful. 1. Evan Terry Associates, ADA Facilities Compliance Notebook Supplement (New York: John Wiley and Sons, 1995).

CHECKLIST Receptacle Outlets • People in wheelchairs and others with mobility problems may have difficulty bending; electric cords on the floor thus cannot be retrieved easily. Cup hooks next to an outlet can be a temporary solution to the problem, but a faceplate that holds an unplugged cord is better. • Extension cords can pose a tripping hazard and can become entangled in wheelchairs. To eliminate cords, add receptacle outlets to the floor plan after considering furniture, appliance, and lamp placement. • Determine whether additional outlets are needed in the bedroom for medical appliances, communication systems, alarms, and so on. • An outlet above an exterior door allows a call light or alarm to be added later. A crucial call system should have a backup battery source in addition to the primary power source. • Electrical outlets must be accessible; a height of 15 inches is preferable.1

Subacute Care and Rehabilitation

CHECKLIST Receptacle Outlets (continued) • In the kitchen, locate multiple outlets on the front of the counter for easiest reach. Some appliances may be served by an outlet under the counter. For example, a mixer could be stored under the counter on a pop-up shelf. 1. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) 2002, Washington, DC, retrieved June 8, 2009, from www.access-board.gov/adaag/ADAAG.pdf.

Specialized Services Rehabilitation units provide specialized services including vocational, social, and neurodiagnostic services. In addition, pain management therapy is often offered, and speech and hearing therapy is provided to increase skills as well as cognition and perception. One of the most profitable health-care markets is therapy for work hardening. This type of rehabilitation is increasingly needed to return injured workers to the job. Work-hardening therapy stations may include plumbing and electrical simulations, range-of-motion therapy, and a series of shelves to evaluate reach and lifting ability. Speech therapy is provided by speech pathologists who are trained in the diagnosis and treatment of specific disorders such as swallowing and feeding disorders, cognitive and communication issues secondary to stroke and head injury, voice disorders, and augmentative communication methods. Based on the diagnosis, an audiologist may present a variety of treatment options to patient with hearing impairment or balance problems. In addition, audiologists dispense and fit patients for hearing aids and other assistive listening devices as part of a comprehensive rehabilitative program. Those remaining in hospitals tend to have higher levels of need, like patients with quadriplegia or head injury. Design goals for head injury include heightened patient safety, prevention of agitation, and progress toward social integration.18 Because of their extended length of stay, headinjured patients have greater storage needs than others do. Space should be provided for storage of a power wheelchair and ventilation must be considered for recharging it. Furniture in patient rooms should be movable to allow the option of adding a Craig bed, a mattress with padded vertical sides designed by Alice Hildebrand (one of the proud authors’ mother). This reduces external stimuli and often eliminates the need for restraints.

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EXPERT FOCUS Kohler Demonstration Project A Universal Bathroom Exhibit1 Designed by Cynthia Leibrock and Mary Beth Rampola, a universal bathroom exhibit was completed at the Kohler Design Center offering hands-on universal design training to 150,000 participants each year. The universal bathroom addresses a lifetime of needs, responding to the diversity of our population and our changing needs in each season of life. Universal design acknowledges that one size does not fit all and that a bathroom must meet the needs of children, people who are tall, wheelchair users, and adults of shorter stature. It must accommodate people who use an assistant, a walker, a scooter, or a stroller. It addresses changes in hearing and vision and, compared to standard bathrooms, it offers older people increased lighting levels, lower ambient noise levels, ergonomically designed products, and safety features that accommodate reduced reaction times. Most important, the universally designed bathroom prevents institutionalization by facilitating home health care and aging in place. The exhibit demonstrates that universal design is also invisible, never stigmatizing its users or pointing out their physical differences. Listed below are features that were visually integrated into the design: 1. Turnaround space (shown by a graphic in the floor). A 60- by 60-inch turnaround space provides enough room to maneuver with strollers, scooters, crutches, canes, walkers, and guide dogs. 2. Transfer space. Clear floor space adjacent to the toilet allows parents room to help children. Attendants use the space to help older family members, and people in wheelchairs use the space to transfer to the water closet. 3. Lavatory area. The lavatory and mirror are installed outside of the shower area to keep the mirror from fogging or being sprayed by the handheld shower. For children in wheelchairs, a 36- by 48-inch clear floor space extends under the lavatory. Children have less coordination and actually need more room to maneuver than do adults, who need only a 30- by 48-inch clear floor space. A vanity stool can be used in this space by ambulatory family members who prefer to sit while using the lavatory. A lightweight stool on legs with glides is more stable than a stool on casters. 4. Adjustable-height lavatory. With this installation, the counter can be adjusted between 25 and 42 inches a.f.f. to meet the needs of tall users, adults of shorter stature, children, and seated users. The flexible waste and supply pipes are positioned to prevent burns. No sharp or abrasive surfaces that could injure a seated user project below the lavatory. Clearance for wheelchair footrests extends the full depth of the lavatory. For people with allergies or chemical sensitivities, solid-surface vanity tops are preferable to laminates adhered to pressboard or particleboard, which may off-gas formaldehyde. The horizontal finishes were chosen in light colors to increase ambient light levels, thereby improving visual acuity. For people with vision differences, the edge of the lavatory area is identified by a handrail. The handrail also provides support for standing users, a grip for people repositioning a wheelchair, and a place to hang towels.

Figure 5-8 Kohler universal bathroom. Photo courtesy of Kohler Co. Designers: Cynthia Leibrock, Easy Access, and Mary Beth Rampola, Eva Maddox Assoc.

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EXPERT FOCUS Kohler Demonstration Project (continued) 5. Lavatory controls. The levers can be easily controlled with one hand. They are cued with large markings in red and blue to identify water temperature. Aerating nozzles on taps reduce ambient noise levels; water pressure can be reduced to further quiet the flow. Quieter faucets serve people with a wide range of hearing abilities. People with speech differences who need to be clearly heard and people with reduced vision who depend on their sense of hearing also appreciate lower ambient noise levels. 6. Mirrors. The mirror, at 40 inches a.f.f., can be used by a seated user or an adult of shorter stature. A tilted mirror should not be specified because it distorts the image of the user. 7. Removable cabinets. Each cabinet under the counter is designed as a totally removable freestanding unit. Removable cabinets make the home easier to sell by offering access to a wider market, including people who use mobility aids. A movable cabinet under the sink can serve as a cart between the counter and tub or toilet, perhaps to store equipment for the bowel and bladder program. When the cabinet is moved out, the space under the counter is clear for seated users and the top of the cart can serve as extra counter space. The cabinet has locking casters and a top rail to prevent items from sliding off. Dividers are added to the cabinet for people who are blind, who are helped by having specific places to put each item. Each storage area is labeled so sighted people can put things back correctly. Medications are stored in a locked drawer that is within reach of wheelchair users but not accessible to children. All drawers are equipped with C-grip handles, which are horizontal and centered. 8. Toilet and shower grab bars. Grab bars are installed at 33–36 inches a.f.f. on all sides of the roll-in shower. For the easiest approach to the toilet, grab bars are located behind it and on one side. The grab bars will not chip or injure users with sharp or abrasive edges. They do not rotate within their fittings. A textured finish is applied for a sure grip. 9. Bathtub grab bars. A grab bar is often used by bracing the forearm between the bar and the wall for support. For this reason, install the grab bar exactly 1½ inches from the wall to prevent the entire arm from slipping through the gap. One horizontal grab bar is installed at the foot of the tub when a tub seat is used at the head. Two horizontal grab bars are placed on the long wall, one 9 inches above the tub and the other 34 inches a.f.f. 10. Shelving. Upper shelves are of tempered glass or clear plastic to make the contents more visible by children, wheelchair users, and adults of shorter stature. Four heights of hooks are installed adjacent to the shelves. 11. Accessible shower. A shower is quicker, easier, and safer to use than a bathtub (see Checklist: Showers and Checklist: Bathtubs on pages 183 and 273). This shower can be used from a shower wheelchair or by a standing user. The corner shower is open on two sides to allow access from more than one direction. The wheel-in shower floor is sloped rather than curbed, as a curb may block wheels or become a tripping hazard. A 2 percent slope to the drain is sufficient; a steeper slope makes it too difficult to maneuver a shower wheelchair or gurney. The many joints of the ceramic mosaic floor tile reduce slippage. 12. Shower control. The shower system features temperature and surge controls that ensure a safe flow. The water can be set so that it will not burn a child if the control accidentally bumped. The pressure-balancing feature prevents a surge of hot water that could burn a person with sensation limitations. Continued

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EXPERT FOCUS Kohler Demonstration Project (continued) 13. Handheld shower adjacent to the toilet. The fixture is ideal for use from a shower wheelchair or for cleanup after using the toilet. It can also be clipped to an adjustable-height bracket for use as a conventional shower by a tall standing user, person of shorter stature, or child. The vertical adjustment does not obstruct the grab bars. The valve will not catch the shower hose and requires only one hand to regulate water flow and set the desired temperature. 14. Towel bars are offered in four heights and should be reinforced to withstand emergency use as grab bars. Bathroom walls should be reinforced from floor to ceiling with 3/4-inch plywood or with wood blocking installed between the studs. 15. Shower wheelchair. After one transfer to a shower wheelchair, the user can roll into the shower, under the lavatory, or over a toilet. Multiple transfers to a seat in the shower or to the water closet are not required. With the wheels locked over the toilet, the chair can also be used by a standing person with strength limitations who needs an elevated toilet seat with arms. There is a gap between the two seats and an opening in the front for digital manipulation or for emptying a leg bag. Shower wheelchair storage is also discreetly provided. 16. Shower curtain. The shower is planned with curtains rather than doors, which take up floor space. Ceilingmounted shower curtains have a clean appearance, especially when they curve around two sides of the shower. 17. Shower caddy: To prevent soap, shampoo, and accessories from slipping out of reach, a shower caddy is used. It drains easily and will not rust. A second caddie is installed at a height suitable for children or people of shorter stature. 18. Bathtub. The bathtub has a gently sloping flat (not rounded) bottom for stability. The floor of the tub is slip resistant. The handles can be grasped for entry or exit. The color contrasts with the surroundings to improve visual acuity, and the vertical stripe visually bends at the surface of the water to assist people with vision limitations. 19. Bathtub controls. The lever-type faucet and drain control are easy to operate. Controls are installed toward the approach side. 20. Bathtub seat. A soak in the bathtub relieves pain for many people, but standard bathtub design can make entry and exit difficult. For this reason, a seat is installed at wheelchair seat height, but a standing user can also transfer from it. The edge of the seat is installed flush with the top of the tub; this makes it easy to slide slowly into the tub from the seat with the help of the adjacent grab bars.

Figure 5-9 Universal bathroom with accessible handheld shower. Photo courtesy of Kohler Co. Designers: Cynthia Leibrock, Easy Access, and Mary Beth Rampola, Eva Maddox Assoc.

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EXPERT FOCUS Kohler Demonstration Project (continued) 21. Handheld shower adjacent to the tub. This shower can be used from the seat for a quick cleanup, to help shave legs and wash hair, and by people who do not have the strength to lower themselves into the tub. It can assist all bathers with washing and rinsing, and can be used to bathe a child in a child seat or on a bathing table. 22. Toilet. An elongated toilet installed at a 17-inch height makes transferring or aligning with the shower wheelchair easier than other toilet types. A wheelchair user can also transfer directly at this height, and the flush lever is on the approach side. The quiet toilet serves people with a wide range of hearing abilities. People with speech differences who need to be clearly heard and people with reduced vision who depend on their sense of hearing also appreciate lower ambient noise levels. For a quiet water flow, specify pipes with as large a cross section as possible. 23. Toilet seat. The flat lid is more comfortable to lean against than one that is crowned or dished. The toilet seat is securely installed, but it can always be replaced by an elevated seat if necessary. The seat must not be sprung to return to a lifted position, but it should remain up independently when raised. Men with hemiplegia or one hand only do not have a free hand to hold up the toilet seat while using the toilet. 24. Toilet tissue dispenser. One dispenser is Figure 5-10 Bathtub with safe transfer from shower chair. Photo installed at least 19 inches a.f.f. and yet courtesy of Kohler Co. Designers: Cynthia Leibrock, Easy low enough so that grab bars do not inter- Access, and Mary Beth Rampola, Eva Maddox Assoc. fere with its use. It is installed 7 inches in front of the toilet. The toilet tissue holder must permit continuous paper flow and be usable with one hand. Dispensers that require users to reach into a hole to initiate paper flow must be avoided, and no dispenser should have a sharp or serrated edge. A second tissue dispenser is provided for a constant supply and lowered for use by children (2 to 6 inches above the toilet seat). The cover protects the tissue from the handheld shower. 1. C. Leibrock and M. B. Rampola, Universal Design Form # 170390-AA. Kohler, WI: Kohler Company, 1998.

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Endnotes 1. R. Peck, interview with author Joseph Carella, Nursing Homes, February 1, 1996, retrieved September 23, 2009, from www.thefreelibrary.com/ The+future:+is+Scandinavia+showing+us+the+way%3F-a018113152. 2. M. S. Valins and D. Salter, eds., Futurecare: New Directions for Planning Health and Care Environments (Oxford: Blackwell Science, 1996). 3. American Institute of Architects, Guidelines for Design and Construction of Hospital and Health Care Facilities (Washington, DC: American Institute of Architects Press, 2006). 4. USGBC, LEED Rating Systems, 2009 United States Green Building Council, retrieved on September 26, 2009, www.usgbc.org. 5. J. Carpman and Myron A. Grant, Design That Cares: Planning Health Facilities for Patients and Visitors (Chicago: American Hospital Publishing, 1998), p. 223. 6. L. G. Hiatt, Nursing Home Renovation Designed for Reform (Boston: Butterworth Architecture, 1991), p. 206. 7. L. G. Hiatt, “Long-Term Care Facilities,” Journal of Health Care Interior Design, 2 (1990): 195–205. 8. Hiatt, Nursing Home Renovation, p. 206. 9. Ibid., p. 208. 10. Center for Technology and Aging, Technologies to Help Older Adults Maintain Independence: Advancing Technology Adoption (Oakland, CA: SCAN Foundation and Public Health Institute, 2009). 11. L. Trent, “On the Importance of Color,” Interiors and Sources (September 1994): 48–49. 12. W. B. Kleeman, The Challenge of Interior Design (Boston: CBI Publishing, 1981), p. 79. 13. J. Streim and I. Katz, “Treating Depression,” Provider (May 1994). 14. C. Leibrock and J. E. Terry, Beautiful Universal Design (New York: John Wiley and Sons, 1999). 15. V. Regnier and J. Pynoos, eds., Housing the Aged: Design Directives and Policy Consideration (New York: Addison Wesley Longman, 1987,), pp. 321–328. 16. C. Leibrock and J. E. Terry, Beautiful Universal Design (New York: John Wiley and Sons, 1999). 18. S. O. Marberry, ed., Innovations in Healthcare Design (New York: John Wiley and Sons, 1995), p. 108.

P A R T T W O

AMBULATORY CARE

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A

mbulatory medical care is the predominant method of providing health-care services in the United States and occurs in a wide range of settings. According to the CDC, the largest proportion of care is provided in physician offices. This accounts for 8 percent of all ambulatory medical visits offering general medicine, surgery, pediatrics, obstetrics and gynecology, substance abuse, and others (e.g., psychiatry and neurology). Ambulatory care is also provided in specialty centers including ambulatory surgery, oncology, employee health service, dialysis, and radiology. For the purposes of this endeavor, ambulatory care is defined as any medical service in an outpatient setting where nonurgent care is provided, including home care. Home health care represents an opportunity to contribute to the containment of health-care costs while preserving the quality of care and enhancing patients’ quality of life. This care is only possible with the support of ambulatory facilities.

HEALTH-CARE COST CONTAINMENT The United States spends upward of 17 percent of the country’s gross domestic product (GDP) on health care, equating to $8,160 per person, according to a report by the Kaiser Family Foundation.1 In another report, released by the Organisation for Economic and Co operation and Development (OECD),2 the United States spends more than $2,000 per capita on health care, more than any other industrialized country. In addition, life expectancy in the United States is lower when compared with Japan, Switzerland, Canada, and Australia, and infant mortality rates are higher than most other industrialized nations. Where do the dollars go? Over half of the national health spending accounts for hospital,

physician, and clinical services. Spending on prescription drugs accounts for about 10 percent of health expenditures.3 Nursing home care and home health care account for less than 9 percent of national health expenditures. Americans, insured and uninsured, are using costly hospital emergency rooms as the first point of entry into the health-care system.4 The reasons are varied and include a shortage of physicians, lack of access to specialists, Medicaid reimbursement disincentives, high costs for the uninsured and underinsured, poor coordination among practitioners, growing consumer demand, and inefficiencies throughout the system. Healthcare reform could generate new challenges for providers who need to create innovative, new care delivery models that will expand access to care without adding costs to the system. Dr. David Chin, leader of the PricewaterhouseCoopers Health Research Institute, states, “The quick fix is to build bigger emergency rooms, but increasing supply will only drive up costs. We must find solutions that expand access without adding costs, and we believe the answer lies in new flexible models for care that use the right technologies, incentives and behavior changes to unclog jammed access points.” In addition to the use of telehealth technology, increased worksite and retail clinics for patients, and other strategies, incentives and support for aging in place will lower health-care costs. Ambulatory care that supports patient-centeredness is a key component in the future of American health-care services. Reimbursement policies are currently reducing the demand for acute care in hospitals and nursing homes and increasing the demand for ambulatory care. Length of stay in acute care hospitals is steadily decreasing while “never events,” reasonably preventable medical errors,

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are no longer being reimbursed. Hospitals are not allowed to pass the cost of medical care resulting from such errors to patients. Design opportunities have expanded as the demand for ambulatory care has increased. Ambulatory care is the fastest-growing segment of health care in the United States, but it is also growing more complex. Many diagnostic, interventional, and rehabilitation therapy services are provided in ambulatory care. Outpatient care is being offered in hospital-based ambulatory care centers and freestanding centers. Patients are often referred to distant locations so accessibility and convenience is therefore becoming a major issue. Ambulatory patients are no longer the “worried well.” Sometimes their acuity levels require monitoring and crisis intervention. To accommodate increased acuity, a proliferation of technology in the ambulatory setting is producing increased need for patient and administrative information. Clinical systems, automated medical records, and reference information must all be managed. Building codes and regulatory codes are becoming stricter and consumers more demanding. The successful ambulatory care facility is designed to be responsive to the needs and preferences of patients, to provide patients with access to their medical information, and to empower patients to be active participants in care decisions and the daily management of their health and illnesses. Changes in care will be driven by the onset of chronic disease in baby boomers as they move from mature adult status to the Medicare age group. Boomers will live for decades with chronic diseases before they become “elderly.” These illnesses will often be diagnosed and treated on an outpatient basis. With this emphasis on ambulatory care, we will see an increase in self-health, personal lifestyle training, and education of consumers.

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THE EDUCATED CONSUMER A growing movement in the United States encourages patients to take responsibility for their own health care. Prevention and wellness plans are everywhere. Our system is becoming dependent on educated patients making responsible choices. Planetree is a patient-centered care movement, where responsibility is returned to the educated health-care consumer. The organization was started in 1978 by Angelica Thieriot, when, as a patient, she envisioned a type of hospital where patients could receive care in a healing environment that provided access to information needed to become active participants in their own care and well-being. Today, Planetree is a leader in patient-centered care, promoting the development and implementation of innovative models of health care that focus on healing and nurturing body, mind, and spirit. Planetree has impacted acute care, ambulatory care, and long-term care design criteria. It stands as one of a handful of early innovators leading up to the evidencebased design movement, incorporating many of the patient-centered drivers, but taking it to the next level and conducting research to test design interventions for their impact on patients, visitors, and staff. With an emphasis on prevention, attitudes have changed; there is increasing recognition that tragedies can be prevented. Consumers are demanding information, especially about costs. The health-care system is refocusing on health promotion (e.g., fitness and behavior modification), preventive services (e.g., immunization and prevention of transmission), and health protection (e.g., injury prevention and environmental safety).

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Endnotes 1. Kaiser Family Foundation, Trends in Health Care Costs and Spending, www.kff.org, Publication # 7692–02, 2009. 2. The Organisation for Economic and Co-operation and Development (2009). OECD Health Data 2009. Retrieved October 15, 2009, from http://stats. oecd.org/Index.aspx?DataSetCode=HEALTH.

3. Kaiser Family Foundation. 4. PricewaterhouseCoopers, Jammed Access: Widening the Front Door to Healthcare, 2009, retrieved October 16, 2009, from www.pwc.com/jammedaccess.

6

DAY CARE AND RESPITE

“What we are seeking to preserve is the spirit of the child. The spirit of the child is a sense of wonder. It is a sense of openness, trust, and responsiveness, an ability to simply be, which gets shut down very quickly if the openness and trust are violated.” —Anita Rui Olds

I

s respite possible for the caregiver without affecting the health and development of the loved one? Sandwiched between two generations, many families desperately need relief from parental and child care but are worried about neglecting their responsibilities. A comprehensive study by the National Institute of Child Health and Development1 shows that good day care actually improves skills development in children when compared to those at home with their mothers. The influences of home and family must still predominate, but the study shows that families need not relinquish their responsibilities when children are in day care. Research has also found that more than 80 percent of older people who participated in adult day-care programs maintained or improved their level of functioning. Without day care, most of these participants would have been

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institutionalized. In fact, 63 percent had been Medicaid eligible for institutionalization before entering the program.2 Another study, commissioned by the Clarity and the EAR Foundation found that 89 percent of senior citizens fear losing their independence and want to age in place.3 Sixty-five percent of seniors participating in this study say that they are open to or would like to use new technologies that would assist in sustaining their independence. In addition to benefiting older people and children, day care and respite bring welcome relief to caregivers. The Clarity study quantified the concerns of adult children with aging parents. At the top of the list was worry about their parent’s emotional and physical well-being should they have to enter a nursing home. To address this concern, the National Adult Day Services Association (NADSA) has identified 4,601 day programs operating in the United States, providing care for 150,000 care recipients each day.4 There are three types of adult day care centers: (1) social, which provides meals, recreation, adult education classes, transportation, social services, and some health-related services; (2) medical/health, which provides the social activities along with more intensive health and therapeutic services; and (3) specialized care, providing services for those with diagnosed dementias or developmental disabilities. The trend toward the desire of older persons to age in place has increased the demand for in-home care and other programs and services available during the workday. The cost for adult day services averages $64 per day. Home health aides cost on average $20 per hour, and home companions cost $18 per hour on average, according to the Metlife Mature Market Institute.5 These day-care and respite options provide a less costly alternative to nursing homes and in-home care while allowing their caregivers the time during the day to work with less anxiety over their loved one’s care. Adult day care provides support for clients as well as their caregivers, improving the health of older and disabled people and the ability of caregivers to support them. Another form of care services is respite care. Respite care provides short-term breaks that relieve the stress, restore energy, and promote balance in the life of the caregivers and their loved ones. Respite care may be for families with children who need special care or for families with an elder that needs assistance.

ADULT DAY CARE AND RESPITE Respite care centers provide shelter and support for a few hours to several months. Most facilities offer laundry service, meals, recreational activities, and health care. Nurses and physicians are often available. Some programs

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have even developed alliances with municipalities, industries, and providers to offer a wide range of benefits for their senior guests. One such organization is On Lok Lifeways, which began in 1972 as a day-care center offering home health care and social services to older residents of San Francisco at risk for institutionalization. On Lok Lifeways is a certified PACE program (Program of All-inclusive Care for the Elderly). Actually, the PACE program is modeled on the original On Lok Senior Health Services, developed to create a community-based system of care in the Chinatown/North Beach community of San Francisco. The program has been replicated from coast to coast and vertically expanded to offer day health centers, housing, and intergenerational day care. Because of this program, thousands of older people recommended for nursing home placement have remained in their homes. At On Lok, the design program accommodates all needed medical and social services for the frail older participants. Each day, the health center’s multidisciplinary team provides physical as well as psychosocial care. Services include health assessment, respite care, health education, physical therapy (see Figure 6–1), and counseling. Facilities are provided for dining, showering, grooming, toileting, and laundry. Transportation and home care are also offered.

Figure 6-1 Physical therapy area. Courtesy of Kai-Yee Woo & Associates, San Francisco. Photography: Chas McGrath.

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The Hallen respite care center in Solna, Sweden, provides rehabilitation, training, and 24-hour medical intervention to six patients, primarily those residing in the adjacent independent living apartments. The respite center has the feel of a large home, with six bedrooms grouped around a great room. Independent living skills are restored in the training kitchen equipped with an adjustable-height counter, range with front controls, and an island that serves as the nursing station (see Figure 6–2). This project is nicely detailed with plant lights, a fireplace in the living room, and a warm color scheme to improve visual acuity (see Checklist: Color on page 89). Large windows extend to the floor to increase ambient light and offer a view for wheelchair users. Each bedroom has a private bathroom with an adjustable-height sink. Even the medicine cabinet is lowered for wheelchair users and recessed to prevent injury. The city of Solna, Sweden, has recently conducted a research study focused on elder-care services and quality of life issues for elderly people.6 The study states that much attention on the living conditions of older people are focused on “misery research”—old people with problems, old people as problems, and solutions derived from a medical perspective. The premise of the investigation was that active leisure extends a healthy life and can lead

Figure 6-2 Adjustableheight kitchen accommodates residents with varying skills. Architect: ETV arkitektkontor AB, Stockholm. Photo: Max Plunger.

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to personal development as a person ages. The study showed that a meaningful life is an important factor in the quality of life of the individual, which makes it possible to delay the need for public support and services. Based on the findings of their study, the city of Solna developed a new program called InfoCentret Ankaret. The purpose of this project was to provide security for the elderly through knowledge, networks, and accessibility. The project also provides social and health services, coordinates the resources of professional and voluntary services, and makes use of the knowledge and competence of the elderly.7 The result of the study was to provide community centers in all the neighborhoods in the city of Solna. Five of these centers are specifically for the elderly, based on the success of the Hallen center. Once center, Sockerbiten in Ritorp opened in 2006 and is open for all age groups, creating an intergenerational community. In addition to social services, a hearing and sight consultant, an ombudsman for the elderly, and a nurse focused on supporting visitors’ relatives and other professionals affiliated with this program visit each center on a regular schedule. According to the Head of Elder Care Services for the city of Solna, the centers have developed from therapy services into services that impart happiness—develop, inform, and broaden horizons, and free up creative, physical, and educational impulses, enabling people to realize their inner possibilities—creating support for a meaningful life and enhancing quality of life for everyone.8 In Copenhagen, the Dronning Anne-Marie Centret provides intergenerational day care as well as housing for older people and for single mothers and their children. The homes are separated by patios rather than common walls, and the brick in the corridors or the day-care center was laid to absorb sound.9 The rough texture of the brick also diffuses reflected sound. Poor acoustics have limited the success of intergenerational housing projects in the United States. Most are located in high-density apartment buildings that accentuate the differences in populations. The Centret provides day care and therapies to the entire community, encouraging interaction and integration. In addition, the Centret offers shared workout facilities (see Figure 6–3) and a commercial restaurant open to all rather than a congregate dining facility for older people. In the United States, interest in programs offering intergenerational care is growing. Stride-Rite Corporation pioneered the workplace provision of adult and child day care, with mixed results. Providers learned that the two groups have very different energy levels, as do the individuals within the groups. Some older people could not get enough of the children, but the design failed to accommodate seniors who were not comfortable

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Figure 6-3 Geriatric rehabilitation and workout center. Courtesy of Niels Gjerstrup, Dronning Anne-Marie Centret.

around them. Most successful contact took place at mealtime, but children and elders also worked together on art projects, cooking, and reading. Although each group had its own activity area, the majority of the center was designed for all age levels. Design criteria for intergenerational care include frame chairs that adjust to different heights and abilities (see Checklist: Seating on page 126), and upholstered seating in a variety of sizes (see Checklist: Upholstered Seating on page 127). Entry seating was planned for layering, offering seniors a chance to observe before joining activities. The Dr. Richard A. Sleeman Center for Bennington Project Independence is an adult day-care and rehabilitation facility for adults who need nursing care, medical administration, assistance with ADLs, restorative therapy, social interaction, and recreation. This state-of-the-art adult day care and day health rehabilitation center is located on a historic apple and pear orchard in Bennington, Vermont (see Figures 6–4, C-6, and C-7). In addition to the new facility and preservation of the historic Zechariah Harwood House and apple barn, they are partnering with local horticultural organizations to rehabilitate the apple and pear orchard. The services provided are extensive, from health services to social activities and learning opportunities. Along with a varied and wide range of meaningful adult activities, there are opportunities for independent endeavors as well.

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Figure 6-4 Welcoming entry to the Bennington Project Independence Adult Day Care & Day Health Rehabilitation Service. Gary Corey, Centerline Architects. Courtesy of Timothy Doyon, Photographer.

Participants are greeted at the facility under a large porte cochere, providing full protection for BPI’s van with wheelchair lift. The entry area includes immediate access to a toilet room, and coatroom for storage of participants’ belongings. It was essential that the exit door and the view of the pick-up location were not highly visible from the main activity spaces, to minimize the anxiety or focus of participants having somewhere to go. The plan clearly laid out alternative entrance paths to enable staff to handle a large influx of people arriving and to also direct participants toward groups associated and based on cognitive levels. Most participants continue into the country kitchen, for a familiar homelike atmosphere. Some participants assist the staff with preparation of snacks, while others linger at the kitchen table or pull-up bar. Behind the country kitchen (see Figure 6–5), a large commercial kitchen prepares the daily meals and serves the facility. The meals are served in the renovated barn off of the country kitchen (see Figures 6–6 and C-8). The main barn was dismantled from its former position, rehabilitated, and reerected on a raised foundation to preserve the original appearance of the barn, while maintaining a single level of participant occupancy throughout the facility. The smaller barn was also reerected and houses a private dining area for participants requiring additional assistance with meals as well as a cluster of bathrooms. The bathrooms are supersized to provide enough space for participants using wheelchairs or motorized scooters, and for staff members to assist. Toilets were placed specific distances from the walls to allow enough

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Figure 6-5 The homelike country kitchen is a popular social spot for participants and staff. Bennington Project Independence. Gary Corey, Centerline Architects. Courtesy of Timothy Doyon, Photographer.

Figure 6-6 The rehabilitated barn serves as dining hall and social activity destination. Bennington Project Independence. Gary Corey, Centerline Architects. Courtesy of Timothy Doyon, Photographer.

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space for a two-person assist. Fold-down grab bars were chosen to provide a greater flexibility for participants’ needs. In two of the larger bathrooms, ceiling lifts were incorporated into the design. The living room area provides small groupings for conversational settings. Large sliding glass doors look out over the property, where a future memory garden will be constructed. A beauty salon adjacent to the living room is complete with an Adjust-a-Sink (Accessible Systems) to reduce neck strain. A roll-in shower room is a great benefit for the facility and participants’ families. A treatment room with direct access to the nurse’s office contains a hospital bed for participants who are ill or need rest, and a Connect Chair (IOA Healthcare Furniture). The chair easily reclines to a flat position and rises to a 32-inch height, for easy treatment. This room also has a ceiling lift for easy transfers with the track connecting to an adjacent toilet room. The former farmhouse contains offices, a craft room, a library, and a physical therapy room. Large windows in the physical therapy room provide a connection to the deep porch that looks over the orchards. The design was able to preserve the historic nature of the site and buildings, while creating a homelike environment that is functional for both the staff and the participants. In addition to meeting the programmatic requirements, the design of the building incorporates energy efficient strategies to create a healthy building for the participants, staff, and environment, as well as lower maintenance and operating costs of the facility. Some strategies included developing a tight, high performance building shell with replacement windows in the historic areas of the building, reuse of building materials throughout the interior, as well as natural materials to minimize off-gassing of VOCs that can be amplified by a tight building envelope. Plenty of operable windows and skylights provide ample natural light and ventilation, while landscaping and the covered porch provide necessary shade in the summer months. The building is heated with a wood pellet boiler and solar panels are soon to be added to the commercial kitchen wing roof and wall. Proper placement and correct bulb and ballast selections achieve high efficiency lighting while maintaining proper lighting levels needed to accommodate the aging eye. With the success of the new facility, participation at BPI Adult Day Services has significantly increased. Future plans to expand include the fit-out of the basement to provide additional activity space, a wood shop and kiln room, private physical therapy space, a spa with state-of-the-art tub for bathing care, and gaming and bar area, as well as create a space to become an emergency shelter for the elderly and handicapped. The new facility has allowed the program to continue to serve a great need in the Bennington community, while restoring a historic site for the public to experience the beauty and history of Vermont.

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CHECKLIST Seating • A comfortable chair allows the user to place both feet flat on the floor. Most of the weight should be on the buttocks, and there should be a space between the thigh and the front edge of the seat. Pressure beneath the thigh over an extended period could aggravate circulation problems. • The deeper the seat, the more slant is needed on the backrest for comfort. The angle of both the seat and the backrest should be adjustable. Pressure on the spine decreases as the tilt of the backrest increases. A lumbar cushion also reduces pressure and provides support. • A vertical open space between the seat and the back allows extra room and provides an easy clean-out space for housekeeping. • For adults, the back of the chair should be adjustable in height from 8 to 13 inches above the seat surface. • Plan chairs in a variety of sizes to accommodate both small and large visitors as well as children of all ages. Different styles can also serve as cues for orientation. • In a chair without armrests, the user is more comfortable if the back of the chair is narrower than the width of the shoulders and lower than the shoulder blades. • The user should be able to rest naturally on the armrests, although a lower height may be required for wheelchair use. To facilitate transfer from a wheelchair, these must be slightly below the table apron. • A chair with an armrest that swivels up facilitates transfer from a wheelchair. Make sure that the chair cannot tip forward and that the armrests extend slightly beyond the leading edge of the chair seat. • Armrests should seldom be higher than 8½ inches above the seat for maximum support and reduction of fatigue. Armrests alone support 12.4 percent of body weight. They offer a sense of security and provide support in rising from the chair. Many people get out of a chair by first sliding forward to the edge and then pushing off. • For adults, the seat may have to be adjusted in height, between 132 3 and 202 3 inches a.f.f. (above finished floor). A seat height of at least 18 inches is easier on the knees and hips when sitting or rising. • A high stool may help the user maintain endurance and strength with minimal bending over a task. Mobile stools allow a wide range of motion in places too tight for a wheelchair. Casters should lock for stability. Choose a stool with adjustable seat height, seat angle, armrest, backrest, and footrest. • On frame seating, the seat cushion should compress no more than 1 inch. Firm cushioning is especially important in the area where the spine meets the seat. • Low bracing interferes with rising from a chair if users tuck their feet under the seat to push off.

Day Care and Respite

CHECKLIST Seating (continued) • Seat stretchers provide extra support and stabilize the chair for transfer from a wheelchair. • Hard, not padded, arms on chairs offer support for transferring from a wheelchair. • Choose seating with curved edges, padded corners, and soft surfaces to prevent bruises and pressure on the backs of the knees. • Welting at the front of the seat may hamper circulation to the legs. Removable cushion covers without welting, ridges, and tufts are easier to maintain. • Upholstery fabrics that allow the skin to breathe and prevent slipping also make chairs more comfortable. Use nylon upholstery for abrasion resistance, polypropylene for stain and sun resistance (but not resistance to heat or stretching), and wool for porosity and comfort. Remember that vinyl and plastic coverings may become hot, slippery, and uncomfortable when used on upholstery planned for long-term seating. Shiny vinyl is associated with institutional use and makes an interior appear more sterile. Use a vinyl with a slight texture or pattern. • A high-backed rocker provides head support, but make sure the chair cannot tip. • Persons seated in groups can maintain eye contact and read lips and gestures most easily from swivel chairs. Semicircular seating arrangements are recommended, perhaps around a table. Make sure swivel chairs, recliners, and other movable seating have locking mechanisms. For some, sitting down in and rising from a swiveling seat is difficult. • For people who are sensitive to petrochemicals, specify hardwood or metal furniture rather than composite wood or pressboard frames. Choose pieces with mechanical fasteners instead of glue.

