Putting the Health Back in Healthcare Settings
Much has been written about the need to create healthier environments in healthcare facilities. One might reasonably wonder why healthcare environments would be otherwise. However, after a generation of designing facilities to be more and more sterile, more and more suburban, and more and more maintenance-driven, it’s not hard to see why the pendulum might swing toward a more patient-centered environment.
The recent launch of LEED for Healthcare and its parallel, The Green Guide for Healthcare (GGHC), as well as the growth of green teams and farmers markets at hospitals, illustrate several of the macro- and micro-trends that are emerging.
There is scientific evidence and widespread support for the idea that outdoor environments are good for people. Exposure to the outdoors reduces stress and in measurable ways reduces the amount of medication patients require. There also is evidence to suggest that a well-designed outdoor environment contributes to staff retention and can be a key marketing tool for facilities that are competing for both patients and healthcare professionals.
For instance, a recent advertising campaign features Baltimore-based Mercy Medical Center’s “eco-friendly gardens” in a major television and billboard marketing blitz to promote the facility’s new 18-story expansion tower.
It has been 35 years since the Nurses’ Health Study showed that brisk walking decreases the likelihood of a coronary event in women. It has been 25 years since Roger Ulrich’s study showed that patients require less medication when views of nature are available. In the intervening years, however, meaningful landscapes hardly have been universal despite this indisputable and compelling science.
As landscape architects with a healthcare practice that includes urban and suburban hospitals, senior living, and specialty facilities, Mahan Rykiel Associates Inc. is seeing a number of emerging trends that indicate most facilities, in some way, now are incorporating a healthy environment as part of their design strategy. While sometimes these things may be incorporated simply to satisfy a required checklist, the result is still a healthier environment. Based in the mid-Atlantic, what Mahan Rykiel has seen isn’t necessarily universal, but from a boots-on-the-ground perspective, there are many things converging that indicate a tilt toward landscapes that are not only thoughtful and beautiful, but also good for people and the planet.
The certification process
Now more mandate than trend, GGHC and the newly launched LEED for Healthcare are indicators of this design shift toward health. These guidelines include not only the usual credits for site selection and connections to community, but also credits for exterior access for patients and for outdoor places of respite. These are entirely new credits that speak specifically to the undisputed benefits of the outdoors for patients, families, and staff.
In particular, the GGHC outlines the health issues involved in every single credit of the guideline. This is a powerful message to designers that every decision during planning and design has ramifications that can make a direct and positive impact on the people for whom the facility is actually designed.
Again, at Mercy Hospital, while the project did not attempt LEED certification, the principles of green design were very much part of the planning process, even at the very beginning, with the decision to expand. Like many urban hospitals, Mercy was faced with the difficult task of needing to improve the care environment of the facility within an aging infrastructure. Limited expansion space, limited patient access, limited funds, limited outdoor space, and a widening regulatory process presented daunting challenges. The hospital, however, has been a key component in the urban fabric of Baltimore for more than 150 years, faithfully serving the community, and the decision to remain on the original site kept the hospital close to its core mission.
Creating places of respite and patient access to the outdoors often can be done by incorporating simple elements into an existing facility. For seniors, in particular, having a small overhang covering a doorway allows space for several people to gather to listen to the rainfall. Incorporating a rain chain near a window or door can capture the sight and sound of that rain, even for those patients or residents who are not able to get outside.
In Annapolis, Maryland, for example, a skilled nursing facility incorporated a courtyard garden in the very center of the second floor unit—with a covered doorway and windows surrounding the garden, everyone in the unit can feel a part of the space.
At Providence Hospital, in Washington, D.C., a garden at the main entrance to the hospital welcomes visitors and staff at all times of the day and night. Designed before LEED or the GGHC were well known, it provides important respite and activity space for the entire hospital community. Staff is known to use the garden as an outdoor hallway to go from one place to another—an opportunity to be in a restorative place even for a few moments during busy and stressful days. Journals placed at benches in the garden include pages of entries that speak to the personal importance of this place within each individual’s hospital experience.
One of the most visible trends in healthcare landscapes is the emergence of roof gardens. This is an element that is especially evident in new construction, although existing roofs can be retrofit for certain functions.
Particularly in urban environments where at-grade green space is at a premium, or nonexistent, roof gardens may offer the only location for meaningful landscape. At Mercy Medical Center, the new tower features three levels of roof gardens that provide a number of enhancements to the expanded facility. The design of the building itself and the location of the three gardens were intertwined from the beginning; they were thoughtfully and carefully integrated into the stacking of the building and located adjacent to specific care units.
The eighth floor maternity and the ninth floor intensive care units have direct access to the gardens. Although visible from the adjacent waiting area, the smaller 10th floor garden is accessible only to maintenance personnel; it does, however, provide a valuable storm water function for the building. The gardens are not connected to one another directly, but all are visible from windows in the elevator lobby on every floor. With this location, they serve an important wayfinding and orientation function for the hospital.
The gardens provide respite space for families and staff, and provide important views for patients. Designing these gardens to allow maximum privacy and maximum visibility can be challenging, but with careful selections and locations of plant material, seating, and walking paths, both objectives can be achieved.
As a storm water solution, green roofs can capture and absorb much of the rainwater of a site before it ever reaches the ground. In many cases, this water can be collected and harvested for irrigation or to supply gray water for the building itself. A note of caution: When water is collected in cisterns as both a storm water solution and as a reservoir to supply irrigation, the cistern itself must be carefully designed and sized. Requirements for how quickly storm water must be dispersed and how much must remain in reserve for sprinkler demand can be at cross purposes.
