Kerianne Graham

Kerianne Graham

Architect, NBBJ
Kerianne Graham, a healthcare architect at NBBJ, has worked on projects for some of Boston’s and New York’s most well-known institutions, including Massachusetts General Hospital, Brigham and Women’s Hospital, Faulkner Hospital and NYU Langone Medical Center. Although her career in healthcare design began largely accidentally, her passion for it grows with every project. When she is not expanding her knowledge of the industry, she spends her time outdoors — and learning the New York subway — with her pitbull Dolce.

When Facing a Pandemic, Consider Patient Isolation at Four Scales

How the Coronavirus Outbreak Should Change the Way We Think About Designing for Isolation

March 26, 2020

Architect, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post was co-authored by Kerianne Graham and Sarah Markovitz.

 

Right now hospitals across the country are working hard on creative solutions to increase capacity and prepare for a surge patients — or address the surges that have already happened. Recent outbreaks of SARS, MERS, Ebola and other viruses indicate that, especially with the growth of world travel, the likelihood of these pandemics increasing is becoming a greater possibility.

To create a well-functioning hospital that has the flexibility to care for surges of infectious patients, while protecting other patients and staff, we have to think bigger than the patient room. As hospitals seek to manage COVID-19 in the short term, many are currently in the process of building new facilities focused on the long term. Regardless of where a healthcare system’s facilities are in their life cycle, it’s important to think of isolation at multiple scales:

1. The Room
Standard hospital design includes a provision for isolating infectious patients within a select number of individual rooms per unit, with dedicated mechanical systems, anterooms and the ability to create negative air pressure to protect the rest of the hospital from airborne infections within the room. On top of this, design that puts additional focus on infection prevention includes strategies to eliminate pathogens, reduce touch and improve personal protection compliance.

2. The Unit or Floor
Planned isolation rooms typically only account for a handful of the total rooms on a patient floor and are not typically cohorted, or grouped together. As we’ve learned from previous outbreaks — and are further understanding from the current one — increased demands for isolation may include the need to cluster a population of patients and further protect staff. To make this possible, spaces should be thought of with the ability to close off a full portion of a unit or even a full floor by negatively pressurizing the whole area. By creating a sub-unit or floor dedicated to the care of patients with infectious disease we can heighten staff awareness and precautions, limit access to only the very few people who are needed to care for the patients, increase the efficiency of staff overseeing this special population and decrease the cost of the HVAC system by consolidating it in a limited area.

3. The Building
Flexibility at the scale of an entire hospital building can also help control infection. Consider alternative places for triage to protect other patients and staff; for instance, enclosed ambulance entry courts could feature exterior plumbing and electrical hookups so the hospital can build a temporary, tent-like structure with separate, protected pathways: one for staff to enter and don protective gear, and another for patients to enter and exit to wherever they will receive care. Spaces such as recovery rooms (PACUs), emergency department (ED) sub-units and observation units can be adapted to accommodate more standard patient care — as long as headwalls are designed to accommodate surge capacity — so that the ICUs and patient floors that can be switched to negative pressure can remain available for care of infectious patients.

4. The Network
Finally, for healthcare systems that have multiple hospitals and greater resources, what if one building (or multiple buildings) could be designated the center at which to isolate a patient type — coronavirus patients, for instance — and allow other sites to remain open for the general population? Steward Health Care in Boston is doing this by converting its 159-bed community hospital in Dorchester to focus only on COVID-19. Planning for these full-building conversions allows a system to keep the most at-risk patients in the safest, most appropriate healthcare environment.

Planning and designing with these scales in mind can help give a healthcare system the flexibility it needs to function not only during the day-to-day, but also during unpredictable and rapidly-changing events when patient care is most critical.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Sean Airhart/NBBJ.

