NBBJ Developed the First Open Core Hospital Design. Twenty Years Later, Here’s What We’ve Learned

August 18, 2021

Partner, NBBJ

This post was co-authored by Ryan Hullinger and Eric Koffler.

 

With provider burnout looming as a key challenge post-pandemic, the impetus is increasingly on hospitals to explore measures to improve the working environment. Open core, an innovative hospital layout which distributes care team work areas along corridors within patient wings, is one approach that can benefit caregiver wellbeing and performance as well as the patient experience. While the layout is still comparatively new, it has been refined through numerous projects around the country since the first open core hospital was designed by NBBJ for the Great River Medical Center in Iowa in the early 2000s. Our experience provides valuable insights and lessons which underscore the advantages and trade-offs of the layout to providers, patients and hospitals.

But First…What is Open Core?
Hospitals have traditionally used a “racetrack” layout, which accommodates patient rooms around the exterior and situates work areas and offstage functions in a central block. Open core layouts, by contrast, move the major support functions such as break rooms, staff lockers, conference rooms, elevators and offices into a centralized hub that connects to patient wings. Patient wings feature double-wide 16-foot corridors with 8-foot-wide clinical zones along one side that house decentralized team workstations and alcoves for commonly used supplies and equipment. Each workstation has two seated stations and two walk-up positions, with visual sight lines to four patient rooms. Patient wings in open core are double-loaded—with patient rooms on both sides of the corridor.

Why Adopt an Open Core Layout?
Open core is not for every hospital, but it does offer the following key advantages over traditional racetrack layouts:

Enhanced Staff Wellbeing
Access to daylight and views is the number one amenity associated with employee wellbeing and satisfaction. Open core maximizes daylighting in team work areas by distributing workstations along patient wings with rooms and windows on both sides, which significantly increases overall daylight levels throughout the day. Similarly, off-stage support zones including staff respite areas, which are usually windowless in racetrack designs, benefit from views by being on the building perimeter in open core layouts.

Open core also reduces the distances caregivers need to travel by situating key supplies in proximity of work areas. By minimizing repetitive physical activities like obtaining supplies, open core can reduce mental and physical stress and enable nurses to spend more time directly caring for patients.

High Performance Workplace with Improved Visibility
A key feature of open core layouts is that providers can always see the entire wing. With any activity readily visible, teams can respond more quickly during emergencies and communicate more easily during normal operations. Open core work areas draw on design lessons from the workplaces of leading tech companies, creating a more open, collaborative workspace with enhanced sightlines that ensure teams have easier access to one another.

Improved Patient Experience
Open core also enhances the patient experience by putting care teams closer to patients. In our experience, patients in open core hospitals have reported high satisfaction with their care, especially the accessibility and proximity of care teams. Additionally, the double-wide, daylit corridors of open core foster a calmer, more welcoming environment than traditional 8-foot corridors. Finally, noise levels, which can impact stress, are reduced by spacing team work areas along the corridor rather in one place.

When Open Core May Not be the Right Solution
The open core layout can have significant advantages over racetrack layouts, but it may have certain disadvantages depending on a project’s parameters including:

Elongated Footprint
While open core layouts aren’t typically larger than racetrack layouts, they are usually more elongated. Consequently, tighter sites with constrained elevator locations may be more suited to racetrack than open core layouts. Open core layouts also typically have about 15% more exterior surface area than comparable racetrack layouts. More exterior surface enables better daylighting, but it can also require larger investments in exterior cladding.

Non-Conventional Structural Grid
To enhance sightlines, open core layouts may have a non-orthogonal structural grid which can be challenging to accommodate within renovation projects. This grid may also require transfer beams on lower floors to align the upper and lower grid systems depending on the type of functions housed below the inpatient tower.

Lessons Learned from Two Decades of Open Core

Drawing on our experience designing open core hospitals over the past twenty years, there are two key lessons that have contributed to the success of these projects:

Leverage Mock-Ups to Prepare Staff for the Changes in Workflow
Full-scale mock-ups enable detailed input from all departments on design options for patient rooms and work areas, fostering buy-in and ownership of the design. Mock-ups can be particularly useful on open core projects as a way of building consensus, as open core introduces design concepts that may be new to staff. As one example, staff are often skeptical that open core layouts can enable ICU-level visualization of patients, but mock-ups can demonstrate the sight line performance.

Manage the Cultural Shift
Open core layouts can introduce significant operational changes, and success depends on effectively aligning every workstream—which can be challenging given that leadership changes often occur during multi-year hospital construction projects. Ensuring a continuity of vision—the translation of design intent to behavioral and cultural shifts and ultimately operational performance—is critical.

