Healthcare Design Basics 1119813670, 9781119813675

Table of contents :
Healthcare Design Basics
Contents
About the Authors
Acknowledgements
Chapter 1 Introduction
Organization
Design Exercises
Additional Resources
Getting the Most Out of This Book
Companion Website
Additional Resources
Chapter 2 Evidence-based Design
What Is Evidence-based Design (EBD)
Origins of Evidence-based Design – A Brief History
Importance to Design
Principles and Process
Attributes of Evidence-based Designers
Associated Organizations
Additional Resources
Chapter 3 General Elements of Healthcare
History of the US Medical System
Codes, Regulations and Industry Standards
Specialized Facility and Mechanical Requirements
Specialized Demands on Healthcare Workers
The Built Environment’s Role
Additional Resources
Chapter 4 Holistic Analysis
Stakeholders
Operating Standards, Codes, Profitability + Administrator’s Perspectives
Holistic Analysis
Holistic Analysis of the Typology and Its Stakeholders
Case or Precedent Studies
Interviewing and Observation
Integrative Design
Summary
Additional Resources
Chapter 5 Room Requirements
Prototypical Space Requirements for Areas Found in Most Healthcare Facilities
Technology
Resilience
Additional Resources
Chapter 6 Major Specialties
Pediatrics
Dentistry
Gerontology
Palliative Care
Psychological + Psychiatric Practice
Orthopedic Offices
Internal Medicine
Alternative + Naturopathic Medicine
Additional Resources
Chapter 7 Group Practices
Single Specialty Group Practices
Multiple Specialty Group Practices
Employed Physician Practices
General Considerations
Typical Shared Functions and Components
Additional Resources
Chapter 8 Clinic Practices
Community Health or Care Clinics
Urgent Care Facilities
Facility Specific Treatment Spaces
Additional Resources
Chapter 9 Specialized Ambulatory Centers
Ambulatory Surgery
Physical Therapy
Cancer Treatment Centers
Dialysis or Kidney Treatment Centers
Additional Resources
Chapter 10 Architectural Considerations
Sustainability
Structural Systems
Shell or Exterior Envelope
Mechanical Equipment + Technology
Interior Construction
Materials
Medical Equipment + Technology
Adaption + Resilience
Codes
Additional Resources
Chapter 11 Lighting
Review of Basic Lighting Principles
Natural Light
Artificial Light
Occupant Concerns
Additional Resources
Chapter 12 Interior Finishes + Furniture
Healthcare-Specific Considerations
Interior Finishes
Furniture
Additional Resources
Chapter 13 Biophilia
What It Is….and What It’s Not
Why Biophilia Is Important
Integrating Biophilic Elements
Attributes + Elements of Biophila
Application in Healthcare Facilities
Additional Resources
References
Chapter 14 Health + Well-Being
What Is Well-Being + Why Is It Important
Implications for Medical Facilities
Elements + Strategies in Healthcare Settings
Rating Systems that Address Well-Being
Foundations of a Healthy Building
Long-term Implications
Additional Resources
Appendix I Base Plans
Appendix II Assignments and Exercises
Glossary
Index
EULA

Citation preview

HEALTHCARE DESIGN BASICS

H EA LTHCARE D ES I G N BA SICS M A R K K A R L EN , PhD, AIA, NCIDQ (deceased)

S AG L I N DA H ROBERT S, Assistant Professor, Interior Architecture, Chatham University, PA, USA

K Y R A K T UCK ER ,

Program Chair and Director, Interior Architecture Program, Chatham University, PA, USA

Copyright © 2023 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) 750-4470, 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 http://www.wiley.com/ go/permission. Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/ or its affiliates in the United States and other countries and may not be used without written permission. All other trademarks are the property of their respective owners. John Wiley & Sons, Inc. is not associated with any product or vendor mentioned in this book. 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. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors 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 for 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 formats. For more information about Wiley products, visit our web site at www.wiley.com. Library of Congress Cataloging-in-Publication Data Names: Karlen, Mark, author. | Roberts, Saglinda, author. | Tucker, Kyra Krotec, author. Title: Healthcare Design Basics/ Mark Karlen, Saglinda H. Roberts, Kyra Krotec Tucker. Description: Hoboken, NJ: John Wiley & Sons, 2023. | Includes bibliographical references and index. Identifiers: LCCN 2023000320 (print) | LCCN 2023000321 (ebook) | ISBN 9781119813675 (paperback) | ISBN 9781119813736 (pdf) | ISBN 9781119813729 (epub) Subjects: LCSH: Sustainable design—Textbooks Classification: LCC QR111. P333 2023 (print) | LCC QR111 (ebook) | DDC 579/.1757--dc23/eng/20230602 LC record available at https://lccn.loc.gov/2023000320 LC ebook record available at https://lccn.loc.gov/2023000321 Cover image(s): Courtesy of Saglinda H Roberts Cover design: Wiley

 

CONTENTS

About the Authors

ix

Acknowledgements

xi

Chapter 1

Introduction1 Organization2 Design Exercises 2 Additional Resources 2 Getting the Most Out of This Book 3 Companion Website 3 Additional Resources 3

Chapter 2

Evidence-based Design What Is Evidence-based Design (EBD) Origins of Evidence-based Design – A Brief History Importance to Design Principles and Process Attributes of Evidence-based Designers Associated Organizations Additional Resources

Chapter 3

General Elements of Healthcare History of the US Medical System Codes, Regulations and Industry Standards Specialized Facility and Mechanical Requirements Specialized Demands on Healthcare Workers The Built Environment’s Role Additional Resources

Chapter 4

Holistic Analysis 21 Stakeholders21

5 5 5 6 7 8 9 9 11 11 12 12 18 18 19

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CONTENTS

Operating Standards, Codes, Profitability + Administrator’s Perspectives22 Holistic Analysis 22 Holistic Analysis of the Typology and Its Stakeholders 23 Case or Precedent Studies 24 Interviewing and Observation 25 Integrative Design 26 Summary27 Additional Resources 27 Chapter 5

Room Requirements 29 Prototypical Space Requirements for Areas Found in Most Healthcare Facilities 29 Technology51 Resilience51 Additional Resources 52

Chapter 6

Major Specialties 53 Pediatrics53 Dentistry55 Gerontology59 Palliative Care 61 Psychological + Psychiatric Practice 61 Orthopedic Offices 63 Internal Medicine 65 Alternative + Naturopathic Medicine 66 Additional Resources 68

Chapter 7

Group Practices Single Specialty Group Practices Multiple Specialty Group Practices Employed Physician Practices General Considerations Typical Shared Functions and Components Additional Resources

71 71 71 72 72 74 77

Chapter 8

Clinic Practices Community Health or Care Clinics Urgent Care Facilities Facility Specific Treatment Spaces Additional Resources

79 80 82 84 85

Chapter 9

Specialized Ambulatory Centers Ambulatory Surgery Physical Therapy Cancer Treatment Centers Dialysis or Kidney Treatment Centers Additional Resources

87 88 91 93 96 98

Chapter 10 Architectural Considerations 101 Sustainability101 Structural Systems 103 Shell or Exterior Envelope 104

CONTENTS

Mechanical Equipment + Technology 105 Interior Construction 106 Materials111 Medical Equipment + Technology 111 Adaption + Resilience112 Codes113 Additional Resources 113 Chapter 11 Lighting115 Review of Basic Lighting Principles 115 Natural Light 116 Artificial Light 119 Occupant Concerns 119 Additional Resources 123 Chapter 12 Interior Finishes + Furniture 125 Healthcare-Specific Considerations 125 Interior Finishes 127 Furniture129 Additional Resources 131 Chapter 13 Biophilia133 What It Is….and What It’s Not 133 Why Biophilia Is Important 134 Integrating Biophilic Elements 138 Attributes + Elements of Biophila 138 Application in Healthcare Facilities 141 Additional Resources 141 References142 Chapter 14 Health + Well-Being What Is Well-Being + Why Is It Important Implications for Medical Facilities Elements + Strategies in Healthcare Settings Rating Systems that Address Well-Being Foundations of a Healthy Building Long-term Implications Additional Resources

143 143 143 144 148 149 150 150

Appendix I Base Plans

153

Appendix II Assignments and Exercises

161

Glossary

173

Index

181

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ABOUT THE AUTHORS

Mark Karlen (1929–2022) was an architect, educator, and author with extensive experience working in and teaching in the field of interior architecture. His other titles include Lighting Design Basics, Space Planning Basics, and Sustainable Design Basics. Saglinda H Roberts is an Assistant Professor in the Interior Architecture program at Chatham University and has over 30 years of extensive experience in a broad range of project typologies. Her focused research is on the holistic analysis and integration of stakeholder needs. Kyra Krotec Tucker is Chair of the Interior Architecture & Immersive Media programs at Chatham University and the principal of Kyra Tucker + Associates Interior Design. She has over sixteen years’ experience working in commercial and healthcare design.

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ACKNOWLEDGEMENTS

We would like to acknowledge: All the support from the team at Wiley Publishing especially all those in the editorial, production departments. You saw value in expanding the Basic series yet again, and walked with us through the whole process. All the wonderful collaborators. We are grateful for all your insight, talent, time and willingness to be involved. The students at all our respective university who helped to vet the work, show us how to improve it, and how to create a step-by step process to start to understand the complexities of beginning healthcare design. All the clients over all the years that helped us explore and understand the multitude of requirements, aspects, and experiences from a broad range of spaces and typologies. You have made us the educators, designers, and researchers that we are today. I would especially like to acknowledge the insight, knowledge, experience, and great stories of the masters from Mark Karlen, who was a dear friend and colleague. This book was originally his idea. I consider it a privilege to work have worked with him over many years in many different capacities. He will be greatly missed by all that knew him.

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Chapter

1 INTRODUCTION

The purpose of this book is to provide a single resource aimed at upper-level undergraduate or beginning graduate students in interior design or architecture programs wishing to understand healthcare design in a conventional studio setting. It is the hope that it can also provide a resource as the student moves into their professional career. The book primarily examines ambulatory facilities and the spaces that are typically included within those facilities. It covers a variety of typical medical specialties, clinics, and ambulatory care facilities within the 5,000 square foot range. Hospital settings or large long-term care facilities are not covered here. The book is set up to lead the student step-by-step through the design of a range of typical healthcare facilities. The chapters are organized to logically establish a design process starting with the underlying rationale or goals of specialized practices and then move on to holistically analyze the needs of the patients, medical and general staff, as well as visitors. This approach enables the designer to develop spaces that efficiently accommodate the functional aspects required to provide optimum medical treatment as well as meet the emotional, psychological, and physiological needs of all stakeholders. The users of this book are expected to possess basic knowledge and skills of design, drafting, and space planning. Design exercises can be completed either as hand drawings or with the use of computer drafting. Projects are designed to be developed and used in a studio classroom setting or independently. Note should be made regarding terminology used throughout this book. Every effort has been made to use standard professional terminology, but that in itself is misleading. Many words or phrases such as “criteria matrix,” “relationship diagram,” “block plan,” or “barrier free” are used by some professionals and not others. Professionals can use the same word to mean different things and students may not have had the opportunity to come across some of the terms that are used. Do not allow this lack of universality in terminology to become a stumbling block in the learning processes. Exploring unfamiliar terms and phrases helps in developing a strong professional process.

Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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ORGANIZATION The book is organized in 14 chapters that provide a holistic overview of the basic information required for healthcare design projects. • Evidence-based Design, its origins, underlying philosophies, and its importance to healthcare, along with procedures and strategies, are reviewed in Chapter 2 • General Elements that should be present in every healthcare project like ergonomics, wayfinding, infection control, and how the design of healthcare facilities can reduce turnover and medical errors and how the history, governmental, business, and administrative aspects of healthcare shape design are covered in Chapter 3 • Holistic Analysis Methodology that encourages the inclusion of all stakeholders including the facility administrator, client, patient, medical staff, maintenance staff, community, the site, cultural context, and profitability is illustrated in Chapter 4 • Typical space planning requirements for the most common spaces within each medical typology are examined along with space planning exercises to provide practice and reinforce learning are in Chapter 5 • Major specialties such as pediatrics, dentistry, gerontology, psychological, palliative and hospice, rehabilitation and substance abuse, and alternative and neuropathic medicine are covered in Chapter 6 • Group Practices including single specialties practices and multiple specialty practices are examined in Chapter 7 • Community Care Clinics that also serve as community centers, urgent care facilities, and facility-specific treatment spaces like college dispensaries are covered in Chapter 8 • Specialized Ambulatory Care Facilities such as cancer treatment centers, dialysis, physical therapy, and outpatient surgery centers in Chapter 9 • General Architectural Considerations including a brief overview of codes are covered in Chapter 10 • Lighting design as it applies to healthcare design in Chapter 11 • Interior finishes and furniture, including bariatric considerations, are covered in Chapter 12 • Biophilic Design and strategies for incorporating it at a deep level in Chapter 13 • Well-Being in regards to lifestyle and the built environment and the new focus of healthcare focusing on prevention in Chapter 14

DESIGN EXERCISES The examination of each practice is accompanied by design exercises of varying complexity and scope that are used throughout the book interchangeably in each section. These exercises are meant to provide valuable practice, reinforcement, and exploration, as well as increase overall knowledge. Applying newly learned information in a practical way provides important opportunities to learn further and embed information and processes more deeply.

ADDITIONAL RESOURCES Each chapter includes a list of additional resources for further study. These resources have proved valuable to the authors as they have written this book, taught, or researched for healthcare projects. They are meant to supplement the subjects covered in this text and are provided for those who wish to explore topics at a deeper level, or have more specialized information.

I ntrod u ction

GETTING THE MOST OUT OF THIS BOOK The book was specifically designed to be used in a Healthcare Studio, though the information here would be just as useful for the individual learner at the beginning of designing healthcare projects. The information in this book is meant to be applied, not just read. Putting newly acquired knowledge to work shortly after reading is at the heart of learning and can greatly increase comprehension. In the classroom setting, the value of this book is enhanced by the exchange of ideas among students working in collaborative groups, instructor’s comments, and openclassroom critiques and discussions. Beyond the classroom, the reader should take advantage of every opportunity to evaluate existing and published projects and talk with experienced design professionals. Although this book prescribes a particular approach to designing healthcare projects, it should be understood that there are a range of successful methodologies in existence. In the professional community of healthcare designers, the problem-solving process can be varied. It is expected that the individual, after repeated experience with actual problems, will develop personalized methodologies for themselves.

COMPANION WEBSITE A companion website to this book has a variety of tools and resources not found in the printed text. Please explore for additional resources and information.

Additional Resources Design Drafting by Francis Ching Form, Space + Order by Francis Ching Evidence-Based Healthcare Design by Rosalyn Cama Medical and Dental Space Planning by Jain Malkin Space Planning Basics by Mark Karlen and Rob Fleming

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Chapter

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EVIDENCEBASED DESIGN

WHAT IS EVIDENCE-BASED DESIGN (EBD) Evidence-based design is an iterative and integrative approach that bases its decisions on findings from current best practices, the organization and its occupants, and knowledge gained through the scientific study of human interaction with spaces, environments, materials, acoustics, and visual stimuli. The design team looks for deep-level connections between the physical world and the inner psychological and neurological workings of human beings to inform the guiding principles, objectives, and strategies. With the overriding focus on improving design outcomes and providing dignity and support for everyone within system, the profession highly values sharing and publishing data to further industry knowledge and provide credible measurable changes in health, behavior, and learning capability directly related to the built environment.

ORIGINS OF EVIDENCE-BASED DESIGN – A BRIEF HISTORY Florence Nightingale Florence Nightingale was one of the first people to acknowledge and address the importance of the built environment in healthcare and healing. The Environmental Theory, first presented in 1859, is based on her observations and experiences as a nurse during the 1850s cholera outbreak and the Crimean War field hospital in the 1860s. This was the period in history when “Germ Theory” was just being accepted, and handwashing started to be viewed as an important factor in preventing cross contamination. Sanitation was one of the biggest concerns with more people dying of cross-contamination infection than their original injury. In 1862 she published Notes on Nursing: What It Is and What It Is Not, where she proposed that healing increased when patients had access to clear air, water, bedding and Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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bandages, light or daylight, effective removal of waste, and the patient’s body, as well as the doctors’ and nurses’ hands were regularly cleaned. She also believed that it was important for the patient to have a view outside and that controlling the noise in and around the patient was beneficial. Florence Nightingale’s Environment Theory went on to influence hospital design, patient care, and sanitary conditions for the rest of the nineteenth and twentieth centuries. They are still the basis for design, nursing, and infection control practices today. Her observations and suggestions were considered to be the beginning of healthcare reform.

Alvar Aalto – Paimio Tuberculosis Sanatorium Alvar Aalto was a Finish Architect who had an active practice from the 1920s through 1970. One of his most famous projects was the Paimio Tuberculosis Sanatorium. It has been studied and admired for its innovative and beautifully simple, yet effective design solutions since it opened in 1933. Aalto viewed the building as an instrument of healing and approached the design program as a logical scientific problem, not purely as an aesthetic expression. He was new to healthcare design, therefore collaborated heavily with the medical professionals running the sanatorium. To respond, the buildings are very long, tall, and thin with an orientation allowed all 145 patient rooms to have access to south–southwest exposure for optimal sun and daylight through floor to ceiling windows. These windows were designed as two separately framed panels that were slightly offset. This allowed fresh air to enter each room without a direct draft as well as conditioning it in the winter before it entered the space. The social spaces were designed to allow individual control over personal contact for infection control and social preferences. The building configuration and its details respond to the needs and purpose of the occupants, not a preconceived footprint or idea. It’s still an excellent example of holistic collaboration and configuring a building to fit its purpose based on research that serves it occupants.

Roger Ulrich Roger Ulrich is perhaps the most well-known and influential evidence-based design researcher. He brought Evidence-based Design to the forefront of the design industry in 1984 with his now seminal study showing positive differences in patient recovery based on the view outside their hospital window. Evidence-based Design has grown as a profession since then and includes the fields of neuroscience, psychology, science, and architecture. It is also known as human-centered design and is based on an iterative process involving a broad range of interdisciplinary researchers, engineers, designers, and all the stakeholders.

IMPORTANCE TO DESIGN There is a large body of research that connects the built environment with human behavior, health, and well-being. The configuration, materials, and composition of the built environment have been shown to affect patient stress, healing rates, staff effectiveness, and perceived quality of care. The basis of Evidence-based Design (EBD) is to improve the quality of health and well-being and the built environment based on credible research. It strives to be constantly evolving to meet the needs of clients, society, and emerging research. It’s focused on improving design protocol and performance outcomes through innovation based on knowledge and experience. It helps designers understand their clients and occupants better, while possibly discovering and solving potential issues that were unknown. The EBD process possesses an incredible opportunity to improve life for a large number of people and serve society by creating the best possible environment for them to work, play, and heal in.

E v idence - based D esign

PRINCIPLES AND PROCESS EBD strives to look at projects from each occupant’s perspective. Interviews, mapping, research, observations, surveys, actual performative data, and established research from all related fields need to be analyzed by the whole interdisciplinary team. The process may reveal shifts in design objectives or opportunities for innovative approaches to solve issues or improve occupant outcomes that were previously unseen. The focus is on the outcome not preconceived or specific solutions, especially at the beginning.

8 Principles of Evidence-based Design According to the Center for Healthcare Design Evidence-based Design (EBD) should follow 8 basic principles: DEFINE goals, vision, directions, and objectives for the team to articulate and pursue FIND resources with relevant research through existing sources or create basis for new studies INTERPERT findings and assess credibility and applicability to current project CREATE preliminary conclusions, concepts, and guidelines to influence design directives HYPOTHESIZE outcomes directly related to design strategies/directives and establish testing or performance criteria COLLECT information and data from baseline strategies and compare with preliminary guidelines MONITOR application and implementation of research, established guidelines, and design strategies MEASURE postoccupancy satisfaction and occupant input to revise and adjust future design directives

Iterative Process Evidence-based Design (EBD) is an iterative process. Meaning that information and solutions are continually examined, analyzed, tested, and reworked rather than the traditional linear process. The following are steps to better define that process: GATHER Information and External Intelligence REVEAL Possible Design Solutions QUESTION and Analyze EXPLORE Possibilities DECIDE to duplicate existing research or innovate PREMEASURE Critical Features for Positive Outcomes ALIGN Strategic Objective or Stated Outcomes

Types of Research Qualitative Research Qualitative research focuses on understanding or discovering the deeper aspects of human behavior by collecting and analyzing nonnumerical data. It seeks to understand or explore experiences, behavior, and interactions for valuable information that cannot be gained with measurements alone. The five main types of qualitative research are: ETHNOGRAPHY – The researcher embeds themselves into the life or routine of the occupants.The researcher can take a purely observational role, or be an active participant in the function of the organization or space actively experiencing single or multiple perspectives.

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NARRATIVE – Interviews, journals, or documents are used to gather data from one or multiple subjects over time to gain a fuller picture of occupant experience. PHENOMENOLOGY – Experiential or perceptual based view using observations, interview, video, or on-site visits to gain insight or perspectives from users/ occupants. GROUNDED THEORY – Systematic data collection and analysis based on a question or data set. Repetitive ideas, elements and data are grouped, categorized, or coded to form new theories or directives. CASE STUDY – Gathers detailed and in-depth information based on existing project or topic to gain best practices, design strategies, approaches, or outcomes. Quantitative Research Quantitative research is the systematic gathering of information that is transferred or converted into numerical or statistical form. The numerical data represents choices or activity in an unbiased way to identify patterns or to verify or refute a hypothesis. Data collection can be conducted on larger samples or populations to produce generalized results. The four main types of quantitative research are: DESCRIPTIVE – Looks to understand an event, situation, or population through observation and measuring characteristics, trends, or categories through case studies, observations, and surveys CORRELATIONAL – Used to identify the relationship between two variables. Positive correlation shows both variables change in the same direction; a negative correlation shows both variables change in opposite directions EXPERIMENTAL – Aims to measure the effect of one or more independent variables by using the scientific method of only varying one variable at a time. Exacting records are kept to identify the effects QUASI-EXPERIMENTAL – Looks to determine a cause-and-effect relationship like experimental research, but the groupings are less random and is more plausible in real-world situations.

ATTRIBUTES OF EVIDENCE-BASED DESIGNERS Designers can apply evidence-based design principles and strategies regardless of the project typology, the formality of the process, or the client’s desire. Credible research, occupant experience, functional needs, and the input of an interdisciplinary team should be part of every project. The following attributes drive the EBD process but should be qualities that all designers should strive to make part of their professional analytical skills. BE CURIOUS – Choose to look deeper at every aspect, use the Japanese principle of 5-Whys which progressively asks why five times to reveal the underlying or root cause of a problem or issue. BE OPEN to information and new ideas – Approach the design problem free of preconceived solutions and freely welcome information that may initially contradict your initial thoughts. INCLUDE EVERYONE – Look at all stakeholders and their position and concerns. Understanding all sides of a design problem is essential if a holistic solution that truly solves the problem and increases positive outcomes is to be found. VALUE ALL INPUT AS VALUABLE AND VALID – All stakeholders have something to contribute regardless of their professional standing. Many times, the best ideas come from outside the profession; these can give the fullest view of the project.

E v idence - based D esign

UNDERSTAND IT’S A PROCESS – All stakeholders may not be at the same place. Uncovering deeper patterns and more holistic solutions takes time and multiple iterations. Being willing to explore the projects and its needs will yield the best results for everyone.

ASSOCIATED ORGANIZATIONS These are organizations that are especially associated with Evidence-based Design in healthcare settings. They provide valuable information, certification, and networking opportunities. Center for Health Design (CHD) American Association on Health Disability (AAHD) American Academy of Healthcare Interior Designers (AAHID) National Library of Medicine Agency for Healthcare Research and Quality Healthcare Associated Infections Organization The Journal of Healthcare Infection Society Healthcare Design Expo + Conference Facilities Guidelines Institute Institute for Patient Centered Design Nursing Institute for Healthcare Design Society for Advancement of Gerontological Environments

Additional Resources Books A Pattern Language by Christopher Alexander Brain Landscape by John Paul Eberhard Evidence Based Healthcare by Rosalyn Cama Environmental Psychology for Design by Dak Kopec Place Advantage by Sally Augustin The Architecture of Health: Hospital Design and the Construction of Dignity by Michael Murphy with Jeffrey Mansfield and MASS Design Group The Memory of Place by Dylan Trigg The Poetics of Space by Gaston Bachelard Topophobia by Dylan Trigg Articles ± Websites Academy of Neuroscience for Architecture (ANFA) Website: anfarch.org Applying Evidence Based Design to Healthcare Facilities. Retrieved from HMC Architects Website: hmcarchitects.com/news/applying-evidence-based-design-to-healthcarefacilities-2018-09-21 Evidence Based Design Accreditation and Certification Study Guide. Retrieved from The Center for Health Design Website: www.healthdesign.org/clinic-design/solutionlibrary/resources/evidence-based-design-accreditation-and-certification-study The New Standard for Making Hospitals More Hospitable, Hospitality Healthscapes. Retrieved from Boston University School of Hospitality Administration Website: www.bu.edu/bhr/2017/06/07/hospitality-healthscapes The Center for Healthcare Design Website: www.healthdesign.org/topics

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The Center for Health Design, Ambulatory + Clinic Design. Retrieved from the Center for Health Website: ambulatory.healthdesign.org The Center for Health Design, Insights + Solutions. Retrieved from The Center for Health Design Website: www.healthdesign.org/insights-solutions?f%5B0%5D=field_ resource_type%3A1088 Think Better- Neuroscience: The Competitive Advantage. Retrieved from Steelcase Website: www.steelcase.com/eu-en/research/articles/topics/open-plan-workplace/ think-better University of North Carolina Institute for Healthcare Quality Improvement, University of North Carolina School of Medicine Website: www.med.unc.edu/ihqi/about-us Why Architectural Education Need to Embrace Evidence-Based Design, Now. Retrieved from ADPro Website: www.architecturaldigest.com/story/architecture-educationneeds-to-embrace-evidence-based-design-now#:~:text=Architects%20today%20 face%20a%20unique,unconsciously%2C%20see%20and%20be%20in.

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3

GENERAL ELEMENTS OF HEALTHCARE

Healthcare is an industry that is influenced by many factors including a nation’s governmental view of its importance or applicability to certain populations. As the authors are from the United States and that is their main point of reference, a brief history of how the US medical system came to be follows. The point is to understand that there are many factors that influence medical and healthcare facilities across the world, and sometimes even within a single country. Being aware of history and all the resulting factors for the location of the project can provide illumination of design directives, or governmental and/or agencies requirements, making the process more streamlined.

HISTORY OF THE US MEDICAL SYSTEM 1800s – Lumber companies in the Northwest were some of the first to have ­compensated physicians to care for their workers. This would be one of the ­earliest precedents for employer-provided health insurance as we know it today. 1900s – National Convention of Insurance Commissioners introduced a model for other states to follow to regulate health insurance. A few years later, the American Association for Labor Legislation proposed a bill for mandatory health insurance. 1929 – Baylor University Hospital in Dallas,Texas, collaborated with area schools to provide healthcare to teachers, forming the beginnings of Blue Cross health insurance plans. 1930s – The Great Depression highlighted the need for health coverage. Aqueduct workers were given fixed rates for healthcare at a local hospital. This evolved into a managed care system, which is what we refer to today as HMOs and PPOs. Late 1930s to mid-1940s – The Social Security Board recommended national health insurance to be included in the Social Security system. Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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Early 1950s – A federal reinsurance fund was proposed so that private insurance companies could help expand health coverage to its policyholders; around the same time, the Federal Security Agency proposed health insurance benefits for Social Security beneficiaries. 1965 – Medicare was enacted providing insurance for senior citizens (age 65 and older). 1973 – Disabled citizens under the age of 65 became eligible for Medicare. 1996 – Health Insurance Portability and Accountability Act (HIPAA) created additional protections for people with preexisting health conditions. 2010 – Affordable Care Act (ACA) was signed to increase the affordability of health insurance and protect citizens with preexisting conditions. It also enabled children up to 25 years old to remain on their parents’ health insurance plan. The ACA has lowered the amount of uninsured in the US. Healthcare design is certainly influenced by its political and historical evaluation. Understanding this evolution sheds light onto current requirements, legislation, and codes. An understanding of these issues aids in designing and guiding the client through the creation of new facilities. Healthcare legislation does have an impact on the built environment and design directives, similar to how the Affordable Care Act created the need for more primary care clinics, or HIPPA requiring modifications for privacy or changing the way certain areas within a healthcare facility are configured.

CODES, REGULATIONS AND INDUSTRY STANDARDS Building codes are laws that dictate the minimum guidelines when designing a healthcare facility. There are multiple codes that apply to healthcare projects as well as industry standards or other rating systems. The client will have an understanding of other regulatory agencies that must be included or approve design solutions or if there are rating systems they wish to pursue. The Facility Guidelines Institute (FGI) standards are heavily utilized in healthcare design and are considered an industry standard. Federal facilities have additional guidelines, standards, codes, and regulations that must be followed. There are outside accreditation bodies that rate facilities, direct design strategies, and construction protocols to assure quality of care and are required for certain government funded medical coverage. An example would be The Joint Commission (TJC) which is a United States-based nonprofit organization that accredits healthcare organizations and is considered the standard for healthcare design. Another example would be the Commission on Accreditation of Rehabilitation Facilities (CARF) which is an international nonprofit organization concerned with setting standards for rehabilitation and behavioral health institutions. As a design professional, it is important to understand the client’s accreditation, or desired accreditation goals, as many of these have standards for the design of the physical environment. For more detailed information see The Center for Health Design website regarding safety standards.

SPECIALIZED FACILITY AND MECHANICAL REQUIREMENTS Healthcare facilities regardless of their typology should embody all the standard principles of design. They should seek to meet the experiential, functional, social, and cultural needs of the project, consider the site and ecosystem, and work as an integrated whole while being beautiful and resonating deeply with its occupants. In addition to all fundamental aspects of design, there are specialized or expanded requirements present in all healthcare projects that need to be at the forefront of the design process.

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Identifying and Including Stakeholders Stakeholders are any person, group, or agency that would or could be affected by, has an interest in, or could affect the project or its design. In healthcare projects this includes providers, staff, maintenance and cleaning staff, patients, families, administration, owners, designers, architects, engineers, equipment dealers, contractors, neighbors, government officials, the community, donors, or associated outpatient centers. Identifying all the stakeholders is a process that takes place during the initial project phases and is based on collaboration and research. Establishing this can result in a list, but many times a chart or map is created that shows all the stakeholders and their relationships, very similar to systems thinking mapping. By illustrating the relationships with a diagram or map, deeper patterns and connections, or areas of concern are more easily seen and can be addressed; see Figure 3.1. The next step is to assemble a diverse interdisciplinary team that represents the broad perspective of the stakeholders that is focused on collaboration and finding the best possible outcomes. They need to be willing to think outside the box to find solutions to problems revealed by interdisciplinary examination, research, and design. The holistic analysis process is covered in more detail in Chapter 4. MAINTENANCE

CONNECTION TO NATURE

STERILIZATION

INFECTION CONTROL

EXPERIENTIAL GOALS

PATIENT EMOTIONAL NEEDS

SUSTAINABILITY GOALS

NUMBER OF PATIENTS SERVED

FUTURE GROWTH

SUPPLY CHAIN DIALYSIS TREATMENT CENTER

NEIGHBORHOOD IMPACT EMPLOYMENT STATUS ECONOMIC STATUS TRANSPORTATION

STAFF FUNCTIONAL EFFECENCY PATIENT TO STAFF RATIO

PATIENT MOBILITY

PATIENT COMFORT

STORAGE NEEDS

STAFF EMOTIONAL NEEDS

ERGONOMICS

ADDITIONAL MEDICAL CONDITIONS

Figure 3.1  Sample of Stakeholder Mapping. Source: Saglinda H Roberts

Infection Control Inflection control is of utmost importance and the primary focus in any healthcare facility as healthcare-associated infections (HAI) and other easily transmittable illnesses or diseases are of primary concern. The objects, surfaces, and healthcare workers themselves are constantly exposed to multiple pathogens from multiple sources and these can be transported between patients or areas of the built environment without the person’s knowledge. Infection that happens outside of person-to-person contact can be linked with surfaces, materials, environmental conditions, design and layout, cleaning and disinfection processes, and education, with hand hygiene the most important component. Many of the pathogens can persist on surfaces for days or months, and some are even present after cleaning products have been applied. The surfaces, sometimes

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referred to as vehicles of transmission or pathogen reservoirs, can be elements of the built environment, equipment, clothing, or patient care items. Cross contamination or cross infection also depend on how much physical contact there is, type of surface material, cleaning methods, and environmental conditions. The main ways to prevent cross-contact infection or contamination are to increase hand hygiene, create physical barriers to transmission and areas of isolation, make informed surface selections, and institute-educated cleaning protocols. The three main ways the built environment can affect or help deter cross-contact infection are: Surfaces Surfaces are constantly touched by patients and healthcare workers and can be potential reservoirs for all types of pathogens. Surfaces are classified as either hard or soft. Examples of hard surfaces would include doors, door knobs, counters, equipment, floors, keyboards, etc. Soft surfaces typically include upholstery, privacy curtains, clothing, linens. Both types of surfaces can be the root of cross infection. Researching the chemical composition of a surface and the ability of pathogens to adhere to it can be of great help in determining its best use. There is a growing body of materials that have surface coated or impregnated antimicrobial treatments, natural elements like silver or copper in them, or have fine textural configurations that reduce the ability for pathogens to adhere or grow on their surface. The research and long-term effects on human health of all of these options need to be carefully examined and weighted against cross infection. Environmental Conditions Environmental conditions are determined by the HVAC (Heating Ventilation Air-Conditioning) systems. Codes and Facility Guidelines for medical and healthcare facilities all have HVAC requirements. These requirements need to be complied with to satisfy the law, but whereever possible increasing their performance matrix should be considered. How air flows between spaces needs to be carefully analyzed as well as which sections of a facility should be zoned separately, or on separate HVAC systems. These considerations are essential to controlling cross contamination through environmental means. For more detailed information, see Harvard T.H. Chan School of Public Health, or The Center for Health design. Cleaning and Disinfection Cleaning and disinfection are as much about the operations and organizational policies as they are about the cleaning products and staff. Employing education or training, monitoring and compliance systems, and clear procedures and chains of responsibility can increase disinfection. These are not typically the responsibility of the design professional, but being aware of them allows a fuller understanding of the need, the chance to help educate, and the ability to collaborate with infection professionals from the beginning of the process. Areas that typically do fall within the responsibility of design professionals are material selection, room layout, sink or handwashing locations, surface or component configurations, and HVAC systems. Studies have shown that even surfaces that appear clean, or that have recently been cleaned still contain pathogens whether they are considered hard or soft surfaces. Soft surfaces or things like privacy curtains or upholstery are a huge reservoir for pathogens, and hard surfaces like window sills or keyboards are commonly overlooked areas in the cleaning routines. Understanding material specification and the compounds best used for cleaning is paramount along with helping to establish cleaning responsibility, protocol, easy ways to determine if they are clean, and ways to measure compliance are all imperative to disinfection and true cleaning. Looking into alternate methods of disinfection like UV light or other emerging techniques can increase effectiveness without chemicals and decrease labor.

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Areas directly within the design professional’s responsibility is the configuration of details like base, casing, or moldings, the type of flooring and the number of seams that are required, what type of millwork and the opening mechanisms, the position of the sink in relationship to the patient, where are the hand hygiene stations, are there opportunities for hands free operation of elements, or are there easily cleanable options for opening and closing the privacy curtain, and what are the facilities for patients to practice hand hygiene just to name a few. Engaging a Multidisciplinary Infection Team composed of material specialist, product manufacturers, staff and providers, facilities and maintenance staff, infection engineers, and design professionals early in the process can greatly improve infection control and issues with cross infection. For more detailed info see The Center for Health Design website regarding Infection Control.

Perception of Cleanliness The perception of cleanliness is based on the visual observation of patients or visitors and their expectations or understanding of what clean looks like. Studies suggest that the appearance of a medical facility is what is most important in a patient’s evaluation of cleanliness. As important as disinfection and cleanliness are to reduce cross infection or healthcare-associated infections, the perception of cleanliness is the most important determinate to a patient’s satisfaction with care, trust, and impression of facility’s professionalism. How a medical facility is perceived can affect their competitiveness in the growing healthcare market, and this includes the visible environmental services staff. Patients have access to more information, have a broader selection of healthcare choices, and are demanding more aesthetically sensitive and pleasing environments along with higher quality care. To increase the perception of cleanliness in a facility design, professional need to include both cleanability and the appearance of cleanliness into the matrix of all their design decisions. This means that the finish, coloring, texture, and pattern of a material, finish, or detail is just as important as the chemical composition. Flat, satin, or brushed finishes hide dirt better than shiny or semigloss finishes. Slight patterns or changes in the color hide dirt or imperfections easier than solid colors. Colors that are in the medium color range hide dirt easier than very light or very dark colors. This is a double-edge sword so to speak, because most cleaning still relies on visual inspection or is prompted by visible soiling, and the disinfection properties of materials are still of paramount importance in a healthcare setting.

Heightened Need for Physical and Perceptual Comfort People visit healthcare facilities for many reasons. They may be experiencing the best moments of their life, like the arrival of a new baby or positive news regarding their health. They could also be experiencing the worst possible news they could imagine, like the death of a loved one or a bad health diagnosis, and be in extreme physical pain at the same time. Whatever the situation, the patients, as well as the caregivers accompanying them, most likely have heightened emotional states. In the case of illness or injury there are heightened physical and physiological states which can amplify noise, glare, pain, or any type of discomfort. Because of the increased sensitivity it is especially important to pay special attention to occupant comfort, understanding that comfort may take a broader spectrum than is typical. Creating environments that focus on as many different, flexible, adaptable, and variable forms of comfort will be the most appreciated by the occupants. Flexibility, variability, and adaptability relate to furniture types and styles: lighting levels and angles; noise or sound from adjacent TVs, music, or conversations; nodes, groupings, or arrangements of furniture; exterior waiting areas; access to nature or natural elements; materials and finishes; or anything else that is relevant. Occupant comfort can also be increased by providing distraction like televisions, aquaria, toys for younger children, computer stations, free Wi-Fi with easily accessible outlets, books or magazines, garden areas, or walking paths.

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A calming comfortable environment includes being sensitive to any possible stressors for the population served. For instance, installing artwork featuring pregnant women or babies in an OB/GYN office is not appropriate as some users may have traumatic past experiences and be deeply hurt by these images. The point is to understand that anything typically experienced in any other space could be heightened in healthcare facilities and the best preliminary treatment for any condition is to be calm and relaxed and willing to communicate in a meaningful way with the providers. This is best achieved when the patients feel physically and emotionally comfortable and safe as they are waiting to see a provider or are actually being treated.

ADA (Americans with Disabilities Act) and Universal Design ADA is a law that prohibits discrimination based on disability. In regards to design it establishes standards to allow full and equal access to facilities and amenities. Most often it is thought of as allowing wheel chair access, but includes far more. Specific clearances, configurations, and sizes are prescribed by law and are required to be included in every type of project, but are of special importance in healthcare facilities because of the larger population with limitations. Universal design is a principle that strives to create environments and products that can be accessed, understood, and used by the greatest number of people without special adaptions. The focus is on the full spectrum of people who make up the diverse population and considers permanent and temporary limitations in addition to medical or physical conditions. The principles of Universal design are: Equitable Use: Is useful and marketable to people with diverse abilities Flexibility in Use: Accommodates a wide range of individual preferences and abilities Simple and Intuitive Use: Easy to understand regardless of user’s experience, knowledge, language skills, or education level Perceptible Information: Communicates necessary information effectively regardless of ambient conditions or sensory abilities Tolerance for Error: Minimize hazards and adverse consequences from accidental or unintended actions Low Physical Effort: Efficient use with comfortability and minimum fatigue Size and Space for Approach and Use: Provide adequate space to approach, reach, use regardless of body size, posture, or mobility While building codes, ADA and Universal Design provide a basis for design, design professionals must dig deeper to understand the occupants and how they will be using the space. Access and building use begin before occupants are in the building and include how they will be getting to the facility. Planning for adequate parking and access to public transit is just as important as the interior features. While ADA requires a minimum of 36″ openings, if patients are in power or bariatric wheelchairs, that width opening will not be adequate, restricting access to a portion of the population. Truly understanding the population accessing the facility and designing for the broadest level of accessibility, inclusion, and therefore equity should be the highest goal in all design and is especially important in healthcare environments. For further study and more detailed information and requirements, please see the Additional Resources section at the end of the chapter.

Standardization Standardization is the principle or methodology used in healthcare facilities that can be applied at multiple scales and to all aspects of a healthcare facility regardless of its size or typology. It is seen as an effective and efficient way to provide consistent care

G eneral E le m ents o f H ealthcare

at the lowest cost while still providing personalized care that addresses each patient’s unique healthcare situation. Though it can be applied to every aspect of the facility the implications to the built environment will be what is examined in more detail here. When applied to the built environment standardization looks to reduce unwanted clinical variation by increasing efficiency and treatment outcomes through intuitive use of spaces. This means that each type of space is design to be exactly the same. For example, each exam room would have the cabinetry, sink, exam table, standard equipment, and mechanicals in the exact same location. All the supplies within the cabinets would be exactly the same and stored in the exact same order in each exam room. The purpose for this is so providers can focus on threating the patients and not searching for supplies or equipment that they need. It not only increases efficiency, but allows the provider to constantly be focused on the patient and their treatment. Errors are reduced, and it would follow that the patients would be more satisfied and that costs are lowered. Research is still being done to better support these hypotheses more fully. This approach is obviously easier to apply to new construction or large-scale renovations, but applying these principles at whatever levels possible to existing facilities is still beneficial to providers and patients. Standardization is not always fully embraced and therefore creating dialog and collaboration to at least examine possibilities and form strong partnerships between all parties involved in healthcare facilities is many times part of a design professional’s job.

Mechanical Requirements Research has shown that environmental conditions like air temperature, relative humidity, air exchange rates, introduction of fresh air, and pressure differentials can affect the rate of growth of microorganisms. Optimal conditions for cross infection in healthcare facilities are: TEMPERATURE: 68–75 degrees Fahrenheit RELATIVE HUMIDITY: 30–60% (it is very hard for pathogens to replicate or grow at low levels of humidity) AIR EXCHANGE RATE: 6–15 Air Changes per Hour (ACH) PRESSURIZATION: Negative pressure rooms to reduce pathogens spreading to other areas. Positive pressure rooms to keep pathogens from entering room Healthcare facilities may require additional zones, separately controlled or contained systems than a typical commercial project. It is not uncommon for there to be additional or ancillary filtration or purification systems involved as well. Research has also shown that an increase in outdoor or fresh air into a building’s mechanical system increases cognitive function and reduction of toxin levels. These are all important factors to consider when designing the HVAC system for healthcare facilities. Codes are considered the minimum compliance based on past experience. Understanding the emerging research and possible improvements to the built environment that affect people’s lives is one of the design professional’s primary tasks. To refer to the current codes refer to ASHRAE (American Society of Heating, Refrigeration and Air-Conditioning Engineers) Codes for medical facilities. For the growing research regarding the introduction of fresh air and occupant health see Harvard T.H. Chan School of Public Health.