Share this:  envelope facebook twitter googleplus tumblr linkedin
Comment Follow nbbX

Four Factors Driving Healthcare Interior Design

How to Ensure Healthcare Interiors Contribute to a Healing Environment

January 6, 2020

Architect, NBBJ

Editor’s Note: This post was co-authored by Kerianne Graham and Edwin Beltran. It was originally published in Building Operating Management.

In healthcare, interior design has moved beyond just materials to consider elements like wayfinding, biophilia, natural light, and more. Even more important, however, is to think about how those elements combine to create a healing experience for patients, visitors, and staff. That experience is driven most by four factors — people, process, place, and technology — all of which have an impact on interior design.

At the Palo Alto Medical Foundation San Carlos Center, drought-resistant plants suited for the California climate reduce the need for artificial irrigation while connecting with people’s innate love for nature.

 

1. People

An outstanding experience is one that uniquely responds to the physical, cognitive, and emotional needs of the diverse population of users who experience a space, which, in a healthcare environment, typically means patients, family, and staff. Healthcare environments should address those needs in a way that is supportive, enabling, inspiring, and dignifying.

One way for interior design to improve the experience for patients and their families is to reduce the anxiety of the unknown. First impressions matter. An appropriate space of arrival, like an atrium or lobby, that considers the needs of key populations, can help people feel welcome and navigate clearly. For instance, at the new replacement hospital for the Southeastern Louisiana Veterans Health Care System, research showed that many Louisiana Veteran patients would be traveling great distances to the hospital, so the designers located necessary amenities like bathrooms prominently near the front door.

Arrival spaces can extend beyond the lobby, too. In the Lunder Building at Massachusetts General Hospital, a sixth-floor atrium welcomes patients and visitors to the patient floors with comfortable furniture, abundant daylight, and plantings.

Spaces like this also help patients and their families establish a positive routine, especially for those, like oncology patients, who may visit the hospital frequently. Welcoming, easy-to-find areas like the café, chapel, and garden space can help to shift a person’s focus away from treatment.

And don’t forget about staff. Studies show that caregiver satisfaction is directly correlated to patient recovery times, so ensuring the physical and mental wellbeing of the care team translates directly into improved medical outcomes. One solution, simple in concept but difficult in execution, is to bring daylight deep into the “backstage” areas of a hospital, such as patient-floor corridors or even the sterile clinical zones where caregivers spend much of their day.

Private staff space is also important, especially for behavioral health providers, social workers, and case managers — really, anyone who might deliver bad news or work with critical patients — who may often need to recenter themselves after a stressful situation. And because staff are more likely to use spaces that are out of view of patients and families, it is critical to provide separate, more private places of respite. These spaces can resemble “mothers’ rooms,” with comfortable movable furniture, soft materials, a calming color palette, and dimmable lighting. They can also be outdoor, landscaped spaces which rely on nature to provide a sense of calm, as at the new Big Lots Pavilion for behavioral health at Nationwide Children’s Hospital.

What’s more, the caregiver experience can be improved by connecting staff — and their patients — to the organization’s mission of care. Nationwide Children’s accomplishes this with brand standards that employ video throughout the hospital depicting staff talking about their experiences, their passions, and their purpose.

 

2. Process

While process improvements aren’t often considered an interior design issue, every process change has a design implication. Every provider seeks an efficient care model that supports business goals and positive patient outcomes, but those processes must always focus on creating an outstanding, personalized experience for patients and their families.

Consider the waiting experience. Typically patients sit in the waiting room, staring at the door where nurses emerge, waiting for their name to be called, getting more and more anxious. Simply reconfiguring the seating so patients aren’t staring at the door can make a big difference. While many institutions are working to reduce typical wait times, patients still need places to rest between the stages of their visit, and families will still experience waiting if they’re not accompanying the patient to the treatment space.

For even greater impact, consider activity-based waiting. Like activity-based workplaces, this means giving people options: the option to socialize, to work, or to retreat in private. This can be achieved with different types and groupings of furniture, with a range of spaces from quiet to active, and with access to food and drink. Waiting time doesn’t have to be wasted time — waiting time can allow people to be productive, educated, entertained, or simply together.