CHECKLIST Upholstered Seating • Proper cushioning prevents skin ulcers. Test for proper cushioning by putting the full weight of your closed fist in the center of the seat. You should not feel the springs or supporting boards. • Soft cushions make wheelchair transfer difficult. Down cushions, for example, are too soft. If the deck itself is too soft, add plywood under the cushion for support. • Users with strength differences may have trouble rising from the center cushion of a long sofa. A shorter sofa allows more flexibility in furniture arrangement and puts the user closer to an arm-rest for support when rising. Continued

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CHECKLIST Upholstered Seating (continued) • Bucket seats and some contour seats make it difficult to shift or change position. • Rockers aid muscle tone, digestion, and circulation, but they should be locking to aid in transferring. • To easily rearrange rooms, put casters on all furniture except those pieces used for transfer. Casters allow furniture to be pushed out of the way for wheelchair or gurney clearance and help families rearrange furniture to include all visitors. • Avoid furniture that involves unusual angles of exertion, like sleeper sofas and some reclining rockers. • Seats at the same height as a wheelchair (17–19 inches a.f.f.) facilitate transfer and reduce the difference in eye levels for conversation. • Recess the base of the seat at least 6 inches for wheelchair footrests. • Many people lean on upholstered seating for support while standing. The legs of sofas and chairs should be at the corners of the seat. The back legs should extend outward so the feet are even with the top of the backrest. • Consider a chair with a controlled pneumatic lift. Models with movable seats and armrests are available. • A high-backed chair can provide both protection from drafts and a feeling of security. For users who nap in the chair, look for an adjustable head cushion. • Unless the chair is very low to the floor, the user also may need a footrest. For users with back problems, choose a footrest that is high enough to keep the knees bent at a height slightly above the waist. Choose footrests that are easily removable. Low ottomans can pose a tripping hazard, however. Keep these well away from high-traffic areas. • Many users with different abilities are slow in responding to a fire, so fire-resistant furnishings are critical. California Technical Bulletin 133 requires that the product as a whole be tested rather than its individual components. • For stability, avoid slippery fabrics on seating. Textured fabrics with corrugation offer more friction and can help users maintain an upright sitting position for extended periods. (Slicker fabrics on the seat, however, may help weaker users slide into deep booths and auto interiors.)

DAY CARE FOR PEOPLE WITH DEMENTIA A study conducted by the University of Massachusetts’ College of Public and Community Service and Gerontology Institute10 focused on adult day health-care services in Massachusetts for persons living with

Day Care and Respite

Alzheimer’s disease and related dementias. The study objectives were to describe existing practices; explore programs specifically designed for participants who are in late-stage dementias; address challenges that adult day care services are now encountering; and envision new paradigms for meeting the needs of persons with early-state and early-onset dementia. The study found a wide range in the length of stay in adult day care for people with dementia, from less than three months to more than 10 years. Many had to wait to get into the program, with waiting lists ranging from two weeks to three months. At the time of the survey, there were 219 persons who would have waited an average of 5.25 weeks for adult day health services in Massachusetts. The study also addressed the need to increase services for the growing elderly as the baby boomers age. The respondents requested the following: • • • • •

Expanding support groups into the evenings Additional exercise groups Outings (shopping, theater, museums) Participant/volunteer opportunities Intergenerational day services to allow guests to assist in child care, offering a chance to give back to the community and feel a sense of belonging • Public and staff education • Increased space • Kitchen facilities While not new paradigms, the ideas expressed were a clear reminder of the complexity of programming and facility considerations. The study also suggests that the importance of adult day-care facilities will grow, particularly for those older adults who choose to age in place. The Louis Feinstein Alzheimer’s Daycare Center is a hospitable environment built within a community park, located in Cranston, Rhode Island (see Expert Focus on Adult Day Services and Respite on page 131). Features include a large skylight to increase daylight penetration and a breakfast bar with a view of the kitchen (see Figure 6–7). A changing area with clothing storage and laundry is approachable from both the reception area and the main programming area (see Figure 6–8). Many of the consumers are incontinent, and this plan allows for quick changes without embarrassment.

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Figure 6-7 Skylights and breakfast bar. Project: Louis Feinstein. Photo © Frank Guillani.

Figure 6-8 Alzheimer’s Day-Care Floor Plan. Project: Louis Feinstein. Courtesy of Robinson Design.

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EXPERT FOCUS Adult Day Services and Respite KEITH DIAZ MOORE, PH.D., AIA Architecture Chair, University of Kansas

The continuum of long-term care provision for the elderly is entering a period of fundamental reconsideration. The confluence of a collapsing global economy, an aging demographic tsunami, and runaway healthcare costs has catalyzed innovation in the field. These forces are triggering family adaptations, such as three-generation homes, and requiring breadwinners to work multiple jobs. Lost work time is an increasing concern both for employers, in terms of lost productivity, and for employees, in terms of lost income. More agile and responsive models of care are needed to meet these needs. One quietly effective and efficient solution is Adult Day Services (ADS). Recent information suggests that a full day of ADS costs about the same as three hours of home health care. Adult Day Services are also significantly less expensive than assisted living. Yet ADS remains underutilized and underavailable; as of 2004 there were 3,400 ADS centers in the United States but there was a market need for 8,500. With the graying of America, this need will only continue to grow. ADS offer short-term respite care where a family may place a loved one in a care setting for a given period of time, such as after work, weekends, or overnight. These more responsive care models will increasingly become the norm. From a design perspective, the new models present momentous opportunities for creativity. We must always remember that the physical setting is the “silent partner” in enhancing quality of life in long-term care settings. In both Adult Day Service and Respite Care settings, people are coming and going each day, making transition critical. The approach and entry sequence must foster engagement as well as security. How can that sequence allow varying degrees of commitment while providing opportunities for rest? Conversely, how is the entry configuration organized so that the exit is not an appealing diversion? Spaces must be appropriately sized for the activities that occur there. For example, new research and theory suggests that activity group sizes of greater than 12 should generally be avoided. No longer should the physical environment be organized around the “multipurpose” room intended to maximize flexibility. Large public bathrooms and central storage facilities should be replaced by smaller toilets and supply rooms distributed throughout the facility. It is critical for designers to understand the programs of Adult Day Services and Respite Care because they vary greatly. No matter how compelling and high-quality the program, we must design to the range of experiences for elders and persons with dementia. Places of solitude, such as gardens, reading nooks, or den spaces, will be welcomed by participants as well as by staff, who may need to redirect an anxious participant. Lastly, let us never forget the lessons of history and the clear importance of daylight, air, and nature in care settings. From the Asklepion in ancient Greece through the cloister gardens of the Middle Ages, we have recognized that daylight, air, and nature are integral to any therapeutic setting. Thus many principles of sustainable design ought not only be integrated into care setting design concepts but should be considered essential. Adult Day Services and Respite Care are alternatives to the institutional model of long-term care in which seniors are isolated from the community. With their agile and responsive characteristics to community needs, Adult Day Services and Respite Care enrich the constellation of care options that will help us meet our moral obligation to our Aging Society in the coming decades.

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CHILD DAY CARE Children in day care range in age from a few months to 5 years. Within each age they have a range of developmental stages that define the physical environment needed to support quality learning. Every design detail impacts the cognitive, social, and physical needs of the child: the caregiver to child ratio, square feet allocation per child, group size, and age. Children need an open place to be themselves, not a closed environment designed for the convenience of adults. For children, the environment is a medium for experimentation and learning. Again, everything in the environment matters. Child-care centers should be filled with artistic, interactive surfaces to explore with the hands and eyes, with movement and activities that a child can enjoy. Children must interact with the environment on a sensory level. Surfaces should softly reflect light, invite touch, offer surprising fragrances, and produce interesting sounds. Children learn through these sensory experiences. Movement is another way children learn. Children need to move about in the space yet feel comfortable, competent, and in control. Comfort comes from changes in sensory stimulation within a predictable framework, like a flickering fire or a warm breeze.11 Comfort does not come from maintaining a static position. Day-care learning spaces must accommodate six basic activities: quiet learning, large motor activities, crafts, games, drama, and therapeutic exercise.12 Quiet areas are used for reading, resting, and time out. These areas must offer security and protection. Large motor activities should offer the opportunity for change within secure parameters. Dr. Anita Olds designed a play structure with a secure hideaway: a 150-year-old dead maple hollowed out for children to explore (see Figure 6–9). A smaller log was carved into a series of steps leading to a slide built from another log. Halogen lighting created a dappled effect, like light in a forest. Finishes should be soft and safe, and although this discussion is limited to family-centered design, note that finishes should be planned for ease of maintenance. Craft areas may offer paint, clay, water, and sand. Drama spaces may include a puppet theater, playhouse, and costumes, while games may vary from simple board games to sophisticated computer challenges. Large motor activities include sliding, climbing, swinging, and crawling. Innovative day-care centers offer therapeutic exercise areas planned to improve a wide range of abilities. Pediatric rehabilitation components can engage children while offering functional restoration. Elements of one system, including stepping stones, logs, cubes, ramps, and toadstools, pop up from the floor. These elements are used in upper-body exercise, fine motor skills development, coordination, and cognitive training (see Figure 6–10).

Day Care and Respite

Figure 6-9 Enchanted Forest play area. Courtesy of Gail Collins and Anita Rui Olds.

Figure 6-10 Rehabilitation area. Courtesy of Guynes Design Inc.

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Day-care centers should be designed universally to accommodate children of all ages, sizes, and abilities. The range of activities should foster independence, social interaction, skill development, and confidence. Children of all abilities and ages enjoy participating in cooking activities, eating, computer games, music, and reading. Older children may enjoy a separate elevated space where they can remain “above it all.” Child-care centers should be planned to create a transition between school and home. Long, disorienting corridors and institutional finishes are not appropriate. A homelike atmosphere must be created, beginning with a warm welcome at the reception area and extending throughout the activity and rest areas. Indirect lighting (on rheostats for naptime) offers an inviting ambience that does not glare in the eyes of children lying on their backs (see Checklist: Universal Lighting on page 90). Lighting should support visual access to all areas, including the exterior. Homelike environments offer comfort and security, freeing children to experiment within safe parameters. On average, children spend about 85 percent of their time indoors. According to GreenGuard Environmental Institute (GEI), a typical classroom or home may have anywhere from 50 to 500 airborne volatile organic compounds (VOC) present.13 Children respond differently to indoor air pollution than adults and are susceptible to related health risks, including asthma, cancer, and reproductive and developmental problems. It is the designers’ responsibility to plan safe and healthy environments for children. Compliance with the GreenGuard Children’s and Schools Certification Program is a first step. It is a voluntary program for controlling indoor air pollution that offers standards set specifically for children. In addition, GEI has a web-based resource tool for the selection of interior finishes, materials and furniture. Child-care facilities are complex and rich in detail, combining psychosocial, developmental, and physical requirements. Child-care environments must be conducive to learning and to expressing creativity in a healthy and sustainable learning environment. Endnotes 1. NICHD Early Child Care Research Network, NICHD Study of Early Child Care and Youth Development (SECCYD). National Institutes of Health, 2006. 2. L. Noelker, The Impact of Environmental Problems on Caring for Impaired Elders in a Home Setting. Paper presented at the 35th Annual Scientific Meeting of the Gerontological Society of America, Boston, 1982. 3. L. Harmon, “Adult Day Care: An Attractive Alternative to Nursing Homes and a Source of Peace of Mind,” Family and Marriage Community, December 8, 2008.

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4. NADSA, “Adult Day Services: Overview and Facts,” National Adult Day Services Association, retrieved October 21, 2009, from www.nadsa.org/adsfacts/default.asp. 5. Metlife Mature Market Institute, “National Survey of Adult Day Services Costs and Annual Home Health Care Rates,” Business Wire, September 30, 2008. 6. J. Horvath-Lindberg, “Open Day Centre Services in Solna: A Description,”City of Solna, Office of Care Services for Elderly and Disabled, 2007. 7. B. Arnetz and T. Theorell, in H-E Olson, PM ang. ett fritidsperspektiv för äldre (Stockholm: Institutet för Fritidsvetenskapliga Studier, 2002), p. 2. 8. Horvath-Lindberg, “Open Day Centre Services in Solna.” 9. V. Regnier, Design for Assisted Living: Guidelines for Housing the Physically and Mentally Frail (New York: John Wiley and Sons, 2002), p. 294. 10. N. Silverstein, C. Wong, and K. Brueck, Living with Alzheimer’s Disease: A Study of Adult Day Health Services in Massachusetts, Alzheimer’s Association and Massachusetts Adult Day Services Association (MADSA), October 2008. 11. A. Rui Olds, Child Care Design Guide (New York: McGraw-Hill, 2000). 12. Ibid. 13. GREENGUARD Environmental Institute, GREENGUARD Children and Schools Certification, 2009, retrieved October 21, 2009, from www.greenguard. org/Default.aspx?tabid=96.

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ccording to a new report prepared for the California HealthCare Foundation, recent trends in health-care service delivery show progress toward patient-centered and family-centered care initiatives. There has been an increase in the use of medical technology and new models of providing underserved populations with access to quality health services.1 This report states that a new paradigm of ambulatory care is being developed that redirects the focus from treatment to prevention. The one-size-fits-all reactive approach is changing into a more integrated patient-centered approach. According to the Institute of Family-Centered Care, the core concepts of family-centered care are: (1) dignity and respect, (2) information sharing, (3) participation, and (4) collaboration.2 These concepts are grounded in good communication.

ACCESSING THE FACILITY The patient’s overall satisfaction with the experience begins before the patient reaches the front door. Visual cues, including exterior signage and architectural features, guide the patient to the entry of the clinic. Other considerations include:

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• • • •

Proximity to public transportation Location within the area of the patient population served Hand-held maps prior to the appointment Architectural and landscape features supporting the way-finding program

Exterior signage must be clear to direct and inform to prevent confusion, unnecessary frustration, and loss of time. In Design that Cares,3 the authors offer the following suggestions for developing a successful exterior signage system: • • • • •

Be consistent in the language used. Keep the message short (no more than seven words). Clarity in message should be similarly interpreted by all users. State the message in positive terms. Use words and phrases that are well within a sixth-grade reading level.

Parking is another factor for many in the progression to the facility entry. When arriving by personal vehicle, visitors and patients need access to safe, well-lit parking with clear direction through signage and environmental cues to navigate toward their destination. For ambulatory facilities, the ADA requires 10 percent of the parking spaces to be accessible unless the facility specializes in treating people with mobility impairments in which case 20 percent of the spaces must be accessible.4 Each accessible space must be located on the shortest route of travel to an accessible entrance (see Checklist: Parking and Curb Ramps on page 138).

CHECKLIST Parking and Curb Ramps For more information, refer to the ADA Standards. • All entrances from parking garages, tunnels, and elevated walks must be accessible. • Provide at least one van accessible parking space if 25 or fewer spaces are provided. • The width of a standard accessible space or van accessible space is 96 inches. • The access aisle width for standard accessible space is 60 inches, with a vertical clearance of 80 inches. The width of the access aisle for a van-accessible space is 96 inches, with a vertical clearance of 98 inches.

Medical Offices

CHECKLIST Parking and Curb Ramps (continued) • The slope of accessible parking spaces must not exceed 2 percent (1:50). • Curb ramps located where pedestrians must walk across them or where they are not protected by handrails or guardrails must have flared sides. The maximum slope of the flare must be 1:10 on a 48-inch accessible route. If the route is less than 48 inches, use a 1:12 maximum slope. • Curb ramps with returned curbs may be used where pedestrians would not normally walk across them. • Keep all curb ramps within marked crossings (excluding flared sides). • If diagonal (or corner-type) curb ramps have returned curbs or other welldefined edges, the edges must be parallel to the direction of pedestrian flow. • The bottom of diagonal curb ramps must have 48-inch-minimum clear space. If diagonal curb ramps are provided at marked crossings, the 48-inch clear space must be within the markings. • If diagonal curb ramps have flared sides, they must also have at least a 24-inch-long segment of straight curb located on each side of the curb ramp and within the marked crossing. • Raised islands in crossings must be cut through level with the street or have curb ramps at both sides and a level area at least 48 inches long between the curb ramps in the part of the island intersected by the crossings. • For security purposes, the parking lot should include audio communication to security guards and parking attendants, video cameras, and appropriate lighting.

CHECKLIST Passenger Loading Zone For more information, refer to the ADA Standards. • The passenger loading zone should be visible from the entry door. • At a minimum, the passenger loading zone must be 5 feet wide and 20 feet long, parallel to the vehicle space. • The zone must be slightly sloped for drainage, not to exceed 1:50. • A minimum vertical clearance of 114 inches is needed by some vans. • From the access aisle or passenger loading zone, an accessible route should be provided to all buildings on the site. The route should be free of auto traffic and protected from adverse weather elements. It should be well illuminated and maintained. Continued

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CHECKLIST Passenger Loading Zone (continued) • The minimum clear width for a single wheelchair is 36 inches, but a universal route is 44 inches wide (except at tight turns). For two wheelchairs to pass, the route must be 60 inches wide. • To improve visual acuity, use color and texture on sidewalk intersections leading directly into the street or parking lot. • A covered entrance with a passenger loading zone is required by the Americans with Disabilities Act (ADA) only in health-care facilities where the stay may exceed 24 hours, but ideally, all medical offices should provide one. In addition to a cover, a doorman or greeter is helpful to patients. Valet parking, on the other hand, poses problems. Many patients do not like to trust their vehicle to valet parking, especially if the vehicle has hand controls or special accommodations.

The journey continues as patients and visitors transition from public transportation, taxi or parking their vehicles to the main entrance. They need to become oriented to their location and feel they are safe to progress comfortably toward the entrance. Visual cues play an important role in this process. The main entrance should be easily identified and welcoming, providing outdoor seating for those waiting for transportation. Signage, locator maps, and adequate illumination can help direct patients and visitors to their destinations. The entrance is a physical transition from the exterior to the interior environment, providing the visitor and patient a first impression about the facility and an opportunity to orient themselves to the facility and figure out where they need to go. Interior signage and maps in concert with an information desk can help with this orientation to the facility and familiarize the users with the way-finding system and how to look for additional information when it is needed. For those who may need additional assistance, the attendant at the information desk should be able to provide additional support. CHECKLIST Elevators For more information, refer to the ADA Standards. • In some existing buildings, the ADA permits an accessible elevator to be a minimum interior size of 48 by 48 inches, but an interior of 54 by 68 inches is much more usable. Dimensions must even be larger to accommodate a gurney including a clear opening of at least 48 inches.

Medical Offices

CHECKLIST Elevators (continued) • Consider separate elevators for public and staff use, especially if staff transports patients on gurneys. • The elevator should be automatic and self-leveling (within a tolerance of ½ inch). Leveling should be tested with a full load as well as without a load. • The elevator should start and stop smoothly, and a fold-down seat and stationary handrail should be provided for use by people with differences in balance and strength. A seat on each floor outside of the elevator is also helpful. • A visual indicator on each elevator control button should light when touched and extinguish when the command is completed. • All car controls, as well as the car platform, landing sill, and car threshold, should be illuminated to at least 5 fc (footcandles). • Position indicators should incorporate redundant cuing, offering both visual and audible cues. • In the corridor, an audible signal should sound once for the up direction and twice for the down (or use a spoken announcement of up or down). • Call buttons should be installed at a maximum height of 42 inches, with the up button on top. Consider installing a second call button at a height of 36 inches for use by short people and children. • Any object placed or installed beneath the call buttons should not project into the space more than 4 inches. • A call button should be a minimum of ¾ inch in diameter. • Hall lanterns indicating which car is answering the call should be a minimum of 2½ inches in diameter. • A 2-inch-high raised floor designation should be mounted on each side of the hoist way entrance. It should be installed at a height of 60 inches, and a second designation should be installed at 48 inches a.f.f. (above finished floor), when appropriate, for children. • Interior control panels should be installed within reach from a wheelchair. Controls for children should be installed at a height of 36 inches. Some panels are designed to be mounted horizontally to improve reach. Arrange the numbers in ascending order, reading from left to right. A floor number or other raised designation should be installed to the left of the button and should contrast with the background. • Numerals above the door should light and a signal should sound as the car passes or stops at a floor. A spoken announcement may be substituted for the signal. • The elevator should have a sound signal to indicate that it is safe to enter or exit. • If the door becomes obstructed, it should reopen without requiring contact and remain open for at least 20 seconds. Continued

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CHECKLIST Elevators (continued) • The ADA standards and the Uniform Federal Accessibility Standards (UFAS) require only that a door remain open for as little as five seconds in response to a call. This is insufficient time for many people to respond, even if forewarned of arrival by redundant cuing. • An emergency communication system inside the car should comply with ADA standards in height, hardware, and length of cord, if any. A vocal system (like an intercom) should be incorporated in addition to an alarm system. Intercoms are easier to use and tougher to vandalize than systems requiring the use of a handset. Only the nonverbal alarm system is required, however. Instructions for use should be both tactile and visual.

REGISTRATION AND WAITING The registration process and waiting room experience set the tone for the patients’ and their families’ perception of quality of care. Average wait times for outpatient care is about 24 minutes, though wait times are longer on weekends and during health crises like the recent H1N1 flu epidemic. To improve appointment scheduling, modeling software can be used to simulate appointment schedules. Alternative appointment schedules can then be implemented to reduce patient waiting times without the need for additional resources.5 The design of the waiting areas has also shown to have an impact on the waiting experience and satisfaction with quality of care. One study showed that perceived quality of care was greater for waiting rooms that were nicely furnished, well-lighted, contained artwork, and were warm in appearance.6 Another study of hospital waiting areas concluded that appealing design attributes are associated with more positive environmental appraisals, improved mood, altered physiological state, and greater reported satisfaction.7 Upon approach to the waiting area, there should be a clear view to allow patients and their families the opportunity to assess the situation prior to entering the space. To help with orientation and to accommodate people with hearing impairments, avoid the clutter of tall arrangements of flowers and accessories on furniture. These items block a clear line of vision to the space beyond as well as to interpreters and other people in the room. Visual impediments in the entry space may make it more difficult to maintain eye contact, to read lips and gestures, to hear, and to be heard.

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EXPERT FOCUS Interior Design Trends in Medical Office Building (MOB) Design MARGIE SNOW, AAHID, ASID, IIDA, LEED AP Principal, Gallun Snow Associates

The MOB encompasses a variety of health-care services including primary care, urgent care, and specialty services including women’s centers, cancer centers, and outpatient surgery. Growth trends have shifted to more community-based care facilities. This is due in part to hospitals becoming more specialized and their patients more critical. Hospitals charged with providing care for all are creating safety-net clinics, such as community health centers, to provide uninsured low-income residents access to health care outside of hospital emergency rooms. These centers provide a range of services from primary and urgent care to behavioral health and social services. They tend to be more culturally sensitive to their clientele as well as more accessible to urban patients dependent on public transportation. Evolving health-care models are more inclusive of the patient and family in the healing process, focusing on communication between patient, family, and physician. Studies have shown that the physical environment has significant impact on patient health outcomes. The design focus has shifted toward healing environments in a broad sense. Today, designers must consider the impact their interiors have on indoor air quality, reducing anxiety of patients and families, providing efficient, effective work spaces for staff, and providing finishes that have long eco-friendly life cycles, along with providing a welcoming, pleasant space for patients and families. Information from studies in evidence-based design and sustainable design along with Planetree concepts have impacted the interior design of the MOB. Planetree’s holistic focus on meeting the needs of mind, body, and spirit encompasses not only a method of care delivery, but of design process. Respect for patient dignity and privacy, a positive and welcoming waiting experience within clinic space, access to technology and information, inclusion of the family in the care experience, use of healing art and nature, have all positively impacted the design. Focus Groups are requesting expanded service options related to care. Examples include spiritual space, retail pharmacies or specialty boutiques that cater to specific patient needs, massage therapy, small technology libraries, community rooms, and coffee/juice carts or cafés. This focus on the total health of the patient has transformed the design emphasis in the MOB. Sustainable design practices have also impacted the MOB design process over the last five years. Focus on sustainability is more frequently being integrated into to the vision, values, and core mission statement of clients. Healthier indoor environments for patients, families, and staff through better IEQ, increased access to daylight/views, and a trend to more efficiently designed spaces are being addressed. Energy efficient lighting, mechanical, electrical and plumbing (MEP) systems, and more durable materials impact not only the quality of the MOB and the cost of construction, but the lifetime cost of operations. Designers in the health-care industry are challenged to keep informed about the effect on health of materials, products, and processes. The health-care design industry as a whole is reacting to the focus on maintaining health by incorporating strategies on the front end of the planning process that support overall patient, family, and staff well-being. The design of the MOB needs to accommodate shifting care models, new technology, and client needs. Better communication and more definitive studies will be the tools to carry us into the next phase of creating Medical Office Buildings that truly support the work of healing.

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Patients and their families judge a clinic by small design details and visual impressions. Sensibly designed and maintained reception areas show respect for patients as people and contribute to humanizing the experience of visiting a medical office. Provide a secure place for coats, boots, and umbrellas. Plan a public telephone in the waiting room and drinking fountains at different heights (see Checklist: Drinking Fountains and Water Coolers on page 144). Offer large-print magazines on a lowered rack. Locate a children’s area away from door swings and traffic areas but within sight of the receptionist. These design details are appreciated by patients of all ages, sizes, and abilities.

CHECKLIST Drinking Fountains and Water Coolers For more information, refer to the ADA Standards. • Blind people who use canes cannot detect water coolers with floor clearances exceeding 27 inches. People in wheelchairs require a clearance of at least 27 inches for a front approach, so this must be the exact clearance to meet the needs of both populations. • A second fountain should be mounted at standard height. When children frequently use the space, a third fountain should be considered with a spout no higher than 30 inches and a clear knee space of 24 inches. • The spout of a water fountain for shorter adults and wheelchair users should be no higher than 36 inches. It should be located close to the front of the unit with a water flow parallel to the front edge. • The flow must be at least 4 inches high to facilitate use with a cup. A paper cup dispenser adjacent to the water fountain allows use by many people who have differences in reach and coordination. • A recessed fountain or cooler for wheelchair users optimally should be 17 to 19 inches deep. The recess should be a minimum of 30 inches wide and a maximum of 24 inches deep for a front approach. For a side approach, the alcove must be 60 inches wide if the depth exceeds 15 inches. • Controls on all fountains should be located near the front edge. They should be operable with one hand without pinching, tight grasping, or twisting of the wrist. An automatic sensor is most easily operated by people of all sizes and abilities.

Each counter should provide a surface for writing (at 42 inches a.f.f.) and a lowered surface (30–34 inches a.f.f.) for wheelchair users, children, and shorter adults. The check-in counter should be open and welcoming, while providing privacy for the patients and families. For wheelchair use,

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Figure 7-1 Alternate exit. Courtesy of Watkins Hamilton Ross Architects.

the top should be 30 to 34 inches a.f.f. with clearance of 27 inches below. A minimum accessible width of 36 to 42 inches should be provided. A checkout counter should be placed adjacent to the exit. It is thoughtful to plan a separate the exit so that patients need not walk through the reception area after a procedure (see Figure 7–1). This door may also be used as an alternate entrance for emergencies (see Checklist: Accessible Signage on page 250). These considerate details denote the sensitivity of the providers and their awareness of the patients’ needs. Through window views and contextual design, a center can relate to the neighborhood and the people for whom they are providing care (see Figure 7–2). The center must also acknowledge American cultural norms. Americans appreciate more personal space, preferring to maintain a separation of intermediate distances, which were rated as more comfortable, preferable, and appropriate rather than more extreme close or far distances.8 A variety of seating options— single seating, small group seating—using furniture that can be moved by the users to create a comfortable seating arrangement is recommended. Patients and their families sometimes wait for hours, especially in obstetricians’ and gynecologists’ offices. Seating must be comfortable and should be rated for use according to static and dynamic force criteria for the overall chair, the seat and the arms.

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Figure 7-2 Mexican decor in context with the location. Project name: Scripps Ambulatory Surgical Center. Interior architecture: Jain Malkin Inc. Photography: Steve McClelland Photography.

One of the elements that have shown to increase patient and visitor satisfaction is access to nature and natural light. Window views of the surrounding landscape or gardens provide visual distraction and natural light. The waiting area can be planned in an atrium or adjacent to a courtyard (see Figure 7–3). Water elements provide white noise and visual distraction, an opportunity to design a less stressful environment (see Figure 7–4). Natural light can be provided via a solarium, clerestory, or skylight (see Figures 7–5 and 7–6). Depending on the size and configuration of the skylight, light shelves, and other mechanisms can be used to increase lighting levels and manage heat gain (see Checklist: Universal Lighting on page 90 for additional criteria for lighting).

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Figure 7-3 Courtyard garden provides access to nature and positive distraction to destress. Odell Associates, Inc., Architects. Courtesy of Hilliard Photographics, Inc./Joe Hilliard.

Figure 7-4 Water features provide visual and auditory distraction. WHR Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

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Figure 7-5 Natural light. WHR Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

Figure 7-6 Natural light with grand stair. WHR Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

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Natural light deinstitutionalizes and humanizes the reception area. Positive distractions such as artwork, aquariums, and puzzles are other elements that help make the office less threatening. Room dividers and wall systems can be used to exhibit revolving projects, to house an entertainment center, or to store patient and family education materials (see Checklist: Room Dividers and Wall Systems on page 150). Education is an important component for all ambulatory centers. In an effort to sustain a high level of satisfaction and perceived quality of care, some facilities are allocating a separate space for education so that ongoing opportunities to provide patients with educational media can be provided. Consider an adjacent reading room (see Figure 7–7), lending library, and computer station with Internet access to current medical research (see Checklist: Computer Stations for All Abilities on page 150).

Figure 7-7 Resource library. Courtesy of Lowell General. Designer: TRO. Photography: Ed Jacoby.

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CHECKLIST Room Dividers and Wall Systems For more information, refer to the ADA Standards. • Avoid partitions with legs that extend into traffic areas. The legs can pose a tripping hazard and can limit access by wheelchair users. • Ventilation to control heat buildup and odor is an important feature if the room divider is used to conceal a television, computer, or appliance. • Heavier items, like televisions, can be more easily managed on swing-out shelves or turntables. Deep shelves and clothing racks should roll out. • Pull-out shelves and drop-lid desks are available on many wall systems, offering the option of lower work surfaces for use from a wheelchair. • For people in wheelchairs, cabinets and drawers must be raised at least 9 inches from the floor to allow footrest clearance. • Keep drawers in wall systems at a reachable height (under 32 inches). Patients in wheelchairs may have trouble reaching to the back of drawers that are installed any higher. • When planning shelf heights and depths, consider the maximum reach of the patient in a wheelchair. • If a phone is placed in the wall system, plan a shelf for phone books, a clip on the shelf to secure a note pad, and space for a text telephone (also known as TDD and TTY). This telephone requires 6 inches of vertical clearance and an outlet within 48 inches.

CHECKLIST Computer Stations for All Abilities For more information, refer to the ADA Standards. • Voice recognition systems (which accept spoken commands) are commonly available. These work well for many patients, even those with vision limitations, if the system provides audio feedback of each choice and command. Software is also available to enlarge text and images. • For people who are blind, Braille systems and optical readers are helpful add-ons. A Braille display orally “reads” the information from the screen and also presents it in Braille. Printed information can be scanned, reprinted in Braille, or “read” by the speech synthesizer. • Keyboards should be placed on a surface 5½ to 7 inches above seat height. • Consider large keys for people with differences in coordination. • Membrane keyboards are available for people who cannot depress keys.

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CHECKLIST Computer Stations for All Abilities (continued) • A speech synthesizer offers voice output for a person who cannot use the screen or who has speech impairment. The computerized voice lets the user hear the information printed on the screen. It provides immediate audio feedback as data are entered on the keyboard, so mistakes are easily identified. • When used with a telephone interface, a synthesizer can serve as a speakerphone, allowing two-way conversation without the use of voice. • Computer peripherals are becoming more user friendly for people with varying abilities. A printer system, for example, can be operated with a mouth stick, by voice, or by hand without requiring manual dexterity. One excellent example of a user-friendly device is a disk-loading system that can be fully operated with a mouth stick. • People with learning differences benefit from the immediate feedback offered by computers. Learners see, hear, and feel information (on a touch screen) to reinforce the message and allow for a variety of learning styles. • Plan an adjacent shelf with at least 6 inches of vertical clearance for text telephone use of the computer. Locate an outlet within 48 inches.

EXAMINATION AND CONSULTATION In a consulting room, every effort should be made to remove communication barriers. The patient should be fully clothed and seated at the same level as the provider, perhaps at a round table with four chairs. The purpose of the family consulting room is to provide a nonthreatening meeting space that allows for privacy and Health Insurance Portability and Accountability Act (HIPAA) compliance. The consulting room is typically adjacent to three or four exam rooms and a nursing station. In a decentralized plan, these few rooms form a pod with a provider team assigned to each. Each team may be composed of two doctors, one assistant, one receptionist, and one billing person. Patients and their families work with the same receptionist, assistants, and doctors on each visit, maintaining a sense of intimacy even in a high-volume practice. A series of pods reduces the anonymity of one large clinic with 50 exam rooms. Pods may be organized around a central courtyard with access to light and nature. For privacy, the foot of the exam table should be angled away from the door opening, and the door swing should also be planned to offer a degree of privacy (see Figure 7–8). For acoustical privacy, the door should have a

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solid core (see Checklist: Doors and Checklist: Door Hardware on pages 74 and 76). The walls could feature staggered stud construction with insulation (see Figure 7–9). Exam tables should be adjustable in height for shorter people, children, people in wheelchairs or on gurneys, and older people. The exam room should be furnished with a guest chair, hooks for clothing, and a mirror, in

Figure 7-8 Exam room plan. Courtesy of Jain Malkin Inc.

Figure 7-9 Staggered stud construction. Courtesy of C. Harris, Dictionary of Architecture and Construction, 1995, reproduced with permission of The McGraw-Hill Companies.

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Figure 7-10 Dressing room with lockers. Courtesy of Chambers Lorenz Design Assoc.

addition to the workstation for the health-care provider and a place to house educational materials. If the dressing room is separate from the diagnostic area (such as the imaging suite), lockers should be provided for valuables (see Figure 7–10). Exam rooms and dressing rooms may be named instead of numbered for a less institutional approach (see Figure 7–11). These rooms should include an emergency communication system and perhaps a buzzer or light to call for assistance. Carpet or carpet tiles can provide a soft surface with a warm surface temperature, providing comfort for bare feet (see Checklist: Carpeting on page 21). The advantages of carpeting include noise reduction characteristics, the humanizing effect on the environment, and the contribution to reductions in falls and resultant injuries, particularly for the elderly.9 Recent research has shown that carpet does not contribute to health-care acquired infections (HAI), making it a safe and comfortable flooring surface for many hospital areas.10 Adjacent to the exam rooms, provide a toilet room with a specimen pass-through. In many practices, the staff-controlled toilet room replaces the public rest room so patients can be reminded by staff if a urine sample is needed.

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Figure 7-11 Dressing room signage. © Al Payne. Designer: Orcutt/Winslow Partnership. Project: Scottsdale Healthcare’s Breasthealth Center.

Self-Care Self-care is performed by the patient for the prevention and management of medical conditions. It is usually initiated by a health-care professional. For example, a primary care physician may suggest a plan for a patient to control weight, manage diabetes, or increase exercise; a nutritionist may play a similar role. Physical therapists generally have a self-care plan that work with their treatment plan for patients to follow in between treatments. Occupational therapists help to restore and/or maintain the skills necessary to permit physically and mentally disabled people to perform daily living tasks of self-care to sustain their independence. A nursing care plan is used to determine the patient’s need for assistance and ability to develop a higher level of self-care appropriate for the condition. Why does self care matter? About 90 percent of the care a person needs to manage a chronic disease is the responsibility of the patient. Evidence is growing that self-management interventions such as self-monitoring and decision making lead to improved health outcomes, increased patient satisfaction, and reductions in hospital and emergency room expenses. According

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to authors Colin Greaves and John Campbell, self-care affects health outcomes through several pathways:11 • Increased adherence to treatment regimes • Better lifestyle choices (physical activity, diet, not smoking) • Improved monitoring of symptoms to inform treatment/self-care decisions • Effective communication with health professionals • Better use of social support networks to achieve positive health outcomes Collaborative problem solving, goal setting, active and sustained followup, and high-quality education support behavior modification. From a design perspective, these activities underscore the importance of consultation rooms where patients can meet with the care provider team. Larger clinics may be able to provide a dedicated education space for group meetings and educational presentations. This space may include a kitchenette, comfortable seating, computers, and multimedia technology.

Laboratory Many clinics provide laboratory services within their practice, though some clinics do not, requiring a patient to go to a separate facility. These facilities may be part of an existing acute-care facility or a freestanding laboratory. The provider of this service should provide an environment that supports safety, privacy and comfort to minimize stress for the patient. While the waiting area may be smaller than that of a large clinic, it should extol the same quality of care through the use of artwork, interior design, natural and artificial light, and comfortable seating. The check-in and check-out area(s) should be welcoming and efficient in processing the order for laboratory services, payment, and insurance. The blood-draw station should be large enough to accommodate the patient, the health-care professional, the typical monitoring equipment, and storage for supplies. Pay special attention to privacy and HIPAA compliance. Finally, a bathroom with a specimen pass-through should be located adjacent to the waiting area and the blood-draw rooms.

SPECIALIZED PRACTICE This discussion is limited to family-centered design in several of the most common medical specialties, with exemplar studies of current design solutions.

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Pediatrics Pediatric patients benefit from the same design elements as adult patients: welcoming lobby and waiting spaces, access to nature, natural light, and areas with a variety of seating choices. Opportunities to design engaging spaces of exploration and play should not be missed. The Affinity Health System’s Pediatric clinic is one of six family clinic prototypes being developed with Flad & Associates. The architect’s goal was to create a recognizable building that reflects Affinity Health System’s quality of care and helps patients easily locate community-based clinics (see Figures 7–12 and C-9). This branding is expressed in each clinic by a large vaulted lobby (see Figure C-10), an adjacent healing garden (see Figure 7–13), and a history wall. It is located in the lobby serves to reflect regional events as well as the history and culture of the institution. Patient flow and comfort are central to the organization of each clinic with clear and efficient way finding. The functional layout supports staff communication, improves work efficiency, and minimizes work-related stress (Figure 7–14). Pediatrics is a high-volume specialty where physicians sometimes see six to eight patients per hour. Arriving and departing patients and their families should be separated with separate check-in and check-out processes that do not overlap (see Figure 7–15). Clinics should also separate sick children from well children in reception to prevent the spread of contagious disease.

