Creating a Center for Wellness
Wellness centers in many variations are being developed throughout the United States, with the most typical model being a hospital-based outpatient center with integrated wellness services. Although most of these centers are owned by healthcare institutions, generally they are freestanding and on sites near or within residential neighborhoods. Throughout this decade, these centers will be at the forefront of healthcare construction in all sectors of the country. Fueling this trend are general health-consciousness movements, along with reimbursement-driven incentives, to keep people healthy.
In essence, the wellness philosophy combines strategies of pre-vention with rehabilitation. It is a holistic approach that entails keeping people well rather than treating them once they become sick. For those who do become sick, wellness is integrated into recovery programs, promoting lifestyle changes to achieve sustained good health. The concept is simple—with exercise, information, and education, people increase their chances to lead healthier and more independent lifestyles.
Wellness centers link a clinical continuum of care with retail fitness in a physical setting that encourages lifestyle improvements.
Along with general strength and cardiovascular conditioning, specific services include rehabilitation therapy, occupational therapy, and cardiac rehabilitation. Beyond these basic services, most facilities also provide aerobic exercise and aquatic therapies, including lap swimming. Educational programs, such as nutritional counseling, weight loss support, and smoking-cessation courses, are essential to the wellness philosophy and are often provided during evening hours. Many facilities are also providing services such as massage, chiropractic, acupuncture, and yoga.
It is in the interest of institutions to contribute to this good health trend with specific building responses that reinforce the wellness philosophy. Integrating therapeutic services with retail fitness facilities represents a paradigm shift in healthcare and thus requires unique, responsive building solutions. Under this premise, strategic design themes can be used to achieve quality design solutions, as well as to meet objectives essential to the success of a wellness center. These design themes include:
Each of the specific themes addresses aspects of creating cost-effective, quality healing environments. Therefore, they can be easily adapted to projects that range in function from critical care units to wellness centers. Resulting from objectives defined by owners, these design themes can strongly influence building outcomes. Interestingly, numerous objectives specified for wellness centers are best achieved by using such themes during the design process.
Flexibility/Modularity allows the facility to change without requiring renovation and enhances the likelihood of staff integration. In a wellness center, staff integration means that the physical therapy staff and the fitness staff overlap, so that both are qualified and prepared to meet the needs of all customers. It also establishes conditions in which to build less space and use it more efficiently. Spatial and Sequential Hierarchy suggests concentrating financial and strategic focus on areas within the facility determined to be the most significant, in this case, the wellness center.
Designing the building with a Universal Grid and Clinical Core will permit future renovations to be less disruptive and more easily accomplished. Seeking ways to achieve Creative Problem Solving puts the facility on the cutting edge and pronounces to its users that the institution is committed to advanced techniques in the treatment of its clientele. Each theme defines an objective desirable for nearly all applications in healthcare facilities; however, this article focuses on how their use can aid wellness centers in achieving their operational and clinical goals.
To illustrate the connection between themes and objectives, this article examines the Health Services Center (HSC), part of an overall institutional reconfiguration plan at Stamford Hospital, Stamford, Connecticut. The HSC is a 225,000-square-foot facility that houses comprehensive outpatient services, including 40,000 square feet for wellness and lifestyle enhancement.
In recalling the project's genesis, Gail Evans, former vice-president of planning at Stamford Hospital, says, “In creating the HSC, our goal was to develop a cost-effective facility to complement our integrated healthcare delivery program. With the ever-evolving dis-covery of new healthcare modalities, we needed to make sure our new wellness center could respond to the needs of today, while being well positioned to meet tomorrow's changes, all within the interest of cost containment. There also is the need to move the healthcare paradigm focus from illness to prevention/early treatment.”
Providing ultimate facility flexibility in healthcare architecture is often aspired to, yet seldom achieved. Why? Too often it is because designers customize spaces to the specific needs of the users, thereby inhibiting the ability to accommodate future change without renovation. Creating a facility that can change without requiring demolition and construction is the goal of this theme. It can be achieved in three distinct ways: (1) creating universal rooms, or modules, that maintain the potential for multiple functions; (2) appropriately assembling these rooms so that they assist in eliminating territorial borders between services; and (3) allocating certain spaces as shared, and strategically placing them so that the shared services have access to them.
To achieve flexibility, a concerted effort must be made in the programming phase of a project to ensure that a maximum number of spaces can accommodate multiple functions. This involves consideration of a room's size, configuration, and utilities. During this phase, thought should be given to determining the appropriate quantity of space in order to attain optimum utilization of the en- tire facility, not just individual departments. With support and nonclinical spaces, there is a need to determine the potential for sharing of spaces, as well.
Later, during schematic design, the services must be carefully colocated to take advantage of the shared spaces and multiuse rooms anticipated during programming. For example, when two services are colocated, one should factor the volumes of each service to determine if treatment areas on their borders can shift relative to their volumes. The goal is to assure that the line of demarcation between services can adjust as volumes dictate in any given period. Hence, departmental borders are eliminated and an expanding/contracting relationship between distinct services occurs, thereby allowing optimum utilization within appropriate amounts of space (Figure 1).
