The Marriage of Form and Function: Creating a Healing - KI.com

The Marriage ofForm and Function:Creating a Healing Environmentby Bonnie K. Litch

A revolution has occurred in how hospitals are beingdesigned and constructed in the 21st century. With theadvent of the Center for Health Design’s Pebble Projectand other efforts and studies, more institutions are lookingfor ways to bring together aesthetics and the mission oforganizations to create a “healing environment” for bothpatients and staff. The fall 2004 issue of Frontiers of HealthServices Management explored this topic, stating, “The oldmodel of provider-centered care, for which most of the[hospital facilities] were designed, does not lend itself tothe newer, more efficient model of patient-centered care.”This movement recognizes the design elements that helpreduce stress and promote safety and healing, while consideringecological issues. Two hospitals in the Midwest havetaken these elements to heart.Clarian West Medical Center—Starting From ScratchWhen leaders at the Clarian West Medical Center in Avon,Ind., were charged with the task of building a new hospital,they started from scratch. What they ultimately createdwas an environment totally committed to healing and topatient-centered care.Al W. Gatmaitan, FACHE, president and CEO of ClarianWest, credits the following as critical to the construction ofa “healing sanctuary.” He says, “The key was integratingthree ideas: a healing physical environment; the work ofhealthcare and the technology needed; and the relationshipsthat must develop among patients, families and staff forhealthcare to work well.” To meet these goals, Gatmaitanand his team worked closely with the architects anddesigners to bring together elements such as natural light,colors, materials and elements of nature to help adapthospital form to comfortably fit with healthcare function.“We asked ourselves if there is a right way, a better way toprovide healthcare,” says Gatmaitan. “How do we create anenvironment to meet the high standards for quality andsafety desired by our staff, the patients and the community?How do we make our hospital a place where people wantto work? And, what kind of physical environment fostersbetter and more efficient care for patients while providingthem a healing atmosphere?”The result was a beautiful, functional 76-bed, suburbanfacility that married aesthetics to performance. Built onmore than 70 acres, Clarian West is an institution designedspecifically to take care of not just patients, but also theirfamilies and the caregivers who work there. “There is a growingbody of research that draws a clear connection betweenenvironment and healing,” says Gatmaitan. “Our goal was tobe very intentional in creating an environment that enhancesthe work of our physicians and caregivers by helping themreduce anxiety and stress as well as to return some freedom ofchoice and control to our patients and their families. We feelso strongly about this notion of a ‘healing sanctuary’ that weadopted it as one of our core operating principles, rightalongside other vital elements such as patient safety.”Advocate Lutheran General Hospital—Transforming an Aging FacilityClarian West is not alone in embracing these principles.Renovations at Advocate Lutheran General Hospital (ALGH)in Park Ridge, Ill., are underway, transforming its 617-bedteaching hospital—originally built in 1959—into a facility tomeet the needs of the community for the next 50 years. Plansfor the newly renovated facility are already under constructionand include 382,623 new and 30,612 renovated square feetand an eight-story building with 192 private rooms. Additionalprivate rooms will be created in the existing hospital.Ginger Barthel, FACHE, vice president for ClinicalOperations, believes the success of any overhaul beginswith a vision. ALGH’s vision was to “create a facilitythat expands and enhances Advocate Lutheran GeneralHospital and Lutheran General Children’s Hospital’sleadership in providing quality healthcare to patientson a regional basis.” To meet this goal, the organizationdeveloped a set of guiding principles that are dividedReprinted from 21Healthcare ExecutiveJULY/AUG 2007ache.org

