Teri Oelrich

Teri Oelrich

Partner, NBBJ
Teri Oelrich, RN, BSN, MBA, joined NBBJ as one of the first-ever clinicians to work for an architecture firm. Now with more than two decades of experience in clinical practice and healthcare design, she is a partner leading the firm's healthcare practice on the West Coast.

Many Rural Hospitals Are Not Prepared For COVID-19 Surge. Here’s How They Can Be.

Five Design and Planning Strategies Will Be Critical to Adapting to the Pandemic

April 30, 2020

Partner, 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 initially appeared on Forbes. It was co-authored by Teri Oelrich and Bryan Langlands.

 

So far the coronavirus pandemic has been concentrated mainly in New York, Detroit and other major cities. But there is a problem brewing that has received little attention: over two-thirds of rural counties have now reported COVID-19 cases. The pandemic presents a formidable challenge for rural hospitals, which have faced 120 hospital closures over the past decade and frequently struggle to recruit staff and balance the books.

The effects of the pandemic on rural hospitals don’t make the headlines the same way major cities do, partially because the problem is spread out across places many have never heard of. For example, Idaho’s Blaine County has one of the highest infection rates in the U.S. With only 25 hospital beds, Blaine starkly illustrates how the virus can rapidly overrun the healthcare infrastructure of rural communities.

There are critical steps rural hospitals can take now to adapt to the pandemic. Here are five design and planning strategies that will be critical to success.

Develop regional care strategies

Rural communities are usually served by small hospitals that frequently lack the capacity and resources necessary to deal with a spike in COVID-19 cases. One method of mitigating this shortcoming is to develop a regional care strategy with other rural facilities in the region, in which patient care is coordinated to enhance capacity and minimize infection risk.

Areas with multiple hospitals within a roughly 150-mile radius should begin designating one facility as a COVID-19 hospital and care for non-COVID-19 patients at other facilities. The non-COVID hospitals could then potentially perform elective treatment and alleviate some of the financial burden caused by the crisis. Tools like this COVID-19 Inpatient Bed Demand Calculator can help in determining local and regional capacity needs and where coordination may be most beneficial.

Alternative care sites, such as converted dorms, motels or hotels, can also be used to care for non-COVID-19 patients or to monitor less severe COVID-19 cases. Missoula, Montana, for instance, is planning to purchase a motel to use as a safe shelter for those isolating and self-quarantining during the pandemic. Similar buildings can also be repurposed to house caregivers who treat coronavirus patients, or to house out of town doctors, nurses and staff temporarily assisting beleaguered hospitals.

Rural hospitals can also partner with larger urban hospital systems to support care needs. Telemedicine can help provide input from specialists that don’t typically live in rural areas. It could also help rural hospitals receive temporary ventilators, PPE distribution and clinical staff.

Apply for federal aid

While the CARES Act includes a number of provisions to assist rural hospitals— including small business loans, $100 billion in new funding, and Medicare payment improvements— providers can also apply for FEMA Public Assistance (PA) funding. Certain emergency protective measures taken by hospitals in response to COVID-19 are eligible for reimbursement at 75% federal cost-share under the PA program, which is using a new streamlined application process. Applying for federal funding is no small task and requires significant investment in time and follow up documentation. Often hospitals engage consultants who have been successful with previous federal applications to assist them with this process. There is good news though: the cost of consultants to handle applications is covered by FEMA.

Prioritize clear signage and wayfinding

It is critical that COVID-19 patients are able to seek care without inadvertently infecting the general hospital population. This is especially true for rural hospitals, where care for more vulnerable long-term care patients is frequently integrated within the facility. Navigating in and around a hospital can be confusing and stressful, which makes signage and wayfinding vitally important for getting COVID-19 patients where they need to go while minimizing the risk of infecting others.

It is important to have a comprehensive wayfinding system for COVID-19 patients that is succinct, unique and recognizable. For example, using an unusual color like pink to direct patients to the right place helps the signage stand out, as does simple language like, “Follow the pink circle if you have COVID-19 symptoms such as dry cough, fever, and shortness of breath.” This unified wayfinding theme should be employed at every step of the patient’s journey, from the hospital website to signage as patients approach and enter the hospital. COVID-19 patients arriving in personal vehicles could, for example, be directed by signage to a separate parking lot to wait to be tested before entering the hospital.