Transition planning, which encompasses strategizing, managing and training to facilitate a move into a new facility, can be critical in this regard. Adapting to a new facility can be disruptive and people are naturally resistant to change. Transition planning can help leadership achieve the type of cultural shift required for open core by working through key issues with staff to ensure operational readiness

The past twenty years of projects have demonstrated the benefits open core can bring in areas like staff wellbeing, patient care and performance. Open core may not be the right solution for every hospital, but it can be a highly successful approach depending on a hospital’s goals and location. And, given the challenges hospitals face, from provider burnout to improving the patient experience, we anticipate that open core will be a solution more hospitals explore in the near future.

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America’s Shadow Pandemic

Here’s How To Design Now For The Behavioral Health Crisis Ahead

April 12, 2021

Partner, NBBJ

This post initially appeared on Forbes. It was co-authored by Ryan Hullinger and Sarah Markovitz.

The past year forced healthcare and design professionals to quickly reimagine hospitals in order to meet the influx of patients with Covid-19. But far less attention has been paid to the shadow behavioral health pandemic. That’s why healthcare systems should start planning now to integrate best practices in design so the physical spaces are well-equipped to provide patients with the support they need.

While the coronavirus pandemic has taken an unprecedented physical toll on millions, the resulting social isolation, economic uncertainty and other context-related stressors have also led to a dramatic increase in behavioral conditions including depression, anxiety, isolation, PTSD, eating disorders and substance abuse, as well as rising levels of self-harm and suicidal ideation. This can be seen across nearly every segment of American society, but it’s especially pronounced among children and young people, BIPOC persons, essential and frontline workers, caregivers, and those with preexisting psychiatric conditions.

Reimagine behavioral health design to plan for patient surges
When providers, architects and builders collaborate to respond to rapidly evolving healthcare needs, a lot can happen. Look no further than the Covid-19 crisis, where we quickly built field hospitals, triage tents, drive-through testing and vaccination facilities. Just as we’ve worked to meet the surge in demand for physical care, we now need to ask ourselves, how will healthcare design teams proactively respond to the pending surge in behavioral healthcare need?

One idea is to adapt the flexible field hospital approach that allowed us to significantly expand care capacity at the height of the pandemic for use in behavioral health care delivery. By leveraging the latest innovations in pre-fabricated and ‘pop up’ architecture, we could deploy community-responsive and integrated behavioral health clinics in and near schools, workplaces, retail spaces and places of worship. This approach is flexible, scalable and transportable, giving us an opportunity to expand behavioral healthcare access in underserved communities – both in low income urban areas and in rural areas that often don’t have access to specialty care.

And there are opportunities to design these surge spaces in a way that addresses the other major behavioral health challenge – a shortage of qualified practitioners and specialists – through design layouts that maximize caregiver sightlines and by integrating advancements in telehealth with in-person, physical support space. This reimagination of behavioral healthcare ‘surge’ spaces gives us an opportunity to redesign the experience – destigmatizing treatment, bringing it closer to where people live and work and removing as many barriers as possible.

Rethink emergency room space
A sobering trend over the course of the pandemic has been an uptick in suicidal ideation, attempted suicide and self-harm requiring emergency mental health treatment.

According to a recent report from the CDC, ”through most of 2020, the proportion of pediatric emergency admissions for mental problems, like panic and anxiety, was up by 24 percent for young children and 31 percent for adolescents compared to the previous year.” Hospitals from Philadelphia to Anchorage are reporting their concerns over the rise in patients of all ages coming to the emergency department for urgent behavioral health support.

But traditional emergency departments were not designed to care for behavioral health patients well. They often lack appropriate dedicated space and because of inefficiencies, can be more expensive as well. This insufficient behavioral health bed capacity can mean that patients can spend days waiting for placement in a proper care environment.

Healthcare organizations like Nationwide Children’s Hospital in Columbus, Ohio, are working to fill the gap. Nationwide Children’s opened a new nine-story pavilion just before the pandemic in 2020 that includes a dedicated psychiatric crisis department. This functions like an emergency room, but it was designed from the ground up for children experiencing a mental or behavioral health crisis. As well as a youth crisis stabilization unit, in which treatment is provided by a multi-disciplinary behavioral health team consisting of a care coordinator, clinicians, psychiatrists, nurses, and specialists in family support and therapeutic recreation – all working together to address the core needs of pediatric patients.

Seeing this amplified need, Massachusetts General Hospital worked with design and construction teams to expedite the completion of a new behavioral health emergency department during the pandemic. Recognizing that behavioral health patients were both a bottleneck in the emergency department and that their experience was sub-optimal, they built a separate section where patients can be cared for appropriately while waiting for bed placement, allowing them to begin treatment with trained staff, rest privately, and if they are able, to leave their private, safe rooms and socialize in a small lounge space overseen by nursing staff.