Healthcare facilities also are paying closer attention to the food that is served and supplied on their campuses. As a symbol of a healthy community, there is hardly a more potent symbol than serving food that is grown locally and organically. Rooftop gardens can play a key role in providing a venue for at least a limited supply of fruits, vegetables, and spices that can be incorporated into the facility kitchen.
As mentioned briefly in the context of roof gardens, the growing importance of supporting healthy food alternatives to patients, staff, and even the local community is evident in the emerging trend to invite farmers markets onto hospital grounds. In the Baltimore area, Greater Baltimore Medical Center, Johns Hopkins Hospital, and Harbor Hospital all feature farmers markets during the summer that are open to the public.
Depending on the healthcare facility, small fruits, vegetables, and herbs within existing gardens spaces can provide opportunities to not only enhance the menu of the cafeteria but also provide meaningful gardening therapy in a rehabilitation or senior setting. The addition of fresh spices to a menu can enhance flavors significantly for seniors—a population that may have reduced senses of taste and smell. With food more enjoyable to eat, more calories might ultimately be consumed, providing important health benefits to an often fragile population.
Finally, even if no food is actually grown on the premises, incorporating a compost area on the grounds can contribute to a more organic landscape maintenance program. Healthcare facilities are considering these options more often, and the health benefits to both people and the environment are clear. The emergence of conferences that address this topic, such as CleanMed and FoodMed, is evidence that this trend is likely to continue to grow.
Changing storm water solutions
The State of Maryland has now implemented its Stormwater Management Act of 2007, which establishes an entirely new approach to managing runoff on a site. Instead of using centralized (usually large) structures for capturing and treating runoff, the state now requires runoff to be treated closer to the source with smaller, less invasive measures. Known as environmental site design, these measures include “integrating site design, natural hydrology, and smaller controls.”
From an aesthetic viewpoint, this means that these collection points will be located closer to buildings, more native plant material will be used, and, potentially, these “measures” can be incorporated into a cohesive site and enhanced landscape plan. For healthcare settings, this has enormous possibilities. The requirement to now bring native plant material closer to building occupants where they can easily view the seasonal changes in the plantings, along with birds and other wildlife that may be attracted to them, brings new animation to hospital treatment, waiting, or in-patient rooms.
At rehab or senior facilities, this could mean a venue for a new walking path or simply a more interesting stroll from a parking lot. With more natural systems in place to absorb water, better soil quality, and the need for less chemical treatment of large areas of lawn or specialty planting, the environment is healthier, too. In all cases, these environmental improvements are enrichments to the human healing experience.
The challenge for designers will be to incorporate these measures seamlessly into the landscape. While Maryland seems to be on the forefront of this trend, other states will surely follow, and there is even some consideration being given to this approach at the national level.
Specialized care facilities
Understanding of the outdoors as a healing and restorative environment can be found not only in the acute care world, but also in specialized healthcare venues, where this element can be particularly valuable. Specialized treatment centers—such as the Renfrew Center in Philadelphia for patients with eating disorders, the infusion center for cancer treatment at Baltimore Washington Medical Center, and Baltimore’s Kennedy Krieger Institute for treatment of children with severe brain disorders—are all examples of facilities that have embraced landscapes as part of the healing process.
For example, when Kennedy Krieger Institute was planning its new outpatient facility, the clinical staff was clear that incorporating a large outdoor space would be integral to its treatment programs. The facility stressed that any therapy that could be done inside could also be done outside, and in many cases it could be done better outside.
Much of the treatment at Kennedy Krieger involves programs that provide experience with real-world problems that are encountered by patients every day—navigating a curb, walking on varying surfaces, and exploring the sensory conditions of a rich environment. As landscape architects for the project, Mahan Rykiel was charged with finding a design solution that would provide such a space, but also one where staff could unwind and siblings might stay occupied during long periods of waiting.
The garden is designed as a series of flexible spaces that can accommodate individual or group therapy and offers larger spaces for special events. All parts of the fountain are intended for direct interaction and are sized to be accessible from a wheelchair. Paving surfaces vary from pavers, to cobble, to resilient surface, to gravel. There are short ramps, longer ramps, steps, and curbs—all included to allow therapists to introduce their patients to real-world mobility elements.
From an environmental perspective, the half-acre garden replaces a surface parking lot—replacing black asphalt with more reflective hardscape, increasing the amount of permeable surfaces and providing new shaded areas where none had existed before.
The synergy between healthy people and healthy outdoor environments is becoming more evident in healthcare facilities. Coupling compliance with regulations an
d adherence to various guidelines with design ingredients that enhance healing can be a powerful combination. A roof garden that provides a calming view from a patient’s bedside, absorbs runoff, or provides space for fresh vegetables; a mulch path around gently curving rain gardens where butterflies hover; or pockets of herbs tucked into a planted border along the walk between existing buildings, are all ways that designers can easily incorporate these elements into their projects.
At the same time, these landscape decisions allow healthcare providers to send a simple but important message about their facility: This is a place where healing is important on a personal level and on a global level. That this message seems to be resonating more and more is a positive trend. HCD
Lydia Stone Kimball, ASLA, LEED AP BD&C, is Principal, Mahan Rykiel Associates Inc., Landscape Architecture, Urban Design and Planning. She can be reached at firstname.lastname@example.org.