A Rigorous Approach to Evidence-Based Design
In recent years, military health facilities across the nation are increasingly embracing the concept of evidence-based design (EBD). Military hospitals are incorporating elements of EBD in new construction, expansions, and remodeling to ensure all military medicine beneficiaries receive a high quality of care, regardless of where they seek care.
The new Irwin Army Community Hospital taking shape at Fort Riley, Kansas, is a perfect example of how EBD has greatly influenced the development of a military medical facility’s healing environment.
The U.S. Army Corps of Engineers-Kansas City District contracted with the LEO A DALY/RLF joint venture to provide a world-class medical facility that is not only designed to the latest military and private sector standards but also incorporates cutting-edge EBD principles. As such, the Irwin Army Community Hospital replacement project was designed and is being constructed with a highly rigorous and energetic approach toward EBD.
Totaling approximately 522,000 square feet, this healthcare facility will include a 263,000-square-foot inpatient community hospital, a 289,000-square-foot outpatient clinic, a central energy plant, an ambulance garage, and parking for 1,600 vehicles. When the $334 million facility opens in 2014, it will serve the 1st Infantry Division’s military personnel and their families on Fort Riley and in the surrounding areas.
The Department of Defense’s Military Health System (MHS) stipulates that a healthcare facility should have the following operational characteristics (Source: http://www.tricare.mil/ocfo/docs/AchievingWorldClass.pdf):
- Basic infrastructure;
- Leadership and culture;
- Processes of care;
- Knowledge management; and
- Community and social responsibility.
While the Irwin Army Community Hospital project responded to each of these tenets in different ways, one specific condition under the basic infrastructure tenet stands out—adherence to EBD principles.
The Department of Defense has a checklist approach to EBD that not only affords design teams a comprehensive process but also allows them to consider logical solutions for a particular facility type. Not all design checklist requirements need be employed, and additional considerations can be entertained specific to the institution or building site.
An example of Irwin Army Community Hospital’s checklist is presented below, indicating some of the principles that were expected in order to create a patient- and family-centered environment in the obstetrics department.
EBD checklist used at Irwin Army Community Hospital.
A Fort-Riley-specific checklist was created by Susan O’Hara, RN, MPH (O’Hara HealthCare Consultants LLC), nurse consultant to the LEO A DALY/RLF team, from the Department of Defense’s master checklist, and also based on her own experience as well as the team’s experience.
“We wanted to create a master list for all of the primary departments of the medical facility so requirements could be analyzed using a systems approach throughout the duration of the submission phases,” O’Hara says.
The checklist identified all the critical principles the project team needed to evaluate in order to make the initial design decisions, even before the charrette stage. These principles extended from the building architectural design into furnishings, equipment, and site planning. This formalized process, however, didn’t stifle innovation and design initiatives.
For example, the healing gardens, a major element designed by landscape architect Bowman, Bowman & Novick along with LEO A DALY architects and civil engineers, incorporate a unique water feature that starts at the upper entrance to the facility, cascades down a wall, and moves down into a water rill, with the water ultimately gathering in a quiet pool.
In the deliberations that arose from the checklist’s emphasis on meditation areas and healing gardens, the design team chose to provide patients and staff with a labyrinth for quiet, contemplative walks away from the noisier side of the healing garden. The labyrinth, which wasn’t initially in the checklist, was added late in the design phase but was incorporated seamlessly into the project.
While the Department of Defense’s MHS uses templates (formerly guide plates), the process also allows design teams to modernize these templates as new EBD features arise that may be desired for inclusion in the project. The labor, delivery, recovery, and postpartum template was modernized to provide patient care at the bedside, nurse server storage just inside the room, enhanced family space, access to a jetted tub for comfort, and a customized, hospitable feel to the room.
Incorporating EBD ideas from other military agencies
The U.S. Army Health Facility Planning Agency (HFPA) has a strong interest in how EBD is incorporated into the design and construction of a new hospital. HFPA works with many architects and engineers in the development of its facilities and often cross-pollinates strong ideas among its projects in development. One such idea is the implementation of decentralized nursing stations and patient care at the bedside.
The Irwin Army Community Hospital project provides an optimal mix of decentralized options for nursing staff, including patient care at the bedside, along with a smaller central nurse station on each nursing unit. This design is based on patient needs, staff experience level, and the staff efficiency needed at the unit.
While patient-centered care is highly important in EBD, staff efficiency also is critical to the Department of Defense. A recent study by the U.S. Navy at the Bethesda Naval Medical Center demonstrated that providing patient lifts reduces staff fatigue and injuries. Also, other studies indicate the payback period from using lifts is 4.3 years (Source: http://www.nursingworld.org/MainMenuCategories/ANAPoliticalPower/State/StateLegislativeAgenda/SPHM.aspx).
Additionally, a bariatric or orthopedic patient has the option of exercising while being attached to the patient lift. As such, all the medical/surgical and acuity-adaptable rooms at the Irwin Army Community Hospital are being outfitted with patient lifts.
Another notable EBD provision in the Irwin Army Community Hospital is the attention paid to meditation space and a chapel. Decentralized meditation spaces were provided for patient use and staff counseling in the emergency department and obstetrics unit.
A primary, centrally accessible chapel was an early goal of the design team. The chapel was moved from the basement early in design to the base of the central tower element on the main floor to make it more visible and accessible for its users. Using the flexibility of the tower location, the chapel design incorporates a high ceiling space and a curved ceiling element that is uplifting to the patients and staff.
While the EBD checklist process outlined here creates some additional design development work, it
provides a structure and guide during the design phase, ensuring that a logical and thoughtful approach is taken. Its rigorous approach ensures all options and methods are scrutinized, all considerations are reviewed, and design decisions are channeled appropriately for the overall betterment of the project.
By following this process, the Irwin Army Community Hospital project team has designed a world class facility to provide healthcare for our nation’s warriors and their families, while also ensuring that the funding provided for the project is used effectively and efficiently.
Richard J. Onken is a registered architect, project manager, and medical planner with LEO A DALY. For more information, please visit www.leoadaly.com.