Screen patients in triage tents

One method of minimizing contact between potentially infectious and non-infectious patients is to set up a triage tent for COVID-19 screening. This is a temporary outdoor structure, frequently set up in a parking lot, which is separate from the emergency department and enables patients to be triaged before they enter the facility. A triage tent must accommodate space for at least four activities—a place for visitors to queue, a check-in area, a waiting area, and private screening rooms. Because the interior of the tent has no walls, screens can be used to create separation and privacy, in addition to flexibility.

Tents need to maintain CDC protocols, such as social distancing of at least six feet, while being able to test the highest number of people at one time. For example, a triage tent of 25 feet by 45 feet can hold no more than 15 people seated. Ensuring the space is as simple as possible to clean and sanitize is also critically important. Frequently vinyl-wrapped tents are used along with furniture and fixtures from the hospital. Some hospitals have even rented tents, complete with lighting, smoke detectors and HVAC, from fire departments.

Make common areas safer

Ensuring safety is an ongoing challenge for hospitals. It is of particular concern in common areas like building entrances, waiting rooms and lounges, where patients and visitors congregate and transmission risks may be more acute. There are several design strategies that can help mitigate these risks while still reassuring and comforting patients and visitors.

Material and furniture selection— including the use of antimicrobial surfaces like copper and easy to clean furniture pieces with seamless detailing and solid surfaces— can help minimize the risk of coronavirus surface transmission. Similarly, touchless surfaces like automatic doors and hand sanitizer dispensers can reduce infection risk. Seating arrangements can also be moved or otherwise modified to create sufficient space between patients to support social distancing. It is also advised to divide patients into infectious and non-infectious groups, supported by adequate signage and physical separation.

As the pandemic expands into rural communities, their hospitals are tasked with the difficult job of safeguarding the health of communities that are typically older, less affluent and less healthy than urban populations. While constrained by capacity and resource challenges, rural hospitals also have a history of adaptability and flexibility that may enable them to deal more nimbly with the rapidly evolving pandemic landscape. Design and planning strategies such as those outlined above can play a major role in supporting them in this critical work they are doing for the communities they live in and support.

 

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 Luke Hayes.

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In Control

Hospital Command Centers Are Changing How Providers Care for Patients and Coordinate Logistics

December 4, 2019

Partner, NBBJ

Editor’s Note: This post was originally published in Healthcare Design. It was coauthored by Teri Oelrich and Donald Bellefeuille.

Hospitals represent some of the most complex buildings on our planet, monitoring tens of millions of data points, pieces of equipment and people every day. Examining and tracking all these interconnected and critical parts in real time is a great challenge, especially when delays can be a matter of life and death. In response, many health systems, hospitals and outpatient centers are developing command centers — akin to air traffic control centers — to meet the need for monitoring, analyzing and tracking the thousands of pieces of data.

These centers — the so-called “brains” of a facility — take different forms, from a room to a series of rooms, located on- or off-campus depending on scope and space needs. They are equipped with a variety of technologies, powered by artificial intelligence and predictive analytics, to process and display a range of real-time data, from hospital bed availability and patient transfers to equipment tracking and patient monitoring. Housed within these centers is a variety of professionals, including doctors to update care protocols, nurses to monitor patient stats and vitals, technicians skilled at telemetry, and aides to monitor patients. Incorporating environmental, patient transport and material management staff can also ensure efficiencies in bed turnover, patient movement and supply delivery, helping keep costs in check by increasing overall throughput and occupancy.

This setup allows hospitals to be proactive rather than reactive by helping staff address issues as they arise. For example, staff can receive alerts when backups occur in the imaging room and patients are waiting for services, helping to quickly resolve the flow issue. Centers that monitor the physiology of patients can use the algorithms generated to spot patient changes much faster, allowing clinical staff to intervene and treat the issue sooner and avoid medical complications. Command centers can also help unite previously siloed teams, from inpatient room logistics to procedure schedulers to clinical specialists, and enhance communication among employees, enabling staff to coordinate alerts and more easily track follow-ups through a patient’s electronic medical record. Finally, these spaces can also help boost patient and family satisfaction and provide comfort to loved ones who are reassured knowing there are multiple layers of monitoring and care in place.

 

Design Considerations

When deciding where to locate a hospital command center, it’s important to keep in mind that these facilities don’t require expensive hospital-grade space. This can create flexibility, as both on-site and off-site locations are suitable. For a large hospital network, an off-site command center outside the urban core may help lower costs because it’s less expensive to build and can free up space for clinical care on campus. However, a smaller rural hospital may choose to keep a single-room command center on-site for integrated access and cross-utilization of staff.