Figure 7-12 Exterior detailing and material selection is an important part of branding for community-based clinic. Affinity Health System, Menasha, Wisconsin. Flad Architects, Madison, Wisconsin. Courtesy of Philip Prowse Photography, Minneapolis, Minnesota.

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Figure 7-13 Site plan shows relationship of public space and healing garden. Affinity Health System, Menasha, Wisconsin. Flad Architects, Madison, Wisconsin. Courtesy of Philip Prowse Photography, Minneapolis, Minnesota.

Figure 7-14 Plan view of pediatric community clinic. Affinity Health System, Menasha, Wisconsin. Flad Architects, Madison, Wisconsin. Courtesy of Philip Prowse Photography, Minneapolis, Minnesota.

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Figure 7-15 Separation between incoming and outgoing patients and their families. Courtesy of Jain Malkin Inc.

In pediatric offices, a public rest room should be planned adjacent to the waiting room. Parents need to change their babies without the inconvenience of requesting access to a private bathroom in the back. A unisex bathroom allows an adult or an aide to accompany children of either sex without concern. All toilet areas and exam rooms need to be large enough to accommodate several siblings at once. Properly planned, these larger rooms also accommodate parents, strollers, and children who use wheelchairs, walkers, or guide dogs (see Figure 7–16).

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Figure 7-16 Minimum-size unisex toilet room. Courtesy of Evan Terry Associates, P.C.

Diagnostic Imaging Centers Advances in imaging technology have drastically accelerated due to the development of digitized information technology.12 Not only does it provide a better way of imaging soft tissue, but it is more efficient and cost effective than relying on film media, which requires processing and development. Diagnostic imaging includes magnetic resonance imaging (MRI), computed tomography (CT), nuclear imaging or position emission tomography (PET), mammography, radiology, ultrasound, and fluoroscopy. Patients may arrive at the ambulatory diagnostic imaging center with a scheduled appointment or not, with centers configured to separate the flow of these two types of patients. The check-in area should provide for multiple patients to check in at the same time, with dividers to provide visual and acoustical privacy (see Figure 7–17). After check-in. the patient may briefly wait in the general waiting area before being directed to an individual dressing room adjacent to the procedure room. Here the patient can change and wait with privacy, which is preferable to gender-specific subwaiting rooms with all patients waiting together for procedures. The Memorial Herman The Woodlands diagnostic imaging center provides advanced imaging services, a comprehensive breast and bone center, and a bladder center. Knowing that the MRI and PET equipment can be intimidating and stressful to patients, the center looks more like a high-end

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Figure 7-17 Private registration to support HIPAA compliance. Courtesy of RAD Consultants.

spa than a digital imaging center. The interior design is appreciated by the patients, their families and staff (see Figures 7–18 and 7–19). The materials, colors, and textures provide a soothing environment, with comfortable seating and a variety of lighting levels. The space brings calm and comfort to what may be a stressful procedure or examination for patients and family members (see Figures 7–20 and C-11).

Ambulatory Surgery Outpatient surgery is also called same-day surgery because patients are discharged on the day the procedure takes place. It offers patient and family convenience while reducing the expense and fear of entering a hospital for an overnight stay. There are seven stages of patient flow: preadmission, arrival, patient preparation, induction, recovery, post-recovery, and discharge.13 Preadmission and arrival take place in the reception area, although a private entry may be provided for patients who need or desire more anonymity. In outpatient surgical facilities, families wait for much longer periods than in other practices, sometimes most of the day. Every detail of the interior is noticed and every benefit appreciated. Choices should include comfortable

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Figure 7-18 A soothing color palette provides a calming atmosphere in the waiting room. Memorial Hermann The Woodlands Medical Office Building III. Morris Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

seating of all sizes, a place to conduct business with a telephone and access to computers or use of personal computer, and an entertainment center. These design details contribute to a less stressful environment, a necessary consideration even though stress levels may be lower in outpatient areas than in hospital waiting rooms.

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Figure 7-19 Color and texture provide interest to the waiting area. Memorial Hermann The Woodlands Medical Office Building III. Morris Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

Plan areas for patient preparation, induction, recovery, and post-recovery where the family can stay with the patient and move through the process along with their loved one. (see Figure 7–21). Some thoughtful practices plan a space for help with hair and makeup before discharge (see Figure 7–22). Plastic surgeons typically use gray mirrors and low-level lighting in these spaces to minimize the immediate impact of bruises. Most patients are discharged in wheelchairs and should be met by transportation near a private discharge area that does not cross paths with those entering the facility. Outdoor seating in this area is helpful for those waiting for a ride. Plan a slip-resistant surface that drains away from the door. The exit should be protected from wind to allow the door to be easily opened (see Checklist: Passenger Loading Zone on page 139).

Oncology and Cancer Care The survival rate for all cancers diagnosed is increasing, up from 50 percent for the years 1975–1977 to 68 percent for 1999–2005.14 The reduction in the overall cancer death rates has resulted in the avoidance of about

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Figure 7-20 Digital imaging services in a calm environment with positive distraction through the use of art and light. Memorial Hermann The Woodlands Medical Office Building III. Morris Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

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Figure 7-21 Preoperative/postoperative recovery suites. Courtesy of Ellerbe Becket. Photography: Koyama Photographic.

650,000 deaths from cancer over the last 15 years. However, cancer still accounts for more deaths than heart disease in those younger than 85 years of age.15 That said, when one is diagnosed with cancer it is an extremely personal condition, with feelings of shock, confusion, sadness, and fear. It affects not only the one with the cancer diagnosis, but also family and friends. The design of cancer treatment centers benefit from a strong patient-centered care design, focusing on beautiful aesthetics, natural light, access to nature, and comfortable surroundings. The Bon Secours St. Francis Cancer Institute is a welcoming sight to those arriving for care. It offers traditional architectural detailing, such as the heavy timber arrival canopy, low-sloping roofs with deep sheltering overhangs, copper gutters, and cedar piers. It also features warm natural materials such as wood, stone, and terra-cotta tile roofing (see Figures 7–23 and C-12). The center is 55,000 square feet in a two-story design on 5½ acres of land. Enveloped in a wooded setting, the facility benefits from extensive landscaping with several healing gardens, water features, and walking trails provide a variety of environments for visitors to experience.

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Figure 7-22 Grooming area. Courtesy of Watkins Hamilton Ross Architects.

The interior of the St. Francis Cancer Institute is infused with natural light, the continued use of stone and wood with comfortable furnishings creating an atmosphere of spiritual healing. The waiting area is lodgelike, with a double-story stone fireplace, leather-upholstered seating, and Internet access (see Figure 7–24). The facility also has a café that excels at providing comfort food; a well-appointed, comfortable resource center; and a prayer room with the adjacent garden (see Figures 7–25).

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Figure 7-23 Contextual detailing for exterior of Bon Secours St. Francis Cancer Institute. Image Courtesy Odell Associates, Photography by Hilliard Photographics, Inc./Joe Hilliard

The facility hosts a range of treatments and specialists under one roof for the convenience of those receiving treatment and care. The technology and equipment—Chemotherapy, Linear Accelerator (Linac), and Intensity Modulated Radiation Therapy (IMRT) provide state-of-the-art cancer-fighting treatment in an environment that is uplifting and exemplifies the quality of care. A floor-to-ceiling window offers infusion patients with a tranquil view of a beautiful garden. The radiation therapy rooms are located down the hall with access to another garden (Figures 7–26 and C-13). Patients receive professional care from a cosmetologist and can shop for specialized clothing and hair and skin-care products at a boutique. The Spectrum Health Lemmen-Holton Cancer Pavilion is designed to provide an advanced array of outpatient cancer services in a six-story, 284,000-square-foot pavilion. Multidisciplinary treatment teams, advanced technology laboratories, an oncology research department, and specialty physician offices are housed in a single location, ensuring timely and accessible care. This means that a patient can receive a comprehensive treatment plan in a few hours, rather than days. Efficiency at this level helps to diminish the fear and provide support to a patient reeling from time-sensitive information about their health. Designed with input from cancer experts and former patients, this patientcentered care facility focuses on providing a center for healing and a place of

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Figure 7-24 The two-story lobby welcomes visitors with warm natural materials and lodgestyle seating. Image Courtesy Odell Associates, Photography by Hilliard Photographics, Inc./ Joe Hilliard

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Figure 7-25 Resource center and library with natural light, comfortable seating, and computer stations inviting visitors to stay and learn more. Image Courtesy Odell Associates, Photography by Hilliard Photographics, Inc./Joe Hilliard

Figure 7-26 Healing gardens are located throughout the site for visitors to enjoy outside as well as providing visual access for patients during treatment. Image Courtesy Odell Associates, Photography by Hilliard Photographics, Inc./Joe Hilliard

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hope for patients and their families. Patients are greeted by name and families are invited to be on the treatment team. Small details make a big difference in the patients’ perception of quality of care. At this facility, comfort takes priority. Robes are offered instead of hospital gowns. Access to nature is provided by the indoor/outdoor life garden, a six-story atrium with lush plantings and waterfalls. This serves as a positive distraction while enhancing the space with natural light; accommodations for family and friends are provided throughout the facility with variations on waiting, education, respite, gardens, meditation areas, and a café so they can be near their loved one.

Endnotes 1. A. Joseph, A Keller, and G. Gulwadi, Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign (Oakland, CA: California Healthcare Foundation, 2009). 2. Institute for Family-Centered Care, “Advancing the Practice of Patient- and Family-Centered Care in Primary Care and other Ambulatory Settings,” 2009, retrieved February 4, 2010, from www.familycenteredcare.org/pdf/ GettingStarted-AmbulatoryCare.pdf. 3. J. Carpman M. Grant, Design That Cares: Planning Health Facilities for Patients and Visitors, 2nded. (Chicago: American Hospital Publishing, 1993). 4. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) 4.1.2(5), Washington, DC, 2002, retrieved February 3, 2010, from www.access-board.gov/adaag/ADAAG.pdf. 5. P. Harper, and H. Gamlin, “Reduced Outpatient Waiting Times Improved Appointment Scheduling: A Simulation Modeling Approach,” J. OR Spectrum 25:2 (2003): 207–222. 6. A. Arneill and A. Devlin, “Perceived Quality of Care: The Influence of the Waiting Room Environment,” J. Environmental Psychology 22:4 (2002) 345–360. 7. P. Leather, D. Beale, A. Santos, J. Watts, and L. Lee, “Outcomes of Environmental Appraisal of Different Hospital Waiting Areas,” Environment and Behavior 35:6 (2003): 842–869. 8. D. Thompson, J. Aiello, and Y. Epstein, “Interpersonal Distance Preferences,” Journal of Nonverbal Behavior 4:2 (2005): 113–118. 9. L. Sehulster and R.Y.W. Chinn, Guideline for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Disease Control and Prevention, MMWR 52 (No. RR-10 Pt II), 2003, retrieved December 2003 from www.cdc.gov/ncidod/hip/enviro/guide.htm. 10. D. Harris, A. Pacheco, and A. Lindner, “Detecting Potential Pathogens on Hospital Surfaces: An Assessment of Carpet Tile Flooring in the Hospital Patient Environment,” Indoor and Built Environment (in press): 1–11. 11. C. Greaves and J. Campbell, “Supporting Self-Care in General Practice,” British Journal of General Practice 57(543) (2007): 814–821.

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12. R. Kobus, R. Skaggs, M. Borrow, J. Thomas, and T. Payette, Building Type Basics for Healthcare Facilities (New York: John Wiley and Sons, 2000). 13. J. Malkin, Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures, 3rd ed. (New York: John Wiley & Sons, 2002). 14. American Cancer Society, Cancer Facts and Figures 2009 (Atlanta, GA: American Cancer Society, 2010): 2. 15. J. Ahmedin, R. Siegel, E. Ward, Y. Hao, J. Xu, and M. Thun, “Cancer Statistics, 2009,” Cancer Journal for Clinicians 59 (2009): 225–249.

8

WELLNESS CENTERS

W

hat is wellness? More than ever before, we hear this term in the news, on billboards, from our government, and through conversations with friends and co-workers. The health status of America is in decline; life expectancy has not kept up with other developed countries, and chronic illness is on the rise. The leading causes of death include heart disease, cancer, stroke, Alzheimer’s disease, and diabetes.1 These chronic illnesses can be managed through drug therapy, surgery and lifestyle changes and monitoring. Diabetes, for example, is common, disabling, deadly, and costly. The CDC reports that 23.6 million people in the United States (7.8 percent of total population) have diabetes, and that 1 in 3 Americans will develop diabetes sometime in their lifetime, losing, on average, 10 to 15 years of life.2 The percentage of overweight children in the United States is growing at an alarming rate; 33 percent of children and adolescents are obese3 and are at risk for becoming a diabetic during their childhood or as an adult. A leader in fitness and lifestyle, Charles B. Corbin, Professor Emeritus in the Department of Exercise and Wellness at Arizona State University, defines wellness as positive health exemplified by quality of life and a sense of well-being.4 The many dimensions of wellness are reflected by our health,

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fitness level, and emotional status. It impacts every area of our life: social, spiritual, physical, emotional, and medical, just to name a few. Other types of wellness include occupational, intellectual, environmental, and financial wellness. We have the knowledge, the technology, and the opportunity to make real changes in our society and increase wellness to have a better quality of life. Wellness centers are facilities that combine medical and fitness elements into a comprehensive health-care center.5 It is an important and growing part of health-care delivery. The wellness center is a place where physicians, alternative medicine practitioners, physical and occupational therapists, and others can develop a care plan that approaches preventive and restorative health from a holistic point of view, supporting the trend toward self-management, where individuals are active participants in their care and health. Through the wellness center model, integrative medicine and telemedicine combine to improve the quality of life through monitoring, self-care, and collaboration with an individual’s medical team. Conceived as a small southeastern Florida town with pre-1940s architecture in 1996, Celebration, Florida, is pedestrian-friendly community (a)

Figure 8-1 (Continued )

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(b)

(c)

Figure 8-1 Celebration Health floor plans. Courtesy of Florida Hospital Celebration Health.

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with educational, commercial, and health-care resources. It looks like a peaceful village from the turn of the century. But the traditional homes are equipped with technology that supports an interactive multimedia network that can be used to connect the entire community. Each home can be linked to Florida Hospital’s Celebration Health, a 60,000-square-foot health and wellness center so physicians can monitor pulse, blood pressure, EKG, body weight, and pulse-oximetry of patients at home, along with other telemedicine diagnostic services. Primary, secondary, and tertiary health care are offered at Celebration Health, a 100-bed acute-care hospital, which bears little resemblance to a traditional hospital. Equipment and staff are hidden behind the scenes, an idea borrowed from Disney World, which is located adjacent to Celebration (see Figure 8–1). Located on a 60-acre campus, this center is housed in a low-rise building for maximum light and air penetration. Members (not patients) and guests approach on a tree-lined drive and enter an atrium resembling the lobby of an upscale hotel. The atrium is filled with sunshine and flowers, diminishing the institutional feel of many acute health-care facilities. The atrium and galleries connect to all major destinations in the building, offering easy way finding (see Checklist: Environmental Wayfinding and Orientation Cues on page 253). Each health and wellness center member or guest is greeted by a receptionist in a polo shirt and khakis, not an institutional hospital uniform. There are few traditional waiting rooms. In the ED, for example, members and guests with minor emergencies wait separately from those with major trauma, shielding patients and their children from disturbing situations. Celebration Health is an early adopter of the paperless hospital, utilizing technology to update digital medical records, view X-rays, and access lifelong medical histories. Prescriptions are transmitted directly to the pharmacy. Computers with touch screens are located throughout the center. Members use the computers to find answers to medical questions or receive nutritional information. They may join fitness classes online or browse through a medical library. They can learn about a wide range of subjects including selfcare, caring for older parents, stress management, and choices in complementary medicine. Members and guests can determine their “health age,” a chronological age based on physical, emotional, and spiritual condition. In the pharmacy, they can access information about products and services to enhance their overall health plan. Doctors offer fitness prescriptions to address individual health needs. The wellness center is used by both the healthy and healing. Rehabilitation

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and therapy are integrated into the fitness center, removing fear associated with checking into a hospital. For athletes, biomechanical assessments, sports psychology, sports nutrition, and performance enhancement prescriptions are available. Electronic notebooks are attached to the training equipment to evaluate progress. If a member slacks off, the equipment “tattles” to the staff, triggering a friendly follow-up note.

TRANSFORMING HOSPITALS INTO WELLNESS CENTERS New trends are showing a shift from inpatient care to outpatient care with a focus on health promotion and wellness. The emergence of hospital-based fitness/wellness centers presents an alternative delivery of health-care services. These centers make ambulatory care more accessible and bring healthcare providers into the community, serving needs across the continuum of care.6 With health-care insurance reimbursement declining, hospitals continue to look for ways to diversify their businesses. The hospital-based wellness center is a viable way to retain members by extending services to meet the needs for preventive and restorative health. It also invites the community into the hospital through the wellness center door, providing a warm welcome to the hospital’s services instead of a frightening institutional disincentive. The wellness center must be conveniently located with ample parking and extended hours (see Checklist: Parking and Curb Ramps on page 138). Members must be comfortable and secure, but the design must go beyond meeting basic needs; it must motivate people to change. For example, a running track elevated with views of another activity area or designed in an unusual configuration offers a variety of visual stimuli (see Figure 8–2). Perhaps the track runs through the other exercise areas, providing a positive distraction for those involved in all the programs of the center. Lighting under the handrail on the track is a nice design detail. Hospital wellness centers must accommodate diversity and a wide range of abilities. It is a mistake to target youth exclusively when the market can be expanded to include older users as well. Wellness should be a lifetime commitment, and design should reflect the needs of the entire human lifespan. For example, equipment must be selected to meet a variety of needs and appeal to members of all ages. Low-speed treadmills and lowweight training machines should be offered. Both must feature user-friendly

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Figure 8-2 Track elevated over a basketball court provides visual stimulation. Courtesy of OWP&P Architects and Paul Schlismann Photography.

controls. Private areas for training can be provided for those who do not want to advertise their body profile. Just as hospitals profit from a wellness component, wellness centers also profit from offering services traditionally provided in hospitals. Healthcare services provide backup for the wellness program. For example, if a personal trainer recognizes an injury, a physical therapist can be consulted. If a weight-control program is unsuccessful, it can be adjusted by a dietitian. Sports injuries can be prevented by educational programs and treated immediately when they occur. Prevention can be enhanced by regular physical examinations as well as by proper diet and exercise.

DESIGN ELEMENTS As health services increase in wellness centers, beepers will replace overhead paging to reduce ambient noise levels and to allow members to work out while waiting for diagnosis or treatment. Most wellness centers offer telephones for member use, and provide wireless Internet access for member’s convenience.

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Fitness Area The design and color scheme throughout the facility should be determined early in the project so that it can be coordinated with everything from T-shirts to landscaping. This is called environmental branding, the approach to architecture and design that aligns a three-dimensional space with the brand positioning. It is a marketing tool that aims to express the brand’s essence throughout the facility and permeate through all marketing materials. Lighting in the fitness area should be primarily indirect to prevent contrast glare or a dazzle effect from exercise positions (see Checklist: Eliminating Glare on page 87). Windows should be placed to create a sense of openness, allowing in healing daylight. Windows provide views to the outside for members working out, but it also advertises the fitness activities within the center to those passing by (see Figure 8–3). Most activities should be clearly visible from the reception area as well, for monitoring as well as marketing. Viewing healthy users encourages participation. However, some users prefer a secluded workout area.

Figure 8-3 Windows encourage participation and provide enticing view from outside. Courtesy of Healthcare Environment Design.

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In planning the fitness area, provide a cushioned floor for training with free weights. Understanding the spatial and organizational needs for laying out fitness equipment, such as grouping machines that train similar muscle groups, are programming issues that need to be addressed early during the schematic phase of design. Provide multiple power sources for the machines, using flat wire under carpet tiles or a raised floor system. Some fitness equipment may require special outlets. The aerobic/fitness class area should be self-contained and insulated to prevent noise transmission to other tenant spaces above and below, as well as to adjacent spaces within the wellness center. Many flooring choices are available for aerobic areas, including wood flooring with foam backing, vinyl flooring with padding, rubber flooring, and carpet with appropriate backing. Another choice is to use antifatigue flooring tile. Mirrors are typically lined across the long wall where the class instructor is located on a raised platform and are useful to correct form while exercising.

EXPERT FOCUS Recommendations for Enhancing the Family Experience in Hospital-Based Wellness Centers LAURA BAUER, RID, LEED AP Project Designer, lauckgroup, Austin, Texas

American society has become obesogenic, characterized by environments that promote increased food intake, nonhealthful foods, and physical inactivity.1 How does a family’s attitude toward nutrition and exercise influence an individual’s level of health, beginning at childhood? Adult role models such as teachers, child-care givers, and parents set a leading example for children regarding awareness and approach to their own nutrition and wellness. If obese parents maintain poor eating and exercise habits, it is highly likely that their children will follow suit. Research shows that the parents do not even recognize that their overweight children are in fact overweight.2 Would family members be more likely to succeed with their individual doctor-recommended treatment plans if the entire family could be treated at the same wellness center simultaneously? If so, hospital-based wellness centers could be designed to provide a family experience that is both effective and convenient for parents and their children to accomplish health and wellness improvements. Designing a secure, dedicated area for children with small-sized equipment and a separate music system would allow children to be part of what may otherwise be an adult-only wellness center. The children’s area is not meant to be a container for day-care services or a playground, but instead it would be supplied with useful tools for fun (jump ropes, hula hoops, obstacle courses, and so on). At the same time it would offer structured fitness programs for varying physical developmental stages.

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EXPERT FOCUS Recommendations for Enhancing the Family Experience in Hospital-Based Wellness Centers (continued)

Additional recommendations for the design program include: 1. After-school treatment and/or fitness programs for children with transportation provided by schools or wellness center. Goal: Increase consistency of child participation at wellness center and provide transportation relief for working parents. 2. Sports/exercise programs for children during after-work/early evening hours. Goal: Increase consistency of adult participation at wellness center by providing “child care with a purpose” for working parents who visit the wellness center after hours for their own treatment and/or fitness programs. 3. Separate teen training area with exercise equipment and certified personal trainers. Goal: Educate teen guests to safely operate equipment, achieve health improvements, and build teamwork and awareness within their peer group. 4. Children’s library containing books, videos, and games for multiple age levels that function as learning tools for a healthy lifestyle. Goal: Create childhood awareness regarding eating smart, staying active, and the importance of taking accountability for one’s own health. 5. Physical therapy and rehabilitation programs for children, teens, and adults that welcome nonrecovering family members to observe and participate. Goal: Educate individuals to assist their recovering family member(s) during the healing process when at home. 6. Family classes that focus on various health subjects including nutrition, obesity, diabetes, and other diseases that may be present in the household within one or multiple family members. Goal: Infuse awareness and understanding within the family unit so that all individuals are: (1) accountable for their own wellness and can work as a team to achieve positive changes within their lifestyle, and (2) knowledgeable and able to care for disease-suffering family members when at home. 1. Centers for Disease Control, Overweight and Obesity, 2010, retrieved from on March 7, 2010, from www.cdc.gov/obesity/. 2. R. Young, K. Schwartz, J. Monsur, P. West, and A. Neale, Primary Care of Overweight Children: The Importance of Parent Weight and Attitudes about Overweight: A MetroNet Study. Journal of the American Board of Family Medicine 21(4) (2008): 361–363.

Adjacent to the fitness area, provide space for warm-up and stretching. Courts for tennis, racquetball, squash, volleyball, and basketball should also be considered (see Figure 8–4). In addition, consider a retail space for fitness clothing and supplies (see Figure 8–5). The fitness assessment area is considered the heart of the wellness center. Each member begins with an evaluation that leads to creation of an individual treatment program. If a physician has provided a prescription for

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Figure 8-4 Floor plan showing athletic courts. Courtesy of OWP&P Architects and Paul Schlismann Photography.

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Figure 8-5 Retail space. Courtesy of Ohlson Lavoie Corporation, Denver, CO. Photo: Brian Fritz

a wellness plan, it will be reviewed so that the fitness assessment considers special requirements for that member. Special equipment may be integrated into this area to evaluate cardiovascular fitness, pulmonary function, aerobic work tolerance, strength, and flexibility. It may also be necessary to take blood and urine samples and to assess body fat percentage.

Extended Services Wellness centers frequently lease space to health-care providers offering services to the entire community. Many wellness centers now offer cardiac rehabilitation with stress testing, sports medicine, occupational therapy, physical therapy, and industrial rehabilitation. Appropriate workspace and offices should be planned to accommodate these practitioners. A day spa is very compatible with the tenets of the wellness center, extending the

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revenue stream even further. A spa may offer massage therapy, herbal wraps, facials, sauna, and steam. Many wellness centers successfully incorporate a restaurant into the facility. The restaurant location should indicate clearly that it is open to all, not just the members of the center. Restaurant staff may offer heart-healthy cooking classes. A mobile cooktop can be wheeled into classrooms for this purpose, or a demonstration kitchen can be planned. Child day-care services may also be planned for use by nonmembers. Give special attention to acoustics to prevent noise transmission. Include an adjacent bathroom for children (see Chapter 10).

Locker Rooms and Wet Areas There is a lack of flexibility, almost a planned obsolescence, in the design of many wellness centers. This is especially true in wet areas. Without a plan for expansion, there is no way to adjust to changing user needs without incurring large expenses in the future. Movable walls can be specified in these areas, allowing modification to meet the needs of shifting gender populations. Movable therapy pools, showers, and lockers are other examples of flexible elements. Personal lockers are a real convenience to members. The locker room should provide some separation from wet and dry areas as well as proper humidity control. Private changing areas should also be provided; curtains are easier to use than doors, especially for those using mobility aids. Seating in the locker room is helpful for expectant mothers, older people, and wheelchair users who transfer to a bench to change clothes. Benches should be planned in several seat heights ranging from 11 inches for children to 19 inches for people in wheelchairs. It may be helpful to wall-mount a handrail (at 34–38 inches a.f.f.).7 next to one bench (see Checklist: Handrails on page 260). Hooks and shelves are also helpful. A full-length mirror that can be viewed from the bench is also useful to people of all heights and abilities. It should be installed no lower than 9 inches a.f.f. to prevent damage from wheelchair footrests.8 At a minimum, a 36-inch-wide accessible route should be planned through the locker room and wet area, including the lavatories, stalls, showers, and pools. The shower area is frequently planned between the locker room and the pool area (see Checklist: Showers on page 183). The public bathroom must be usable by people of all sizes, ages, and abilities (see toilet stalls and lavatories checklists on page 185).

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CHECKLIST Showers For more information, refer to the ADA Standards. • Provide a shower wheelchair. After one transfer from the wheelchair to the shower wheelchair, the user can roll into the shower, under the sink, and over a toilet without additional transfer. • A universal shower can be used by all members, including shower-wheelchair users and those on gurneys. It must be 30 by 60 inches minimum to comply with the ADA Standards. Grab bars should be installed on all sides (33–36 inches a.f.f.). • The shower floor should be sloped rather than curbed, because a curb could block wheels and become a tripping hazard. If the entire floor of the room cannot be sloped to a drain, a flexible curb is another solution. • A steep floor slope (exceeding 2 percent) makes it difficult to maneuver a shower wheelchair. • Water can also be contained by recessing instead of sloping the floor of a wheelin shower. Use a grating to raise the floor height to that of the bathroom. A grating and ramp can also be used to access an existing shower with a lip (see Checklist: Ramps on page 258). • A second shower with a seat should be provided for ambulatory users who need to sit and people in wheelchairs that can transfer to a seat. This shower must be small so wheelchair users can reach the grab bars for transfer. Shower controls should be mounted on the wall opposite the seat and offset to the shower entrance. • Specify a fold-up shower seat to clear the space for standing users. The seat should be slip-resistant, with small openings for good drainage. Make sure the corners are rounded. • Small transfer-in showers require a ½-inch curb to contain the water. During transfer to a shower seat, the front wheels of a wheelchair are placed over the curb to prevent the chair from sliding backward. • Shower stalls should have rounded corners inside and out for safety and ease of maintenance, and the floor should be slipresistant.

Transfer-in shower. Uniform Federal Accessibility Standards.

Continued

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CHECKLIST Showers (continued) Shower Sizes and Clearances, ADA Accessibility Guidelines (ADAAG). • Plan all showers with curtains, not doors. An open shower that requires neither curtains nor doors is easily accessible and helpful for people with allergies. Shower frames and curtains retain moisture and encourage mold growth; furthermore, plastic shower curtains may release irritants when heated. • Equip each shower with an adjustable handheld shower fixture. This system is ideal for wheelchair users. The fixture can be clipped to a bracket for standing users. • The valve should not catch the shower hose and should require only one hand to regulate water flow and set the desired temperature. An integral thermometer and surge control provides a safe flow of hot water. • The flexible hose should be at least 60 inches long, but some users may require a hose as long as 72 inches. • Choose a model with a water-volume control in the showerhead. • Specify a showerhead bar for vertical adjustment that does not obstruct the grab bars. • A shower shelf or caddy can prevent soap, shampoos, and accessories from slipping out of reach. Choose one in solid brass, plastic, or stainless steel to prevent corrosion and rust; make sure that it drains easily. • Plan multilevel soap dispensers. • For convenience, store towels in a cabinet close to the shower. • Consider planning a separate shower for children with controls at a height no greater than 36 inches and with the grab bars at 18 inches minimum to 27 inches a.f.f. maximum. • A sensor can be used to start the children’s shower automatically upon entering. The temperature can be preset to prevent burns. • Some lever controls prevent burns by maintaining temperature if the control is bumped by accident. This feature is also helpful to children just learning to use the controls. Another option is an integral thermometer, which allows the temperature to be preset.

For more information, refer to the ADA Standards. • The approaches to accessible toilets should alternate throughout the building, because some people are stronger on one side than the other. • Accessible stalls of minimum size must have toe clearance of 9 inches a.f.f. (12 inches for children). Larger stalls are preferable. Florida requires a minimum size of 68 by 68 inches.

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CHECKLIST Toilet Stalls • In larger stalls, a partition to the floor can provide a positive stop for a person using a mobility aid. • In an accessible stall, the door must swing out. Actually, this is a convenience on all stalls. • Stalls should be equipped with gravity-closing hinges and hardware that does not require tight grasping, pinching, or twisting. • A lavatory in the stall allows for additional privacy for cleanup. • A tissue dispenser should be at least 19 inches a.f.f. and yet low enough so that grab bars do not interfere with its use. It must be installed on the side wall 7 to 9 inches in front of the toilet. • The dispenser must permit continuous paper flow and be usable with one hand. Do not use a dispenser that requires users to reach into a hole to initiate paper flow or a dispenser with a sharp or serrated edge. • Consider two tissue dispensers for a constant supply, with one at a lower height for children (2 to 6 inches above the toilet seat). • The tissue dispenser should be recessed so it does not interfere with mobility aids.

CHECKLIST Lavatories For more information, refer to the ADA Standards. • Wall-mounted lavatories are easy to wheel under if properly installed. Deeper wall-mounted lavatories must be supported by extra bracing. • Water supply and drainpipes can be plumbed in a horizontally offset position to free knee space. Sharp or abrasive edges around or under the lavatory may injure a seated user. Insulate pipes under approachable lavatories or add a removable cover to prevent burns. Plastic pipe may not require insulation if the maximum hot water temperature does not exceed 120°F. • Thermostatic controls limit maximum temperature and prevent sudden changes. • The height of the lavatory is critical in accommodating the needs of people with varying ranges of motion. People in wheelchairs need a rim no higher than 34 inches with knee clearance of 29 inches at the front edge. This height is also usable by most standing adults and many children. Children in wheelchairs require a rim that is no higher than 30 inches and knee space of at least 24 inches. Continued

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CHECKLIST Lavatories (continued) • A clear floor space of 30 by 48 inches should be provided, extending under the lavatory a maximum of 19 inches. Children in wheelchairs require a clear floor space of at least 36 by 48 inches, extending under the lavatory a maximum of 14 inches. • For people with differences in vision, identify the edge of the lavatory area by contrasting with a color. Color-coded hot- and cold-water controls are also helpful. • A single-lever faucet can be easily controlled with one hand; spring-loaded faucets take more strength to operate. • Mount faucets and controls on the front apron of the counter or to the side of the lavatory to improve reach. • A universal faucet control is operated without use of hands. It senses any object underneath and flows at a safe, preset temperature. These valves can be programmed to open and close the flow at preset intervals, without the use of external controls. If a self-closing valve is used, the faucet should remain open for at least 10 seconds. • A temperature control prevents burns. Set the mix valve at a temperature of 115°F to start; do not exceed 120°F. • The corners of the vanity should be rounded if they extend into the room around the lavatory. • The bathroom mirror must be low enough to reflect the wheelchair user’s image. In most cases, it must be installed to the top of the splash. The bottom of a permanently installed mirror should be no higher than 40 inches (34 inches for children). A tilted mirror distorts the image but provides a fuller view than a flat mirror. • Wall-mounted paper towel and soap dispensers must project no more than 4 inches into the clear floor space. They must be mounted no higher than 36 inches for children. The preferred installation is on the surface of the counter.

CHECKLIST Toilets and Urinals For more information, refer to the ADA Standards. • Elongated toilets are easier than standard size to use when transferring or aligning with the shower wheelchair for toileting. • Use a toilet with a seat adjustable to wheelchair height for adults and children (11 to 19 inches). Most accessible toilets are too high to easily empty a leg bag into. The lip of the toilet needs to be below the level of the drainage tube since the leg must be elevated to this level to empty the bag.

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CHECKLIST Toilets and Urinals (continued) • A low toilet with a high seat leaves a gap between the two. For the bowel or bladder program, it may be necessary to reach into this gap. Specify a seat with an opening in the front. • Firmly attach a toilet seat with a wide bench for ease in transferring from a wheelchair. • The toilet seat must not be sprung to return to a lifted position, but it should remain up independently when raised. Men with hemiplegia or only one hand do not have a free hand to hold up the toilet seat while using the toilet. • The clearance below a wall-mounted toilet provides extra floor space for wheelchair footrests. • The flush valve lever should be on the wheelchair approach side. The toilet should be easy to flush, requiring no more than 5 lbf (pounds of force) for operation. A portable toilet flush lever extension may be needed. The universal design is a sensor for automatic flushing. • For people with differences in hearing, the noise created by water flow should be reduced. Consider low-pressure cisterns instead of high-pressure heads. Reduce ambient noise by specifying pipes with as large a cross-section as possible. • Accessible urinals must be specified with a maximum rim height of 17 inches a.f.f., but a floor-mounted urinal is more accessible to small boys and others who need a lower rim. • A clear floor space of 30 by 48 inches must be provided in front of each urinal. • A urinal in a stall is preferable for privacy in emptying a leg bag. In public urinals, the privacy shields must not extend past the front edge of the urinal into the clear floor space. • The accessible urinals should be wall-mounted a minimum of 14 inches from the wall.

Swimming and Aqua Therapy Pools The pool area should be designed to accommodate a range of activities, from lap lanes and resistance therapy to aqua therapy and classes. The image of the pool area could be that of a resort or spa environment. While it is advantageous for the member to have a view toward the outside of the pool area to the fitness area or exterior grounds, it is important that members receiving the benefits of therapy not feel exposed to those passing by.9 A trend in pool

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design is the zero-entry pool. In a designated area of the pool, there is a slope entry providing a safe “beach-like” entry into the water. This can be designed to meet the requirements for easy access for children, older people, and wheelchair users. When a zero-entry is not a viable solution, another option is a ramp into the swimming pool can meet the ADA requirements for safe entry (see Figures 8–6 and C-14). At a minimum, a 4-foot-wide route should be planned around the pool. It should not exceed a slope of 1 inch of rise per 10 inches of length. It should be 36 inches wide and have railings on each side, which can be used to guide a shower chair on entering and exiting. Both the ramp and the route should have a nonslip surface. Another option is a portable lifting device, which can be used in place of a ramp. A series of steps can also be used to access a pool or spa, with the highest step planned at wheelchair seat height (17–19 inches). After transferring to the top step, wheelchair users slide down from step to step. A hydrotherapy spa is an important addition to the wet area, but it presents acoustic challenges. The pump should be placed in an isolation closet and the spa location should be carefully planned to prevent noise transmission to other areas. Members appreciate the privacy of a gender-specific spa in each locker room.

Figure 8-6 Ramp into a pool. Courtesy of Healthcare Environment Design.