Providing options also transforms a patient’s experience of his or her room and creates a sense of normalcy. Like the waiting area, patient rooms can be designed to support a variety of modes, from rest, to socialization, to work, to meals and more. A recent patient room concept, inspired by micro-apartment design, aimed to do just that, with fold-down tables and retractable sleeping platforms so patients and families can work, socialize over a meal, or visit overnight.

Some of these concepts made it into the design of the Fetal Care Center at Nicklaus Children’s Hospital, where the millwork in labor and delivery rooms includes an integrated fold-down table, so new a mother can enjoy breakfast the next day with her newborn and her partner. Other recent projects are installing mini-fridges and microwaves so patients can save food for when they’re ready to eat, or so their families can bring homemade meals to share in the hospital.

Even when integrated furniture isn’t possible for spatial or budgetary reasons, flexibility can also be provided with moveable furniture so visitors can reconfigure the room to look at the patient, the physician, or even just out the window.

 

3. Place 

An outstanding experience is created by leveraging the physical qualities of an environment to project a distinctive identity that embodies and reflects the aspirational qualities of your brand. It is a place that visually communicates your mission, culture, and values while spatially promoting, supporting, and enabling the behaviors and actions associated with those broader goals.

Interior design can also put patients at ease by connecting them to the place where they live and by giving them a sense of belonging, either with architecture that evokes the vernacular traditions of an area, or with design elements that reference local history and culture. Throughout University Medical Center in New Orleans, for instance, custom design touches pay homage to the ornamentation and rich heritage of New Orleans, from environmental graphics with historic motifs and city scenes, to the large courtyards that reference the vernacular architecture of courtyard homes in the French Quarter. These features help patients not only feel at home, but also navigate the large campus.

Another recent example is the expansion of Swedish Medical Center in Edmonds, Wash. Here, design features celebrate Edmonds’ logging heritage, with 250-year-old boom logs that greet visitors in the lobby and salvaged wood integrated into the landscapes. The architecture also references the region’s glacial past, with striated metal panels that evoke geological strata.

Landscape is another essential element of place. Native plantings take biophilia to the next level, by connecting not only with humans’ innate love for nature in general, but for their love of the everyday natural world in which they live. It is also inherently sustainable — at the Palo Alto Medical Foundation San Carlos Center, for example, drought-resistant plants suited for the California climate reduce the need for artificial irrigation.

 

4. Technology

Finally, the healthcare experience — like so many other things — is being transformed by technology. Technology enables people to become more active participants in their own care, and those who do so are likely to have improved health behaviors, positive care outcomes, and enjoyable care experiences. Simple engagement tools such as personal tablets and self check-in kiosks are already well-established in many settings, but the opportunities for deploying technology throughout the care experience are expanding rapidly.

One important role of technology is to strengthen communication between patients and caregivers. This can be accomplished with telemedicine — remote consultations with care providers — patient tracking systems, patient portals, and, in the not-too-distant future, medical-grade wearable devices. Telehealth systems can also improve communications between caregivers themselves, especially among distributed care teams.

Another important goal is transparency and information sharing, to ease patients’ anxiety by keeping them informed about where they are in the process. As artificial intelligence becomes more sophisticated at understanding our daily patterns, it can be used to remind people of their upcoming medical appointments. Virtual concierges can be used to check people in remotely and guide them to their hospital destination. Real-time location systems can the track patients throughout their healthcare journey, much like airplane check-in apps that text travelers updates on their flight status.

Real-time location systems also make it possible to reduce the size of waiting rooms and convert that space to variable, flexible environments that take activity-based waiting to a whole new level, providing freedom and choice for patients and staff. Thanks to technology, waiting doesn’t even have to be in the hospital at all — waiting can happen anywhere, and patients can receive the same level of service they’ve come to expect.