Another key issue to consider is the scope and type of command center. Will it serve a single hospital or a whole system? Will the command center include one site or multiple sites with collocation and remote collaboration? Generally, a command center that monitors patient flow would be about 1,500-2,000 square feet, but the overall size depends on the amount of services a hospital plans to incorporate. For example, a command center that intends to include centralized physiological monitoring for a hospital, or for several hospitals, would need at least double or triple the space requirement noted above. Services like remote patient sitters and emergency and disaster response will also require additional square footage. In all respects, command centers should be designed to expand to accommodate future technology and added services, as well.

These variables will also impact the number of staff members who need to be accommodated in the center as well as the size and layout of workstations. For example, while a typical workstation in a medical facility is 6 feet by 8 feet (48 square feet) per person, many other details need to be considered for a command center, such as the number of monitors per station, acoustical or visual privacy, ceiling heights to accommodate large hanging computer screens, and lighting controls that ensure proper screen readability and minimize glare. This means the workstation could be smaller or larger, depending on services and equipment requirements.

Other space needs may need to be accommodated, as well. For example, command centers that incorporate telemedicine capabilities will need private rooms with monitors so the practitioner can have private conversations with patients, much like what occurs in an exam room. Having respite spaces that allow command center staff who work with frequent auditory alarms and visual alerts to get quiet off-screen time is also important to prevent fatigue and burnout. Testing different layout scenarios and building mockups of the physical space to gather feedback from a variety of key stakeholders and decision-makers can help maximize space and lead to more efficient design solutions that work for everyone.

 

Accounting for Costs

The main factors that drive the cost of command centers are construction fees to build the facility, the initial expense of equipment to outfit the center, and then technology upkeep. Selecting an appropriate site for a command center is critical, as the cost to build can hinge on several factors, such as off-site versus on-site locations and urban versus suburban versus rural settings. Backfilling unused, older hospital space with a command center can often be more costly than new construction in non-hospital space due to the difficulties in retrofitting modern technology into old, ill-configured space. Once all the requirements have been established, it’s vital to consider the business case for both options (backfill and new construction) to determine a cost-effective choice that fulfills not only immediate needs but the long-term evolution of the command center.

Additionally, equipment costs, as well as technology maintenance and staff training, need to be considered. Command center designs must support powerful systems that harness the algorithms, predictive analytics and artificial intelligence that can help command center staff coordinate logistics and monitor patients. Therefore, the command center will need emergency power, highly efficient Wi-Fi technology, its own data center and integration into the system’s back-up data storage.

 

What’s Next?

As healthcare undergoes a technological revolution, hospital command centers, still in their infancy, are paving the way for other smart innovations. For example, with assistance from a command center, what if every hospital could employ artificial intelligence-driven patient monitoring to assist caregivers to create a customized precision medicine plan that’s tailored to a specific patient, and then adjust it in real time?

Additionally, other technologies could be supported via command centers, such as transport robots that deliver automated medical supplies and patient medications throughout a hospital. Cloud-based remote monitoring could provide closer communication between hospitals and patients across the full treatment timeline — from pre-admission to treatment to recovery and long-term care.

Hospital command centers can improve patient outcomes and experiences, optimize care delivery and lower operational costs. By designing spaces that host real-time hospital data and machine learning and unite staff across hospital departments, command centers can improve the ability of staff to care for patients, predict and flag medical risks and streamline patient care.

Banner image courtesy of Tim Griffith/NBBJ.

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‘It Is Crucial That We Send the Message That Behavioral Health Patients Are Valued.’

A Conversation with Tammy Felker, Registered Nurse and Architect, NBBJ

October 11, 2019

Partner, NBBJ

Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis.

 

NBBJ: You plan spaces across specialties, but you are especially focused on behavioral health facilities. Given your expertise, how should these spaces evolve?

Tammy Felker: In the past, behavioral health spaces were designed like jails and featured prison-grade materials, such as tamper-proof lighting fixtures and plumbing. As a result, these environments feel institutional and cold.

Thankfully a shift in mindset is starting to transform the industry, creating a normalized care experience so patients feel safe, but also valued. Fixtures are becoming less institutional-like, and there’s a holistic emphasis on providing warm and therapeutic spaces.

One specific area we’re investigating is the integration of circadian lighting. Regulating sleep-wake cycles is especially important to the behavioral health population for healing, and it is ripe for further study and analysis.