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COMPREHENSIVE SERVICES One example of hospital-based wellness programs is the Condell Medical Center’s Inner Spa. Located in the Women’s Center, the spa features soft lighting, soothing colors, and three water elements to welcome the visitor and/or patient (see Figure 8–7 and C-15). A full-service spa off the main lobby of the hospital was designed purposely to expand the public’s view of health care and healing (see Figure 8–8) and to forge a greater link with the community. In addition to traditional spa services such as massage, manicure, and pedicure, the Inner Spa offers cosmetic consultation to women who may suffer disfigurement from chemotherapy, surgery, or other medical condition. Patients can now consult about prosthetics or be fitted for a wig as part of a truly integrated health-care program. Surrounding the spa are the women’s diagnostic center, which has mammography and ultrasound; a day-care center; and obstetrics and gynecology physician offices. In close proximity to the spa is the Condell Café, providing a casual environment, much like a coffee shop and gift shop combined.

Figure 8-7 Waiting area welcomes guests with soft lighting and a neutral color palette. Condell Medical Center. Pratt Design Studio. Courtesy of Steinkamp Photography.

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Figure 8-8 Vanity for hospital-based spa. Condell Medical Center. Pratt Design Studio. Courtesy of Steinkamp Photography.

In conclusion, wellness centers are exploring the entire continuum of care, from illness to optimal health. Most provide information to the community in the form of health education programs. Wellness centers also encourage their members to apply this information to self-care, going beyond care of the body to encompass the mind and spirit as well. This holistic approach treats the person, not just the disease, using mild, natural methods whenever possible. Finally, the continuum leads to a high level of wellness that combines traditional and complementary medicine with a lifestyle approach. The result is optimal physical health, emotional serenity, and mental clarity. Today, most of the diseases we encounter are lifestyle diseases with influencing factors we can control. . . . The future is the extension of quality of life, dying as old as we can as young as possible. DES CUMMINGS, JR., CEO Florida Hospital Development

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Endnotes 1. K. Robinson, “Trends in Health Status and Health Care among Older Women,” Aging Trends, no. 7 (Hyattsville, MD: National Center for Health Statistics, 2007). 2. Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion: Diabetes—Successes and Opportunities for Population-Based Prevention and Control, 2009 (Atlanta, GA: CDC, 2009). 3. “Obesity in Children and Teens,” American Academy of Child and Adolescent Psychiatry, no. 79 (May 2008), retrieved February 22, 2010, from www.aacap. org/cs/root/facts_for_families/obesity_in_children_and_teens. 4. C. Corbin, G. Welk, and W. Corbin, Concepts of Physical Fitness: Active Lifestyles for Wellness, 13th ed. (Columbus, OH: McGraw-Hill Companies, 2005). 5. J. Gallup, Wellness Centers: A Guide for the Design Professional (New York: John Wiley & Sons, 1999). 6. J. Seymour, Humanizing Healthcare: Fitness/Wellness Centers as the Community Locus for Health Promotion, 2010, International Academy for Design and Health, retrieved February 22, 2010, from www.designandhealth.com/uploaded/documents/Publications/Papers/Thomas-Seymour-WCDH-2003.pdf. 7. U.S. Architectural and Transportation Barriers Compliance Board (Access Board), Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) 4.37.5, Washington, DC, 2002, retrieved February 3, 2010, from www.access-board.gov/adaag/ADAAG.pdf. 8. C. Leibrock, and J. Terry, Beautiful Universal Design (New York: John Wiley & Sons, 1999). 9. J. Gallup, Wellness Centers: A Guide for the Design Professional (New York: John Wiley & Sons, 1999).

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ippocrates stated that the art of medicine is incomplete without health-care settings, which he recognized as a factor in the healing process.1 Florence Nightingale theorized that the positive manipulation of the environment promotes healing.2 In 1929, Alvar Aalto provided sun balconies offering fresh air and sunlight for the treatment of tuberculosis.3 In recent years, great progress has been made in the design of health-care facilities driven by culture changes in health-care institutions. A shift toward: (1) patient-centered care, (2) sustainability, and (3) evidence-based design indicates an increasing demand for a holistic physical environment as a partner of care. One of the recognized leaders in patient-centered care is Planetree, an organization founded in 1978 to develop and promote models of care that focus on healing and nurturing the body, mind and spirit. Planetree advocates healing environments and access to information making patients active participants in their own care and well-being. Today, informed patients are maintaining decision-making authority and increasingly seeking a collaborative relationship with providers. They are becoming more responsible for their own health. A patient-centered care model focuses on the patient, family, and clinical staff experience. It is based on respect for patients, coordination of care, patient education, physical comfort, emotional support, and involvement with family and friends.4 The Planetree patient-centered model of care focuses on humanizing, personalizing and demystifying the health-care experience. Architecture is one of ten components of the Planetree patient-centered model of care, providing spatial organization and connection of patients, family, and staff to the building, gardens, and grounds around the facility. The physical environment

also supports the other components of the Planetree model of care: human interaction, food and nutrition, patient and family education, family involvement, spirituality, human touch, healing arts, complementary therapy, and healthy communities.5 The second element, sustainable design, includes the ability to optimize site potential, minimize nonrenewable energy consumption, use environmentally preferred products, protect and conserve water, enhance indoor environmental quality (IEQ), and optimize operational and maintenance practices.6 The Leadership in Energy and Environmental Design (LEED) green building certification system provides the framework for identifying and implementing green building design, construction, operations, and maintenance solutions.7 The LEED rating system for health care was developed specifically to meet the unique requirements of healthcare facility design. Projected outcomes point to decreased ecological harm and increased patient healing and staff satisfaction.8 However, the research on green building practices is very limited.9 As more health-care facilities pursue LEED certification, the demand for justification based on measurable outcomes will continue to grow, requiring evidence that LEED-certified buildings increase the return on investment, occupant health, and productivity while decreasing operating costs. The third element, evidence-based design (EBD), is defined as design decisions based on the best available information from credible research and evaluation of existing projects. An essential factor in the process is critical thinking by the design professional to synthesize the available evidence to fit the design problem.10 Though this shift toward the use of evidence to support the design of health-care environments has been emerging over

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the past 30 years, a growing body of research shows that design of the built environment contributes to key outcomes for both patients and health-care staff. Some of these outcomes include: (1) patient healing, (2) patient and staff safety, (3) reduced stress, (4) patient and family satisfaction, (5) staff effectiveness, (6) reduced staff turnover, and (7) reduced operating costs. Financial challenge is the top issue confronting hospitals. Hospitals have experienced a reduction in Medicaid and Medicare

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reimbursement, an increase in the cost of health-care services, and challenging healthcare reform. In a market where competition is keen and cost containment is beyond the understanding of mere mortals, hospitals are finding that quality care, efficiency, and safety are venues for improving the bottom line. We have come full circle, demonstrating that patient-centered care, environmental quality, and evidence to support design decisions offer value to both health-care systems and to the patients they serve.

Endnotes 1. J. Currie, The Fourth Factor: A Historical Perspective on Architecture and Medicine (New York: American Institute of Architects, 2007). 2. L. Selanders, Florence Nightingale: An Environmental  Adaptation Theory (Thousand Oaks, CA: Sage Publications, 1993). 3. Currie, The Fourth Factor. 4. S. Stone, “A Retrospective Evaluation of the Impact of the Planetree Patient-Centered Model of Care on Inpatient Quality Outcomes.” Health Environments Research & Design Journal 1:4 (2008): 55–69. 5. S. Frampton, L. Gilpin, P. Charmel, (eds.), Putting Patients First: Designing and Practicing PatientCentered Care (San Francisco: Jossey-Bass, 2003). 6. U. S. General Services Administration, Sustainable Design Program, retrieved March 2, 2010, from www.gsa.gov/sustainabledesign.

7. USGBC, What LEED Is. U. S. Green Building Council, retrieved March 2, 2010, from www. usgbc.org/DisplayPage.aspx?CMSPageID=1988. 8. Center for Health Design and Health Care without Harm, Designing the 21st Century Hospital: Environmental Leadership for Healthier Patients, Facilities and Communities (Concord, CA: Center for Health Design, 2006). 9. USGBC, Research Committee Position Statement: Funding for Research Advancing High-Performance Green Building, March 2007, retrieved March 2, 2010, from www.usgbc.org/ShowFile.aspx? DocumentID=2464. 10. K. Hamilton, “The Four Levels of Evidence-Based Practice” (electronic version), Healthcare Design 3 (2003): 18–26.

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ospitals know that if a woman is pleased with her birthing experience, she will return for her family’s future health-care needs. For this reason, birth centers are viewed as a marketing tool and are frequently designed as the showpiece of the hospital. Today’s woman is interested in a high-quality birthing experience. She is having fewer children, often waiting until her 30s or 40s to have her first child, perhaps her only child. She wants the event to be special. From the initial examinations to the actual labor and delivery, design detail can determine the quality of this unique experience.

INNOVATIONS IN BIRTH CENTERS The design of birth centers must take several key points into consideration: (1) the experience they want to provide for their patients; (2) the cost differential of varying configurations; and (3) the intangible cost of quality of care. In a labor, delivery, recovery room (LDR), mothers are transferred into a postpartum unit after the birth experience, where their infant may room in or be placed in the well-baby nursery. The labor, delivery, recovery, postpartum room (LDRP), mothers remain in the room throughout their stay, barring complications.

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In the LDRP, health-care services are delivered to the mother’s room, lessoning the risks associated with a patient transfer. Couplet care, which places an emphasis on the mother and baby being cared for together by the same care team, is based on the belief that babies should remain with their mothers in order to provide the postpartum environment to prepare mothers for going home. In an LDR, the mother and baby move out of the LDR room to a separate postpartum room. There is some discussion about the pros and cons regarding this choice. In fact, over the last decade, some hospitals with mother-baby units designed for LDRP have changed to LDR units with separate postpartum care since a birthing bed may be uncomfortable for the duration of a new mother’s stay. In addition, noise levels, monitoring, and nursing are all reduced in the postpartum unit. Another concern for high census units is how to move the mothers through their stay and have beds open for new arrivals in labor. Some hospitals have both LDR and LDRP units. In one such hospital, patients can request to move to the postpartum unit instead of staying in the LDRP. The beds are more comfortable, Dad gets his own bed, the unit is quiet, and the family has downtime to be together. Although it is typical for the baby to room in with the new parents, the wellbaby nursery provides respite and, in some cases, round-the-clock care for a new infant with complications. Temporary nursery care is appreciated if the mother does not feel well or if she requires a sedative. She may also choose to place the infant in the nursery while she is bathing or if she is having difficulty sleeping. The St. David’s Women’s Center of Texas is now the largest comprehensive women’s center in Central Texas (see Figure 9–1). What started as a

Figure 9-1 St. David’s Women’s Center of Texas exterior. Earl Swensson Associates, Inc. Courtesy of James F. Wilson.

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simple addition to existing women’s services grew into a freestanding facility designed and dedicated entirely to the health and wellness of women. Commitment from physicians’ groups, in addition to growth and volume projections, showed that such a facility would be the best approach. While capacity has grown, the impact to the environment has been minimal through effective and conscientious design and engineering. This patient- and family-centered environment respects privacy and dignity. The physicians’ offices, labor and delivery suites, women’s diagnostics, and registration functions are integrated into the final form of the building. The three-story, light-filled atrium lobby is welcoming, featuring a unique spiral stair that encircles contemporary mobile art (see Figures 9–2

Figure 9-2 Three-story atrium lobby for St. David’s Women’s Center of Texas. Earl Swensson Associates, Inc. Courtesy of James F. Wilson.

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and C-16). The stair connects to family waiting areas. A combination of carpet and tile in these areas helps buffer sound. Moveable furniture in flexible seating groupings is used in the quiet waiting space, which provides privacy for families. Access to nature is provided with a heavily landscaped outdoor space that includes a water feature—offering yet another option for family respite. Intuitive way finding and appropriate signage throughout help lessen apprehension for both patients and families. Diagnostics are located on the first level, physician groups’ offices occupy the second, and labor and delivery are on the third level. LDRP private patient rooms on the third level are all zoned with patient, family, and staff spaces. Large windows in every room serve as positive distractions and provide access to natural light. Computers in all the postpartum rooms and computer carts on wheels allow inroom charting. Other efficiencies include decentralized clinical support space and shared equipment storage closets between every two patient rooms.

THE BIRTH ROOM In hospitals and standalone birth centers, the mother’s room should be designed to treat the birth as a gratifying experience. Maternal choices may include walking, sitting, or even soaking in a tub to relieve discomfort. The mother can choose her own food or allow her family to provide comfort and support by preparing a meal for her in a kitchen available for family use (see kitchen checklists on pages 101 and 102). Prentice Women’s Replacement Hospital was design by CannonDesign for Northwestern Memorial Hospital as an opportunity to respond to the expressed needs and preferences of women, both for themselves and for their family members. The hospital supports patients and caregivers alike, enabling a comprehensive approach to health care for women through all stages of their lives. The Labor and Delivery unit has private rooms designed to allow mothers to recover after birth and to get acquainted with their newborns. High-tech equipment and medical gases are stored out of sight, concealed in cabinets or a storage closet. The headwall provides easy access to equipment that the nurse may need throughout the birthing process. A hand-washing sink should be available in the room, planned for hands-free operation by staff. Lighting should be soft and indirect. Medical lighting must be available when needed, including a surgical light recessed

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in the ceiling over the bed. Other details in this room include a refrigerator for use by the mother and her visitors, flat screen TV with a DVD player, stereo system, and reclining chair or sleep sofa, patient chair, and visitor seating.

EXPERT FOCUS Summary of Evidence-Based Design Meets Evidence-Based Medicine: The Sound Sleep Study—Validating Acoustic Guidelines for Healthcare Facilities JO SOLET, PH.D, ORFEU BUXTON, PH.D., JEFFREY ELLENBOGEN, M.D., WEI WANG, PH.D., AND ANDY CARBALLIERA, B.M.1 Healthcare quality surveys report patient sleep disruption from noise as a very common and serious complaint. Disrupted and/or limited sleep has been demonstrated to have adverse impacts on several important health measures and outcomes, including blood pressure, weight gain, heart disease, pain, stress levels, and inflammation. However, no quantification of the relationship of common hospital sounds to patient arousal has been available to guide policy, design and technical innovation. In this study, twelve sleeping fully monitored healthy adult human subjects were exposed to a series of 14 hospital sounds, including voices, derived from the recording of an inpatient medical-surgical unit. The sounds were delivered in rising decibel level steps during all stages of sleep at a Harvard Medical School affiliated sleep laboratory. The research steps of this project included the following: (1) record real hospital sounds to develop a “virtual hospital” soundscape; (2) expose subjects, during all sleep stages, to soundscape components; (3) quantify specific physiological and cognitive responses; (4) demonstrate sleep arousal probability thresholds; and (5) organize outcome data to inform the Acoustic Guidelines. The selection, screening, and physiologic measurement of sleep disrupted participants in this study required the following: • Adult human subjects who had no medical or psychological problems, including sleep and hearing disorders. • Robust methodology for presenting adequate numbers of scientifically valid reproducible sound stimulus exposures to subjects during two full nights of sleep monitoring. • Analysis of all subject arousals attributable to sound stimulus exposures controlling for depth of sleep at stimulus presentation and loudness of sound (with repeated measures for statistical precision).

Key Findings and Recommendations The combined responses of all sleeping subjects are reported as sleep-stage-specific arousal probability curves. The curves demonstrate the percent of those subjects experiencing lightened sleep or full arousal for each of 14 sounds (stimuli) at stepwise decibel levels from 40 to 70 dB(A). Phone and intravenous infusion pump alarms that are intentionally designed to be alerting were effective in evoking the highest arousal probabilities. Continued

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EXPERT FOCUS Summary of Evidence-Based Design Meets Evidence-Based Medicine: The Sound Sleep Study—Validating Acoustic Guidelines for Healthcare Facilities (continued) Recommendations • Answer IV alarms promptly and lower background sound levels so important alarm signals can be easily discerned. • Reduce telephone ring tone volume to prevent transmission beyond the patient rooms. • Set telephones to stop after a specific number of rings. Staff conversations (charted as good c, bad c—related to prognosis conveyed), as well as voice paging, were also shown to be highly alerting. The threshold curves for voice stimuli are consistent with the arousal recollections reported by our subjects and documented as troublesome in health-care quality surveys. Voice level exposures can be modified behaviorally as well as through design and construction solutions. Recommendations • Materials and surfaces can be chosen to limit sound transmission from nurses’ stations. • Special consulting spaces can be allocated for nurses for whom voice-based information can be transferred away from open hall areas, yet not far from nursing stations. • Protocols such as dimming hall lights at night as a “quiet cue” can be incorporated as part of behavioral protocols to limit sleep disruption by staff voices. With regard to other stimuli, those with shifting contours (towel dispensers, door close, toilet flush, and ice machine) tended to be more arousing than those with continuous contours. Recommendations • Ice machines should be architecturally isolated from patient areas or dramatically reengineered. • Quieter or low-tech alternatives for automatic hand towel dispensers (often described as disruptive by patients) should be substituted. • Proper door hardware will limit latch noises; door gasket selection will better protect patients from hall and nurses’ station noise, as well as blocking transfer out of noise generated within that patient room. • Policy regarding keeping patient doors open should be reexamined. Other options should be considered, including systems-level solutions such as telemetry to a common station and assignment of staff to specific patients, allowing them to be individually alerted to patient needs.

Conclusion Design and construction mandates related to acoustics can be expected to enhance performance through more accurate communication, increased speech privacy and HIPAA compliance, lowered staff stress levels, decreased medical errors, and limited patient sleep disruption. Together these should produce better clinical outcomes, reduce staff turnover rates, and provide advantages in the competitive marketplace, all of which carry positive cost implications. 1. J. M. Solet, O. M. Buxton, J. M. Ellenbogen, W. Wang, and A. Carballeira, Evidence-Based Design Meets Evidence-Based Medicine: The Sound Sleep Study (Concord, CA: Center for Health Design, http://healthdesign.org/, 2010). © Copyright 2010 Center for Health Design; right to use granted by permission of CHD.

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CHECKLIST Flooring Microbial Growth Sheet vinyl flooring or carpet tile with impermeable backing prevents leakage from spills and protects the subfloor better than vinyl composition tiles (see Figure 9–3).

Figure 9-3 Sheet vinyl flooring. Courtesy of Polyflor XL 2000, distributed in the U.S. by Bonar Floors. Manufactured in the U.K. by James Halsted, Ltd.

Continued

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CHECKLIST Flooring (continued) Nonwax sheet vinyl flooring is a good choice for areas that may require frequent cleaning; the products are attractive and the cost to maintain the flooring presents a saving over waxed floors for cost of material and labor, however life-cycle cost analysis should include refinishing or replacing over time

Design Intervention For people with allergies, low-VOC adhesives and leveling compounds should be specified. Avoid high-contrast patterns in floor coverings, which can make small objects on the surface difficult to locate, especially for people with low vision. Contrast the floor color with the wall color to highlight the edges of the room. Also, contrast the floor with the furniture to prevent collisions and accidents when sitting. Ceramic tile, impregnated wood, rubber, and solid vinyl floor coverings (with nonskid polish) are easily used with carts, gurneys, and wheelchairs. Deep joints in a width greater than 3/4 inch may hold the wheel of a wheelchair, gurney, cart, or stroller. Protruding joints may produce a washboard effect, which can cause extreme discomfort, pain, or spasticity for the wheelchair or gurney user.

Appearance Floors with a high percentage of vinyl resin are the most resistant to stains. Rubber and solid vinyl floors are the most resilient and dent resistant. Self-shining synthetics eventually need touch-up and should not be used in hightraffic areas. Solid vinyl floors or floors with a large proportion of vinyl resins are the best choice for abrasion resistance in such areas. Solid-colored vinyl and inlaid patterns are more resistant to abrasion than vinyl prints. Solid colors appear soiled more quickly than do patterned floors. Soiling is also exaggerated by both very light and dark colors. Mid-range to darker values helpto hide marks left by wheelchairs, but dark floors without a pattern show dust and footprints. Dark colors also absorb light, a consideration for clients with vision differences who require increased lighting. Cushioned floors can be permanently dented by braces, canes, high heels, and other sharp objects, but they do reduce such high-frequency noises as footsteps. Durability is limited in high-traffic areas.

Slip Resistance In bathrooms and other potentially slippery areas, specify sheet vinyl impregnated with corundum chips. The seams can be chemically or heat welded to prevent leakage. This surface is easier to maintain than some other nonslip floors.

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CHECKLIST Flooring (continued) Self-shining synthetics may be too slick for many people. Rubber and nonwax vinyl floors provide better traction. A rubber floor polished with a water emulsion provides better traction for wheelchairs than does a smooth quarry tile. A rubber floor in the bathroom is a good choice for slip resistance. Textured wood floors offer surprisingly good traction. Avoid wood floors with shiny polyurethane finishes, which offer limited traction and produce reflected glare. They are especially difficult for people in power wheelchairs. Textured quarry tile and ceramic mosaic tile, especially in small sizes with many joints, offer better traction (and less glare) than do shiny ceramic tiles. However, joints are porous and will require systematic sealant to mitigate microbial contamination. When greatest traction is needed, select a tile with an abrasive face, such as silicon carbide, carborundum, or grit. A slightly raised pattern reduces slipping, but cobblestones and uneven surfaces may impede rolling traffic. Irregular paving and flooring materials look as if they provide good traction, but they may cause tripping, especially for users of mobility aides. According to ADAAG, nonskid surface must have a friction coefficient no less than 0.6 (0.8 for ramps), whether wet or dry. A rubber floor often exceeds this criterion and is a good selection, especially in a design with a slightly raised disk or strip. Rubber floors may also lightly cushion falls. Rubber flooring is resistant to wear, slippage, abrasion, cigarette burns, and most oils, acids, and alkalis. It shows fewer scuff marks than does solid vinyl, but rubber surfaces are not recommended for commercial kitchens, operating rooms, or spaces subject to heavy rolling loads and grease stains. Patterned vinyl can be substituted because it resists grease and oil and does not easily show scuff marks. Hard surfaces must be slip resistant or treated with a nonskid wax. Test slipping with a crutch angled at approximately 70 degrees from the horizontal.

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CHILDREN’S HOSPITALS

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oday, children’s hospitals are focused on providing care and research to address social and medical issues faced by our youngest constituents. Children’s hospitals provide specialized care for infants, children, and adolescents, with most facilities offering a wide variety of pediatric specialists to care for all types of health-care issues. Care is designed for kids and their families, and kids are not treated as “little adults.” When a child is hospitalized, the entire family becomes the patient. Many children’s hospitals today provide round-the-clock access for parents and family with private patient rooms for rooming in. The expectation is that the physical environment supports and empowers patients and families in the active participation of their care. Family participation is a key component of patient-centered care and directly relates to patient/family satisfaction. The child may be much more comfortable with a parent as a primary caregiver. In the patient-centered care nursing model, the parents are part of the caregiving team. Children and families should be empowered with choice. Design can empower, providing efficacy, comfort, positive distractions, and a sense of belonging. Efficacy is exemplified by access to medical records and information through libraries or the Internet. Comfort can be offered by a chair or sofa that opens into a

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Figure 10-1 Alligator play sculpture. Courtesy of Zimmer Gunsul Frasco © Eckert & Eckert.

bed for parents who wish to stay with the patient. Some hospitals provide overnight guest suites. Positive distractions are exemplified by destinations where parents and children can get away (Figure 10–1): a garden, a chapel, children’s art gallery, and a family lounge. The remainder of this chapter is dedicated to empowering children and their families via design. Perhaps the most important goal is efficacy, keeping children and their families effective in the hospital environment.

EFFICACY Children and their families seek independence, competence, and control. For a child in a health-care facility, competence means being able to choose to play, to continue to go to school while in the hospital, and to care for themselves. At Shands Children’s Hospital (a hospital within a hospital), children from all over Florida and the United States are diagnosed and treated for complex medical conditions. Juxtaposed against fighting life-threatening disease is the Child Life Program, with child development specialists who help children and their families cope with the stress and anxiety of hospitalization.

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These professionals help to normalize the hospital environment to help make the experience more positive. They also provide support for children preparing to undergo tests and procedures and allow patient the opportunities to experience control and self-expression through therapeutic play. Finally they instigate “medical play” to help children understand their condition by allowing children to rehearse, role play, and establish coping skills. This hospital has its own social network. Children who have ongoing treatments coordinate with their hospital friends to return to the hospital at the same time for their next round of treatment. This builds relationships that may last through their lifetime. The hospital also provides technology to help them balance their hospital social group, school friends, and class assignments. Another program provides artists and performers to encourage patients and their families to engage in arts and craft activities, musical performances, theater performances, and special occasion meals. These activities are designed to foster a sense of community among families experiencing similar challenges. The program also extends the Shands community into the University of Florida and Gainesville communities. Children and their families need to be effective in their environment. They want to be able to see over desks, drink from water fountains, open doors, and use the bathroom with or without a wheelchair (Figure 10–2)

Figure 10-2 Family toilet room. Courtesy of Evan Terry Associates, P.C.

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(see accessibility checklists on pages 210 and 212). Illness can restrict movement, yet children have a need for movement without assistance. Treatment areas should be planned so children can walk or wheel to them on their own, but young patients are frequently disabled by forgotten design detail (see Checklist: Accessible Routes for Children on page 210). The route requires a second set of signage to meet the needs of children and their parents. In elevators, Braille and raised lettering must be mounted on both jambs at 48 inches a.f.f., below the 60-inch cues required by the ADA. The elevator call button should be installed at 3 feet a.f.f.; redundant elevator controls should also be specified inside the cab at or below this height.

CHECKLIST Accessible Routes for Children For more information, refer to the ADA Standards. • Maintain a clear width of 44 inches on the accessible route (instead of the 36 inches required for adults). Children require more maneuvering space. • Objects should not protrude more than 4 inches on the route. Protruding objects as low as 12 inches a.f.f. could be a hazard to a blind child. • Clear floor space at controls along the route should be increased to 36 by 48 inches. For example, this larger clear floor space must be provided at elevator call buttons, drinking fountains, and telephones. Each control must be within reach. Clear floor space should extend no more than 14 inches under objects. • Door levers should be mounted 30 to 34 inches a.f.f. • Signs should be centered no higher than 48 inches a.f.f. • Eliminate all ramps on the accessible route. The maximum slope of an accessible route for children is 1:20. Ramps are not required at this slope. • A second set of handrails at stairs should be mounted 20 to 28 inches a.f.f. It is also recommended that the vertical clearance between handrails be at least 9 inches in order to reduce the risk of entrapment. Some health-care standards are more stringent than ADA. • The diameter of the handrail should not exceed 1¼ inch. • Drinking fountains and telephones cantilevered from walls or posts must provide knee clearance (24-inch minimum) and toe clearance (12-inch minimum) below the unit for a forward approach. The knee space should extend 14 inches under the fountain or phone. The spout on drinking fountains must be no higher than 30 inches a.f.f.

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Treatment rooms should provide seating at a variety of seat heights ranging from 11 to 19 inches for children. A full-length mirror should be provided in the dressing space, installed no lower than 12 inches a.f.f. (to protect it from wheelchair footrests); it should be viewable from the seat or bench. A grab bar adjacent to the bench is helpful for wheelchair users and for those who have difficulty bending and stooping (see Checklist: Grab Bars on page 95). Heights vary from 18 to 27 inches a.f.f. depending on the ages of the children served. A zigzag grab bar may be the best solution. All public spaces in the hospital must be planned to empower children and their families. Restaurants must provide accessible seating and lowered service counters. Tray slides at 34 inches a.f.f. are helpful to adults using wheelchairs, adults of shorter stature, and some children, but most children in wheelchairs need a section lowered to 30 inches above the finished floor. Tableware, condiment areas, self-service shelves, and dispensing devices must be approachable and within reach. Many hospitals provide a family reference library. Books for children should be stored 20 to 36 inches a.f.f. The library should include 44-inchwide access aisles, lowered checkout counters, and accessible fixed seating, tables, and study carrels (26 to 30 inches a.f.f.). Most important, libraries must provide children and their families’ access to the Internet, email, scanners, and copiers. Access to digital libraries expands the library to sources providing information much needed by parents and families (see Checklist: Computer Stations for All Abilities on page 150). Windows should be planned low enough for children to see out but high enough to prevent damage from wheelchair footrests (12 inches a.f.f.). Casement windows with controls on the bottom are easier for children to reach. Sliding, hopper, and awning windows can also be reached. Doublehung windows can drop unexpectedly and are difficult for everyone to open (see Checklist: Windows on page 59). Hooks, hangers, and shelves should be redundantly planned at a variety of reach ranges. Also consider installing pegs or wall-mounted racks between the counters and cabinets for storage within reach of children in wheelchairs. An adjustable-height counter or table can accommodate a variety of ages and abilities. In the patient bathroom, accessible detail becomes critical for use. The height of the tub should match the height of the wheelchair seat. The height that serves most adults and children is 17 inches a.f.f., but the needs may vary from 11 inches for children to 19 inches for adults. A handheld shower helps all kids, not just those in wheelchairs. It also makes it easier for a parent to rinse a child’s hair without getting shampoo in their eyes. Children can also be bathed in a child seat or on a bathing table that fits in the tub.

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COMFORT AND SAFETY Children are visually more comfortable with reduced scale. The children’s hospital should be scaled to support the child—smaller, quieter, and more manageable. Monumental doors should be eliminated. It is most important to keep the scale manageable in transition spaces like entries, porches, and elevator lobbies. A child may need more tactile, auditory, and visual stimulation than an adult. Provide an environment that encourages fantasy, a space that gives children permission to act out their fears and relieve their anxiety. Carpet tile provides a tactile, quiet, and comfortable surface for play. Carpet tiles are a viable solution for health-care environments since, in the event of contamination with blood or other organic substances, the tiles can be removed, discarded, and replaced.1 Over the years, studies focusing on material contribution to the indoor environmental quality have shown that, while carpet acts as a sink, there is no evidence to suggest that carpet has been a direct source of nosocomial infections.2 In one study, the attributes of soft flooring increased satisfaction of patients and reduced risk of injury from falls and indicated that, with appropriate maintenance, carpet tiles have a positive impact on the unit design without creating health hazards that one usually assumes with contamination.3

CHECKLIST Accessible Bathrooms for Children For more information, refer to the ADA Standards • Maximum and minimum mounting reach heights should be specified for three age ranges: 36 inches (high) and 20 inches (low) for ages 2 through 4, 40 inches (high) and 18 inches (low) for ages 5 through 8, and 44 inches (high) and 16 inches (low) for ages 9 through 12. These ranges are the same for forward and side reaches. Door levers should be mounted 30 to 34 inches a.f.f. Signs should be centered no higher than 48 inches a.f.f. • The centerline of the water closet must be 12 to 18 inches from the side wall or partition. A centerline placement of 12 inches is recommended for children ages 3 and 4, 15 inches for children ages 5 through 8, and 15 to 18 inches for children ages 9 through 12. • The height of water closets must be 11 to 17 inches, measured to the top of the toilet seat. A seat height of 12 inches is recommended for ages 3 and 4, 12 to 15 inches for ages 5 through 8, and 15 to 17 inches for ages 9 through 12. • Urinal rim height should be a maximum of 14 inches a.f.f. Privacy shields must not extend past the front edge of the urinal.

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CHECKLIST Accessible Bathrooms for Children (continued) • Mount grab bars 18 to 27 inches a.f.f. instead of 33 to 36 inches, as is specified for adults. The rear toilet grab bar is required to be at least 36 inches long. A grab bar height between 18 to 20 inches is recommended for ages 3 and 4, 20 to 25 inches for ages 5 through 8, and 25 to 27 inches for ages 9 through 12. • The maximum diameter of the grab bar must be 1¼ inches. • The flush valve must be mounted on the wide side of the toilet. The flush valve should be mounted no higher than 36 inches at water closets serving children ages 2 through 4, 40 inches at those serving children ages 5 through 8, and 44 inches at those serving children ages 9 through 12. • Toilet paper dispensers should be mounted 14 to 19 inches a.f.f., measured to the dispenser centerline. A dispenser height of 14 inches is appropriate for ages 3 and 4, 14 to 17 inches for ages 5 through 8, and 17 to 19 inches for ages 9 through 12. • With a wall-mounted toilet, plan a minimum depth for standard stalls of 59 inches. • In standard stalls, the front partition and at least one side partition should be at least 12 inches above the floor to provide toe clearance. • Provide a rim clearance of 27 inches a.f.f. minimum and knee clearance of 24 inches a.f.f. minimum under lavatories, provided that the rim or counter surface is no higher than 30 inches. Lavatories used primarily by children ages 5 and younger need not provide these clearances if space for a parallel approach is provided. • Provide clear floor space of 48 by 36 inches extending no more than 14 inches under lavatories. • Sink depth should not exceed 5½ inches. • Faucets should be located within 14 inches of the front of the bowl. • The bottom edge of the mirror should be no higher than 34 inches a.f.f. • Knee space at least 24 inches high, 30 inches wide, and 14 inches deep must be provided under accessible tables and counters. • Plan a surface height of 26 to 30 inches a.f.f. on vanities, tables, and counters.

EXPERT FOCUS Unique Challenges for Children’s Hospitals DAK KOPEC, PH.D. MS.ARCH., IDEC, CHES, CMI Associate Professor, Newschool of Architecture and Design, San Diego, CA

Children pose unique challenges to architects and designers because they interpret and respond to the built and natural environment in ways that are often very different from adult responses. These interpretations and responses are often related to their physical and cognitive development. An unfortunate reality is that there are an assortment of conditions that negatively affect the health and well-being of children, many of which command hospitalization. Continued

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EXPERT FOCUS Unique Challenges for Children’s Hospitals (continued) Children not only experience the health-care environment differently than adults, but their developing bodies may respond to pharmacological therapies in atypical ways. For example, children often respond to tall facades and large open atriums with fear, whereas adults often associate such features with quality.1 Likewise, because children up to age two lack adult values of stomach acidity, pharmaceuticals such penicillin and ampicillin are absorbed into the child’s body more quickly than an adult’s. These are just two examples that demonstrate why childr en cannot be regarded as little adults; they are a unique population with distinctive needs. When children are removed from their homes, they often experience high levels of stress. Children and teenagers are especially vulnerable to the negative effects of stress partly because they interpret it differently than adults and they have not yet developed successful coping mechanisms to aid them when dealing with a stressful event. Studies have shown that when a child is accompanied by the continuous presence of one or more family members in the health-care environment, he or she will experience a reduction in stress.2 Likewise, other research indicates that the sound of mother’s voice helps to foster feelings of safety and security within the child.3 Some research suggests that children are more at ease when they are placed in private rooms, allowing certain medical procedures (usually those that take a significant amount of time, such as dialysis) to be performed in their rooms.4 Experiencing pain and discomfort while in familiar surroundings and with the support of a family member has been shown to decrease a child’s overall level of anxiety. Also, because children have an affinity for their own language decreasing the use of a language foreign to the child can help reduce the child’s overall level of stress.5 Because of the profound effects that a health-care facility can have on a child, hospital administrators have started to recognize the need for family-centered health care. As part of this approach, proper accommodations must be made to allow a family member to spend the night with the child in his or her hospital room. These rooms should also accommodate the necessary medical equipment required for the child. However, there should be storage provisions so that equipment can be concealed, thus preventing associations between the illness, procedures, and the environment from remaining at the forefront of thought for the child and his or her family members. 1. D. Kopec, Environmental Psychology for Design (New York: Fairchild Books, 2006). 2. S. K. Dudley and J. M. Carr, Vigilance: The Experience of Parents Staying at the Bedside of Hospitalized Children. Journal of Pediatric Nursing 19:4 (2004): 267–275. 3. E. B. Goldstein, Sensory Perception, 6th ed. (Florence, KY: Wadsworth Publishing Company, 2001). 4. D. Fanurik, M. L. Schmitz, J. L. Koh, G. A. Martin, M. Wood, L. Sturgeon, and N. Long, Hospital Room or Treatment Room: Where Should Inpatient Pediatric Procedures Be Performed? Children’s Health Care 29:2 (2000) 103–111. 5. Goldstein, Sensory Perception.

HVAC also plays an important role in the comfort of children and their families. Children, wheelchair users, and adults of shorter stature are relegated to the lower, colder part of the space and may require higher ambient temperature levels. Individual HVAC controls are the solution. These should be installed at a reachable height (44 inches a.f.f. for older children). When children are very ill, they need to be in more subdued surroundings.4 Carpeting and acoustical tile can be used to reduce ambient noise

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levels (see Validating Acoustic Guidelines on page 201). A quiet telephone at the bedside with a light instead of a ring is a detail helpful for children with hearing impairments as well. In the bathroom, select a faucet control that prevents sudden temperature changes when bumped by accident. This feature is also helpful to children just learning to use the controls. Another option is an integral thermometer, which allows the temperature to be preset. Both systems should include a pressure-balancing feature that prevents surges of hot and cold water. As an alternative, a sensor could be used to start the shower automatically when children enter. The temperature can be preset to prevent burns.