The Marriage of Form and Function: Creating a Healing Environmentinto three different categories: patient safety goals;enhanced patient/family-centered care operations; andenhanced operational effectiveness and efficiencies.To figure out how best to accomplish these principles,ALGH sought a greater understanding of its stakeholders’needs. “When developing our plans for renovations, weconducted several different focus groups to discover whatelements they thought were critical to creating the rightenvironment at ALGH,” says Barthel. “We brought togetherphysicians, nurses, patients and their families and supportpersonnel; every stakeholder in our hospital. In the end, weheld 300 separate meetings and had 162 consistently involvedwith the design process.” Through these sessions, they foundseveral common themes: privacy, comfort, security, safety,family-centered care and convenience. These aspects becamethe backbone of the renovations and construction.Here are some elements both institutions believe arecrucial to creating a healing environment:Bring the Outside InAt Clarian West, the healing experience begins for patientsbefore they walk through the door. The campus featureswalking trails, ponds and gardens, and the building has anabundance of windows, some more than three stories high,which bring soothing outdoor views and natural light toboth public spaces and the all-private patient rooms. Lightwill play a key role at Advocate Lutheran, with room plansthat include large picture windows that cover the entire wall.Patients will be able to control the amount of ambientlight they receive through darkening shades.Make Patient Privacy a PriorityPrivacy is very important to a patient’s healing environment,and both institutions reflect a commitment to this principle.“We don’t have strangers in our rooms with us at home, sowhy would we be comfortable with that scenario when weare at our most vulnerable?” says Clarian West’s MedicalDirector James Fesenmeier, MD. That element of privacyalso helps facilitate open, honest communication betweenthe patient and his or her healthcare team.Provide Hotel-Like AmenitiesAt Clarian, patient rooms feature home-like amenities suchas flat-screen televisions, DVD players, Internet connections,over-the-bed reading sconces and artwork.Designers at ALGH also believe that an engaging environmentis important to helping the healing process. In additionto refreshments and entertainment, patients will beable to access educational tools in their rooms via thetelevision. Phone and Internet connections will helpthem communicate with the outside.Clarian West extended the hotel philosophy to its foodservice. Instead of a pre-selected tray of breakfast, lunch anddinner arriving for all patients at the same time every day,patients at Clarian West order from a diet-appropriate menuanytime between 6:30 a.m. until 7:30 p.m. “Room servicehas been an unqualified success,” Gatmaitan explains. “In anenvironment where so many decisions are taken out of yourhands and placed into the hands of experts, the ability to eatwhat sounds good when you’re hungry is empowering. Italso helps make mealtime an ‘event’ that serves as a positivedistraction for the patient and their family.”Create Soothing AestheticsClarian West paid particular attention to each detail, creatinga soothing atmosphere from paint choices to the buildingmaterials. “The color palette is soothing and natural—a continued effort to bring the healing power of natureindoors,” says Gatmaitan. “Building materials such asstone and slate complement the color palette and addtexture, all of which affect the overall experience.”“True healing environments are constructed in ways thathelp patients and families cope with the stresses of illness,”22Reprinted fromHealthcare ExecutiveJULY/AUG 2007ache.org

The Marriage of Form and Function: Creating a Healing Environmentsays Jain Malkin, a Clarian West consultant in thedesign of innovative healthcare environments. “Everydecision—from lighting, layout and décor to heatingand cooling—can further a patient’s healing. Whetherwe eliminate noise, provide pleasant music andimagery, or allow a patient privacy and more optionsfor passing the time, we are providing a place wherethey can focus more on healing.”Focus on Relationship-Centered CareAn important component of Clarian West’s healing philosophyis a commitment to relationship-centered care. AsGatmaitan states, “We believe that healthcare is completelydelivered through a caregiver, and the technologyinvolved is only a tool. Patient care is the result of aseries of relationships throughout the day. Our success isjudged by how we manage and interact with the patients.”He offers an analogy. “Building high-tech equipment iscomplex, but every step in the process is a known entity.Hospitals, on the other hand, are unpredictable. There aresome mechanized activities in a hospital environment(medication administration and food delivery, for example),but their success cannot be realized without an understandingof the human element in the process. The onlyway to work in a hospital environment is to concentrate onrelationships and how everyone interacts. While engineeringefficiencies are important to our design, creating anenvironment where we can build good relationships withquality caretakers while learning from our mistakes and theexperience of others is equally as critical.”Make Rooms Functional,But Not at Expense of PatientRecognizing that the hospital setting is a complex seriesof communications and relationships, space is designedto anticipate how these communications occur and howthe entities relate. At Clarian, patient rooms are all-privateand considerably larger than the industry standard,measuring 320 square feet including the bathrooms.The space includes a work zone for staff and a patientarea with a flat-screen TV and refrigerator built intothe casework. Headwalls have been placed to givepatients a convenient view of the outdoors through thefloor-to-ceiling windows. There also is a nursing alcovebetween every two rooms.In addition, technology has been assimilated into theroom unobtrusively at Clarian West. Computers andmonitors are carefully placed for both patient andstaff convenience, and the support/supply functionsare hidden behind doors. Physicians and nurses canwork comfortably without necessarily having to standand can easily engage in conversations. There is an“onstage/offstage” approach in corridor and roomplanning so that patients and families do not seeequipment and supplies being wheeled around.Sophisticated communication devices eliminate pagingand other intrusions. “We try to put the intensework involved in delivering healthcare out of sightand out of mind,” says Gatmaitan.Advocate Lutheran also will divide its rooms intospecific spaces that have different purposes. “We willhave a family zone, patient zone and staff zone tomeet the needs of each group,” says Barthel. “Staff hasconvenient access to medical equipment and suppliesthat are out of sight of the patients. Medications willbe locked in the room, eliminating the need for nursesto go somewhere else to get them. We believe that thisefficiency will reduce medication error opportunity.”These features will help the hospital to meet one ofits guiding principles—enhanced operational effectivenessand efficiencies. To meet this goal, they alsowill include a universal floor plate, standardized roomlayout, PCs in each room for electronic medicalrecords documentation, nurse servers, decentralizednurses stations, cross corridors to ease access, floors24Reprinted fromHealthcare ExecutiveJULY/AUG 2007ache.org