Real-time location systems apply to supplies as well, making it possible to implement just-in-time inventory, which reduces the amount of space needed on patient floors for storage. What can that space become? The possibilities for improving the experience for patients and staff are almost limitless.

Not all technological advancements may affect interior design directly, but they will affect operations, and as operations change, they will free up new opportunities for design.

 

On Beauty 

Neuroscience research has shown that the human brain reacts to beauty — that is, to spaces in which form, proportion, volume, light, materiality, landscape, and other sensory aspects are balanced and working in tandem. Our attention changes in environments that are diverse and dynamic and surprising. Around things it perceives as beautiful, the brain calms, and stress — measured in cortisol levels — decreases. Most people cannot explain why they react the way they do, but they definitely perceive it.

To cite just one example, the landscape at the Neuroscience Center at Riverside Methodist Hospital in Columbus, Ohio, is designed to store stormwater runoff while enhancing the lobby experience and campus grounds. Water flows from the roof into a series of illuminated, architectural concrete weirs, then into a basin where it is retained and filtered by wetland plants — selected for scale, texture, seasonal color, and ease of maintenance — before passing into the campus’ drainage system. The resulting landscape is beautiful, functional and — judging by the visitors who crowd the lobby windows during storms to watch it in action — even dramatic.

What’s more, beauty should be democratic. When people are in beautiful spaces, they feel better about themselves. Beauty shapes a person’s entire experience, and nowhere is this more important than in healthcare. By considering the people you’re designing for, the processes and behaviors you want to encourage, the unique qualities of the places where people live and work, and the ways in which technology can advance not only medical care but also the human experience, we can create truly transformative healthcare environments that help people live and work their best.

Banner image courtesy Bruce Damonte/NBBJ.

Share this:  envelope facebook twitter googleplus tumblr linkedin
Comment Follow nbbX

In a Virtual Age, Physical Connection Still Matters — Especially During a Hospital Stay

The Inpatient Room of the Future Must Appeal to Baby Boomers and Millennials Alike. Here's How It Can.

February 8, 2017

Architect, NBBJ

Editor’s Note: At NBBJ, we’re at the forefront of using research and technology to drive breakthroughs in healthcare, from streamlining the design process with virtual reality, to incorporating digital analytics in healthcare planning. At the same time, we know technology isn’t the only tool for solving healthcare challenges — after all, studies show the most effective care occurs when caregivers themselves are satisfied.

This week, we’re highlighting some of the human factors that must be paired with data and technology in order to bring healthcare into the future. This article was originally posted by Becker’s Hospital Review. It was co-authored by Kerianne Graham and Ryan Hullinger.

 

Demographic changes are pulling healthcare in contradictory directions. Millennial patients, born into a mobile world, are driving investments in telemedicine, on-demand services and dispersed ambulatory care. Yet an aging population of baby boomers will soon require more acute and inpatient settings. Given these conflicting demands, what can institutions do to meet the needs of both demographics? And how do these needs specifically inform the design of the inpatient room?

In proposing a solution, we first need to understand who these patients are, what they value and how they lead their lives. First, the differences: the two generations are at unique stages in life, have different health needs, have different relationships with technology, and while one group is exiting the workforce, the other is entering it for the first time. But interestingly, the two generations have more in common than might be expected. Both are at critical points in their lifetimes, and both generations are cost conscious, socially minded and value family relationships.

Boomer-Millennial-Chart

 

When members of these generations require a hospital stay, they want to remain connected — to their families, to their work, to their care providers, to anything and everything outside the walls of their hospital room. These days, in-room connectivity is more than an amenity. It is a care imperative. It ties patients and families to their broader support network at a time when they need it most. Additionally, both generations want to understand the value of their care and be able to tie their choices to that value. They want technology to work for them, to improve how they are cared for and the outcomes of that care. And perhaps most importantly, they want to be able to involve their family members in their care.