Acoustic and Visual Privacy Acoustic and visual privacy are important in every typology, but especially important in healthcare environments where sensitive information or conversations are happening all the time. The Health Insurance Portability and Accountability Act (HIPAA) requires protection of personal and health information within healthcare facilities. This requires

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extra thought and provisions at check-in or processing areas, file and administrative areas, and between exam rooms. This can also affect communication and collaboration policies that typically take place in hallways or other open office areas. Visual privacy measures need to be given special consideration at exam rooms entrances, screening areas, testing areas, or anywhere patients may need to be partially or fully undressed or in hospital gowns. For more information on the importance of acoustic and noise control see The Center for Health Design website regarding Noise.

Thermal Comfort Thermal comfort can be a challenge in medical facilities because of the differences in activity levels between patients and healthcare providers or staff. This requires additional design directives and goals to the project. The best way to ensure that all occupants have the highest levels of thermal comfort is collaboration with engineers and other stakeholders at the very beginning of a project to create the zoning of HVAC systems to meet the needs of all activity levels and spatial requirements. Chapter 10 deals with mechanical systems further.

Materiality Materiality in healthcare environments takes on special meaning; it is one of the main factors in infection control. They also need to withstand very heavy traffic, heavy wheeled equipment, extensive and harsh cleaning protocols, and still look beautiful and not contribute to the toxin levels in a space. Flooring greatly contributes to the safety of a facility and visual acuity of patients. Many manufactures have special healthcare collections, and industry standards and codes dictate many of the finishes. Materials are dealt with in more detail in Chapter 12– or see Additional Resources below.

SPECIALIZED DEMANDS ON HEALTHCARE WORKERS In general, the healthcare fields are a mentally, emotionally, and physically demanding profession. The level of intensity can change with the specific typology, but all areas the healthcare field have the propensity to be stressful, affecting providers and staff alike. Shifts in medical offices are typically around 8 hours per day, but for providers who are on call, or do rounds at the hospital before and after office hours their shifts could be between 10 and 12+ hours per day. Nurses in a hospital setting can walk between 2 and 5 miles per day. The healthcare field has a high rate of turnover and fatigue is cited as one of the major reasons for changing jobs. Burn-out in the medical professions area is very real issue. Many facilities are designed to be extremely functional for medical treatments, but don’t take into consideration that the providers and staff space much of their time cut off from any view of the outside. This causes them to lose a sense of the passage of time, and negatively affects their circadian rhythms in turn affecting their stress levels and overall well-being. Designing to meet the health and well-being of the healthcare providers and staff is as important as considering the needs of the patients and their families or caregivers.

THE BUILT ENVIRONMENT’S ROLE The built environment has the ability to improve efficiency, function, and more and more research and studies are showing the health and well-being of its occupants. Some simple ways that a building can improve the lives of all its occupants are as follows: Space planning and  Adjacencies – By properly arranging spaces that are typically used together time and energy are saved. This allows rooms, spaces, and

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functions to be arranged how they work best, driving the overall configuration of a facility, instead of preconceived norms that don’t address actual behavior. Travel Distances – By working collaboratively and studying the actual movements and work flow of the facility as an outside observer, travel distances can be reduced. This translates to greater efficiency, less physical stress on providers, and more effective treatment for patients. Daylight and Views for Everyone – Research is continually showing the importance of daylight, natural light, and views of the exterior. In most ambulatory facilities, the providers and staff spend more time there than the patients. Asking how to provide daylighting and views to the most people for most of their day allows interesting and radical design decisions to be considered that improve the aesthetic and functional aspects of a facility. Break Spaces and Areas of Respite – The ability to step away from the stress, or simply having a place to eat during long sifts or use the restroom within close proximity to duty areas is a very important way to relieve the constant stress that can be part of the medical profession. Providing areas for private phone calls or access to the outdoors that is private and away from patients allows time for respite, relief from stress, and can reenergize and lower stress levels of providers and staff. T   hese may seem like vey minor things, but are so often absent from healthcare workers’ lives. The overriding purpose of the built environment is to support, protect, and provide refuge for all occupants.

Additional Resources Books Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin The Architecture of Health: Hospital Design and the Construction of Dignity by Michael Murphy, Jeffery Mansfield and MASS Design Group Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Articles and Websites Architecture That’s Built to Heal. Retrieved from TED.com Website: www.ted.com/talks/ michael_murphy_architecture_that_s_built_to_heal?language=en Clean Hands Save Lives: A Systems Approach to Improving Hand Hygiene. Retrieved from The Center for Health Design Website: www.healthdesign.org/insights-solutions/ clean-hands-save-lives-systems-approach-improving-hand-hygiene Contact Transmission, Part 1: The Role of Surfaces in Healthcare-Associated Infections. Retrieved from The Center for Health Design Website: www.healthdesign.org/ insights-solutions/contact-transmission-part-1-role-surfaces-healthcare-associatedinfections Contact Transmission, Part 2: Materials, Design, and Cleaning. Retrieved from The Center for Health Design Website: www.healthdesign.org/insights-solutions/contact-transmissionpart-2-materials-design-and-cleaning Gallery: The beauty of Architecture Heals. Retrieved from IDEAS.TED.COM Website: ideas.ted.com/gallery-the-beauty-of-architecture-that-heals Harvard T.H. Chan School of Public Health Website: www.hsph.harvard.edu History of Health Care Reform Debate. Retrieved from the Medicare Supplement Website: https://www.medicaresupplement.com/news/history-of-health-carereform-debate/

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Hospitality Healthscapes: The New Standard for Making Hospitals More Hospitable. Boston University School of Hospitality Administration Website: www.bu.edu/ bhr/2017/06/07/hospitality-healthscapes Materials Health in Healthcare Facilities. Retrieved from the Healthcare Facilities Today Website: https://www.healthcarefacilitiestoday.com/posts/Material-Health-inHealthcare-Facilities--25210 The Center for Health Design, Topics Page. Retrieved from The Center for Health Design Website: www.healthdesign.org/topics The Center for Health Design, Safety Toolbox. Retrieved from The Center for Health Design Website: www.healthdesign.org/safety-toolbox The Center for Health Design, Noise Toolbox. Retrieved from The Center for Health Design Website: www.healthdesign.org/noise-toolbox The HEPACART Complete Guide to Hospital Anterooms. Retrieved from the HEPACART Website: www.hepacart.com/a-complete-guideto-hospital-anterooms?hsCtaTracking=10b6266b-e2f6-49e0-96afa907288c5263%7C2c31b19b-b60b-424d-b49e-f92ca3379d69 What can Healthcare Learn from Retail + Hospitality. Retrieved from HealthSpaces Website: info.healthspacesevent.com/blog/what-can-healthcare-learn-from-retailhospitality What is Universal Design. Retrieved from the National Disability Authority, Centre for Excellence in Universal Design Website: universaldesign.ie/what-is-universal-design

Chapter

4

HOLISTIC ANALYSIS

Design is problem solving. Design is also a service profession. We serve humanity by creating environments that best serve their intended function, in the most efficient and beautiful manner, for the broadest population of users. To do that we need to have a very broad, comprehensive understanding of the problem and how it affects or interacts with everything. Our goal should be to look for and be committed to finding the best long-term holistic solutions that go beyond mere aesthetics to solve the deeper problems that emerge. Our research and understanding of the problem are what should be informing and shaping our design directives and solutions. Depending upon the level of experience with the specific typology being designed, the steps mentioned below could take place in a different order. The sequence is less important than seeking to holistically understand the project. Some of the ways that we can do that are understanding who is or will be affected by our project, where our project is located, what the comprehensive goals of our client and the people who use it are, and what are the best practices or lessons learned from previous projects. The order in which we research or examine the below elements can change in relation to our experience with a specific typology, but they should all be there at some point if we are to truly address every aspect of a design project.

STAKEHOLDERS In regards to the built environment, or design, “stakeholders” are anyone who is affected by, has an interest in, or could affect the project. In the past this typically meant the owner or client, the designer, and the contractor. The way it is approached now is to consider everyone involved from all sides of the project. This means the occupants, not just the patient and providers or medical staff, but the administrative staff, business development, facility administrators, maintenance, cleaning, volunteers, patients, n­ eighbors, zoning boards, all other design and engineering professionals, equipment distributors, and whomever else can be identified. Every person from every aspect of a project, surrounding neighborhood, or profession has a valuable and valid point of view and information leading to better Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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design decisions. It is the design professional’s job to facilitate this conversation and confer the proper respect and value for each person’s contribution.

OPERATING STANDARDS, CODES, PROFITABILITY +  ADMINISTRATOR’S PERSPECTIVES Healthcare facilities are a highly complicated and regulated typology. Design decisions are highly regulated by codes, as well as best practice procedures from governing bodies and healthcare organizations. These protocols can create a pathway for more efficiency in healthcare projects, as well as create requirements. Understanding where each organization stands in regard to the applicable codes or operating standards is crucial. Many healthcare organizations have adopted a culture of quality and performance improvement. This working model is often referred to as LEAN (Leadership. Eliminate waste. Act now. Never ending). Although this model originated in manufacturing, many of the principles apply to healthcare. Designing for LEAN or quality and performance improvement is reliable for reducing operating costs and optimizing the delivery of care. Design professionals should understand these principles so that they can observe the users and make recommendations for changes in the built environment to improve efficiency. As much as healthcare facilities are focused on providing the most effective treatments, they still need to be profitable in order to keep running. This along with the codes and operating standards will affect the final design. The design professional needs to be aware of every aspect of the client’s concerns and find a way to incorporate them into the solution without sacrificing the needs of other stakeholders.

HOLISTIC ANALYSIS It is the design professional’s responsibility to be aware of all aspects that will affect a project. Design of the built environment does not stop at the structure’s walls. Every structure is placed on a site that is within a community which affects how the people interact with it.

Site and Climate Looking at the actual site (piece of land a building is placed on) is the very first step. This is true regardless if it is an existing structure or one that has yet to be created. Establishing the existing landscape features, ecosystems that should be preserved, and how the sun moves across the property should influence the building configuration or placement of interior spaces. Creating a list of opportunities and challenges with the site can also provide clarity when establishing design strategies. Knowing the structure and flow of the community can help establish increased connection or shelter from it, according to the specific project needs. The site information should be overlaid onto the site plan and used to better understand the best location for green spaces, outdoor spaces, user comfort, connection with surrounding community, as well as energy savings and ecosystem preservation. Passive systems are covered in Chapter 10.

Community, Cultural Context The cultural context of the facility’s location should be influencing the design directives and design decisions. Cultural context can include anything from the visual aesthetics of the surrounding structures to the attitudes toward medical care of the facility’s demographic. It also looks at the density of an area, is it residential, urban, rural setting, and incorporates

H olistic A nal y sis

that into the design. Cultural context also involves understanding the level of care that is expected, should it have a presence in the community or would the patients prefer it to be more private. All of these factors should be assessed and influence your design.

Administrative Concerns or Goals Healthcare facilities are heavily regulated by codes, industry standards, and business or financial goals. Understanding these goals that are specific to the healthcare industry at the beginning of the project can save time and money. Using established operating or design criteria specifically designed for healthcare facilities as a basis for design can assure the performative and functional aspects of the design are met.

HOLISTIC ANALYSIS OF THE TYPOLOGY AND ITS STAKEHOLDERS Holistic design solutions begin with holistic analysis. Holistic analysis starts with the ability to examine the project and typology from multiple angles or lenses. By looking at a project through the lenses of beauty or experience, cultural context, function or performance, and interrelatedness or systems thinking, a broader set of needs and relationships is exposed. This broader view of a project allows for more holistic design solutions that resonate more deeply with the occupants, are more efficient, connect to the culture as well as being beautiful. Below is a brief explanation and areas of exploration for each of these areas or lenses.

Experiential Aspects or Goals This is where the aesthetic, perceptual, subconscious aspects of a space are explored. Some of the questions to explore would be: • • • • • •

How do we want people to feel in this space? What are they coming to the space with that we would like to mitigate or maintain? What aspects of prospect and refuge do we need to support? What are the aesthetic goals? What sense of self-worth, care, or equity are we engendering or creating? How can the project be restorative to the occupants?

Functional or Performance Aspects This is where the objective, measurable, factual aspects of a project and how it functions are examined. Some of the areas to be explored would: • • • • • • • •

Energy savings or sustainable measures Climate and site features to capitalize on or mitigate Adjacencies and processes for functions within or between spaces Organizational or professional standards that need to be met Size and number of people to be served and corresponding staff Program of spaces and approximate sizes Lighting and lighting levels required Technical, millwork, or equipment required

The medical field in general and the specific typology being designed for all have very technical and regulated practices. The designer should strive to understand as much as possible but also rely heavily on collaborating with the medical and engineering professionals.

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Cultural Context This is where the underlying connections, purpose, and meaning of a project are explored. Some aspects or questions to explore would be: • • • • •

What type of culture or social structure are the occupants coming from? What type of culture and interactional structure do we want to develop or create? How are we supporting equity with our project? What type of interaction do we want to create with the surrounding community? Are there historical elements that we need to consider? Either socially or architecturally? • How are we creating connection with nature? • Are there geographic norms that we need to consider? Either socially or architecturally?

Interrelational or Systems Thinking This is where we examine how all the aspects of a project and its location interact and influence each other. Some of the aspects or questions to explore would be: • What are the parts that make up a whole and how are they connected? (Understanding that each is a part and a whole.) • What are the relationships, networks, or flow between the functions? • What are the deeper patterns visually or functionally? • How should the spaces and/or occupants relate to each other? • How should the project relate to the site? • How can the project restore or positively influence the site, community, and urban area? All these questions may appear overwhelming at first, but taken one step at a time they will slowly allow the designer to see the deeper patterns of a project and illuminate possible solutions for creating more efficient, beautiful, and meaningful designs. The additional time at the beginning of the design process makes establishing design directives, goals, and guiding principles easier. The design process and development become more streamlined and focused, and the resulting project resonates deeper with the client and occupants.

CASE OR PRECEDENT STUDIES Case or precedent studies look at existing projects of similar typologies and size or are in the same geographic areas as our potential project. Valuable information and knowledge can be gained in examining how similar problems were handled and what the “lived” experience for others has been. Meaning, how have they functioned since the time of opening, and what were the lessons learned from their designers, or that we can learn by assessing and analyzing. This is not about “copying” projects, but looking to learn from past strategies. Case or precedent studies can also give us deeper information regarding a typology or geographic location that we don’t have personal experience with. Design is a collaborative business and this is just one of the ways that we can all help each other learn, grow, and create projects that serve the public in a deeper more holistic way. Some of the initial ways to find projects is to look for international, national, or regional healthcare awards. In analyzing previous projects, we should be looking at the following aspects:

H olistic A nal y sis

Basic Case Study Focus Basic information regarding the project location, architects, engineers, and designers, number of years in operation. Any awards or research into its effectiveness as a typology can help to inform best practices. Some sample questions would be: General Design Directives Population it was designed to serve? Evidence-based Design or Environmental Psychology factors addressed? Aesthetic or Experiential goals or directives? How does the project relate or interface with the surrounding area? What type of green spaces or daylighting and views does it provide? Look to Understand the Thought Process behind the Physical Factors Such As Furniture Lighting Programmatic interrelationships? Are they mandatory or preferable? Security features (physical and emotional) As you are analyzing, seek to understand the basis for the decisions. Were they purely aesthetic, or what are the deeper needs that the selections fill? Additional Questions Are there any historic, geographic, or cultural factors that drove this project? Gardens, landscaping, or access to nature, views, or daylight? Any Sustainable features present? Overarching Analysis Questions From the images available, how does it feel to be there? What can we learn about programing, adjacencies, or relationships? What do we see as advantages to this project? (Things that would be great to replicate) What are some areas of concern with this project? (Things we should look to avoid or address) Best Practices? Anything else interesting or helpful in understanding what makes these project successful? Any other topics can be explored that you as a designer feel would be helpful for creating the best design that meets the deepest needs of the client, occupants, community, and all other stakeholders. The areas you explore will depend greatly on your past experience, familiarity with the geographic location, and cultural community. The broader your base of information, the better design solution you will be able to come up with.

INTERVIEWING AND OBSERVATION This is where all the various topics discussed previously as well as all your foundational design knowledge comes into play. This allows for intelligent focused questions and conversation that move the project forward. Conveying a basic level of understanding shows your commitment to the project and inspires the client’s confidence.

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Interviewing is a continual process throughout the entire design and construction process. Your experience level with the typology or if you are also using an integrative approach to design will also inform the process and the amount of research you do before your initial and subsequent interviews. Asking specific and general questions regard the client, their project goals, and the details of how their facility functions and serves should be informing all phases of your design. The exact questions will be different for each client, but should follow the lines of the four aspects of holistic research above. Spending time observing how the office, staff, and patients function or move about the space can increase your understanding of the day-to-day functions of the office, as well as provide insight into how to streamline processes. As the initial design progresses, subsequent interviews to discuss the developing design and the questions that arise will be pivotal in creating a design that holistically addresses all the factors and seeks to solve the design problem on a deep level. Please refer to Space Planning Basics and the Additional Resources below for more information.

INTEGRATIVE DESIGN Holistic integrated research is an essential beginning to the design process. Taking this research and moving forward toward collaborative or integrative design is the next essential step. There are several methods to successfully involve all the stakeholders in an organized and productive fashion. This approach may be a very new for some, but yields great rewards and projects that truly meet the needs of all occupants at a deep level. The ability to have the greatest influence on a project with the lowest cost is during schematic design, when everything is still on paper and decisions aren’t set in stone. Traditionally designs were created by each specialty separately and then reviewed and changed as the design and construction documents were developed. Integrative design seeks to bring all the professions and stakeholders involved into the design process during the initial schematic design phase. All the codes, regulations, program directives, and defining elements of a project are researched and presented at the beginning of the project. Representatives from each stakeholder then work together to establish an initial design approach that incorporates input from all perspectives. Approaching a project this way increases ownership, alignment, and transparency, allowing focus to be on the best possible solution for everyone; it also reduces changes and redesign costs. There are several established patterns that integrative design processes can take; they would be: CO-CREATIVE – All stakeholders are involved in a hands-on design exercise. Many times, this exercise is done with what is called “manipulatives.” In this case the Manipulatives would be scaled cutouts or small blocks that relate to different functions or pieces of furniture that the stakeholders move or place on a blank floor plan. Three-dimensional or digital designs can be worked on this way as well. The intent is to have everyone cooperate and work collectively to present their needs or desires for a space. CHARRETTE – Based on the principle that the best work is done in quick focused work sessions.The idea is to generate as many ideas as quickly as possible without getting caught up in the fine details, because they will be vetted at a later time. Teams are created with representatives from each stakeholder group so all interests are represented. Everyone is encouraged to participate, and all input is to be considered equally valid and valuable. Designs are then evaluated by a larger group and assessed for their “Optimistic” aspects or those to be pursued further and “Cautions” or those items to be investigated or researched further. Depending on

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the length and overall purpose of the charrette, there can be multiple rounds that further explore the initial designs. AIA (American Institute of Architects) INTEGRATED PROJECT DELIVERY (IPD) – The AIA has a guide available to the public which outlines their approach to integrated design and reviews the benefits. AIA looks at IPD as a full project process that begins with schematic design and ends with project completion. The guide gives instruction on the principles of IPD, how to set it up, the legal documents and contracts that would be involved, and the responsibilities of each party. LEED (Leadership in Energy and Environmental Design) INTEGRATED DESIGN PROCESS – Encourages collaboration between all the principle professionals to increase performance, environmental benefits, and human comfort. IDP is a three-phase process that spans the entire design and construction process. It requires documentation and administrative paperwork as well as postoccupancy evaluation. Following LEED’s Integrative Design Process will earn the project points that count toward the projects rating level.

SUMMARY In general, the healthcare fields are a mentally, emotionally, and physically demanding profession. The level changes with the specific specialty, but all areas of the healthcare field have the propensity to be stressful, affecting doctors and staff alike. Shifts in medical offices are typically around 8 hours per day for staff, but providers can be on call or do rounds at the hospital before and after office hours with their shifts could be between 10 and 12+ hours per day. The healthcare field has a high rate of turnover and fatigue is cited as one of the major reasons for changing jobs. Fully understanding the factors from every perspective is critical to creating spaces that truly function well and meet the needs of all occupants and increase wellbeing.

Additional Resources Books Integral Sustainable Design by Mark DeKay Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen, Rob Fleming Sun, Wind and Light by Mark DeKay Sustainable Design Basics by Sharon Jaffee, Rob Fleming, Mark Karlen, Saglinda The Architecture of Health: Hospital Designs and the Construction of Dignity by Michael Murphy with Jeffery Mansfield and MASS Design Group Articles ± Websites Clean Hands Save Lives: A Systems Approach to Improving Hand Hygiene. Retrieved from The Center for Health Design Website: https://www.healthdesign.org/insightssolutions/clean-hands-save-lives-systems-approach-improving-hand-hygiene The Big Rethink Part 3: Integral Theory by Peter Buchanan. Retrieved from the Architectural Review Website: www.architectural-review.com/archive/campaigns/the-bigrethink/the-big-rethink-part-3-integral-theory The Center for Health Design, Topic Page. Retrieved from The Center for Health Design Website: www.healthdesign.org/topics

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ROOM REQUIREMENTS

PROTOTYPICAL SPACE REQUIREMENTS FOR AREAS FOUND IN MOST HEALTHCARE FACILITIES The prototypical spaces outlined below are plans that examine the basic elements typically seen or required for each space. They are meant to give you a broad general idea of what each space is, how it’s used, and to know what you should be thinking about and discussing with your client. The spaces are based on a General Practitioner’s office and are therefore generalized, basic requirements. Furniture, finishes, and color specifications and requirements are dealt with in Chapter 12 and lighting is dealt with in Chapter 11. The best design solution incorporates input from all the stakeholders and analyzes the systematic use of space holistically while meeting basic requirements and current best practices for each of the spaces profiled from the staff as well as patient viewpoint. There are no set rules or absolutes; each design should be specific to the client, user, setting, and purpose of the specific medical practice. Each typology and each practice may have different or additional requirements and place a differing value on each of the elements outlined below. Information gathered from the client should take precedence over what textbooks demonstrate or show as typical or required. Communication, discussion, and investigation with an open mind will be key in designing meaningful, efficient spaces.

Reception and Waiting Overview The reception area is the first space that a patient encounters when they enter a medical facility. This is the area that sets the tone for the whole practice and alerts the patient to the level of care, professionalism, cleanliness, and respect that they can expect to receive. There should be clear lines of sight from the entrance to the check in desk, intake area, as well as a controlled point of access to the treatment areas. Ideally there should be a Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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restroom that can be easily accessed from this area as well. The waiting area should provide a variety of seating options for a broad range of users. The seating options should include, but not be limited to, individual chairs with arms for a sense of personal separation as well as to aid with sitting and standing, bench seating to accommodate people with small children or those wishing to sit together, bariatric seating, as well as play areas for children if appropriate. Some waiting areas also separate patients who are there for well or routine visits and those who are ill to reduce the chance of infection transmission. This is especially true for pediatric offices. Please see Figure 5.1 and Figure 5.2 for floor plans that illustrate the basic and optimal elements of waiting areas. Staff Needs Experiential and Adjacency Requirements • Direct line of sight to the entrance door and waiting area from a seated position • Acoustic separation/privacy between staff areas and waiting. Usually achieved with a sliding glass panels • Physical and visual separation of work areas from the waiting areas to maintain privacy and provide an uncluttered appearance from the waiting area • Access to administration, other staff, and exam areas FF + E (Furniture, Fixtures, and Equipment) • Work surface to accommodate computer monitor, keyboard, scanner/printer along with adequate writing space • Comfortable and highly adjustable task chair rated for 24/7 use • Filing space predicated by practice and office procedures • Large-volume printer that is shared with other staff and the general office area Patient Needs Experiential Requirements • • • •

Clean, calming, uncluttered, professional appearance Sense of acoustic privacy during check in process Distracting elements such as artwork, magazines, aquarium, sometimes television Sense of separation or privacy from others to maintain personal space and acoustic privacy between patients or patient groups in waiting area • Consider neurodiversity, patient anxiety, and other physical limitations • Universal Design principles FF + E • • • • •

Variety of seating options – arm chairs, side chairs, benches, love seat, bariatric Dividers between chairs placed back-to-back Acoustic privacy/barriers Surface for personal items while checking in Occasional tables in seating area for personal belongings

Basic Waiting Areas Basic Waiting Area Items of Note: • Clear visual connection from entrance to check-in or receptionist • Clear circulation patterns from main entrance to reception desk to exam area

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• Provide varying types of seating options and lighting • Seating should align with number of exam rooms, doctors, and typical visit time so that there is adequate room and seats available • Receptionist should have visual control over all of waiting area

Figure 5.1  Basic Elements of Waiting Areas. Source: Medical and Dental Space Planning, Malkin 2014, p. 99, figure 3–76. Optimal Waiting Area

Figure 5.2  Optimal Elements of Waiting Area. Source: Medical and Dental Space Planning, Malkin 2014, p. 120, figure 3–100. Optimal Waiting Area Items of Note: • Sick and well patients are separated to reduce cross infection and cleaning protocols • Restroom is easily accessible to patients without going into the exam area. Not show here, but both areas should have access to a restroom • Play areas for children that can be overseen and monitored by parents or caregivers • Generous area for entering and exiting the facility, separation walls help to reduce drafts • Highly durable flooring is shown in the main traffic area in and out of the facility • Receptionists share equipment

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Accommodating Children Overview With practices that either specialize or focus on children, like pediatrics, or offices where families often visit, like Family Medicine or OB/Gyn practices, having a waiting area that especially accommodates children’s need for movement and visual stimulation can be a great benefit as shown in Figure 5.3. Staff Needs Experiential and Adjacency Requirements • • • •

Visual contact from Reception desk Children entertained Parents calm and confident that children are safe with access and line of sight Sense of physical safety and means of preventing infection from sick patients

FF + E • Access to handwashing • Line of sight Patient Needs Experiential and Adjacency Requirements • Ability to maintain visual contact to be assured of safety and ability to redirect undesirable conduct • Easily cleanable surfaces • Measures to reduce possible sound transmission to other parts of the waiting areas • Calm environment that considers population served along with possible stressors FF + E • • • •

Interesting visual and tactile surfaces Toys that encourage creativity and learning with storage areas Possibly physical activity like small play sets or large toys to “ride” Can also include things like Aquaria to provide visual stimulation and Biophilic contact

Optimal Features for Accommodating Children Optimal Features for Accommodating Children Items of Note: • • • • •

Sick and well patients are separated Separate restroom available right off the waiting area, though there should be one on the well side too Play areas that can be monitored by parents or caregivers Ample room for children to move and walk around as well as for strollers or baby carriers There is a contagious exam room adjacent to the sick waiting exam entrance that is separated from the other exam rooms or diagnostic areas

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Figure 5.3  Optimal Elements for Accommodating Children. Source: Medical and Dental Space Planning, Malkin 2014, p. 120, figure 3–100.

Intake Area Overview The intake area is where the patient is sent to after checking in. These areas are mainly used in larger or group practices. This is where information regarding personal medical records, insurance, healthcare professional being visited, and reason for the visit is confirmed. Acoustic and visual separation is necessary because of the sensitive and personal information being transferred. Acoustic privacy is also a part of the requirements or the Health Insurance Portability and Accountability Act (HIPAA). There should be a place for the patient to sit, a counter surface for personal belongings, and writing, as signatures are almost always required to receive treatment. The staff person needs ample desk area to accommodate their computer(s) and monitor(s), scanners, printers, forms, and files as well as be able to make eye contact while meeting with the patient. Most often if there is more than one intake area, there will be a physical separation between stations on both the staff and patients. Please see Figure 5.4 and Figure 5.5 for floor plans that illustrate the basic and optimal elements of In-Take or Reception areas. Staff Needs Experiential and Adjacency Requirements • Reduced visual and audio distractions to enable full attention and focused vocal communication • Easy access to large copier/printer while still maintaining visual contact with patient • Access to all individual equipment, files, and forms in an organized manner FF + E • Comfortable, highly adjustable, and durable task chair • Work surface large enough to hold equipment (monitor, keyboard, small scanner/ printer, forms, and file storage) and still provide writing and work area

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• Clear area for face-to-face contact for conveying verbal information and to pass forms or written information • Access to large-scale printer and all required forms and supplies Patient Needs Experiential Requirements • Sense of visual and acoustic privacy • Ability to clearly hear and understand staff member FF + E • Durable, comfortable chair with arms • Counter space to place personal things while accessing insurance information and signing forms • Knee space to aid in accessing counter as well as space for accompanying family, guest or children Basic Reception Area

Figure 5.4  Check-in and Reception Area. Source: Medical and Dental Space Planning, Malkin 2014, p. 121, figure 3–101. Basic Reception Area Items to Note: • • • • • • •

Clear line of site to entrance Visual control over entrance and waiting area Clear visual signals and intuitive understanding of where to go to check in Adequate room for computers and technical equipment and the ability to make eye contact with patient Acoustic separation and privacy from waiting area Some form of privacy regarding personal information Discussions should be had regarding patient access to screen. Some intake processes require patients to read or see the staff’s screen • Pay attention to the reach distance to the patient so staff isn’t constantly straining

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Optimal Intake or Reception Area

Figure 5.5  Intake Area with Dividers. Source: Saglinda H Roberts. Optimal Intake Area Items to Note: • • • • • •

Full or partial height walls allow for greater level of privacy Number of stations allows greater intake of patients Staff is usually dedicated to intake and processing of initial information and medical status Level higher level of acoustic and visual privacy Recommended for group or multidiscipline practices or where sensitive information is conveyed Most people are right-handed having the computer on that side of the desk allows staff to keep hand on mouse and controls while interacting with patients • Discussions should be had regarding patient access to screen. Some intake processes require patients to read or see the staff’s screen • Pay attention to the reach distance to the patient so staff isn’t constantly straining

Exam Rooms Overview The exam rooms are where the physician, nurse, and technician and patient most often meet and where examinations and procedures are performed. This area also serves as a secondary waiting area used to ascertain more detailed medical information like blood pressure, body weight, height, and to confirm medical history and specific reason for the visit. This is also where the patient will change into a dressing gown, if required for a procedure or examination. Acoustics are of great importance to limit sound transmission between exam rooms and the corridor. This also falls under Healthcare Insurance Portability and Accountability Act (HIPAA) requirements. Though there may be exceptions, exam rooms have become very standardized in their layout and requirements. Please see Figure 5.6 for standard exam room layouts of varying size. Staff Needs Experiential and Adjacency Requirement • • • •

Consistency of equipment and supply placement, referred to as “Standardization” Clean organized space Adequate space to move around patient and room during examination Easy access between counter with sink and exam table

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FF + E • Counter with upper and lower cabinets for storage and small sink. Current practice is for all storage cabinetry to be locked. • Exam table placed at optimal position to facilitate the typical type of examination • Desk height surface for computer or adjustable wall mounted computer • Stool • Optional – Light box display for showing test results • Privacy curtain in front of or around the door for second level of privacy Patient Needs Experiential Requirements • • • •

Clean organized space to convey professionalism Sense of quiet, calm, and privacy while waiting or being examined Ability to be occupied while waiting Placement of exam table to provide privacy

FF + E • Surface and hooks for personal belongings in accordance of ADA and Universal Design standards • Chair for patient to sit during consultations • Chair for guest or family to sit • Calming artwork or informational posters being sensitive for potential stressors • Curtain to create private changing area or to shield exam table from door or public areas Basic Exam Rooms Basic Elements of Exam Rooms to Note: • Door swing is an important element in patient privacy. • Elements stay the same regardless of room size, the amount of space to move around, or have additional people is what changes. Consider practice and their interaction with patients when deciding on room sizes. • Bed position is usually angled so provider can easily access three sides of the patient. There are practices where the exam table is typically against the wall. • Windows or natural light are an added benefit, but not necessary. Exam rooms can be on the interior of a floor plan. • Make sure that the work area and cabinetry can accommodate all the required equipment and supplies as well as the amount of work area typically needed.

Figure 5.6  Exam Rooms of Varying Room Sizes. Source: Medical and Dental Space Planning, Malkin 2014, p. 32, figure 3–3.

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Nurse’s Station Overview The nurse’s station is where the nurses do all their administrative work, research, in-house testing, sample collecting, and specialist scheduling. This area also houses their medical supplies, equipment, and the locked prescriptions and controlled substances. Many times, nurses meet with patients to exchange information and test samples, but is also a place where they will be conducting work that requires privacy. It needs to be in a centralized location adjacent or convenient to the exam rooms as well as close to the reception and office areas. Please see Figure 5.7 and Figure 5.8 for floor plans that illustrate the basic and optimal elements of Nurse’ stations. Staff Needs Experiential and Adjacency Requirements • • • • • • •

Convenient to exam rooms, restrooms, reception, and office Visual and acoustic privacy for computer, record work, or phone conversations Visibility of areas being supervised Place to meet with visitors, physicians, and other staff for brief consultations Organized efficient storage of supplies and equipment Intuitive organization because of multiple users Circulation that accommodates multiple users

FF + E • A combination of counter height/standing work space with knee space for occasional sitting along with Desk height work areas if desired. • Upper and lower cabinetry for supplies. Current practice is to have all cabinetry lockable. • Adequate counterspace for all testing equipment and computer stations as well as areas for performing tests, and writing. • Electric, data, and plumbing as required with consideration for future needs. • File storage, specialized medical equipment, small printer/fax machine, multiple land lines. • Specialized locked cabinetry for prescription and controlled substances. • Optimally a pass-through window from the restroom for the passage of samples or testing material. • Highly adjustable durable ergonomic seating. Patient Needs Experiential and Adjacency Requirements • Visual access from exam rooms or corridors • Ease of access to interact with the nurses when required • Have confidence that their testing samples and information will be handled with efficiency, accuracy, and privacy FF + E • Small area to transfer samples, supplies, or written information • Place to put personal belongings during interactions with staff • Depending on the practice a chair with arms may be required for extended conversations or short tests

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Basic Nurse’s Station

Figure 5.7  Basic Elements Nurse’s Station. Source: Medical and Dental Space Planning, Malkin 2014, p. 121, figure 3–101. Basic Nurse’s Station Items of Note: • • • • • • • •

Adequate stations for the number of employees per shift Visual access to most if not all exam room entry points Area to meet with patients for information, brief consultations, shots or tests Sink and refrigerator Increased mechanical and plumbing requirements Locked upper and lower cabinetry for supplies and equipment Standing height counter on patient side to provide writing surface patients and privacy for staff Data and phone lines as well as printer

Optimal Nurse’s Station

Figure 5.8  Optimal Elements of Nurse’s Station. Source: Medical and Dental Space Planning, Malkin 2014, p. 130, figure 3–114.

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Optimal Nurse’s Station Items to Note: • • • • • • •

Larger area to preform task Each person has larger work station Area for all providers to work in open and collaborative setting Visual oversight of large area of office Centrally located to reduce travel distances Expanded area to provider and patient communication Standing height counter on patient side to provide writing surface and privacy for staff

Business Office Overview The business office is where all the billing, administrative, and insurance claims work takes place. Access to the files and supplies is critical. Many times, this area is connected to the reception and nurse’s area for the ease of shared information. Understanding how each practice uses, stores, and shares medical information and patient files is imperative for creating efficient function of the administrative aspects of a medical practice. Most practices have fully electronic medical records, as required by the Patient Protection and Affordable Care Act (PPACA) some don’t or have their paper records for their own use. In some offices this person is also responsible for client contact regarding payment or appointments with specialists or testing facilities. Depending on the size of the practice, the business responsibilities can also be handled by someone who also acts as a receptionist, or there may be several people who are required to handle this work. Each practice will have different operating procedures and preferences so it is important to discuss these at the beginning of the project. Please see Figure 5.9 and Figure 5.10 for floor plans that illustrate the basic and optimal elements of a business office. Staff Needs Experiential and Adjacency Requirements • • • •

Clean uncluttered area with plenty of storage Easy access to files and medical records Acoustic privacy for phone calls regarding payment or medical information Close to medical files and many times to the receptionist

FF + E • • • • •

Adequate work surface, in addition to what is used for equipment Monitor, keyboard, adding machine, multiline landlines, Fax machine File cabinets dependent on individual office practices for file storage Large-volume printer/copier/scanner – May share this with receptionist or intake areas Ergonomic Task chair and at least one guest chair

Patient Needs Experiential Requirements • Sense of visual and acoustic privacy for discussing financial or health information FF + E • Guest chair • Small writing area or surface for signing forms or taking notes • Area for personal belongings during visit

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Basic Business Office

Figure 5.9  Basic Business Office Plans. Source: Medical and Dental Space Planning, Malkin 2014, p. 99, figure 3–76. Basic Business Office Items to Note: • • • •

In same area as receptionist. This allows shared oversight of patient intake and physical resources. Number of staff and size of office will depend on case load of practice. Staff may also be responsible for other administrative tasks for the office and medical side of the practice. There should be visual and acoustic privacy measures employed to protect personal information.

Optimal Business Office

Figure 5.10  Optimal Elements for Business Offices. Source: Medical and Dental Space Planning, Malkin 2014, p. 121, figure 3–101.

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Optimal Business Office Items to Note: • • • • •

Privacy separation between check-in and office area Larger workstations Easy access between all related areas Windows create pleasant work environment Areas of visual and acoustic privacy for private meetings if needed

Consulting Rooms Overview Consulting rooms are where patients go to have discussions or consultations with the physician that do not include a medical exam. Many times, this is for test results, or additional appointments regarding a condition that was dealt with previously or ongoing concerns both personal and medical. Depending on the office size and specialty this can be a separate room which can also function as a conference room or be the doctor’s private office. This is many times the place where patients receive bad news regarding their or a loved one’s medical condition. Please see Figure 5.11 and Figure 5.12 for floor plans that illustrate the basic and optimal elements of consulting rooms. Staff Needs Experiential and Adjacency Requirements • Comfortable place to concentrate and have patients feel secure and calm • Acoustic separation for concentration and to reduce distractions • Closer to private offices and away from higher traffic areas of the office FF + E • Table or surface other than the meeting table/desk to keep test results, medical files, other information • Cabinets for supplies related to any medical diagnosis, to keep medical equipment and office supplies out of direct view • Comfortable chair, preferably with a swivel base, to ease access to multiple equipment • Monitor and computer to show test results or any other visual aids required as part of the conversation • Any other specialty specific equipment Patient Needs Experiential and Adjacency Requirements • Sense of privacy, calm, and security. The patient should feel comfortable. • Warm comfortable office environment that is less medical and sterile than an exam room. • It should have acoustic privacy from a HIPAA stand point, but also so they can feel confident, free, and comfortable expressing emotion without fear of being overheard. • A soothing more residential feel can help the patient be relaxed.

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FF + E • Comfortable chairs with arms to add a sense of protection as well as aid in sitting or standing. Typically for three or four people. • A desk or table for small group discussions and also to have a place for personal belongings, brochures, medical test results to be viewed or reviewed. • Good flexible lighting that can also be changed from bright for reading reports and records to lower levels if more of a relaxed conversation is taking place Basic Consulting Room Basic Consulting Room Items of Note: • Provider’s office also acts as the consulting area. This saves space, but has several limitations • Computer monitor should be able to move to face guest chairs • Creates a separation between patients and providers by being behind a desk • Allow concealment options for sensitive information • Create pleasant atmosphere to reduce stress for patients

Figure 5.11  Consultation Room. Source: Medical and Dental Space Planning, Malkin 2014, p. 207, figure 5–34. Optimal Consultation Room

Figure 5.12  Optimal Elements for Consulting Room. Source: Medical and Dental Space Planning, Malkin 2014, p. 122, figure 3–102.

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Optimal Consultation Room Items of Note: • • • • •

Neutral area without personal or private information or office clutter Large monitor easily seen by the entire room Area for props, materials, or refreshments Round table that doesn’t reinforce hierarchical relationships Should have extra acoustic or sound transmission strategies

Procedure Rooms Overview Procedure Rooms, are sometimes called Minor Treatment or Minor Surgery, are to facilitate the procedures that require more extensive medical equipment than is in a regular exam room. They can vary in size and equipment, and be are usually larger than an exam room but smaller than an operating room in a hospital setting. These rooms are designed more like a surgery room in a hospital and may also contain small Xray equipment. They are used for short surgical procedures that only require local anesthesia and pose little risk of complications and therefore do not have the same requirements for sterile isolation like an operating room. Please see Figure 5.13 and Figure 5.14 for floor plans that illustrate the basic and optimal elements of procedure rooms. Staff Needs Experiential and Adjacency Requirements • • • •

Confidence that all equipment and supplies are organized to protocol and readily available Patient to feel calm and confident in the skill of the attending medical staff Ease of access to supplies and equipment Ability for equipment and supplies to be flexible according to the procedure being done

FF + E • • • • • • • • • • •

Well-ventilated space and easily cleanable surfaces and furniture Operating table that is height adjustable Multidirectional and adjustable high-intensity lighting Adjustable stool for medical staff Several rolling stainless steel side tables Storage and display cases for equipment and instruments Resuscitation equipment – (defibrillator, airway intubation, drugs for resuscitation, or other equipment) Handwashing and or sink area Often a central place for equipment for the medical office Emergency power outlets may be required Always consult with infection control professionals to ensure proper specifications

Patient Needs Experiential Requirements • Confidence in physician and facility equipment and its cleanliness FF + E • Place for personal belongings during procedure • Place to change if required

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Basic Procedure Room

Figure 5.13  Basic Elements Procedure Rooms. Source: Medical and Dental Space Planning, Malkin 2014, p. 121, figure 3–101. Basic Procedure Room Items of Note: • • • • •

Adequate circulation space around all four sides of the table High-intensity adjustable lighting is required Door wide enough to accommodate stretcher or gurney Cabinetry to accommodate equipment and supply storage as well as work areas Sink

Optimal Procedure Room

Figure 5.14  Optimal Elements Procedure Rooms. Source: Medical and Dental Space Planning, Malkin, 2014, p. 207, figure 5–34. Optimal Procedure Room Items of Note: • Expanded floor plan to allow for additional equipment or providers • Movable equipment and tables for supplies and instruments

R oo m R e q u ire m ents

• Separate Scrub area for sterilization • Adjacent to treatment areas • Separate recovery area that could double as an exam room

Storage Spaces Overview Storage spaces for medical facilities fall under several categories. One that holds basic operating supplies such as paper products, cleaning products, office supplies, printer paper, forms, exam table covers, and basic nonmedical procedure accessories. Another for medical equipment that is shared between rooms or is only used in special instances is better stored in a central location. Restricted medical supplies, prescription drugs, and controlled substances such as needles and syringes, oxycodone, or painkillers need to be stored in a locked and monitored area. This is an even higher propriety and concern than it has been in past years and many offices are going to a system where all storage facilities are locked and monitored. The importance of carefully planned storage areas cannot be overestimated for any of the areas. Locations as well as the details of what needs to be stored and the associated organizations systems should be carefully discussed with each client. Please see Figure 5.15 and Figure 5.16 for floor plans that illustrate the basic and optimal elements of storage areas. Staff Needs Experiential and Adjacency Requirements • Organization and ease of accessibility for daily office and medical supplies • Confidence in safety of restricted drug storage from unauthorized access FF + E • Possibly in different locations throughout the office – restricted storage should be located by nurses’ station or office for easy monitoring • Shelving or other organizational systems of varying sizes to maximize storage capacity and meet the particular needs • Locking case or built-in casework as needed for specific functions and in specific locations Basic Storage

Figure 5.15  Basic Elements Storage Spaces. Source: Medical and Dental Space Planning, Malkin 2014, p. 121, figure 3–101.