A SENSE OF BELONGING Family-centered design supports a care model that understands the value of the family in the care of the patient. Children are apprehensive when they come to the hospital. So much is unknown or not understood; they don’t feel like they really belong. In an attempt to create a personal space that is familiar, many children actually bring more belongings to the hospital than the average adult patient and need more storage space than adults. They also need a safe place to secure personal possessions. A lockable drawer should be planned in the patient room. A deep windowsill can be used to display toys. Open shelving and labeled bins may encourage kids to put things away. Children and their families need a way to personalize their space. Plan a large bulletin board with magnets that can be used to display cards. White boards allow children to draw decorations for their own room. Digital media can be used to display selected artwork from a host of images like those available at ArtThread’s online gallery. Dell Children’s Medical Center of Central Texas (DCMCCT) has been heralded as the first hospital in the world to receive LEED Platinum Certification, realizing their goal to build a hospital that supports the health of children, native wildlife, and the local economy (see Figure 10–3).5 In the face of emergent issues such as “pay for performance” (the end of reimbursement for treating medical errors or harmful incidents), DCMCCT is committed to providing therapeutic environments that contribute to positive outcomes for patients and staff. The new hospital was designed to minimize environmental stressors through the selection of appropriate lighting and good indoor air quality. Careful consideration of material choices supports sustainable design practice and indoor environmental quality (see Figure 10–4).

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Figure 10-3 Main entry and iconic tower of Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Courtesy of Marc Swendner, photographer and Seton Family of Hospitals.

Figure 10-4 Material selection for sustainable design included indigenous materials providing context. Karlsberger Architects. Courtesy of Marc Swendner, photographer and Seton Family of Hospitals.

Children’s Hospitals

Patients are given control over their environment. Clear way finding throughout the facility is intended to minimize stress and empower patients and their visitors to take ownership of the facility. Choices of lighting, media, and artwork encourage a sense of control; the hospital offers menu based food service giving patients and their families control and choices for primary meals and snacks. Private patient rooms are generously sized and designed with features to promote family-centered care (see Figure 10–5). They are furnished with a daybed, storage, comfortable seating, and a desk with Internet access. Families can use the Internet to pay bills, schedule appointments, and build websites to communicate with friends and families. Each room also has a flat-screen television with DVD player. Infrastructure is in place to add movie rental, games, and education software in the future At the unit level, a waiting room for families provides a place to spend time while patients are sleeping or receiving treatments. Each set of eight rooms in a pod have a nursing station just outside their doors providing visual access and close proximity for nurses to provide care (see Figure 10–6). Each patient floor has a family resource center with online and printed materials for up-tothe-minute information on a wide range of medical conditions and treatments. These rooms are staffed to provide personal consultation when needed.

Figure 10-5 Private patient room accommodates families and supports participation in care. Karlsberger Architects. Photograph: John Durant.

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Figure 10-6 Nursing stations located within pods of eight patient rooms. Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Photograph: John Durant.

POSITIVE DISTRACTION DCMCCT is filled with positive distractions for patients and staff alike. From the moment you walk in the door, interactive artwork creates a sense of wonder and excitement throughout the facility (see Figure C-17). The art was chosen for healing rather than simple aesthetics. The hospital has no fewer than seven gardens, with visual access through glass walls in the corridors and other public places (see Figures 10–7 and C-18). Each garden is accessible for patients and their families and friends as well as staff. One garden is a three-acre, multilevel healing garden complete with a labyrinth, human sundial, and reflecting pond and bridge. The gardens and courtyards throughout the facility represent each of the seven eco-systems corresponding to a distinct area of the Central Texas Region that Dell Children’s hospital serves. When designing for children, the creative juices start flowing and before you know it you are working with a host of artists and technology geeks planning how patients and visitors are going to experience the physical environment. Maybe it is a mapped constellation on the ceiling with little telescopes along the railings (see Figure 10–8). Perhaps you can build an aquarium into the front of the reception counter or add a fountain with foot-activated pads to turn on jets of water (see Figure 10–9). Playrooms provide a place to escape from treatment and the isolation of the patient room. In addition to delighting the young of any age, positive distraction also provides opportunities for respite—walking the labyrinth or spending time in a butterfly garden (see Figure C-19).

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Figure 10-7 A courtyard garden to visit also provides visual access from indoors. Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Photograph: John Durant.

Figure 10-8 Constellation on the ceiling. Courtesy of NBBJ.

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Figure 10-9 Fountain controlled by children. Courtesy of Shepley Bulfinch Richardson and Abbott.

Children’s art is effective in creating a whimsical, distracting environment. Art can be transferred to ceramic tile or recreated in stained-glass windows. Neutral-colored walls maximize the visual impact of the art and provide a background for personalization in the patient rooms.

EXPERT FOCUS Positive Distractions in Pediatric Healthcare Environments SARAJANE L. EISEN, PH.D. Texas Christian University

Children in hospitals face many psychological challenges: restriction of freedom, strangeness of surroundings, loss of trust, fear of painful procedures, feelings of abandonment by parents—all in unfamiliar setting. Limited cognitive development may limit the array of internal coping skills available to these children.1 Because the psychological and physiological state of children in healthcare settings affects the healing process, the environment must include specific elements that support the reduction of stress for children. The practice of Positive Distraction Theory reduces stress and pain perception among pediatric patients. Distraction here refers to directing attention that provokes pleasurable interest and distracts from worries and

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EXPERT FOCUS Positive Distractions in Pediatric Healthcare Environments (continued) vexations in the immediate environment. Children perceive their environment holistically; all the environmental characteristics together comprise the physical health-care environment. They do perceive isolated stimuli, but it is the total composition of all stimuli that determines their responses to the environment.2 In order to be able to predict the ways in which environmental stimuli can reinforce or weaken one another, the knowledge of effects of each environmental stimulus must be determined. In a study comparing the effect of two forms of distraction on injection pain among preschool children, the participants were randomly assigned to receive touch, bubble-blowing, or standard care with their DTP injection. The results indicated that pediatric patients responded to direct, focused forms of positive distraction (touch and bubble-blowing) that reduced pain perception.3 In another pain study, the effectiveness of virtual reality (VR) was examined with 7- to 14-year-old pediatric oncology patient groups. Results indicate that VR effectively reduced children’s distress. In a single-case design4 researchers found that VR was effective in reducing anxiety and perception of pain from the port access process of an 8-year-old patient with acute lymphocytic leukemia, suggesting that VR can be used as an alternative or complementary nonpharmacological pain mitigation technique. A similar finding was made when patients were asked to enter a virtual environment by playing video games or by wearing a headset.5 Art can also reduce stress. In her preference study of hospitalized and nonhospitalized children, Eisen demonstrated that children across all four cognitive developmental ages prefer representational nature art to abstract art.6 Contrary to common assumptions that children prefer cartoonlike or fantasy images, a study with patients at Memorial Hermann Hospital in Houston, Texas, showed that children highly rate nature images with bright colors, water features, and nonthreatening wildlife.7 In fact, nature images rated higher than typical child art (art created by children) for children in the age group of 7 to 17, but not with younger children 5–7. Because preferences differ between younger and older children, designers must accommodate such differences in their selections of art. Music therapy, as a positive distraction, also has been shown to reduce the impact of pain perception. Walworth examined the cost-effectiveness of music therapy as a procedural support in pediatric health-care settings.8 Participants received music therapy-assisted when they underwent computerized tomography scans, echocardiograms, and other procedures. Results of music therapy-assisted procedures indicate the elimination of patient sedation, a reduction in procedural times, and a decrease in the number of staff members present for procedures. As evidenced through the incorporation of these positive distractions in pediatric health care, the experience of patients and care delivery is enhanced through stress reduction and pain perception. The overall hospital experience may become a more positive, supportive experience for the patients, as well as their family and care givers. 1. R. Oksala and J. Merenmies. “Children’s Human Needs in Intensive Care.” Intensive Care Nursing 5 (1989), 155-158. 2. M. J. Bitner, “Servicescapes: The Impact of Physical Surroundings on Customers and Employees.” Journal of Marketing 56:2 (1992): 57–71. 3. L. Sparks, “Taking the ‘Ouch’ Out of Injections for Children: Using Distraction to Decrease Pain,” American Journal of Maternal/ Child Nursing 26:22 (2001): 72–78. 4. Jonathan Gershon; Elana Zimand; Rosemarie Lemos, Barbara Olasov Rothbaum, and Larry Hodges, “Use of Virtual Reality as a Distractor for Painful Procedures in a Patient with Pediatric Cancer: A Case Study.” Cyberpsychology and Behavior 6:6 (2003): 657–61. 5. H. G. Hoffman, D. R Patterson, G. J. Carrougher, and S. R. Sharar, “Effectiveness of Virtual Reality-Based Pain Control with Multiple Treatments.” Clinical Journal of Pain 17:3 (2001): 229–235. 6. S. L. Eisen, “The Stress-Reducing Effects of Art in Pediatric Healthcare: Art Preferences of Healthy Children and Hospitalized Children.” Journal of Child Health Care 12:3 (2008) 173–190.

Continued

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EXPERT FOCUS Positive Distractions in Pediatric Healthcare Environments (continued) 7. U. Nanda, K. Hathorn, C. Chanaud, and L. Brown, Research on Art for Pediatric Patients. Paper presented at Healthcare Facilities Symposium and Expo, Chicago, October 2–4, 2007. 8. D. D. Walworth, Procedural-Support Music Therapy in the Healthcare Setting: A Cost Effectiveness Analysis, Journal of Pediatric Nursing 20:4 (2005): 276–84.

Therapy as Play A life-size game board called Rehab 1, 2, 3 rewards children with music when a therapy sequence is completed (see Figure 10–10). This is just one of the pediatric rehabilitation components designed to engage children while providing rehabilitation. During therapy, rocket ships take off, ping-pong balls go crazy, and confetti flies. Some elements of the system pop up from the floor. Stepping-stones, logs, cubes, balls, ramps, and toadstools are used in upper-body exercise, fine motor skills development, coordination, and cognitive training. A climbing wall, a Velcro wall, and a cognitive wall make therapy fun. Other optional components include a puppet theater, a funhouse mirror, and a technology center complete with computers and video games.

Figure 10-10 Interactive play with life-size game board called Rehab. 1, 2, 3. Courtesy of Guynes Design Inc.

Children also have a universal attraction to water, making water therapy an attractive alternative environment for occupational and physical therapy, enhancing physical improvements through the properties of water. Aquatic therapy can help achieve desired improvements in mobility, coordination, strength, endurance, balance, and self-confidence. Therapists develop personal programs for each child that include water games and activities so that the child is having fun while accomplishing important therapeutic goals. A ramp into a swimming pool should not normally exceed a slope of 1 foot of rise per 10 foot of length, but the slope may need to be more gradual

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for children. It must be 44 inches wide with edging and handrails on each side, which can be used to guide a shower wheelchair during entry and exit. Children in shower wheelchairs become buoyant (and lose control of their wheelchairs) at a depth of 30 inches. Water elements are frequently integrated into play areas as well (see Checklist: Outdoor Play Areas for Children with Disabilities on page 224). An outdoor play area or garden can serve as a strong reference point to help with orientation to the building. It offers a child the energizing fragrance of spring. It meets the child’s need to be active, breathe fresh air, soak up some sun, and get away from the hospital (see Figure 10–11). Windows also provide a temporary visual escape to nature. Children spend so much time in the windows of the New York Foundling Hospital that the hospital installed radiant heating panels above the windows to warm them. Shutters on the windows can entertain the children with a light show of changing pattern.

Figure 10-11 Outdoor water play. Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Photograph: John Durant.

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CHECKLIST Outdoor Play Areas for Children with Disabilities An element of fun and mystery must be balanced against the functional requirements of children with disabilities. Heavy vegetation may surround a path that is barely accessible, but to a child in a wheelchair, it becomes a fun ride through the jungle. Running or wheeling through a fountain can be an adventure or an unwelcome surprise to a blind child when there is no tactile warning. Play areas may allow children of all abilities to develop their skills or prevent them from participating. Designers must tread the fine line between creating exciting challenges and creating barriers. Accessible fun often involves a degree of challenge, but Figure 10-12 Archeological dig with missing the risk must be based on anthropometric data and existing rib. Courtesy of Moore lacofano Goltsman, Inc. safety standards. Accessible routes must be stable, firm, and slip resistant, with surfaces like decomposed granite, asphalt, wooden boardwalk, resilient mats, and concrete. Platforms can be used by children in wheelchairs to safely transfer to play structures. Sand play areas can be provided in a variety of heights for play on the ground or in a wheelchair. Boulders or posts can provide back support in the play area. Accessible benches in a variety of heights should provide back support as well. One exciting installation allows children to control the flow of water. By pressing on a bollard, children cause the water to flow at ground level on one side (for wading) and at a raised height on the other side (for access by children in Figure 10-13 Fossil discovery. Courtesy of wheelchairs). This installation also features a mastodon rib Moore lacofano Goltsman, Inc. cage as a climbing structure (see Figure 10–12). A missing rib provides access by children who use wheelchairs and walkers. The “archeological dig” features a fossil discovery, a stimulating tactile experience for sighted and unsighted children (see Figure 10–13). Native American drums provide auditory stimulation at a variety of heights for standing and seated users. The swing area provides an accessible ground surface and a bucket swing for younger children or those with balance limitations. The play area integrates all children, improving their physical, social, and intellectual abilities. Signage and audible cues for orientation provide perceptible information about the play area. A wind chime can provide a sense of direction to all users, not just to people with low vision or reduced cognitive skills that depend on redundant cues. Caterpillar pull handles on the exterior doors Figure 10-14 Caterpillar entice children out of the garden to the indoors (see Figure 10–14). pull handles. Courtesy of HEWI, Inc.

Children’s Hospitals

Endnotes 1. L. Sehulster, and R.Y.W. Chinn, Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR, 52 (No. RR-10 Pt II), 1–48, 2003, retrieved April 6, 2010; full report available at www.cdc.gov/hicpac/pubs.html. 2. D. Harris, A. Pacheco, and A. Lindner, “Detecting Potential Pathogens on Hospital Surfaces: An Assessment of Carpet Tile Flooring in the Hospital Patient Environment,” Indoor and Built Environment 19, 2:239-249 (2010). 3. D. Harris, “Environmental Quality and Healing Environments: A Study of Flooring Materials in a Healthcare Telemetry Unit,” Dissertation Abstracts International, 4202(00), DAI-A61/11, 2000 (University Digital no. AAT 9994253). 4. J. Malkin, Hospital Interior Architecture (New York: John Wiley & Sons, 1992). 5. R. Guenther, and G. Vittori, Sustainable Healthcare Architecture. (Hoboken, NJ: John Wiley and Sons, 2007).

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ne-third of all Americans are likely to suffer from mental illness or substance abuse sometime during their lives, and almost every American family will be touched by mental illness.1 Fortunately, great progress has been made in medical treatment; most people with chronic mental illness can be stabilized with medication and remain in the community. Institutions and addiction recovery facilities are being replaced with treatment-adherence clinics providing medications that correct genetically based addictions and diseases.2 Most clients receive treatment on an outpatient basis, remaining in their homes with the support of ambulatory care facilities (see Part Two). For those requiring inpatient care, psychiatric facility design has a tremendous impact. The design program must support a normalized lifestyle, patient independence, integration of the family, mental therapy, and physical healing.3 Design detail can make a significant contribution to achieving these goals. A systemic review of research publications and clinical anecdotes over the past fifty years indicate that the psychiatric hospital environment can play a significant, if under recognized role in patient and staff functioning. This review states that patient-centered design features can positively affect social, cognitive, motivational, emotional, and physical processes among patients and staff4 (see Figure 11–1).

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Some of the early research on the influence of space and architectural features and the effect on mental health patients have been conducted by Mayer Spivack. It focuses on normalization.5 Spivack maintains that patients are influenced by their environment, discussing “standing behavior” elicited by a space. For example, a bedroom induces the standing behavior of escape (through sleep) to most users. Access to the bedroom is not always desirable during the day when patients are being encouraged to face their reality, not to escape from it. Spivack also references Humphrey Osmond’s theory of sociopetal (radial) and sociofugal (gridlike) space.

Figure 11-1 Removing physical barriers from the Nurse Station promotes interaction between staff and residents. Adventist Behavioral Health, Adolescent Sexual Offender’s Residential Treatment Unit. Perkins+Will. Courtesy of © Maxwell MacKenzie.

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Sociopetal space brings people together, while sociofugal space keeps them apart. Sociopetal space encourages people to discuss personal feelings. For example, personal space is easier to establish around the perimeter of the room, so most socializing takes place in this sociopetal space. The center of the room is less protected; furniture arrangements, area rugs, and lighting, and low partitions can be used to redefine it as sociopetal space. These “behavior markers”—architectural elements supporting specific behaviors, offer a range of choices to the patient, articulating the space and maintaining a sense of personal identity.6 In one study conducted at a maximum-security hospital, a comparison of furniture arrangement across the hospital, wards with furniture arranged in group seating had a lower rate of patients requiring seclusion and a lower rate of casualty incidents than the wards with furniture placed in nonsocial patterns.7 Improved attitudes and increased social interactions were recorded. Room size also determines sociopetal space. The smaller the room, greater is the social interaction. There is less isolation and less passive behavior in small rooms.8 Private bedrooms and smaller spaces produce more frequent and appropriate social interaction.9 Privacy and confidentiality can also be supported by design detail, including sound-absorbing materials and finishes. Limit sound transmission and place windows and doors away from sources of noise. Carpet can be effective in deinstitutionalizing the space, reducing the ambient noise while providing a limited amount of cushion in the case of a patient fall. Carpet borders may be problematic for people with compulsive behavior disorders; they may be unwilling to step on the edge or move into a space defined by a border. Intimacy can be encouraged by soft natural lighting and variety in the color and texture of finishes (see Checklist: Color and Checklist: Universal Lighting on pages 89 and 90). A quiet, soft environment can help the patient to stabilize and return to everyday life.

PATIENT INDEPENDENCE The partnership between care philosophy and environmental design creates an opportunity for mental health facilities to return control, efficacy, and independence to their clients. Individuals may personalize their private room, choose a room in their favorite color, and regulate their environment with individual HVAC and lighting controls. Piped-in music is replaced with

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personal choice of music in each room, and spaces are differentiated to support individual activity choices. A public day room is ambiguous space, difficult for patients to understand and control. Rather than a large, flexible space, several rooms should be planned to support various activities. A lounge for reading may be furnished with large, overstuffed chairs. Another activity area may provide seating around tables for games, hobbies, or study. Boundary definition may be improved by using square tables;10 round tables make personal space more difficult to define (see Figures 11–2 and 11–3).

Figure 11-2 Organic patterning adds interest to an open dayroom and activates long corridors. Adolescent Residential Treatment Unit Conceptual Floorplan. Perkins+Will. Courtesy of Perkins+Will.

Figure 11-3 The floor pattern and color designate activity areas and define entry points into resident rooms. Adolescent Residential Treatment Unit Floorplan. Perkins+Will. Courtesy of Perkins+Will.

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INTEGRATION OF THE FAMILY Family-centered design softens the blow of admitting a family member to the hospital and encourages family members and friends to visit. A family activity area, perhaps several smaller rooms can be planned for socializing, dining, and entertaining. In some facilities, a small kitchen may be planned to provide normal family activities, like providing a meal or snack. For the safety of patients, controlled access should be planned for the kitchen. Of course, all sharp utensils must be locked away, and the temperature of hot water should be controlled. Small appliances should be permanently installed; perhaps a refrigerator, a toaster oven, and a microwave (which is considered safer than a range). Cabinets should be within reach without using stools or chairs. Overnight accommodations for family use may also be provided, perhaps in an apartment within the complex. Patients can also stay in the apartments with their families as a transition to home care. Families may also be granted access to patient recreation areas, encouraging community interaction with the facility. Public educational centers are becoming more popular; these offer space for seminars and perhaps a community library for information about mental illness. These resources are particularly appreciated by families trying to come to terms with these diseases. Family therapy rooms should also be considered. These spaces are planned for privacy but are sometimes used by therapists for observation of family dynamics. Acoustics are a primary consideration; assure control of both ambient and transmitted noise.

PUBLIC AND SOCIAL AREAS Research has shown that when expected behavior patterns are not clearly defined by space, all behavior feels out of place and random.11 Signage must be clear, consistent, and redundantly cued (see Checklist: Accessible Signage on page 250). Provide landmarks every 20 feet; memorable personal cues like collections and patient art are more effective than unfamiliar cues in improving orientation. Even a “bulletin board” can serve as a personal cue. For safety, use Velcro or a magnetic board instead of a cork board with pins or tacks. Orientation can also be improved by posting the day and date on the bulletin board. Crossing off days on a calendar can be discouraging, reinforcing a sense of lost time.

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Figure 11-4 Safety concerns are addressed through direct sightlines between the open Nurse Station and dayrooms. Adventist Behavioral Health, Adolescent Girl’s Residential Treatment Unit. Perkins+Will. Courtesy of © Maxwell MacKenzie.

Space must be clearly defined. Flexible space should be minimal because it can be disorienting and lead to inappropriate behavior. Orientation to unfamiliar and changing surroundings is problematic for people with mental illness. Today, inpatient facilities are planned with clear spatial differentiation. Dayrooms have been replaced with clearly defined treatment space, individual seclusion spaces, and auditoriums with sophisticated audiovisual equipment (see Figure 11–4). When patients are acting out, a quiet room may be necessary. Generally, the room is used to calm the patient, but it may also be used to protect patients from harming themselves or others. The patient may be observed in this room, either through safety glass, plastic, or by video camera. Because the patient may be on the verge of suicide, the room may contain nothing more than a bed bolted to the floor, a mattress, and an inoperable window with a view. The bottom of the door must be secured to prevent razor blades, matches, or pills from being passed under. A bathroom should be close, if not connected.

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Access to nature and natural light is critical to treatment. In one research study, length of stay for depressed patients in sunny rooms averaged 16.9 days, while those in dull rooms required 19.5 days of care.12 Daylight can be incorporated into the interior with skylights, solariums, atriums, and courtyards. Light must minimize shadows, exaggerated images, and sensory distortion.

EXPERT FOCUS Behavioral Health Design Research MARDELLE MCCUSKEY SHEPLEY, D.ARCH., AIA, ACHA, EDAC, LEEDAP William M. Peña Endowed Professor and Director, Center for Health Systems and Design Texas A&M University

There are multiple sources that address design detailing in behavioral health facilities, most of which focus on suicide prevention, contraband control, and resistance to abuse. In the case of suicide prevention, the focus is on the specification of accessories that diminish the opportunity for self-abuse, such as mirrors that can be broken and used to harm oneself or others. The storage of contraband is also of concern and generally addressed by the absence of design details, such as ceiling tile systems that allow for the concealment of prohibited possessions (e.g., drugs). The high use of this type of facility requires specification of resilient furniture and finishes and furniture that is substantial enough not to be thrown or easily vandalized. Emphasis is placed on how to achieve the environment described above while maintaining the appearance of a noninstitutional facility. At the Camarillo State Hospital and Developmental Center Children’s Units, designed by The Design Partnership in San Francisco, California, we were interested in addressing these details, but also wanted to go beyond them to develop an environment that had spatial characteristics that, by their nature, would encourage positive behaviors. Some evidence to guide the design of therapeutic architecture was already available, such as the role of visual and physical access to nature in reducing stress, and the importance of spaces that support social interaction. It was less clear if the design could serve to deter negative behaviors such as aggression and self-abuse. During the programming process an intriguing opportunity presented itself. When asking staff about the function of the staff workroom they mentioned that this was the location in which they filled out Special Incident Reports. When staff described the content of Special Incident Reports, they told us that they were required to record the occurrence of negative events such as aggression, self-abuse, AWOL events, suicide, and rape. Additionally, they noted the location of the event. We were immediately struck by the opportunity to conduct a study that would compare negative incidents and the location in which they took place. This information could potentially identify inappropriate spaces, which in turn, could inform the design process. With the help of Camarillo staff, we collected data on negative behaviors and behavior locations. The data were analyzed statistically and patterns were identified. These patterns included, among other results, the unexpected frequency of negative behaviors in corridors, dormitories, and near the telephone. Subsequently we used this information to make specific design decisions, such as the elimination of patient corridor spaces, the switch from dormitory to private and semi-private patient rooms, and the location of the telephone near the staff station. Continued

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EXPERT FOCUS Behavioral Health Design Research (continued) Why were these spaces particularly problematic? Perhaps the corridors were perceived as lacking territorial definition, so they made good targets for aggressive interaction. Perhaps the dormitories interfered with a deep need for privacy and exacerbated feelings of alienation. Perhaps the problems at the telephone were a result of heated arguments with family members. We were unable to explore these hypotheses in any detail, but they did provide a framework for the subsequent design decisions. An interesting aspect of this pilot study1 was that after the project was complete we waited a year, and then collected data again to see whether the architectural interventions were effective in reducing the severity or the frequency of negative behaviors. We found a drop in the total number of incidents, although the frequency of the most serious incidents remained the same. From this we concluded that the environment could have a mitigating impact on day-to-day negative behaviors, but that the more profoundly internalized expressions of undesirable behavior were less resistant to the impact of the physical environment. We would encourage all design firms and organizations to conduct studies in their facilities and disseminate the results. Design research in behavioral health facilities is still very limited, although the potential for creating therapeutic environments is promising. 1. M. Shepley, “Predesign and Postoccupancy Analysis of Staff Behavior in a Neonatal Intensive Care Unit,” Children’s Health Care 31:3 (2002): 237–253.

THE MIND-BODY CONNECTION Today’s psychiatric facilities recognize the link between a healthy body and a healthy mind. Treatment should include recreational, physical, and occupational therapy as well as psychiatric treatment. Activity is critical. Many patients are restless and have difficulty with inactivity, especially waiting. Time management is frequently an issue, and this is exacerbated by reactions to psychotropic drugs that reduce the ability to sit for long periods. Provide furniture that rocks, bounces, or swivels safely. Gymnasiums with running tracks, weight rooms, racquetball courts, aerobic dance, spas, and swimming pools are planned in many facilities. In addition to encouraging physical fitness, facilities must protect patients from physical harm, especially self-induced injury. Specify breakaway closet rods and hooks and use flush door hardware to prevent suicidal patients from hanging themselves. Plumbing, light bulbs, and sockets must be hidden or designed to restrict access. Diffusers, switches, light fixtures, and grilles must be installed with tamper-proof screws that require a special tool to remove. Sharp objects must be eliminated. Fixtures and artwork must not have glass components; mirrors must be specified in laminated glass. Razor blades can be hidden behind baseboards; glue and screw the base to the wall and

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eliminate the base in closed units. Window blinds should be sandwiched between layers of safety glass. Some patients develop sensitivity to bright light as a side effect of their medications. Window shading should be installed on ceiling-mounted rods. It should be controlled by wands, or better yet, mechanically controlled. For security, emergency windows should be operated from the exterior with special keys and elevators should have a key-only option. Fire door locks should be alarmed. Doors for patient use should have contrasting frames, while doors to dangerous areas or rooms for staff-only use should be visually blended with the wall. Each door must have double-swinging hinges so it cannot be blocked with furniture or by a patient who has fallen. Exposed furniture and door hardware can be tied to another object with belts, stockings, or shoelaces; to prevent barricading, injury, and escape, hardware must be recessed and installed with security screws. Movable furnishings also must be planned to discourage injury and suicide attempts. Furniture must be heavy and difficult to throw. Sharp edges must be eliminated. Furniture must not be placed near the entrance to the room, where it could be used in a surprise attack. A tall piece of furniture can be tipped on an attendant or another patient, and some hardware can be disassembled and used as weapons. Patients can be injured by rocking on chairs and tabletops until they come loose. A sled base stabilizes a chair and the tabletop should be permanently attached to the base. Edging, like vinyl T-moldings, can be picked apart and removed. In the patient room, the bed should be placed on a platform rather than on a metal frame that could be disassembled. The mattress should be nonspring for the same reason. Avoid zippers and pockets that could be used to hide dangerous objects. Drawers in the nightstand should be difficult to remove and soundly constructed. The wardrobe should have a lockable door or drawer for grooming supplies that require staff supervision during use. Finishes should be tamper-proof and virtually indestructible, but not institutional. Color and pattern can make a tremendous contribution if carefully selected. Some patterns are too distracting for clients who have difficulty maintaining concentration for long periods (see Checklist: Pattern, Texture and Contrast on page 236). Many have problems screening out external stimuli. Excess clutter, overhead announcements, noisy pedestrian traffic, and vacuum cleaner noise are examples of negative distractions. Wood adds warmth without excessive distracting pattern. Although our discussion is limited to family-centered design, it should be noted that wood and other wood-look materials are easily maintained and repaired. Lightly patterned wall covering is also easily maintained. It should be specified in

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commercial weight and 108-inch widths for a seamless installation. Corner guards prevent patients from picking at the edges. Bathrooms are particularly dangerous and difficult to detail. Excessive thirst is a common reaction to psychotropic drugs, resulting in increased demand for bathrooms. Exposed plumbing could be disassembled and used as a weapon; it must be covered in each bathroom. Use toilets with flush valves that cannot be disassembled rather than toilets with tanks. Showerheads must be recessed and activated by a sensor with thermostatic control. A patient can easily block the drain in the shower, sink, or toilet. Install a central drain in each bathroom to handle the overflow. Ground-fault circuit interrupters and fail-safe touch controls must be specified. Bathroom shelves and toilet paper holders must have collapsible connectors. Shower curtains must have breakaway Velcro to foil suicide attempts. Curtains must be ceiling mounted to prevent the rod from being used as a weapon. It is difficult to motivate some mentally ill people to physically care for themselves. Medication frequently slows metabolism to the point where each motion requires extraordinary effort. It feels like each task is being performed in a vat of molasses. In addition, psychotropic drugs reduce manual dexterity, making tasks like bathing especially difficult. Design elements can be used to increase motivation, providing positive incentives to participate in healthy behaviors. This goal requires imagination; the key is to make each activity fun. For example, a hot tub is more fun than a bath. An active game is more motivating than a scheduled exercise regime. With a little creativity, clients can be encouraged to exceed their physical and mental limitations to achieve better health. CHECKLIST Pattern, Texture, and Contrast • A lower ceiling helps a room appear cozier and less institutional. In addition, many people in wheelchairs or on gurneys are more comfortable with a lower ceiling height. Pattern can be used to visually lower an existing ceiling, and warmer colors can reduce the perceived ceiling height as well. Orange and red tones come to focus behind the retina and cause the surface to visually advance or lower, while blue and green tones come to focus in front of the retina and appear to recede. • Contrast between the wall and the floor helps to define boundaries. A contrasting door frame draws attention to the doorway. Because most doors are left open, the molding should contrast with the walls, not necessarily with color of the door. In the bathroom, provide contrast between the countertop and bowl. Contrasting toilet seats may help in seeing the edge of the toilet.

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CHECKLIST Pattern, Texture, and Contrast (continued) • Visually confusing mirrors produce patterns that are distracting and can make concentration and orientation difficult (see Checklist: Environmental Wayfinding and Orientation Cues on pages 253). • For people with schizophrenia and others who suffer from distortion of perception, keep colors and textures as unambiguous and understated as possible. • Limiting textures and colors in interior decor is helpful for the many people with mental illness who are susceptible to sensory overload. Low-intensity colors, especially for background surfaces, are most appropriate for this population. • People who spend much of the day in bed may grow tired of facing a patterned or highly textured wall covering. Use strong patterns only on walls adjacent to or in back of the bed. Even in these locations, texture and pattern may produce a response of stimulation rather than relaxation. • Stripes on the wall can appear to be bars and wavy patterns can appear to be in motion, affecting mobility. • Texture makes tones appear darker, absorbing important ambient light. • Value contrasts of more than two digits on the gray scale are adequate to increase the imagery of objects. (The gray scale consists of 10 increments from black to white and can be found illustrated on the back of many printer’s rules.)

Endnotes 1. AHRQ, Mental Health: Research Findings (Washington, DC: Agency for Healthcare Research and Quality, 2009): 1. 2. R. Miller, E. Swensson, “New Age Public Won’t Settle for Old-Fashioned Facilities,” Health Facilities Management 8(3) (1995): 32, 34, 36–38. 3. T. Duffy, B. Huelat, “Psychiatric Care Units,” J. Health Care Interior Design, 2 (1990): 89–103. 4. B. Karlin, R. Zeiss, “Environmental and Therapeutic Issues in Psychiatric Hospital Design: Toward Best Practices,” Psychiatric Services 57:10 (2006): 1376–1378. 5. J. Malkin, Hospital Interior Architecture (New York: John Wiley and Sons, 1992). 6. W. Ittleson, H. Proshansky, L. Rivlin, “Bedroom Size and Social Interaction of the Psychiatric Ward,” Environment and Behavior 2:3 (1970): 255–270. 7. S. Baldwin, “Effects of Furniture Rearrangement on the Atmosphere of Wards in a Maximum-Security Hospital,” Hospital and Community Psychiatry 36:5 (1985): 525–528. 8. Ittleson, Proshansky, and Rivlin, “Bedroom Size and Social Interaction of the Psychiatric Ward, 255–270.

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9. C. Holahan S. Saegert, “Behavioral and Attitudinal Effects of Large-Scale Variation in the Physical Environment of Psychiatric Wards,” Journal of Abnormal Psychology 82 (1973): 454–462. 10. J. Malkin, Hospital Interior Architecture (New York: John Wiley and Sons, 1992). 11. M. Spivack, Institutional Settings: An Environmental Design Approach. (New York: Human Services Press, 1984). 12. K. Beauchemin, P. Hays, “Sunny Hospital Rooms Expedite Recovery from Severe and Refractory Depressions,” Journal of Affective Disorders 40 (1996): 49–51.

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ven during the biggest financial crisis since the Great Depression, the design and construction of acute-care facilities has remained strong. According to Reed Construction Data, $17.1 billion was spent in 2009. Upward of 650 medical projects are currently under construction across the United States, representing 46 million square feet of space.1 Though renovation has increased, new construction is still significant and expects to continue to grow over the coming years. Reasons for this abound: demographics are changing, aging facilities are being replaced, and seismic structural requirements have increased. Hospital administrators are facing challenges that will impact the growth and the bottom line for health-care systems. Reimbursement changes, health-care reform legislation, staffing issues, and developing alternative revenue streams are issues at the forefront. Challenges to administrators become opportunities for designers. According to the 2010 AHA Environmental Scan report, critical issues facing hospital adm inistrators include health-care quality, patient safety, technology, human resources, demographics, finance, and especially information technology and e-health. The new IT systems measure and report clinical outcomes, reducing medical errors, promoting patient safety, and connecting the hospital with remote

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environments.2 Implementing new technology is costly to hospitals, but through the American Recovery and Reinvestment Act of 2009, the federal government plans to invest $36 billion to update medical information technology.3 Telemedicine is capable of transforming how health-care services are provided. Through this use of technology, physicians can determine whether a patient needs to go to the emergency department or the doctor’s office. The primary impediment to the use of remote monitoring technology is physician reimbursement. It is difficult for doctors to justify the technology when it adds more work to their day without more income. There are also liability, security, and privacy concerns.4 According to the Agency for Healthcare Research and Quality, aggregate quality of care has improved each year from 1994 to 2008. However, the rate of improvement has slowed in recent years and there is a significant geographic variation in quality of care.5 Informed environmental design contributes to the level of efficiency, environmental health, and other aspects of quality to improve patient care.

CRITICAL TRENDS AND ISSUES IN ACUTE-CARE DESIGN Patient- and family-centered care clearly focuses on the well-being of individual patients. It provides support for participation of family members as collaborators of the patient’s care. In acute care, patient-centered hospitals provide the latest medical technology in a healing environment. They encourage patient and family involvement and participation through a range of services dedicated to a holistic approach. The physical environment—the exterior grounds, the architecture, the indoor environment—plays an important role in the facilitation of patient-centered care. Planning and programming for an environment that supports patientcentered care depends on an understanding of how a health-care organization interprets the fundamental tenets of care and health-care processes that define their patient-centeredness. Planetree, a leader in patient-centered care, maintains that the design of an acute-care facility must support the follow ten components of patient-centered care: 1. 2. 3. 4.

Human interaction Access to information Family involvement Nutrition

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5. 6. 7. 8. 9. 10.