 

What are the most impactful changes that could be made to how behavioral health spaces are designed?

The first change is to rethink spatial density. Studies show that too  many people in a small space can increase aggression. In behavioral health centers, giving enough square footage beyond the code minimum, so everyone has their own space, can make a difference in creating a normalized environment.

Another is to provide room for physical activity, from yoga to treadmills. Research demonstrates the positive benefits of exercise on anxiety and depression. Current building codes for inpatient behavioral health units don’t require exercise areas, but as a result, they are missing a great way to support the link between lifestyle choices and behavioral health.

A third element to consider is nature integration, ideally with access to the outdoors. Design that addresses our primal connection to nature can help decrease blood pressure and the use of pain meds. Even an area for horticultural therapy and opportunities to take care of plants can help.

 

Why should investments in treatment and design go hand-in-hand?

Our spaces and places convey meaning, and it is crucial that we send the message that behavioral health patients are valued. In fact, it may be more important to have a well-designed behavioral health facility than a typical healthcare space. That’s because behavioral health patients typically spend very little time in their bedroom and are constantly interacting with staff and other patients. Meals are usually in a group setting, and there are different therapy sessions, from art to group to individual sessions. Design needs to be supportive of this treatment model.

 

What makes you hopeful when it comes to addressing the behavioral health crisis?

The first is the Affordable Care Act and healthcare parity laws that require treatment of mental illnesses just like physical illnesses — and that people can get insurance that covers behavioral healthcare. Funding to train more doctors, nurses and other staff that specialize in behavioral health is another. In Washington State, Governor Jay Inslee is proposing an initiative that puts funding in place for a new 150-bed behavioral health teaching hospital in Seattle, along with community behavioral health centers across the state.

 

Images courtesy Sean Airhart/NBBJ.

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When Nursing Meets Architecture

Building a Unique Nurse Consultant Role in Healthcare Design

September 5, 2018

Partner, NBBJ

Editor’s Note: This post was originally published on Medscape. It was coauthored by Kristina A. Krail, RN, BSN, MPH, and Teri Oelrich, RN, BSN, MBA.

Nurses as Design Consultants in Architecture

As a nurse, have you ever watched in wonder the marvel of a new hospital rising out of the ground? Are you curious about the history of your campus or building — how it came to be or who created the design? Have you enjoyed serving on a committee when your organization was planning a new building, unit, or renovation? Was there ever a time in your nursing practice when you were frustrated with the design of your work setting and asked yourself, “What were they thinking?”

If you answered “yes” to any of these questions, you may be interested to know about the small but growing group of nurses who work directly with architects, engineers, and construction managers to build or renovate healthcare facilities. Employed as clinical consultants, project managers, planners, data analysts, or group facilitators, these nurses play a vital role at the cornerstone where the design and healthcare industries meet. By representing the various constituents through a keen understanding of the perspectives of each (and the language they use), and by leveraging those effective interpersonal skills honed as healthcare providers, nurses employed in this serve a vital role in all stages of the design process.

This area of specialty is relatively new. In 1989, the architecture firm NBBJ became one of the first to employ full-time nurses after I completed my MBA and responded to a NBBJ job posting for healthcare consulting. Today, I’m a partner in the multimillion dollar company.

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Co-author Kris Krail (at right)

At NBBJ I am joined by, among others, Kris Krail, who came to the firm serendipitously after a long career in nursing administration serving as a chief nursing officer at a variety of hospitals. She was excited to join an architecture firm because her father was a draftsman, she was active in preserving historical buildings, and the most enjoyable times during her administrative practice were when her hospitals were in a building mode.

Although the American Nurses Association does not yet recognize this type of work as its own specialty, it does direct interested professionals to the Nursing Institute for Healthcare Design — a 150-person organization of like-minded professionals with a common goal of integrating clinical expertise into the planning and design of healthcare environments.

The Role of Design Consultant

Nurses in the architecture, engineering, and construction industries must possess leadership qualities, demonstrate emotional intelligence, and be nurse experts in their field of functional or clinical specialty. We work both internally within a project team and externally with healthcare clients, so the ability to collaborate and communicate is paramount, and well-honed writing and public speaking skills are essential. They must also be comfortable and self-assured enough to interact with all client levels of personnel, from entry-level service staff to physicians and board members. An advanced degree may be required, but more important is the ability to demonstrate astute organizational skills and manage projects in a self-directed way.