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Basic Storage Items of Note: • Located near where supplies will be used • Accommodates varying sizes of supplies or equipment • Should be equipped with shelving or organizational system that corresponds to the size of supplies being stored • Locked depending on nature of items stored Optimal Storage Space Optimal Storage Space Items of Note: • • • •

Expanded area with appropriate shelving or organizational system Space optimized for maximum capacity and larger items IT equipment in separate area In close proximity to area of use

Figure 5.16  Optimal Elements for Storage Spaces. Source: Medical and Dental Space Planning, Malkin 2014, p. 533, figure 10–76.

Break Spaces Overview Break spaces are a place where providers and staff have a chance to get away from their workload and meet basic needs like eating, using the restroom, and getting relief from a stressful atmosphere. It also provides a chance for collaboration and communication between concerned staff. All offices which have more than two employees should have a break area, even if it is a very small space that only allows for food storage, a coffee maker and supplies for eating, and a chair or two. Though breaks are regularly scheduled as part of a person’s workday schedule, issues with patients, medical emergencies, or patient conditions frequently take priority over an employee’s scheduled break. Even in medical offices doctors and staff can work long hours and even short breaks have been shown to substantially increase mental clarity, ability to cope with stressful situations, and individual well-being. This in turn increases employee satisfaction and the level of medical care. See Chapter 3 for more detail. Please see Figure 5.16 and Figure 5.18 for floor plans that illustrate the basic and optimal elements of break areas. Staff Needs Experiential and Adjacency Requirements • Feel that they are removed from patient area • Acoustic and visual privacy from patients

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• Ability to relax • Should be warm, inviting, and clean • The number of people and size can significantly change the feeling of the space Basic Break Room Basic Break Room Items of Note: • • • • • •

Counter space for food prep Upper and lower cabinetry for supplies Sink, refrigerator, and microwave Table and seating area Area for coats or personal belongings Windows with views of nature or representational artwork

Figure 5.17  Basic Elements for Staff Break Areas. Source: Medical and Dental Space Planning, Malkin 2014, p. 120, figure 3–100. Optimal Break Room Example

Figure 5.18  Optimal Elements of Break Areas. Source: Medical and Dental Space Planning, Malkin 2014, p. 58, figure 3–30.

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Optimal Break Room Items of Note: • • • • • • •

Space can accommodate all staff and providers per shift or more Enlarged seating and prep area Area for varied seating options, computer stations, or TV area Large windows for exterior views and daylight Adjacent to larger conference room to be used for meetings or social functions Area for personal belongings separate Proximity to staff entry

Restrooms Overview All offices need to provide restrooms as a practical amenity and because a restroom is required for many of the medical tests. There should be separate bathrooms for patients and staff for privacy and to reduce infection transmission. Depending on the size of the facility and number of employees, there may be the need for multiple staff and patient restrooms. In many larger practices, the physician will have a private restroom adjoining their office. Ideally there should be a patient restroom easily accessible from the waiting area and one that is within the exam area. Please see Figure 5.19 and Figure 5.20 for floor plans that illustrate restroom locations in relation to other spaces. Staff Needs Experiential and Adjacency Requirements • • • • •

Private staff only restroom Located closer to the office and administrative areas Not easily accessible to the public to discourage use Easily cleanable surfaces Sense of calm, refreshment, and escape

FF + E • Storage for personal and restroom supplies • Counter areas for personal grooming • Universal Design and ADA Standards need to be met Patient Needs Experiential and Adjacency Requirements • • • •

Confidence in cleanliness Convenient location to waiting and exam areas Ability to bring small children into restroom if required Light, open, and refreshing

FF + E • • • • •

Area to place personal belongings Counter area at sink for any personal or grooming items as well as diaper changing stations Area for temporary sample placement Ideally pass-through window to nurse’s station for transference of samples Universal Design and ADA Standards need to be met

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Restrooms Accessible from Waiting Areas Restrooms Accessible from Waiting Areas Items of Note: • Easily accessible from waiting areas without going into the exam areas, or requiring staff to provide admittance • Entrances are easily discernable but also protected from direct view into waiting or public areas • Multiple restrooms dependent on number of people accommodated in waiting areas

Figure 5.19  Restrooms Adjacent to the Waiting Area. Source: Medical and Space Dental Planning, Malkin 2014, p. 58, figure 3–30. Restroom Adjacent to Lab Space and Exam Rooms

Figure 5.20  Restrooms with Easy Access from Exam Rooms with Pass-Through to Lab. Source: Medical and Dental Space Planning, Malkin 2014, p. 34, figure 3–5. Restrooms Adjacent to Lab Space and Exam Rooms Items of Note: • Pass-through to Lab space is critical • Easy access from lab critical for testing and efficiency • Should be accessible to exam rooms without having to go through public or waiting areas

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Corridors Overview Corridors are the spaces that connect all other spaces within a facility and need to accommodate multiple levels of ableness. They contribute to the efficiency of the people using the spaces, and reducing the length of travel increases the efficient use of space. Corridors can also be used as waiting areas for procedure rooms, or communication areas between staff members or staff members and patients such as at the nurse’s station. When functions other than direct travel are required, such as if the corridor is used as a staging or waiting area, or for short consultations, it is critical that extra space be allotted as to not impede normal traffic. It is also important to follow ADA, Fire Safety, and other codes or governing bodies for distances, turn-around areas, and dead-end corridors. Protection of surfaces from impact or damage are of special concern in corridors. For more specific information, see Space Planning Basics. Staff Needs Experiential and Adjacency Requirements • Organization to separate the public (patient access) and private areas (staff only) of the facility • Ability to freely travel between spaces, while carrying things without hitting opposing circulation or elements of the built environment • Clear line of sight • Ability to meet with staff or patients unimpeded by other circulation • Acoustic separation between offices and exam rooms and sound absorption FF + E • Crash rail to protect wall • Handrails or grab bars depending on practice typology, these can also act as wall protection Patient Needs Experiential and Adjacency Requirements • • • •

Clear line of sight to destination Clear distinction or designation between staff only areas Ability to travel freely without being bumped into or navigate without extreme maneuvering Clearly accommodate multiple levels of ableness. Reference Universal design principles

FF + E • Handrail system to aid with stability or walking depending on the practice typology • Protected area if corridor when used as staging or waiting area

Stairs Overview Stairs allow vertical movement within a space. This can be between floors, or within a single level. To promote efficiency, safety and inclusion or people and equipment movement, changes in floor levels should be kept to a minimum, and where absolutely necessary an ADA accessible ramp also needs to be provided. Stairs that connect different floors of a facility are most often positioned according to fire safety standards and would be designed as in conjunction with the requirements of life safety plan. For more specific information, see Space Planning Basics and the Additional Resources listed at the end of the chapter.

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TECHNOLOGY Overview Technology continually plays a larger role in medical practices. The extent to which each practice uses technology is what you’ll need to uncover during the programming phase; however, many practices are behind in this area. Electronic medical records have replaced paper medical files in most practices. This enables providers and medical staff to electronically input their notes, diagnoses, and directly submit prescriptions to the pharmacy. The two main ways this occurs is to either have computer in each room, usually mounted to the wall on an adjustable arm, or for each medical and staff member to have their own laptop on a rolling cart or that they carry with them. Medical and testing equipment continually changes to rely more heavily on technology. The main thing to keep in mind is that technology is constantly evolving and designing for flexibility and change is the best strategy.

Staff Needs Experiential and Adjacency Requirements • Ability to adjust screen height, keyboard location, and angles to reduce glare • As much flexibility as possible depending on the equipment or technology • Highest quality systems and network the budget will allow FF + E • • • •

Highly dependent on practice type, discussions are critical Work space or wall mounted hardware for computer monitor + keyboard Adjustable stool Any other medical equipment required for practice typology

Patient Needs Experiential and Adjacency Requirements FF + E • Ability to see screen if required • Access to Wi-Fi during waiting periods

RESILIENCE Overview Resilience in this case means the ability to change, withstand change, or to be able to change use or purpose from what was the original design intent. The ability to change to accommodate new purposes, technology, or even new uses is extremely important to maintain the viability of the practice. It also greatly affects sustainability by reducing the amount of waste generated, and allows a medical practice to easily incorporate the latest technology and procedures without great financial cost. Approaching current needs as basic for design and understanding that physical needs are always evolving and planning for change is an important aspect of creating resilient spaces. The COVID-19 pandemic illustrates the importance of facilities to be able to change their purposes and uses, and ways of operating.

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Staff Needs Experiential and Adjacency Requirements • • • •

Preliminary research and discussions about possible scenarios Clear, visible access to mechanical and technological resources Clear understanding of process to change Be able to maintain eye contact with patient while using computer

FF + E • Additional electrical and mechanical requirements and outlets that can easily be changed with technology updates • Additional space requirements based or possible scenarios

Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Fitting the task to the human: A Textbook of Occupational Ergonomics 5th Edition by Karl HE Kroemer Human Factors in the Built Environment by Linda Nussbaumer Interior Graphic and Design Standards by SC Reznikoff Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara, Julius Panero Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith Articles ± Websites DEA 6530 Design Dilemmas The Staff Breakroom, by Giyoung Park. Retrieved from Content Delivery Network Website: cpb-us-e1.wpmucdn.com/blogs.cornell.edu/ dist/a/3723/files/2013/09/Staff-break-room-1cvr5wu.pdf Minor Surgery in Primary Care. Retrieved from IntechOpen Limited Website: www. intechopen.com/chapters/68792 Universal Design and Accessibility. Retrieved from the General Services Administration (GSA) Website: https://www.section508.gov/develop/universal-design

Chapter

6

MAJOR SPECIALTIES

This section covers medical practices that focuses on a particular aspect of the medical field with a defined set of patients, disease, philosophy, or skill. These are medical staff that have spent an additional four to eight years, or more, studying and researching their area of practice in a very deep and specialized way. Specialist are sought out when seeking care for specific illness, injury, condition, or health concern. In many ways the spaces that are required for their medical practices/facilities to run smoothly are the same or similar to the ones profiled in Chapter 5. This chapter is to explore areas that differ or are required in addition to what was covered previously.

PEDIATRICS Overview Pediatrics is a medical practice that is concerned primarily with children and adolescents from birth to age 21. They have completed intensive training to understand the differences in the anatomical, psychological, and physiological differences between children and adults. The challenge of pediatric offices is to incorporate ergonomics, anthroprometrics, and aesthetics for children of varying ages, adolescents, and the adults that will be accompanying them. Pediatric offices will have areas for children to play or be entertained as part of the waiting area. These areas need to be out of the way of the main traffic patterns, but still visible to the receptionist and waiting parents. Many offices also provide separate areas for “sick” children and those there just for routine visits to reduce spread of infection. Having a restroom available from the waiting area with a changing station and seat for toddlers is especially important in this type of office. Please see Figure 6.1 for a floor plan that illustrates the optimal elements of a pediatric office.

Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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Staff Needs Experiential and Adjacency Requirements • Calming peaceful atmosphere to counteract the broad range of emotions, reactions, and behavior of a younger demographic of patients • Visible monitoring of all public or patient areas • Ability to accommodate siblings or multiple adults during visits FF + E • Furniture and equipment that is flexible and adaptable to a variety of age groups with varying human dimensions • Variety of exam rooms to accommodate adolescents, or sibling exams (more than one child is examined in the same room) • Exam tables with extended height adjustment settings • Visually interesting or unique furniture and equipment to act as positive distractions

Patient Needs Experiential and Adjacency Requirements • Visual stimulation and color to be attractive and interesting to children, while still being pleasing, neutral and not overwhelming to adolescents and adults • Positive distractions to occupy children, lessen perceived wait time and reduce stress of parents or caregivers FF + E • Variety of seating options to accommodate differing patient groups • Furniture and equipment designed to meet a variety of children’s ergonomic needs across age groups • Easily cleanable entertainment stations and toys geared for all ages and comprehension levels

Pediatric Office Example Pediatric Office Items of Note: • Keeping sick and well children separate as much as possible decreases cross infection as well as increases parent’s sense of confidence and satisfaction • Having area for children to play while waiting where parents can monitor them is critical for an orderly waiting room and increases the children’s willingness toward treatment • Exam rooms are similar in size and function to prototypical exam rooms. Positive distractions may be used to keep children interested before and during examination • Aesthetics should be engaging, but not too age specific as pediatrics covers a broad range of ages • Size and scale of furnishings and fixtures should be adjusted to accommodate prometrics of younger population with the understanding that adults and teens will also be using the spaces • Some offices have special contagious or sick exam rooms

Ma j or S p ecialties

Figure 6.1  Pediatric Office Floor Plan. Source: Medical and Dental Space Planning, Malkin 2014 p122 Figure 3–102

DENTISTRY Overview Dentistry is a medical practice that focuses on the prevention and treatment of the teeth and supporting structures of the mouth such as gums, bone structure, and mechanics of the jaw. There are many specialties within the field and can be handled within a dentist’s office or operate separately. Dentistry involves several very specialized areas – the treatment, hygienist, and sterilization areas differ greatly from other medical practices and their specialized requirements need to be accommodated. Plumbing in some form is usually required in all areas as well as increased electrical requirements based on equipment. It is important that all the areas are calming, relaxing, and uncluttered to assure patients. Please see Figures 6.2, 6.3, and 6.4 for floor plans that illustrate the basic required elements of a dental treatment rooms and standard layouts for hygienist areas. Figure 6.5 illustrates how all the areas relate in a dental office. .

Specialized Areas to Be Considered • Treatment Rooms • • • • •

Strive for the smallest footprint as possible Look for ways to make things compact Spaces are usually designed in pairs to reduce space requirements and cost Equipment and sink can be shared Can be multiple staff working on one patient

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• Hygienist Areas • Usually designed in pairs for space and equipment sharing • Smaller space requirements depending on practice philosophy or operating standards • Single staff working on patient

• Sterilization Work Area • • • • • • •

Centralized location to Treatment and Hygienist locations Work surface for all equipment and activities Equipment should be placed in order of work flow Could be multiple people working in this area at one time Sink and other plumbing is important Storage and inventory system required for supplies and materials Specialized equipment on wheeled carts with associated storage space

• Storage area • • • •

Needs to accommodate large bulk supplies and facilitate stock rotation Should be away from patients but easily accessible for staff Individual shelving is recommended for ease of access and product protection Can be part of sterilization Area

Staff Needs Experiential and Adjacency Requirements • Logical and careful consideration of workflow and process in space planning as well as layout of all cabinetry and equipment • Clean, uncluttered work surfaces with highly organized and standardized equipment placement • Areas and equipment to protect them from radiation exposure FF + E • • • • • • •

X-ray machines – at each station/chair most often shared between stations Larger X-ray area to do full mouth array Computers at each station Cabinetry to house equipment and provide work surface for staff Wall mounted TV to act as positive distraction for patient All dentistry related equipment Swivel stool

Patient Needs Experiential and Adjacency Requirements • Clean, uncluttered atmosphere to convey professionalism • Calming – as many people are afraid or nervous • Source of positive distraction – usually wall mounted TV that can be viewed while reclining during treatment FF + E • Comfortable ergonomic dentist chair – proper ergonomics with increased comfort reduces movement • Area for personal belongings during treatment

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Optimal Dental Treatment Example Floor Plan Hygienist Floor Plan Hygienist station Items of Note: Hygienist areas are greater in number than treatment rooms and should be easily accessible from the waiting area Stations often share equipment Usually only one large X-Ray area is required in close proximity to all hygienist stations Size and requirements of laboratory may vary with practice specialties Sterilization is high priority and requires more area than in typical offices Aesthetics and perception of cleanliness is paramount Aesthetics for all public areas are usually upscale

PASS-THRU X-RAY BETWEEN TWO OPERATORIES, EXCEPT WHEN OFFICE USES HANDHELD PORTABLE X-RAY.

FLAT SCREEN DR./ PATIENT MONITOR 10'-0"

18"

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18"

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S

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3'-0" FLAT SCREEN MONITOR FOR ASSISTANT ASSISTANT'S CART

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11'-0"

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• • • • • • •

3'-0"

CEILING MONITOR FOR PATIENT

TRAY/TUB PASS-THRU UPPER CAB.

Figure 6.2  Optimal Treatment Room Layout. Source: Medical and Dental Space Planning, Malkin 2014 p502 Figure 10–37

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Figure 6.3  Alternate Layouts for Treatment Room Layouts. Source: Medical and Dental Space Planning, Malkin 2014 p506 Figure 10–44

OPEN FLOOR PLAN

FIXED-WALL FLOOR

Figure 6.4  Potential Hygienist Layouts Comparing Open Systems and Constructed Walls. Source: Medical and Dental Space Planning, Malkin 2014 p510 Figure 10–50

Ma j or S p ecialties

Figure 6.5  Dental Office Floor Plan. Source: Medical and Dental Space Planning, Malkin 2014 p504 Figure 10–39 (zoomed)

GERONTOLOGY Overview Gerontology is a multidisciplinary branch of medical science that studies the physical, social, psychological and cognitive aspects of aging. The focus is to promote well-being on all levels and improve the quality of life in aging adults. This field also explores the changes to society as a whole that result from an aging population. They can act as patient advocates and oversee multifaceted treatment plans and approaches. Geriatrics is a subset of gerontology which focuses on the medical aspects of aging adults. Some of the more common conditions treated would be osteoporosis, arthritis, dementia, cardiovascular disease, hypertension, cancer, and diabetes. Overall, there should be an extra allowance for circulation space to accommodate mobility devices such as canes, walkers, and a greater incidence of wheelchairs. The proportion of consultation spaces to exam rooms should be increased, as sometimes the visits are not based on physical examination. Many patients have a reduced level of hearing, sight, and physical mobility, therefore universal design strategies need to be given the highest priority. Please see Figure 6.6 for a floor plan that illustrates optimal elements of gerontology offices.

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Staff Needs Experiential and Adjacency Requirements • Additional space to accommodate mobility aids and maneuver FF + E • Highly adjustable equipment, seating, and exam tables • Easily accessible mobility aids

Patient Needs Experiential and Adjacency Requirements • • • • • •

Clear consistent visual articulation between the floor, wall, and furniture Prominent directional and wayfinding cues Respectful supportive atmosphere Reduce travel distance between patient areas as much as possible Moderate levels of positive stimulation such as water features, artwork, aquaria Acoustic control is very important for privacy and patient hearing acuity

FF + E • • • • • •

Variety of stable high-back seating options with arms to aid in sitting or standing Extra and/or adjustable lighting sources to accommodate differing visual acuity Ability for all patient-related amenities to be flexible or adjustable Carpet to reduce noise reverberation and falls Wall protection that can also act as handrails Rounded corners for softened visual appearance as well as to reduce injury

Gerontology Floor Plans

Figure 6.6  Gerontology Office. Source: Medical and Dental Space Planning, Malkin 2014 p88 Figure 3–64

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Gerontology Office Items of Note: • • • •

Special attention should be paid to travel distances, keeping patient areas as close to the waiting area as possible Extra consideration should be given to clearances and amount of circulation spaces Many appointments can be had in consultation rooms instead of always needing an exam room Adjustable and adaptable furniture should be a priority

PALLIATIVE CARE Overview Palliative care is specialized medical care for people living with serious illness that looks at the whole person. It involves an interdisciplinary team including a specialist in palliative care, a nurse, pharmacist, social worker, dietitian, and other professionals as needed. The concentration is on improving the quality of life for the patient and their family by working to relieve all the symptoms of the illness and treatment as well as the stress that can accompany long-term illness. There are varying models of treatment that range from outpatient care, to inpatient care, to hospice care. There is also community-based care which focuses on giving palliative care while the patient stays connected to the community in which they live, meaning care can take place in their home or existing place of residence. Patients can seek palliative care at any stage of the illness or condition and be of any age. Palliative care depending on the size of practice or specialty can be very similar to the gerontology office shown in Figure 6.6. If there are specialized populations served, such as children, adjustments to the prometrics and aesthetics can be made.

PSYCHOLOGICAL + PSYCHIATRIC PRACTICE Overview Psychiatrists, psychologists, therapists, and social workers study and treat people’s cognitive, emotional, and social processes and behaviors. They use a variety of treatments, and either specialize on a condition or population sector, or are generalists. Patients can be seen individually, in small groups or as a couple, or in larger groups for group therapy. The consultation rooms are the main sites of interaction between patient and care giver, and can vary in size depending on the number of people in the session. Group therapy rooms should be able to seat approximately 12 people. It is important that all areas of the office are as tranquil, calming, and neutral as possible. Many offices have a more residential feel. Sound attenuation is extremely important for privacy and all areas should be treated to reduce sound transfer. If the practice does child therapy, there needs to be play rooms with adjacent observation rooms so that the therapist can observe child behavior without influencing the outcome. Filming equipment in these rooms is required by law for child abuse cases. Please see Figure 6.7 for a floor plan that illustrates optimal elements of psychiatry offices.

Staff Needs Experiential and Adjacency Requirements • Calming atmosphere; some prefer windows or some not • Ability to observe children in play therapy through a two-way mirror from adjacent room

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• Flexibility to have different meeting/treatment styles within each area • Sound privacy – no sound enters the room from other areas • Place of respite to recharge between sessions FF + E • • • • • •

Consultation room that is at least 14ʹ x 14ʹ and can also be used as the therapist’s office Bookshelves, writing surface, and desk with files if used as an office as well Comfortable chairs Furniture and layout depend on particular treatment style and practices Hypnosis treatments requires reclining chair or chaise lounge to elevate legs Child therapy requires play room with toys, and possibly art supplies and sink for cleanup with adjacent observation room with recording equipment • Kitchenette or snack area with sink in or close to group therapy rooms • Storage areas to organize and reduce clutter

Patient Needs Experiential and Adjacency Requirements • • • • • • • • •

Calm peaceful aesthetics that feels welcoming Prospect and refuge Views of nature or nature-inspired art Residential feel Waiting area that provides sense of privacy and protection Sense of physical, emotional, and auditory privacy Ability to make eye contact with therapist (and see the door) Organized clutter-free environment Positive distractions such as art, fountains, sculpture, aquaria

FF + E • • • • • •

Comfortable chairs of all types (stacking for group therapy rooms) Occasional table for drinks or personal belongings, or therapy material Area to accommodate coats and personal belongings in consultation room As much adjustability as possible with furniture, lighting, and positions Soft furnishings or rugs Easily cleanable items that don’t show use or wear easily

Psychiatric + Psychological Care Floor Plan Psychological+ Psychiatry Office Items of Note: • Adding expanded lines of sight helps to improve prospect refuge which is especially important in this typology • Large areas of exterior views are incorporated except in public waiting, where privacy from the “street” is important to patients • Addition acoustic privacy and sound transmission strategies are critical to for a feeling of privacy • Overall organization with separation between public and private spaces • All spaces focused on exterior and natural spaces • Ability to adapt, add on, or accommodate a separate wing with restorative physical treatments such as weight lifting, gym, arts, cooking, + nutrition are easily available

Ma j or S p ecialties

• Spaces can be adapted to group counseling or larger events • Spaces stress openness and light to convey a sense freedom COUNSELING

COUNSELING

COUNSELING

COUNSELING

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CONF

RECEPTION

RR

BREAK

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ENTRANCE WAITING

Figure 6.7  Psychiatry Office with Potential for Addition Services. Source: Saglinda H Roberts

ORTHOPEDIC OFFICES Overview Orthopedics is the branch of medicine that focuses on the prevention or correction of injuries or disorders of the skeletal system and associated muscles, joints, and ligaments. Methods of treatment can include surgery, physical therapy, or medical treatments. The physical examination can take place outside of the individual exam rooms to make use

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of shared diagnostic equipment and additional space to assess movement or posture. Additional space is required for diagnostic equipment and movement assessment, and some offices have their own X-ray and MRI machines as well. Physical movement is many times impaired or painful for patients, so keeping patient-centered functions closer together can aid in patient comfort and treatment efficiency. Please see Figure 6.8 for a floor plan that illustrates optimal elements of Orthopedic offices.

Staff Needs Experiential and Adjacency Requirements • Flexibility within exam rooms • More floor space to accommodate evaluation and diagnostic procedures with patient and doctor both standing or moving in each space • Central diagnostic area with equipment appropriate to the specialty or treatent types covered FF + E • Standard Strength training and exercise equipment such as stationary bikes, elliptical machines, free weights or resistance training • X-ray light box and/or digital monitors in exam rooms • Wider hallways or circulation for mobility aids • Centralized collaborative work stations

Patient Needs Experiential and Adjacency Requirements • Sound and acoustic privacy • Sense of physical safety and accommodation for any injury or condition FF + E • Varied and/or adjustable furniture and equipment • Stable chair with arms • Step stools for exam tables

Orthopedic Office with Diagnostic Area Floor Plans Orthopedic Office with Diagnostic Area Items of Note: • • • • • • •

Extra circulation space should be allowed to accommodate mobility aids Exam tables can be placed against the wall to increase floor space in exam rooms Diagnostic area should be centrally located Team/collaborative administration area should be adjacent to diagnostic area and have visual contact Staff and provider break area should be close to treatment areas Adequate open space should be allowed for multiple types of small- and large-scale movement analysis Practices that specialize may have other equipment or diagnostic requirements

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EXAM

EXAM

EXAM

EXAM

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Figure 6.8  Orthopedic Office with Diagnostic Area. Source: Saglinda H Roberts

INTERNAL MEDICINE Overview Internal medicine is a specialty that focuses on applying scientific research to diagnose, and treat the internal organs. Many people use an internist as their primary care physician or for complex health conditions or illnesses. Internists can be generalists or specialists. Much of their practice is spent on diagnostics, therefore doctors may spend significantly more time with a patient, sometimes preferring to have initial meetings in consultation rooms, and their facilities have additional research and testing equipment not normally found in other specialty typologies. Patients may need to travel throughout the office to different testing locations, so understanding and planning for this type of circulation is critical. Lab work and testing are a large part of the diagnostic process, so extra and enlarged areas for these spaces is required. Please see Figure 6.9 for a floor plan that illustrates optimal elements of internal medicine offices.

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Staff Needs Experiential and Adjacency Requirements • Adequate space to comfortably meet with patients • Access to all required technology and paper resources • Clear and efficient circulation patterns from testing areas to consulting and exam rooms FF + E • Larger lab and storage areas to accommodate testing equipment • Larger number of consulting rooms • Larger size consulting and exam rooms due to multiple people and longer time spent with patients

Patient Needs Experiential and Adjacency Requirements • Sense of being cared for and valued as they are being moved around the facility for testing FF + E • Same as standard medical offices • Comfortable waiting areas at testing and lab areas that accommodate personal belongings

Internal Medicine Floor Plan Internal Medicine Items of Note: • Amount of diagnostic and testing equipment is far more extensive than most practices • Lab facilities are larger and more extensive in amount of equipment and mechanical requirements • Need for clear, smooth, and circular circulation patterns between exam rooms and all testing facilities to eliminate bottlenecks or pinch point in the traffic flow • Small waiting areas are necessary outside of the diagnostic and testing areas

Figure 6.9  Internal Medicine Floor Plan. Source: Medical and Dental Space Planning, Malkin 2014 p34 Figure 3–5

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ALTERNATIVE + NATUROPATHIC MEDICINE Overview Alternative medicine is a term that describes treatments that are outside of traditional or mainstream medical treatments, or those not taught in medical school. In general, the practices employed are those not based on Western medical practice, and focus on whole body, mind, and spirit restoration using naturopathic and/or non-chemical derivatives. Some of the more prominent or well-known treatments are chiropractic medicine, acupuncture, Shiatsu, massage therapy, energy therapies, Reiki, herbal medicine, and Ayurvedic medicine. Naturopathic medicine is also considered alternative medicine; it uses natural remedies to help the body heal itself. It uses herbs, vitamins, massage, acupuncture, exercise, and nutritional means to bring about healing. Focuses on whole person, mind, body, and spirit, seeking the root causes, not just treating symptoms. It can be a practice by itself, or employed by a traditionally certified medical doctor as part of their practice. Osteopathic medicine is a branch of traditional Western medical education that focuses on the “whole person” approach that treats the entire person, not just the symptoms. Preventive care and lifestyles that fight illness are promoted. They are allowed by law to prescribe medicines and can be generalists, family practitioners, or specialists in any field. Many hospitals and cancer treatment centers are starting to include alternative or naturopathic medicine as part of their services because of the positive effect that can be seen in patients health and is referred to as integrative medicine or practices. Private practices that employ one or several types of alternative treatments are still the most common form of alternative medicine.

Staff Needs Experiential and Adjacency Requirements • Sound attenuation between spaces FF + E • Variety of consultation and treatment spaces • Treatment spaces need to be large enough so provider can access all sides of the treatment table • Sink is usually not needed in each room, though one in the facility is necessary • Table or counter for treatment equipment and accessories • Laundry facilities within office

Patient Needs Experiential and Adjacency Requirements • Visual and auditory privacy FF + E • Changing area with clothes and personal belonging storage

Ma j or S p ecialties

Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Fitting the Task to the Human: A Textbook of Occupational Ergonomics 5th Edition by Karl HE Kroemer Human Factors in the Built Environment by Linda Nussbaumer Interior Graphic and Design Standards by SC Reznikoff Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara and Julius Panero Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith Articles and Websites AIA (American Institute of Architects) Healthcare Awards AIA 2018 Healthcare Awards. Retrieved from the 2018 AIA/AAH Healthcare Awards Website: www.aia.org/resources/198741-aiaaah-healthcare-design-awards-2018 A New Era Dawns in Behavioral Health Design. Retrieved from Design and Health AIA Website: www.aia.org/articles/6120749-a-new-era-dawns-in-behavioralhealth-desig:31 Design for Aging. Retrieved from AIA (American Institute of Architecture) Knowledge Net Website: network.aia.org/communities/community-home?communitykey=a83686b64432-4ac2-a3a1-b91a6808a014&tab=groupdetails Design Research and Behavioral Health Facilities. Retrieved from The Center for Health Design Website: www.healthdesign.org/system/files/chd428_researchreport_­ behavioralhealth_1013-_final_0.pdf Eight Essential Elements of an Ideal Dental Office. Retrieved from the Dentaltown ­Magazine Website: www.dentaltown.com/magazine/article/4792/eight-essential-­ elements-of-an-ideal-dental-office-design IIDA (International Interior Design Association) Healthcare Design Awards Military Medical Hospital. Retrieved from AIA (American Institute of Architecture) Top Ten Website: www.aiatopten.org/node/358 Sweetwater Spectrum Community. Retrieved from AIA (American Institute of Architecture) Top Ten Projects Website: www.aiatopten.org/node/369 T. Boone Pickens Hospice and Palliative Care Center. Retrieved from the Mesa Design Group Website: mesadesigngroup.com/portfolio_page/t-boone-pickens-­hospiceand-palliative-care-center Towards a Silver Architecture: Optimizing Design for Geriatric Patients. Retrieved from ­Medical Construction + Design Website: mcdmag.com/2015/05/toward-a-silverarchitecture-optimizing-design-for-geriatric-patients/#.VW37sTdIJyE The 6 Principles of Naturopathic Medicine. Retrieved from the Association of Accredited Naturopathic Medical Colleges (AANMC) Website: aanmc.org/6-principles UK Healthcare Opens New Integrative Medicine Clinic Space. Retrieved from University of Kentucky News Website: uknow.uky.edu/uk-healthcare/uk-healthcare-opensnew-integrative-medicine-clinic-space-offers-services-patients Universal Design and Accessibility. Retrieved from the General Services Administration (GSA) Website: https://www.section508.gov/develop/universal-design

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GROUP PRACTICES

Group practices are becoming more and more prevalent in the medical fields. They serve several purposes that range from sharing physical space and testing equipment or on-call emergency and administration work. The financial and liability risk can also be a significant factor in influencing the decision to create a group practice. As healthcare corporations and hospitals expand, smaller or solo practices are be bought and consolidated. Here is a brief overview and the related design considerations.

SINGLE SPECIALTY GROUP PRACTICES Overview A single specialty group practice is where there are least two physicians are practicing the same specialty or type of care. They share office space, equipment, oversight, and financial responsibilities. Physicians often choose this option for regularly available collaboration, shared off-hours coverage, the ability to have vacation time covered, potential for larger patient base, and greater capital resources for equipment and employee benefits. Some common examples would be OB/Gyn, Physical Therapy, Orthopedic, or Cardiac practices, but any general or treatment specialty can choose to form a group practice. From a design standpoint it is like designing one big office because the equipment and its use is consistent across all physicians and everything can be shared equally.

MULTIPLE SPECIALTY GROUP PRACTICES Overview A multi-specialty group practice is where physicians of varying specialties join to create one practice. These multi-specialty groups are usually formed by specialties that work collaboratively as in internal medicine where a broad number of specialties are used to diagnose and treat patients. Multi-specialist practices can provide integrative Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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collaboration for physicians and a single source for a broad set of specialists for patients. Other benefits include state-of-the-art medical technology, greater access and communication across specialists, and more collaborative care models. From a design standpoint, understanding what elements or resources are to be shared and which are not, and how to create separation between them is key.

EMPLOYED PHYSICIAN PRACTICES Overview Employed physician practices can be either single or multi-specialty, are typically owned and managed by hospitals or healthcare corporations. Physicians are employees rather than partners without input or responsibility for how the practice is run. These occur when solo or small practices are purchased and combined or when hospitals or corporations hire directly for ambulatory or urgent care facilities. These types of practices can also be a group of separate practices sharing one medical office which may include using the same physical spaces on alternating days. Even though the financial structure and the physician’s responsibility and involvement may be different, from a design standpoint they would be treated as a single or multi-specialty group practice. Understanding who the main decision makers are is also a very important factor.

GENERAL CONSIDERATIONS It is important to understand the business structure and whether the practice is a single specialty or multi-specialty practice before starting the design or even interview process. These factors are foundational in forming the very basis of your interview questions as well as design approach by greatly influencing the amount of shared and/or separate features or elements in the facility. It also influences how and where patients will be circulating throughout the office to use various equipment or areas, increasing the importance of smooth circulation and traffic flow. There should be adequate room and logical connections between areas that are used the most. It is also critical to keep in mind there will be people with differing ambulatory abilities. Determining which areas can be shared and which areas are restricted will help to guide your choice in the overall organizational structure. Following are several typical organizational typologies.

Centralized Plan Centralized planning gives a very cohesive and unified impression. Although there may be many separate physicians or care givers, the office appears and is sensed to function as a comprehensive whole. Many of the areas and elements are shared. This works very well for a multi-partner single specialty medical practice or a multi-specialty practice where many if not all elements are able to be shared (Figure 7.1).

Satellite Plan The centralized core can accommodate all the shared functions along with a larger centralized reception and waiting areas. In the schematic below there are additional waiting areas outside each of the specialties. Though there are distinct separations between typologies, or departments/functions, there are shared circulation spaces and open access to each of the areas where patients and staff can move freely between them. There could also be more distinct boundaries if so desired by the clients or predicated by the nature of the individual typologies (Figure 7.2).

G ro u p Practices

Figure 7.1  Schematic Diagram of Centralized Plan, Single Specialty Group ­Practice. Source: Medical and Dental Space Planning, Malkin 2014 p398 figure 7–5.

Figure 7.2  Schematic Diagram of Satellite Plan, Multispecialty Group Practice. Source: Medical and Dental Space Planning, Malkin 2014 p404 figure 7–11.

Satellite Pods Distinct and separate practices that share the same space with single administrative or lab functions are best accommodated with this structure. The sections or pods can be visually and experientially very separated, or as closely related as the client desires or as the available space dictates. This type of organizational structure could even be applied to multiple floors. The individual practices are self-sufficient and contained, with the exception of few ancillary functions and services (Figure 7.3).

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Figure 7.3  Schematic Diagram of Decentralized Plan, Single Specialty Group ­Practice, Pod Concept. Source: Medical and Dental Space Planning, Malkin 2014 p401 figure 7–8.

TYPICAL SHARED FUNCTIONS AND COMPONENTS The financial benefits of sharing spaces and equipment are some of the main motivators of physicians forming group practices. There is also the efficiency of combining non-medical functions which free up physicians and care givers to spend more time with patients, and reduces operating costs overall. The client interview is of primary importance here to gain a deeper understanding of what areas and functions can be combined and what cannot. Understanding the work flow as well as the number of people using the spaces is extremely important in determining the square footage and elements needed. Following are some classic examples of areas typically combined and are applicable for both single and multi-specialty group practices.

Reception and Waiting Areas Reception and waiting areas are two of the most commonly combined spaces in group practices. The number of seats and check-in areas need to be adequate for the amount and flow of patients for all the care givers that will be on duty at one time. Seating capacity should be designed to accommodate an hour worth of patients. By doubling the number of patients that can be seen in an hour and subtracting the number of available exam rooms the number of seats in the waiting area can be determined. This then determines the square footage of waiting area. For example, if there are 8 care givers, who see 4 patients an hour each and there are 3 exam rooms per care giver the total number of seats needed in the waiting area is 40. P = Average Number of patients per hour per care giver (4 per hr) D = Number of care givers (8) E = Number of Exam rooms (3 each or 24 total) S = Seating 2P× D − E = S or (2 )4 × 8 − 24 = 40 (Malkin 2014, p. 409) Seating should be arranged in groups for privacy and should include a variety of seating options. Space for wheelchairs should be in addition to that outlined earlier and the type of practice should also be considered when allowing extra space.

G ro u p Practices

Labs Determine if the group practice is just increasing the output or volume of one type of procedure, or if there will be diversity in processes and volume which will help in understanding the square footage, mechanical, plumbing, storage, and work area needs of the lab.

Restrooms The number is determined by the medical typology and how much lab work they do which requires restrooms. The added number of restrooms allows for them to be dispersed throughout the patient areas for more convenient use. In general, there should be at least one by the waiting area, one adjacent to the lab, and one in the exam areas. There should be private restroom for the staff, number to be determined by the number of staff using them.

Exam Rooms In general, the rule for exam rooms in a group practice is one less than what they can see per hour. This could change depending on how long or extensive the exam process is. Again, careful investigation and understanding of the practice is critical here. The equipment and size of exam rooms need to accommodate the basic requirements for all of the medical typologies that are served in the facility.

Administration, Insurance, and Accounting Because the patient base is usually larger than solo or small practices, the business and insurance offices, as well as file storage may need to be larger to accommodate the work flow and volume. Key factors in the location of these offices is whether patients need access to them or not. They are usually adjacent to the check-in areas, but if patient access isn’t a concern they can also be in a more remote location of the office.

Physician’s Offices The total number of offices depends on how many physicians are on duty or in the office at a given time and if they are willing to share offices or not. There may also be a group area for doctors with open desking in addition to private offices. The number of offices or arrangement can also depend on if the facility is the physician’s main location or a satellite office. Depending on the type of practice, the preferred configuration can be grouped together or dispersed among the exam or lab areas.

Consultation Rooms Depending on the medical typology there may be more or less consultation rooms in a group practice than in a solo or small practice. In group practices, consultation rooms could also double as temporary offices for visiting physicians, conference spaces, or non-exam oriented patient appointments. Their location and grouping will depend on the specific medical practice’s style of working. Some prefer the consultation rooms to be grouped together, closer to the reception area, while other practices prefer them to be dispersed among the exam rooms, or even adjoining exam rooms or physician’s offices.

Break Room or Staff Lounge Break rooms or staff lounges are important to promote refuge and rest for the staff, provide place to eat lunch, store personal belongings, and provide a setting for social

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connections and collaboration. Ideally there should be a variety of seating options and ability to have larger group gatherings with restrooms close by. Refrigeration and prep space should be enlarged to accommodate the full number of people in the facility. Having the staff area away from the exam rooms and patient areas provides sound separation and a greater sense of privacy for the physicians and staff. This, many times, acts as the point of staff entry as well. Separate Components and Functions Regardless of organizational pattern or if the group practice is a single specialty or multi-specialty, there may be areas, equipment, or exam rooms that group practices prefer not to share. These are mainly specialized diagnostic or procedural equipment, or specialized exam rooms. With multi-specialty group practices, they may also prefer to have smaller waiting areas for each typology or practice type after patients check in at a central reception area. The organizational style will determine this as well as an understanding of the specific client and their practice. Please see Figure 7.4 for a floor plan that illustrates optimal elements for a multi-specialty group practice.

Figure 7.4  Multispecialty Group Practice Clinic. Source: Medical and Dental Space Planning, Malkin 2014 p407 figure 7-14a.