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A healing environment Arts and entertainment Touch Spirituality and diversity Integrative therapies Healthy communities

EXPERT FOCUS Color in Healthcare RUTH BRENT TOFLE, BENYAMIN SCHWARZ, AND SO-YEON YOON1 University of Missouri, Department of Architectural Studies

The evidence-based knowledge for making informed decisions regarding color application has been fragmented, sporadic, conflicting, anecdotal, and loosely tested. Many health-care providers, designers, and practitioners in the field have questioned the connections between color and behavior of people. They suspected the value of color as a psychotherapeutic aid, and searched for empirical reasoning for the various color guidelines in health-care settings. As a response to the diverse opinions on the impact of color in health-care design, the Coalition of Health Environments Research (CHER) commissioned an extensive review of literature to determine if there is empirical evidence supporting the use of color for healing purposes in health-care environments. The onerous task of the study was to distinguish among common myths and realities in the body of research and application of color in health-care design. Utilizing online searches of existing bibliographies and databases in multiple disciplines, more than 3000 citations were reviewed to examine information that could have had credible support for application of color in health-care design. The results of the critical review of the pertinent literature produced no reliable explanatory theories that may help predict how color influences people in health-care settings. Regrettably, we found that much of the knowledge about the use of color in health-care environments comes from guidelines based on highly biased observations and pseudo-scientific assertions. Six key findings were identified: 1. There are no direct linkages between particular colors and health outcomes of people. 2. Specifying particular colors for health-care environments in order to influence emotional states or mental and behavioral activities is simply unsubstantiated by outcomes. 3. Perceptual impressions of color applications affect the experience and performance of people in particular environments with regard to spaciousness or confinement. This is attributed to contrast in brightness or darkness of colors, and less by hue. 4. Multiple user groups and subcultures assume they can prescribe universal guidelines for color. It has not worked in the past and will not work in the future. It is a futile endeavor. 5. There is no evidence to suggest a one-to-one relationship between a given color and a given emotion in color-mood association. Emotional responses to colors are caused by culturally learned associations and by the physiological and psychological makeup of people. Continued

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EXPERT FOCUS Color in Healthcare (continued) 6. Color perception does not occur in a vacuum but within a web of experiential conditions, which modifies a person’s judgmental processes. The conditions include noise, temperature, clutter, medical equipment, odors, and more. The person’s role in the settings (patient, staff, or visitor), physical condition (sickness, pain, tired, ambulatory or bedridden), and psychological state (awareness of surroundings, influence of drugs, anxiety, dementia) all affect their perception of color. Points to Remember • Design research of color in the environment is at an early stage of theory building. Findings in one location are neither necessarily generalizable nor applicable to all settings. Nevertheless, disseminating research findings about what we know and don’t know about color in health-care is critical to building a knowledge base. • The field of color is nestled in both the humanities and the sciences. The application of color in health care cannot be all science. It has to supplement the creative, artistic aspect of decision making in the design process. The integrative psychological, physical, and spiritual aspects of health care require a delicate balance between research and the aesthetic talents of designers. Intentional design is strengthened by embracing multiple skills and multiple intelligences. • There are no universal truths of color in environments that are good for all people, of all places, and at all times. Rather than using a set of uniform specifications for particular colors, use the following: • Understand the local culture. Be sensitive to geography and demographics. Conduct focus groups for alternative color palettes. These local findings are of primary importance to users and are an alternative to “tube sock, one-size-fits-all” recommendations. • Improve the perception of spaciousness or confinement by concentrating on visibility (i.e., quantity of illumination, figure/ground contrast, size of object or form, and consider light reflectance values of color). Emphasize issues of brightness and darkness of color rather than hue. • Maximize flexibility/variability to increase individual control and accommodate the widest range of color preferences by providing options in lighting (i.e., control, chromaticity of lamps, light direction, figure/ground contrast, dimmers, window treatments, and natural daylight). • Be sensitive to the private, dynamic, and fragile nature of color perception, preferences, and impressions as a function of conditional changes in the environment, culture, psychology, and physiology. Be an astute listener to emotional, spiritual, and ideological needs in health-care settings. 1. Ruth Brent Tofle, Benyamin Schwarz, So-Yeon Yoon, and Andrea Max-Royale, Color in Health Care Environments (San Francisco: Coalition of Health Environments Research, 2004).

In 1992, the first hospital designated as a Planetree hospital was MidColumbia Medical Center (MCMC) located in northern Oregon. They implemented the Planetree philosophy of patient-centered care facility wide. Nursing stations were decentralized, patients had access to their medical records, and a library was established with resources for education and opportunities for interaction. Complementary therapies and

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programs that focused on art and entertainment created a place very different from what most people expect of a hospital (see Figure 12–1). Today, MCMC still holds true to the Planetree philosophy, providing a patient-centered experience, advanced medical and diagnostic technologies, and high quality of care. In 2007, MCMC was awarded the Designated Planetree Patient-Centered Hospital designation, an award that recognizes achievement and innovation in fostering a culture within the hospital that prioritizes patient comfort, dignity, empowerment, and wellbeing (see Figure 12–2). Upon entering MCMC, the importance of the physical environment is apparent. The main entrance opens into a large waiting area filled with

Figure 12-1 Musical performance in the corridor. Courtesy of The S/L/A/M Collaborative, Architects and Engineers.

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Figure 12-2 Tai Chi session on Labyrinth support a culture of patient empowerment at MidColumbia Medical Center. Courtesy of Jim Semlor, Semlor Images.

comfortable seating and bathed in soft lighting. Original artwork from local artists provides context and interest to complete the welcoming atmosphere. An alternate entrance features a four-story glass atrium with terra-cotta tiled floors, a towering plant-covered rock waterfall, and a baby grand piano. Positive distractions abound from a visiting clown or a pet therapy dog (see Figure 12–3). Since the original implementation of Planetree, MCMC has developed new initiatives to reciprocate the expanded definition of health. The Center of Mind and Body Medicine is the cornerstone of this effort. This center provides integrative therapy for stress reduction. Relaxation tools like acupuncture, yoga, and tai chi are merged with medical and diagnostic approaches to cardiac rehabilitation, diabetes management, and pain management. The cancer center was grounded in similar programming to provide a complete arsenal of healing tools. These include mind- body integrative therapies, chemotherapy, and radiation technology in a beautiful healing environment (see Figures 12–4 and C-21). To round out the systemic patient-centered care program, the hospital trains staff to help design and stage memorable experiences for patients and families.

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Figure 12-3 Pet therapy, one of the many positive distractions that humanize a hospital environment. Courtesy of Desert Samaritan Medical Center, Phoenix.

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Figure 12-4 Comprehensive Integrated Therapy Program provided before and after treatment in one of the Meditative Rooms with view of healing garden. Mid-Columbia Medical Center Celilo Cancer Center. Courtesy of Jim Semlor, Semlor Images.

CHECKLIST Planning a Healing Garden For every patient, visitor, and staff member, the long hours spent in a hospital can be a stressful experience. Nearby access to natural landscape or a garden can enhance people’s ability to manage stress and thus potentially improve health outcomes.1 A garden offers the opportunity for fresh air, quiet reflection, a walk, and, with the healing garden, learning opportunities. Each plant in a healing garden is labeled with an explanation of the medication it produces. As patients learn the derivations of their medications, they also learn that nature is responsible for many of their cures. Madagascar periwinkle yields the drug Vinblastine, which is used to treat Hodgkin’s disease. The drug Vincristine Sulfate is used for the treatment of leukemia. Yew is the basis for Taxol, which is given to patients with ovarian and breast cancer, and Mayapple is used to produce Etoposid, which fights testicular cancer. Garlic and lavender are traditional homeopathic remedies. Herbs are used in aromatherapy. Patients may even be inspired to grow herbs at home or pick a bouquet for their hospital room.

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CHECKLIST Planning a Healing Garden (continued) James Burnett, an innovative Houston landscape architect, would like to do more. He would like to plan a bed-accessible garden (see Figure 12–5). “I [want] the option to be rolled outside into a garden instead of staying inside with Jeopardy on the TV all day and the smell of Lysol everywhere,” says Burnett. “We lost our connection to nature because we thought we could solve everything with technology.” In his design, the garden becomes a part-time patient room. Beds would be equipped with weatherproof medical gases and a call system.

Figure 12-5 Conceptual design of patient room with the bed in the garden. Courtesy of the Office of James Burnett.

Clare Cooper Marcus at the University of California at Berkeley has studied the correlation between hospital gardens and change of mood. From a survey of 24 hospitals, she determined that 95 percent of patients, employees, and families derived a therapeutic benefit from hospital gardens.2 Gardens can be used for structured physical therapy, horticultural therapy, and recreation therapy (see Figure 12–6). The garden is a place where patients and family can be distracted from their pain and anxiety. Windows to the garden reveal patterns of sunlight filtering through plants of various colors, a sensory environment that contrasts sharply with the sterility Continued

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CHECKLIST Planning a Healing Garden (continued) of the hospital. Terminally ill patients have a spiritual need for a meditative garden. As time in the hospital increases, the patient’s sense of time and location can decrease. A garden can help put everything back in order.

Figure 12-6 Family garden. Courtesy of The Office of James Burnett.

A well-maintained garden inspires confidence in the care provided at the hospital. It provides sensory stimulation, especially when plants are varied in size, blooming cycle, texture, color, and fragrance. The garden should be safely planned for use by children (see Outdoor Play Areas for Children with Disabilities on page XX). Avoid hazardous and thorny plants. Specify nontoxic plants to protect children, pets, and people with allergies. Some garden seating should be movable so families can sit together. Some should be stable with supportive backs, extended arms, and clear floor space for transferring from a wheelchair. Elevated gardens can be planned for patient use. For those in wheelchairs, pots and planters should be at least 2 feet in height and accessible from both sides if they exceed a 2 feet depth. They can be mounted on stands, walls, or racks. A vertical garden offers easy access to both ambulatory and seated patients (see Figure 12–7).

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CHECKLIST Planning a Healing Garden (continued)

Figure 12-7 Window provides garden view from a gurney. Courtesy of Jain Malkin Inc. Photography: Steve McClelland.

1. S. Edge-Gumbel, “Flower Power: The Proper Garden Can Cultivate a Wealth of Hospital Benefits,” Health Facilities Management 9 (June 1996): 6. 2. C. Cooper Marcus, Healing Gardens in Hospitals 2005, white paper retrieved March 11, 2010, from www.idrp.wsu.edu/Invited_files/Clare%20Cooper%20Marcus%20—%20Healing% 20Gardens%20 August%2029%202005.pdf.

Compassionate, safe, accessible, high-quality care elicits other factors that extend the definition of patient-centered care. In the 2004 study on the role of the physical environment in the hospital of the twenty-first century, the research team identified rigorous studies linking the physical environment to outcomes in four areas: (1) reduction of staff stress and fatigue, and increased effectiveness in care delivery; (2) improved patient safety; (3) reduction of stress and improved patient outcomes; and (4) improved overall health-care quality.6

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Patient safety includes the reduction of hospital-acquired infections, injuries, and medical errors. Based on the CDC’s estimate of 1.7 million health-care-acquired infections (HAI) and 99,000 associated deaths per year,7 the medical costs of preventable HAIs range from $5.7 to $6.8 billion for inpatient hospital services8 The causes of patient falls in hospitals are well documented. Most patient falls occur in the patient room, followed by the patient bathroom. Falls were usually caused by slippery floors, inappropriate door openings, poor placement of handrails, and inappropriate furniture and toilet heights.10 Evidence has suggested that many falls occur when patients are attempting to get out of bed unassisted or unobserved.11 This has led to decentralized nursing stations or nursing pods throughout the unit for increased observation. Larger private patient rooms support family presence to assist with care.12 Additional important design features to reduce the risk of falling include maximizing clear floor space, proper selection of assistive apparatus, and alcoves in corridors to store equipment. Locate the bathroom on the same wall as the headwall to reduce distance and provide continuous handrails to assist with mobility (Figure 12–9).

CHECKLIST Accessible Signage For more information, refer to the ADA Standards. • Identify accessible facilities and parking with the international symbol for accessibility. Under the symbol, additional signage may be required. For example, parking for vans requires a sign stating “Van Accessible.” “Area of Refuge” signs are also required. • Text telephones must be marked with the international symbol for a TTY. • Volume-control telephones and assistive listening systems must be identified by the international symbol of access for hearing loss. The symbol also may be used to notify persons of the availability of other auxiliary aides and services such as real-time captioning, captioned note taking, sign language interpreters, and oral interpreters. • Inaccessible elements like entrances, exit stairways, toilet rooms, drinking fountains, and elevators must have signage providing directions to accessible features. • Directional signage mounted over 80 inches a.f.f. must employ 3-inch characters, at a minimum.

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CHECKLIST Accessible Signage (continued) • Contrast, proportion, and redundant cuing are important signage features. Light yellow or white letters on a black background are the most readable for partially sighted users.1 The ADA Accessibility Standards recommend a contrast level of 70 percent. Contrast in percent must be determined by the following formula: contrast = [(B1—B2)/B1] x 100, where B1 is the light reflectance value (LRV) of the lighter area and B2 is the light reflectance value (LRV) of the darker area. • People who are color-blind have difficulty with signs relying on contrast between red and green. • People using different languages and learning skills may understand colored pictograms more easily than words. • Signs that provide tactile and audible cues as well as visual cues are important to people with differences in vision, reading, and learning abilities. • Tactile signs must include letters or symbols raised a minimum of 1/32 inch and must be accompanied with Grade 2 Braille. It should be angled for ease of use. Raised Arabic numerals and standard block uppercase letters without serifs are required. Raised characters must be 5 8 inch high but no higher than 2 inch. • In the event of an emergency, exit signs should be backed up with a middlefrequency audible signal to aid in location of an exit. • Tactile maps lead users from larger to smaller details about a space. The metal ball on a tactile map indicates the location of the sign (see Figure 12–8).

Figure 12-8 Tactile map. Courtesy of Roger Whitehouse.

Continued

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CHECKLIST Accessible Signage (continued) • Required tactile signs must be mounted at a height of 60 inches a.f.f. (48 inches for children) on the latch side of the door. A person must be able to approach within 3 inches of signage without encountering protruding objects or standing within the swing of a door. • Audible signs may have touch controls or, with a controlled audience, include infrared or low-frequency radio signals. Receivers can be distributed in stadiums, auditoriums, hotels, convention centers, museums, schools, and so on. The receiver scans the area for audible messages. • Some facilities offer an interactive audiovisual tour on a handheld unit with large touch buttons and a visual printout. This unit is helpful to people with hearing, coordination, and visual differences. • All signs should be placed to avoid glare from windows and light sources, and glare-free materials should be selected. • Illumination levels on the sign surface should be in the 100 to 300 lux range (10 to 30 fc) and uniform over the sign surface. Signs should be located such that the illumination level on the surface of the sign is not significantly exceeded by the ambient light or visible bright lighting source behind or in front of the sign. • Proportion can also improve visibility. Letters and numbers must have a widthto-height ratio between 1:1 and 3:5. The letter X, for example, could be 3 by 5 inches. The ratio of the stroke width to the height must be between 1:5 and 1:10. If each line used to make the X is 1 inch wide, then the line itself could be between 5 and 10 inch long. • Spacing between lines of text should be 25 to 30 percent of the point size. • Many people with disabilities have limitations in movement of their heads and reduced peripheral vision. Thus, signage positioned perpendicular to the path of travel is easiest for them to notice. People can generally distinguish signage within an angle of 30 degrees to either side of the centerline of their faces without moving their heads.2 • Raised borders around signs containing raised characters may make them confusing to read by touch. 1. J. Salmen, “Low Vision Print Legibility.” Universal Design Newsletter. Issue 8 (January 1994). 2. Ibid.

Considerations for the selection of flooring include color contrasts between walls and floors, transitions with no more than 1/8 inch change of elevation and the selection of carpet tiles or cushioned flooring with a matte finish to minimize reflected glare. Furniture should be sturdy and

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Figure 12-9 Design for safety—patient room design to minimize risk of falling. Courtesy of RAD Consultants.

stable with locking rollers. A patient chair should be located near the bed for easy transfer. Many hospitals are reviewing their policies regarding patient lift systems, lift teams, nursing staff requirements, and patient handling. A comprehensive design needs to consider ceiling mounted or mobile lifts, clearance associated with the use of lift teams, and other forms of support like handrails and grab bars. CHECKLIST Environmental Wayfinding and Orientation Cues Wayfinding Cues How do I get there from here? To find the way through a building, cues must be read from signage and from the environment. Yet in most hospitals there is little spatial differentiation; walls are all the same color (for ease of maintenance), and all floors are finished with the same material. • The form of the building provides the strongest way-finding cue. Reduce the number of corridors and limit the building symmetry. Logically place the points where directional choices must be made. • Secure displays of personal collections provide important way-finding and orientation cues. Continued

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CHECKLIST Environmental Wayfinding and Orientation Cues (continued) • A unique patient room entrance can help locate a specific room from down the corridor. The floor tiles in front of each patient room doorway can be differentiated. Gateways and footprints can be added to the carpet. A private mailbox can be installed next to each patient room so the patient can look forward to receiving mail each day. • Color and pattern can be planned for way finding. Corridors can be color-coded for easy directions. • Lighting is also used in way finding. Include a night-light so patients can find their way to the toilets. • Visual connection of spaces also improves way finding. In some hospitals, patients can view corridors from the common area. Other spaces provide patients a chance to observe activities prior to entering. Views to the outside also help. • Convert corridors into atriums and galleries to improve way finding. • Use consistent lighting details at all major decision-making points. Repeat a hospital icon or logo at these points. Use only one symbol per sign. • To guide patients into the hospital, the vehicular approach needs to be clear and visually differentiated from the ambulance entrance. • A lowered ceiling subtly delivers the message that the space is changing from public to private. • Ensure direct visual access to the reception desk from the entrance. The information desk should be easily distinguished from other counters and windows. Olsen and Pershing found that 74 percent of all of patients stopped at this desk to receive way-finding information.1

Orientation Cues Where am I now? Stress caused by disorientation can raise blood pressure, increase fatigue, cause headaches, and produce feelings of helplessness.2 • Small, clearly differentiated spaces aid in orientation. Plan unique layouts for each entry and courtyard. Interior entrances can be recessed for additional spatial differentiation. • Redundant cuing that appeals to all five senses can improve orientation and reduce loss of memory. Patients rely on tactile cues, like objects and air currents, for orientation. Fragrances and visual shapes are also important orientation cues. • A view of the sky and ground helps to maintain circadian rhythms and to prevent hallucinations and disorientation. Patients often experience disorientation between day and night, especially in spaces without windows. Exterior views can also help with awareness of seasonal changes.

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CHECKLIST Environmental Wayfinding and Orientation Cues (continued) • A clock in the patient room can help with time orientation. Also, write the date and day of the week on a whiteboard using nontoxic markers. Don’t mark off days on the calendar, which can reinforce a sense of loss of another day. • Too many repetitive elements in the design may cause disorientation. For example, doors repeated the full length of double-loaded corridors (corridors with rooms off both sides) is confusing. Long corridors themselves can be disorienting. • Side lights and other accent lighting (instead of flat fluorescent light) can help people to maintain orientation within a room. • Plan chairs in a variety of sizes to accommodate both small and large visitors as well as children of all ages. Styles can also be varied to serve as cues for orientation. • To help with orientation and to accommodate people with hearing impairments, avoid tall arrangements of flowers and accessories on furniture that could block visual cues. • Side lights and vision panels in doors help with orientation, allowing patients to look inside to see if this is where they really belong. At the entrance to each waiting room, glass block serves as a nice transition, allowing patients to see through from the corridor for orientation. • An outdoor play area or garden can serve as a strong reference point to help with orientation to the building. A wind chime provides a sense of direction to all users. • Visually confusing mirrors produce distracting patterns that can make concentration and orientation difficult. These problems are exacerbated in hospitals by constant interruption, drug intervention, and other medical treatments. Because patients are prone much of the time, it is more important to differentiate between the ceiling and walls than between walls and the floor. 1. J. Carpmanand and M. Grant, Design That Cares: Planning Health Facilities for Patients and Visitors, 2nd ed. (Chicago: American Hospital Publishing, 1993). 2. S. Schumaker and J. Reizenstein, “Environmental Factors Affecting Inpatient Stress in Acute Care Hospitals,” in Environmental Stress, ed. G. W. Evans (New York: Cambridge University Press, 1982).

A relatively new area of development in acute health-care facility management and design is the accommodation of bariatric patients. Bariatrics is the science of providing health care for those who have extreme obesity. According to the CDC, 67 percent of adults ages 20–67 and approximately 15 percent of children and adolescents are overweight or obese,13 with associated medical costs of up to $147 billion annually.14 The Facility Guidelines

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Figure 12-10 Plan view of bariatric patient room and bath. Courtesy of RAD Consultants; illustration by Laura Bauer.

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Institute has new recommendations specifically for accommodating the bariatric population with dignity. Based on these guidelines, bariatric patient rooms will increase in size, with a clear floor area of 200 square feet to accommodate equipment, sized and structurally designed to accommodate a larger patient (see Figure 12–10). Mobile bariatric equipment includes beds, stretchers, wheelchairs, and patient lifts. Fixed equipment may include large-bore MRI/CT, surgical tables, and exam tables. Door sizes will increase to adapt to larger patient beds with side extensions. Minimum clear dimensions of 60 inches on both sides of the patient bed and the foot of the bed is likely to force a significant increase in the size (width and depth) of the patient room.15 The most significant design changes for the bariatric patient are in the bathroom. Toilet and sink fixtures are floor-mounted with clearance for assistance on each side. A weight-bearing capacity of 1,000 lbs. must be planned. Handrails must also be able to support 1,000 lbs. They are located adjacent to the sink to provide support in addition to the sink and its surrounds. The minimum shower stall size increases to 48 inches by 72 inches.16 Ten percent of furniture in all waiting areas is recommended to be bariatric, with a minimum weight capacity of 600 lbs (see Figure 12–11 and Figure C-22). In the emergency department, diagnostic spaces, and

Figure 12-11 The Arissa Collection easily integrates into any environment and delivers a single solution for every body type. Courtesy of KI.

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treatment areas, the furniture capacity increases to 1,000 lbs.17 Waiting room bariatric-rated chairs can be used for guest seating, but at this time, bariatric patient chairs, sleeper benches, and sofas are not on the market. As these new recommendations are implemented, there will be opportunity for development of furniture and fixtures to extend the same level of patientcentered care as in the rest of the hospital.

CHECKLIST Ramps For more information, refer to the ADA Standard. • To prevent segregation by design, ramps should be designed universally and appear to be an integral part of the architecture. • A universal ramp does not exceed a grade of 1:20. Over two-thirds of wheelchair users cannot use an ADA-compliant ramp with a 1:12 slope and a 30-foot length. • The slope of the landings and the cross slope of the ramp should not exceed 1:50. • Wood ramps are easy to build (and to dismantle). Use fire-retardant wood that has been pressure-treated (or is decay resistant, like redwood). Hot-dip galvanized bolts and screws (with washers) should be used to resist corrosion. • Commercial nonskid surfaces are appropriate for wood ramps. Do not specify carpet for ramps, especially indoor-outdoor carpeting, which may become slippery when wet. Sheet vinyl and painted surfaces are also slippery when wet or dusty. • Permanent concrete ramps should be surfaced with a sand-float or broom finish brushed across the slope, not with it, to prevent slipping. • Cover exterior ramps in climates with ice and snow. Built-in electric heating coils can also be considered. • Curbs with a minimum height of 2 inches must be installed on both sides of the ramp to serve as guardrails for wheels and crutch tips. Use these low curbs instead of side walls to prevent scrapes and bumps. • Shorter ramps without handrails should have flared sides to prevent tripping accidents. • The flat landings at the beginning and end of ramps and at any turnaround point should be at least 5 feet in length. • The ramp should be directed toward the handle side of the door if the door opens onto the ramp. If the door opens into the building, orient the ramp to the hinge side of the door (see Figure 12–12). • The width should be a minimum of 36 inches for one-way traffic, including wheelchairs, 48 inches for two-way ambulatory traffic, and 60 inches for two wheelchairs to pass.

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CHECKLIST Ramps (continued)

Figure 12-12 Ramp oriented to door swing. ADAAG (2002).

CHECKLIST Stairs For more information, refewr to the ADA Standards. • People with reduced balance may be able to manage steps more easily than ramps. • People with mobility differences have difficulty negotiating spiral and curved staircases, which require balance and dependence on the handrails. • Straight staircases must provide a safe stopping place midway between floor levels to help those who are prone to dizziness or who need to conserve energy. A seat on the landing is helpful to many. Landings at frequent intervals minimize the distance a user can fall. • Landings at exterior stairway entrances may become slippery when wet, so they must be slightly sloped (not exceeding 1:50) for drainage. Continued

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CHECKLIST Stairs (continued) • Do not design steps with abrupt or square nosings that project more than 1½ inches. It’s easy to catch a toe on this overlap. Use wedge-shaped fillers on existing square nosings. • Open risers are nearly impossible for people with canes or other mobility aides to use. For a similar appearance, consider clear filler for an open riser. • Keep every riser a constant height (7 inches maximum preferred) and every tread a constant depth (11 inches minimum). • Tread width must also be consistent within each flight, as varied widths can create optical illusions that affect the balance of users. Avoid confusing patterns on stairway floor coverings for the same reason. • To prevent people from walking into hanging stairways or other elevated protruding objects, install wing walls or curbs under them. Guardrails or planters can also be used. • Color-contrast the edges of treads and risers so they can be spotted more easily. This is especially important on the first and last steps. With self-illuminating strips, the edges can be seen in the dark. • Single stairs can be difficult to see and are dangerous when they are not expected or lighted properly. Many building codes do not allow their use, but when it is allowed, changing the texture or color on a single stair helps. • Texture should be used to mark stairway landings and other areas that are hazardous to people with differences in vision.

CHECKLIST Handrails For more information, refer to the ADA Standards. • A handrail diameter of 1¼ inches allows the strongest and most comfortable grip. • The handrail should have rounded ends or return to the wall, floor, or post to minimize the chance that it will snag clothing and cause a fall. It should not extend into the pedestrian pathway by more than 4 inches. • A handrail should also clear the adjacent wall by 1½ inches. This gap is enough to allow a panic grab during a fall, but not wide enough to be dangerous. Many people place their entire lower arm on the handrail to push up; the arm can become wedged between the wall and the rail if a larger clearance is allowed. • To prevent scraped knuckles, the wall surface behind the handrail must not be abrasive. Texture can be used on the handrail itself for improved grip and orien-

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CHECKLIST Handrails (continued) tation. Notches or grooves can be cut in the rail to identify location. Braille and audible cues may also be added. Handrails should not rotate within their fittings. • Contrast the handrails from the wall so that they can be seen quickly in an emergency. • Handrails should be continuous on the inner rail at switchbacks and doglegs, and the gripping surface must be uninterrupted. Mount handrails for accessible ramps and stairs at a height of 34 to 38 inches above the stair nosing or ramp surface. • Handrails should always be installed on both sides of a stair or ramp to accommodate people who are stronger on one side than the other • Handrails are required on ramps if the rise is greater than 6 in. or its horizontal projection greater than 72 inches. • A handrail can be recessed to a maximum of 3 inches if the recess extends at least 18 inches above the top of the rail. • The handrail should extend 12 inches beyond the top and 12 inches plus the width of one riser beyond the bottom of stairs and ramps. At the bottom, the handrail should continue to slope for a distance of the width of one tread. The remaining 12 inches should be horizontal. • At least 3 feet of clearance must be provided between the handrails on stairs (4 feet on stairs adjacent to an area of refuge).

COOPERATIVE CARE AND VIP SUITES Cooperative care and VIP suites are alternatives for inpatient hospitals to reduce the cost of care and raise health-care quality. Some patients may be receiving treatment at the hospital on an outpatient basis, but need additional care that can be provided off-site. Other patients may be transitioning from inpatient care to independent care. These alternatives serve as a transition between hospital and home, allowing the patient to recuperate in a comfortable environment under physicians’ care, in a hotel or home-like setting. Nursing, therapy, radiology, and laboratory services are available in the cooperative care facility with a medical technician acting as the concierge on each floor.

Cooperative Care Model The Rhode Island Hospital is one of the first successful mergers of hospital and hotel—with a twist. With one simple change, the hospital lowered

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operating costs by 30 percent and construction costs by $70.00 per square foot. It increased market share and reduced its daily rate by $200. Treating the same illnesses as a traditional inpatient hospital does, its acute-care length of stay was reduced by 50 percent. The hospital also reduced its readmission rate and improved patient outcomes and satisfaction with care. Medication errors dropped to 79 percent below the expected rate, and slips and falls were reduced by 41 percent. In addition, the hospital improved both job satisfaction and staff retention rate. What was this simple change? All of this was accomplished by asking patients to bring a care partner with them when checking into the medical hotel. The partner stays with the patient in a room that features the comforts of home, the amenities of a hotel, and the security of a hospital. The partner provides much of the routine care and is taught to take vital signs, to chart the results, to take the patient to and from treatment, and to give medication. On discharge, patients have to take their own medication anyway, so it is best to start in the hospital, where help is available if a medication error is made. The partner also monitors the patient, providing comfort and support. In the process, both patient and partner learn to collect data about the illness. They deal with discharge realities while they build skills and confidence to manage at home. In the cooperative care model, the patients wear street clothes. They have the security of locked private rooms (each with a safe), which they share with a partner who cares about them. Dependence on strangers is less than in traditional hospitals; nurses do not enter the rooms without permission. Patients and staff are given beepers in lieu of an overhead paging system. Patients have access to a resource center providing computer searches and current medical research (see Checklist: Computer Stations for all Abilities on page 150). They order their own food in the dining room. They stay in control. Patients and their partners know what to anticipate. The reduction in medication errors and slip and fall is the direct result of an educated patient and a caring partner. The home-care training reduces the readmission rate. The increased patient satisfaction with care reduces litigation and insurance rates. When patients and their families care for themselves, pressure on staff is reduced. High staffing levels are no longer needed. Only three night nurses are required in the Rhode Island Hospital Cooperative Care 74-bed facility, greatly reducing operating costs. The facility has fewer nursing stations, simpler mechanical systems, and fewer rooms with oxygen, which translates into lower construction costs.

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Another example of a cooperative care facility is at the Lied Transplant Center at the University of Nebraska Medical Center. While being diagnosed and treated at the Medical Center, a patient will stay at the Lied Transplant Center and be treated to hotel-style service and amenities. Rooms at the Lied Transplant Center are designed to combine medical functions with comfort and privacy. The rooms have comfortable furnishings, plenty of storage space, and adjustable lighting. Suites are available with separate sleeping and living areas and a kitchenette. The center has a resource room where patients and their families can check their email, search on the Internet, watch a movie, play games, and read. Everyone staying at the Lied Transplant Center has access to the exercise room. It provides the opportunity for patients to regain strength while care partners and guests can work out while they are away from home. To accommodate for families, the facility has a playroom filled with toys, games, and videos to entertain children. For practical convenience, the center has laundry rooms located on three floors and provides dry-cleaning and laundry services by request. The healing gardens provide a quiet place for reflection and conversation. These gardens are based on the principle that interaction with nature produces psychological and emotional effects that enhance healing and emotional well-being. For a successful cooperative care unit, physician buy-in is a key component. Not only must providers be willing to refer patients to the unit, they must also change their thinking to a family-centered paradigm from the traditional staff-centered model. In summary, the design program for cooperative care emphasizes the following priorities: • Patient and partner convenience is a higher priority than staff convenience. People also take priority over machines and process. Clear circulation routes and way-finding systems are provided for guest convenience (see Checklist: Environmental Wayfinding Cues and Checklist: Orientation Checklists on pages XX and XX). Treatment and diagnostic areas must be located close to patient rooms. • The unit’s distinct identity is based on hospitality, which is very different than a medically intensive identity. Arrival and departure areas should reflect the standards of a fine hotel. • Costs, including construction and operations, are controlled. About 85 percent of the time, inpatients call for a nurse because they are cold, hot, thirsty, or have to go to the bathroom.18 A partner can easily address these needs, saving nursing time and resulting costs.

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VIP Suites The VIP suite is an emerging market-driven model where guests have the option for upgraded patient environments. The design and amenities are hospitality influenced (see Figure 12–13). Typically, the patient is ambulatory, recovering from surgery, receiving diagnostic tests or an executive physical. VIP suites may be housed in a separate unit or located within a patient unit

Figure 12-13 Family lodging during recovery. Courtesy of Shepley Bulfinch Richardson and Abbott. Photo: Steve Rosenthal.

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throughout the hospital. When the VIP suites are in their own unit, a separate VIP entrance may be provided (see Checklist: Building Approach and Checklist: Passenger Loading Zones on pages 69 and 139). Staff and equipment are kept out of sight and a separate traffic pattern is established. A dedicated service elevator and pneumatic tube system reduce employee traffic. The policies of the VIP suite are different from an inpatient room at the hospital. The guests are not awakened for baths, medication, maintenance, examinations by interns, or meals. Room amenities may include terry-cloth robes, fresh flowers, a daily newspaper, and business services upon request. Many VIP units feature a gift shop, conference center, fitness center, solarium, and chapel. Most provide round-the-clock security. One even serves high tea from 2:00 to 4:00 p.m. Memorial Hermann Hospital VIP Suites is a luxurious, handsomely appointed 11-suite patient floor with fine materials. Sleek, modern surfaces of

Figure 12-14 VIP patient room with living area. WHR Architects, Inc. Courtesy of Fran Brennan Photography.

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granite, limestone, wood veneers, and etched glass provide a rich backdrop for the soft carpeting and furnishings. The patient floor has a fully equipped business center and a conference room for patients and families to meet with their physician team. A concierge service is provided to see to each patient’s special requests. To ensure privacy and peace of mind, entry to the suites is restricted to professional staff and guests. Exterior doors remain locked at all times and are continually monitored by video surveillance to maintain security. Each patient suite incorporates state-of-the-art technology in a patientfriendly, healing environment. Patients have control of their environment; including shades that can be operated from the patient beds by remote control (see Figures 12–14 and C-23). The elegant bathroom features granite vanities to provide space for personal amenities, lighted mirrors, concealed plumbing, elegant fixtures, and natural material. Built-in granite shelving houses hospital-provided Egyptian cotton towels Figures 12–15

Figure 12-15 VIP suite bathroom featuring lighted mirror, granite counters, and hidden plumbing. WHR Architects, Inc. Courtesy of Fran Brennan Photography.

General Hospitals

and C-23). Sometimes it is what you don’t see that makes a difference, for instance, flush valves and bed pan washers concealed by stone-tile-clad panels. The nurse station and corridor incorporates classic architectural detailing to provide ease in way finding (see Figures 12–16 and 12–17). The nurse station is centrally located to provide prompt service to the patients and guests. Another public area is the library—a comfortable retreat for family and guests to gather and relax (see C-24). Custom millwork holds books, magazines, and newspapers; and granite counters provide beautiful yet durable surfaces for complimentary refreshments.

Figure 12-16 Memorial Hermann Hospital VIP Suites nursing station. WHR Architects, Inc. Courtesy of Fran Brennan Photography.

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Figure 12-17 Entrance to the Memorial Hermann Hospital VIP Suites. WHR Architects, Inc. Courtesy of Fran Brennan Photography.

EXPERT FOCUS VIP or Signature Suites in Acute Care, Expanding Medical Services, and Demand for Private Luxury Suites LOUISE CARTER, AAHID, IIDA, EDAC, RID Principal and Director, Healthcare Interiors, MORRIS ARCHITECTS

While most hospital owners (profit or not-for-profit) continue to provide VIP suites or signature suites, there have been numerous changes in these upgraded patient rooms over the past decade. These changes are primarily due to increased consumer demands for higher-quality health-care services, provided in a luxury hotellike environment. Fortunately these demands are reasonable to attain because of improved technology at lower costs. For example, flat-screen televisions with integral DVD and CD players are commonplace. Upscale and efficient LED lighting is readily available for specialty sconces, overbed lights, lighted mirrors, and accent lighting for millwork units or architectural niches.

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EXPERT FOCUS VIP or Signature Suites in Acute Care, Expanding Medical Services, and Demand for Private Luxury Suites Furniture and upholstery improvements offer a wide range of high-quality, durable, and handsome options for designers and architects. Today, more than ever, high-quality health-care architecture and interior design is achievable because design professionals better understand how to balance function, durability, and aesthetics (see Figure 12–18). Health-care owners can demand unique design solutions within a reasonable budget and expect to accomplish their design as well as financial goals. The greatest challenge today in health-care furniture and finishes is longer lead times, because manufacturers no longer keep significant inventory. Instead they initiate production upon receipt of orders.

Figure 12-18 Signature Suite family living area at the Memorial Hermann Memorial City Heart & Vascular Institute. Morris Architects, Inc. Courtesy of Rick Gardner Photography.

Similar to furniture, artwork, and accessories are critical to the success of a well-designed VIP Suite. Original art and unique accessories provide the finishing touch to complete a healing environment, and these products have also improved with a broad range of selections at a lower price point. Continued

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EXPERT FOCUS VIP or Signature Suites in Acute Care, Expanding Medical Services, and Demand for Private Luxury Suites (continued) Timeless and well-designed finish materials, such as wood-look flooring, decorative and sophisticated resin panels, wall treatments, and acoustical ceiling treatments are readily available (see Figure 12–19). Manufacturers of these products have been pushed by health-care professionals to develop better-designed products for health-care application, using cutting-edge technology for infection control with greater design flexibility.

Figure 12-19 Signature suite patient room at the Memorial Hermann Memorial City Heart & Vascular Institute. Morris Architects, Inc. Courtesy of Rick Gardner Photography.

Design professionals are demanding the use of inherently sustainable materials in conjunction with highlevel aesthetics and performance—all with great success. Finishes and furniture fabricated with eco-friendly methods are “the norm” and manufacturers are being required to document their environmentally sound manufacturing processes. Hospital owners advertise their endorsement of a “zero footprint” environment through their commitment to green architecture and furniture. Involving artists from their local community is both sustainable and supportive of the local economy.

