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.

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Formerly Hidden, Beautiful Infrastructure Is Now Back in the Limelight

We Have a Once-in-a-Generation Opportunity to Reimagine Infrastructure as a Community Asset

December 16, 2019

Urban Design Director, NBBJ

Editor’s Note: This post was originally published in Next City.

America’s infrastructure is in dire need of significant investment — the American Society of Civil Engineers has infamously given the United States a cumulative D+ on its Infrastructure Report Card, with a D+ for energy infrastructure in particular. Our electrical grid alone is estimated to need $2 trillion in investments over the next 30 years.

However, as conversations continue about the need for a Green New Deal and overdue upgrades to the nation’s infrastructure, we also have a once-in-a-generation opportunity to reimagine the role that infrastructure can serve in cities. Infrastructure should be conceived as a community asset, both providing equitable new public space and contributing to the beauty of cities, at a time where pressure on urban land is at a premium and civic pride often waning.

This is not a novel concept. The Victorian Era transformed London — and all of Great Britain — with roads, railways, bridges, embankments, sanitation infrastructure and more, much of which remains among the city’s most beloved landmarks and public spaces. Similarly, Jean-Charles Adolphe Alphand, a chief engineer and director of public works in Paris during the mid-19th century, brought beauty to the water and sewer systems of the city.

The United States saw a similar push in the 1930s and 40s with the Works Progress Administration (WPA), which, in addition to Art Deco civic buildings across the country, built iconic infrastructural projects like the Hoover Dam, Blue Ridge Parkway, San Antonio River Walk and dozens of national parks and monuments, projects that were both functional and beautiful, that created new opportunities to make wonderful and unexpected public places. For the WPA, infrastructure encompassed much more than bridges and roads — it included theaters, stadiums, parks and other examples of civic architecture — and this broad definition inspired people to design infrastructure that is integral to its surroundings.

Today we have the opportunity to take these examples even further, by reimagining America’s tens of thousands of decaying urban infrastructure assets — our dams, reservoirs, water tanks, power stations, rail yards, sewage works, electricity pylons, pumping stations and more — to create infrastructure that is both functional and beautiful. Of course we must build sustainable infrastructure, powered by renewable sources, that will conserve energy and reduce carbon and, in so doing, create better places for people — and reduce lifecycle costs. But even beyond that, we can redesign these assets in such a way that more seamlessly integrates them into the urban fabric, supporting a more varied public realm and community development. Here’s how.

Celebrate the Utilitarian

There is often an attitude that if we make infrastructure a “dumb box” no one will notice it, but in cities in particular, infrastructure is often unavoidable and visible from many different viewpoints. The best infrastructure doesn’t pretend it’s invisible, but celebrates its contribution to the community, around-the-clock and around-the-seasons.

We’re already starting to see contemporary visions that embrace infrastructure as a civic and community asset. In Copenhagen, the whimsical power plant Amager Bakke is topped by an artificial ski slope, hiking trail and climbing wall. Medellín’s public space program known as Unidades de Vida Articulada (UVA), or Articulated Life Units, has created public parks and community centers around repurposed water tanks.

And in the United States, my firm NBBJ designed the recently opened Denny Substation — Seattle’s first new electrical substation in 30 years — as a piece of infrastructure that’s also an active public amenity. In addition to housing electrical equipment for Seattle’s grid, it has a public park, walking path, two community centers and a public art program delivered in partnership with the city’s Department for Arts and Culture through its 1% for Art Fund.

Balance Safety and Security with Public Access

The extent to which infrastructure can be celebrated depends on what it is, because some places — like electrical stations — can’t be open to the public for safety or security reasons. But there’s no reason why infrastructure can’t be architecturally interesting — or integrated into an earthen mound to become part of the landscape. Levees and floodwalls are the classic example — in Staten Island, a 5.3-mile sea wall in development will double as a barrier against storms and sea level rise and serve as a new public promenade and bike pathway . But an even more extreme example is furnished by Anaheim Public Utilities, which completely buried an electrical substation beneath a 2-acre community park.

Create Productive Tension

Architecture at its heart is a social experiment, and cities are our laboratories. If we’re creative and break boundaries in a thoughtful way, we can create unusual, interesting tensions to redefine the urban experience. When, for instance, a bridge or viaduct is seen only as part of a functional problem to be solved — indeed, a problem that can practically be solved by ordering from a catalogue — we are missing an incredible opportunity for civic expression. Happily it is increasingly recognized that a bridge is both a place in its own right, and infrastructure that connects places. In Dallas, a public-private partnership comprised of the Texas Department of Transportation, the City of Dallas, and The Woodall Rodgers Park Foundation led the development of Klyde Warren Park, a 5.2-acre parkspace hovering alongside a freeway overpass that includes multiple performance stages.