G ro u p Practices

Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Fitting the task to the Human: A Textbook of Occupational Ergonomics 5th Edition by Karl HE Kroemer Human Factors in the Built Environment by Linda Nussbaumer Interior Graphic and Design Standards by SC Reznikoff Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara and Julius Panero Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith

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CLINIC PRACTICES

Clinic practices are a healthcare model where corporations employ clinicians instead of the group practice model where physicians and providers are in partnership model of ownership and management. The administration aspects of a practice are handled by the employer, providers can focus solely on providing care, and financial resources are typically greater than single or group practices. A clinic can be for primary care, or focus on a specialized area of medicine, community, or be a combination of specialties that are typically used in conjunction with each other such as orthopedics, surgery, and physical therapy. This model of practice is becoming more and more common because of the increased financial and productivity gains. In many aspects the types of spaces required are the same as profiled for general practitioners in Chapter 5, but with varying differences based on the specific typology, cultural needs, and size of the practice. The Center for Health Design (CHD) is a nonprofit organization focused on supporting the healthcare, construction, and design industries and focused on leading them toward creating improved environments for care and healthy aging. The following are some of the recommended elements all clinics and ambulatory based practices/facilities should have. The scale and complexity of the below elements will be greatly influenced by the specific practice and the demographics of the people and area which they serve and should always consider Universal Design Principles. • Informational signage that is accessible for a broad range of users, regardless of ability, language skills, or age • Acoustics limiting noise, sense of privacy among patients and their families, and strategies to limit cross infection in public areas • Provide multiple and varied types of waiting areas with positive distractions and activities that are applicable for the demographic with internet access • Room for accompanying family members or care givers should be included in all spaces • Preferably have access to daylighting, outdoor views, and possible outdoor waiting areas or therapy gardens Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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• Furniture that meets a large variety of physical sizes and abilities • Standardization with technology and equipment in all areas The other notable aspect of clinic practices and healthcare is the trend of replicating the focus of the hospitality market on aesthetics, service, and customer experience. This is a very real movement and there are supported findings that these changes improve healing rates, well-being, patient satisfaction, as well as increases profitability. Attention to the aesthetics, amenities, and spatial divisions also helps to create calmness, trust, and the perception of quality of care. These principles are especially prevalent in clinic and group practice settings. The below elements and requirements are in addition to all the general conditions for each area outlined in Chapter 5, with the client’s and stakeholder’s input taking precedence over textbooks or other experience.

COMMUNITY HEALTH OR CARE CLINICS Overview A community healthcare clinic is typically focused on family medicine, but also can be focused on practice specialties used in conjunction with each other like OB/GYN, Women’s Care, Family Planning, and Pediatrics. Clinics are many times located in areas of high need and should be culturally sensitive to the population being served, taking into account socioeconomic conditions and ethnic and cultural views as well as addressing the general beliefs regarding medical care. Their purpose as a social hub or community gathering center that serves the community by providing job counseling, education, or childcare facilities needs to be explored during the programing stage and addressed during preliminary design. This typology can also be called a Health Center, Community Clinic, or Community Health Center or Clinic. The facility may be focused on treating those without insurance, are under insured, or are charged on an ability-to-pay basis. They may or may not be supported by the federal or local government or Health Services organization. Each of these financial support models may dictate design and operational directives. Please see Figure 8.1 for a floor plan that illustrates optimal elements of community health centers.

Staff Needs Experiential + Adjacency Requirements • • • • • •

Separation between medical and social or community spaces Sense of physical safety and security as well as from cross contamination Sense of belonging if using shared spaces because of rotation or shifts Areas for collaboration – central admin and provider areas Acoustic and visual privacy Break areas and areas of respite

FF + E • Security features for medical equipment, spaces and drugs if also used for social or community purposes • See chapters outlining specific practice typologies for specific requirements • Explore specifications or prerequisites that are related to business model or population being served

Patient Needs Experiential + Adjacency Requirements

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• Sense of physical and emotional safety • Understanding, respect, and adherence to cultural and social values • Sense of welcome and respect for patient and caregivers FF + E • See list of general CHD requirements and the specific spaces in Chapter 5 • Additional social or community spaces that facilitate the proposed use

Community Health Clinic Plan

Figure 8.1  Community Health Center. Source: Medical and Dental Space Planning, Malkin 2014 p163 figure 4–29. Community Health Clinic Items of Note: • Large waiting area with alternate seating options if available. Walk-in appointments are common so being able to accommodate a larger number of patients and varying wait times is important

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• Dispersed and/or compartmentalized treatment areas that are self-contained with provider and exam spaces that can accommodate differing specialties, increase infection control, or help to disperse the patients evenly throughout the available space • Provide patient toilet facilities for each area or location of exam rooms • Not shown above are areas for provider respite, break, or personal belongings. Make sure these areas are close to all treatment areas • Pharmacy is included in facility to increase patient access to medications needed without extra stop • Exam room size and configuration are the same as family practice office • Some facilities may have diagnostic equipment or procedure rooms based upon areas or practice or specialties

URGENT CARE FACILITIES Overview Urgent Care Facilities are considered to be the middle ground between your primary care provider and the emergency room at a hospital. They can provide immediate care for a large variety of health conditions that are not life threatening. Typically, appointments are not required and the facilities can be open longer and after normal business hours as well as holidays. Treatment can be less expensive than emergency rooms and require less wait time. Because of these factors and their dispersed locations, they can be considered more convenient and are becoming a popular option with patients as well as being more profitable. The broad variety of healthcare conditions that are handled can indicate that larger or more spaces are needed along with a more extensive set of equipment such as an X-Ray machine, small laboratory, or procedure room. Depending on the facilities business model, staff may have longer working shifts and require additional facilities to handle changing, sleeping, eating and showering. Please see Figure 8.2 for a floor plan that illustrates optimal elements of urgent care facilities.

Staff Needs Experiential and Adjacency Requirements • • • • •

Areas for collaboration – central admin and provider areas Separation between patients based on acoustic and visual privacy Break areas or areas of respite Sense of physical safety and security as well as cross contamination issues Outdoor views and access to daylight ideally all the time but at the least in respite/ break areas

FF + E • • • • •

Areas for more advanced or specialized equipment and procedures Security and separation devices throughout facility Locker rooms and sleeping quarters based on hours of operation or shift lengths Broader range of equipment and supplies in each exam room See Chapter 5 for basic requirements for each area

Patient Needs Experiential and Adjacency Requirements • Acoustic separation between waiting and treatment areas • Assurance of cleanliness

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• Assurance of quality of care • Assurance of confidentiality + privacy when in all areas FF + E • See list above of general requirements • Comfortable waiting area with positive distractions • See requirements for waiting rooms in Chapter 5

Urgent Care Floor Plans

Figure 8.2  Urgent Care Facility. Source: Medical and Dental Space Planning, Malkin 2014 p131 figure 3–115 Urgent Care Items of Note: • Larger waiting area due to many if not all patients being on a walk-in basis with multiple areas and easily accessible restrooms

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• Have larger and possibly more extensive lab and procedure areas than family practice due to the large range of treatments covered • May have more diagnostic equipment such as a small MRI or X-Ray area • Circulation corridors that connect treatment and diagnostic areas without having to pass through public entry ways • May have larger number of treatment rooms per doctor ratio given office location, demographic, or treatments provided

FACILITY SPECIFIC TREATMENT SPACES Overview These would be small medical care facilities meant to provide general medical care for a specific “in-house” population. They would typically be found in elementary or high schools, colleges, universities, military bases, or prisons. The purpose is to treat a broad range of non-serious illnesses and injuries and/or also act as a triage or staging area for more serious injuries that will be treated elsewhere. They are not equipped with emergency or x-ray equipment like an Urgent Care Facility. The number of providers and staff can vary depending on the size of the facility, so flexibility and efficiency are of utmost importance. Flexibility is critical as these facilities are usually small and may need to accommodate more than one function, or multiple occupants with various needs at one time, or serve a multitude of purposes. Acoustics, lighting, and privacy are still important features, but will vary depending on the specific facility they are housed in. Prisons or military bases with have requirements for overnight stays where college dispensaries may accommodate overnight stays, and K-12 schools will not. The equipment and resources provided to care givers will be dependent on the most likely or typical type of treatment for that particular typology. Please see Figure 8.3 for a floor plan that illustrates optimal elements of facility specific treatment clinics.

Staff Needs Experiential + Adjacency Requirements • • • •

Areas of respite preferably with outdoor views Areas for quiet and focused work with visual and acoustic privacy Line of sight or ability to observe patients in various stages Ability to change the physical space while still having standardization of equipment and resources

FF + E • • • • • • • • • •

Broad range of equipment and supplies related to probable treatment needs Access to handwashing + plumbing Fixed and movable storage options Varied sitting and standing work space Exam room/area Ward areas/patient rooms for overnight or probationary periods Highly adjustable seating Administrative work area Break area with private restroom and shower is optimal Laundry facilities

C linic Practices

Patient Needs Experiential and Adjacency Requirements • Sense of safety and privacy in highly flexible environment • Acoustic + visual separation/privacy • Ability to rest FF + E • • • •

Waiting area with variety of options Stretchers or beds for laying down (depends on type of facility and typical length of stay) Secure and non-secure area for personal belongings Access to restrooms, including shower is optimal

Facility Specific Floor Plan

Figure 8.3  Facility Specific Treatment Clinic or Infirmary. Source: Saglinda H Roberts Facility Specific Treatment Clinic Items of Note: • • • • •

Flexibility in use of spaces Flexible spaces so broad range of procedures can take place on typically small population Break, changing, and showering facilities for providers as they often spend long shifts Toilet rooms available by infirmary and waiting areas for infection control Providers have private facilities

Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Fitting the task to the Human: A Textbook of Occupational Ergonomics 5th Edition by Karl HE Kroemer Human Factors in the Built Environment by Linda Nussbaumer Interior Graphic and Design Standards by SC Reznikoff

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Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara, Julius Panero Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith Articles and Websites AIA (American Institute of Architects) Healthcare Awards Cedars-Sinai, Play Vista Physician Office + Urgent Care. Retrieved from the AIA (American Institute of Architects) Website: www.aia.org/showcases/198686-cedars-sinai-playavista-physician-office– IIDA (International Interior Design Association) Healthcare Design Awards AIA (American Institute of Architects) 2021 Healthcare Design Awards. Retrieved from the AIA Website: www.aia.org/resources/6415366-2021-healthcare-design-awards The Center for Health Design Website: https://www.healthdesign.org Clinic Design. Retrieved from The Center for Health Design Website: ambulatory. healthdesign.org Having It All: New Trends in Clinic Design. Retrieved from the Healthcare Design Website: healthcaredesignmagazine.com/trends/architecture/having-it-all-new-trends-clinic-design Healthy Outlook: q+A With MASS Design’s Michael Murphy. Retrieved from the Healthcare Design Website: healthcaredesignmagazine.com/trends/architecture/healthyoutlook-qa-with-mass-designs-michael-murphy Hospitality Healthscapes: The New Standard for Making Hospitals More Hospitable. Boston University School of Hospitality Administration Website: www.bu.edu/bhr/2017/06/07/ hospitality-healthscapes List of Design Recommendations for Clinic Design. Retrieved from The Center for Health Design Website: www.healthdesign.org/sites/default/files/files/news/Clinic%20 Design%20Recommendations_FINAL%202011.pdf Perkins + Will, Featured Healthcare Work. Retrieved from Perkins+ Will Website: ­perkinswill.com/projects/health/#area-of-expertise Universal Design and Accessibility. Retrieved from the General Services Administration (GSA) Website: https://www.section508.gov/develop/universal-design What Healthcare Can Learn from Retail and Hospitality. Retrieved from HealthSpaces Website: info.healthspacesevent.com/blog/what-can-healthcare-learnfrom-retail-hospitality

Chapter

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SPECIALIZED AMBULATORY CENTERS

Ambulatory practices are those that treat patients who do not stay overnight, or what is referred to as an “Outpatient” basis. These can be typical doctors or specialists, or have additional requirements or where patients spend an extended amount of time as part of their treatment or visit. Patients spending a significant amount of time in the facility adds complexity and the need for increased basic facilities as well as access to daylight, views, privacy, artificial lighting, and overall comfort. The emotional status of the patient and accompanying caregivers also becomes of greater importance as well. Following the guidelines from the Center for Health Design (CHD) for clinics also apply here. Special accommodations should be made in the floor plan and the site plan to have pick-up and drop-off areas that can accommodate a limited number of cars for brief amounts of time. The length of treatment times or patient visits also affects the type and quantity of interior facilities or amenities that will be required. As with all other facilities this information should be determined and analyzed with the stakeholders during programing and schematic design. The following requirements are in addition to all the general conditions for each area outlined in Chapter 5, with the client’s and stakeholder’s input taking precedence over textbooks or previous experience. The Center for Health Design (CHD) is a nonprofit organization focused on supporting the healthcare, construction, and design industries and focused on leading them toward creating improved environments for care and healthy aging. The following are some of the recommended elements all specialized ambulatory based practices/facilities should have. The scale and complexity of the elements will be greatly influenced by the specific practice and the demographics of the people and area which they serve and should always consider Universal Design Principles. • Informational signage that is accessible for a broad range of users, regardless of ability, language skills, or age • Acoustics limiting noise, sense of privacy among patients and their families, and strategies to limit cross infection in public areas Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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• Provide multiple and varied types of waiting areas with positive distractions and activities that are applicable for types of demographics with internet access so patients and their caregivers can achieve a sense of privacy over extended wait times or stays • Room for accompanying family members should be included in all spaces • Preferably have access to daylighting, outdoor views, and possible outdoor waiting areas or therapy gardens • Furniture that meets a large variety of physical sizes and abilities • Standardization with technology and equipment in all areas The other notable aspect of clinic practices and healthcare is the trend of replicating the focus of the hospitality market on experience, aesthetics, and customer service. This is a very real movement and there are supported findings that these changes improve healing rates, wellbeing, patient satisfaction, as well as increases profitability. Attention to the aesthetics, amenities, and spatial divisions also helps to create calmness, trust, and the perception of quality of care. These principles are especially important in specialty ambulatory care where extend time is spent by patients and their accompanying caregivers or family. The following elements and requirements are in addition to all the general conditions for each area outlined in Chapter 5, with the client’s and stakeholder’s input taking precedence over textbooks or other experience.

AMBULATORY SURGERY Overview Ambulatory surgery centers are set up to handle scheduled surgery procedures that do not require an overnight stay at the hospital. They are usually shared by a multitude of doctors or surgeons who perform surgery on designated days and times. This enables the specialized surgery facility to be used at the highest efficiency, saving each surgeon the cost of having their own surgery facility, or overwhelming the hospital facilities. There are a variety of business and operational models that can determine its layout and process. These centers are most often “freestanding” meaning not attached to or part of a local hospital, but they can be. Patients and their accompanying care givers can be at the facility for approx. 4–6 hours depending on the type of surgery performed and the patient’s condition or reaction to surgery. It is therefore important to take the extended occupancy times in to account when designing all areas of the facility. Aesthetics, physical comfort, daylighting, and positive distractions are very important for all areas, and having access to internet, varied types waiting areas and furniture, aid in giving a sense of privacy and separation which is extremely important to the waiting caregivers. Providing access to food and beverages is a wonderful amenity for someone that is there for any extended time. Special arrangements for patient drop off and pick-up are extremely important here as the majority of people have very limited mobility after surgery. Direct, efficient patient flow through prep areas, pre-surgery waiting, or pre-op, operating theaters, recovery, and discharge areas are essential for the surgeons, providers, and staff. Support areas for all stages are required within close proximity to each. Break areas with lockers, changing areas, and restroom facilities are required for the staff. There may be facilities that also require consultation spaces for before surgery, after surgery, or both. Standardization is of utmost importance to increase efficiency and reduce errors since multiple groups of surgeons and their staff will be using the areas. Depending on how the facility is operated, the surgeon may bring some or all of his own staff with him, or he may be working with staff that is always assigned to the surgery facility. Building and regulatory codes may provide guidance or specifications for adjacencies, materials, HVAC metrics, and any other elements in this type of facility. Inspections may also be required in addition to the typical local or municipal building codes. Please see Figure 9.1 for a floor plan that illustrates optimal elements of ambulatory surgery centers.

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Staff Needs Experiential + Adjacency Requirements • • • • • •

Rest and hygiene areas within patient areas and separate break rooms Ability to visually and physically monitor several patients simultaneously Assurance of required equipment and resources to meet any patient condition Clean efficient flow of patients through the facility Areas for collaboration Daylighting, views, understanding of the passage of time

FF + E • • • • • • • •

Locker rooms with showers Standardized support areas and equipment adjacent to each stage of the process Administration areas adjacent to each stage Furniture and equipment that is highly flexible and adaptable Heightened infection control in keeping with appropriate professional and local codes Electrical and mechanical requirements for all equipment and infection control Physical and acoustic separation between patients Acoustic privacy in administration or collaborative areas

Patient and Accompanying Caregiver Needs Experiential + Adjacency Requirements • • • • • •

Stress reducing atmosphere with positive distractions Physical comfort to make the long waiting periods easier Privacy and sense of security (emotional and physical) Variety and ability to change settings (accompanying caregivers) Views, outdoor areas, and daylighting Acoustic privacy, and reduction or operational noise, or other patients

FF + E • • • • • • • •

See recommendations from CHD earlier for all areas Visual, physical, and acoustic separation from others in each of the staging areas Variable seating options and locations Forms of positive distraction Internet access Food and beverage service options or availability in waiting areas Lockers or storage for personal belongings Guest chair with arms and small movable table

Ambulatory Surgery Floor Plan Ambulatory Surgery Center Items of Note: • Space planning allows for clear progression through the surgery process • All stages are clearly separated following the progression through the process of pre-op, surgery, recovery and exiting the facility

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Figure 9.1  Ambulatory Surgery Center. Source: Medical and Dental Space Planning, Malkin 2014 p429 figure 8–4

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• There are no cross interactions between stages meaning patients do not retrace their steps through the facility • There is clinical and administrative support adjacent to each area to increase efficiency and eliminate cross contamination • Surgery or operating theaters are physically separated from the rest of the areas. The level of sterilization and separation will be defined by each facility • Circulation spaces are generously designed for multiple foot and gurney traffic • Patient toilet rooms are located in each area to reduce cross traffic and cross contamination • Staff changing, break areas, and business administration are separated from patient areas • Additional technical or equipment requirements could vary given the predominant types of surgery performed and should be coordinated with the medical professionals and engineers Though the example shown in 9.1 is a larger facility, the areas and features could easily be reduced to accommodate a smaller patient load.

PHYSICAL THERAPY Overview Physical therapy is an allied health profession that uses specially designed exercises, equipment and physical treatments to restore, enhance, or preserve movement in the body. It is focused on evaluating the mechanical aspects of a person’s body movements in relation to their skeletal and muscular systems. Patients can be referred to a physical therapist after injury, trauma, surgery, or age-related loss of function. Patients wear loose fitting clothing, so individual rooms are not required. Everyone shares a broad range of exercise machines, equipment, or props during treatments so generous floor space is required. This floor space is also needed to properly evaluate walking or other types of movement. Patients work independently as well as with a therapist on a set routine of individualized exercises or treatments. Therapists usually work on several patients at one time, so visual contact between stations or therapy tables is essential for safety and efficient progress of treatment. It also allows the patient to have a sense of being valued and cared for. The ability for therapists to survey the whole treatment floor from the individual work stations is also critical. Physical therapy treatments also incorporate heat, cold, and hydrotherapy that include additional equipment like ice machines, large steamers, or heating equipment. These are usually in a centralized location for easy access. Understanding all the electric, water, and mechanical needs is key for a well-functioning practice. Please see Figure 9.2 for a floor plan that illustrates optimal elements of physical therapy offices.

Staff Needs Experiential + Adjacency Requirements • • • • • •

Generous spacing to facilitate treatments and evaluation of multiple people Visual access and control of all areas Area of acoustic privacy while maintaining visual contact with treatment area Break spaces away from treatment areas Centralization of common or shared treatment elements Daylight and views

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FF + E • • • • • •

Place for more private conversations or treatments Treatment tables of differing sizes and heights some with articulating features Adjustable stools for therapists at treatment tables Efficient and organized storage systems for each type of therapy equipment and prop Plumbing, mechanical, and electrical outlets for all machinery and equipment Laundry, sink area, or lab area for molds, prosthetics, and hygiene

Patient Needs Experiential + Adjacency Requirements • • • • • •

HVAC design to accommodate greater levels of physical activity Positive distractions during repetitive or painful treatments Ability to visually have contact with therapist when they are treating other patients Ability to choose the level of interaction with other patients Sense of privacy during time with physical therapist Pleasant positive atmosphere

FF + E • Storage areas or lockers for personal belongings during treatment • Stable chairs with arms for sitting or therapy uses • Flexibility and adaptability with equipment and treatment tables

Physical Therapy Floor Plans

Figure 9.2  Physical Therapy Floor Plan. Source: Medical and Dental Space Planning, Malkin 2014 p451 figure 9–2 Physical Therapy Items of Note: • Private and open treatment tables allow for patient preference, or treatment specific privacy • Providers can easily monitor patients and the space while at desk completing administrative tasks

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Treatment tables and therapy equipment grouped by type of use or activity Open areas allow space for flexibility of patient diagnosis or treatment activities Separate break and changing facilities for staff and providers with acoustic and physical separation Large expanse of windows provides positive distractions for patients and improved working conditions for staff Extent of “Manipulatives” and ancillary equipment may vary or increase depending on specialties or treatments provided • Adequate storage is essential and is required throughout the treatment area

CANCER TREATMENT CENTERS Overview Cancer treatment centers can be ambulatory and/or in-patient facilities that focus on the specialized treatments to combat all types of cancer. They can be teaching and research facilities as well, meaning that in addition to simply treating patients, they could include researchers, laboratories, and teaching facilities, or require additional space to accommodate students as well as the provider and patient in spaces. Cancer treatment is a time of great stress, fear, uncertainty, and upheaval of normal life for patients. Every aspect of the facility needs to take this into consideration. The overwhelming goal is to convey a sense of calm, tranquility, reassurance, and control. Aesthetics, acoustics, and access to nature is especially important, as is multiple and varied types of experiences for the waiting and meeting areas. Patients and their caregivers could be in the facility for hours at a time so comfort for both is essential. Patients may come from out of town for weeks at a time for their treatments and are staying in temporary living arrangements, so the treatment center should be more along the lines of a hospitality facility, with the difference that people could be spending hours in the waiting areas. These spaces should be aesthetically pleasing, and provide multiple private nodes allowing many different activities. Including amenities such as coffee bars, cafes, or work sharing spaces can provide for the needs of patients and their accompanying care givers over the extended periods of treatment times. The staff is challenged with needing to constantly monitor patients, yet provide them with a sense of privacy during their treatment. Some people find great comfort in the relationships made during treatments, while others do not, so allowing patients control over when with whom they interact with is important. The overall size of the facility and the extent of diagnostic or treatment equipment such as MRI or X-Ray facilities or extensive laboratory or testing facilities depend on the type or size of the facility and the types of treatments they provide. Cancer treatment facilities are so varied in size that Figures 9.3 and 9.4 focus mainly on the infusion/ treatment areas. The current best practices for all facilities are following more of a hospitality model allowing multiple types, sizes, and nodes for waiting before and during treatments. The many technical aspects related to the specific equipment, chemicals, and processes are dictated by medical professionals and engineers, and their inclusion need to be designed collaboratively in strict accordance with their recommendations for each facility and the desired level of treatment. Whole treatment facilities are very complicated and not covered here. For more information, please see the additional resources at the end of the chapter or excellent case studies.

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Staff Needs Experiential + Adjacency Requirements • Ability to visually monitor multiple patients at one time • Easy and efficient circulation patterns between patients and their treatment equipment and work stations • Access to daylight and nature ideally in all areas • Areas of respite close to patient areas • Chemical mixing areas in close proximity to treatment areas with special exhaust and visual contact FF + E • • • • • •

Centrally located nurse’s station with multiple and flexible work stations Counter space, work area and equipment space as per client’s requirements Sink area Restrooms with at least one shower facility Lab facilities Separate entry for staff and supplies

Patient Needs Experiential + Adjacency Requirements • • • • • •

Sense of security, safety, dignity, and control as much as possible Sense of privacy and respite Ease of access and intuitive or logically organized circulation and placement of elements Sense of being welcomed, seen, and cared for Extra room for caregivers Clear, direct wayfinding and circulation

FF + E • • • • • • • • •

Control of lighting, temperature, views, interaction with others Ergonomic seating for patient WiFi connectivity in patient and waiting areas TV for positive distraction Views, daylight, natural elements, and access to nature if possible Seating options for accompanying caregivers Counter and casework for supplies and equipment Multiple types of waiting areas in multiple areas of the facility Areas for accompanying care givers in treatment areas

Cancer Infusion Center Floor Plans Cancer Treatment Center Items of Note: • • • • • •

Allow for physical and acoustic privacy while maintaining visual contact for providers. Allow for flexibility of patient visual and acoustic privacy levels Provide visual access to exterior views and daylighting Clear paths and lines of sight to aid in wayfinding, patient observation, and sense of security Nodes and pockets of diversified waiting areas within the treatment areas, allowing for flexibility and privacy End corridors with windows, glass + light

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• Keep corridors shorter for aesthetics and function • Access to natural areas and gardens from waiting areas can increase occupant wellbeing and connection to nature • Create clusters of treatment rooms with nurse’s stations to provide sense of openness, increased personalization, and reduce travel distances for providers and staff • By having the windows in the public spaces and interior glass, daylight, exterior views, and nature are more available, and have a greater presence for all occupants • Look at creating more and smaller labs/treatment equipment to reduce travel, time away from patients, and increase visual and physical proximity

Figure 9.3  Open Plan Infusion Area. Source: Saglinda H Roberts

Figure 9.4  Private Infusion Suites. Source: Saglinda H Roberts

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DIALYSIS OR KIDNEY TREATMENT CENTERS Overview Dialysis or kidney treatment centers are facilities that perform life sustaining blood purification for people whose kidneys can no longer do it. Patients visit the facility several times a week and can spend up to 16 hours per week undergoing dialysis treatments. Creating distinct zones for public activity, patient treatment areas, and support areas increases efficiency for the providers as well as conveys a sense of care, dignity, and humanity to patients that is so essential. The staff is challenged with needing to constantly monitor patients and maintain high levels of sterilization, while providing them with a sense of privacy and humanity. Giving patients as much control as possible over their surroundings and the level of social interaction with other patients greatly improves their experience and therefore willingness to maintain their treatment schedule. Because of the long hours patients spend at the facility, multiple times a week, providing nature, sunlight, and views of nature increase the aesthetics, help maintain balanced Circadian rhythms, and create a positive distraction. Depending on the facility and the extend of patient support services there may be the need for treatment or exam rooms, dieticians, laboratory facilities, social workers, and other technical support services. Please see Figure 9.5 for a floor plan that illustrates optimal elements for dialysis or kidney treatment centers.

Staff Needs Experiential + Adjacency Requirements • Easily maintained line of sight to all patients to effectively and efficiently monitor treatment • Daylight, natural views • Efficient circulation and access to both patients and support areas/services • Areas of respite easily accessible to patient areas • Smaller patient groupings provide ease and greater efficiency in visual monitoring • Adequate space to move around each patient to facilitate treatment and for associated equipment FF + E • Centrally located nurse’s station with multiple work stations • Counter space, work area, and equipment space along with corresponding mechanicals • Sink area (at least one) • Restrooms with at least one shower facility • Lab facilities • Equipment and treatment cleaning in close proximity • Sterilization areas separate, but easily accessible • Increased mechanical and electrical needs throughout all areas including treatment area • Separate entry for staff and supplies

Patient Needs Experiential + Adjacency Requirements • Sense of privacy during treatment if desired • Sense of dignity and being treated in a humane way, • Visual contact with providers,

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• Sense of security related to level of care, cleanliness, and to counteract the vulnerability felt during treatment • Pleasant aesthetics to increase the desire to maintain proper treatment schedule • Daylighting and natural or exterior views • Multiple positive distraction alternatives to help manage long treatment times • Ease of access for transportation and use of facility FF + E • • • • •

Ergonomic treatment chair Area for personal belongings Wifi and or computer access with easily accessible outlets Line of sight to nurses Options for activities with other patients or privately

Dialysis or Kidney Treatment Center Floor Plans

Figure 9.5  Rainier Beach Clinic, Northwest Kidney Centers. Source: Mahlum Architects, Seattle,Washington. Dialysis or Kidney Treatment Center Items of Note: • • • • • •

All areas have multiple views of either the exterior or natural spaces for patients and providers Space planning very clearly separates public access from private or provider access Wayfinding is clear and direct and aligns with patient progression through facility Providers have constant and expanded line of sight of patients Patients are never looking directly at other patients Patients are broken up in treatment groups, which increases the sense of humanity and care as well as makes it easier for providers to visually access treatment progress • Travel distances for providers were considered and reduced where possible • Areas for expansion were considered and designed into the solution

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Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Fitting the task to the Human: A Textbook of Occupational Ergonomics 5th Edition by Karl HE Kroemer Human Factors in the Built Environment by Linda Nussbaumer Interior Graphic and Design Standards by SC Reznikoff Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara, Julius Panero Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith Articles and Websites AIA (American Institute of Architects) Healthcare Awards IIDA (International Interior Design Association) Healthcare Design Awards AIA (American Institute of Architects) 2021 Healthcare Design Awards. Retrieved from the AIA Website: www.aia.org/resources/6415366-2021-healthcaredesign-awards Cancer Center of Western Wisconsin. Retrieved from BWBR Architects Website: www.bwbr.com/portfolio/westfields-hospital The Center for Health Design Website: https://www.healthdesign.org Clinic Design. Retrieved from The Center for Health Design Website: ambulatory. healthdesign.org Having It All: new Trends in Clinic Design. Retrieved from the Healthcare Design Website: healthcaredesignmagazine.com/trends/architecture/having-it-all-new-trendsclinic-design Healthy Outlook: q+A With MASS Design’s Michael Murphy. Retrieved from the Healthcare Design Website: healthcaredesignmagazine.com/trends/architecture/healthyoutlook-qa-with-mass-designs-michael-murphy Hospitality Healthscapes: the New Standard for Making Hospitals More Hospitable. Boston University School of Hospitality Administration Website: www.bu.edu/ bhr/2017/06/07/hospitality-healthscapes Interactive Clinic Design Tool, Provides Full List of Design Considerations Related to Phase of Design and Space. Retrieved from The Center for Health Design Website: ambulatory.healthdesign.org/clinic-design/design-recommendations List of Design Recommendations for Clinic Design. Retrieved from The Center for Health Design Website: www.healthdesign.org/sites/default/files/files/news/Clinic%20 Design%20Recommendations_FINAL%202011.pdf Mayo Clinic Dialysis Services Overview. Retrieved from Mayo Clinic Website: www. mayoclinic.org/departments-centers/dialysis-programs/overview/ovc-20464948 Memorial Sloan Kettering Monmouth. Retrieved from Architonic Website: ­www.­architonic.com/en/project/perkins-will-memorial-sloan-kettering-­ monmouth/5106338 Memorial Sloan Kettering Monmouth Ambulatory Care Center. Retrieved from Perkins  +  Will Website: perkinswill.com/project/memorial-sloan-kettering-monmouthambulatory-care-center MSK Monmouth Cancer Center. Retrieved from Healthcare Snapshots Website: ­healthcaresnapshots.com/projects/3555/msk-monmouth-cancer-center Perkins  + Will, Featured Healthcare Work. Retrieved from Perkins+ Will Website: ­perkinswill.com/projects/health/#area-of-expertise

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Rainer Beach Clinic. Retrieved from Mahlum Architects Website: www.mahlum.com/ projects/rainier-beach-clinic Rainier Beach Clinic. Retrieved from 2021 AIA (American Institute of Architects) Healthcare Design Awards Website: www.aia.org/showcases/6415406-rainierbeach-clinic Richard M Schulze Family Foundation American Cancer Society Hope Lodge. Retrieved from the Perkins + Will Website: perkinswill.com/project/hopelodge-houston Universal Design and Accessibility. Retrieved from the General Services Administration (GSA) Website: https://www.section508.gov/develop/universal-design What Healthcare Can Learn from Retail and Hospitality. Retrieved from HealthSpaces Website: info.healthspacesevent.com/blog/what-can-healthcare-learn-from-retailhospitality

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Chapter

10 ARCHITECTURAL

CONSIDERATIONS

The aim of this chapter is to review main topics or areas of concern the interior designer/architect should address in collaborating with other built environment professionals. Many of these topics are not the direct responsibility of an interior designer/ architect, but they should definitely have a basic knowledge or understanding of them as it will be their responsibility to interact, coordinate, and be involved in the installation of each product or service. All of these components are essential to the total project and are therefore critical to understand. Including all the stakeholders, on all sides of the table, is extremely important to a well-designed, smoothly executed design project. Some of these stakeholders are clients, occupants, providers, staff, maintenance or facility people, contractors, engineers, architects, sustainable designers, real estate professionals, developers, business professionals, local governing boards, neighbors, and anyone else that could be affected by your project, or whose input could be helpful in making design decisions. The topics covered here correspond to both new construction and renovations to existing buildings at differing levels. It is the design professional’s responsibility to evaluate and understand to what extent each is to be included in each project. What follows is a very general overview of some basic elements that every designer should be aware of. Experts or professionals from each of the topics should always be consulted and involved from the beginning stages of a project.

SUSTAINABILITY Everything, Everywhere, Always Regardless of whether a client is looking to pursue a sustainable rating system, designers have the ability to move a project toward sustainability and efficiency with their design decisions and process. The focus or path to “Sustainability” should start from the very beginning of the project as each decision can move a project either closer or farther away from being sustainable. This is by no means a complete guide for sustainability, just Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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some simple steps that everyone should be taking and considering in the design of their project. See the Additional Resources section for more information.

Climate, Site + Orientation The very first thing with any project is to analyze and understand the specific climate of where the project will be located geographically. Understanding the typical weather patterns, forces, or potential catastrophic events is crucial for including mitigation strategies allowing the building to retain its integrity over time and protect its occupants. Knowing the general climate can also inform building configuration, landscaping, interior placement, and shading strategies, all of which reduce energy use and increase user comfort. The next step is to examine the site, the plot of land where the project will actually be located, to see if there are additional elements that can be used to reduce energy use, provide for occupant comfort, or that should be addressed in the mitigation strategies. Understanding the site also includes looking at the sun pattern, or the way the sun moves across the property. It should inform decisions regarding the best orientation for the building and which of the interior functions should be located in which areas of the buildings. All the information gathered about the site should be plotted on a site plan to inform design decisions moving forward. Figure 10.1 illustrates the sun and wind patterns in a three-dimensional way that allows the designer to understand how the climate interacts with the building and how to design for the greatest energy savings and introduction of natural light.

Figure 10.1  Wind and Sun Patterns Relationship to Building Orientation. Source: Sustainable Design Basics, Jaffe, Karlen, Fleming and Roberts 2019 p168 figure 7.3 These steps are the same for new or existing buildings. Of course, with new buildings there is greater flexibility with configuration and orientation, yet even with existing structures there are many choices that can improve the interior environment and reduce energy usage.

Passive + Active Systems Passive systems are those that do not require outside energy, have moving parts, or technology. Some examples would be shading from overhangs, landscape features, or other structures, windows, or air movement based on predominate winds, or thermodynamics. Active systems are those that have moving parts, or use outside energy or technology. Some examples of these would be solar panels, wind turbines, hydronic heating, or geothermal heating and cooling systems. These use natural forces, but there is energy and/or technology required to convert or run them. Passive systems not only reduce energy usage, but also introduce many of the elements related to health, well-being, and general satisfaction with a facility such as the

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NORTH

SOUTH

SU MM ER

introduction of fresh air, daylighting, views, and visual access to nature, yet add very little cost to a structure. Figure 10.2 shows how a simple overhang can greatly reduce heat gain and glare during the summer months, while allowing the desired heat gain and increased light during the winter months. (Where heating is a main concern during the winter) Active systems can initially require a greater capital investment, but depending on local and government incentives and the type and amount of energy used by a facility, they can produce great savings and return on investment as well as the ability for the facility to be more resilient or self-sufficient in times of crisis.

TER

WIN

Figure 10.2  Passive Shading and Solar Gain Based on Sun Angles per Season. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017 p30 figure 4.2

STRUCTURAL SYSTEMS The structural system of a building can be a highly complicated system compromised of multiple elements that allow it to stand and withstand physical forces. The weight from the building itself, the contents, people, and physical forces such as wind, snow, or rain are all transferred down through the building to the foundation. What follows is a very general overview of some basic elements that every designer should be aware of. Depending on the location, size of the building, sustainability initiatives, and cost factors, the structural elements can be made of wood, steel, concrete, laminated or mass timber, or any combination of these. Older or historic structures can have other types of structural systems. Understanding general principles of physics, structure, and the building’s specific structural system will allow the interior designer/architect to be able to collaborate effectively and propose intelligent and creative design decisions and options. Regardless of the extent of changes being made to an existing building it is always best practice to have a structural engineer involved. Once the structural elements are designed or ascertained through exploration in an existing building you will understand the constraints and the areas where you can add interest, character, and openness to your design. Having a basic understanding of structural components increases your ability to creatively shape space to benefit the function as well as the aesthetics of a building.

Structural Systems Some of the most basic structural approaches for non-high-rise buildings are as follows: Structural Grid This is where the structural members of beams, columns are configured in a pattern similar to a three-dimensional grid. Many buildings use this approach and the grid can be

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of consistent dimensions or not. Most, if not all, the weight of the building is transferred to this grid, allowing the interior walls and possibly the exterior walls to be “non-load bearing.” This means they can be altered without affecting the structural integrity of the building. Changing the structural grid has many serious ramifications and usually is not done. It is much easier to make changes to the interior configuration of an existing space, or do an additions or new building to accommodate new purposes or configuration Load Bearing Façade This is where the exterior walls of the building are integral to the load bearing system of the structure. It can also mean that the exterior wall is responsible for supporting itself and the wall above it. This approach can be used in conjunction with a structural grid or other types of structural systems. Having the wall be part of the structural system means that if you want to add doors, windows, or remove large sections of it you may be limited as to where and how large any openings can be. Non-Load Bearing Façade With non-load bearing facades, all the exterior skin of a building or exterior finish is handled per floor and transferred to the grid and down to the foundation. This means that changes to the exterior can be done without structural implications and it makes renovations or additions to an existing facility easier and less expensive. The structure of an existing building can be changed, but it can require extensive work that goes all the way down to the foundation and can add considerable cost. There are cases where the cost of structural changes is considered worth it to a client. For new construction it can be of great benefit to have the structural engineer involved at the very early stages of the design process so that the structural components designed best support the existing and possible future uses of a building. Regardless of the extent of changes being made to an existing building, it is always best practice to have a structural engineer involved.

SHELL OR EXTERIOR ENVELOPE The exterior walls of a building can be referred to as the shell or envelope. The term skin or façade are more specific to the finish materials of the exterior walls, but may sometimes be used to refer to the whole of the exterior walls. The exterior walls of a structure are in actuality a system that is meant to protect the occupants from the weather and hopefully reduce energy usage. It can be a structural component of the building or not. It does however usually have structural members that at least support the exterior finish, windows, and doors that pierce it, technically called fenestrations. There should also be insulation material; the type, size, and thickness will depend on the building’s geographic location. The interior finish and it’s supporting structure are also considered to be part of the exterior envelope. Figure 10.3 illustrates the typical components of the exterior envelope or shell. The materials can change, but the principles are the same. Understanding exactly which components are involved with the exterior walls can greatly affect any additions or renovations. With existing buildings or renovation work the exterior envelope is present and decisions are required to determine the extent of change that will happen and may be limited by the budget. With new construction the exterior envelope is designed to accommodate all the structure, insulation, fenestration, and aesthetic goals of the current purpose and client. The interior designer/architect’s interaction with the exterior envelope is focused on assessing the sustainability of the structure, as well as the opportunities and challenges with thermal comfort, daylighting strategies, natural ventilation, and increasing exterior views.

A rchitect u ral C onsiderations

Cladding Continuous Rigid Exterior Insulation Rodent Protection for Exterior Insulation

Gypsum Board Cavity insulation

Concrete Slab

Drainage Pad Ground Slopes Away from Wall

Rigid insulation Concrete Foundation Wall Concrete Footing Below Frost Line

Figure 10.3  Section through Exterior Wall. Source: Sustainable Design Basics, Jaffee, Karlen, Fleming and Roberts p199 figure 8.2. Engineers, architects, and other building professionals are responsible for the actual design and construction of the exterior envelope. The goal for interior designers/ architects is to be able to collaboratively interact with other building professionals and propose intelligent strategies related to toxin remediation, sustainability, and the introduction of daylighting, air flow, views, or other aspects of health and well-being.

MECHANICAL EQUIPMENT + TECHNOLOGY Heating, ventilation, and air conditioning (HVAC) are an essential and crucial part of any healthcare facility and technology is integral and ever-growing component of diagnostic procedures and communication. Engineers and installers that understand the special requirements of the specific healthcare facility typology are the key.

Indoor Air Quality Indoor air quality affects thermal comfort, infection rates, and cognitive function. It includes the temperature, humidity, flow, as well as the introduction of fresh air from outside the building. Reducing infection is one of the highest priorities in a medical facility and controlling air quality is at the base of it. This can be achieved with greater introduction of outside air, creating a pattern of airflow that moves away from infected patients, and increasing filtration and purification systems. The differing functions within a specific healthcare facility or between typologies may vary. Areas that treat infected patients or where surgical procedures are preformed can have different requirements than administrative or waiting areas. Mechanical engineers should always be included in even preliminary conversations.

Controls + Zoning Zoning in regards to HVAC systems refers to sections of a building that are exclusively controlled, provided for, and recirculate through separate or a bank of separate mechanical unit(s). Zones effectively divide up a building into compartments that are theoretically self-contained. The reasoning and advantage of this is that it can be heated

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or cooled at a rate that response to the specific occupant’s needs and the way the exterior climate forces act on it. For example, If the south side of the building has a lot of glass, and the sun is hitting it all day, it will require more air conditioning than a space on the north side of the building that never gets any direct sunlight. Improper zoning in a building is the basis for most of the complaints and problems with thermal comfort. In a medical facility, this approach also allows for contaminants to be isolated or treated in a contained area, and not passed through the whole building. Because of this, the controls, zoning, and design of the HVAC systems need to be given extra attention. How HVAC zones are established and controlled is of utmost importance in reducing cross infection, or the spread of disease in a facility. From a thermal comfort and sustainability standpoint, it has also been shown that if people are given the ability control their thermal comfort, they report being more satisfied as well as use less energy. HVAC Systems should be designed to handle the worst-case scenario based on actual weather patterns, and not strictly by established charts of what the outside temperatures could be using the cubic feet of a space, not simply by the square footage of the floor plate. We talk more about thermal comfort in Chapter 14 – Well-being.

Plumbing, Electric, + Data Plumbing, electric, and data access are essential for all areas of every medical facility. Coordination with equipment suppliers, engineers, and all stakeholders is necessary to assure that all current and future needs can be met. Providing ability for future growth, easy access, centralization, and flexibility are key.

Design for Flexibility The healthcare industry and diagnostic equipment are evolving and progressing at a rapid rate. Technology changes and the mechanicals to support are constantly evolving. Hospitals and health facilities can too easily turn into labyrinths because of multiple additions or changes made over the years. Many buildings are torn down simply because they are too hard to repair or update. Accepting and planning for growth and change at the beginning of the design process will result in better facilities, patient care, and save money over time because of less down time during renovations. The initial design should incorporate ways to easily upgrade and change the original design. Using integral theory or SWOT analysis that was reviewed in Chapter 4 during the schematic design phase can help with this. Skidmore Owning and Merrill’s prototypical research on mixed-use, multi-family housing for London titled Intelligent Densities|Vertical Communities provides an excellent case study and the thought process around flexibility and future adaptability. Their main strategy was to locate all the mechanicals and technology in an easily accessible core. centralized core This same principle of centralization can be applied to healthcare facilities in a medical facility. This approach is important from a sustainability standpoint, but also from a capital investment and service disruption point of view.