What is good for patients is good for providers
Beyond serving the industry with better capacity to deal with behavioral health surge events, there is also the issue of longer-term care. Even before the pandemic, designers and behavioral health administrators were working together to guide a sea change in the look, feel and approach of treatment spaces such as residential care programs – one that is a vast departure from the cold and clinical environments we typically associate with mental health institutions. And these shifts have proven even more critical in the pandemic.

Employee burnout within behavioral health fields was alarmingly high before 2020 (at a rate of up to 40%). This past year has magnified the challenges for our frontline workers facing the current mental health epidemic; staff who themselves are dealing with stress, isolation from loved ones, increased patient load, concerns about getting sick, and often having to act as surrogate family members for their patients.

Design strategies responsive to the latest research on the impact of our physical environment on the brain can improve well-being and outcomes for both patients and for the staff guiding their recovery.

  • Designing with nature: Incorporating views or courtyards, walking paths and outdoor gardens — has been shown to reduce stress and improve patient outcomes. Daylight and fresh air also promote recovery from depression and bipolar disorders.
  • Bringing in amenities allowing for active engagement: At both the Big Lots Behavioral Health Pavilion at Nationwide Children’s Hospital and Ohana Montage Health in Monterey, CA, amenities like centralized gyms and sporting facilities and gardens for growing fruit and vegetables help reduce stress and elevate a sense of competency and control.
  • Minimize noise where possible: Care should be taken to minimize ambient noise, as doing so has been shown to decrease stress levels. This can be accomplished through material and layout considerations, such as placing seclusion rooms or other potentially noisy spaces outside the main corridors, dayrooms and therapy areas.
  • Focus on lighting: Poor sleep quality is associated with a slew of behavioral health issues Integrate best practices in lighting healthcare settings for optimal well-being. These strategies include the use of daylighting wherever possible, allowing for high light levels in the early part of the day, and shifting color temperature, table-mounted lighting and dimming lights to low levels in the couple of hours before bedtime.

While the prevalence of mental and behavioral health challenges has existed in society long before the pandemic and will exist well-after, the past year has cast an intense spotlight on our need to create appropriate space for treatment and care. This requires balancing short and long-term thinking and planning – developing immediate design solutions to scale-up care while investing in expanding access and care in communities in a way that normalizes care.

If you or someone you know is thinking about suicide, please call the National Suicide Prevention Lifeline at 800-273-TALK (8255) or text the Crisis Text Line at 741-741.

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A Healthier Planet Starts With Hospitals

Eleven Strategies to Reduce Energy Use and Increase Wellbeing

February 23, 2021

Principal / Sustainable Design Leader, NBBJ

@MargaretMontgo1

While hospitals are dedicated to healing, they are some of the most resource-intensive buildings on the planet. On average, they use twice the energy of most other building types. In the U.S., the healthcare system accounts for 10% of the nation’s total carbon dioxide emissions.

Typically complex and large, hospitals must operate 24/7. While essential, this results in higher energy use than a typical building. This has both an immediate and direct impact — in the cost of operational energy use — as well as longer term, significant effects of climate change on public and individual health. It’s important to address energy consumption in hospitals as it can lower operating costs, extend the life of utility equipment, reduce emissions and perhaps most important, create environments that support life especially at fragile moments.

How can hospitals reduce their energy use — as part of a holistic system of sustainable benefits — and stay operationally resilient, but still maintain solid, round-the-clock care? Fortunately, design can help hospitals tackle these sustainability issues.

In the U.S., hospitals have an average energy use intensity (EUI) — which is energy use per square foot — of 234 kbtu/sf/year. Yet a holistic system of design strategies now make it possible to reduce the energy use of healthcare buildings by almost 70%.

Two new hospitals in the Seattle area, including Overlake Hospital Medical Center’s FutureCare East Tower and St. Michael’s Medical Center Acute Care Expansion, utilize simple yet innovative design features to dramatically lower their energy use. Together, both hospitals illustrate key ways healthcare buildings can lower their energy use and achieve groundbreaking performance. Below are a series of sustainable design features hospitals can implement so they are more energy-efficient, employ healthier materials and reduce their carbon footprint.

Key Strategies to Lower Energy Use and Foster Sustainable Healthcare Systems

Energy Modeling as a Design Tool
Much in the same way that an institution begins a design and construction project with a budget — which is used as a constant measurement tool — a project can benefit from an “energy budget” to steer energy performance design. An energy budget sets an energy target at the beginning of the project and deploys modeling tools to measure the impact of a building’s needs and design changes on iterative energy, in a similar way that construction estimates work to track the progress of the work and keep the project on track. It’s critical to monitor energy and carbon budgets from the beginning so the client and design team can set and achieve sustainable goals, check progress and adjust at each phase to be sure the project is on budget.