The Marriage of Form and Function: Creating a Healing Environmentdivided into modules, maintained line of sight, residentsleep rooms, positive and negative airflow rooms, andbariatric rooms.Keep Staff Morale in MindBoth institutions include special, out of the way places forstaff to “decompress.” At ALGH, floors will have atranquility room for staff in each unit with a recliner,soft music and turn-down lights. They have such a spacein their existing hospital and found that it is a significanthelp in lifting staff morale. Clarian West also has foundthat it is important in reducing employee stress levels.Remember the FamilyAt Clarian West, families who have a loved one in surgeryare not tied to a designated surgery waiting room for theduration of the procedure, which can sometimes last severalhours. Instead, they may choose to use a hospitality pager,which gives them the freedom to visit a variety of smallwaiting areas throughout the building, take a stroll throughan outdoor garden or stop by the café for coffee and a biteto eat by the fireplace—all without the fear and stressthat they might miss an opportunity for an updatefrom a nurse or surgeon.Don’t Forget About SafetyAs safety concerns are a key issue in the hospital environment,ALGH has given a great deal of thought to safetymeasures—from ensuring the physical safety of patients andstaff to encompassing safety precautions in patient care. Forexample, access to patients and staff will be limited to predesignatedfamily and friends to help protect individualsfrom potentially dangerous situations. Patient bathroomswill include handrails and wheelchair accessible showers tohelp prevent falls. Besides reducing fall risk, AdvocateLutheran also has committed to several additional safetygoals, including procedures for patient identification, communicationeffectiveness between caregivers, medicationsafety, nosocomial infection reduction and hand hygiene.OutcomesNow in its third year of operation, Clarian West’s newbuilding has been a tremendous success. The institutionhas made its financial targets, while embracing new designsand technology. More importantly, surveys during the lastfour quarters have shown a strong positive response fromstakeholders. When asked if patients would recommendClarian West, the institution has scored consistently in thetop 25 percent, and it was in the top 10 percent forNRC+PICKER scores for inpatient care.Clarian West has gone four quarters without a significantmedication error in adult inpatient care and inthe ICU. Hospital-wide, it has experienced a rate ofone per 125,000 doses and improving.In addition, employee satisfaction is high, with a top10 percent score in a staff perception survey. Ninetythreepercent of employees believe that the hospitalinvests in their future, and 95 percent say ClarianWest is a great place to work. These figures areespecially critical, as the organization does not usea recruitment firm. They are not the leader in pay,yet staff referral is the top source of new hires.For Gatmaitan, these positive outcomes are not asurprise. “We don’t think that we have just beenlucky,” he says. “We found a perfect combinationof technology, environment and relationships thathave proven to be effective. We tell this story in ournew employee orientation to help reinforce ourorganizational culture and the application of theconcepts of science and engineering to the humanityof the work that we do. The risk of error exists. Wedon’t hide our mistakes; we encourage staff to usethem as a teaching experience.”ALGH has been making great strides in its efforts to achieveLeadership in Energy and Environmental Design (LEED)26Reprinted fromHealthcare ExecutiveJULY/AUG 2007ache.org

certification on this project. It is one of a few hospitals inthe Midwest to pursue this goal, which focuses on thesustainability and renewability of the environment throughthe use of renewable resources and incorporation of themany healing aspects of the design.The hospital has been receiving positive responses tothe plans of its new facility. It has created mock roomsfor evaluation; and these full-size renditions of thenew ICU and general care rooms allow all staff—fromhousekeepers to physicians—to provide input via surveys.Former patients and their families have touredthe mock rooms and have been asked for their opinions.Reaching out to the “customers” has provided keysuggestions to the design staff, and it has endeared thecommunity to ALGH as it shows it truly cares whatits constituents think.From Barthel’s point of view, it makes good sense to bringpatients into the process. “One of the patients we consultedwas wheelchair bound and significantly visually impaired,”she says. “His suggestions on issues regarding distance,sound and accessibility were critical, as we would have neverthought of them on our own. We simply did not have hisexperiences in life to come up with these ideas.” Patientfeedback, along with staff input, has allowed Barthel andher team to make changes throughout the design process.For both organizations, design and function have beeninterlinked to create an atmosphere that inspires staffand promotes healing. And they feel that any additionalcost for construction is an investment into thefuture of their organizations. As Gatmaitan says, “Froma business standpoint, we believe that the incremental costfor implementing a design like this—and it can be fairlysignificant, as much as 10 percent to 15 percentmore—will be amortized to virtual nonexistence over theanticipated life of the building and have a minimalimpact on an annual income statement. Then there arecost savings that occur when incidence of falls andinfection are reduced. But more importantly, we anticipateimproved revenues from enhanced referrals andreduced cost for staff recruitment and retention. It is awin-win situation.”Bonnie K. Litch is a freelance writer based in Northbrook, Ill.Pebble Project UpdateThe construction of Clarian West Medical Center was not the first timethat Clarian Health Partners had dipped into design experimentation.The organization signed on to become one of the first Pebble Projectswhen it created a new cardiac care unit several years ago. The PebbleProject, an enterprise to implement and test elements of a healing environment,is the brainchild of the Center for Health Design (CHD). CHD is aresearch and advocacy organization of healthcare and design professionalswho want to improve the quality of healthcare through building architectureand design. Launched in 2000, there are currently 37 projects across the countryat this time. For more information, visit www.healthdesign.org/research/pebble.Reprinted from 27Healthcare ExecutiveJULY/AUG 2007ache.org