INTERIOR CONSTRUCTION Interior construction is the backbone or skeletal system of any of the functional or visual aspects of an interior space. The interior structural elements must first be self-supporting, then accommodate the physical needs of the required equipment and mechanicals that are placed on them, and then be appropriate for any finish materials. The interior spaces are the area where the Interior Designer/Architect will have the most influence in a project. Having full knowledge of the occupant’s requirements, codes, zoning, applicable accreditations standards, materials and the construction considerations to support

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is paramount for a successful project and career. This section deals more with the general construction aspects of a project, specific materials will be dealt with in Chapter 13 – Interior Materials and Furniture.

Floors Floors take the highest amount of use and abuse in a healthcare facility. They are also the most important feature from a health and safety standpoint. Floors are also a major contributor to unwanted noise caused by foot traffic, rolling equipment, because the typically hard surfaces reflect sound more easily. When considering flooring choices, the following factors should be taken into consideration: • Type and amount of traffic? • What are the cleanability needs? • Infection control and cleanability are paramount in any medical facility. • Where will the traffic be coming from and going to? • Patients coming from the outside weather will be different than providers and staff going from halls to treatment areas. • What are the chances of, and duration of water or moisture laying on the floor? • This is a concern for slipping and penetration to the subfloor which can cause delamination of the flooring or failure of the system itself. • Amount and length of standing that will take place? • Standing on surfaces that are somewhat softer or compress slightly, like vinyl, linoleum, or commercial carpet, are much easier on the skeletal system than those with less flexibility like ceramic tile or concrete. • Will this area be used more by the patient or provider, and who is the most important to accommodate? • What amount and type of rolling equipment will be used? • Are there any extraordinary weight requirements that need to be met? • Will the manufacturer’s recommended subfloor treatment promote or detract the finish’s performance or infection control? All of these components help to determine the best flooring choice for each area as well as any structural considerations or remediation for the floor structure.

Walls + Partitions Walls and/or partitions are the vertical separations between spaces. They can take a variety of forms from constructed partitions to partial height open office furniture systems. They are responsible for our perception of space by providing visual focus or barriers and play a large part in wayfinding. Acoustic privacy is required through the Health Insurance Portability and Accountability Act (HIPAA) and partitions play a major part in maintaining acoustic privacy. Walls must extend to the underside of the floor structure above to prevent sound from traveling from one space to another. Depending on the level of acoustic privacy required, additional modifications to standard wall construction would need to be employed. Constructed Partitions Constructed partitions in commercial projects most often use metal studs, though depending on fire rating and market costs, wood studs can also be used. In older buildings or on renovation projects, wood or other types of interior structural materials may also be encountered. Constructed partitions physically support equipment, and easily supply electrical, mechanical, and plumbing needs. If taken to the underside of the floor structure above, they provide acoustic separation and can provide fire separation, given proper

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construction techniques. They have a low initial cost. The disadvantages are that changes in configuration cost more and take longer to execute than other options, they also contribute to construction waste and increase the amount of material going to landfils. Demountable Partitions Demountable partitions are vertical elements that are supported by tracks and can easily be reconfigured. They extend to the underside of the finished ceiling. Certain manufactures and styles have an option to incorporate connected ceilings to the demountable partitions which helps reduce acoustic transmission. They can provide greater cleanability than other constructed wall finishes and their ability to consistently be reconfigured increases the sustainability of this option. The disadvantages can be the ability to house electric, plumbing, or mechanical elements, lack of acoustic privacy, and incorporating them with HVAC systems and sprinklers. They have a higher initial cost which would be offset with multiple reconfigurations. Systems Furniture Systems or open office furniture consists of panels of various heights that support work surface and storage options. They can be wired to supply electricity and data. These are highly movable and flexible. This type of partitions is only appropriate for work stations that are part of a larger area such as a nurse’s station, lab area, administration area, or components like check-in desks. The lack of acoustic and visual privacy is not suitable for areas where confidential information or conversations with patients or treatment would be taking place.

Ceilings Ceilings are the horizontal plane that defines the upper limit of the interior spaces. Like floors, the materials and configuration greatly affect acoustic quality of a space. The plenum, the area between the finished ceiling material and the underside of the floor or roof structure above, contains the majority of electrical, mechanical, and plumbing. This is also the area where the structural members should extend beyond the finish surface to connect to the floor plate above. Any decisions regarding the ceiling height or configuration need take into consideration the structural and mechanical system that are present as well as the size of the room itself. Generally, it is more pleasant to have a higher ceiling than a lower one. A higher ceiling allows more clearance for equipment, more light from exterior openings, a place for the hotter air to rise, and generally makes the space feel bigger and more open. The ceiling finish can vary with the specific use of the room. Some areas require “easily cleanable” or “scrubbable” finishes. In other areas acoustic control will be the main focus. Maintaining accessibility to the mechanical systems housed above the ceiling in the plenum is very important for future maintenance or renovations. The exceptions are restrooms which normally have gypsum board ceilings for privacy and security reasons. Areas with high security needs should also have a gypsum board ceiling. In healthcare it is good to remember that a large portion of the occupants will be spending their time looking at the ceiling while on exam tables, in beds, or treatment chairs. Always keep in mind, the ceiling is a very visible and powerful design element and can be used to create interest, organize a space, provide direction, and dramatically change the perception of a space.

Doors Doors are an integral part of any interior space as they create division between spaces, purposes, and provide visual and acoustic privacy. They are essential for security and the separation of functions. Doors in the same facility could have very different needs; discussing this at the beginning of the project is essential. Americans with Disability Act (ADA) requires that all commercial and public buildings have 36” wide doorways, so

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this is the minimum. Depending on what type of practice or facility you are designing, doorways may need to be larger. Where beds, stretchers, or gurneys are being wheeled around, 48” or 72” openings are common. Doors, whatever their size, are constantly being bumped into and hit, and therefore need to be of the highest quality with heavy-duty hinges and openers where required. Doors should always be “solid core,” meaning that they have a solid filling inside the frame to better withstand impact and improve structural stability. The finish can be determined by aesthetic preferences and fire rating requirements. Lever handles are the standard since they can accommodate multiple ways of use. Restrooms that will be used by patients need to be equipped with Emergency Rescue Hardware, which allows the door to swing out in case someone collapses against the door. Staff restrooms do not have this requirement. Door swings need to be studied carefully to assure the best performance and efficiency from the staff and the ease of movement and protection of privacy from a patient’s standpoint. The use of sliding doors in certain areas or facility types can be very successful because of the space that they save. These doors can be solid or glass. As with all other aspects of a facility, careful, open collaboration with all stakeholders is essential.

Interior Glazing Interior glazing refers to windows or glass that is used on the interior partitions of a facility. It can also refer to glazing or glass in doors or fully glass doors. The aesthetic and biophilic benefits include, allowing daylight deeper into a space, allowing more access to outdoor views, opportunities for plants and natural elements in a greater portion of the space. Interior glass make a space feel larger as well as provide visual cues essential for wayfinding. For staff and providers, it allows observation of patients while providing acoustic privacy and/or reducing cross infection. If natural ventilation is desired, strategically placed interior glass can enhance air flow through spaces that are deeper within the building envelope. The main concern whenever large expanses of interior glass are used, is to make occupants aware of its presence. Visual cues are needed such as mullions, frosting, or a subtle pattern with decals or etched into the glass. Furniture arrangements and landscaping features can also help a;ert occupants of its presence and keep people from walking into it.

Millwork, Cabinetry Millwork is the name given to any cabinetry, built-in, railing, custom furniture, ceiling features, or many other custom manufacturered aspects of a project. Millwork is an essential component of all healthcare facilities from the receptionist desk to exam room cabinetry to nurse’s stations to operating theaters. It can be as varied as the different practices are in scope. Millwork is first and foremost about function and efficiency and then about aesthetics and cost. It provides great opportunity for creative expression and is the backbone of efficient medical spaces, so it is essential that you understand both aspects of millwork to best assist your clients. The two most prominent ways to approach millwork in a healthcare setting are: Custom Build: All cabinetry and counter work is built specifically for the specific space and specifications provided from the equipment manufacturer is referenced for any incorporation of it into the cabinets or counters. Component: The counter is custom made to fit the specific space, but is comprised of standardized individual units in a number and configuration that fit in the space provided.  These individual units may be on castors that can also work as mobile units or be stationary with the counter top or work surface being fixed.

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There may be times with either approach that there is equipment that needs to be installed or stored under the counter. Regardless of whether the cabinetry is custom or component the electric, plumbing, data, and other mechanical or technical requirements need to be understood by the millworker and contractors and incorporated into the final design. The decision between or combination of the two approaches will depend on the philosophy of the practice, cost, timeline, the rate of turnover in technology, anticipated growth rate, whether the client owns or rents a space, and how long they are anticipating that they will be in that space. The designer should be well versed in the benefits and challenges of each of these factors as it regards millwork to best guide the client to the optimal solution.

Dividing Curtains Dividing curtains may seem like a very small element of a healthcare facility, but they serve an incredibly important function. They can also be referred to as medical room dividers, retractable privacy screens, or cubical curtains. They serve as a light-weight moveable divider which greatly increases the flexibility of a space. In exam rooms curtains provide a private changing space, and depending on their location, assure the privacy of the patient during sensitive exams from public view from the corridor. In clinics, specialized ambulatory care or practices where more than one person may be in a room, they are essential for privacy during treatments or limited visual access between patients. In all cases curtains are suspended by a specially design track with rollers and hooks. Depending on the ceiling construction and height, the track can be mounted directly to the ceiling or extended on a rail system. Regardless of the mounting type, blocking or structural support in the ceiling is crucial. The structure accommodates the weight of the curtain, the force of it being open and closed continually as well as the possibility that it could be used to by a patient to support their weight in case of emergency. The curtain material and composition are covered in Chapter 13 Interior Materials + Furniture.

Acoustics + Acoustic Privacy Acoustics and acoustic privacy are of utmost importantance in healthcare facilities regardless of their type. It allows for better concentration and conveys respect for the patient. The Health Insurance Portability and Accountability Act (HIPAA) requires appropriate safeguards to protect patient health information. Noise resulting from adjacent conversations or treatments can be unsettling to patients and providers alike. The health and well-being aspects of acoustic are covered in Chapter 14, Well-being. All the elements of interior construction and materials can contribute the acoustic quality of a space. The most important strategy in reducing sound transmission between spaces is to extend the interior partitions to the underside of the floor structure above, regardless of the type of ceiling finish. Grouping functions that have more activity and speech associated with them together also aids in reducing unwanted noise transmission. Using areas with little activity like storage areas, file rooms, or restrooms as buffers between louder or high activity spaces and quieter spaces is also an effective strategy. The finish and furniture selections can make substantial reductions to sound transmission between and within a space as well. Ceilings: Select the highest NRC Ratings for materials and especially acoustic ceiling panels, this is the amount of sound that will be absorbed, the higher the number the better. Some acoustic ceiling manufacturers also rate their products for sound transmission through the plenum. This is referred to as sound blocking and rated with CAC number, again the higher the number the better. These figures and ratings are all easily available on the products website page.

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Floors: Are one of the biggest contributors to noise. Look to add “softer” floors like vinyl, linoleum, or commercial carpet as much as possible. These absorb sound waves and are quieter under foot. Walls: Acoustic panels come in many different types and styles in either fabric, wood, perforated metal, or specialized textures. Creating millwork features with acoustic material behind is also another option. Special attention should be given to cleanability as these are highly touched surfaces. Furnishings: Furnishings break up sound waves from foot traffic and conversation, and “fill” a space so that all sound waves are broken up sooner and easier. If higher levels of acoustic privacy or sound proofing are required, consult an acoustic engineer, or Architectural Graphic Standards, or multiple online resources that can provide construction details and methodology.

Detailing The construction of physical buildings is based on plans that are precisely designed and orchestrated on a computer in an office. On real life construction sites, imperfect things happen, like slabs being slightly out of level, or wall studs being twisted or slightly bowed, or it raining before the roof is completed. When working on existing buildings, the chance for things to be “imperfect” is even greater. This is no one’s fault, or mistake, it’s just the nature of the business. One of the goals of detailing is to create ways for these “imperfect” aspects of construction to not be so obvious. We should be designing for “perfection,” knowing full well it won’t be. There are plenty of drafting, designing, and detailing resources that can help in understanding typical configurations that provide ways to adjust and adapt on site, while disguising that things aren’t level, or meet perfectly. One of the main rules is to never end two dissimilar materials on the same plane. Detailing also exists on a larger scale. It consists of an intricate and integral understanding of how the occupants, components, and spaces all work together. It’s making sure that all the mechanical requirements for the equipment are on the plans, and the exact locations are noted along with specifications for methods of coordination and confirmation to happen during the construction process. The initial design should also provide – The initial design should also provide the ability to expand as well.

MATERIALS The specialized considerations for materials used in healthcare facilities revolve around cleanability, infection control, slip resistance, and the ability to withstand very high traffic and constant cleaning with strong cleaning solutions. Any selections must also be able to withstand moisture or water without compromising their performance or safety. Balancing cost, performance, aesthetics, and sustainability can be a challenge. Engaging in long-term analysis evaluating more than initial cost is essential for the best results. More specific information regarding interior finish materials is covered in greater detail in Chapter 13.

MEDICAL EQUIPMENT + TECHNOLOGY Healthcare facilities of any kind are very equipment- and technology-intensive. Technology and equipment are a rapidly changing industry, so the ability to adapt to future changes and repairs is of utmost importance. Including all possible stakeholders along with contractors and maintenance people in this area will enable the design to be the most relevant to current needs while still being able to meet future needs. There will be approximately three overall types of equipment in a medical facility. Stationary, movable, and those shared between locations. It is imperative that the electrical,

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data, mechanical, and plumbing requirements are met for all three types in a worst case scenario, meaning designing for the greatest amount of equipment to be used at the same time. The design should also consider adding in extra mechanicals for unseen future equipment. The increase of tele-medicine opens a whole new avenue for technology, equipment, and possibly spaces. Be sure to explore this option with your clients so the proper technology can be installed during construction when it easier and the cost is lower. It is not the designer’s responsibility to select or be involved in equipment specification. The most important role of the designer is to effectively collaborate with all specialists and coordinate the mechanical requirements with all the associated engineers making sure they are clearly and accurately represented on all the plans and specifications. Opting for the long-term, high-level view of the equipment and technology requirements will help the facility to be designed with the utmost flexibility.

ADAPTION + RESILIENCE Adaption and resilience are considered the ability to change or adjust, or to be flexible or pliable. This doesn’t mean only in response to adverse conditions or extreme events, but most importantly, to be able to accommodate the natural changes and progression a building takes over its life. This is should be high priority for a healthcare facility looking for longevity in their current building or for sustainability issues related to landfill waste, energy use, or embodied energy. Some of the natural changes that a facility can experience are growth, decline, change in technology, increased amount or new types of equipment, changes in treatment or best practices, or new uses for existing buildings. Other changes that should be considered are climate change, extreme weather events, natural disasters, civil unrest, emergency events, power outages, land availability, limited use, or pandemics. The best designs will have investigated these possibilities, acknowledge the fact that buildings are constantly evolving and will design with the future in mind. The several integrated design processes outline in Chapter 4 are excellent ways to gather input from all stakeholders and evaluate future opportunities or threats the structure may need to respond to, as flexibility for flexibility’s sake rarely benefits anyone. Understanding the current use and the most probable future use will allow spaces that function efficiently now, as well as be able to change quickly to meet the future. If the building is broken down into categories according to their relative cost, longevity, and ability to change, it can illuminate the best design strategies to employ during an open discussion about an organization’s goals for their facility. Most Expensive Parts of a Building

Elements With the Longest Life

Site Site work Foundation Structure Roof Mechanical systems

Site Site work Building placement + orientation Foundation Masonry work Structure

Least Expensive Parts of a Building

Elements With the Shortest Life

Interior partitions Technology Finishes + colors Furniture Ornamentation

Interior walls Technology Finishes + colors Function, activities or purpose

Easiest Parts of a Building to Change

Hardest Parts of a Building to Change

Finishes + colors Materials Furniture Purpose or activity

Orientation Foundation Structure

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We can see that the elements that typically get the most attention are the least expensive relatively, have the shortest life, and are the easiest to change. What if we gave more attention to the least flexible and most expensive elements such as building placement, the foundation, and the structure? These also tend to last the longest, and are the greatest predicators for future expansion and longevity. Making simple modifications to building placement on the site, the configuration or sizing of the structure, and the location of and accessibility to technology can greatly enhance the ability for future change. Other strategies that increase the longevity of a structure are, choosing materials meant to last, evaluating potential extreme events, and climate change, incorporate daylighting and natural air flow, anticipating new purposes, and seeking to create a place that people will love and want to care for.

CODES Codes are an essential part of any design and construction project. They are designed to keep populations safe and provide inclusive, equitable access to all buildings and spaces. There are international, national, local, and township codes or requirements that must be met for each project. The specific code requirements for each project can only be determined by a careful examination in coordination with the local governing bodies. Following are some generally accepted code requirements. It is the responsibility of the designer, owner, and contractor to make sure they are in compliance with what is required by the specific jurisdiction where their project will be located.

General International Building Code (IBC). Retrieved from International Building Code website: codes.iccsafe.org/content/IBC2021P1 International Fire Code (IFC). Retrieved from International Fire Codes website: codes.iccsafe.org/content/IBC2021P1 International Plumbing Code (IPC). Retrieved from International Plumbing Code website: codes.iccsafe.org/content/IPC2018 National Electrical Code (NFPA70). Retrieved from National Electrical Code ­website: www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-andstandards/detail?code=70

Specialize for Health-care Facilities ASHRE (American Society of Heating, Refrigeration, and Air-Conditioning Engineers) Health-Care Facilities Resources. Retrieved from ASHRE website: www.ashrae. org/technical-resources/bookstore/health-care-facilities-resources National Fire Protection Association (NFPA99) Health Care Facilities Code. Retrieved from National Fire Protection Association website: www.nfpa.org/codes-andstandards/all-codes-and-standards/list-of-codes-and-standards/detail?code=99

Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Interior Graphic and Design Standards by SC Reznikoff How Buildings Learn: What Happens After They are Built by Stewart Brand

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Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Sun Wind Light by Mark DeKay Sustainable Design Basics by Sharon Jaffe, Mark Karlen, Rob Fleming, and Saglinda Roberts Sustainable Design for the Built Environment by Rob Fleming and Saglinda Roberts Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara, Julius Panero The Architecture of Health: Hospital Design and the Construction of Dignity by Michael P Murphy Jr., Jeffrey Mansfield and MASS Design Group Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith Articles ± Websites Designing Healthcare for Surge Capacity. Retrieved from the Gensler Research + Insight Website: www.gensler.com/blog/designing-healthcare-for-surge-capacity Facility Guidelines Institute Website: fgiguidelines.org/guidelines/2018-fgi-guidelines U.S Department of Health + Human Services Website: https://www.hhs.gov U.S Department of Health + Human Services, Laws + Regulations Website: www.hhs. gov/regulations/index.html U.S Department of Health + Human Services, The HIPAA Privacy Rule Website: www.hhs.gov/hipaa/for-professionals/privacy/index.html Intelligent Densities|vertical Communities, Skidmore Owing Merrill (SOM). Retrieved from the SCRIBD Inc Website: www.scribd.com/document/394262902/Som-IntelligentDensities-Vertical-Communities The Structural Blog – types of Structural Systems in Buildings. Retrieved from The Structural Blog Website: thestructuralblog.com/types-of-structural-systems

Chapter

11 LIGHTING

Without light nothing would be visible. Lighting can make or break any project and greatly change the tone, focus, or feeling of a space. Lighting is absolutely critical to perform the functional tasks involved in any healthcare facility with every typology having its own specific requirements. Lighting is a powerful tool that should be viewed as another design element in the composition of a space. As healthcare environments are moving more toward a hospitality or residential aesthetic, it is even more important for lighting design to be considered as integral part of the overall design, and go beyond the mere functional. Even though lighting professionals will be involved, it is important that designers have a basic knowledge of lighting and lighting applications in healthcare settings. For more detailed information see Lighting Design Basics and the Additional Resources listed below.

REVIEW OF BASIC LIGHTING PRINCIPLES The types of lighting are broken down into the functions or aesthetics they provide and are typically referred to as layers. The most common layers are: TASK LAYER: Illumination that is focused on the physical or functional work or task being accomplished. It requires an understanding of the task, where the people completing it will be located in the physical space, as well as the specified or desired level of light (foot candles). Eliminating shadows and glare is of the utmost importance. AMBIENT LAYER: Provides general lighting to help occupants move throughout the space and can provide the overall ambience or mood of the space. DAYLIGHTING LAYER: Light that is available or enters the space from windows, doors, or ceiling apertures. This reduces need for artificial light, provides health benefits and opportunities for views. Could require controlling glare and heat gain with either exterior or interior means.

Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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FOCAL LAYER: Highlights architectural features, art, displays in retail, important spatial features usually focused on illuminating vertical surfaces. Identifies key elements of a design using lighting to lead people intuitively through a space and therefore is a very strong design tool. The source of focal lighting is usually not seen. DECORATIVE LAYER: The purpose is to catch the eye, add visual interest, direct attention, create spatial form. Accomplished with surface mounted or hanging fixtures that speak to the quality and style of a facility or its owners. The light output from these fixtures is usually lower, but can be used to meet task lighting requirements. All these different layers should be thought of as elements in a composition. This composition of light should support the purpose of the space, direct people moving through or using it, highlight the spatial composition and architectural features, and promote the design directives and aesthetic goals of the project. For addressing the functional and task-oriented aspects of the facility it is imperative that the designers and lighting professionals work in close collaboration with providers, staff, and all those that will be using the spaces. Different typologies may have very different standards and needs for both natural and artificial light.

NATURAL LIGHT Natural light, also called daylight, has been shown to be extremely important to physical, emotional, and psychological health. It has also been shown to reduce stress and increase healing rates. It is just as critical for staff and providers to have access to natural light throughout the day as it is for patients. In ambulatory facilities the focus should be on providing opportunities for staff and providers to have exposure to natural daylight, as patients are only in the facility for limited amounts of time. The exception would be for cancer treatment and dialysis centers where patients are in the facility for several hours at a time undergoing treatments as profiled in previous chapters. The addition of natural light also reduces the amount of artificial lighting required, which saves energy. Codes and rating systems will provide requirements or guidelines for lighting levels. For more details on the benefits of natural light see Chapters 13 + 14 or the Additional Resources listed below.

Daylighting Strategies Windows or Side Lighting Windows are openings in the vertical face of a building. They are the easiest and most common way of introducing daylight, or natural light into a space. They can be placed at any level off the floor. The higher an opening is off the floor plane of a space, the deeper light will project into that space. Having windows lower to the floor plane provides outside views. Using a device called a light shelf, Figure 11.1, enables shading when needed and bounces light deeper into the space. A combination of all options is ideal. Protecting from unwanted heat gain, glare, or extreme intensity of light is something that should be considered with all windows or vertical openings.These conditions can be mitigated with exterior shading structures, landscaping, or interior blinds. Mitigating heat gain is best done with exterior shading features when possible as this keeps heat from entering the structure, various examples are shown in Firgures 11.1, 11.2, and 11.3 Other considerations are the function of the space and the privacy of the people inside. In exam rooms or other sensitive areas, placing windows higher on the wall allows for privacy while still admitting light and views.

L ighting

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Figure 11.1 Window with Light Shelf. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 31, figure 4.5.

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Figure 11.2  Clerestory Window with Overhang. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 30, figure 4.2.

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Figure 11.3  Monitor or Clerestory Vertical Openings. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 30, figure 4.4. Top Lighting Top lighting is considered any light that enters the building or space from a horizontal or vertical opening typically in the roof structure. It has the benefit of providing natural light deeper into the floor plan or to multiple floors at the same time. These features can also create dramatic spatial configurations and add vertical interest

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while being functional. The most common ways to incorporate light from above are with skylights, Figure 11.4 or roof monitors, Figures 11.5 and Figure 11.6. Roof monitors can take multiple configurations and have single or multiple ways for light to enter the building. They can also incorporate magnifying systems to help increase the intensity of light or dispersing strategies to reduce its glare. Depending on the application, roof monitors can be operable and part of the natural ventilation system of a building. Windows or glass areas of roof monitors can also be referred to as Clerestory windows.

Figure 11.4  Skylight. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 30, figure 4.1.

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Figure 11.5  Sawtooth Monitors. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 30, figure 4.3.

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Figure 11.6  Monitor or Double Clerestory. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 30, figure 4.4.

L ighting

ARTIFICIAL LIGHT Artificial lighting is essential as it provides the lighting levels that are needed to accurately complete the administrative and medical tasks of a facility on a consistent basis. Having the proper levels of light, which are measured in footcandles, is critical and varies with each task or function of a building or medical typology.There are international and local codes which dictate basic lighting levels as well as state and professional codes and requirements for lighting levels. It is paramount that the designer a basic understanding of codes and lighting levels required even when lighting professionals are involved. The type of light source is referred to as a lamp or lamping. There are various types of lighting sources available. Each type of lamp has a different profile composed of the amount of energy it uses, the available color range of its light, physical size, heat it disperses, quality of light, and color rendition or how colors look compared to daylight. In selecting the types of light fixtures to be used, looking at the quality of light, possible aesthetic options, longevity, and the initial cost will give you the best option for each situation. The color of artificial light can have a great effect on occupant health as well as aesthetic implications.The color of light is measured in Kelvin, and each lamp type has its range of colors. T   he color of light can range from reddish through yellow to blue. T   he lower the number, the more it tends toward the red or yellow range, the higher the number toward the bluer range. For example, the standard incandescent light bulb is 2700k where the standard fluorescent bulb would be 4000k. When several sources are used together, the color difference is very evident and can be distracting or diminish the aesthetics of a space. Special care should be given to specifying a consistent light color when selecting fixtures or lamping types. The color of light or Kelvin is readily accessible on manufacturer websites or lamping packaging. As mentioned above healthcare facilities of all kinds are moving toward a more hospitality and residential feel, therefore use of fluorescent fixtures outside of purely functional spaces is rarely acceptable. Controlling artificial light is important for user comfort, and cost efficiency. The level and complexity of control will depend on the size and technology level of the facility. Automatic sensors allow lighting levels to be changed according to the natural light present, time of day or activity in the space. Whether these controlling systems are based on motion, time, or current light level is a discussion that should include the lighting professional, designer, client, providers, and all users of the space. There should also be adequate manual switching and dimming so lights can be turned on or off or adjusted for special needs outside of automatic controls if present.

OCCUPANT CONCERNS Providers + Staff The main focus for providers and staff is ability to see adequately to perform the needed tasks. Lighting that can facilitate effective cleaning is also of great importance. Patient and work areas are used for multiple treatment or procedure types; flexibility is also of great importance. Having the patient feel safe and comfortable is important since calmer patients are easier to examine. The specific requirements for specialized treatment areas or processes should be closely collaborated with the providers, staff, and lighting professionals. Below are some general rules for the main spaces of a healthcare facility. Task Lighting EXAM ROOMS – The primary function is examining the patient, so high-intensity light levels are desired. This is most often achieved with a fluorescent or LED Troffer ceiling fixture. It should be positioned over the main areas of the exam table, but should not shine directly into the patient’s eyes. Since fluorescent fixtures are

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more difficult and expensive to dim, when required an alternative is to “double switch” them. This means that instead of one switch that turns on all four light bulbs, there are two switches that each turn on two light bulbs at a time. Specialized task or high intensity light is supplied by movable floor fixtures that providers can adjust for their particular needs. CABINETRY  +  SINK AREA – Undercabinet lighting to provide task lighting on counter top. LABS or RESEARCH AREAS – Undercabinet lighting to illuminate the work surface. Additional lighting in the room to provide lighting to the other work surfaces. The main thing to avoid is light behind the people working at a particular area/station as that will cast direct shadows on their work area. Lighting placed on either side of the main work areas provides light coming in from each and doesn’t create shadows as well as reduces glare. PROCEDURE ROOMS – Require highly specialized intense light mounted in the ceiling as well as mobile lighting.These areas are best designed by collaboration between the providers and the lighting professionals to make sure that all the requirements are met. General Lighting EXAM ROOMS – Depending on the size of the exam room and available natural light, the double-switched fluorescent fixture and undercabinet lighting may be enough. The exam room should be evaluated to assure that the proper footcandle levels can be achieved for general movement, conversation, and treatment that does not require intense physical examination. CIRCULATION – Typically lighting is placed in the middle of the circulation space highlighting the main path of traffic. If evaluation, triage, or tasks requiring visual acuity also take place in circulations space, lighting styles, types, and footcandles need to be closely examined to assure adequate levels of light are provided to meet the needs of the providers and staff. Flexibility Flexibility in all areas of healthcare facilities is critical. The ability to easily change and adapt the lighting to each specific patient or examination allows for better diagnosis and treatment. Planning to include this at the beginning of design also saves time and money continually over the life of the facility. Health + Circadian Rhythms Providing the proper levels of light and exposure to daylight will support provider’s health and well-being which directly affects the level of care they are able to provide to patients. Better and healthier working conditions directly correspond to staff retention and satisfaction as well as reduce fatigue. Notice that the light fixture, Figure 11.7, is over the patient so that there is high level of light for the physical examination, but is not shining in the patient’s eyes as they lay on the exam table. In addition, the one 2 × 4 fluorescent fixture provides adequate lighting for the whole area. T   he undercounter lighting, Figure 11.8, at the work area can be used if specialized task lighting is required there.

Patient + Caregivers Aesthetics Aesthetics give unspoken cues to the quality and professionalism of a facility. Aesthetics also convey or signal the value placed on the patient and can affect the

L ighting

Figure 11.7  Lighting Plan Typical Exam Room. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 176, figure 15.5.

Figure 11.8  Elevation of Lighting and Cabinetry and Work Surface. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 176, figure15.6.

emotional state of a patient. As mentioned previously, healthcare facilities of all types are moving toward the feel of hospitality spaces and away from cold institutional space. By enabling patients to feel calm, cared for, valued, and to have a sense of trust for the medical professionals they will be easier to treat, and be more satisfied with their treatment. General Lighting for Public Areas General lighting should be provided for circulation between spaces and for required physical or mental tasks within the exam spaces. These levels are generally dictated by codes. Special consideration should be used when designing for special populations or those with diminished eyesight. Decorative or focal layers can be used to provide this type of lighting adding to the aesthetics. Task Lighting for Public areas Specific focused light should be provided at the check-in areas, portions of the exam room and waiting areas, or wherever patients may be required to access information. It is valuable to have varied and multiple types of lighting within all areas because medical conditions or age may precipitate the need for more or less light for occupants to be comfortable or to see. Including alternate light sources for family or caregivers is also important.

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Daylighting + Views Daylighting and views produce very positive benefits in healing, behavior, and sense of well-being. T   hey can also be a means of positive distraction that helps to calm the patient.They should be incorporated as much as possible into all areas of a medical facility. When used in exam, treatment rooms, or sensitive areas having the windows higher or partially obscured allows for more privacy without the use of window treatments. In all spaces it is critical to make sure that the general or task lighting is not offensive to the patients by having patients look directly into a light fixture, or causing shadows for providers or staff during exams or treatments or other tasks.

Waiting, Lounge or Circulation Spaces These spaces can be the areas where all of the lighting layers can be used to their fullest to produce an aesthetic that reflects the professionalism and core values of the facility. Lighting plays a huge role in wayfinding and gives subtle clues to spatial organization and how patients should be moving through the space or using it. Providing flexibility, lighting level options, and user control are of great value in serving a diverse population. The lighting plans in Figure 11.9 show several different options for lighting levels, source types, and light direction. These are important options for people with differing vision abilities. Figure 11.10 demonstrates the aesthetics of the lighting, how it emphasizes the architectural configuration of the space, and provides visual cues that direct visitors’ attention to the check-in desk.

Figure 11.9  Lighting Plan for Waiting Area. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 151, figure 13.5.

L ighting

Figure 11.10  Elevation of Waiting Area. Source: Lighting Design Basics, Karlen, Spangler, Benya, 2017, p. 151, figure 13.6.

Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Biophilic Buildings by Stephen Kellert et al. Designing with Light by Jason Livingston Human Factors in Lighting by Peter R Boyce Interior Graphic and Design Standards by SC Reznikoff Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Light and Space by Louis Kahn Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Sun Wind and Light by Mark DeKay Sustainable Design Basics by Sharon Jaffee, Rob Fleming, Mark Karlen, Saglinda H Roberts Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara, Julius Panero Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith Articles ± Websites International WELL Building Institute Website: https://www.wellcertified.com 14 Patterns of Biophilic Design. Retrieved from Terrapin Bright Green Website: www. terrapinbrightgreen.com/report/14-patterns 77 Best Lighting Design Books. Retrieved from ArchDaily Website: www.archdaily. com/946540/77-best-lighting-design-books

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12 INTERIOR

FINISHES + FURNITURE

HEALTHCARE-SPECIFIC CONSIDERATIONS Interior finishes and furniture play a huge role in healthcare facilities and their importance is sometimes overlooked. They convey the aesthetic qualities, impressions of professionalism, and cleanliness of a medical practice. They are also what the patients come in contact with most often, and are therefore an essential part of infection control. Each healthcare typology will have its own specific requirements for finishes and furniture that are associated with the particular demographic that is being served. All finishes and furniture in a healthcare setting need to be able to stand up to heavy cleaning schedules with a multitude of chemicals and many times bleach. All surfaces should be nonporous to reduce the number of pathogens that can be trapped on the surface. Working with infection specialists along with the medical practice to determine the most effective methods and cleaning agents will enable the design professional to make sure that all the finish and furniture selections meet the performance and cleaning needs of a particular organization or facility. Furniture also needs to withstand abuse and heavier weight loads, and be inclusive of different body styles or seating requirements. It is imperative to only specify commercial, healthcare grade furniture as it is built to higher standards to stand up to the heavy use and traffic associated with medical facilities, and usually integrates modular aspects to extend the furniture’s life or aid with cleaning. Each typology will have its own specialized requirements related to the size of furniture or special physical or cognitive aspects of the patients they typically serve. Integrating universal design principles and maximizing flexibility will provide a long-lasting furniture solution.

Infection Control The mitigation of infections spreading through the healthcare environment is of the utmost importance in healthcare design. Infection control is a concern for all surfaces in a healthcare facility. Always consult with an infection control professional to understand Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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the appropriate specification for each space or surface in a facility. For more detailed information see Chapter 3. All Surfaces • The proper sterilization of a surface is dependent on its chemical composition. Knowing and understanding that is at the base of material selection, and needs to be considered from the very beginning of the design process. Knowing the cleaning protocols and probability for contamination fro each surface will be a useful tool in making decisions regarding each particular finish. • Consider surfaces that people touch most frequently. Many finishes now have antimicrobial properties, but at minimum, the surfaces should be able to be disinfected with a cleaning agent which can vary by the facility. Floors • Areas of a healthcare facility differ by function and flooring specifications need to be considered based on the function of the space. • Medical standards dictate the appropriate or required flooring level of cleanability required for infection control and amount of traffic and procedures/activities performed. • All flooring should be easy to clean and have the ability to withstand strong chemical cleaning process regardless of prescribed cleaning levels. • Look for antibacterial or antimicrobial materials to reduce surface contamination. • Special installation practices may apply, like heat-welded seams or integral base. • Select low-VOC (Volatile Organic Compounds) options and be aware of recycling and end-of-life processes. Walls • Any material used should be smooth and easy to clean with no ridges, crevices, or perforations that could collect dirt or contaminates. • Finish could have antibacterial or antimicrobial finish to help reduce surface contamination. • Paint or vinyl wallcovering are both acceptable options. Select low-VOC finishes and those that require less chemical for the installation process. • Additional requirements for cleanability may apply depending on the function of the space or adjacent work surfaces. Ceilings • Space use and function dictate the appropriate level of cleanability and construction for each type of space within a medical facility. • Grid at acoustic ceiling panel ceilings should be easily cleanable. Joints and seams should be kept to a minimum or eliminated where possible. • Panel material, surface configuration, and cleaning protocols need to be compliant with codes and CDC (Center for Disease Control) recommendations. Furniture • Furniture is a high touch component of any healthcare setting. Understanding the need for constant cleaning and sterilization is the first priority. • The arms or the top of the back of the chair are where people’s hands touch the most. Designing these to be hard, nonporous surfaces will make it easier to keep clean in between regular deep cleaning and increase the longevity each piece.

I nterior Finishes + F u rnit u re

• Upholstery material, for at least the seats should be nonporous product like vinyl. There are some fabrics that can withstand bleach or harsh chemicals. and repel liquids, check with facility and cleaning protocols first to see if these qualify for your application. • Looking for furniture with easily replaceable components like arm caps or seat backs or that can easily be reupholstered will extend the life of the furniture and allow for easy replacement if damage occurs. • Look for furniture that has minimal perforations, reveals, or seams that could be dust and dirt collectors. Look for furniture that allows dust and dirt to fall free from the chair, usually accomplished with a void between the seat and back, referred to as a “crumb catcher.” Counter Tops or High Touch Areas • Easy to clean nonporous material that has the ability to be sterilized with harsh chemicals or bleach repeatedly. • Free of textures, patterns, seams or crevices and minimize reveals or anything else that could collect dirt or pathogens. • Look for antibacterial finish materials or those that naturally repel pathogens. • Separate areas for “clean” and “dirty” functions. • Consider no-touch fixtures or accessories whenever possible.

INTERIOR FINISHES Interior finishes in a healthcare setting create a specific aesthetic while serving and supporting a specific function. Understanding the specific performative requirements for a particular finish as well as the recommended and standard cleaning practices of a facility is critical. Understanding the clients’ needs and how they maintain and sanitize their environment is also also critical to the overall longevity of finish selections and the building as a whole. If finishes are selected that will be damaged by the established cleaning practices of an organization, other selections should be made. All finishes must comply with all building and fire codes that pertain to its typology, size, construction type, occupancy classification, geographic location, as well as local regulations, or any other legislative constraints. In addition, each medical specialty, typology, or practice may have its own requirements or preferences. It is important to fully understand the typology needs and work collaboratively to include all the infection control protocols and other stakeholder input when selecting finishes.

Floors • Medical standards dictate the appropriate or required flooring finish by function based on level of cleanability required for infection control. The wall base type corresponds to the flooring and infection control standards. • All flooring will need to stand up to heavy foot traffic, wheeled traffic, cleaning with heavy duty commercial chemicals and/or bleach on a frequent basis. • Conform to the prescribed Coefficient of Friction (COF), which measures the slip resistance of each type of flooring. There are levels designated for each area by Americans with Disability (ADA) and OSHA (Occupational Safety and Health Administration). COF is noted on the back of most if not all flooring samples or in manufacturer’s product information.

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• Design solutions for handling dirt and moisture that are typically associated with building entrances. The treatment depends on the geographic location and the typical weather patterns. • Create strong visual acuity between the floor and wall plane to help with visual or cognitive differences. Understand that all populations will be using the space. • Be sure to use flooring or floor color changes to visually signal any changes in levels or elevations. • Steer away from strong, drastic, or overwhelming patterns as these can be confusing or disturbing to those with differing physical, perceptual, visual, cognitive, or sensory abilities. • Choose the material with the best acoustic properties from the acceptable flooring types for each specific use. • Select low-VOC finishes and those that require less chemical for the installation process.

Walls • The type of wall substrate is determined by the activity level of the area and the propensity for damage it could possibly receive. Gypsum board or high impact gypsum board is most common, but other high-traffic areas could require special impact resistant panels, or space-specific wall panels or finishes. These are all dictated by codes and best practices. • Infection control is a high priority for wall substrates and wall finishes. All finishes and substrates will need to stand up to constant cleaning with heavy duty chemicals and/ or bleach. • Handrails or crash rails are commonly used in public areas or corridors.  They protect the wall and wall finish as well as provide walking or balancing aids for those who need it. It is essential that proper blocking is specificized and installed in these areas to accommodate the extra weight and stress. • Paint or vinyl wallcovering are both acceptable options for wall finish. Paint is less expensive and can easily be maintained and repainted. Vinyl wallcovering has a higher initial cost, but can help protect the wall substrate, shows less damage, and can be cleaned easier. Type II or higher vinyl wallcoverins should always be selected for healthcare or commercial areas as it is thicker and holds up better. • Walls can also be a source of acoustic control. Make sure that materials meet cleanability requirements or are placed where they will be away from pathogens. • All wall finishes must comply with all applicable building and fire codes. • Select low-VOC finishes and those that require less chemical for the installation process.

Ceilings • Key component in acoustic control and comfort in all areas of the facility. • Provide aesthetic opportunities with pattern, materials, and volumetric options. • Most common type of ceiling is suspended acoustic ceiling panels or tiles (ACP or ACT). Panels provide high acoustic rating while allowing access to the plenum and mechanicals in the ceiling. They are not acceptable in all areas because of privacy and cleanability reasons, please be sure to check the specific requirements before selection. • Bulkheads or other aesthetic ceiling solutions can be used in any area where appropriate and in compliance with the required sanitary or building codes. Bulkheads over wall cabinetry many times is used to eliminate the horizontal area on top of the cabinets to eliminate the accumulation of dust and dirt or pathogens.

I nterior Finishes + F u rnit u re

Emerging Materials • Manufacturers are continually bringing new and innovative interior finish products to market to increase the functional aspects and the aesthetics of healthcare spaces. • Many products are including antibacterial or antimicrobial coatings or components to their products or creating special product lines for healthcare. • Exploration into the chemical composition of products and their natural or innate ability to reduce pathogens continues to improve products. • Products like Sharklet, a microscopic pattern that mimics the pattern of shark skin, have been shown to prohibit pathogens from adhering to surfaces without chemicals. This is being tested on bed rails, door hardware, and food trays for possible use in other areas.

FURNITURE Patients and providers are continually interacting with furniture and therefore the function, comfort, durability, and cleanability are paramount. Furniture for any typology must meet the requirements of a large and diverse set of users. Selecting pieces with the greatest amount or level of adaptability is key in being as inclusive as possible. Using Universal Design strategies and following the requirements of ADA and other codes will also allow the largest group of users to be accommodated comfortably. Code compliance and industry or specialty standards should be understood at the beginning of the selection process.