Outside the Building
In new hospital construction and renovations, it is critical to address the exterior of the hospital. In climates with variable temperatures, outdoor design strategies can keep both heat out in the summer and the cold out in the winter. Shades on the outside of a building can help keep the interior from getting too warm, providing a triple benefit: it decreases the use of mechanical systems and lowers operational costs to cool the building, allows the use of smaller and more efficient heating and cooling systems and makes spaces more comfortable for patients, caregivers and visitors.

High-Performance Windows
Views to nature can speed healing. In patient rooms, windows with two or three layers of glass can reflect heat gain and provide insulation. In some facility types, patient rooms can benefit from operable windows — those that can open and close. Where that’s not feasible, amenity areas like caregiver break rooms and dining areas can benefit from both the natural ventilation and daylight, which can improve cognition, boost mood and decrease stress.

Efficient Heating and Cooling
Heating and cooling strategies that capture outdoor cool air to cool hospital interiors and heated air to preheat fresh air entering the building can reduce energy use by more than 200%. To build efficient heating and cooling systems, it can help to tune the amount of energy needed so equipment only runs when it is required. For example, hospitals can use high-efficiency air cooled chillers for the peak cooling loads in summer and high-efficiency condensing boilers for the coldest days in winter. It’s also important to invest in better controls, especially to allow unoccupied turndown of high-intensity spaces such as operating rooms. By building in adaptability, these smart systems can save significant amounts of energy.

Separate Thermal and Ventilation Systems
An additional building technique is to separate systems that distribute fresh air with those that warm and cool spaces, especially in hospital inpatient rooms. This goes hand-in-hand with exterior building strategies and sun protection touched on above. Used together, these techniques can create smaller energy demands and as a result, more efficient equipment for cooling and heating. In addition, keeping an air circulation system separate allows for more compact ducts and less dedicated space for these systems.

Lighting Strategies
Smart lighting strategies such as features that maximize abundant natural light via high-performance windows, light wells and skylights, particularly in cloudy climates, can help reduce energy use. Additional strategies include dimmable interior and exterior LED lighting that is programmed to turn off when not in use.

Utility Efficiency Funding
Although utility funding varies by country and jurisdiction, where available, utility rebates can compress the return on investment for high efficiency projects to a shorter timeframe, sometimes to just a year or two.

Innovative Materials
By prioritizing healthy materials, healthcare environments can reduce the amount of greenhouse gases emitted during the production and construction process and create spaces that better support healing. Although typically used in commercial buildings, cross-laminated timber (CLT) — pre-fabricated engineered wood panels — provide unique opportunities to transform healthcare environments. CLT has a low carbon footprint and the natural healing benefits of wood that calm and reduce stress. It can also be easily assembled off-site to save construction time and costs, increasing the timeframe in which clinical operations and revenue can take place.

Renewable Energy
Rather than rely solely on fossil fuels for energy, transitioning to clean, renewable energy, such as solar roofs in sunny climates, can provide a sustainable supplemental energy source. Other renewable energy sources such as wind power can provide a greener source of energy, and even help hospitals become energy independent. Transitioning to clean, renewable energy will be a key energy management move over the coming years as the cost competitiveness of renewables overtakes fossil fuel costs. Make a plan for electrification — if not immediately, then over time. This will enable healthcare campuses to wean themselves off fossil fuels and take advantage of a rapidly greening electrical grid and the attendant carbon emission reductions.

Landscape Elements
Outdoor landscape features like trees and green plants not only lower the temperature of their immediate surroundings in the summer, they can significantly increase air quality as they release oxygen, store carbon dioxide and filter out pollutants, making them natural purifiers. Views and exposure to nature has numerous restorative benefits for patients and caregivers, such as lower heart rate and blood pressure, and less need for pain medicine. Furthermore, hospital gardens with sustainably grown local food can nourish staff and patients while reducing costs associated with imported food.

Green Transportation
It’s important to consider what happens outside the hospital too. Staff, patient and visitor travel to and from a hospital can have a crucial impact. Transit connections, areas to wait for rideshares, walkability and bike-friendliness — via design strategies such as welcoming landscaped paths and covered designated areas for drop-off and pick-up — can reduce the reliance on cars and the costs associated with parking development and maintenance.

To Summarize
The conversation around energy-efficient and sustainable hospitals is only just beginning. As more hospitals consider sustainability as not just a “nice-to-have,” but a critical component of their overall strategy and business model, countries will continue to see accelerated progress. With the right policies, further breakthroughs and innovative systems — such as all-electric and net zero carbon facilities — hospitals can lower and even eliminate carbon emissions from energy consumption. As a result, they can reduce the use of critical resources, provide long term cost-savings and support a healthier environment for people and the planet.

 

Banner image courtesy Bruce Damonte.

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