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EXPERT FOCUS VIP or Signature Suites in Acute Care, Expanding Medical Services, and Demand for Private Luxury Suites (continued) Health-care owners have expanded their medical services for VIP suite patients to include concierge and spa services (massages, manicures, pedicures, hair care) as well as interpreter services. Gourmet menus are also available, along with high tea and continental breakfasts for guests as well as patients. While the majority of patients in a VIP suite are businessmen or -women and foreign diplomats, many patients today utilize VIP suites for their annual executive physical. The confidentiality, privacy, and security are worth the added expense. The highest level use of VIP suites remains in women’s services, including labor delivery room, labor delivery room postpartum, postpartum and gynecology. Oncology and orthopedic patients are also common consumers of VIP suites. The greatest operational challenge for VIP suites is the ongoing nursing shortage. VIP suites patients are very demanding, with the highest level of expectations. Because of the shortage, nurses can select their preferred shifts and units of care, which often does not include VIP suites. While the physical environment is soothing and luxurious, the added amenities are often not adequate incentive for many health-care providers. The quality level of care, design, operational functions, and medical technology has improved so significantly throughout the entire health-care campus that “regular” patient rooms are often the equivalent of a high-end hotel to many patients, as well as the staff. This has not diminished the patient demand for VIP suites, but has impacted operational strategies by health-care administrators.

CHECKLIST Tables • Specify a stable base that will support a person who leans on the edge of the top. • Table and desk surfaces should reflect 30 to 50 percent of light. Darker woods, including rosewood and walnut, may reflect as little as 9 percent. A white top reflects too much light and can tire the eyes. Shiny and glossy surfaces also produce too much glare. • A round or oval top on a pedestal base allows a wheelchair user to approach from all directions, but is less stable than a table with legs. • Select a table with a border clearly identifying the edge. • Specify a round table or a table without sharp corners to prevent bruising. • Adjustable-height tables accommodate a variety of projects and reading. High tables (32–36 inches) offer a closer approach for a wheelchair user. High tables also facilitate use of the shoulders and upper arms. If too high, however, such tables may put pressure on the back. • Children require a knee space of 24 inches from the underside of the table to the floor (see Checklist: Accessible Routes for Children on page 210). Continued

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CHECKLIST Tables (continued) • Low crossbars between table legs may prohibit wheelchair access. Crossbars should be recessed a minimum of 19 inches from the front edge of the table. • Skirt boards should be recessed a minimum of 12 inches. • Tables with a minimum clearance of 27 inches allow a wheelchair user to slide under the table apron. • A sled base is easier than traditional legs to move over textured surfaces. • Specify locking casters so that tables can be moved for storage.

CHECKLIST Patient Beds • Typically, a hospital bed is specified for cooperative care and VIP suites to provide the adjustments needed to accommodate for a variety of patients. Many patients struggle to find a comfortable angle for sleeping. Patients who are not susceptible to pressure sores can elevate their knees to relieve lumbar pressure. Elevated beds can also be helpful to clients with respiratory ailments or nausea. Some designs are more hospitable in appearance than others. • A fitted bedspread will not catch in a wheelchair or gurney. • Consider the installation of ceiling eyebolts above the bed for trapezes, tracks, frames, or lifts to aid in transfer or a change of position in bed. As an alternative, provide a trapeze that can connect to the headboard when needed. • A headboard with an upper edge approximately 10 inches above the mattress level may be used for support to rise to a standing position. • A headboard (or head wall) with built-in compartments or shelves can hold television controls, clocks, telephones, communication devices, bed controls, and alarm systems. • A mattress should provide good heat retention, offer sufficient absorption to allow ventilation, and be flame-retardant. It should be firm with little side play. • Systems that allow a person to lie motionless while the mattress adapts to simulate position changes are also available. • All mattress systems should be evaluated for ease of transfer to and from a wheelchair and for dressing in bed. Specify a mattress with a firm edge to help in transferring. • The mattress cover should be changeable and washable. People with allergies often require cotton box spring covers and mattresses with cotton batting and ticking.

General Hospitals

CHECKLIST Patient Beds (continued) • People with limited circulation may prefer to sleep on sheepskin because the fleece serves as a soft support, conforming to the body and improving ventilation and absorption. The sheepskin should be washable. • Keep the mattress and nightstand at equal heights so that the patient can slide a hand across the mattress to the nightstand to locate objects.

CHECKLIST Bathtubs • A soak in the bathtub relieves pain for many people, but standard bathtub design can make it difficult to get in and out. It can be especially difficult to transfer from a wheelchair into a poorly sized tub or a tub with a track. For a tub and shower combination, specify a trackless installation. • For seated users, the height of the tub should match the height of the chair seat. The height that serves most adults and children is 17 inches a.f.f., but the needs may vary from 11 inches for children to 19 inches for an adult (see Checklist: Accessible Bathrooms for Children on page 212). • A seat installed on the end of bathtub is helpful when transferring from a mobility assistance device. The extra length of the tub and seat may extend the floor space in the bathroom to allow a 5-foot turnaround space for wheelchair users. • Bevel the edge of the seat so that it can be used as a headrest and slant the end of the tub to make it easy to slide slowly into the tub from the seat, using the adjacent grab bars. For additional comfort, the slant may be contoured for extra back support. • Install a handheld shower to use from the seat. This is useful to people who do not have the strength to lower themselves into the tub. • Generally, a bathtub should have a flat (not round) bottom for stability. • The floor of the tub must be slip resistant. • Look for tubs with narrow rims or handles that can be grasped when getting in and out. • Use a contrasting stripe to identify the bathtub rim and base perimeter. Vertical stripes in the tub help to identify the amount of water through refraction or bending of the stripes at the level of the water. • Choose a lever-type faucet and drain control for easy operation. Controls must be installed toward the approach side. • To eliminate controls, specify an automatic fill system that programs use and presets the temperature and water level. This is especially helpful if sensitivity to temperature is a factor.

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CHECKLIST VIP Patient Bathroom Amenities • When space allows, consider including a combination washer-dryer. Most people cannot reach the bottom of a top-loading washer from a wheelchair. Frontloading machines also make it easier to lift wet and heavy clothes. Side-hinged doors allow closer wheelchair access than do bottom-hinged doors. • Install an ironing board that drops down from the wall. Portable ironing boards are awkward to set up from a wheelchair and are bulky to store. • Install a retractable clothesline or wall-mounted hanger over the bathtub. Add a second line at 48 inches a.f.f. for seated users. • Storage areas in the patient bathroom are often insufficient and require extra planning. With higher cabinets, interior shelves should be of reinforced glass or clear plastic to make the contents more visible to children, shorter people, and wheelchair users. • A cabinet mounted to the side of the sink is more convenient for access from a wheelchair than a cabinet mounted above the sink. When reaching over a counter from a wheelchair, anything over 44 inches a.f.f. is out of reach. • Drawers beside the sink area, perhaps in a cabinet on wheels, can fill most remaining bathroom storage needs. On all drawers, C-grip handles should be horizontal and centered. • Recess a soap holder so that it does not interfere with wheelchair use and transfer; plan multilevel soap dispensers. A liquid soap dispenser may require less coordination than retrieving bar soap from a holder. • A spa can be made accessible to many people through the addition of a series of steps, the highest of which should be at the height of a wheelchair seat (17 to 19 inches a.f.f.). The user can slide from one step to the next, employing natural buoyancy to help with transfer. • A fold-down utility tray in the bathtub or spa is another convenience.

Endnotes 1. G. O’Dell, L. Runy, 2010 AHA Environmental Scan (Washington, DC: American Hospital Association, 2010). 2. HIMSS Analytics Foundation, 19th Annual HIMSS Leadership Survey Final Report (Chicago: Healthcare Information and Management Systems Society, 2008). 3. Price Waterhouse Coopers, Rock and a Hard Place: An Analysis of the $36 Billion Impact from Health IT Stimulus Funding, 2009. Price Waterhouse Coopers. 4. IRS Exempt Organizations, Hospital Compliance Project, Final Report (Washington, DC: Internal Revenue Service, 2009). 5. National Healthcare Quality Report, (Rockville, MD: Agency for Healthcare Research and Quality, 2008).

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6. R. Ulrich, C. Zimring, The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity, (San Francisco: Center for Health Design, 2004). 7. Center for Disease Control and Prevention, Estimates of Healthcare-Associated Infections, Washington, DC, 2010, retrieved March 15, 2010, from www.cdc. gov/ncidod/dhqp/hai.html. 8. Center for Disease Control and Prevention, “The Direct Medical Costs of Healthcare-associated Infections in U.S. Hospitals and the Benefits of Prevention,” (Washington, DC: CDC, 2009). Available at www.cdc.gov/ncidod/ dhqp/pdf/Scott_CostPaper.pdf. 9. R. Ulrich and C. Zimring, The Role of the Physical Environment in the Hospital of the 21st Century. 10. S. Hignett and T. Masud, “A Review of Environmental Hazards Associated with In-Patient Falls,” Ergonomics 49:5–6(2006): 605–606. 11. A. Hendrich, P. Bender, and A. Nyhuis, “Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients,” Applied Nursing Research 16:1 (2003): 9–21. 12. Center for Disease Control and Prevention, Obesity and Overweight. Center for Disease Control and Prevention. Fast Stats, 2010, retrieved January 25, 2010, from www.cdc.gov/nchs/fastats/overwt.htm. 13. E. Finkelstein, J. Trogdon, J., Cohen, and W. Dietz, “Annual Medical Spending Attributable to Obesity: Payer-and-Service-Specific Estimates,” Health Affairs 28, no. 5 (2009): w822-w831. DOI: 10.1377/hlthaff.28.5.w822. 14. Facility Guidelines Institute, Guidelines for Design and Construction of Health Care Facilities (Chicago:American Society for Healthcare Engineering, 2010). 15. Ibid. 16. Ibid. 17. B. Komiske, “Innovations of Note: Cooperative Care—The Ultimate in PatientCentered Care at a Lower Cost,”Journal of Healthcare Design vol. IX (1995).

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EMERGENCY DEPARTMENTS In a typical year, there may be approximately 120 million visits to hospital emergency departments (ED) in the United States, slowly increasing from year to year. Only about 16 million of those visits were considered emergent, and about a third of the visits were for an injury. The ED is the gateway to the hospital for about half of all admissions, excluding obstetric admissions. Of ED visits that were admitted to the hospital, about 2 percent were admitted to the intensive care unit (ICU). Wait times are always a concern in a busy ED. The median wait time before being seen by a clinician was 31 minutes.1 These statistics indicate that the ED is being overused, reducing quality of care for those truly requiring emergency help. Many factors—increased use of the ED by the uninsured; increased age and number of chronic conditions of patient; staffing shortages in clinical care; declining public and private reimbursements; and disasters (natural and man-made)—are beyond the control of emergency care providers.2 However, strategies to improve efficiency and provide patient-centered care create opportunities for design to contribute to the patient quality of care in emergency medicine.

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The David I. Saperstein Emergency Department at the Ronald Reagan UCLA Medical Center, designed by Pei Partnership, Perkins+Will, and RBB Architects, delivers world-class medical treatment using cutting-edge technology in a compassionate, patient-focused environment. The ED is certified as a Level I Trauma Center for adults and pediatrics. The 20,000-square-foot ED is a comprehensive emergency facility serving nearly 40,000 patients annually. The design of the ED is an open, patient-friendly layout with 31 single patient rooms (Figure 13–1) providing better privacy, reduced noise, and increased versatility for diagnosis and treatment. The patient rooms are configured around a centralized nursing station for continuous monitoring (Figure 13–2). Each patient room has a television and phone for convenience. The unit has several pediatric-friendly rooms, two triage rooms, multiple trauma bays, a designated low-acuity patient care area, and a psychiatric care suite. A concierge greets patients and becomes their initial point of contact (see Figure 13–3). Those waiting to be seen can enjoy natural light and visual access to surrounding gardens and gathering spaces. The waiting area has a separate waiting zone for pediatrics with a TV and child-friendly activities. The adult waiting area is separated into high- and low-acuity areas, designed to increase patient satisfaction while waiting for treatment (see Figure 13–4).

Figure 13-1 Privacy and reduced noise are accomplished through private rooms. Trauma suite at the David I. Saperstein Emergency Department at the Ronald Reagan UCLA Medical Center. Perkins+Will, Pei Partnership, and RBB Architects. Courtesy of Benny Chan/Fotoworks.

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Figure 13-2 Open plan with central nursing station for clear access to ER patient rooms. David I. Saperstein Emergency Department at the Ronald Reagan UCLA Medical Center. Perkins+Will, Pei Partnership, and RBB Architects. Courtesy of Benny Chan/Fotoworks.

Figure 13-3 Concierge desk becomes the first point of contact. David I. Saperstein Emergency Department at the Ronald Reagan UCLA Medical Center. Perkins+Will, Pei Partnership, and RBB Architects. Courtesy of Benny Chan/Fotoworks.

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Figure 13-4 Separate waiting areas for adult (high and low acuity) and pediatric patients. David I. Saperstein Emergency Department at the Ronald Reagan UCLA Medical Center. Perkins+Will, Pei Partnership, and RBB Architects. Courtesy of Benny Chan/Fotoworks.

Figure 13-5 Emergency is seamlessly connected to central public core providing access to amenities. St. Vincent’s Hospital South Tower. Earl Swensson Associates, Inc. Courtesy of Kieran Reynolds Photography.

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St. Vincent’s Birmingham hospital also has a mission of holistic care with a healing, safety-focused environment that is patient centered, family friendly, and staff supportive (see Figure 13–5). The South Tower houses a new emergency department with 29 rooms, supporting patient privacy and HIPAA compliance. Much attention was placed on design to support efficiency, designing for caregiver work processes. Satisfaction of the ED staff has improved in the new spaces, largely due to the fact that the efficiency of design and quietness of spaces cut down on stress and confusion. This translates into shorter wait times; and more efficient, focused patient care by the emergency medical and clinical staff.

INTENSIVE CARE UNITS Intensive care units (ICU) provide comprehensive and continuous care for patients who are critically ill and medically unstable. Admission to an ICU is a potentially stressful event. Pain, fear of diagnostic or therapeutic procedures, sleep deprivation, restricted mobility, and limited visitation concur to induce a sense of isolation. This environment may impair patients’ communication with staff and lead to “ICU psychosis” or delirium.3 Some changes in emotional health occur in 20–30 percent of people who spend more than 5–7 days in an ICU. The design of the ICU has traditionally focused on technology and staff interventions. (see Figure 13–6). The Institute of Medicine strongly recommends that health-care systems become patient centered rather than clinician or disease centered.4 The nursing model should focus on patient preferences and needs. Patients and families should be given the freedom to make their own decisions in an environment that supports family coping, cultural and spiritual needs, visitation, quality care, family presence on rounds and resuscitation, and palliative care.5 From a design perspective, this translates into waiting rooms that are close to patient rooms and include family-friendly amenities. Patient rooms should be sized to accommodate family presence during rounds and interventions. The patient room is a place where prayer and adherence to cultural traditions are encouraged and respected. Today, ICU patient rooms are private—gone are the semi-private and wards of the past. This has provided increased opportunities to design patient-centered care in a high-tech environment. Many ICUs have open visitation and encourage family members to be there at all times. Medical

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Figure 13-6 ICU floor plan. Courtesy of Spector Group with Guenther Petrarca.

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equipment should be stored out of sight when not in use. During use, it should be placed out of the direct sightline of the patient and family whenever possible. Storage must address security and display. Lockable storage should be planned, perhaps in the nightstand or the wardrobe. A display shelf for personal possessions is a thoughtful addition. The telephone should be placed within reach. For ease of use in bed, specify large push buttons in the handset, not in the base unit. Visual access to and from the nursing station is necessary for both the nurse and the patient. Some patients may be too weak to operate a call system. They depend on visual and aural contact. For those who can use the call system, ensure that all controls are lighted for nighttime use, usable by either hand, and operable without tight grasping, pinching, or twisting. They should be intuitively operable and visible, with large, high-contrast lettering. Visual access from outside the room is necessary for caregivers (see Figure 13–7), but there must be provisions for control of visual privacy by the patient. Today, many units have glass walls between the patient room and corridor with breakaway glass doors. Privacy is controlled through the specification of integral blinds (mini-blinds within the window) or a vision panel system. This is a similar concept to integral blinds but utilizes three sheets of glass providing control of opacity. Acoustical privacy is also a priority. Private rooms give the family an opportunity to have confidential conversations with the patient and protect

Figure 13-7 Sliding or pivoting glass doors provide visual contact with caregiver and patient. WHR Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

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from ambient noise. ICU noise levels may be hazardous to health. In one study, 105 healthy women experienced poorer sleep when they were exposed to noise levels characteristic of a critical-care unit.6 Noise has been shown to contribute to fewer visits by family and more staff turnover.7 Design detail can make a significant contribution to acoustical control (see Expert Focus, Validating Acoustic Guidelines, page 201). ICU patients and their families should also be offered options in lighting and HVAC control. Some patients may prefer ambient temperatures of 75° or more and humidity levels as high as 50 percent.8 Controls for lighting and HVAC could be combined with the call system described above (lighted for nighttime use, usable by either hand, easily operable, and visible). Nightlights allow nurses to check on patients without disturbing their rest; supplemental lighting can be used for examinations. Nursing stations may be a combination of centralized and decentralized, located outside the patient rooms providing better visual access to their patients and better communication with the clinical team. Patient units and the patient rooms within those units are getting larger. More space is allocated to accommodate the multidisciplinary team model, bringing technology to the bedside and family participation. Other issues contribute to the quality of care for ICU patients, decreasing the need for patient transports to other areas of the hospital: 1. Access to diagnostic (MRI and CT) and interventional technologies 2. Point-of-care services by ancillary clinicians 3. Access to laboratory and diagnostic services9

EXPERT FOCUS Critical Environments as Laboratories for Research D. KIRK HAMILTON, FAIA, FAIA, EDAC Associate Professor of Architecture, Texas A&M University

The design of critical-care environments is extremely serious business. The stakes are often quite literally life-or-death. In response to such a context, today’s health-care design professionals make many of their most important project decisions on the basis of careful interpretation of credible research. High-quality design for contemporary health care, especially hospitals, is often based on the best available evidence. Uncertainty, however, remains. Even the most experienced practitioners cannot be sure of the ensuing outcomes. Further research about the environment’s impact on physiology, psychology, sociology, and organizational performance is needed. In fact, the critical health-care environment itself can become the research setting. Each such environment may need to be fitted with instrumentation, cameras, and measuring devices intended to capture useful research data.

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EXPERT FOCUS Critical Environments as Laboratories for Research (continued) What are some examples of possible productive research? There can be research about organizational performance with departmental or systems measures to advance our understanding of the physical environment’s role in enhancing efficiency and productivity in vitally important areas like emergency departments, critical-care units, acute patient care units, imaging departments, intervention suites, surgery and recovery, or neonatal intensive care. Other research might focus on the systems and features within specific health-care environments. We might see useful findings about lighting, noise, choice of finish materials, or the mechanical systems that provide heating, cooling, humidity control, and filtration. We need to know about the performance of materials in the context of infection control and the spread of harmful organisms. Systems such as elevators, lifts, pneumatic or gravity tubes, and ubiquitous communications technologies are worthy of deliberate study. The ways in which patients can be isolated when contagious, or in jeopardy of infection, will surely be worth special study. As immune-compromised populations increase and the threat of pandemics grow, we will need better understanding of universal precautions, hand hygiene, anti-microbial materials, positive and negative pressure, and HEPA-filtration, to name only some of the issues. A classic type of research is environment/behavior study. One can study the role of the environment in hand hygiene compliance, observation of patients by staff and family, work design for nurses and other types of staff, or the factors surrounding error episodes. Numerous studies of the way staff interacts with the environment in the course of their work are possible. The environment can make a supportive contribution to the work process, or it can be a barrier to effective performance; it is rarely neutral. Research can also focus on the people found in the environment, such as patients, families, nurses, staff, and physicians. How would the designs be different? Each design planned to become a research site would need to have some number of hypotheses about outcomes and be fitted with any instrumentation needed to confirm these hypotheses. To justify the effort associated with such research, the design should be able to be modified based on the findings. Consequently, such designs would place a premium on flexibility and adaptability. Imagine a design that performs its intended function yet the research data shows that changes might offer significant improvement. If the setting can be altered to accommodate such change without undo difficulty, then the new, higher-performing environment can be in place long before the rest of the building becomes obsolete. Suppose a major academic medical center was planning a new bed tower—could they build two types of patient rooms, or four, to compare features such as locations of hand-washing sinks, features of caregiver stations, access to medical gasses, alternates for ceiling lifts, toilet options, or accommodations for families? Could one room design offer more efficiency for nursing tasks? Could the medical center build two different designs for the patient units on two floors in order to study decentralized nurse positions or travel distances to distributed supply locations? Could they test alternative means of safely delivering and administering medications? Could the less successful environments finally be altered to be like the more successful ones? The need for effective and efficient designs that demonstrably contribute to improved safety, clinical, performance, and financial outcomes is clear. There is value in the ability to treat these critical environments as learning laboratories. Rigorous measurement can, at the minimum, confirm the effectiveness of “best practice” designs and offer reliable guidance for future projects. The research from an active learning lab can suggest important changes and adaptations to deliver still further improvement. This approach delivers a powerful self-correcting model for both health-care organizations and for their evidence-based design professionals.

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CHECKLIST Wardrobes and Dressers • Specify lockable carpet casters on the wardrobe. • Hooks, shelves, and hanger bars in wardrobes should be adjustable for access by children, shorter people, and wheelchair users. Many can reach 4 feet. a.f.f., although a maximum of 3 feet is optimal. • Keep upper shelves transparent or wire for visual access by children, shorter people, and those in wheelchairs. • Utilize space at a reachable level with racks and shelves attached to the backs of swinging wardrobe doors. Sliding wardrobe doors or bifold doors swing out of the way of the wheelchair but cannot be used for storage. • A locking drawer and a shoe shelf at 9 in. a.f.f. are handy features. • Drawers are a good indication of quality. As a test for ease of use, grasp one corner to see if the drawer opens easily. • Patients often use dressers for support when walking or transferring to a wheelchair, so structural integrity is important. • To allow one-handed use, look for drawers narrow enough to open with one central C-grip. • Look for hardware that can be operated with a closed fist or slightly opened hand. • Interiors of wardrobes and dressers should be light-colored to increase visibility. • Look for rounded corners on case goods. The General Services Administration (GSA) Federal Supply Service has required all furniture corners and edges to be rounded to a minimum of 1/8 inch. Rounded corners are especially good for clients with vision problems and those who bruise easily.

SPECIALIZED INTENSIVE CARE UNITS Cardiac Intensive Care Units At Methodist Hospital in Indianapolis, Indiana, the cardiac ICU (CICU) added 56 universal patient rooms to address the needs of cardiology patients and their families. In the past, these patients were moved as many as ten times from ICU to step-down care units. These moves were difficult for patients as well as family members, who had trouble even finding the patient. With the new rooms, the patient remains in place throughout the entire stay.

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To develop the design program, a focus group of patients was used and a mockup room was constructed. It was determined that the room must be oversized and planned with three zones to accommodate patient, family, and staff. The patient zone features a hospitality decor with cabinets on the head wall to conceal the medical gases. The staff zone, between the patient bed and the nursing station, is divided by glass that electronically frosts to provide privacy. The family zone incorporates a chair that makes into a bed for rooming-in (see Figure 13–8). The project produced positive outcomes, including reduced medication errors and falls, increased staff efficiency, and improved patient and family satisfaction.10 However, the unit no longer functions in its original capacity as an acuity-adaptable cardiac setting. The acuity level of patients on the unit has increased, eliminating the need for a step-down feature to the unit.11 With the most comprehensive, fully integrated wireless hospital system in Colorado, Platte Valley Medical Center is one of the few hospitals capable of wireless monitoring patients’ vital information from anywhere within the facility. They have a Level IV Trauma Center and newly expanded

Figure 13-8 Cardiac Comprehensive Critical Care (CCCC) Typical Patient Room Plan. Clarian Health. Courtesy of BSA Design, Indianapolis.

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heart program with the addition of the Cardiac Catheterization Laboratory. Through an arrangement with the Children’s Hospital, the new building features Colorado’s only Level II Special Care Nursery with eight private rooms for at-risk infants, incorporating overnight family accommodations. WHR provided health-care design expertise, medical planning, operational impact consulting, and interior design to produce a hospital built with locally appropriate materials throughout the project, as well as designing a simple elegance that created feelings of a warm, welcoming, and comfortable atmosphere. Because the project was budget driven, cost consciousness was a key factor on a daily basis. Exterior and interior materials were incorporated and the design was planned to feature breathtaking views of surrounding mountains (see Figure C-25).

Neonatal Intensive Care Units A recent trend of neonatal ICU (NICU) design has been to provide single family rooms (SFR) for neonates and their families. Several factors have contributed to the popularity of SFR design: • A positive impact of developmentally appropriate care on infant outcomes • An increased understanding of kangaroo care, the directive of the FGI Guidelines for the Design and Construction of Healthcare Facilities to provide private patient rooms • A need for patient privacy • The success of innovative prototypes One study that focused on the multiple factors leading to the decision to design SFR units used a multimethod research design to evaluate the NICU environment. The study considered patient outcomes, construction costs, and the impacts on staff and families.12 It showed that SFR NICU design provides solutions for increasing parent privacy and presence, increased staff satisfaction, and reduced staff stress. The cost differential between SFR NICU design and traditional open-bay design was 3 percent, negligible when considering the patient outcomes. The study concluded that parent presence and developmental care may influence the health and growth of neonates. Babies of very low birth weights are surviving, necessitating increased lengths of stay in neonatal ICUs (NICUs). They are exposed to high levels of noise and light. Several studies documented noise levels above 49 dBA, which is higher than recommended levels in the NICU (30–40 dBA). Some studies suggest that staff conversations are a major contributor to noise levels.13–16

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The infants’ circadian rhythms may be interrupted for months at a time as they remain under fixed lighting, and their vision may be distorted as they look through an oxyhood. One strong study documented longer sleeping, less time feeding, and increased weight gain when the intensity of light and noise was reduced between 7 p.m. and 7 a.m.17 Another study of cycled lighting confirmed the weight gain, also reporting that the infants were able to be fed orally sooner. They also spent fewer days on the ventilator and on phototherapy and displayed enhanced motor coordination.18 Ambient lighting levels should be adjustable between 1 and 60 fc, measured at the mattress level of the incubator. Higher levels of light can cause infants to lose their eye-blinking reflex. Separate procedure lighting (between 150 and 200 fc) should be available without increasing the lighting level for other babies in the same room. Full-spectrum lighting and warm reflecting color are important choices when monitoring jaundiced or cyanotic babies. Windows providing exposure to natural light may help to establish circadian rhythms while improving staff morale. Although infants do require sensory stimulation, the quality of tactile, visual, and aural stimulation must be controlled (see Figure 13–9). One study documented reduced stress levels in infants in an NICU when exposed to music. The infants also improved their feeding, retained weight, and reduced their length of stay in the hospital.19

Figure 13-9 The NICU environment impacts health outcomes in neonates. Courtesy of RAD Consultants.

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The Boekelheide Neonatal Intensive Care Unit (NICU) at Sanford Children’s Hospital focuses on the needs of their small patients and families. Public spaces included a welcome area and a play area for visiting children. The unit provides Level III care with single family rooms. With approximately 700 admissions per year, a neonatologist is on site twenty-four hours a day in the 45 family suite and 58 bed NICU (see Figure 13–10). Focused on providing family-centered care, the design of the environment include 36 temperature-controlled incubators, indirect lighting, noiseminimizing alarms, a family welcome area, and web-cam access. Parents are encouraged to claim the unit as their own with amenities such as laundry facilities and a comfortable inviting environment (see Figure 13–11). The design team relied on evidence to support the design to reduce hospital stays and improve outcomes, both short-term and long-term. Each family suite has large windows to allow for views of nature and natural light that can be controlled by room-darkening shades (see Figure 13–12). Indirect lighting and sound-deadening ceiling and floor covering materials help to provide control of the environment. The room has a family zone that can be closed off with a privacy curtain, a parent wardrobe, and a workspace for parents (see Figure 13–13). The furnishings are comfortable—a rocker/recliner near the incubator and a sofa that folds out for sleeping. The nursing work area has a hand-washing sink, counter space, a computer, and a refrigerator.

Figure 13-10 Level III NICU at Sanford Children’s Hospital. Courtesy of Sanford Health.

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Figure 13-11 Parents like the design attributes of the public spaces, while appreciating the privacy gained by single family rooms. Courtesy of Sanford Health.

Figure 13-12 Single-family rooms provide control of the environment for parents of neonates. Courtesy of Sanford Health.

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Figure 13-13 Parents have their own space within the single-family room. Courtesy of Sanford Health.

EXPERT FOCUS Design Challenges for Developmental Care of the High-Risk Infant DR. ROBERT D. WHITE, MD, CHAIRMAN OF THE COMMITTEE TO ESTABLISH RECOMMENDED STANDARDS FOR NEWBORN ICU DESIGN, AND NEONATOLOGIST AT MEMORIAL HOSPITAL OF SOUTH BEND The newborn intensive care unit (NICU) presents unique design challenges. Premature infants are developing neuronal connections at a pace unequaled at any other time in life. This process is largely influenced by external stimuli, both from the environment and from the expected maternal input in the form of taste/smell, touch, movement, and voice. Providing an environment that is both nurturing to the infant and supportive to the family is crucial to establishing normal brain development in the high-risk infant.1 For families, the NICU experience can also be life-changing. Post-traumatic stress disorder has been described in the parents of NICU patients; for many, a simple stimulus will bring fearful memories flooding back of bright lights, noisy alarms, even smells and faces. Caregivers too are deeply affected by the environment of care, both physically and mentally; health issues related to ergonomic challenges or shift work are being increasingly recognized, and burnout is a common problem. Two major strategies have evolved to address these concerns. First, standards for NICU design have been developed that promote an optimal sensory environment for the infant, easy access for families, and more desirable working environments for caregivers.2 Second, single-family rooms (SFRs) are becoming commonplace, intended both to control undesired stimuli around the baby’s bed and to enhance the quantity and quality of parent-infant interaction. Data is now appearing that indicate providing for round-the-clock presence of the family can produce substantial benefits for their babies.3

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EXPERT FOCUS Design Challenges for Developmental Care of the High-Risk Infant (continued) Even so, challenges remain for those planning new NICU designs. Larger, quieter, more private NICUs risk separating nurses from their babies and one another, and families also can feel isolated from caregivers and other families.4 Fortunately, strategies are becoming evident to address these concerns. First, NICUs of the future must anticipate and embrace communication technologies that connect caregivers with their babies’ monitors, equipment, and electronic record, with other caregivers, with support services elsewhere in the hospital, and with the outside world. Second, designers should provide gathering places that permit several staff members to collaborate while still remaining in close visual and physical contact with the patient rooms. Third, similar gathering places should be provided for families within the NICU, designed for comfort, interaction, and support. These gathering areas for staff and families may be adjacent or separate but in any case should provide abundant access to sunlight, art, and music. In the 1980s and 1990s, designers and clinicians reveled in displaying their new state-of-the-art technology in bright, sterile-appearing NICUs. We are now entering an era where technology is ever more ubiquitous but is being relegated to its proper place as a behind-the-scenes servant to the babies for whom the NICU is home during a crucial stage of their lives, and for their families and caregivers. 1. R. D. White (ed.), The Sensory Environment of the NICU: Scientific and Design-Related Aspects, Clinics in Perinatology 31(2), 2004. 2. R. D. White, “Recommended Standards for the Newborn ICU.” Journal of Perinatology 27 (2007): S4–19. 3. A. Ortenstrand, B. Westrup, E. B. Brostrom, I. Sarman, S. Akerstrom, T. Brune, et al., “The Stockholm Neonatal Family Centered Care Study: Effects on Length of Stay and Infant Morbidity.” Pediatrics 125 (2010): e278–85. 4. D. D. Harris, M. M. Shepley, R. D. White, J.H.S. Kolberg, and J. W. Harrell, “The Impact of Single Family Room Design on Patients and Caregivers: Executive Summary.” J Perinatol 26 (2006): S38–48.

Families of patients in the NICU are extremely vulnerable to the physical environment. NICU settings are particularly significant in their impact due to the frailty of the infants and the stress and feelings of fear and loss experienced by their families. A recent study focused on family experience, primary family relationships in the NICU between one family and another, families and staff, and families and infants.20 This study found that parents spent more time in conversation with parents of other infants in the SFR unit. However, the study did not show a difference in family interactions with staff. The most interesting findings indicated that families in SFRs interacted more with their infants than families in open-bay settings. The parents in SFR rooms spent more time sitting or standing by their infant and holding their infant, suggesting that the physical environment supported privacy. Developmental care and kangaroo care could be also be implemented within a controlled, private environment.

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FAMILY WAITING Though many critical-care patient rooms have designated space for family members, families also need to spend some time in the waiting area. The waiting environment should be quiet, comfortable, and family friendly. Many of the attributes of the Planetree (see Part 3: Acute Care Hospitals and Chapter 12) focused on meeting and facilitating the needs of the family. Planning should be flexible to support private groupings of furnishings that allow families to sit together. A separate zone to accommodate children should be provided with a wall-mounted flat-screen TV, possibly a DVD system, child seating and tables, books, and toys. Carpet tile flooring provides a soft surface for children and creates playful design opportunities (see Figure 13–14).

Figure 13-14 Colorful carpet tile makes a soft landing for children. Courtesy of The Mohawk Group.

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The lounge should be equipped with a desk and telephone where a receptionist, typically a volunteer, can provide families with information about the patient. Telephones for visitor use should be located outside the waiting room for privacy. Access to the Internet and email is important, and a computer with a password-protected message center may be a good way to share information. The lounge should also offer access to outdoor spaces, providing a change of venue. Windows with garden views also bring natural light into the building. A nourishment station or a small kitchen (see universal kitchen checklists on pages 101 and 102 and Expert Focus: Universal Kitchen Project on page 64) may be located adjacent to the waiting area. Vending machines and a coffee bar should also be offered. The restrooms are best located outside of the waiting space so that their use is not advertised (see toilet, lavatory, and urinal checklists on pages 185 and 186). Plan a pleasantly appointed consultation room for meetings with clinicians, social workers, chaplains, and grief counselors. This room can also be used for respite. The fruit of silence is prayer. The fruit of prayer is faith. The fruit of faith is love. The fruit of love is service. The fruit of service is peace. —Mother Teresa

Endnotes 1. S. Pitts, R. Niska, J. Xu, and C. Burt, National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary (Washington, DC: CDC National Center for Health Statistics, 2009). 2. Committee on the Future of Emergency Care in the United States Health System, Hospital-Based Emergency Care: At the Breaking Point (Washington, DC: National Academies Press, 2007). 3. S. Fumagalli, L. Boncinelli, A. Lo Nostro, et al., “Reduced Cardiocirculatory Complications with Unrestrictive Visiting Policy in an Intensive care unit.”Circulation 113 (2006): 946–952. 4. J. Davidson, K. Powers, K. Hedayat, et al., “Clinical Practice Guidelines for Support of the Family in the Patient-Centered Intensive Care Unit,” Critical Care Medicine 35:2 (2007): 605–622. 5. M. Topf, “Effects of Personal Control over Hospital Noise on Sleep,” Mount Sinai Journal of Medicine 60:6 (1993) 522–527. 6. L. Hiatt, Long-Term Care Facilities (Concord, CA: Journal of Health Care Interior Design, 1990).

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7. D. Harris, “Environmental Quality and Healing Environments: A Study of Flooring Materials in a Healthcare Telemetry Unit,” Dissertation Abstracts International, 4202(00), DAI-A61/11, 2000 (University Digital no. AAT 9994253). 8. D. K. Hamilton and M. M. Shepley, Design for Critical Care: An EvidenceBased Approach (Maryland Heights, MO: Architectural Press, Elsevier, 2010). 9. A. Henrich, J. Fay, and A. Sorrells, “Effects of Acuity-Adaptable Rooms on Flow of Patients and Delivery of Care,” American Journal of Critical Care 13:1 (2004). 10. Hamilton and Shepley, Design for Critical Care. 11. D. Harris, M. Shepley, R. White, K. Kolberg, and J. Harrell, “The Impact of Single Family Room Design on Patients and Caregivers: Executive Summary,” Journal of Perinatology, Supl 3 (2006): S38–S48. 12. W. Kent, A. Tan, M. Clarke, and T. Bardell, “Excessive Noise Levels in the Neonatal ICU: Potential Effects on Auditory System Development,” J Otolaryngol 31:6 (2002): 355–360. 13. Y. Chang, C. Lin, and L. Lin, “Noise and Related Events in a Neonatal Intensive Care Unit,” Acta Paediatr Taiwanica 42:4 (2001): 212–217. 14. L. Gray and M. Philbin, “Effects of the Neonatal Intensive Care Unit on Auditory Attention and Distraction,” Clin Pediatr 31:2 (2004): 246–260. 15. M. Philbin, “The Influence of Auditory Experience on the Behavior of Preterm Newborns,” J Perinatol 20:8, part 2 (2000): S77–S87. 16. N. Mann, R. Haddow, and L. Stokes, “Effect of Night and Day on Pre-Term Infants in a Newborn Nursery: Randomized Trial,” British Medical Journal 293 (1986): 1265–1267. 17. C. Miller, R. White, D. Hagar, and T. Denison, “The Effects of Cycled versus Non-cycled Lighting on Growth and Development in Pre-term Infants,” Infant Behavior and Development18 (1995): 87–95. 18. J. Caine, “The Effects of Music on the Selected Stress Behaviors: Weight, Caloric and Formula Intake, and Length of Hospital Stay of Premature and Low Birth Weight Neonates in a Newborn Intensive Care Unit,” Journal of Music Therapy, 28:4 (1991): 180–182. 19. M. Shepley, D. Harris, and R. White, “Open-bay and Single Family Room Neonatal Intensive Care Units: Caregiver Satisfaction and Stress,” Environment and Behavior 40:2 (2007): 249–268. 20. M. Shepley, D. Harris, R. White, and F. Steinberg, F. Family Behavior in a Singlefamily Room NICU. The AIA Report on University Research, 3. Washington, DC: The American Institute of Architects (2006), pp.174–185.

