Health Care Facilities  

Overview

"We shape our buildings and afterwards our buildings shape us..."
Winston Churchill (May 10, 1941)

Health care facilities encompass a wide range of types, from small and relatively simple medical clinics to large, complex, and costly, teaching and research hospitals. Large hospitals centers may include all the various subsidiary health care types that are often independent facilities. The old expression, "You never get a second chance to make a good first impression" applies to health care facilities. The facility conveys a message to patients, visitors, volunteers, vendors, and staff. The facility also communicates a torrent of clues about the organization and the medical care being provided there. The clues start at the approach to the facility, the drop-off area, the parking lots, and the street signs. Ideally, that message is one that conveys welcoming, caring, comfort, and compassion, commitment to patient well-being and safety, where stress is relieved, refuge is provided, respect is reciprocated, competence is symbolized, way-finding is facilitated, and families are accommodated. The facility also influences employee service attitudes and behaviors. Finishes, signage, and artwork must be carefully selected, well coordinated, and integrated. Security can be balanced with some features apparent to patients/visitors, while conveying a message of safety. Thoughtful design can help ensure the proper first impression is created and sustained.

VA Medical Center, Dallas, Texas

The design of health care facilities is governed by many regulations and technical requirements. It is also affected by many less defined needs and pressures. The most pressing of these are workforce shortages, reimbursements, malpractice insurance, physician-hospital relations, capacity, care for the uninsured, patient safety, advances in technology, and patient satisfaction per a recent American College of Healthcare Executives survey of hospital CEOs.

The entire health care system is under great pressure to reduce costs, and at the same time, be more responsive to "customers". The aging are the heaviest users of health care services, and the percentage of the aging in our population is increasing significantly. At the same time, rapid technological advances, often involving very sophisticated techniques and equipment, make more diagnostic and treatment procedures available. The consequent increase in health care costs is not easily accommodated. Designers find increasing focus on limiting both construction costs and the costs of their design services, while compressing construction schedules and still meeting the highest quality standards.

As cost pressures increase, health care facilities find themselves in increasing competition for both patients and staff. Architecture is often recognized as an important tool in attracting and retaining the best doctors and nurses, the most successful HMOs and insurance plans, and the most patients. Consumer decisions are based on cost, accessibility, quality of service, and quality of medical care. An aesthetically pleasing facility is a key aspect of the perceived quality of care.

Health care is a labor-intensive industry, and much of that labor is highly skilled and highly paid. Since 60 to 75% of hospital expenses are labor costs, a design that increases operational productivity or efficiency and reduces staffing needs can have a major impact on the bottom line. (Don Blair, then at Perkins + Will, estimated that the cost of one full-time staff person is equivalent to the debt service on $1 million of borrowing per Architectural Record of May 1997.) Likewise, operations and maintenance costs over the typical 50-year life cycle of a hospital contribute up to 80% to the equation, so anything designers can do to facilitate maintenance and reduce total life-cycle cost will have tremendous returns on a relatively small up-front investment. (Source: Federal Facilities Council.)

Flexibility must be a basic feature of any new health care facility to keep it from rapid obsolescence in the face of changing needs and technologies. Health care facility needs are evolving rapidly, and the direction of that evolution is difficult to forecast with any certainty. New equipment technologies, new treatment methodologies, changes in diseases, and changes in the patient population base all impact the facilities that house them. Inpatient care is steadily being reduced while outpatient services are growing. There is increasing emphasis on special-care units and smaller satellite facilities rather than large, centralized facilities.

In the past, communicable diseases were the major health problem, and sanitation or cleanliness was the main characteristic of a healing or therapeutic environment. Cleanliness remains extremely important, but there is increasing recognition of the value of a pleasant, easily-understood, and non-threatening environment for patient recovery. For example, the Planetree Hospital philosophy of "demystifying medicine" emphasizes such a physical environment as part of its approach. Good design in the health care setting starts by recognizing the basic functional needs, but does not end there-it must also meet the emotional needs of those who use such facilities at times of uncertainty, dependency, and stress.

The Health Insurance Portability and Accessibility Act of 1996 (HIPAA) regulations address security and privacy of "protected health information" (PHI). These regulations put emphasis on acoustic and visual privacy. While HIPAA does not regulate facilities design, its implications for healthcare facilities may affect location and layout of workstations that handle medical records and other patient information, paper and electronic, as well as patient accommodations.

There is a noticeable movement from hospital-based acute care to outpatient care, and toward a more holistic, preventative, and continuous care of health and wellness.

Sustainability must be a consideration for the design of all health care facilities. Many sustainable design features can be incorporated into health care facility design, including daylighting, energy and water conservation, nontoxic materials and finishes, and sustainable operations and maintenance. Health care facility energy and water conservation standards must meet Energy Policy Act of 2005 (EPACT) and Executive Order 13693 requirements. The Energy Independence and Security Act of 2007 provides additional requirements for energy conservation.