Ergonomics Ergonomics is the study of the relationship between people and their work environment and the devices they use. It includes understanding Human Dimensions, also known as Anthropometrics, measures and studies the required skeletal and muscular functioning required for each activity and the resulting stress or “load” that is put on the body. The goal is to relieve stress and create products, furniture, and spaces that work along with the innate structure of the human body. This is particularly important in healthcare facilities where staff are continually engaging in repetitive movement over long periods of time and patients come in with injuries, differing abilities, or disease which affects their capacity for movement or increases physical sensitivity. Flexibility and adaptability of all the elements in the built environment allows maximum inclusion and the comfort for all users.

General Rules Selecting furniture for healthcare facilities can be a very demanding process. Function, durability, strength of construction, codes compliance, and cleanability all need to be considered in addition to the aesthetic and pricing considerations. Some general rules or questions to ask for all healthcare furniture: • Examine and investigate construction. Metal chassis and steel frame construction or heavy duty reinforced structural components are most desired. Many manufacturers have specially designated healthcare lines. • Replaceable components or easily reupholstered seats or back make damage repair easier and extends the life of the furniture. • It should have no seams or areas for dust, dirt, or pathogens to collect. • Be able to stand up to heavy continual cleaning with harsh chemicals and/or bleach. • Is it stable, and can it withstand or be able to be used as an aid in standing or sitting? People of differing physical abilities need different levels of support or help in sitting or standing. • Does it support higher weight categories and are there Bariatric models available? • Upholstery should be nonporous and easily cleanable, and will it hold up to constant cleaning and sterilization with harsh chemicals and/or bleach?

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Patient Furniture The design professional needs to assess the needs of each project typology before selection begins. A large part of the furniture selection process depends on the amount of time the furniture will be used and the typical demographic using it. The overriding goal is to functionally and aesthetically meet the specific needs of the typology and support all users of the space. • Furniture can be used as a positive distraction or organizing factor for everyone, especially those who are neurodiverse. • Furniture and furniture arrangements can provide a sense of prospect and refuge, respite, privacy, or respect for varying sized groups. • Furniture should represent different configurations that can be adaptable to multiple populations. There should be a combination of arm and armless seating, bariatric seating, larger sized seating, and multiple person seating options in waiting areas. Adjustable furniture is also a good option. • Appropriate furniture and positive distractions for children should be included in all typologies but especially those geared to families or children. • Patient treatment areas can be the sites of increased risk of pathogens; therefore, upholstery and surfaces should have increased cleanability. • Provide fully adjustable examination tables to accommodate the largest population of patients with easily cleanable upholstery. Many times the medical facility will take responsibility for examination tables or other treatment specific furniture.

Provider and Staff Furniture The providers and staff are the people who will be spending the most amount of time in the facility. Fatigue and body strain are major factors for healthcare workers. Understanding the tasks, the frequency, and required medical and administrative equipment involved is the first step in specifying furniture that is supportive and comfortable for long-term use. • Adjustability and flexibility are paramount as furniture for providers and staff need to accommodate a large variety of users. with varying physical or ergonomic needs. • Reception, business, and administrative staff need ergonomic chairs with adjustability and lumbar support. Adjustable desks and other office equipment should be specified whenever possible. • Breakroom or locker room furniture can be of commercial grade with finishes that are easily cleanable. Areas for lactation should be included as well as other areas of private respite. Furniture for lactation rooms should follow standards for sterilization.

Artwork Artwork can greatly enhance any space and can be particularly soothing in a healthcare situation. Special attention needs to be paid to the subject matter and style though.There are some rules that should be followed when selecting artwork for healthcare environments. • Artwork in a healthcare facility needs to compliment the aesthetic without triggering emotional response. The demographic of the facility should be taken into consideration. For example, in an obstetrician/gynecology office, imagery of mother and child is inappropriate, as not all patients seeking care are able to bear children or this imagery could illicit strong unwanted or unpleasant emotional responses from patients. • Imagery of people or gendered artwork is not recommended as it can trigger an emotional response as well as not all patients identify with their biological sex assigned at birth.

I nterior Finishes + F u rnit u re

• Nature images are preferred. Realistic images are preferred over abstracted or ambiguous images. Close-up photography is recommended.

Overall Design Aesthetic The design aesthetic of a healthcare setting should be supportive of the end users as well as support the brand or culture of the organization. In general healthcare environments should feel supportive, secure, clean, and friendly. The patient should feel confident in the quality of care they are receiving, the cleanliness of the facility, and that they are respected and valued as a person and patient. These things are conveyed with every design decision that the design professional makes. Holistically understanding the demographic of the patient, the culture of the facility and the organization are the first steps and should influence every decision.

Use of Color To date, there is no scientific evidence guiding the use of color or its role in healing. Therefore, as design professionals, it is important to understand your user group and what would most appeal to them, or be most supportive of the treatment. The way people perceive and experience color varies and different people or populations will see and evaluate the same colors differently. It’s always best to go with colors that are generally considered neutral, and warm, with the natural pallet being the safest. Some other guiding principles for the use of color in healthcare environment are: • Strong or trendy colors should be used on things that can easily be changed like accessories, paint or upholstery. • For more permanent areas or those that are more costly to change, use neutral classic colors. This will contribute to the longevity of the facility and allow multiple renovations without looking dated. • There are cultural and geographical implications to color. It is critical that these are understood and investigated in the beginning with your holistic analysis process. • There are brand implications to color and these should be explored in collaboration with the organization and the client early in the design process. • Color can be used to help define spaces and articulate architectural features, or direct attention. Care needs to be given to keep the environment calming and supportive.

Additional Resources Books Architectural Graphic Standards 12th Edition by American Institute of Architects, Dennis J Hall and Nina M Giglio Color, Environment, and the Human Response by Frank H Mahnke Fitting the task to the human: A Textbook of Occupational Ergonomics 5th Edition by Karl HE Kroemer Human Factors in the Built Environment by Linda Nussbaumer Interior Design Materials and Specifications 4th Edition by Lisa Godsey Interior Graphic and Design Standards by SC Reznikoff Lighting Design Basics by Mark Karlen, Christina Spangler, and James R Benya Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment and Clinical Procedures by Jain Malkin Space Planning Basics 4th Edition by Mark Karlen and Rob Fleming Time-Saver Standards for Interior Design and Space Planning by Joseph Martin DeChiara, Julius Panero Universal Design Handbook 2nd Edition, by Wolfgang Preiser and Korydon Smith

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Articles ± Websites International Living Future Institute Declare Website: declare.living-future.org Behind the Vinyl Curtain: the Sobering Reality of Many Building Materials. Retrieved from Perkins + Will Website: perkinswill.com/news/behind-the-vinyl-curtain-the-soberingreality-of-many-building-materials The Center for Health Design Interactive Design Diagrams. Retrieved from The Center for Health Design Website: www.healthdesign.org/insights-solutions/interactivedesign-diagrams The Center for Health Design, Topics Page. Retrieved from The Center for Health Design Website: www.healthdesign.org/topics Contact Transmission, Part 1: the Role of Surfaces in Healthcare-Associated Infections. Retrieved from The Center for Health Design Website: www.healthdesign.org/ insights-solutions/contact-transmission-part-1-role-surfaces-healthcare-associatedinfections Contact Transmission, Part 2: materials, Design, and Cleaning. Retrieved from The Center for Health Design Website: www.healthdesign.org/insights-solutions/contacttrans​mission-part-2-materials-design-and-cleaning Facility Guidelines Institute Website: fgiguidelines.org Materials Health in Healthcare Facilities. Retrieved from the Healthcare Facilities Today Website: www.healthcarefacilitiestoday.com/posts/Material-Health-in-HealthcareFacilities–25210 Sharklet Technologies Inc Website: www.sharklet.com The Toxic Footprint of Our Hospitals. Retrieved from IDEAS.TED.COM Website: ideas. ted.com/the-toxic-footprint-of-our-hospitals Transparency Website and Precautionary List. Retrieved from Perkins + Will Website: perkinswill.com/news/perkinswill-launches-revamped-material-transparency-websiteand-%c2%91precautionary-list%c2%92-of-hazardous-building-materials

Chapter

13 BIOPHILIA

WHAT IT IS….AND WHAT IT’S NOT Biophilia is a theory first put forth by Harvard Professor E.O. Wilson in 1984 in his book Biophilia Hypothesis. It asserts that humans have a biological, inherent longing and need for connection with the natural world and its processes. This need and fascination go beyond aesthetic enjoyment of the natural world and influences emotional, cognitive, and even spiritual development. It states that humans have an integral and reciprocal relationship with nature and the natural world. Stephen Kellert and Elizabeth Calabrese put it this way: “Biophilia and biophilic design necessitates recognizing how much human physical and mental wellbeing continues to rely on the quality of our relationships to the world beyond ourselves of which we remain a part” (Kellert and Calabrese 2015, p. 21). The main objective of Biophilic Design is to create healthy and supportive spaces to increase occupant health with ecologically sound environments. The goal is to provide opportunities at all scales for occupants to be exposed to natural living elements, processes, or those based upon their patterns. The fields of neuroscience, evidencebased design, and environmental psychology continue to conduct research that supports the theory of Biophilia. These professions are showing that exposure to nature, natural elements, and the animals that inhabit them does improve physical, mental, and emotional health, healing and increases efficiency and productivity. Designing the built environment based on these strategies supports people while conserving or restoring the site and surrounding ecosystems. Biophilia is NOT just putting potted plants in a space or landscaping around a building, having plenty of windows, or including a green wall. These are all wonderful elements, but the principles of Biophilia go much deeper and are much more comprehensive. As the American writer and naturalist Henry Beston put it, “Nature is a part of our humanity and without some awareness and experience of the divine mystery, man

Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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[or woman] ceases to be man [human]” (Kellert and Calabrese 2015, p. 22). Biophilic design is about creating experiences with nature, natural systems, rhythms, or patterns that influence occupants at a deep level.

WHY BIOPHILIA IS IMPORTANT According to the Environmental Protection Agency (EPA) Report on the Environment (ROE) on July 26, 2017, the average person spends approximately 90% of their time indoors (US EPA 2018). Research in environmental design, evidence-based design, and neuroscience have found that the built environment deeply effects human consciousness, actions, and physical, emotional, and psychological health. John Paul Eberhard in his book Brain Landscapes: The Coexistence of Neuroscience and Architecture puts it this way, “… architectural design can change our brains and behavior. The structures in the environment… affect our brains and our brains affect our behavior” (2009, p. XIV). This tells us that the built environment plays a large role in people’s lives. If we are deeply affected in a positive way from exposure to nature and natural elements, spending the majority of our time indoors is at the very least, not letting us reach our potential. Outlined below are some of the positive benefits and reasons why including exposure to Nature and Natural elements is important.

Staff, Patient, and Visitor Health and Well-Being Faster Healing Roger Ulrich, in his now-famous research between 1972 and 1981, profiled sets of almost identical patients with the same surgical procedures in a hospital in Pennsylvania. The major difference between patients was the view outside of their hospital window. Ulrich (as cited by Eberhard 2009, p. 168) found that “…patients in rooms with outdoor views were discharged on averaged. 74 days earlier, with less negative remarks from the caregivers, [easier to care for], and required less pain medicine the first 5 days of recovery than those in the other rooms.” Beauchemin and Hays in their 1998 study entitled: Dying in the Dark: Sunshine, Gender, and Outcomes in Myocardial Infarction (as cited by Agustin and Fell 2015, p. 29) found that “Cardiac intensive care unit patients on the sunny side of buildings have different outcomes than people on the non-sunny side. Women on the sunny side of these units spent less time in the unit and mortality rates, in general, were lower in the brighter rooms.” These two studies alone speak strongly to the importance of including Biophilia and Evidence-based Design research as a foundation for healthcare facility design and the importance of site orientation to the health and well-being. • The benefits of healing faster with less medicine are obvious from the patient’s side, but healthcare facilities and medical professionals also greatly benefit. The facilities can accommodate more patients, stress on staff is reduced, and cost of care can be reduced. • Greater patient satisfaction positively effects the medical staff by reducing burnout, increasing their productivity. • If mortality rates are affected by a patient’s relationship to sun than we as designers need to reevaluate the foundations of how we design healthcare facilities. Health and healing should be driving the configuration of the building and its relationship to the site and other design decisions. • When mortality rates are changed simply because of orientation to the sun and light, this should cause warning signals to go off in our brains that all design needs to change.

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Increased Productivity, Reduced Stress, Eye Strain, and Employee Turnover Stephen Kellert and his associates conducted studies within office settings that found “… natural lighting, natural ventilation, and other environmental features result in improved worker performance, lower stress, and greater motivation” (Kellert et al. 2008, p. 4). They also found that “…even briefly viewing nature settings can produce substantial and rapid psychological restoration from stress” (Kellert et al. 2008, p. 91). Though Kellert’s research was conducted in an office setting his findings are applicable to healthcare as well. Medical staff typically work between 10- and 12-hour shifts in highly stressed, physically demanding circumstances, many times with little or no breaks. Providing easily accessible, integrated interactions with natural elements is an extremely effective way to provide moments of respite and stress reduction. Easing the emotional and physical toll of their jobs. • This emphasizes the importance of considering the well-being of the medical and support staff as well as patients when including access to nature. • Employee turnover in medical facilities is one of the biggest problems they face. It places financial burdens related to hiring, training, shortages in caregivers, and can increase the burden on those who are already employed. Sick leave is also a large problem. • Eye strain is not something that is always noticed, or articulated, but can be very distracting or even debilitating. This can easily reduce productivity and create long-term physical issues ad well as quality of care if not dealt with. • Introducing Biophilic elements such as light, air flow, and exposure to nature with thoughtful design strategies is possible without costly or complicated solutions.

Cognitive Function Neuroscience, evidence-based design, and environmental psychology are all constantly studying the connection between the built environment, nature, and cognitive functioning. Kellert and his associates, in their research, discovered that “Contact with nature has been linked to increased cognitive functioning on tasks requiring concentration and memory” (Kellert et al. 2008, p. 4). FP Innovations found that “People are better able to do focused work after looking at images of natural environments but performance on focused work is not affected by looking at images of urban environments” (Augustin and Fell 2015, p. 29). Harvard’s Center for Heath and Global Environment have done studies that show by increasing the percentage of fresh air into a space through the HVAC systems, cognitive function can be increased on average by between 61% and 101%. Increases in cogitative scores for what is classified as “Crisis Reaction” being even higher, in the 97%–131% range (Allen et al. 2016, p. 13). Kellert’s research also found, “… natural lighting, natural ventilation, and other environmental features result in improved worker performance, lower stress, and greater motivation” (Kellert et al. 2008, p. 4). • In the medical field, where life and death decisions are required in a split second, any chance to increase cognitive function should be explored. • Increasing the introduction of fresh air into HVAC systems, and/or providing options for user-controlled access to fresh air (operable windows or skylights) should be of high priority. • Higher productivity also affects profits and financial health. • Better working conditions is also an aspect of equity, and is an expression of empathy.

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Physiological Benefits FP Innovations is a not-for-profit research and development institute that specializes in the creation of scientific solutions in support of the Canadian forest sector. They were commissioned to study the connection between the use of wood in the built environment and health outcomes in a report entitled: Wood as a Restorative Material in Healthcare Environments. Their study references over 110 separate publications profiling the health benefits of viewing and experiencing nature, sunlight, indoor plants, wood, and natural sounds. Though some of the profiled studies were conducted in offices and educational settings the findings are still applicable in a healthcare setting. A brief summary of the some of the major physiological responses to nature, natural elements, and materials in FP Innovations’ study are listed below: • • • • •

Lowers Blood Pressure Decrease Heart Rate Changes Brain Waves to Increase Concentration + Relaxation Lowers Pain perception Increases Vitamin D to help in the treatment of mental illness, depression, and other diseases. • Hormonal Balance • Circadian Rhythms • Increases melatonin production

Psychological Aspects Animals + Behavioral Changes A little discussed aspect of Biophilia is contact with animals. Kellert et al. conducted experiments using animal contact and care as therapy with boys ages 9–15 years old in a residential facility with Attention Deficit/Hyperactivity Disorder (ADHD), Conduct Disorder (CD), or Oppositional Defiant Disorder (ODD). The study showed long-term positive changes to behavior, impulse control, and stress reduction. These positive changes extended into multiple experiences outside of the therapy sessions or when they were in direct contact with the animals the boys were caring for (Kellert and Wilson 1993, p. 185). Universities, counseling centers, and long-term care facilities are starting to understand the benefits of having visiting animals interact with patients, staff, and students to help with healing, socialization, loneliness, and stress. • Opens a whole realm of possibilities in how the built environment can be an active tool or system for affecting or creating the desired human behavior. • Facilities that treat neurological disorders and diseases as well as schools, detention centers, or prisons, or even rehabilitation centers could greatly benefit from the inclusion of animals. • Look at changes to the built environment to better accommodate the inclusion of service or therapy animals. • Not all types of practices or facilities need to have dedicated areas for visiting or resident animals to be effective. • Some simple indoor and outdoor spaces would make the possibility of including animal interaction much easier and therefore more likely. • Rooms with easily cleanable surfaces, floor drains, or enclosed outdoor areas that are easily accessible from multiple indoor spaces would facilitate animal’s needs. • Including animals could greatly increase the ease of care, healing rates, and occupant behavior. • Look for ways to provide observational interaction with animal and or bird life that is present on the site.

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Perceived Health, Well-Being + Satisfaction Research is finding that a person’s perceived satisfaction or sense of well-being is just as important as their actual physiological health. This extends to areas like productivity, stress levels, satisfaction with their employers, customer service, or healthcare treatments. Though Biophilia goes far deeper and is far more inclusive than adding plants to spaces, there are strong supported findings showing that plants can make substantial ­differences in an occupant’s perceptions, stress levels, and productivity. Research shows that “People working in offices with plants perceive that their health is better than ­people working in the same space when plants aren’t in place” (Augustin and Fell 2015, p. 13). That they “… put people in a better mood and improve confidence and openness of the mind to the surrounding world… [and have] a positive social effect in ­relation to alliance and morality” (Augustin and Fell 2015, p. 13). They also found that “…simply enriching a previously spartan place with plants served to increase productivity by 15% … Tasks were completed faster and – importantly – without the accompanying rise in errors” (Augustin and Fell 2015, p. 14). The implications are especially important for healthcare where mistakes and errors could cause life-threatening situations.

Creation of Place All our experiences happen in a physical place. This can be a natural setting, but many times it is in a constructed environment, or what is referred to as the built environment. It can be a building, room, garden, landscape, or an urban setting. It is the sense of belonging, comfort, or attachment we feel or ascribe to the physical space we are in is what designers refer to as “Place.” It also includes feelings of physical and emotional safety. Dylan Trigg, in his book, The Memory of Place, expresses it this way, “Although we fundamentally shape our surroundings, ultimately place exists independently of human life, in turn shaping us” (Trigg 2012, p. 2). “… the places in which we live, live in us. More precisely, those places live in our bodies…being sites of spatial history…” (Trigg 2012, p. 33, emphasis in original). He goes on to explain that this becomes part of our permanent memory and can even change our sense of self. Think of the difference between being in a ghetto versus a historic park. This has great importance for healthcare settings where important life events can take place, or where people are spending large portions of their time. The consideration of the type of “Place” being created is important because: • The spaces that we design can have very deep and lasting effect on the people who visit or use our spaces, even if it is for a very short time as it is where some of life’s most dramatic events take place, both positive and negative. • Biophilic elements can help create a sense of place, and are essential elements in some of the most loved buildings. Examples would be the Guggenheim Museum in New York, Falling Water, or the Sydney Opera House. • Creating a sense of place increases occupant satisfaction, productivity and sense of safety, care, and comfort. • Buildings that people love, and want to be in, will be preserved, which in turn effects sustainability and long-term preservation efforts.

Social and Cultural Implications It is important to understand that all projects are located within a community which has its own culture and that the influence of a designer extends beyond the four walls of a project. Each project and client have their own culture, or a culture and sense of community that it wishes to achieve or replicate within its building. Looking at the project from that larger scale, community lens, allows for the discovery of holistic solutions to heighten the experiential and functional goals of the project.

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Kellert and his colleagues studied how communities with Biophilic elements influence the residents. They found that, “People living in proximity to open space report fewer health and social problems … more positive valuations of nature, superior quality of life, greater neighborliness, and a stronger sense of place than communities of lower environmental quality. These findings also occur[ed] in poor urban as well as more affluent and suburban neighborhoods” (Kellert et al. 2008, p. 4). The most important elements they found were trees. The presence of trees, “…were associated with higher levels of attention and self-discipline, less violence and other aggressive behavior, lower crime rates, and better interpersonal relations” (Kellert et al. 2008, p. 111). • Design professionals have the ability to influence all aspects of a project especially when supported findings point to positive outcomes affecting occupant health, well-being, and satisfaction. • A supportive culture and atmosphere are crucial for those in highly stressful and uncertain times. • Contributing to the larger neighborhood and surrounding culture multiplies its influence and contribution to health and well-being. • Providing comfort at the personal level for the patient and their family or visitors makes caring for them easier and allows healthcare professionals to focus on medical care.

INTEGRATING BIOPHILIC ELEMENTS Stephen Kellert was a Professor Emeritus of social ecology and senior researcher at Yale University. He worked with many of the top researchers in related fields exploring the benefits of biophilic design and how they could be incorporated in architecture, landscape design, and urban planning. He has authored over 150 publications on the subject. Elizabeth Calabrese is a licensed, practicing architect specializing in Biophilic design and has taught biophilic and ecological design at University of Vermont for over 20 years. In 2015 they coauthored an article The Practice of Biophilic Design, which outlines the basic attributes of Biophilic Design and its importance to occupant health and well-being, or physiological effects. Below is a brief overview of their research and is meant to a give deeper sense of Biophilia’s importance and how it can be easily included in your projects. The opportunities and strategies are endless and only bound by our own creativity. See the Additional Resources section below for more detailed information on incorporating Biophilia principles.

ATTRIBUTES + ELEMENTS OF BIOPHILA Direct Experience of Nature Involves direct visual or physical contact as well as brief momentary experiences. To be of value, these need to be meaningful, diverse, and include movement when possible or applicable. LIGHT – Physiological effects: Circadian rhythms, passage of time, wayfinding, aesthetics, reduced eye strain. Architectural strategies: Windows, glass walls, skylights, Clerestory windows, atriums, reflecting surfaces or colors. AIR – Physiological effects: Thermal comfort, productivity, sensing variations throughout the day and seasons. Architectural strategies: Operable window, passive air flow, thermal dynamic air movement, HVAC system cycling, outdoor areas, pergolas, porches or covered areas attached to interior spaces. WATER – Physiological effects: Relieve stress, provide or mask sound, enhance health  +  performance, activates multiple senses (auditory, visual, or olfactory).

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Architectural strategies: Interior or exterior fountains, views of large bodies of water, interior waterfalls, water gardens or wetlands, aquaria. PLANTS – Physiological effects: Purify air, increase concentration, creativity, performance and productivity, reduce stress, improve health, and comfort. Architectural strategies: Abundant local species vs. exotic, ecologically connected, atriums, constructed exterior landscapes, viewed through windows. Single or isolated plants rarely have the same benefits. ANIMALS – Physiological effects: Can be calming, connection to natural world + past history, positive behavior, increases verbal communication in therapy sessions. Architectural strategies: Feeders in landscape, green roofs, tree + plant species to attract in exterior landscape, aquaria, aviaries, webcams or video, spotting scopes, visiting animals. **Note there are also fears that can be associated with certain species, research clients, and setting as a precaution to avoid this. WEATHER – Physiological effects: Experience nature  +  passage of time or seasons, mental stimulation, part of survival instinct. Architectural strategies: Direct exposure to outside spaces, windows + window walls, operable windows, porches, decks, balconies, pavilions or colonnades, gardens. NATURAL LANDSCAPE + ECOSYSTEM – Physiological effects: Comforting, user preference over artificial or human-dominated landscapes. Architectural strategies: Functional + variable systems, forest glades, constructed wetlands, green roofs, aquatic ­environments, direct views accessed by observation platforms, windows, or direct interaction. FIRE – Physiological effects: Source of physical and emotional comfort, light, relaxation reduce stress, fractals (repeating form at varying scales). Architectural strategies: Fireplaces, hearths, outdoor spaces with fire or flames, varying warm light, light with color + movement. **Depending on applications fear can also be associated with fire; please research clients and setting to avoid this.

Indirect Experience of Nature Involves representations of nature or natural forms, process, systems, or other aspects of the evolving natural world. IMAGES OF NATURE – Physiological effects: Intellectually + emotionally satisfying, preference with occupants or users. Architectural strategies: Photographs, paintings, sculpture, murals videos of plants, landscapes, water, animals; should be repeated, thematic + abundant; single or isolated images have less impact. NATURAL MATERIALS – Physiological effects: Stimulating, reduce stress, lower blood pressure, promote healing, improved creative performance. Architectural strategies: Visual  +  tactile applications, finish materials, building elements, exposed natural structural elements, furniture, interior elements, exterior elements, wood, stone, leather, cotton. NATURAL COLORS – Physiological effects: Connection to nature, soothing. Architectural strategies: Muted tones of rocks, soil, plants, foliage, sky, location specific. SIMULATING NATURAL LIGHT + AIR PATTERNS – Physiological effects: circadian rhythms, psychological  +  mental stimulation, reduce eye strain, increase comfort, concentration + well-being. Architectural strategies: Varying light sources, full spectrum light sources with roof monitors, skylights or clerestory windows, movement and variability in lighting, varying airflow, temperature or humidity to simulate outside conditions NATURALISTIC SHAPES  +  FORMS – Physiological effects: Occupant preference, lower blood pressure, positive impact on mood  +  attentiveness. Architectural strategies: Leaflike forms, animal forms, or fractals in fabric, finishes, forms, structural or architectural forms.

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EVOKING NATURE – Physiological effects: Occupant preference, reduces stress, improved mental engagement. Architectural strategies: Abstracted principles or forms from natural elements, roof lines, windows, finishes, fabric, textures, furniture, interior and exterior materials cohesion. INFORMATIONAL RICHNESS – Physiological effects: Reduce stress hor­ mones, improved mental engagement. Architectural strategies: Richness of details or materials, organized and evolving spaces or forms, material textures, structural composition, lighting, ornamentation. AGE, CHANGE  +  PATINA OF TIME – Physiological effects: Sense passage of time, connection to seasons and daily cycles, positive illustration of adaptation  +  aging. Architectural strategies: Naturally aging materials, allow weathering, natural finishes, intertwining of building and site. NATURAL GEOMETRICS – Physiological effects: Observer preference, positively impact perception and physiological stress response. Architectural strategies: Self-repeating but varying forms, sinuous form, fractals, hierarchy in scale, golden ratio, Fibonacci sequence. BIOMIMETIC FORM – Physiological effects: Observer preference. Architectural strategies: patterns  +  textures from nature, lighting form, architectural elements, finishes, patterns, materials, systems and structures modeled on nature or biological forms.

Experience of Space and Place Elements or attributes of the built environment that inspire an emotional, intellectual sense of attachment or belonging to a physical location. PROSPECT + REFUGE – Physiological effects: Feelings of safety + protection, reduce stress, improve concentration, reduce boredom, irritation + fatigue. Architectural strategies: Long views, areas of protection especially from behind or above, views between rooms or areas of activity, vistas to outside, sheltered areas, balconies, nooks, transparent materials, furniture, dropped ceilings, blinds, shades + screens, interior + exterior importance. ORGANIZED COMPLEXITY – Physiological effects: Observer preference, reduce physiological stress. Architectural strategies: Exposed structure, floor plan, exposed mechanicals, interior  +  exterior form, materials  +  finishes, color + texture, circulation patterns, need to be variable + diverse, plants if varied. INTEGRATION OF PARTS TO WHOLES (FRACTALS) – Physiological effects: Reduce stress, create intrigue. Architectural strategies: Central focal point, sequential linking of spaces, spatial boundaries, vernacular forms columns, finishes + materials. TRANSITIONAL SPACES – Physiological effects: Provide sense of passage + transition, add mystery, light + air variability, stimulate pleasure response. Architectural strategies: Vestibules, porches, pergolas, gateways, courtyards, colonnades, hallways, interior + exterior, landscaping. MOBILITY + WAYFINDING – Physiological effects: Reduce stress, fatigue + irritation, improve comfort + sense of security. Architectural strategies: Clear lines of sight, clear pathways to entry + egress, transparent materials, open plans, elevated planes, views, landmarks, finish + material variability, lighting, architectural configuration, interior glass, location of stairwells at exterior building. CULTURAL + ECOLOGICAL ATTACHMENT TO PLACE – Physio­ logical effects: Improved mental engagement, increased happiness, connection to community  +  place, encourage conservation, reduced stress. Architectural strategies: Vernacular forms, indigenous materials, forms, and vegetation, courtyards, views, gardens, interior + exterior.

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APPLICATION IN HEALTHCARE FACILITIES The applications in healthcare spaces are limitless. From what has been covered above the inclusion of nature and natural elements extends far beyond the aesthetic, showing the depth and extend the built environment can have on well-being, health, and healing. These principles should be employed to the greatest extent in all areas of a healthcare facility, but particularly in the lobby or entrance areas, waiting areas, patient rooms, and staff areas. Staff spend the most time in healthcare facilities and their health and well-being should be considered as a primary concern, as their well-being greatly affects the quality of treatment they are able to provide to the patients.

In Summary All people that use a space benefit from the incorporation of Biophilic elements. By including these Biophilic elements, we are not only making more beautiful and enjoyable projects, but are affecting healing rates, occupant well-being, and productivity. Employee health and reduced healing rates in turn affect the financial health of an organization along with promoting equity and inclusion. By understanding all the benefits of Biophilia you can educate your client and promote strategies that meet all of their goals: financial, functional, cultural, and aesthetics. There are so many wonderful sources of information out there on the benefits of including natural elements into the built environment, this chapter just scratches the surface. The intent is to give you just a brief glance of the possibilities and inspire your curiosity and creativity.

Additional Resources Books Biophilic Design: The Theory, Science and Practice of Bringing Buildings to Life by Stephen Kellert, Judith Heerwagen and Martin Mador Brain Landscape: The Co-existence of Neuroscience and Architecture by John Paul Eberhard Building for Life: Designing and Understanding the Human-Nature Connection by Stephen Kellert Healing Spaces: The Science of Place and Well-being by Esther M Sternberg Sustainable Design Basics by Sharon Jaffee, Rob Fleming, Mark Karlen and Saglinda H Roberts Sustainable Design for the Built Environment by Rob Fleming and Saglinda H Roberts The Biophilic Hypothesis by Stephen Kellert and EO Wilson The Memory of Place by Dylan Trigg Welcome to Your World by Sarah Williams Goldhagen Articles ± Websites 14 Patterns of Biophilic Design. Retrieved from Terrapin Bright Green Website: www. terrapinbrightgreen.com/report/14-patterns View through a window may influence recovery from surgery. Retrived from National Library of Medicine: https://pubmed. ncbi.nlm.nih.gov/6143402/ Biophilia and Biomimicry: what’s the Difference? Retrieved from the Terrapin Bright Green Website: www.terrapinbrightgreen.com/blog/2017/02/biomimicry-­ versus-biophilia Biophilic Design Initiative. Retrieved from the International Living Future Website: living-future.org/biophilic-design The Death of the Modern Hospital: towards a Restorative Healthcare Architecture. Retrieved from the ReseachGate Website: www.researchgate.net/

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publication/327593839_The_Death_of_Modern_Hospital_Towards_a_restorative_ healthcare_architecture Effects of Biophilic Indoor Environment on Stress and Anxiety Recovery: a Betweensubjects Experiment in Virtual Reality. Retrieved from the ScienceDirect Website: www.sciencedirect.com/science/article/pii/S0160412019336347 International WELL Building Institute Website: https://www.wellcertified.com Healing Spaces: The Science of Place and Wellbeing by Ester M Sternberg The Practice of Biophilic Design. Retrieved from Biophilic-Design Website: www.biophilic-design.com Stephen Kellert Biophilic Design Awards. Retrieved from International Living Future Website: living-future.org/biophilic-design/award Wood as a Restorative Material in Healthcare Environments. Retrieved from the Truline Truss Website: https://trulinetruss.ca/wood-as-a-restorative-material-in-healthcareenvironments

References Allen, J.G., Bernstein, A., Cao, X., Eitland, E.S., Flanigan Skye, Gokhale, M., Goodman, J.M., Klager, S., Klingensmith, L., Laurent, J.G.C., Lockley, S.W., Macnaughton, P., Pakpour, S., Spengler, J.D., Vallarino, J., Williams, A., Y   oung, A. and Yin, J., 2017. Building Evidence for Health: The 9 Foundations of a Healthy Building. Harvard TH Chan School of Public Health. Augustin, S. and Fell, D., 2015. Wood as a Restorative Material in Healthcare Environments. 301009845. FP Innovations. Eberhard, J.P., 2009. Brain Landscape: The Coexistence of Neuroscience and Architecture. Oxford; New York: Oxford University Press. Kellert, S.R. and Calabrese, E.F., 2015. The Practice of Biophilic Design. https://www. biophilic-design.com. Kellert, S.R., Heerwagen, J., and Mador, M. 2008. Biophilic Design:The Theory, Science and Practice of Bringing Buildings to Life. 1st edn. Hoboken, NY: John Wiley & Sons, 2008. Print. Kellert, S.R. and Wilson, E.O., 1993. The Biophilia Hypothesis. Washington D.C.: Island. Trigg, D., 2012. The Memory of Place: A Phenomenology of the Uncanny. Athens: Ohio University Press. United States Environmental Protection Agency, July 16, 2018, 2018-last update, Report on the Environment Indoor Air Quality [Homepage of United States Environmental Protection Agency], [Online]. Available: https://www.epa.gov/reportenvironment/indoor-air-quality [7/21, 2018].

Chapter

14 HEALTH +

WELL-BEING

WHAT IS WELL-BEING + WHY IS IT IMPORTANT Well-being is far more than being physically healthy or the absence of disease. It includes emotional and psychological stability, as well as social engagement and the level of satisfaction one feels. Well-being is an experience that reflects high life satisfaction, happiness, and includes the ability to manage stress effectively. It is subjective, meaning everyone’s experience could be different and can be greatly affected by a person’s physical health. Research is still exploring how physical health and a sense of well-being are intertwined or connected. Neuroscience, Evidence-based Design, and Environmental Psychology are showing that health and well-being are directly related to a perceived better quality of life, healing, and higher social functioning. The healthcare sector is especially interested in exploring the connection between well-being and the built environment because of the quantitative findings related to behavior, healing, pain reduction, staff retention, and increased productivity that can be achieved. Spaces that promote well-being also increase equity, social interaction, culture, and better support occupant function while being financially viable. This needs to be a priority for both patients and staff.

IMPLICATIONS FOR MEDICAL FACILITIES It is becoming more and more evident through quantitative research that the built environment can greatly affect healing rates and a person’s physical health. At the same time, healthcare treatment is moving toward a more holistic approach that increasingly supports preventative medicine as well as alternate methods of healing. This includes physical screenings aimed at physical health, preventitive treatments, and accepting the Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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growing importance of preceived well-being as an integral part of health and healthcare design. More and more clients are demanding projects and facilities designed to support the psychological, social, and emotional needs of patients to support advancing medical and technological sides of healthcare treatment along with efficient functioning. Since the studies by Roger Ulrich, referenced in Chapters 2 and 13 regarding the increased healing rates with outdoor views, many subsequent studies have provided quantitative findings that indicate positive changes in patient behavior, staff retention, cognitive function, pain reduction, healing rates, and patient satisfaction. Even small changes in any of these factors over time and/or multiplied by the number of patients a facility treats equates to dramatic and exponential improvements. It is of utmost importance that the places that we go for healing are not making conditions worse, or creating new health issues.

ELEMENTS + STRATEGIES IN HEALTHCARE SETTINGS At the most basic level, promoting health and well-being is about not damaging people or the environment with the structures that are meant to protect us. This includes materials, finishes, cleaning products, fresh air introduction, HVAC, adjacencies, equipment, adaptability, lighting, ergonomics, and so many more things. Each decision that we make can have exponential rippling effects; therefore, it is imperative that we understand all the ramifications of our choices and are quick to call in others whose expertise can complement ours and provide additional information. People spend 90% of their time indoors; some studies even say 95%, and employees are the greatest expense in any business. These points are the same or of greater importance for healthcare facilities where staff turnover and shortages are a major problem. Occupants are affected by every detail of the built environment whether they can articulate it or not, which in turn affects their behavior. This maybe even more important for the staff because of the many hours they spend in the facility. Below are basic elements of healthy buildings or spaces that support or increase health and well-being.

Toxins Toxins are considered to be anything that when introduced into the body can cause unfavorable reactions, disease, harm, or death. Toxins can be natural or artificial. Construction components and building materials such as adhesives, asbestos, lead, mercury are prevalent sources in new and older buildings. Some common biological contaminants such as radon, mold, fungi, rodents, or carbon monoxide can create health issues as well. Testing and careful research during the selection and specification stage are critical in eliminating toxins from the indoor environment. Evaluating existing structures for these elements during renovation projects is a critical step. See the Additional Resources section below for website and testing information.

Indoor Air Quality Indoor air quality refers to the levels of contaminants present in the air inside of the building. It is measured in relation to the exterior air. All components of the building and mechanical systems affect the indoor air quality. Off-gassing, the release of toxic chemicals from building materials, is one of the biggest concerns. Air quality is also affected by the surrounding site, and may require special filtration or mitigation efforts to ensure a clean air supply is entering the building. Air quality is something that is often taken for granted, but Harvard’s TH Chan School of Building Health did a study showing that cognitive function could be improved 101% high with 100% fresh air introduction (Allen et al. 2016). Reference the link below in Additional Resources for the full paper.

H ealth + W ell - B eing  

Natural Light Natural light is light that comes from the sun and is also referred to as “daylight” in the design professions. It can be replicated with specially design bulbs and now there are systems that change the color of the light to replicate how true daylight changes as the day progresses. Daylight is extremely important to the human body because it regulates our hormone levels, sleep cycle, immune system, circadian rhythm, and vitamin D production. Daylight is considered to be white and has a high color rendition index which is very useful aesthetically and for visual acuity. Some of the benefits of natural light are in addition to the neurological benefits mentioned above are; reduced recovery time, less pain medication, increased productivity, and reduced turnover. The natural light can come from any orientation and does not need to include direct sunlight or views to be beneficial.

Nutrition Nutrition refers to the ability of the body to absorb and use nutrients to support life. It is more evident than ever that a person’s diet is an indicator of long-term health, and even a predictor of future disease. It affects a person’s physical, mental, and emotional health and healing rate, yet is rarely associated with design. For providers, the long hours, and the demanding nature of their work, make access to nutritional food a very rare occurrence. Providing break areas that are dispersed throughout the facility or are closer to the nurse’s station that is stocked with healthy and appealing food could make all the difference. It may also include reviewing policies to provide ample opportunities for good nutrition. For patients it could be by changing meal policies, or even providing small kitchenettes in the rooms or floors that would give patients and staff freedom and flexibility in the times and types of food they eat and when. Some rating systems have requirements for food to be grown on site or that it is available.

Water Sixty percent of our body is water. We need it to live, but it must be free of pollution and toxic substances. Providing easily accessible water sources for both patients and staff is an important. The WELL rating system dictates the maximum distance an employee should have to travel to be able to access drinking water as a way to promote good health. There are also restorative and medical benefits either in use during physical therapy or as a way to mask sound, or to reduce stress. Extra structural considerations are required in therapy areas. Using water features as a way to reduce stress, mask sounds, provide interest, and introduce natural elements into a healthcare environment can be an effective strategy in the public areas of a healthcare facility.

Physical Exercise Physical exercise is considered any movement that helps to develop or maintain physical fitness. Even small nonrigorous movement or activity is extremely beneficial to the human body. It improves circulation, muscle tone, and can reduce heart disease, blood pressure rates, cholesterol levels, obesity, and depression. In a healthcare setting some of the staff are very physically active and could benefit from having it reduced, while there are others that would benefit from having their activity increased. Providing efficient adjacencies for highly active team members and planned options for change or movement for others is the key. Moveable, or adjustable desks are great option; centralized shared resources, amenities, or break areas are another easy strategy. Providing detail rich, landscaped exterior areas that adjoin parking is another viable strategy that also adds green space.

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Ergonomics Ergonomics is the applied science of studying human movement and how it interacts with products and spaces. The focus is on efficiency, safety, and promoting healthy movement and action. It is applied at multiple scales from the product level to buildings and site design. It is based on the study of anthropometrics prometrics, and uses that knowledge to design products and spaces that facilitate efficient use without damaging the human body. Properly designed furniture, permanent fixtures, and spaces are more comfortable and therefore reduce pain and pressure points. This benefits the staff by reducing repetitive movements and patients by making them more comfortable during their wait or examination. Permanent, long-term physical damage can be the result of improperly design elements, so it is critical that there is a deep understanding of all types of human bodies and how they will be using a certain element.

Sound + Acoustics Sound is an important part of our environment. It is transmitted by waves that travel through the air or physical elements and does not need a clear path of travel. It is how most people communicate. Sound waves can alert us of a car before we see it coming, or bring pleasure by hearing music. If the volume is too loud, or there are too many sources, it can be hazardous, distracting, or affect our ability to concentrate or rest, and this we refer to it as noise. In hospital settings this is the most often noted as the reason people can’t rest or sleep. The human voice is especially disruptive and acoustic privacy is regulated by Health Insurance Portability and Accountability Act (HIPAA). The interesting part about sound is that though we may learn to ignore consistent or repetitive sounds, the brain always is stimulated. Unwanted sound and acoustic privacy can be achieved in multiple ways, and depending on the severity, an acoustic expert may need to be retained. Simple strategies for mitigating unwanted sound transmission begin with construction techniques the easiest of which is taking partitions all the way to the underside of the underside of the floor plane above. In specialized situations, wall construction can incorporate sound-deadening techniques. Space planning, interior material selections, absorption products, or sound-masking systems can be employed. Mitigating exterior sources of unwanted sound can be achieved by proper window selection and installation, space planning, screening, or landscaping.

Thermal Comfort Thermal comfort is a person’s or group’s satisfaction with the thermal environment. Thermal comfort is based on six different components. These components are air temperature, air velocity (how fast is it moving), humidity (how much water is in the air), radiant temperature (the heat or cold coming off objects), clothing level (what we have on), and metabolic heat (what we are doing). All these factors greatly influence how a person will feel in a given situation. The complicated thing about thermal comfort is that everyone’s perception can be different, and in a healthcare situation, there are vast differences in metabolic and health levels. Providers and staff are moving a lot, where patients are not. There are values placed on each of these six components that engineers use to determine the heating and cooling loads, and which dictate codes for each space. It is essential in a healthcare situation that multiple zones are used to best accommodate each type and level of activity and occupant. It has been shown that people are more satisfied if they feel that they have control over their space, so allowing for as much individualized control as possible will increase occupant satisfaction for staff, providers and patients.