Why shouldn’t an infrastructure project also have community space, art projects, a dog park and be net zero? Until the Denny Substation was completed it hadn’t been done before, and now we can learn from that project and apply similar thinking elsewhere.

Getting Creative with Your Budget

The client for an infrastructure project is often a public utility, which has limited resources for capital projects, and for political reasons what they do spend can’t be viewed as frivolous. However, infrastructure can be beautiful without costing a lot of money, especially if it can incorporate things that are a part of daily life, like seating, murals, or interesting, solar-powered lighting.

This may require designers to be creative with project concepts and materials, the latter of which must be both durable and cost-effective. It may also require creative financing by accessing the budgets of multiple agencies — for instance, both the public utility and the parks department — or by forging innovative new public-private partnerships.

At London’s Queen Elizabeth Olympic Park, infrastructure across the over 500-acre site was transformed into public art by leveraging funding from a mix of government, arts sector, and private support sources including the Greater London Authority, Arts Council England, and the London Development Agency.

Small substations are encased by a wood slat structure that has poetry and simple drawings carved into it that reference the industrial heritage of the Olympic Park site. Artist Martin Richman used recycled materials to transform a pedestrian underpass and a bridge onsite into swirling artworks to activate what could have been unmemorable project elements. And a security fence atop an infrastructure building covered in grass converts the five Olympic rings into an image of a low-frequency oscillation sound wave. The wave, designed by Carsten Nicolai, was digitally printed onto the fence, with five cycles of intensity that seem to pulse across the artwork.

Engage the Community

Finally, because infrastructure serves the community — and because we want any additional benefits to be enthusiastically adopted by the public — the community needs to have a voice in challenging norms and defining new ways of designing infrastructure. Many urban designers and planners are already adept at public engagement, so the more these experts can be enlisted in creating boundary-pushing infrastructural projects and the more they can double down in their commitment to thoughtful and comprehensive community consultation, the better.

As architects and designers, we are trained in the Vitruvian elements of architecture: “commodity, firmness and delight.” That is, architecture should be useful, solidly constructed and beautiful. Infrastructure is no different. We all know that infrastructure should meet our basic needs and be robust and reliable, especially in a world where resiliency is becoming more and more important. As we develop infrastructure that addresses climate change — from coastal resilience to heat-island mitigation and diverse sources of energy — the opportunity is even more present to celebrate our infrastructure. Indeed, can it delight us as well? If delight is essential to infrastructure, not only will it create new urban experiences, but we will be more likely to sustain it, thus promoting cost-effectiveness.

The challenge ahead is a great one: Climate change will stress our communities like never before. If we can redefine infrastructure as the provision of both essential services and an expanded public realm, perhaps our descendants will look back to this time period as a new golden age for cities and the infrastructure that sustains them.

Banner image courtesy Benjamin Benschneider/NBBJ.

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Escaping Good Design

Landscape Architects Must Mindfully Contradict Some Principles of ‘Good Design’ in Their Work

December 11, 2019

Founding Partner, Gustafson Guthrie Nichol

Editor’s Note: This essay was originally authored for the December 2018 issue of A+U. It is reprinted here with the permission of the publisher.

Landscape architecture is popularly known as a gentle and passive field, staffed with pleasant people who are content to take satisfaction in the benefits inherent in our chosen media of plants, pollinators and playgrounds. To some degree, this “nice guy” impression is true, as confirmed by walking through the earnest and agreeable discussions between competitors that fill the hallways between sessions at the American Society of Landscape Architects (ASLA) convention each year. But this benign image of landscape architecture could not be more deceptive in its misrepresentation of the rebellious,  unpopular and conflict-ridden work that is often required to produce the most gentle, seemingly effortless, public landscapes.

I frequently warn landscape-architecture students about this when I visit schools, knowing that the most well-suited of them will not be put off but further engaged and excited about the challenging and, at times, lonely work in front of them as responsible landscape designers. Young landscape architects are prepared to make heroic arguments for trees, stormwater and greenspace — preaching to the choir in many contexts today — but they rarely imagine themselves making arguments for uncool and seemingly draconian design measures, like blocking desire lines, fortifying edges, controlling sightlines and restricting entries into a space.