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Co-author Teri Oelrich (at left)

The work itself and the benefits derived from the role are also varied, which makes the job enjoyable for us. No two days are ever alike; joy comes from interacting with a variety of people both within our firm as well as on the client side. Our nursing and healthcare expertise is relied upon extensively, but our “people skills” are also counted on, because architects are classic introverts. We achieve great satisfaction through building coalitions, managing conflict, and facilitating teams in resolving problems. There are always numerous opportunities to teach and mentor — another favorite nursing skill that gets tapped into often.

It’s hardly an easy job. We are called upon to balance priorities, often at odds, between building requirements and patient care or staff needs. Resource allocation — staffing, dollars, space, and time — continues to be a challenge for all involved. We have to go where our clients are, and so some travel is entailed, a requirement that either fits into one’s work/life balance equation or it doesn’t. And there are always deadlines, tight schedules, and sometimes late nights.

Still, the satisfaction realized by being involved in creating a new setting for patient care is unmatched. The opportunity to translate the needs of staff, patients, and families to those who design and build those settings creates a legacy that makes an impact for years to come — a legacy of spaces that are not just newer but also better, more efficient, safer, and more healing.

Banner image courtesy of NBBJ.

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It’s Time to Design a Better Experience for Behavioral Health Patients

How to Deliver Better Care While Freeing up Hospital Space

March 28, 2017

Partner, NBBJ

Editor’s Note: A version of this post was previously published in the Puget Sound Business Journal.

The United States faces a mental health crisis, with 26% of people nationwide suffering from psychological illness or addiction. When these patients are at their most vulnerable, our communities’ emergency departments (EDs) are used as dumping grounds and holding areas due to the shortage of appropriate resources.

While any treatment is better than none, EDs are often unequipped to treat these specific patients, especially in smaller cities that are challenged by less capacity and staffing or by fewer specialized facilities. Treatment in the ED often comes with loud noises, bright lights, chaos and seclusion — which can aggravate and trigger complications for a behavioral health patient. EDs are also an expensive treatment option, increasing the cost of care for the patient and the public.

The trend of patients seeking care in EDs instead of psychiatric institutions is not new. In 1963 Congress passed the Community Mental Health Centers Act to deinstitutionalize the mentally ill. The goal was to stop “quarantining” the mentally ill and provide voluntary humane treatment. Unfortunately, this act has not been successful; the deinstitutionalization movement has been called the trans-institutional movement, with patients instead filling EDs, jails, prisons, and homeless shelters.

A Healthy Path Forward

Luckily, healthcare organizations are working with partners in their communities to overcome these challenges. For example, Kaiser Permanente and MultiCare are actively participating in programs to provide appropriate treatment for behavioral health patients — from better training of emergency responders, to preventive health measures, to better funding models.

Another solution is to redesign our treatment facilities. In Portland, Oregon, is Unity Health, envisioned by the Randall Charitable Trust. Together with a series of healthcare institutions, the trust remodeled a shuttered hospital into an inpatient behavioral health hospital with a psychiatric emergency services department. Several architectural firms came together to design appropriate spaces for care and treatment, not just stabilization until a patient is “good enough” to be released.

For example, at Unity, the typical ED exam room allows patients to dim, brighten or turn off lighting completely. While a seemingly benign solution, there is conclusive evidence on the power light has to hinder or support healing, especially with those suffering from anxiety attacks.

The project also focuses on reducing noise. When sound becomes too acute in healthcare settings, it can raise stress levels, boost blood pressure levels and require additional medication. These side effects work against providers as they seek to support their patients. The new design focuses on creating quieter spaces — using sound-absorbing materials, sliding doors and acoustical tiles to decrease noise levels.

In addition, behavioral health patients often react to each other’s outbursts, so the design relies on patient monitoring for safety. Not only does this allow for patient privacy, it also prevents patients from being put in windowless, isolated rooms.

A Call to Action

Despite the best efforts of the Affordable Care Act, the cost to treat behavioral health patients is skyrocketing. To counter the cost impact, we need to create programs for understanding, rehabilitation and prevention to ensure behavioral health patients find wellness and stay well. Studies show that for every 10% increase in mental health spending, the prison population is reduced by 1.5%. It’s clearly better to spend our resources on creating a well-balanced environment — through programs, assistance and facility design — than incarceration.

While the nation grapples with the uncertainty of healthcare under a new administration, we can take steps now to ensure patients suffering from behavioral health issues are given the tools and resources necessary to lead healthier, happier lives.

Image courtesy of Pexels.

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