At the same time, many providers operate within extremely tight cost and space constraints and need to do more with less. In order to resolve this tension, we took a page from the “micro apartment” movement when considering how to design a hospital room that will meet the expectations of both boomer and millennial patients. Like a micro apartment, our patient room design economizes space and maximizes flexibility. It can be reconfigured by the family or staff throughout the day to support consultations, plug-in time for working, dinners with family, sleep and, of course, use of technology.

Consultations
This setup resembles the most typical use of a patient room, and is meant to provide a space where the patient, family and providers — both present and remote — can connect as an integrated care team.

Work+Relaxation-web

Plug-in
We all have different activities that are important to us or help us relax, and we need time and a place in which to do them. Providing a space for patients or family members to stay connected to their work, social networks and entertainment helps them return more quickly to their routines.


Dining
Meals together have always been celebrated as a unique opportunity for providing comfort and encouragement to loved ones. Creating a way for visiting family members to share meals in the room rather than leaving for the cafeteria allows their time to be less fragmented and more normalized and supportive. Plus it reduces the abandonment concerns that trouble many family members (especially parents) who feel like they can’t afford to leave the patient/s side.

Dinner-web

Bedtime-web

Sleep
While it is not new to provide family members with a pull-out chair or couch, their ability to stay overnight and get real rest is often limited by space. Using a full size Murphy bed gives family members a more comfortable space in which to spend the night, rest well and wake up better prepared to support their loved ones the next day.

Consult-web

Technology
Present throughout the patient’s stay, technologies that are both visual and non-visual enhance experience and support better outcomes. Visual technologies — such as a video screen and camera — allow for telemedicine consults with an outside or remote provider; they can also display the patient’s stats, care plan, food and nutrition and can help them better engage in their own care. Invisible technologies — such as sensors embedded in the room — can track any number of vital statistics, deliver medications or supplies and take unnecessary burdens off of staff so they can work at top of license. All of the panels in the wall system are rail-based and demountable to easily support repair and upgrades as technology evolves.

For addressing infection control, UV disinfection technology could be built into the system to clean the surfaces between uses. And while this proposal entails a moderate cost increase, we believe that the increased family engagement that that the system promotes can accelerate healing, reduce average length of stay and decrease costs in the long run.

Whether we’re designing for millennials, baby boomers or the generations that surround them, increasing the value of care through increased involvement of patients and their families is a concept that everyone can benefit from. It’s clear that the future of healthcare is about choice and value, and healthcare design needs to rise to that challenge.

Kerianne Graham and Ryan Hullinger are leaders in NBBJ’s healthcare practice, an architecture firm that designs hospitals and clinics for 11 of the 15 U.S. News & World Report Honor Roll Hospitals, including Massachusetts General Hospital, NYU Langone Medical Center, and Brigham and Women’s Hospital.

Banner image courtesy of Pixabay.

Share this:  envelope facebook twitter googleplus tumblr linkedin
Comment Follow nbbX

Hospital Rooms Should Stop Making People Sick

Three Strategies for Reducing Healthcare-Associated Infections

February 18, 2016

Architect, NBBJ

Editor’s Note: This post was co-authored by Kerianne Graham and Sarah Markovitz. An expanded version appeared in Becker’s Hospital Review.

According to the Centers for Disease Control and Prevention (CDC), about 1 in 25 hospital patients have a Healthcare-Acquired Infection (HAI) — that is, an infection that develops as a result of medical care — on any given day, and in 2011 an estimated 75,000 patients with HAIs died during hospitalization. Treatment for these infections has led to annual costs of between $28 and $45 billion, and with changing pay-for-performance penalties, their impact on a hospital’s bottom line will only increase.

Whether you work in a hospital environment, parallel to it, or only engage with it when you or a loved one falls ill, chances are each of us will be somehow affected by an HAI, which is why our awareness of the issue at hand is critical.