INDEX A Accessible Bathrooms for Children, 212, 273 Accessible Routes for Children, 210 acute care, 85, 114, 240, 268, 270 acute care hospitals, 67, 86, 99, 114, 193, 195, 255 ADA (Americans with Disabilities Act), 22, 44, 70, 79, 82–3, 86, 91, 95–6, 103, 107, 138, 140, 169, 191, 210 ADA Standards, 86, 138–40, 142, 144, 150, 183–6, 210, 212, 250, 258–60 ADAAG, 44, 69–70, 75, 77–9, 82–3, 91, 96, 103, 107, 169, 184, 191, 205, 259 Adult Day Services and Respite Care, 131, 135 Affinity Health System, 156–7 aging, 2–4, 6, 8, 19, 22, 24–5, 28, 39, 44–5, 61, 79, 83, 85, 108, 112, 114 Alzheimer’s Disease, 4, 8, 11, 27, 29–31, 38–9, 42, 44, 90, 129, 135, 171 ambulatory care, 7, 113–15, 137, 175 amenities, 15, 262–4, 271, 280–1, 290 Americans with Disabilities Act see ADA

apartments, 5, 7–9, 11–13, 17, 22, 24–5, 29, 39–40, 59, 99, 101, 231 appliances, 92, 104, 106–7, 150 area rugs, 22, 53, 229 armrests, 126–8 “Art Preferences” (Eisen), 221–6 assistance, 3, 8–9, 18, 32, 57, 118, 122–3, 140, 153–4, 210, 257 atriums, 9, 11, 17, 19, 146, 174, 233, 254

behavior, 20, 40, 169, 221, 229, 231, 234, 237, 241, 296 Bennington Project Independence, 122, 124 birth centers, 197, 199, 200, 201, 203, 205 Brawley, Elizabeth, 25, 44, 83 Burnett, James, 247–8 burns, 97, 103, 105, 108–9, 184–6, 215 Buxton, Orfeu, 201

B babies, 158, 198, 288–9, 292–3 backrest, 126, 128 Basics of Housing for Home Health Care, 46 bathrooms, 9, 28, 38–9, 42, 47, 55, 61, 68, 70, 73, 77, 90–1, 106, 123, 204–5, 236 designed, 108 public, 38, 46, 182 universal, 108, 110 bathtub, 95, 109–11, 273–4 Bauer, Laura, 55, 178, 256 Beautiful Universal Design, 61, 94, 97, 112, 191 bed, 3, 5, 12, 38, 40, 46, 71, 73–4, 76, 80, 87, 198, 237, 247, 257, 272 bedrooms, 5, 32, 47, 56, 59, 61, 70, 72, 76, 80, 87, 99, 105–6, 120, 228

C cabinets, 38, 42, 51, 101, 103, 109, 150, 184, 200, 211, 231, 274, 287 upper, 101 call buttons, 141 cancer, 4, 85, 134, 162, 164, 171 Carballiera, Andy, 201 care cooperative, 261, 263, 272, 275 environment of, 97, 292 in-home, 118 inpatient, 175, 227, 261 lifetime, 7, 9, 15 outpatient, 115, 142, 175 palliative, 67–8, 281 resident-centered, 23–4 subacute, 85–7, 92–3

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care models cooperative, 261–2 patient-centered, 194 care partners, 194, 262–3 caregivers, 49, 73, 117–18, 132, 200, 283, 292–3, 296 carpet, 21–2, 28, 56, 73, 153, 178, 200, 212, 229, 254, 258 carpeting, 21, 73, 153, 214 Carter, Louise, 268 carts, 21–2, 109, 204 casement windows, 60, 211 casters, 108, 126, 128 ceiling, 46, 87, 90, 95, 99, 110, 125, 201, 218–19, 236, 253, 255, 285 Celebration Health, 173–4 Center for Disease Control and Prevention, 22, 275 Center for Health Design, 83, 195, 202, 275 Centerline Architects, 123–4 chairs, 20, 29–32, 106, 110, 125–8, 145, 151, 183, 207, 231, 235, 258, 286–7 Checklists Lavatories, 68, 182 Carpeting, 21–2 Color, 89–90 Flooring, 203–4 Security, 54, 56 Showers, 183–4 Stairs, 259–60 Tables, 271–2 Windows, 59–60 child, 56, 78, 109–11, 117, 132, 191, 197, 207–8, 212, 214, 222–4 Child-care centers, 132, 134 children, 40, 59–60, 101–2, 108–11, 117–18, 121–2, 132, 134, 141, 178–9, 184–6, 207–15, 220–4, 248, 273–4, 294 older, 134, 214, 221 younger, 221, 224 children ages, 212–13 children’s area, 144, 178

children’s day-care area, 54, 74 Children’s Health Care, 214, 234 Children’s Hospital Garden Environment, 83 Children’s Hospitals, 207, 209, 211–15, 217, 219, 221, 223, 225, 288 clear floor space, 46, 53, 73, 108, 186–7, 210, 213, 248, 250 clearance, 46–7, 74, 76, 82, 97, 108, 138, 144–5, 184, 187, 210, 213, 253, 257, 260–1 clinicians, 170, 277, 281, 293, 295 clinics, 12, 137, 144, 155–6, 293 Coalition of Health Environments Research (CHER), 241–2 color, 35, 42, 88–91, 95, 110, 112, 120, 140, 160, 162, 186, 229–30, 235–7, 241–2, 247–8, 252–4 comfort, 4, 35, 61, 70–1, 73–4, 103, 126–7, 132, 134, 155–6, 160, 169, 200, 207, 212, 262–3 community, 2, 11, 13, 17–18, 23, 47, 54, 65, 74, 121, 129, 131, 172, 174–5, 181, 189–90 computers, 80, 150–1, 155, 161, 174, 200, 222, 290, 295 Condell Medical Center, 189–90 consumers, 3, 19, 46–7, 61, 80, 115, 129 contrast, 3, 19, 22, 80, 88–9, 95, 106, 141, 204, 235–6, 241, 251, 261 contrast glare, 86–8, 177 convenience, 77, 91, 115, 132, 166, 184–5, 263, 274, 278 corridors, 19–20, 22, 29, 33, 40, 88, 91–4, 97, 121, 141, 218, 233–4, 243, 250, 253–5, 267 costs, 5, 12–13, 54, 86, 114–15, 118, 143, 159, 195, 197, 204, 263, 288 cottages, 30 counters, 47, 60, 88, 101–9, 144, 186, 211, 213, 254, 274

countertop, 39, 64, 236 critical care, 277, 279, 281, 283, 285, 287, 289, 291, 293, 295–6 cues, 20, 28, 41, 126, 237, 253, 255 culture, 23, 156, 242–4 curb ramps, 70, 138–9, 175 curbs, 70, 109, 183, 258, 260 curtains, 4, 110, 182, 184, 236 cushioning, 126–7 D day care, 6, 11, 49, 117–18, 121, 128 adult, 118, 122, 129, 134 intergenerational, 119, 121 dday-care centers, 47, 119, 121, 134, 189 daylight, 9, 19, 34, 42, 89–90, 93, 131, 233 dayrooms, 20, 232 deaths, 3, 70–1, 79, 82, 164, 171 delivery, 197, 200, 296 Dell Children’s Medical Center of Central Texas (DCMCCT), 215–16, 218–19, 223 dementia, 4, 17, 20, 23, 27–33, 35, 37–44, 81, 92, 128–9, 131, 242 Denmark, 5–6, 47 depression, 76, 83, 90, 92–3 design, 2–3, 13, 30–1, 64–5, 86–7, 97, 125, 142–3, 177–8, 194–5, 200–2, 233, 255, 281, 284–5, 287–8 evidence-based, 143, 194 health-care, 241 strong patient-centered care, 164 design demonstration centers, 6, 47 developmental care, 288, 292–3 dining, 11, 15, 29, 32, 34, 43, 59, 68, 76, 90, 119, 231 disabilities, 2, 4–6, 47, 49, 61, 86, 91, 97, 223–4, 248, 252 disorientation, 92, 254 dispensers, 111, 185, 213 distractions, positive, 76, 80, 147, 149, 163, 169, 175, 200, 207–8, 218, 221, 244–5

Index

doors, 4, 21, 28, 32, 36, 39, 46–7, 52, 56, 74–5, 77–9, 82, 88, 91–2, 184, 235 interior, 74–5, 91 doors swinging, 46, 75, 77, 97 doorways, 22, 25, 33, 95, 236 dormitories, 64, 233–4 double-hung windows, 59, 211 drains, 74, 77, 103, 105, 109–10, 162, 183–4, 236 drawers, 42–3, 101, 109, 150, 235, 274, 286 dressers, 286 dressing rooms, 153 drugs, psychotropic, 234, 236 E EBD see evidence-based design Eisen, Sarajane, 220 Elderly, 6, 25, 44, 59, 65, 119, 135 Elderly Hospital In-Patients, 22 Ellenbogen, Jeffrey, 201 elevators, 11, 22, 53, 141–2, 210, 235, 250, 285 entry, 17, 21–2, 54, 75, 82, 110, 114, 137, 139, 212, 216, 223, 254, 266 environment, 6, 19, 28, 31–2, 132, 169, 194–5, 220–2, 228–9, 233–4, 237, 240, 242, 281, 284–5, 290–2 patient-focused, 278 residential, 5, 17, 20 upgraded patient, 264 environmental design, 32, 229 Environmental Wayfinding Cues, 29, 253–4 Environmental Wayfinding Cues and Checklist, 174, 263 EPA (Environmental Protection Agency), 71 ER patient rooms, 279 Ergonomics in Health Care and Patient Safety, 71, 83 European group homes, 59 evidence-based design (EBD), 115, 143, 194, 201–2, 285

exit, 30, 52, 82, 110, 123, 131, 141, 145, 162, 223, 251 Expert Focus, 18, 23–4, 32, 61, 101, 108, 110, 131, 143, 178, 201–2, 213–14, 220, 222, 233–4, 284 F facilities, 6, 11, 81–3, 86, 96–7, 123, 125, 137–8, 140, 169, 177, 194–5, 217–18, 231, 233–4, 262–3 acute-care, 97, 155, 239–40 ambulatory care, 115, 227 cooperative care, 261, 263 hospice inpatient care, 67 inpatient, 232 new, 122, 125 outpatient surgical, 160 families, 2–4, 35, 70–1, 73–6, 82, 117–18, 142–5, 169, 194, 200, 207–9, 217–18, 231, 281, 283–8, 292–5 patient’s, 82 private patient rooms support, 250 families care, 262 family-centered care, 137, 169, 217, 240 family rooms, single, 288, 290–1 finishes, 20, 93, 103, 132, 229, 233, 235, 269–70 fireplaces, 13, 18, 20, 34, 71, 120 fitness area, 177–9, 187 Flad Architects, 156–7 floor, 21, 28, 32, 46, 55, 73, 77–8, 88, 106, 108, 110, 120, 141, 183, 204, 252–3, 259–61 floor space, 110, 273 food preparation area, 64 fountains, 71, 144, 210, 218, 220, 224 drinking, 144, 210 furniture, 19, 28, 33, 42–3, 56, 71, 74, 106–7, 128, 134, 142, 204, 229, 233–5, 257–8, 269–70

299

G games, 97, 99, 132, 179, 217, 230, 263 gardens, 18, 35, 39, 41, 68, 71, 73, 83, 131, 146, 166, 169, 194, 218, 223–4, 246–9 glare, 19, 38–9, 42, 73, 86–8, 90, 95, 134, 205, 252, 271 government, 5–6, 8, 171 grab bars, 46, 53, 94–6, 109–11, 183–5, 211, 213, 253 gratings, 70, 183 Green Mountain Ranch, 49–50, 53 GreenGuard Environmental Institute (GEI), 134–5 group homes, 11, 27–30, 32, 57, 59 guests, 129, 174, 263–7, 271 Guidelines for Design and Construction of Health Care Facilities, 25, 86, 275, 288 gurneys, 9, 21–2, 46, 60, 68, 78, 80, 82, 109, 140–1, 152, 183, 204, 236, 249, 272 H hallways, 46, 53, 68, 88 Hamilton, D. Kirk, 284 handrails, 3, 20, 22, 30, 68–9, 90, 94, 97, 108, 139, 175, 182, 210, 223, 250, 257–61 head injury, 97, 107 headboard, 43, 80, 272 healing environments, 11, 115, 143, 194, 225, 240–1, 266, 269, 296 healing gardens, 35, 157, 164, 168, 246, 248, 263 health, 3–5, 29–30, 46, 49, 51, 54, 115–18, 143, 166, 171–2, 174, 178–9, 194, 199, 213, 215 Health-Care Cost Containment, 114 Health-care environments, 21, 194, 212, 214, 241, 285 Health-care facilities, 8, 11, 22, 67, 140, 169, 194, 208, 214, 225 ambulatory, 9, 11

300

Index

health-care services, 7, 143, 175–6, 195, 198, 240 Healthcare Infection Control Practices Advisory Committee (HICPAC), 169, 225 home, 2–8, 11, 23, 25, 27–8, 33–4, 42, 44–5, 49, 61, 91–2, 117, 134, 174, 179, 261–3 demonstration, 49–50 second, 45 service, 85 home care, 3–5, 119, 231 nursing, 28, 85, 114 home health care, 4, 7, 45–7, 49, 51, 53, 55, 57, 59, 61, 63, 65, 108, 114, 131 home health-care services, 45, 49, 61 hospice, 67–75, 77, 79–83 hospice facilities, inpatient, 81 hospice inpatient environments, 90 hospice patients, 67, 81–2 hospital-based wellness centers, 175, 178 hospital gardens, 247 hospital patient environment, 169, 225 hospital room, 214, 246 hospitality, 263–4 hospitals, 83, 114–15, 142–3, 175–6, 195, 197–8, 208–9, 215–18, 239–43, 245–51, 253–5, 257–9, 261–3, 265, 275, 287–90 patient-centered, 240 traditional inpatient, 262 hotels, 64, 252, 261–2 house, 6, 18, 49, 51–5, 71, 82, 91, 123, 149, 153 housing, 3, 6, 8, 11, 25, 27–8, 30, 44–6, 57, 65, 112, 119, 121, 135 accessible, 8, 45–6 Humanitas Bergweg, 8–9, 11 I ICU see intensive care unit ICU patient rooms, 281

ICU patients, 284 incontinence, 20–1, 38 independence, 2–3, 7, 13, 24, 31, 42–3, 45, 47, 57, 85, 92, 98, 102, 112, 118, 134 indoor environmental quality (IEQ), 143, 194, 212, 215 infants, 197–8, 207, 288–9, 292–3 infection control, 81, 270, 285 information desk, 18, 140 inpatient hospices, 67, 81 inpatient psychiatric units, 229, 231, 233, 235, 237 institutionalization, 2, 4–5, 57, 59, 61, 108, 118–19 intensive care unit (ICU), 234, 277, 281, 286, 288, 290, 292, 295–6 J Japan, 5–6, 61, 114 JCAHO (Joint Commission on the Accreditation of Healthcare Organizations), 81 K Karlsberger Architects, 216–17, 219 kids, 207, 211, 215 kitchen, 5, 30, 32, 34, 47, 51, 54, 56, 59, 61, 64, 81, 99, 102–3, 105, 107 country, 123 universal, 53, 63–5, 101 knees, 126–8, 272 Kopec, DAK, 213 L labor, 197–200, 204 landings, 90, 258–9 lavatories, 46, 108, 110, 182, 185–6, 213, 295 LDRP (Labor, Delivery, Recovery, Postpartum 197–8, 200 LEED (Leadership in Energy and Environmental Design), 194–5 Leibrock, Cynthia, 53, 64–5, 108, 110–12, 191

levers, 43, 51, 60, 76, 78–9, 89, 105–6, 109 life, quality of, 28, 30–1, 67–8, 76, 114, 120–1, 171–2, 190 light, 4, 28, 36, 40, 42, 44, 47, 60, 68, 86–8, 90–2, 132, 141, 204, 271, 288–9 light levels, 86–8 light reflectance value (LRV), 242, 251 lighted mirrors, 266, 268 lighting, 3, 17, 22–4, 28, 32, 80, 90–3, 105–6, 134, 139, 146, 175, 177, 200, 215, 284–5 fluorescent, 30, 90, 93 indirect, 19, 99–100, 134, 290 soft, 189, 244 lighting levels, increased, 22, 108 living, 2–9, 11, 13–15, 17–21, 23, 25, 29–30, 33, 44, 46, 54, 64, 85, 128, 131, 135 living apartments, 15, 17 living areas, 25, 59, 263, 265, 269 living communities, 13, 18–19, 23 living room, 20, 29–30, 42, 46, 56, 71, 99, 120, 125 long-term care, 3, 5–6, 13, 29, 67, 131 long-term care facilities, 2, 81, 90, 112, 295 LRV (light reflectance value), 242, 251 M Marsden, John P., 18 mattress, 107, 232, 235, 272–3 MCMC (Mid–Columbia Medical Center), 242–4 meals, 13, 15, 49, 76, 118, 123, 200, 231, 265 Medical Office Building, 143, 161–3 Medical Offices, 139–41, 143–5, 147, 149, 151, 153, 155, 157, 159, 161, 163, 165, 167, 169 medication errors, 262 medications, 13, 27, 38, 57, 109, 227, 235–6, 246, 262, 265, 285

Index

Memorial Hermann, 161–3 Memorial Hermann Hospital VIP Suites, 265, 268 mental illness, 4, 227, 231–2, 237 Mid–Columbia Medical Center see MCMC mobility, 3, 28, 31–2, 57, 61, 64, 68, 88, 93–4, 99, 222, 237, 250, 273 model, patient-centered, 194 Moore, Keith Diaz, 131 mothers, 107, 117, 197–8, 200–1 motor activities, large, 132 music, 20, 28, 32, 40, 68, 76, 80, 91, 99, 134, 221–2, 230, 289, 293, 296 N National Adult Day Services Association (NADSA), 118, 135 National Center for Assisted Living (NCAL), 18–19 National Hospice and Palliative Care Organization (NHPCO), 67, 82 natural light, 13, 18, 80, 99, 125, 146, 148, 156, 164–5, 168–9, 200, 233, 278, 289–90, 295 nature, 17–18, 71, 73, 81, 93, 131, 143, 146–7, 151, 156, 164, 169, 200, 223, 233, 246–7 neighborhood, 5–6, 8–9, 18, 81, 121, 145 Neonatal Intensive Care Unit see NICU neonates, 288–9, 291 NICU (Neonatal Intensive Care Unit), 234, 288–90, 292–3, 296 nurses, 7, 118, 121, 200, 202, 217, 262–3, 271, 283–5, 293 nursing homes, 2, 5, 8–9, 12–13, 17, 28–9, 39, 83, 88, 90–1, 93, 112, 114, 118, 134 O Omnibus Budget Reconciliation Act (OBRA), 86

orientation, 17, 34–5, 42, 68, 87, 92–3, 126, 140, 142, 223–4, 231–2, 237, 254–5 Outdoor Play Areas for Children, 223–4, 248 outdoors, 35–6, 71, 80–1, 87, 223, 255 outlets, 46, 106–7, 150–1 outpatient basis, 115, 227, 261 overweight, 178–9, 255, 275 overweight children, 171, 178–9 P pain, 68, 71, 76, 97, 99, 103, 110, 201, 204, 214, 221, 242, 247, 273, 281 pain perception, 220–1 parents, 118, 158, 178, 207–8, 210–11, 220, 288, 290–3 parking, 17, 81, 138–40, 175, 250 path, 31, 41–2, 162, 224, 252 patient bathroom, 211, 250, 274 patient bedrooms, 73 patient beds, 73, 257, 266, 272, 287 patient care, 99, 240, 281 patient-centered care, 115, 194–5, 207, 240, 249, 258, 275, 277, 281 patient-centered care facility, 166, 242 patient-centered care movement, 115 patient chair, 201, 253 patient experience, 169, 221 patient flow, 156, 160 patient independence, 227, 229 patient outcomes, 288 improved, 249, 262 patient privacy, 281, 288 patient rooms, 73, 92, 107, 200, 202, 215, 218, 220, 235, 247, 250, 254–5, 257, 278, 281, 283–5 bariatric, 256–7 critical-care, 294 part-time, 247 regular, 271 semi-private, 233

301

single, 278 single family rooms, 293 skilled nursing, 86 universal, 286 upgraded, 268 patient safety, 71, 83, 231, 239, 250 patient satisfaction, increased, 154, 262 patient units, 264, 284–5 patients, 70–1, 79–82, 97–9, 114–15, 142–6, 149–51, 153–6, 159–60, 194–5, 217–18, 227–32, 234–6, 254–5, 261–4, 271–3, 283–7 adult, 156, 215 bariatric, 255, 257 educated, 115, 262 elderly hospital, 21 patients and delivery of care, 296 patterns, 32, 80, 89, 93, 127, 204, 233, 235–7, 247, 254 Pediatric Healthcare Environments, 220, 222 pediatric patients, 220–2, 280 pediatrics, 114, 156, 278, 293 Pei Partnership, 278–80 perception, 17, 19, 89–90, 97, 107, 242 Perkins+Will, 228, 230, 232, 278–80 physical therapy, 13, 99, 119, 179, 181, 222 physicians, 114, 118, 143, 156, 172, 174, 179, 199, 240, 261, 285 Planetree, 115, 194, 240, 244, 294 Planning Health Facilities for Patients and Visitors, 91, 112, 169, 255 pods, 151, 217–18 pool, 15, 17, 19, 182, 187–8, 222, 234 Positive Distractions in Pediatric Healthcare Environments, 220, 222 postpartum rooms, 197, 200 postpartum unit, 197–8 power wheelchairs, 22, 107, 205 Pratt Design Studio, 189–90

302

Index

prevention, 7, 22, 39, 107, 115, 137, 154, 169, 176, 191, 225, 275 privacy, 5, 9, 23–5, 29, 38, 70, 143, 151, 155, 159, 185, 187–8, 199–200, 229, 231, 278 private bathroom, 38, 120, 158 private bedrooms, 70, 229 private patient room, 200, 207, 217, 288 private rooms, 23, 39, 42, 68, 70, 200, 214, 229, 278, 283, 288 programming, 31–2, 79, 129, 240, 244 programs, functional, 24 providers, 4, 8, 70, 74, 112, 114, 119, 121, 145, 151, 155, 194, 263 Q quality of care, 13, 28, 73, 86, 114, 142, 155–6, 166, 169, 197, 240, 284 R rail, 3, 103, 260–1 Rampola, Mary Beth, 108, 110–11 ramps, 3, 46, 69–70, 97–8, 132, 183, 188, 205, 210, 222, 258–9, 261 RBB Architects, 278–80 rehabilitation, 7–9, 17, 49, 85, 87, 89, 91, 93, 95, 97, 99, 101, 103, 105, 107, 109 removable cabinets, 47, 109 research, 2–3, 29, 31, 40, 44, 61, 64–5, 80, 93, 97, 115, 117, 194–5, 214, 241–2, 284–5 residence, 3, 15, 36, 39–41, 56 resident care, 19, 28 residents, 2–4, 7–9, 11–13, 15, 17–18, 20–1, 23–4, 27–30, 32–6, 38–43, 47, 54, 57, 59, 86, 120 older, 11, 42, 54, 119 resident’s room, 33, 38, 40 respite, 99, 117–19, 121, 123, 125, 127, 129, 131, 133, 135, 169, 198, 218, 295

respite care, 118–19, 131 responsibility, 24, 46, 115, 117, 134, 154 retina, 87, 236 Rhode Island School of Design, 61, 64–5 risers, 260–1 Rohde, Jane, 23 Ronald Reagan UCLA Medical Center, 278–80 rooms, 19–23, 39–40, 70–1, 73–4, 80–2, 87, 90–3, 151, 197–8, 200–1, 214–15, 217, 229–32, 235–6, 254–5, 262–3 exam, 16, 151–3, 158 furnace, 56 great, 59, 120 inpatient, 265 locker, 182, 188 mother’s, 198, 200 single-family, 291–2 route, 53, 70, 139–40, 188, 210 accessible, 46, 70, 82, 97, 139, 182, 210 rubber, 204–5 S Sanford Children’s Hospital, 290–2 Saperstein Emergency Department, David I., 278–80 Schwarz, Benyamin, 241 seat, 40, 53, 90, 110–11, 126–8, 141, 145, 183, 186–7, 211, 259, 273 security, 3, 5, 8–9, 11, 17, 22, 42, 47, 52, 55, 70, 79, 81–2, 121, 131–2, 262 security systems, 52, 54, 81–2 self-abuse, 233 self-care, 45, 154–5, 172, 190 Senior Living Sustainability Guide (SLSG), 23–4 services, 2–3, 5, 8–9, 12–13, 24, 28, 30, 45, 67, 81, 100, 118–19, 121–2, 129, 143, 295 inpatient hospital, 250 social, 4, 118–19, 121, 143 Seton Family of Hospitals, 216

SFRs (single family rooms), 288, 290–3 shades, 60, 81, 87, 125 Shands Children’s Hospital, 208 Sheet vinyl flooring, 203 shelves, 101, 107, 109, 150, 182, 211, 272, 286 Shepley, Mardelle, 233 shorter stature, adults of, 108–9, 211, 214 shower wheelchair, 95, 109–11, 183, 186, 223 showers, 3, 39, 46, 51, 53, 68, 96–7, 109–11, 182–4, 215, 236 sidelights, 39, 87 signage, 93, 138, 140, 200, 210, 224, 231, 250, 252–3 signature suites in acute care, 268, 270 signs, 22, 210, 212, 250–2, 254, 262 single family rooms see SFRs sink, 21, 39, 47, 64, 95, 103–5, 109, 183, 212, 236, 257, 274 skilled nursing, 3, 7–8, 17 slide, 75, 94, 101, 103, 110, 132, 272–4 sliding doors, 75 slippery, 38, 127, 258–9 slope, 70, 103, 109, 139, 188, 210, 222, 258, 261 SLSG see Senior Living Sustainability Guide smart home technology, 91 smoke detectors, 51, 55–7 Snow, Margie, 143 social interaction, 39–40, 122, 134, 229, 233, 237 solid vinyl floors, 204 Solet, Jo, 201 Solna, City of, 120–1 sound, 4, 19, 45, 56, 71, 75, 89, 91, 121, 132, 141, 201, 214 Sound Sleep Study, 201–2 spa, 19, 99, 125, 160, 182, 188–9, 234, 274 space planning, 68, 79 spaces, 19–21, 23–4, 38–9, 47, 54, 59, 68, 73, 93–4, 107–9,

Index

125–6, 131–2, 141–2, 212–15, 228–34, 254 activity, 123, 125 clear, 139 familiar, 33 flexible, 43, 230, 232 interior, 17, 19 patient corridor, 233 personal, 17, 33, 70, 145, 215, 229–30 private, 20, 22 public, 15, 17–20, 33, 59, 71, 80, 157, 211, 290–1 retail, 179, 181 small, 43, 93 sociopetal, 229 unfamiliar, 17, 20 staff, 23–4, 28, 30, 38–9, 70–1, 123–5, 143, 174–5, 218, 227–8, 233, 262–3, 281, 285, 287–8, 293 stairs, 51, 68, 88, 90, 98, 200, 210, 261 stalls, 182, 184–5, 187 stimuli, environmental, 221 storage, 24, 60, 71, 80, 99–101, 107, 123, 155, 211, 217, 233, 272, 283, 286 Strategies for Creating Better Care Environments, 31, 44 stress, 52, 76, 118, 155, 181, 208, 214, 217, 220–1, 246, 249, 254, 281, 293, 296 strollers, 21–2, 53, 108, 158, 204 Study of Early Child Care and Youth Development (SECCYD), 134 Subacute Care and Rehabilitation, 87, 89, 91, 93, 95, 97, 99, 101, 103, 105, 107, 109, 111 surface, 35, 70–1, 102–3, 110, 132, 144, 150, 186, 202, 204, 224, 236, 252, 261 surgery, outpatient, 143, 160 surroundings, familiar, 28, 57, 214 sustainability, 23–24, 143, 194 Sweden, 5–6, 27–8, 44, 59, 120

symbols, 18, 250–1, 254 systems, 2, 5, 12, 32, 55, 85–6, 114–15, 132, 140, 142–3, 150, 184, 194, 215, 272–3, 285 T tables, 17, 29, 76, 100, 102, 127, 151, 211, 213, 230, 271–2, 294 tactile maps, 251 technology, 2, 4, 59, 61, 85, 112, 115, 143, 166, 172, 174, 209, 239–40, 247, 281, 284 telephones, 32, 55, 79–80, 92, 150, 161, 176, 202, 210, 233–4, 272, 283, 295 temperature, 97, 110, 184, 186, 215, 242, 273 texture, 69, 80, 89, 121, 127, 140, 160, 162, 229, 235–7, 248, 260 therapy integrative, 241, 244 occupational, 49, 99–100, 181, 234 thresholds, 53, 76–7, 87, 141 tissue dispensers, 185 Tofle, Ruth Brent, 241 toilet, 3, 5, 28, 32, 38–9, 59, 94–6, 108–11, 123, 131, 183, 185–7, 213, 236, 254, 257 high, 94 toilet rooms, 123, 153, 250 toilet seat, 39, 111, 185, 187, 212 touch, 24, 28, 31, 34, 76, 132, 221, 241, 252, 292 touch controls, 51, 104, 252 training, 24, 28, 47, 57, 100–1, 120, 176, 178 transfer, 39, 46, 95, 108, 110–11, 126–8, 182–3, 224, 272–4 transmitted noise, 70–1, 75, 91, 176, 231 Transplant Center, 263 tread, 224, 260–1 treatment, 4, 12, 87, 107, 137, 166,

303

168, 176, 179, 194, 209, 218, 233–4, 246, 261–3, 278 tub, 38, 74, 95, 109–11, 200, 211, 273 U units acute patient care, 285 critical-care, 284–5 universal design, 45, 49, 61, 108, 187 urinal, 187, 212 users seated, 101, 105, 108–9, 185, 224, 273–4 standing, 103, 108–10, 183–4 V Validating Acoustic Guidelines for Healthcare Facilities, 201–2 VIP suites, 261, 264–5, 268, 271–2 virtual reality see VR vision, 17, 19, 23–4, 31–2, 90, 108, 142–3, 186, 251, 260, 289 vision panels, 39, 76, 78, 255 visitors, 12, 40, 55, 70, 80–1, 91, 112, 115, 121, 128, 138, 140, 164, 168–9, 189, 217–18 visual, 3, 141–2, 147, 159, 233, 283, 289 VR (virtual reality), 221 W waiting rooms, 142, 144, 158, 161, 217, 255, 258, 281, 295 wall systems, 149–50 walls, 33, 36, 38, 55, 79, 87–8, 95–6, 106, 109, 123, 125, 152, 234–7, 252–3, 255, 260–1 Wang, Wei, 201 wardrobes, 235, 283, 286 water, 19, 38, 71, 87, 102, 109–10, 132, 183, 188, 218, 222, 224, 273 water closets, 108, 110, 212–13 water coolers, 144 weapons, 235–6 wellness, 171–2, 175, 178–9, 190–1, 199

304

Index

wellness centers, 172–9, 181–3, 185, 187, 189–91 wet areas, 182, 188 wheelchair footrests, 108, 128, 182, 211 wheelchair users, 46–7, 49, 56, 59–60, 75, 78, 94, 103, 108–9, 111, 120, 144, 150, 183–4, 188, 271–4 wheelchairs, 21–2, 59–60, 69–70, 74–5, 77–8, 95–7, 101–3,

105–6, 108, 126–8, 150, 182–3, 185–7, 204, 223–4, 272–4 White, Robert, 292 WHR Architects, 147–8, 265–8, 283 window boxes, 68 window seat, 17, 29, 40 windows, 18, 21, 25, 36, 53, 56, 59–60, 68, 73, 87, 90–1, 145–6, 177, 211, 223, 254

awning, 59–60, 211 women, 18, 189, 199–200, 271 wood, 18, 110, 164–5, 214, 235 wood floors, 53, 205 Y Yoon, So-Yeon, 241 Z zones, passenger loading, 68, 139–40, 162

Figure C-1 Dining on each floor for an intimate restaurant-style dining experience. Assisted Living at Legacy at Willow Bend.Courtesy of studioSIX5

Figure C-2 Small social spaces with view to an exterior garden. Courtesy of Susan Rodiek

Figure C-3 Light color carpet reflects light without the glare. Courtesy of The Mohawk Group.

Figure C-4 Elevated planters provide opportunities for residents to participate in planting. Courtesy of Susan Rodiek

Figure C-5 A wandering garden is a safe environment for residents with dementia. Courtesy of Susan Rodiek

Figure C-6 A historic landmark designed as adaptive reuse for adult day care and rehabilitation services facility. Bennington Project Independence. Gary Corey, Centerline Architects. Courtesy of Timothy Doyon, Photographer

Figure C-7 Back porch provides beautiful views of surrounding orchards and farmland. Bennington Project Independence. Gary Corey, Centerline Architects. Courtesy of Timothy Doyon, Photographer

Figure C-8 Contextual architecture provides flexible space for seniors. Bennington Project Independence. Gary Corey, Centerline Architects. Courtesy of Timothy Doyon, Photographer.

Figure C-9 Branded environment for community healthcare. Affinity Health System, Menasha, Wisconsin. Flad Architects, Madison, Wisconsin. Courtesy of Philip Prowse Photography, Minneapolis, Minnesota.

Figure C-10 A vaulted lobby that is right-sized for a pediatric community clinic. Affinity Health System, Menasha, Wisconsin. Flad Architects, Madison, Wisconsin. Courtesy of Philip Prowse Photography, Minneapolis, Minnesota.

Figure C-11 The reception area is rich with design detail, color, and textures. Memorial Hermann The Woodlands Medical Office Building III. Morris Architects. Courtesy of © Joe Aker, Azphoto, Houston.

Figure C-12 Heavy timber arrival canopy and low sloping roofs, copper gutters, and cedar piers welcome arrivals. Bon Secours St. Francis Cancer Institute. Image Courtesy Odell Associates, Photography by Hilliard Photographics, Inc./Joe Hilliard.

Figure C-13 Gardens surrounding the facility provide respite. Bon Secours St. Francis Cancer Institute. Image Courtesy Odell Associates, Photography by Hilliard Photographics, Inc./Joe Hilliard.

Figure C-14 Pediatric rehabilitation therapy pool. Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Photograph: John Durant.

Figure C-15 Serenity room where guests relax between services. Condell Medical Center. Pratt Design Studio. Courtesy of Steinkamp Photography.

Figure C-16 Atrium lobby with custom mobile art at St. David’s Women’s Center of Texas. Earl Swensson Associates, Inc. Courtesy of James F. Wilson.

Figure C-17 “Butterfly Wall,” interactive digital media artwork entices children of all ages to play. Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Courtesy of Marc Swendner, photographer and Seton Family of Hospitals.

Figure C-18 Tiered garden is a focal point from multiple views. Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Photograph: John Durant.

Figure C-19 The sunburst provides positive distraction — a place to enjoy the warmth of the sun and take a break from the hospital. Dell Children’s Medical Center of Central Texas. Karlsberger Architects. Photograph: John Durant.

Figure C-20 Exterior view of the Celilo Cancer Center at Mid-Columbia Medical Center. Courtesy of Jim Semlor, Semlor Images.

Figure C-21 The Arissa Collection is beautifully crafted to comfortably accommodate all users regardless of their shape and size. Courtesy of KI.

Figure C-22 VIP suite living area. WHR Architects, Inc. Courtesy of Jud Haggard Photography.

Figure C-23 VIP suite bathroom with lighted mirrors, granite surface tops on the vanity, and towel shelves. WHR Architects, Inc. Courtesy of Jud Haggard Photography

Figure C-24 The VIP library is a retreat for friends and family to relax. WHR Architects, Inc. Courtesy of Jud Haggard Photography.

Figure C-25 Breathtaking views are a natural asset for the ICU patient room. WHR Architects. Courtesy of © Joe Aker, AZPHOTO, Houston.

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