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Visual Privacy Visual privacy is the ability to feel that you are safe or protected from unwanted visual intrusion or interaction. It is related to the principle of prospect and refuge in that it provides a sense of physical and emotional safety. This is of critical importance in all types of healthcare settings. People are in very vulnerable conditions when they are in a healthcare facility whether they are in an actual exam room or not. Allowing areas for them to have a safe respite is important. Providing visual privacy in exam rooms is of utmost importance. Visual privacy can be achieved by understanding the line of sight into areas of private functions like exam rooms, restrooms, changing areas, lab or treatment areas, or anywhere a person may feel or be physically be more vulnerable than in public. Some simple strategies are to position exam tables so they face away from the doors, adjust door swings to that there are not clear views into the room as they open, position restroom fixtures out of sight when the door is open. For lobby or more public areas furniture can be arranged in groupings, nodes can be created along corridors, or within spaces, and look to provide multiple smaller waiting areas in favor of larger areas where people are facing each other.

Views Views are considered anything that can distract a person’s attention and provide a long focus for the eyes. These in general are a great benefit for eye health and reduces eye strain; emotionally they provide for abstract thinking, processing, and respite. For staff and providers, they are critical for their physical and mental health. To achieve the benefits of view they can be anything that provides a longer focus, such as through multiple spaces or across a large room. The best cases provide respite, but don’t engage or start another train of thought that could take away from their required focus. The best views as we discussed in Chapter 13on Biophilia are of the outdoors, nature, or what could be considered a “beautiful view.” For physical relief to the eyes, a painting or photograph does not accomplish this, since the focal range is still shorter.

Sense of Place Sense of Place is the intangible but underlying essence of design and architecture. In the very basic sense, it is the setting for all our life’s events…. a physical place that stays with us as a register for events. In healthcare settings these events have the potential to be very good, or very bad. It is the connection to a space, a feeling of belonging and/or kinship, an attraction to or connecting with the beauty of a space. It is a visual thing, but goes much deeper and those subconscious cues give us information about where we are, who the organization proports to be, and how they value us. In the medical realm it speaks to professionalism, quality of care, respect, equity, and value. As a design professional it is the understanding that the built environment is more than strictly visual, tactile, auditory, or possesses olfactory sensations. It is realizing that we are touching deeper aspects of humanity and possibly imprinting people forever. Some of the many benefits are deeper level of engagement with organization, comfort and emotional safety, patient satisfaction, employee retention, and return business. In the long run it contributes to sustainability because it is more likely to be maintained and renovated rather than being torn down and replaced.

Natural Materials + Plants Natural materials and plants were covered in Chapter 13 on Biophilia are mentioned here as well because of their importance to well-being. There are numerous articles outside of the literature on Biophilia that describe positive benefits with supported findings

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related to the positive benefits of natural materials and plants on the psychological, physiological, emotional health, healing rates, staff retention, sustainability and employee satisfaction. People are happier, enjoy a space more, and heal and act better when natural materials, colors, and plant life are included.

Summary It can’t be said enough, all these aspects of a healthy building or space are just as important, and maybe more important for staff and providers as they are for patients and their families.

RATING SYSTEMS THAT ADDRESS WELL-BEING Rating systems can be a great guide or a way to learn more about occupant health and well-being. They are by no means the only way that these issues can be addressed. There are several rating systems like WELL that are specifically focused on the well-being, while others, like Living Building Challenge, have very strong health and well-being components or Leadership in Energy and Environmental Design (LEED) which address health and well-being of occupants with a few elements. There are also healthcare-specific organizations and other research organizations who are addressing occupant health and well-being. Below is a brief overview of the major rating systems and research at the time of writing that focuses on or could be used in healthcare facilities.

WELL Building Standard The WELL Building Standard is a rating system that is focused on enhancing human health and well-being in all building typologies. All of its strategies are backed by scientific research and evidence-based best practices from a wide range of professionals in the health, science, and design world. There are 11Core Concepts in V2 that are composed of an overview of the intent, background reasoning supporting each intent and the prerequisites or optimizations. For more detailed information, please see the link in Additional Resources below. The 11 Core Concepts are: 1. Air 2. Water 3. Nourishment 4. Light 5. Movement 6. Thermal Comfort 7. Sound 8. Materials 9. Mind 10. Community 11. Innovation

Living Building Challenge Living Building Challenge is rating system for all building typologies, sites, and neighborhoods that are created by International Living Future. It is one of the most stringent sustainable building rating or certification programs. It believes that true sustainability also addresses the occupant’s health, well-being, and experience of a project. For more detailed information, please see the link in Additional Resources below. The 7 performance areas covered are:

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1. Place 2. Water 3. Energy 4. Health + Happiness 5. Materials 6. Equity 7. Beauty

Leadership in Energy and Environmental Design (LEED) Leadership in Energy and Environmental Design (LEED) is a sustainable rating system that focuses on energy efficiency and carbon reduction for buildings, neighborhoods, sites, and building operations. There are 8 different rating categories that focus on the big picture of sustainability for the building and site. The categories cover 7 different areas in the following percentages: 35% Climate Change, 20% Human Health, 15% Water sources, 10% Biodiversity, 10% Green Economy, 5% Community, and 5% Natural Resources. For more detailed information, please see the link in Additional Resources below. There are 8 main areas where participants can earn points that determine the level of rating as follows: 1. Location + Transportation 2. Sustainable Sites 3. Water Efficiency 4. Energy + Atmosphere 5. Materials + Resources 6. Indoor Environmental Quality 7. Innovation 8. Regional Priority

FOUNDATIONS OF A HEALTHY BUILDING The 9 Foundations for Healthy Buildings is a list of clear, concise core elements for all buildings and building types. It was the result of research by Harvard’s TH Chan School of Public Health and is a brief compilation meant to alert key stakeholders, developers, real estate professionals, and business of the importance of healthy buildings. For more detailed information, please see the link in Additional Resources below. The 9 Foundations are: 1. Ventilation 2. Air Quality 3. Water Quality 4. Thermal Quality 5. Dust + Pets 6. Lighting + Views 7. Noise 8. Moisture 9. Safety + Security

Global Green and Healthy Hospitals Global Green and Healthy Hospitals (GGHH) is an organization that seeks to transform and strengthen the global health systems. They are focused on sustainability and environmental health, have research, programs, and educational programs to better inform providers and healthcare facilities. For more detailed information, please see the link in Additional Resources below. Their 10 Goals for Health facilities are:

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1. Leadership 2. Safer Chemicals 3. Waste 4. Energy 5. Water 6. Transportation 7. Food 8. Pharmaceuticals 9. Buildings 10. Purchasing

The Center for Health Design The Center for Health Design is a charitable organization that focuses on research, education, and advocacy to promote healthier healthcare environments for patients and staff. They are supported by many major building material corporations. There are many design tools, topic specific research, and case studies as well as guidelines for healthcare typology design. For more detailed information and to explore the extensive resources, please see the link in Additional Resources below.

Summary Rating systems can give us a guide, but we can and should be incorporating as many elements of health and well-being as we can regardless of whether the project is pursuing a rating system or not.

LONG-TERM IMPLICATIONS Reducing Overall Demand for Healthcare Services The movement toward health and well-being goes beyond helping people to heal quicker, retaining staff, or the economic benefits of using less resources. The focus on increasing health and well-being looks to raise the level of health and well-being in all populations to reduce the burden on healthcare facilities and staff by reducing need. As we saw at the beginning of the chapter this can greatly improve people’s satisfaction with their lives and help them be more productive. Increasing the general level of health is also part of social equity, true sustainability, and creating a culture that values every person.

Beyond Healthcare Our obligation as designers is to create the best possible environment for the largest population of users and consider all stakeholders in our designs. It is our duty and privilege to educate others as to their importance in the short and long term and promoting design strategies that improve health and well-being regardless of the typology, chosen rating system or not, or even client’s expressed desire. This involves understanding the elements that promote health and well-being and choosing to incorporate them to the greatest degree possible in every project.

Additional Resources Books A Pattern Language by Christopher Alexander

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Brain Landscape: The Co-existence of Neuroscience and Architecture by John Paul Eberhard Building for Life: Designing and Understanding the Human-Nature Connection by ­Stephen Kellert Color, Environment, and the Human Response by Frank H Mahnke Healing Spaces: The Science of Place and Well-being by Esther M Sternberg Healthy Buildings: How Indoor Spaces Drive Performance and Productivity by Joseph Allen and John D Macomber Sustainable Design Basics Sharon Jaffee, Rob Fleming, Mark Karlen and Saglinda H Roberts Sustainable Design for the Built Environment by Rob Fleming and Saglinda H Roberts The Memory of Place by Dylan Trigg The Poetics of Space by Gaston Bachelord Therapeutic Landscapes by Claire Cooper Marcus and Naomi A Sachs Topophobia by Dylan Trigg Welcome to Your World by Sarah Williams Goldhagen Articles ± Websites 14 Patterns of Biophilic Design. Retrieved from Terrapin Bright Green Website: www. terrapinbrightgreen.com/report/14-patterns 9 Foundations: clear and Actionable Core Elements of Healthy Indoor Environments. Retrieved from Harvard TH Chan School of Public Health Website: 9foundations. forhealth.org Associations of Cognitive Function Scores with Carbon Dioxide, Ventilation, and Volatile Organic Compound Exposures in Office Workers: a Controlled Exposure Study of Green and Conventional Office Environments. Retrieved from the Environmental Health Perspectives Website: ehp.niehs.nih.gov/doi/full/10.1289/ehp.1510037 Behind the Vinyl Curtain: the Sobering Reality of Many Building Materials. Retrieved from Perkins + Will Website: perkinswill.com/news/behind-the-vinyl-curtain-the-soberingreality-of-many-building-materials/-in-healthcare-environments The Center for Health Design Website: www.healthdesign.org/chd Effects of Biophilic Indoor Environment on Stress and Anxiety Recovery: a Between-subjects Experiment in Virtual Reality. Retrieved from the ScienceDirect Website: www. sciencedirect.com/science/article/pii/S0160412019336347 Global Green and Healthy Hospital Agenda. Retrieved from Global Green and Healthy Hospitals Website: www.hospitalesporlasaludambiental.net/wp-content/ uploads/2016/07/Global-Green-and-Healthy-Hospitals-Agenda.pdf Global Green and Healthy Hospitals Sustainability Goals. Retrieved from Global Green and Healthy Hospitals Website: www.greenhospitals.net/sustainability-goals Global Green and Healthy Hospitals Website: www.greenhospitals.net Harvard T.H. Chan School of Public Health Website: www.hsph.harvard.edu Healthy Buildings for Health. Retrieved from Harvard TH Chan School of Public Health Website: forhealth.org International Living Future Declare Website: declare.living-future.org International WELL Building Institute Website: https://www.wellcertified.com LEED Rating System. Retrieved from the US Green Building Council Website: www. usgbc.org/leed LEED V4 Building Design and Construction Checklist. Retrieved from the US Green Building Council Website: www.usgbc.org/resources/checklist-leed-v4-buildingdesign-and-construction Materials Health in Healthcare Facilities. Retrieved from the Healthcare Facilities Today Website: www.healthcarefacilitiestoday.com/posts/Material-Health-in-HealthcareFacilities–25210

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Stephen Kellert Biophilic Design Award. Retrieved from International Living Future Website: living-future.org/biophilic-design/award The Therapeutic Benefits of Salutogenic Hospital Design. Retrieved from the Health Management Website: healthmanagement.org/c/it/issuearticle/the-therapeutic-benefitsof-salutogenic-hospital-design The Toxic Footprint of Our Hospitals. Retrieved from IDEAS.TED.COM Website: ideas. ted.com/the-toxic-footprint-of-our-hospitals Transparency Website and Precautionary List. Retrieved from Perkins + Will Website: perkinswill.com/news/perkinswill-launches-revamped-material-transparency-websiteand-%c2%91precautionary-list%c2%92-of-hazardous-building-materials WELL Building Standard Website: v2.wellcertified.com/en/wellv2/overview WELL Performance Rating. Retrieved from the International WELL Building Institute Website: resources.wellcertified.com/tools/well-performance-rating Wood as a Restorative Material in Healthcare Environments. Retrieved from the Truline Truss Website: https://trulinetruss.ca/wood-as-a-restorative-material

Appendix

I BASE PLANS

These base floor plans of varying size are provided as a starting point for the design exercises outlined in the book. Several of the plans are standalone buildings; others are portions of a larger facility. The larger floor plans could be used to accommodate a larger single or group practice or divided into multiple tenant spaces to be used by multiple typologies. The CAD (Computer-Aided Drafting) plans can be found in the accompanying website. Please feel free to add mechanical restriction or requirements, or make changes to best work with your class.

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Figure A2.1  Base Floor Plan 1,574 Square feet. Source: Saglinda Roberts.

Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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Figure A2.5  Base Floor Plan 3,876 Square Footage. Source: Saglinda Roberts.

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Figure A2.9  Base Floor Plan 8,244 Square Footage. Source: Saglinda Roberts.

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Figure A2.11  Base Floor Plan 17,000 Square Footage. Source: Saglinda Roberts.

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Appendix

II ASSIGNMENTS AND EXERCISES

The following are activities, class exercises, and assignments that the authors have used in the past and are included as an example. The intention is to give the students a chance to practice and further explore the concepts introduced in each chapter. They can also be modified to be used in different chapters or be combined for use as larger assignments or group work. It is up to the individual instructor how they best see fit to use them for their classes and whether or not they are graded. More resources along with floor plans are provided on the website.

CHAPTER 1 INTRODUCTION Introduction to Healthcare Class Exercise Timed | Peer Graded Assignment You have 45 minutes to search the internet and find pictures and the answers to the following for your chosen Healthcare Specialization: 1. Select your typology from the list below: Physical Therapy

Urgent Care

Cancer Center

Dialysis

Dentistry

Psychological Treatment

Palliative Care

Naturopathic or Alternative Medicine

Orthopedic

Community Health Clinic

General Practice

Infirmary

Ambulatory Surgery Center

Urgent Care

Gerontology

Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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2. Research and answer the following items for your chosen topic with information and images: • Basic overview of specialization • List of typical symptoms or reasons patients visit • List of causes • Brief overview of typical treatment options, if any • Design perimeters that effect the patient – Good or Bad • How facility design can help or hinder healing or patient care • Four Pictures of treatment facilities or treatment options 3. Add your information to the shared presentation. 4. Be prepared to present and discuss your chosen area of research with the class. 5. You should have at least 2 resources and URLs attributing sources are required under each image. **The intention is to create a focus on humanizing healthcare facilities by illustrating the patient experience

CHAPTER 2 EVIDENCE-BASED DESIGN Evidence-based Design Theory Analysis 1. Review the Evidence-based Design Theories detailed in Environmental Psychology for Design 3rd Edition by Dak Kopec, Table 2.1, page 40 to become familiar with their principles and applications. 2. Review the project you will be analyzing. 3. Use the Internet to research the project for additional information, images, plans, and/or drawings. 4. Answer the following questions and provide illustrations. 1. How was your theory used? 2. Why do you believe it was used? 3. Was it effective and explain how or why? 5. If you don’t see your theory in the case study projects – think about how it could have been used as well as why you think it wasn’t used? 6. Talk about what you learned + how what you learned can be used moving forward. 7. Look deeply and use analysis skills. ** Students or groups could be each be analyzing a selected Theory, Model, or Perspective of Environmental Psychology for the same project or analyzing and identifying all of them for one project.

Place Observation Exercise Description: You will be conducting an exercise that is often done as part of Evidencebased Design research and Space Planning and Adjacency analysis. Please visit the three different facilities as specified below and spend at least 30 minutes at each location observing the activity and analyzing the features of the Built Environment that play a role in shaping human activity and interaction. Follow the steps below for each place that you visit: 1. Find a comfortable place to observe the area and its activity where you will be out of the way and not influencing what happens in the area/space. 2. Draw a rough floor plan of the area (not to scale) with any distinguishing features + Entrance/Exit points. 3. Take 3 photographs of the area from your vantage point (straight ahead, looking left, looking right).

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4. Observe and record what people are doing: How are they using the space? Are they interacting with each other? If not why? What spaces or areas are they coming from and going to? Where do they stop and talk or interact? Where do they most often sit or stand or hang out? What aspects of the space do people mostly get wrong or struggle with? 5. Record all these observations with approx. time in a log form. After your observation time is complete 6. Indicate the main traffic patterns on the plan you created in step 2. 7. Please answer the following questions below. How do you feel in the space + why? What are the positive aspects? What are the negative aspects of the space? What are the aspects that could be changed to make it function better? What could be changed to make the space feel better? What could be change to make the space function better? Is this a successful project and for whom? 8. Submit your drawings and observations for all three spaces as one PDF organized by place and be prepared to discuss your findings with the class next week. ** Locations can be specified or not. Exercise can also be used to evaluate more performative and programmatic aspects of a space, or healthcare typology. This exercise could also be used during the design of specific facilities as part of a case study later in the textbook/course.

CHAPTER 3 GENERAL ELEMENTS OF HEALTHCARE General and Specialized Elements of Healthcare Design Please submit your PowerPoint of 22 slides to be presented Pecha Kucha Style on your group’s Element of Healthcare Design to the appropriate link. A Pecha Kucha presentation is 20 slides; each shown for approx. 20 seconds. The slides should be a single image with only the main point in words. The purpose is to distill the overwhelming information available for the essential. (Think about approx. one sentence per slide.) 1. Please select from the following topics: Human-Centered Design

Light + Color

Integrated Design Process

Products + Materials

Acoustic + Visual Privacy

Infection Control

Physical + Perceptual Comfort

Universal Design

Daylighting + Natural Elements

Standardization

Administration + Regulatory Requirements

Industry Standards

2. The questions and research points are to be a combination of factual information as well as your analysis. Please explore the following in your presentation: • What is __________ (your design element)? • What are the basic elements of your area of research? • Why is it important to design in general? • Why is it important to healthcare design? • How, why, and where should it be applied or used? • What are the areas for further exploration?

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3. Required Presentation Elements and Order: • First Slide is for the Title • 20 Slides outlining the essential information for your chosen Element of Design • Last Slide is for the Resource List • All Images to have URL source referenced in lower left hand of the slide

CHAPTER 4 HOLISTIC ANALYSIS Holistic Analysis + Iteration Create four (4) iterations of your facility based on the holistic analysis process outlined below and any other research you have completed so far. 1. Use Holistic Analysis form to guide your evaluation of client, stakeholder needs and other requirements for the project. 2. Establish a preliminary program based on your research for your typology. Think about all the spaces that would be needed for your typology. All projects should have some public/community spaces and green space. 3. Create a freehand block drawing based on the perspective of each of the quadrants below: • One (1) Experience Quadrant Plan – which considers only the beauty and experience of your project – how you would like it feel, the aesthetics, or deeper experience goals • One (1) Cultural Quadrant Plan – based only on the cultural apects or connections you would like to create in your project • One (1) Performance Quadrant Plan – based solely on the performance aspects of your project efficiency, adjacencies, sustainability • One (1) Systems Quadrant Plan – how it relates to the site, its neighbors, the rooms within, and any type of passive systems 4. Have the plans ready for the beginning of class to pin up and present to the class followed by collaborative evaluatuation as a group.

Holistic Analysis Form Experiential Aspects or Goals This is where the aesthetic, perceptual, subconscious aspects of a space or project are analyzed. Some of the questions to explore would be: • • • • • •

How do we want people to feel in this space? What are they coming to the space with that we would like to mitigate or maintain? What aspects of prospect and refuge do we need to support? What are the aesthetic goals? What sense of self-worth, care, or equity are we engendering or creating? How can the project be restorative to the occupants?

Functional or Performance Aspects This is where the objective, measurable, factual aspects of a project and how it functions are analyzed. Some of the areas to be explored would: • Energy savings or sustainable measures • Climate and site features to capitalize on or mitigate • Adjacencies and processes for functions within or between spaces

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• • • • •

Organizational or professional standards that need to be met Size and number of people to be served and corresponding staff Program of spaces and approximate sizes Lighting and lighting levels required Technical, millwork, or equipment required

The medical field in general and the specific typology being designed for all have very technical and regulated practices. The designer should strive to understand as much as possible early on but also rely heavily on collaborating with the medical and engineering professionals as the project progresses. Cultural Context This is where the underlying connections, purpose, and meaning of a project are analyzed. Some aspects or questions to explore would be: • • • • • • •

What type of culture or social structure are the occupants coming from? What type of culture and interactional structure do we want to develop or create? How are we supporting equity with our project? What type of interaction do we want to create with the surrounding community? Are there historical elements that we need to consider? Either socially or architecturally? How are we creating connection with nature? Are there geographic norms that we need to consider? Either socially or architecturally?

Inter-relational or Systems Thinking This is where we examine how all the aspects of a project and its location interact and influence each other. Some of the aspects or questions to explore would be: • What are the parts that make up a whole and how are they connected? (Understanding that each is a part and a whole) • What are the relationships, networks, or flow between the functions? • What are the deeper patterns visually or functionally? • How should the spaces and/or occupants relate to each other? • How should the project relate to the site? • How can the project restore or positively influence the site, community, urban area? **Create a form for students to fill out answering the questions for each analysis areas outlined avoce and give students time to fill out and collaboratively discuss in class. Student present their four (4) iterations the next week followed by collaboratively evaluation using a modified charrette process after each student presentation. Students and instructors or guests comment on the “Optimisms” or “Concern/Next Steps” for each design. The comments for both should be written down. Students can then use what they learned from their iterations and collaborative evaluation to move forward in developing their final design.

CHAPTER 5 TYPICAL ROOM REQUIREMENTS Space Planning Exercises Have students create one, possibly more, plan(s) for each of the spaces outlined. Students should be using information from the text as well as research on each of the spaces. • • • •

Basic plan with minimal square footage requirements Plan with more generous square footage requirements Plan with optimal features and generous square footage Plan to accommodate a larger number of providers, staff, and patients

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**Plans can be drawn by hand or using which ever software is preferred by the instructor. The exercise can be used as a homework assignment or as a charrette in class. Adding other restrains or requirements can also add complexity to the exercise, or it can be used as a part of the final project studies as well. This should be done for each of the spaces outlined in the chapter.

CHAPTER 6, 8 + 9 TYPOLOGY SPECIFIC FACILITIES Case Study Case or precedent studies allow us to look at existing projects to discern current best practices and areas that we should be looking to mitigate. They provide valuable information into what works and show examples of innovations to meet ever changing landscape of healthcare design. Evaluating projects from specific typologies as well as from other related areas of healthcare practice can identify areas of innovation or improvement. Please find at least 3 case studies for your chosen typology and evaluate and organize your information based on the following questions and areas. 1. Answer the questions below for each case study along with images to help guide your design. If there are items that don’t apply, please note that. 2. The questions and research points are a combination of recording factual information from your sources and your own analysis. 3. Deliverables: a. Completed case study form for each project b. Pecha Kucha presentation that summarizes all three of your case studies to be presented to the class c. Properly cite quotations and visual images in the text d. Provide resource list for each case study shown at the end of each project 4. Please think deeply about the following things as you do your research: As you are analyzing, seek to understand the basis for what you are seeing. Think about if the selections and decisions were purely aesthetic, or were there other motivations. General Design Information Project Location + Size: Architect + Designers: Number of years in operation: Population it was designed to serve? Evidence-based Design or Environmental Psychology factors addressed? Climate factors addressed: Historic or cultural factors addressed: How is Sustainability addressed: Programmatic and Aesthetic Analysis What are the programmatic Inter-relationships? Are they mandatory or preferable? What physical and/or emotional security features are visible? What are the Aesthetic or Experiential goals and how were they achieved? How does the project relate or interface with the surrounding area? How does the project expose the occupants to nature or natural elements can you see? What is the result of these elements? How are daylighting and views incorporated to the spaces?

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Physical Factors: Look to understand the thought process Furniture Lighting Overarching Analysis Questions From the images available, how does it feel to be there? What can we learn about programing, adjacencies, or relationships? What do we see as advantages to this project? (Things that would be great to replicate) What are some areas of concern with this project? (Things we should look to avoid or address) Best Practices? Anything else interesting or helpful in understanding what makes these project successful? ** This exercise can be used at various times throughout the course for students to look deeply and analyze a specific typology, or Healthcare Design in general.

CHAPTER 7 GROUP PRACTICES Organizational Exploration 1. The idea is to evaluate the different organizational structures typically used and how they would affect the performative aspects of a medical practice. 2. Select a Single Specialty Practice and create a basic or general program of spaces that would be required. 3. Explore adjacencies by creating a bubble diagram for each of the following organizational patterns: • Centralized • Decentralized • Satellite Plan 4. Create a Multiple Specialty Practice using your original Single Specialty Practice and adding typical related practices. 5. Explore the program and adjacencies required for your added typologies. 6. Explore adjacencies for your new multiple specialty practice by creating a bubble diagram for each of the following organizational patterns, incorporating resources or facilities to be shared between practices: • Centralized • Decentralized • Satellite Plan 7. Compare and contrast the differences in functionality, patient experience, and square footage requirements as well as three things you learned and how it will affect your designs in the future.

CHAPTER 10 ARCHITECTURAL CONSIDERATIONS Site Analysis + Case Study Understanding where the project is located dictates many decisions regarding building configuration as well as the organization and placement of interior spaces or functions. 1. Select the geographic area and site you will be using as for your project. 2. Draw your site accurately and to scale.

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3. Indicate North with the appropriate symbol. 4. Research and analyze the Sun Path and Wind patterns for you chosen site. (Wind rose and sun movement with sun angles at the Summer + winter Solstice.) 5. Profile typical temperatures, and rain/snow fall per year to give you a fuller idea of the overall climate. 6. Plot the sun path and predominant wind directions on your site plan. 7. Find a building or project that addresses similar climate factors as your chosen geographic Area. 8. Profile your project and list at least three ways the designers addressed thermal comfort issues in your case study. 9. Answer the questions below for your specific location and project type:What specific strategies could you use to increase thermal comfort, reduce energy usage, and promote occupant well-being. 10. Create and submit a 10 slide PowerPoint or PDF with your research info. **Geographic location can be specified, or selected by student.

CHAPTER 11 LIGHTING DESIGN Profile daylighting strategies for: Patient rooms | Lobby reception areas | Treatment Spaces | Staff lounge or work areas Profile artificial lighting strategies for: Lobby and Reception Areas | Treatment Spaces | Staff Lounge and Work Areas Daylighting Options: | Explore strategies for allowing daylight to penetrate deeper into the building using the sun path and angles for the selected site Research typical footcandle requirements for each space ** This can be done at whatever level the instructor feels comfortable with. This exercise could be done using case study research or by doing drawings designing passive strategies based on the sun path and angles from the research in Chapter 10.

CHAPTER 12 INTERIOR FINISHES + FURNITURE Search design- and healthcare-specific magazines for the following items to establish a shared data base for professional quality healthcare furniture, finishes, and lighting: • • • •

Furniture Finishes Lighting Bariatric Furniture

Enter the Company Name, Brief Description of the product line and style, and the Company’s Website. Be prepared to present your selections by giving a brief overview of the product line and why you selected it. **Create an Excel document with tabs for Furniture, Bariatric Furniture, Finishes, and Lighting. Each section should have columns where students can record the manufacturer name, description of style or target market, company website link, and if desired initials for grading or accountability purposes. Other tabs can certainly be added to the document.

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Environmental Impact and Toxicity Exploration 1. Explore and Evaluate products on Declare, Perkins + Will Transparency, Cradle 2 Cradle, Living Futures Red List. 2. Select a product and profile its components, elements, and chemical composition. 3. Evaluate the benefits of cleaning and infection control with longevity, body burden, and toxicity. 4. Record your information in the provided form and be prepared to present your information to the class. ** Have students present their information through shared or individual slide presentation, or research paper/presentation.

CHAPTER 13 BIOPHILIA Biophilic Charrette Design Exercise Design a lobby space or reception area for a healthcare facility that focuses on your group’s assigned Biophilic Elements. The intention of the charrette is to explore broad creative concepts related to incorporating Biophilic elements in a deep and multilayered, complex way. This section should Biophilic Elements are assigned to each group. The intention is that each group explores 4 different elements in detail so that they can expand the classes knowledge as well as go back to their group with diverse Biophilic strategies. 1. Review the lecture and additional information on your groups assigned Biophilic element. 2. Programmatic Elements that need to be included in your plan • Front Desk or concierge large enough for two people • Seating and/or Gathering Areas to encourage community at different levels 3. Start the design process by iterating multiple ideas for deeply embedding your assigned Biophilic elements into the design in a way that supports and enhances the programmatic purposes. 4. Be prepared to present + discuss your strategies, rationale, and desired outcomes with the class during the collaborative evaluation process. 5. You don’t need to worry about codes, ADA, or using a scale at this point. Concentrate on incorporating innovative ways to deeply embed Biophilic principles into your space. 6. Deliverables: Drawings and pictures necessary to convey your design intent and solutions

• Floor plan showing any design elements • Elevation(s) • Pictures to illustrate concepts, solutions, or inspiration ** Charrette could address other areas within healthcare facilities in the same or different charrette settings. Assigning Biophilic Elements helps students focus their attention to the deeper aspects of Biophilia

Proposed Incorporation of Biophilic Elements Meet with your group after the charrette evaluation to discuss which Biophilic elements you would like to include in your project and your proposed method for doing so. Use images and research information to present your proposed strategies. This proposal will be part of your guiding principles and final grading structure.

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CHAPTER 14 WELL-BEING Established Standards of Health and Well-Being by Rating Systems Please review your section of your selected rating system that addresses health and well-being standards (LEED, WELL, Living Building Challenge) 1. Profile your section in the (shared) presentation exploring and addressing the following topics: • What is __________ (your rating system and standard)? • What are the basic elements or intents of this standard? • Why is it important to health and well-being in general? • Why is it important to address healthcare design? • How, why, and where could it be applied or used? • What are the areas for further exploration? • What did you learn and how will it affect your design? 2. Add your information to the shared presentation. 3. Be prepared to present and discuss your chosen area of research with the class. 4. You should have at least 2 resources and URLs under each image. **This can be used as an in-class exercise or as a homework assignment. An option to expand the assignment would be to add a case study component either requiring students to find a project which exemplifies the standards they are researching or by selecting a project and evaluating which standards it does exemplifie. This could also be used as a separate assignment as well.

HEALTHCARE DESIGN PROJECTS Project 1 – Primary Care Design Problem: • Your client is in a densely populated urban area • This office serves a wide range of demographics from pediatrics to elderly • Due to COVID-19, the client is unable to care for as many patients as they normally would due to distancing • The client would like for you to redesign the clinic to allow for: • 5,000 square feet • Standardization of exam rooms • Traffic patterns that allow for social distancing • Continue to allow for the medical home model/as much one stop shopping as possible • Add additional space for telehealth operations Primary Care Schematics This submission should include: • • • • •

Clear ideation through a documented design process (visual). Concise programming strategy. Rough sketches of circulation, flow, patient, and staff experience. Clear ideation of working through the design process. A 25% drawing submission, to include: • floor plan • circulation diagram(s) • visual explanation of meeting the client’s needs.

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Primary Care Schematics Presentation In a 5-minute presentation, please review the following at minimum (not necessarily in this order): • Your programming and research information • Your schematic planning, and how your plans meet the client needs • Review the design challenges that the end users face and your specific solutions for those problems

Project 2 Ambulatory Care Design Problem: • • • •

Select an ambulatory care typology. Create the client profile and narrative. The floor plan is provided and will be used for project 2 and 3. Project 2 is the pre-project design for project 3. We will refine your design in project 3 as we continue to learn more about healthcare design throughout the course. • The intention for this method is to help you practice perfecting your craft, similar to professional practice. You will learn new things every day that you can apply to your work. Ambulatory Care Schematics This submission should include: • Clear ideation through a documented design process (visual). • Concise programming strategy, evidence that you understand clinical care required for or consistent with your typology delivery. Name your concept and clearly illustrate how you are staying true to your concept. • Rough sketches of space planning, circulation, flow, patient, and staff experience. • A 25% drawing submission, to include: • floor plan • circulation diagram(s) • visual explanation of meeting the client’s needs. Ambulatory Care 35% schematics Building upon your last submission, please take your project to the next level of completion by: • • • •

Demonstrate continued evidence of strong programming and research Demonstrate your concept and how you will continue to develop your design Demonstrate evidence of strong understanding of stakeholder needs Provide neat and accurate drawings that include: • Floor plan • Wayfinding solution • Draft furniture plan • Demonstrate evidence of code compliance including life safety and ADA Ambulatory Care Final Presentation/50% drawing submission A 6-minute presentation reviewing the latest progress and design development 1. Please create an electronic presentation with the following drawings: • Architectural Plan

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• MEP Plan showing electrical, data, plumbing • Wayfinding Plan illustrating 2. Quickly walk us through your plans emphasizing: • Functional aspects + Staff Experience • Life Safety Considerations • Patient Experience • Aesthetic Goals • How your design decisions will improve the functional and aesthetic experience 3. Review next steps to improve your project

Project 3: Ambulatory Care, Refined Continue to refine, develop, and move forward with your research and design from Project 2 Project 3 Ambulatory Care Final Presentation and Drawing Package Create a presentation to review your total project and how you have met all the stakeholder needs. 1. Create a presentation that summarizes all your design strategies, solutions, and aesthetics for your chosen Ambulatory typology. 2. Must submit following drawings and schedules, on a title block: • Floor plan • MEP • Reflected Ceiling Plan • (2) noteworthy elevations • (1) noteworthy section • Finish plan: Wall and ceiling finishes • Finish plan: Flooring plan • Furniture and Artwork Plan • Wayfinding plan • 2 perspective renderings • Finish and Furniture Schedules • Presentation finish and furniture boards 3. Submit the drawing package and presentation as ONE PDF **Each step of the process is supported by individual meetings during studio time

GENERAL SOURCES FOR HEALTHCARE DESIGN PROJECTS OR CASE STUDIES AIA Healthcare Awards HCD Magazine IIDA Healthcare Design Awards MCD (Medical Construction & Design) Magazine Modern Healthcare Magazine Pinders Healthcare Design Awards (UK) The Center for Health Design Living Institute Stephen Kellert Biophilic Awards

GLOSSARY

These are common terms and abbreviations that are used in the profession and throughout this book. Every effort has been made to use standard professional terminology, but that in itself is misleading. This is by no means a complete list and there may be additional terms that are part of the local professional vocabulary that are not listed. Professionals can use the same word to mean different things and students may not have had the opportunity to come across some of the terms that are used here or through-out the book. The purpose of this glossary is to have a central reference for those terms and main principles that are used in the text. Active Systems – Systems in the built environment that have moving parts or use outside energy or technology such as solar panels, wind turbines, hydronic heating or geothermal heating, or cooling systems. ADA – (American with Disabilities Act) – A Federal law that prohibits discrimination based on disability and establishes design standards to allow full and equal access to facilities and amenities. Acoustic Privacy – Reduced, interrupted, or obscured sound transmission to protect people’s privacy during verbal discussions or information transfer. It can also refer or be applied to reducing unwanted sound transfer to increase productivity, cognitive function, or well-being. Alternate Medicine – A term that describes treatments that are outside the traditional or mainstream medical treatments taught in Western medical school and are focused on the whole body, mind, and spirit restoration using naturopathic and/or nonchemical derivatives. It can be practiced by itself or incorporated into traditional medical practice. Ambient Layer Lighting – General lighting that helps occupants move throughout the space and/or provide the general mood of the space. American Society of Heating, Refrigeration, and Air-Conditioning ­Engineers (ASHRE) – Codes that dictate the environmental conditions of the built environment. Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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Ambulatory Care – Medical care services performed on an outpatient basis, without admission or overnight stay at a hospital or other facility. Ambulatory Surgery Centers – Facilities designed to handle scheduled surgery procedures that do not require an overnight stay at the hospital. They are usually shared by a multitude of doctors or surgeons who perform surgery at designated times or days and are most often not attached or part of the local hospital, but they could be. Bariatric – Branch of medicine that deals with the causes, prevention, and treatment of obesity. Measurements and diagnosis are related to a person’s BMI (Body Mass Index). Bariatric Design – The focus on equal access and inclusion for all people by considering clearances, circulation paths, furniture, increased weight, and structural construction. Barrier Free – A design approach that seeks to remove or replace things that keep a person from assessing or using the built environment because of differing physical abilities. Biophilia – The theory that humans have a biological, inherent longing and need for connection with nature and the natural world that goes beyond aesthetic enjoyment and influences emotional, cognitive, and even spiritual development. Biophilic Design – Focused on creating healthy and supportive spaces to increase occupant health and well-being by incorporating natural living elements, processes, or patterns. It draws on the fields of neuroscience, evidence-based design, and environmental psychology. Cancer Treatment Centers – Ambulatory and/or in-patient facilities that focus on specialized treatments to combat all types of cancer using traditional medical treatments as well as naturopathic treatments and can also include research, laboratories, or teaching facilities. Ceiling Attenuation Class (CAC) – Rating that indicates a suspended acoustic ceiling’s ability to block sound traveling through a plenum when the wall does not extend the full height to the underside of the floor above. Center for Health Design – A nonprofit organization focused on supporting the healthcare, construction, and design industries and leading them toward creating improved environments for care and healthy aging. Charrette – Collaborative design process focused on quick iterative work sessions with the goal of creating a large number of design ideas to be vetted and developed at a later time, usually by the same collaborative group. Circadian Rhythms – The natural internal process that regulates the sleep–wake cycle as well as other physical, mental, hormonal, and behavioral changes or functions on a 24-hour cycle. Climate Information or Analysis – Understanding of how the sun moves across the project site or building, which direction the predominant winds blow for each season, how much rain or snow fall typically happens per year, and typical humidity levels per season. Ideally these are plotted on the site plan and aid in design decisions. Co-Creative Design – Focused hands-on work and design sessions that allow all the stakeholders to work usually with templates or manipulative materials to help compose schematic designs and promote engagement and inclusion. Commission on Accreditation of Rehabilitation Facilities – CARF – International nonprofit organization concerned with setting standards for rehabilitation and behavioral health institutions. Community Health or Care Clinics – Facility focused on providing family or general practice medicine located in areas of high need and are culturally sensitive to the population served and many times treat those without insurance, are under insured, or charge on an ability to pay basis. They can also act as a social hub. Cross Contamination – The transmission of pathogens between patients and healthcare professionals based on exposure to contaminated surfaces, materials,

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environmental conditions, design and layout, and the cleaning and disinfection process. Sometimes referred to as healthcare-associated infections or HAI. Cross Infection – The transmission of pathogens between patients and healthcare professionals based on exposure to contaminated surfaces, materials, environmental conditions, design and layout, and the cleaning and disinfection process. Sometimes referred to as healthcare-associated infections or HAI. Crumb Catcher – The slight gap between the seat and back support to aid in cleaning by allowing any particles to fall free of the chair and not be trapped in the intersection between the seat and back. Cultural Aspects or Goals – The underlying social, ethnic, religious, or deeper interaction connections, purpose, and meaning of a project. Cultural Context – The influencing factors from the surrounding social group, community, or the ethnic or religious values or beliefs that influence actions, attitudes, perceptions, or expectations. Daylighting – Illumination provided by direct, indirect, or ambient sunlight that enters a building, also referred to as natural light. Daylighting Layer – Illumination that is provided by the windows, doors, or ceiling apertures, reducing the need for artificial lighting while providing health benefits. Decorative Layer Lighting – Illumination that directs the eye, adds visual interest, directs attention, creates spatial form or perception. Dentistry – The medical practice that focuses on the prevention and treatment of the teeth and supporting structures of the mouth such as gums, bone structure, and mechanics of the jaw. Dental Hygienist – A accredited, licensed preventative oral health professional and staff member in Dentist’s office who focuses on preventative oral care, education, and other services in conjunction with a dentist or dental office. Dialysis Centers – Facilities that perform life-sustaining blood purification for people whose kidneys can no longer do it; these facilities can be focused on treatments only or contain medical offices for examinations as well. Also, can be referred to as Kidney treatment centers. Dispensary – Medical care facilities meant to provide general care for a specific “in-house” population such as a school, college, university, military base, prison, or certain manufacturing businesses. They are meant to treat a broad range of nonserious illnesses or injuries and/or act as a triage or staging area for more serious conditions to be treated elsewhere. Can also be referred to as an infirmary- or facility-specific treatment space. Evidence-Based Design – EBD – An iterative and integrated approach to design based on findings from the scientific study of human interaction with the built environment regarding spatial configuration, materials, acoustics, and visual stimuli. Environmental Psychology – A branch of psychology that explores the relationship between humans and the external world examining the way the natural and built environments shape us as individuals. Ergonomics – The applied scientific study of the human body and its movements in relation to the design of furniture, products, and spaces to promote health and well-being and reduce functional or structural damage. Experiential Aspects or Goals – The aesthetic, perceptual, psychological, or subconscious aspects of a space or project. Facility Guidelines Institute – FGI – Industry design standards for space planning and equipment for healthcare facilities which are the basis for regulatory or licensure when applicable. Facility-Specific Treatment Spaces – Medical care facilities meant to provide general care for a specific “in-house” population such as a school, college, university, military base, prison, or certain manufacturing businesses. They are meant to treat a broad range of nonserious illnesses or injuries and/or act as a triage or

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staging area for more serious conditions to be treated elsewhere. Can also be referred to as an infirmary or dispensary. Focal Layer Lighting – Illumination that highlights architectural features, art, displays, or important spatial features. Functional or Performance Aspects or Goals – The objective, measurable, factual aspects of a project and how it functions. Geriatrics – A subset of Gerontology that focuses on the medical aspects of aging adults. Gerontology – A multidisciplinary branch of medical science that studies the physical, social, psychological, and cognitive aspects of aging. Global Green and Healthy Hospitals (GGHH) – An organization that seeks to transform and strengthen the global health systems by focusing on sustainability and environmental health, and have research, programs, and educational programs to better inform providers and healthcare facilities. Healthcare-Associated Infections – The transmission of pathogens between patients and healthcare professionals based on exposure to contaminated surfaces, materials, environmental conditions, design and layout, and the cleaning and disinfection process. Sometimes referred to as Cross Contamination or Cross Infection. HIPPA – Health Insurance Portability and Accountability Act - A United States federal law created to protect sensitive health information from being disclosed without the patients knowledge or consent. Holistic Analysis – Using the broadest set of perspectives to inform design, including all stakeholders and their needs into the design directives. Optimally engaged in from the beginning of the design process. Human-Centered Design – Iterative and interdisciplinary approach to design based on including all stakeholders and the findings from the fields of neuroscience, psychology, science, and architecture. Also known as, or another name for, Evidence-Based Design (EBD) Infection Control – The focused approach to design, specification, and procedures to reduce the transmission of pathogens between patients and healthcare professionals based on exposure to contaminated surfaces, materials, environmental conditions, design and layout, and the clean and disinfection process. Sometimes referred to as healthcare-associated infections or HAI. Infirmary – Medical care facilities meant to provide general care for a specific “in-house” population such as a school, college, university, military base, prison, or certain manufacturing businesses. They are meant to treat a broad range of nonserious illnesses or injuries and/or act as a triage or staging area for more serious conditions to be treated elsewhere. Can also be referred to as a facility-specific treatment space or dispensary. Indoor Air Quality (IAQ) – The levels of contaminants present in the air inside of a building measured in relationship to the levels in the exterior air and is affected by construction materials and processes as well as any elements that are inside of the building. Interdisciplinary – Approach that seeks to incorporate a broad range of perspectives by including all the stakeholders in the collaboration process, preferable from the beginning of the process. Inter-relational or Systems Thinking Aspects or Goals – The examination of all the aspects of a project and its location interact and influence each other including the ecosystem and urban setting. Internal Medicine – A medical specialty that focuses on applying scientific research to diagnose and treat adult’s internal organs, either as a primary care physician or for those with complex health conditions or illnesses.