Although tracking the initial cause of an HAI can be difficult, studies have identified the leading causes, starting with human behavior and compliance: the CDC identifies hand-washing as “the single most important method to prevent hospital infections.” Hand-washing alone, however, cannot eliminate HAIs completely, because contact with bacteria-laden objects and surfaces can lead to re-contamination, and we’ve learned from more than one institution that turn-over time for cleaning is a major challenge.

It has became clear that eliminating HAIs requires a “systems” approach, with multiple interventions in the design and function of hospitals and clinics. As architects, we recommend our clients take three approaches to make a difference: reduce the number of high-touch surfaces, eliminate potential host surfaces for pathogens, and increase compliance of medical personnel.

FINAL BOARD 24 x 36 - nbbX edit2

Reduce Touch

Approximately 20-40% of HAIs are the result of infection transferred by human touch. Therefore, we suggest reducing the times that staff interact with unnecessary objects before caring for the patient. We turned to the CDC’s list of high-touch surfaces to rethink how staff interact with these objects. Some suggestions can be simply implemented, like trading doorknobs with wave sensors (#1), installing touch-free faucets and hand dryers (#2) and built-in, closed bedpan washers (#3).

Other suggestions require more operational changes: using room-specific, UV-sanitized tablets (#4) for documentation or as controllers for anything from lights to temperature. Still other solutions may seem counterintuitive, such as duplicating the overbed table (#5) — an additional surface is introduced, but it allows for separation of staff and patient surfaces — or storage alcoves where equipment can be stored until needed (#6).

FINAL BOARD 24 x 36 - nbbX edit2

Eliminate Pathogens / Hosts

Microbes are everywhere, but reducing the number of host sites can reduce the chance of infection. For instance, replacing cubicle curtains with electrochromatic “smart glass” (#7) removes an element that can harbor microbes easily passed by contact transmission.

The room layout also makes a difference; inboard bathrooms, by keeping humidity away from cold exterior walls, reduce the likelihood of condensation and mold (#8). The exterior also walls should include appropriate vapor barriers and insulation (#9).

Finally, if we keep harmful microbes out of the patient environment, we can worry less about how we remove them. An average of 421,000 units of bacteria are tracked in on the outside surface of each shoe, including E. coli, which indicates contact with fecal matter; shoe cover dispensers are a simple solution (#10).

FINAL BOARD 24 x 36 - nbbX edit2

Increase Compliance

None of these features matter, however, without the cooperation of clinical staff. To make it easier for staff to follow hand hygiene and infection prevention guidelines, the environment should be optimized with strategic, easily accessible locations for such seemingly simple elements as sanitizer dispensers, masks, gloves, shoe covers, sharps containers, garbage receptacles and contaminated supply disposal units (#11), along with automatic hand washers and dryers at the entry (#12).

Where low-tech solutions aren’t enough, RFID technology can be used for immediate feedback and compliance reports, (though some worry about the “big brother” aspect), and when paired with color-changing LED lighting can provide an indicator and record of hand-washing (#13). Low-tech and high-tech strategies alike, however, require the involvement and buy-in of the staff.

 

Conclusion

HAIs have no simple solution. Product representatives and architects alike must prove that their solutions will do more good than harm, and the quantity of evidence needed to declare something safe is much greater than the evidence needed to declare it poses an unnecessary risk. For instance, a well-known U.S. institution recently banned antimicrobial additives from surfaces in its facilities because the known risk from harmful chemicals outweighed the promised rewards in infection prevention.

With limited scientific proof, and limited existing regulations, it’s vital that we continue with this research to better protect healthcare patients. HAIs may never be eliminated completely, but with careful design, we can build much healthier and safer environments.

Banner image courtesy of COD Newsroom/Flickr.

All other images courtesy Pablo Licari/NBBJ.

Share this:  envelope facebook twitter googleplus tumblr linkedin
Comment Follow nbbX

Follow nbbX