Emerging Issues

There is an increasing emphasis on security, especially in large public facilities, and the need to balance this with the desired openness to patients and visitors.

Evidence-based design. According to the Center for Health Design, "Evidence-Based Design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes. Evidence-based health-care architecture creates safe and therapeutic environments for patient care and encourages family involvement. It promotes efficient staff performance and is restorative for workers under stress. These designs ultimately should improve the organization's clinical, economic, productivity, satisfaction, and cultural measures."

Classification

A trend towards specialization has resulted in a growing number of health care types. Among them are hospitals, nursing homes, outpatient facilities, psychiatric facilities, rehabilitation facilities, hospices, assisted living facilities, congregate housing, adult day care facilities, and various specialized outpatient facilities. The WBDG currently includes sections on the following four specific building types:

• Hospital
• Nursing Home, including Alzheimer's Related Dementia (ARD) units
• Outpatient Clinic, including the specialized diagnostic and treatment areas which may be stand-alone facilities
• Psychiatric Facility, including psychiatric hospitals

Relevant Codes and Standards

Federal Mandates and Criteria

• Executive Order 13693, "Planning for Federal Sustainability in the Next Decade"
• UFC 4-510-01 Design: Military Medical Facilities

Additional Resources

Websites

• AIA Academy of Architecture for Health (AAH) — Contains AAH newsletters, reports, and other documents related to health care design.
• American Hospital Association — Information generally focused on financial and organizational issues, but includes good data on health care statistics and other resources.
• American Society for Healthcare Engineering (ASHE) — An advocate for continuous improvement in the health care engineering and facilities management professions. Contains a Therapeutic Environments Forum with excellent information and sponsors an annual conference on planning, design, and construction.
• American Society of Interior Designers — The first centralized clearinghouse for design and human behavior research on the Web.
• The Center for Health Design — An extensive site focusing on health care facility design.
• Green Guide for Health Care™ — A best practices guide for healthy and sustainable building design, construction, and operations for the healthcare industry.
• The Joint Commission — Has some facility related information, though it is largely concerned with operational issues.
• Practice Greenhealth — The nation's leading membership and networking organization for institutions in the healthcare community that have made a commitment to sustainable, eco-friendly practices.
• Society for the Arts in Healthcare (SAH) — National and international advocacy group for the integration of the arts into the healing health care environment.
• USGBC Leadership in Energy and Environmental Design (LEED) for Healthcare
• VA Office of Construction & Facilities Management (CFM) Technical Information Library — Includes manuals, guides, and other standards covering all aspects of health care facility design.

Publications

• Architectural Record — Monthly journal with a building types study section focusing on health care design every year or so. Online archives include many more projects than those that appear in the printed magazine.
• Building Type Basics for Healthcare Facilities, 2nd Edition by Richard L. Kobus, Ronald L. Skaggs, Michael Bobrow, Julia Thomas, Thomas M. Payette, Stephen A. Kliment. New York: John Wily & Sons, Inc., 2008.
• Design That Cares: Planning Health Facilities for Patients and Visitors, 3rd Edition by Janet R. Carpman, Myron A. Grant. New York: John Wiley & Sons, Inc., 2016.
• Guidelines for the Design and Construction of Health Care Facilities by the Facility Guidelines Institute, 2014.
• Healthcare Architecture in an Era of Radical Transformations by Stephen Verderber and David Fine. Yale University Press, 2000.
• Healthcare Design — A quarterly magazine with design articles and presentations of recent projects.
• Hospitals and Health Networks — A monthly journal of the American Hospital Association. Includes occasional articles on construction.
• Innovations in Healthcare Design: Selected Presentations from the First Five Symposia on Healthcare Design ed. Sara Marberry. New York: John Wiley & Sons, Inc., 1995.
• Journal of Healthcare Design: Volumes I-X — Published from 1988-1997, contains presentations at the annual symposium on Health Care Design.
• Modern Healthcare — A weekly journal for health care executives with frequent articles on design and construction and an annual design awards program. Online articles from 1994.
• Sound & Vibration: Design Guidelines for Health Care Facilities by the Acoustics Research Council. 2010.
• Sustainable Federal Facilities: A Guide to Integrating Value Engineering, Life-cycle Costing, and Sustainable Development by the Federal Facilities Council. Washington, DC: National Academy Press, 2001.
• Time-Saver Standards for Building Types, 4th Edition by Joseph De Chiara and Michael J. Crosbie. New York: McGraw-Hill, 2001.

Others

• Building Research Information Knowledgebase (BRIK) Healthcare Facilities — an interactive portal offering online access to peer-reviewed research projects and case studies in all facets of building, from predesign, design, and construction through occupancy and reuse.