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Iterative Process – The constant evaluation of Information, ideas, or solutions from multiple perspectives, which are then tested and refined to make sure all possibilities are explored. It can be used in any design or research field. Kidney Treatment Centers – Facilities that perform life-sustaining blood purification for people whose kidneys can no longer do it; these facilities can be focused on treatments only or contain medical offices for examinations as well. Also, can be referred to as Dialysis Centers. LEAN (Leadership. Eliminate waste. Act now. Never Ending) – Management approach that originated in the manufacturing sector that is used frequently in healthcare facilities to increase building and employee performance, optimize delivery of care, and reduce operating costs. LEED (Leadership in Energy and Environmental Design) – Rating system that focuses on energy efficiency and carbon reduction for all building types, neighborhoods, sites, and building maintenance and operations. Living Building Challenge (LBC) – Rating system created by International Living Future institute and is one of the most stringent building certification programs focused on holistic sustainability addressing occupant health, well-being, beauty, and community along with resource conservation and energy efficiency. Load-Bearing Façade – A building where the exterior walls are an integral part of the load-bearing system and are responsible for supporting itself and other parts of the building. Mobility Aids or Devices – Any equipment that aids a person with walking or moving around in a space, such as a cane, walker, crutches, scooter, or service animal. Natural Light – Illumination provided by direct, indirect, or ambient sunlight entering a building, also referred to as daylight. Naturopathic Medicine – Focuses on the whole person, mind, body, and spirit, seeking the root causes and not just treating the symptoms by using natural remedies such as, massage, acupuncture, exercise, and nutrition to help the body heal itself. It is also referred to as Alternative Medicine and can be practiced by itself or incorporated into traditional medical practice. Negative Air Pressure – The pressure in the space is less than that of the adjacent or surrounding areas so that any air movement is into the space therefore reducing pathogens spreading to other areas. Neuroscience – The scientific study of the nervous system, how develops, and how it impacts behavior and cognitive functions. Noise Reduction Coefficient (NRC) – An average rating of how much sound an acoustic product can absorb. Non-Load Bearing Façade – The weight of the exterior walls and finish are transferred to the structural grid or foundation and are not responsible for carrying any additional weight and have no role in supporting the structure of the building. Obstetrics and Gynecology (OB/GYN) – A branch of medicine that specializes in the care of women’s health and reproductive issues including pregnancy and childbirth. Orthopedics – A branch of medicine that focuses on the prevention or correction of injuries or disorders to the skeletal system and associated muscles, joints, and ligaments. Osteopathic Medicine – A branch of medicine that is part of traditional medical education focusing on evaluating and treating the whole person by using preventative care and lifestyles to fight illness. They are allowed by law to prescribe medicines and can be generalists, family practitioners, or specialists in any field. Palliative Care – Specialized medical care for people living with serious illness that holistically treats the patient with an interdisciplinary team of medical professionals, dietitians, pharmacists, nurses, and any other related professional. They can treat patients of any age.

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Passive Systems – Systems in the built environment that do not require external energy or technology such as shading structures, overhangs, landscape features, air movement based on predominate winds or thermodynamics. Patient Protection and Affordable Care Act (PPACA) – Act passed in 2010 to establish more affordable health care for lower income households, expand Medicare coverage, and support innovative medical delivery methods. Pediatrics – The branch of medicine that focuses on the health, care, and development of children from birth to young adulthood. Physical Therapy – A health profession that uses specially designed exercise, equipment, and physical treatments to restore, enhance, or preserve body movements. It is focused on evaluating the mechanical aspects of a person’s body movements in relationship to their skeletal and muscular systems. Plenum – The space between the finished ceiling and the underside of the floor structure above in a multistory building which is planned to accommodate all the mechanical and ventilation requirement of the space. Positive Air Pressure – The pressure of air introduced into a space is greater than that of adjacent or surrounding spaces so direction of air movement is “pushing outward” therefore keeping pathogens from entering the room. Psychiatrist – Trained physicians who specialize in mental health medicine focused on diagnosing illness, managing treatments, and providing a range of therapies for complex, serious mental illnesses. The are they only therapists certified to prescribe medication. Psychologist – Have a doctorate-level degree in a field related to psychotherapy and mainly rely on Talk or behavioral therapy. They may also work in research and may not see clients at all. Qualitative Research – Focused on understanding or discovering the deeper aspects of human behavior by collecting and analyzing non-numerical data. It is more focused on experience, behavior, and interactions. Quantitative Research – Systematic gathering of information that is then converted or translated into numerical or statistical data.The numerical data can then illuminate patterns in an unbiased way to inform decisions or theories. Relative Humidity – The amount of water vapor content in the air relative to the amount it could hold at that temperature. Site – The actual plot of land the building is placed on. Site Plan – A scaled plan that outlines the legal boundaries of the plot of land for the project. It should also profile the topography, and include all the landscape features, transportation hubs, pathways, roads, or other exterior elements. Stakeholders – Any person, group, profession, or agency that would or could be affected by, or has an interest in the project, or could affect it in any way. Standardization – Principle within the healthcare industry which looks to increase efficiency, response time and reduce errors by creating identical, standard clinical areas. The principle applies to cabinetry, mechanical, and equipment placement including where supplies are stored. Structural System – Composition of load-bearing elements that allow a building to stand and withstand all the physical forces that it is subjected to such as the weight of the building materials, the people inside, and the physical forces of the environment like wind, snow, and rain. Systems Thinking Map – Tool which visually illustrates or lays out all the different stakeholders, relationships, and influences of a given element or system. It allows for easier identification of patterns, connections, and points of influence or possible change. Sun Path – How the sun moves across the building site from morning to night for each season of the year.

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Task Layer Lighting – Illumination focused on the physical or functional tasks of a space and is focused on providing the appropriate lighting levels and reducing glare or shadows. The Joint Commission – TJC – United States-based nonprofit organization that provides accreditation to healthcare organizations and is considered the standard for healthcare design. Therapist – (Psychotherapist) – Is an all-encompassing term that refers to professionals who work with clients to improve mental health and well-being; the education may vary from Masters to Doctorate level degree, but they are all trained, licensed mental health professionals. Thermal Comfort – The perceived feeling of satisfaction with environmental conditions. It is composed of six factors: Air temperature | Radiant temperature | Air velocity | Humidity | Clothing | Metabolic heat or activity. Toxins – Anything that is introduced into the body that can cause unfavorable reactions, disease, harm, or death. They can be naturally occurring or artificial. Universal Design – A design principle that strives to create environments and products that can be accessed, understood, and used by the greatest number of people without specialized adaptions. Urgent Care Facilities – Immediate care facilities for a large variety of conditions that are not life threatening or critical. Typically, appointments are not required; they are open longer and after normal business hours and can be less expensive and require less wait time than the hospital emergency room. Visual Privacy – Reduced lines of sight to protect information, treatments, or people from unwanted visual contact or connection. It from screens, paper, video, data, and treatment rooms. Well-Being – The physical, emotional, and psychological stability and health of a person along with the levels of social engagement and level of satisfaction an individual feels. WELL Building Standard – Rating system that is focused on enhancing human health and well-being in all building typologies based in scientific research and evidence-based design best practices.

COMMON ABBREVIATIONS AAHD – American Association on Health Disability AAHID – American Academy of Healthcare Interior Designers ACH – Air Changes per Hour ADA – Americans with Disabilities Act AIA – American Institute of Architects ASHRAE – American Society of Heating, Refrigeration, and Air-Conditioning Engineers ASID – American Society of Interior Designers CAC – Ceiling Attenuation Class CARF – Commission on Accreditation of Rehabilitation Facilities CFM – Cubic Feet per Minute CHD – Center for Health Design EBD – Evidence-Based Design EPA – Environmental Protection Agency FF+ E – Furniture, Fixtures, and Equipment – it is also used to classify anything moveable, or added after construction is complete FGI – Facility Guidelines Institute GGHH – Global Green and Healthy Hospitals HAI – Healthcare-Associated Infections HIPPA – Health Insurance Portability and Accountability Act

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HVAC – Heating Ventilation and Air Conditioning systems IIDA – International Interior Design Association IDP – Integrated Design Process IPD – Integrated Project Delivery IWBI – International WELL Building Institute LEAN – Leadership. Eliminate waste. Act now. Never Ending. LBC – Living Building Challenge rating system LEED – Leadership in Energy Efficient Design rating system NFPA – National Fire Protection Association NRC – Noise Reduction Coefficient OB/GYN – Obstetrics and Gynecology PPACA – Patient Protection and Affordable Care Act TJC – The Joint Commission WELL – Well Building Standard rating system

INDEX

Please note that page references to Figures will be followed by the letter ‘f ’; A Aalto, Alvar, 6 Accounting, 75 Accreditation bodies, 12 Acoustics, 84, 146 acoustic privacy, 17–18, 61, 107, 109, 110–111 interior construction, 110–111 specialized requirements, 17–18 see also Privacy; Sound and acoustics Active systems, 103 ADA see Americans with Disabilities Act (ADA) Adaption and resilience, 112–113 Addiction services, 63f Adjustable desks, 145 Administration and administrative work areas, 2, 13, 18, 21, 79 administrators, 22 artificial light, 119 concerns and goals, 23 group practices, 71, 73, 75 indoor air quality in areas, 105 paperwork, 27 provider and staff furniture, 130 room requirements, 30, 37, 39, 40, 48 specialized ambulatory centers, 89, 91, 92 systems furniture, 108 team/collaborative area, 66, 89 Affordable Care Act (ACA), US, 12 Agustin, S., 134 Air and Biophilic elements, 135 exchange rate, 17 fresh air, 17 indoor quality, 105, 144

simulating patterns, 139 see also Natural ventilation Alternative and naturopathic medicine, 66–68 Ambient layer, lighting, 115 Ambulatory centers, specialized, 2, 87–99 administration and administrative work areas, 89, 91, 92 ambulatory surgery, 88–91, 90f cancer treatment centers, 93–95 dialysis/kidney treatment centers, 96–97 environment, 89 example floor plan, 89 labs, 95 stakeholders, 87, 88 standardization, 88 American Association for Labor Legislation, 11 American Institute of Architects (AIA), 27 Americans with Disabilities Act (ADA), 16, 48, 50, 108–109, 127, 128 Animals, 136, 139 Architectural considerations, 2, 101–114 adaption and resilience, 112–113 building codes, 113 detailing, 111 interior construction, 106–111 materials, 111 mechanical equipment and technology, 105–106 medical equipment and technology, 111–112 natural landscape and ecosystem, 139 overhang, 103 prospect and refuge, 140 shell/exterior envelope, 104–105 structural systems, 103–104 sustainability see Sustainability

Armchairs, 30, 34, 37 Artificial light, 119 Artwork, 130 ASHRAE (American Society of Heating, Refrigeration and Air-Conditioning Engineers) Codes, 17 Attention Deficit/Hyperactivity Disorder (ADHD), 136 Attenuation, sound, 61, 68

B Basic case study, 25 Baylor University Hospital, Dallas, 11 Beauchemin, K.M., 134 Bed position, 36f Beston, H., 133, 134 Biomimetic form, 140 Biophilic design, 133–142 application in healthcare facilities, 141 attributes and elements, 138–140 integrating Biophilic elements, 138 objective, 133 place creation of, 137 cultural and ecological attachment to, 140 sense of, 147 and space, 140 rationale for, 134–138 cognitive function, 135 creation of place, 137 employee turnover, 135 eye strain, 135 faster healing, 134

Healthcare Design Basics, First Edition. Mark Karlen, Saglinda H Roberts and Kyra K Tucker. © 2023 John Wiley & Sons, Inc. Published 2023 by John Wiley & Sons, Inc.

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INDEX

increased productivity, 135 physiological benefits, 136 psychological benefits, 136–137 reduced stress, 135 social and cultural implications, 137–138 staff/patient/visitor health and well-being, 134–135 theory, 133 see also Natural colors; Natural light; Natural materials; Naturalistic shapes and forms; Nature; Physiological effects and architectural strategies Biophilia Hypothesis (Wilson), 133 Brain Landscapes (Eberhard, J.-P.), 134 Break spaces for staff basic elements (example), 47f and built environment, 19 group practices, 75–76 and nutrition, 145 optimal items, 48f prototypical space requirements, 46–47, 47f, 48 Building codes see Codes, building Building orientation, sun and wind patterns, 102f Built environment, 2, 5, 6, 14, 15, 50, 129 Biophilic Design, 133 directives, 12 effects on health, 134 holistic analysis, 22 improving, 17, 22 physical, 12 role, 18–19 sense of place, 147 standardization, 17 see also Environment Bulkheads, 128 Burnout, medical professions, 18 Business office, 39 basic plans (example), 40f optimal elements (example), 40f

C Cabinets/cabinetry architectural considerations, 109 break rooms, 47f bulkheads, 128 business office, 39 consulting rooms, 41 dentistry, 56 exam rooms, 36 lighting, 120, 121f millwork, 109 nurses’ station, 37, 38f Procedure rooms, 44f standardization, 17 Calabrese, E., 133, 138 Cancer treatment centers, 93–95 open plan infusion area floor plan, 93, 95f private infusion suite floor plan, 93, 95f Carbon monoxide, 144 Caregivers, taking needs into account in design, 89, 120–121 CARF see Commission on Accreditation of Rehabilitation Facilities (CARF) Case or precedent studies, 8, 24–25

Ceilings infection control, 126 interior construction, 108, 110 interior finishes, 128 Center for Health Design (CHD), 7, 12, 14, 150 clinic practices, 79 website, 15, 18 Centralization flexibility, design for, 106 group practices, 72, 73f physical therapy, 91 plumbing, electric and data, 106 Chairs armchairs, 30, 34, 37 break spaces, 46 comfortable, 41, 42, 62 consulting rooms, 36 dentistry, 56 ergonomic, 97, 108, 130 guest, 36, 39, 42, 89 and infection control, 126 reclining, 62 side, 30 stable, 64, 92 task, 30, 33, 39 wheelchairs, 16, 59, 74 Charrette design patterns, 26–27 CHD see Center for Health Design (CHD) Children accommodating in waiting areas, 32, 33f pediatrics, 53–54, 55f Circadian rhythms, 18, 120 Cleanability, 15, 45, 48, 119, 130, 136 Cleaning and disinfection, 14–15 perception of cleanliness, 15 see also Infection control Clerestory window, 118 with overhang, 116, 117f vertical openings, 116, 117f Climate, 22, 23, 102 Clinic practices, 79–86 community health centers, 80–82, 81f facility specific treatment spaces, 84–85 patient needs, 81 staff needs, 80 urgent care facilities, 82–83 Cocreative design patterns, 26 Codes/building codes, 12, 14, 16, 22, 113, 119 compliance with, 17, 128, 129 Coefficient of Friction (COF), 127 Cognitive function, 135 Colors lamp types, 119 natural, 139 use of, 131 Comfort physical and perceptual, heightened need for, 15–16 thermal, 18, 146 Commission on Accreditation of Rehabilitation Facilities (CARF), 12 Community and cultural context, 2, 22–23

Compliance, 14, 113 with codes, 17, 128, 129 Component, 14, 105, 109, 111, 126, 128 Conduct Disorder (CD), 136 Constructed partitions, 107–108 Consulting rooms, 41–43 basic elements (example), 42f group practices, 75 internal medicine, 65 optimal elements (example), 42f, 43 Controls and zoning, 105–106 Correlational research, 8 Corridors, 83, 128, 147 ambulatory centers, specialized, 94, 95 lighting design, 121 and room requirements, 49–50 Counter tops/high touch areas, 127 COVID-19 pandemic, 51 Crash rails, 128 Cross contamination/infection, 14, 15 Curtains, 14, 110 Custom build, 109

D Daylighting importance to human body, 145 interior glazing, 109 layer, 115 monitor or clerestory vertical openings, 117f Paimio Tuberculosis Sanatorium, 6 strategies, 116–117 and views, 115, 122 see also Lighting; Natural light; Windows Decorative layer, lighting design, 116, 121 Demountable partitions, 108 Dental treatment areas, 55–59 alternate layouts, 58f floor plans, 55, 57f, 59f hygienist areas, 55, 57f overview, 55 sterilization work area, 56 storage area, 56 treatment rooms, 55, 57f Descriptive research, 8 Design aesthetic, 130 Designers, 3, 6, 150 architectural considerations, 101, 102, 110, 112, 113 attributes of evidence-based designers, 8–9 and Biophilic Design, 134, 137 and holistic analysis, 21, 23–25 infection control responsibilities, 15 interior, 1, 101, 103–106 and lighting, 115, 116 sustainable, 101 thought process, understanding, 25 Desks, moveable, 145 Detailing, 111 Dialysis/kidney treatment centers, 96–97 floor plans, 97f Directives, general design, 25 Disinfection, 14–15 Dividing curtains, 110 Doors, 108–109

INDEX

exam rooms, 36f Dying in the Dark (Beauchemin and Hayes), 134

E EBD see Evidence-Based Design (EBD) Eberhard, J. P., 134 Electronic medical records, 50–51 Employed physician practices, 72 Environment ambulatory, 89 architectural considerations, 101 artwork, 130 built see Built environment calming, 15 children, accommodating, 32 clinic practices, 79 color use, 131 comfortable, 16 conditions, 13, 14, 17 ecologically sound, 133 environmental conditions, 14 environmental services staff, 15 ergonomics, 129 flexible, 84 and infection control, 14 infection control, 125, 127 interior, 102 and lighting, 115 materiality, 18 offices, 41 overall design aesthetic, 130 privacy, 17 psychological and psychiatric practice areas, 62 and stakeholders, 23 Universal Design, principles of, 16 and windows, 41 see also Infection control; Windows Environmental Protection Agency (EPA), 134 Environmental Psychology, 143 The Environmental Theory (Nightingale), 5, 6 Ergonomic chairs, 97, 108, 130 Ergonomics, 129, 146 Ethnography, 7 Evidence-Based Design (EBD), 2, 5–10, 143 appreciation of all stakeholders, 8, 9 associated organizations, 9 attributes of evidence-based designers, 8–9 curiosity, 8 defining, 5 and healing, 134 inclusion of all, 8 iterative process, as, 7 openness to information and new ideas, 8 origins, 5–6 principles, 7 research, 134 significance of process to design, 6 Exam rooms, 35–36 basic elements, 36f easy access from, 49f group practices, 75, 76 lighting, 116 general, 120 plan, 120, 121f

task lighting, 119–120, 121 varying room sizes, 36f Experiential and adjacency requirements alternative and naturopathic medicine, 68 ambulatory centers, specialized, 89 break spaces, 46–47 business office, 39 cancer treatment centers, 94 children, accommodating in waiting areas, 32 clinic practices, 80, 81 consulting rooms, 41 corridors, 50 dental treatment areas, 56 dialysis/kidney treatment centers, 96–97 exam rooms, 35 facility specific treatment spaces, 84 gerontology, 60 intake area, 33–34 internal medicine, 66 nurses’ station, 37 orthopedic offices, 64 pediatrics area, 54 physical therapy, 91–92 procedure rooms, 43 psychological and psychiatric practice, 61–62 reception and waiting areas, 30 and resilience, 51–52 restrooms (toilets), 48 storage spaces, 45 technology, 51 urgent care facilities, 82 Experimental research, 8 Exterior envelope, 104–105

F Façades, 104 Facility Guidelines Institute (FGI), US, 12 Facility specific treatment spaces, 84–85 Federal Security Agency, US, 12 Fell, D., 134 Fenestrations, 104 Fire safety, 50 Fixtures, permanent, 146 see also Furniture, fixtures and equipment (FF+E) Flexibility design for, 106 environmental, 84 facility specific treatment spaces, 84 lighting, 42, 120 and technology, 105 Floors and floor plans ambulatory surgery, 89 cancer treatment centers, 94f, 95f dental treatment areas, 55, 57f, 59f dialysis/kidney treatment centers, 97f facility specific treatment spaces, 85f flooring choices, 107 gerontology, 60f hygienist area, dental treatment, 57f infection control, 15, 126 infusion area, open plan (cancer treatment), 95f interior construction, 107, 111

 

183

interior finishes, 127 internal medicine, 66, 67f materiality, 18 orthopedic offices, diagnostic areas, 64, 65f pediatrics area, 55f physical therapy, 92–93f private infusion suites (cancer treatment), 95f psychological and psychiatric practice, 62–63f surfaces, 107 urgent care facilities, 83f Focal layer, lighting design, 116, 121 Footcandles, 119 FP Innovations (not-for-profit research and development), 136 Fresh air, 17 Fungi, 144 Furnishings, 54, 62, 111 see also Furniture, fixtures and equipment (FF+E); Interior finishes Furniture, 128–131 color, use of, 131 “crumb catcher,”126 ergonomics, 129, 146 general rules, 129 infection control, 126 interior construction, 110 overall design aesthetic, 130 for patients, 129–130 for providers and staff, 130 selecting for healthcare facilities, 129 strength/resilience, 125 systems, 108 see also Chairs; Furniture, fixtures and equipment (FF+E); Interior finishes; Seating Furniture, fixtures and equipment (FF+E) alternative and naturopathic medicine, 68 ambulatory centers, specialized, 89 business office, 39 cancer treatment centers, 94 children, accommodating in waiting areas, 32 clinic practices, 80, 81 consulting rooms, 41, 42 corridors, 50 dental treatment areas, 56 dialysis/kidney treatment centers, 96, 97 exam rooms, 36 facility specific treatment spaces, 84–85 gerontology, 60 intake area, 33–34 internal medicine, 66 nurses’ station, 37 orthopedic offices, 64 pediatrics area, 54 physical therapy, 92 procedure rooms, 43 psychological and psychiatric practice, 62 reception and waiting areas, 30 and resilience, 52 restrooms (toilets), 48 storage spaces, 45 technology, 51

184 

INDEX

urgent care facilities, 82, 83 see also Furniture

G Geriatrics, 59 Germ Theory, 5 Gerontology, 59–61 Glazing, interior, 109 Global Green and Healthy Hospitals (GGHH), 149–150 Great Depression, 11 Grounded theory, 8 Group practices, 2, 71–77 centralized plans, 72, 73f employed physician practices, 72 multi-specialty clinics, 71–72, 74, 76f satellite plans, 72, 73f satellite pods, 73, 74f schematic diagrams, 73f separative components and functions, 76 single specialty, 71, 74 typical shared functions and components, 74–76 Guest chairs, 36, 39, 42, 89 Guggenheim Museum, New York, 137 Gypsum board, 127

H HAI see Healthcare-associated infections (HAI) Hand hygiene, 13, 14, 15 Handrails, 128 Harvard Center for Health and Global Environment, 135 Harvard T.H. Chan School of Public Health, 14, 17, 144 Hayes, P., 134 Healing, 134 Health and well-being, 2, 143–150 Biophilic Design, 134–135, 136 defining well-being, 143 elements and strategies in healthcare settings, 144–148 ergonomics, 146 foundations of a Geriatrics healthy building, 149–150 implications for medical facilities, 143–144 importance of well-being, 143 indoor air quality, 105, 144 long-term implications of design for healthcare, 150 natural light, 116–118, 139, 145 natural materials, 147–148 nutrition, 145 perceived health, well-being and satisfaction, 136–137 physical exercise, 145 plants, 147–148 rating systems, 148–149 research, 134–135, 136, 143, 144, 148, 149 sense of place, 147 sound and acoustics, 61, 146 thermal comfort, 18, 146 views, 134, 147 visual privacy, 147 water, 145

see also Circadian rhythms Health Insurance Portability and Accountability Act (HIPAA), US, 12, 17–18, 33, 35, 41, 107, 110, 146 Healthcare facilities administrative aspects see Administrative aspects of healthcare beyond healthcare, 150 Biophilic Design, application in healthcare facilities, 141 building codes, 12 built environment, role, 18–19 complexity, 22 elements and strategies in healthcare settings, 144–148 evolution, 12 general elements, 2, 11–20 history of the US medical system, 11–12 holistic analysis see Holistic analysis methodology industry standards, 12 infection control see Infection control long-term implications of design for, 150 mechanical requirements, 17 overall design aesthetic, 130 reducing overall demand for services, 150 regulations, 12 specialized demands on workers, 18 specialized facility and mechanical requirements, 12–18 standardization, 16–17 Healthcare-associated infections (HAI), 13, 15 Heating Ventilation Air-Conditioning systems (HVAC), 14, 17 zoning, 18, 105, 106 HIPAA see Health Insurance Portability and Accountability Act (HIPAA) Holistic analysis methodology, 2, 21–27 additional questions, 25 administrative concerns/goals, 23 building codes, 22 case or precedent studies, 24–25 community context, 22–23 cultural context, 22–23, 24 experiential aspects or goals, 23 functional or performance aspects, 23 integrative design, 26–27 interrelational/systems thinking, 24 interviewing and observation, 25–26 operating standards, 22 overarching analysis questions, 25 profitability, 22 site and climate, 22 typology, 23–24 see also Stakeholders Human-centered design, 6 HVAC see Heating Ventilation Air-Conditioning systems (HVAC) Hygienist area, dental treatment, 55 optimal room layout, 57f potential layouts, 58f

air exchange rate, 17 ceilings, 126 cleaning and disinfection, 14–15 counter tops/high touch areas, 127 cross contamination/infection, 14, 15, 17 environmental conditions, 14 floors, 15, 126 healthcare-specific considerations, 125–128 hiding of dirt, 15 humidity, relative, 17 indoor air quality, monitoring, 105 materiality, 18 Paimio Tuberculosis Sanatorium, 6 pediatrics area, 53 pressurization, 17 restrooms (toilets), 48 surfaces, 14, 32, 125, 128 all surfaces, 126 temperature, 17 walls, 126, 128 Informational richness, 140 Insurance, 75 Intake area, 33–34 with dividers, 35f optimal (example), 35f Integral theory, 106 Integrated design process, 27 Integrated project delivery (IPD), 27 Interdisciplinary teams, 6–8, 13–15 Multidisciplinary Infection Team, 15 Interior construction, 106–111 ceilings, 108 dividing curtains, 110 doors, 108–109 floors, 107 interior glazing, 109 millwork, 109–110 systems furniture, 108 walls and partitions, 107–108 Interior finishes, 2, 15 ceilings, 128 emerging materials, 128 interior construction, 110 stakeholders, 80, 127 surfaces, 125, 126 see also Infection control Internal medicine, 65–66, 67f Internists, 65 Interviews, 25–26

J The Joint Commission (TJC), US nonprofit organization, 12

K Kellert, S., 133, 135, 137–138 Kelvin, color of light measured in, 119

L I Indoor air quality, 105, 144 Industry standards, 12, 18, 23, 129 Infection control, 13–14

Labs ambulatory centers, 95 group practices, 75 internal medicine, 65

INDEX

lighting, 120 pass-through to, 49f Lamps/lamping, 119 Lavatories see Toilets (restrooms) LEAN (Leadership. Eliminate waste. Act now. Never ending), 22 LEED (Leadership in Energy and Environmental Design), 27, 148, 149 Lever handles, doors, 109 Light shelf, 116, 117f Lighting design, 2, 115–123 aesthetics, 120–121 artificial light, 119 and Biophilic elements, 135 bulbs, 119 circulation, 120 clerestory window, 116, 117f, 118 daylighting layer, 115 elevation, 120, 121f of waiting area, 122, 123f exam rooms, 119–120 flexibility, 120 flexible lighting, 42 general, 120, 121 health and circadian rhythms, 120 light shelf, 116, 117f mobile lighting, 120 natural light, 116–118, 139, 145 occupant concerns, 119–122 for patients and caregivers, 120–121 for providers and staff, 119–120 public spaces, 122 review of basic principles, 115–116 sawtooth monitors, 118 skylight, 118 task, 119–120, 121 task layer, 115 top lighting, 117–118 see also Daylighting Living Building Challenge, 148–149 Load bearing façade, structural systems, 104

M Materiality, 18 Materials emerging, 128 natural, 139, 147–148 sustainability, 111 Mechanical equipment/requirements, 12–18, 105–106 Medical equipment ambulatory surgery, 89 consulting rooms, 41 movable, 111 orthopedic offices, 63 security features, 80 specialties, 37 stationary, 111 storage spaces, 45–46 technology, 51, 72, 105–106, 111–112 X-ray machines, 56, 57f, 64, 82, 83, 84, 93 see also Furniture, fixtures and equipment (FF+E) Medical system, US, history, 11–12 Medicare, US, 12

The Memory of Place (Trigg), 137 Millwork, 15, 109–110 Minor Treatment/Surgery see Procedure Rooms Mold, 144 Moldings, 15 Monitors, 118 Mortality rates, 134 Moveable desks, 145 MRI machines, 64, 83f, 93

N Narrative, 8 National Convention of Insurance Commissioners, US, 11 Natural colors, 139 Natural geometrics, 140 Natural landscape and ecosystem, 139 Natural light, 116–118 effects on health, 145 exam rooms, 36f simulating, 139 see also Daylighting Natural materials, 139 and plants, 147–148 Natural ventilation, 104, 109, 118, 135 Naturalistic shapes and forms, 139 Nature air, 138 animals, 139 direct experience of, 138–139 evoking, 140 exposure to, 135 fire, 139 images of, 130, 139 indirect experience of, 139–140 light, 138 plants, 139 water, 138 weather, 139 see also Physiological effects and architectural strategies Naturopathic medicine, 66, 68 Neuroscience, 133, 134, 135, 143 Nightingale, Florence, 5–6 Noise control, 18, 107 see also Acoustics Non-load bearing façade, structural systems, 104 Notes on Nursing (Nightingale), 5–6 Nurses’ station, 37–39 basic elements (example), 38f optimal (example), 39 optimal elements (example), 38f Nutrition, 145

O Observation, 25–26 Occupational Safety and Health Administration (OSHA), 127 Operating standards, 22 Oppositional Defiant Disorder (ODD), 136 Orthopedic offices, 63–64 Osteopathic medicine, 66

 

185

P Paimio Tuberculosis Sanatorium, 6 Palliative care, 61 Partitions demountable, 108 interior construction, 107–108 Passive systems, 102–103 Pathogens preventing adhering to surfaces, 13–14, 128 reservoirs, 14 Patient Protection and Affordable Care Act (PPACA), 39 Patients, taking needs into account in design alternative and naturopathic medicine, 68 ambulatory centers, specialized, 89 artificial light, 120–121 Biophilic Design, 134–135 business office, 39 cancer treatment centers, 94 clinic practices, 81 consulting rooms, 41–42 corridors, 50 dental treatment areas, 56 dialysis/kidney treatment centers, 96–97 exam rooms, 36 facility specific treatment spaces, 84–85 gerontology, 60 intake area, 34, 35 internal medicine, 66 nurses’ station, 37, 38f, 39 orthopedic offices, 64 pediatrics area, 54 physical therapy, 92 procedure rooms, 43 psychological and psychiatric practice, 62 reception and waiting areas, 30 restrooms (toilets), 48, 49 task lighting, 121 technology, 51 urgent care facilities, 82–83 waiting areas, 32 Pediatrics area, 53–54, 55f Phenomenology, 8 Physical exercise, 145 Physical therapy, 91–93 example floor plan, 92f Physicians’ offices, 75 Physiological effects and architectural strategies air, 138 animals, 139 architectural considerations, 138, 139, 140 biomimetic form, 140 cultural and ecological attachment to place, 140 evoking nature, 140 fire, 139 images of nature, 139 informational richness, 140 integration of parts to wholes, 140 lighting, 138 mobility and wayfinding, 140 natural geometrics, 140 natural landscape and ecosystem, 139 natural light, simulating, 139 natural materials, 139

186 

INDEX

naturalistic shapes and forms, 139 organized complexity, 140 passing of time, 140 plants, 139 prospect and refuge, 140 transitional spaces, 140 weather, 139 Physiotherapy see Physical therapy Place creation of, 137 cultural and ecological attachment to, 140 sense of, 147 and space, 140 Plants, 137, 139, 147–148 Plumbing, electric and data, 106 PPACA see Patient Protection and Affordable Care Act (PPACA) The Practice of Biophilic Design (Kellert and Calabrese), 138 Precedent studies see Case or precedent studies Privacy acoustic, 17–18, 61, 107, 109, 110–111 curtains, 14, 110 door swing, 36f environment, 17 and seating, 74 visual, 17–18, 147 Procedure rooms, 43 basic elements (example), 44f optimal elements (example), 44–45f task lighting, 120 Profitability, 22 Prometrics (Human Dimensions), 129, 146 Prospect and refuge, and visual privacy, 147 Psychological and psychiatric practice, 61–62 addiction services, potential for, 63f biophilic design, 136–137 Public spaces, 122

Q Qualitative research, 7–8 Quantitative research, 8, 143, 144 Quasi-experimental research, 8

R Radon, 144 Ramps, 50 Rating systems (health and well-being), 148–149 Reception area, 29–30, 35, 37, 130 basic (example), 34f and business office, 40f central area, 76 and consultation rooms, 75 group practices, 74 intake areas, 33 optimal (example), 35f pediatrics area, 53 satellite plans, 72 visual contact from desk, 32 see also Waiting areas Regulations, 12

Research areas of, 120 Biophilic Design, 133–135, 137, 138 cancer treatment centers, 93 correlational, 8 data collection, 8 descriptive, 8 Evidence-Based Design (EBD), 134 experimental, 8 and general elements of healthcare, 13, 14, 17–19 holistic analysis methodology, 23, 25, 26 integrated, 26 interdisciplinary, 6–8, 13–15 medical equipment, 89 patient health and well-being, 136, 143, 144, 148, 149 prototypical, 106 qualitative, 7–8 quantitative, 8, 143, 144 quasi-experimental, 8 resilience, 51 scientific, 65 task lighting of research areas, 120 topic specific, 150 WELL Building Standard, 148 Resilience, 51–52 Restrooms (toilets), 48–49 adjacent to/accessible from waiting areas, 49f easy access from exam rooms with pass-through to lab, 49f Emergency Rescue Hardware, 109 group practices, 75 pass-through to lab, 49f pediatrics area, 53 separative bathrooms for patients and staff, 48 Rodents, 144 Roof monitors, 118 Room requirements, 29–52 administrative work areas, 30, 37, 39, 40, 48 break spaces, 46, 47f, 48 consulting rooms, 41–43 corridors, 49–50 exam rooms, 35–36 intake areas, 33–35 nurses’ stations, 37–39 procedure rooms, 43, 44–45f prototypical spaces, 29–50 reception areas see Reception area resilience, 51–52 restrooms (toilets), 48–49 storage spaces, 45–46 technology, 50–51 waiting areas see Waiting areas

S Satellite plans, 72, 73f Satellite pods, 73, 74f Schematic design patterns, 26 Seams, 15 Seating adjustable, 84, 89

bariatric, 30, 129 benches, 30 break rooms, 48 community health centers, 81f ergonomics, 37, 94 group practices, 74, 76 high-back options, 60 interior finishes, 125, 129 pediatrics area, 54 and privacy, 74 reception and waiting areas, 30, 31f, 74 see also Chairs; Reception area; Waiting areas Shell/exterior envelope, 104–105 Side chairs, 30 Sink area, task lighting, 120 Site/site design and air quality, 144 building construction, 111 and climate, 22, 23, 102 community settings, 22 conserving/restoring, 133 ergonomics, 146 food grown on site, 145 internal medicine, 65 interrelational/systems thinking, 24 orientation, 102, 134 site plan, 22, 87, 102 on-site visits, 8 specialized facility and mechanical requirements, 12 Skylight, 118 Social security system, 11, 12 Sound and acoustics, 61, 68, 146 unwanted sound, 146 Space(s) adjacencies, 18–19 break spaces see Break spaces ergonomics, 146 facility specific treatment, 84 hospitality, 121 mobility devices, in gerontology, 59 and place, 2, 140 planning, 18–19, 146 prototypical requirements see under Room requirements public, 122 sound attenuation between, 61, 68 standardization, 17 storage see Storage spaces vertical separations between, walls and partitions as, 107 see also Experiential and adjacency requirements Specialized requirements heightened need for physical and perceptual comfort, 15–16 infection control see Infection control and mechanical requirements, 17 privacy, 17–18 stakeholders, identifying and including, 13 Specialties, 2 alternative and naturopathic medicine, 66–68 dental treatment areas, 55–59 gerontology, 59–61

INDEX

internal medicine, 65 multi-specialty group practices, 71–72, 74, 76f orthopedic offices, 63–64, 65f palliative care, 61 pediatrics, 53–54, 55f psychological and psychiatric practice, 61–62, 63f single specialty group practices, 71, 74 Staff, taking needs into account in design alternative and naturopathic medicine, 68 ambulatory centers, specialized, 89 Biophilic Design, 134–135 break spaces, 46–47 business office, 39 cancer treatment centers, 94 clinic practices, 80 consulting rooms, 41 corridors, 50 dental treatment areas, 56 dialysis/kidney treatment centers, 96 exam rooms, 35–36 facility specific treatment spaces, 84 gerontology, 60 intake area, 33–34 internal medicine, 66 lighting, 119–120 lounge, in group practices, 75–76 nurses’ station, 37 orthopedic offices, 64 pediatrics area, 54 physical therapy, 91–92 Procedure Rooms, 43 psychological and psychiatric practice, 61–62 reception and waiting areas, 30 and resilience, 51–52 restrooms (toilets), 48 storage spaces, 45–46 urgent care facilities, 82 waiting areas, 32 Staff lounges see Break spaces for staff Stairs, 50 Stakeholders, 6, 22, 25, 149, 150 and ambulatory practices, 87, 88 and attributes of evidence-based designers, 8, 9 and clinic practice, 80 collaborating with, 13, 18, 26, 109, 127 defining role of, 13, 21–22 identifying and including, 13, 101 input of, 87, 88, 103, 112 and integrative design, 26, 112 and interior finishes, 80, 127 mapping, 13f and medical equipment/technology, 111 and plumbing/electrics/data access, 106 and room requirements, 29 Standardization, 16–17, 35, 80, 84, 88 WELL Building Standard, 148 Sterilization work area, dental treatment, 56 Storage spaces, 45–46 basic elements (example), 45f–46f dental treatment areas, 56 needles and syringes, 45 optimal elements (example), 46f

prescription drugs, 45 Structural grid, 103–104 Sun angles per season, passive shading and solar grain based on, 103 building orientation, 102f and healing, 136 moving across property, 22 natural light from, 145 optimal position, 6 orientation to, 134 and zoning, 106 Surfaces chemical composition, researching, 14 cleanable, 15, 45, 48, 130, 136 corridors, 50 counters, 33 disinfection/infection control, 14, 32, 125, 126, 128 floors, 107 hard, 14, 107 impregnated antimicrobial treatments, 14 interior finishes, 125, 126 nonporous, 125, 126 preventing pathogens adhering to, 13–14, 128 reflecting, 138 soft, 14 surface coated treatments, 14 vertical, 116 visual and tactile, 32 work, 56, 120, 121f Suspended acoustic ceiling panels/tiles (ACP/ ACT), 128 Sustainability, 102–103 adaption and resilience, 112–113 architectural considerations, 101–103 controls and zoning, 106 creation of place, 137 demountable partitions, 108 designers, 101 flexibility, design for, 106 Leadership in Energy and Environmental Design (LEED), 27, 148 Living Building Challenge, 148 materials, 111 resilience, 112 sense of place, 147 SWOT analysis, 106 Sydney Opera House, 137

T Task chairs, 30, 33, 39 Task lighting, 115, 119–120, 121 Technology, 53, 66, 119, 144 accessibility, 113 and flexibility, 105 medical equipment, 51, 72, 105–106, 111–112 and room requirements, 50–51 turnover rate, 110 Terminology, 1 Thermal comfort, 18, 146 Toilets see Restrooms (toilets) Toxins, 105, 144

 

187

levels of, 17, 18 Travel distances, 19 Treatment rooms, dentistry, 55 optimal layout, 57f Trigg, D., 137

U Ulrich, R., 6, 134, 144 Undercabinet lighting, 120 United States Harvard Center for Health and Global Environment, 135 Harvard T.H. Chan School of Public Health, 14, 17 history of medical system, 11–12 see also American Institute of Architects (AIA); Americans with Disabilities Act (ADA) Universal Design Principles, 16, 48, 59, 79, 87, 128 Urgent Care Facility, 82–83, 84 UV light, for disinfection, 14

V Vehicles of transmission, 14 Views, 6, 25, 91, 116, 145 break rooms, 47f cultural, 80, 82, 89 and daylighting, 115, 122 direct, 139 exterior, 19, 48, 62, 94, 95, 97, 104 long, 140 of nature, 47, 62, 96 outdoor, 79, 84, 88, 109, 134, 144 and well-being, 134, 147 Visual privacy, 17–18, 147 Volatile Organic Compounds (low-VOC), 126, 127, 128

W Waiting areas, 29–31 basic elements (example), 30–31f children, accommodating, 32 corridors as, 49 elevation, 122, 123f group practices, 74 lighting plan, 122f optimal elements, 31f, 32, 33f overview, 30 restrooms accessible from/adjacent to, 49f satellite plans, 72, 73f see also Reception area Walls constructed, dental hygienist layouts, 57f exterior, 104, 105f infection control, 126 interior construction, 107–108, 111 interior finishes, 127–128 paint/vinyl wallcovering, 128 Water, 138, 145 Weather, 139 WELL rating system, 145 Building Standard, 148 Well-being see Health and well-being Wheelchairs, 16, 59, 74

188 

INDEX

Wilson, E.O., 133 Windows clerestory, 116, 117f daylighting, 116–117 double clerestory, 117 and the environment, 41 exam rooms, 36f function, 116

interior glazing, 109 light shelf, 116, 117f with overhang, 116, 117f Paimio Tuberculosis Sanatorium, 6 shading, 116 Wood as a Restorative Material in Healthcare Environments, 136

X X-ray machines, 64, 82, 83, 84, 93 dental treatment areas, 56, 57f

Z Zoning, 18

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