These underappreciated aspects of landscape design are crucial to gracefully guide movement, create suspense and delight and shape the human experience, but they are often ill-received during the design process. In our era of user-centered design, this designer-imposed, intuitively driven, spatial aspect of landscape architecture has not been as popularly appreciated as the programmatic amenities that get dropped into the design, like play structures or food-truck parking. As a result, some landscape architects don’t talk about their important spatial-design work in their presentations and public meetings, for fear that it will be characterized as needless design impositions upon the users of the future landscape. But spatial obstacles, containment and peculiarities in landform are timeless, crucial ingredients in the most satisfying, stimulating experiences of the authentic, site-specific landscapes of our communities.

The tension in communicating the need for assertive, contextually driven landform — creating a legible place, with local character — in balance with the need for user-driven programming and “people amenities” has been heightened by today’s public expectations of function-driven, user-centered or “people-friendly” design values. User-centered design is an overdue and reasonable, primary expectation for the design of workplace furniture, baby carriers, Toto toilets and aircraft cockpits, but, I often plead, not for public space.

With much of our designed environment now offering instant gratification, we need the landscape to withhold its reward. We need to be reminded what it feels like to physically earn a view — even if only by a few extra steps — and to feel the achievement of physically discovering something. To “conceal and reveal” landscape also makes it more humane and interesting than keeping it entirely open, despite what may look better on plan to many viewers. Why walk into a park or plaza, for instance, if one can see every sun-baked square foot of it, in a single glance, from the edge? Good landscape design should block some views.

Good landscape design should also block some desire lines. The most enjoyable, humane landscapes, in the world’s most beloved neighborhoods and wild areas alike, do not become soul-fulfilling or iconic places in our memories by their achievements in pass-through convenience. While encouraging easy passage through any public landscape is important, the design should slow people down and festively register its entry and exit moments, with a thick sense of nature and the particular textures and pace of the local landscape.

Omitting some obvious shortcuts and adding some offsets or corners in a route through a space will always strike some people as the landscape architect treating function frivolously or with naivety toward the needs of the users. “People will always cut corners,” we are reminded, usually with the anecdote about the sage designer of the college green who simply paved the short-cut paths across the space. We’ll take that reminder (and agree with it), but we will do our best to create a place that is for stopping and resting as comfortably as for rushing through.

Good landscape design should not be too cool. We are all being flooded daily with the latest, impeccably photographed design references and planting styles from all over the globe. A commitment to designing authentic, contextual landscape often means a limited palette of plants and materials that are tied, timelessly, to the site’s location. This restraint comes with a high risk of being labeled as boring, especially by locals who have lost the ability to see the unique beauty or esteem in their common landscape. However, I tend to find that limiting oneself in such a way, to locally common influences, actually helps to produce a more distinct and novel landscape and detailing regime. This, in turn, helps both local people and visitors to see, sometimes for the first time in memory, the beauty and value of a local commonality. For instance, at the Bill & Melinda Gates Foundation, locally native “weed trees” like Big Leaf Maple and familiar, native shade plants like Sword Fern and Salal are cheerfully incorporated into the clean-lined campus landscape. This bog-inspired landscape offers daily contact for the employees with their home’s unique natural history, unmistakable foliage color and ecological context. We are regularly asked what tree species the Big Leaf Maples are in the campus, as some people hadn’t noticed their stunning foliage in the same way along roadsides and greenbelts. We incorporated the beautiful texture of common Hardstem Bulrush into the rainwater gardens — an ethnobotanical storied plant that was long considered a weed around the surrounding lakes — and it is one of the other, most asked-about plants by campus visitors.

Celebrating the common, designing to be somewhat inconvenient and delaying gratification: the real landscapes we need today require the designer to advocate for breaking some rules of user-centered design, in order to provide opportunities to interact with a scale of landscape, community and history that transcends our own. Landscape architects must advocate at times for providing a more assertive experience from the common landscape, incorporating raw and peculiar influences like the natural history and ecology of its place, or the cultural patterns of local community.

Unlike other forms of good design, the landscape we need today shouldn’t disappear elegantly before us, in deference to our desire lines and shortcuts. It should stand in our way, present something back to us that we did not ask for, and take us on an unscripted journey — even a small one — when we traverse it.

Banner image courtesy LoggaWiggler/Pixabay.

Gates Foundation sketch courtesy Shannon Nichol/GGN.

Gates Foundation photograph courtesy Timothy Hursley/NBBJ.

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