Creating “universal” spaces that serve multiple services and then locating them to permit their utilization by more than one department eradicates territorial borders. The areas in red are determined in the programming phase and appropriately located during the planning stages to maximize the potential for higher space utilization and staff cross-training.
For wellness centers, this theme is essential to one of the primary goals of the facility—integration. If the facility itself is not designed to promote integration, achieving it operationally is next to impossible. Since wellness philosophies suggest a seamless approach to healthcare delivery—from prevention to treatment to maintenance—this type of facility should provide its services in a borderless and efficient environment. In the wellness mode, the patient becomes a primary contributor to his or her own well-being. The process of health is a collaboration between the healthcare provider, the patient, and the patient's family. “Turf wars” prevalent among most departments in hospital settings serve no value, and it matters little to the consumer if a therapist works in the rehabilitation department or the fitness center, so long as the standard of care is consistent. Likewise, it is of no consequence to the user if a piece of therapeutic equipment belongs to the cardiac rehabilitation department or to physical therapy. The goal is to provide the patient with the best care. The architecture must enhance, not impede, this interaction between patient/consumer and healthcare provider.
The idea is to organize the facility with overlapping functions. At the HSC, it was relatively simple to arrange the functions of acute physical therapy into three gradations of privacy (Figure 2). The most private functions, requiring patients to be in gowns, are carried out in enclosed areas and accessed directly. The middle tier, for therapies requiring moderate levels of privacy, is accommodated in curtained areas, or pavilions. The final, most public, functions are carried out in open treatment areas and include items such as stairs, parallel bars, and cardiovascular equipment. These functions overlap with areas associated with the retail exercise area and create more opportunities for physical therapists to interact with retail customers in the fitness facility. Likewise, sports trainers are able to interact not only with patients undergoing therapy, but also with the physical therapists providing clinical care.
At the HSC, the area of acute rehabilitation requiring the highest degree of privacy is indicated in orange. As the department descends in its requirements for privacy, its proximity to areas within the fitness gym, shown in blue, increases. The area indicated with striping is available to both retail fitness and rehabilitation.
As with treatment rooms between two medical services, exercise equipment inventories need to be based on entire fitness and therapeutic service volumes. If considered individually, inevitably too much equipment will be purchased, requiring more space and leading to higher construction costs and lower overall facility utilization.
By incorporating the basic premises of Flexibility/Modularity, everyone wins—especially the patient. That is the goal. Borders between services are eradicated, creating a facility where patients will ultimately receive more attention and higher-quality service. Less investment is made, and conditions are established to promote a higher quality of care. Furthermore, although these types of areas change over time, facility flexibility is achieved without tearing down walls.
Spatial and Sequential Hierarchy
This particular theme is significant in the initial stages of formulating the building's configuration. Setting service and/or space priorities early will determine critical focal points within the building and outline primary mechanisms by which the building will be understood. Given the ever-present financial constraints on building projects, the theme also helps the design team to focus its efforts and to ultimately apply construction dollars to the most desirable, visible areas. It suggests that back-of-the-house spaces will receive less financial attention than the more high-profile areas.
Inherently, this theme also suggests placing particular emphasis on the mechanisms of wayfinding, both within the building and from the vehicle entrance, because successful navigation within a building is dependent upon corridors and atria with varying heights, widths, and nodal intersections. Conscious use of this design theme will increase the likelihood that hierarchical goals established early in the process will be carried to fruition in the final product.
For wellness centers, this theme is best used by ensuring that the wellness component is visible and expressed within the building. Its placement will indicate the institution's commitment to wellness and the significance of the spaces within the center. If the wellness center is to be a prominent component to the building program, then its placement within the building and the means by which it is seen must be considered from day one.
Rehabilitation suites, with their odd mixture of equipment and activities, are often cluttered and typically located away from primary entrances of a facility. In contrast, athletic centers are commonly designed to showcase the multiple activities occurring within them. Under the athletic model, fitness is celebrated. A balance between the two extremes is the most appropriate for wellness centers. It is desirable to provide discrete, visible access to the fitness and therapeutic areas from several vantage points in the facility. In fact, it is appropriate to see immediately into these areas upon entering the building lobby. The primacy of wellness is established by connecting the areas housing fitness activities to the main entrance space of the building (Figure 3).
At the entry into the facility, the large picture window (at the center of the image) allows direct visual access into the Wellness Center from the main entrance atrium. Establishing wellness as a major aspect of the facility is achieved by its specific placement and architectural treatment.
Universal Grid and Clinical Core
Change in healthcare facilities is constant, yet seldom predictable. Although emphasis should be placed on creating a facility with inherent flexibility, modifying the interiors of a healthcare facility is inevitable; therefore, strategies to help ease the process are necessary.
Needed is a building organization system that permits future renovations that are less costly, less disruptive, and less time-consuming. Therefore, creating buildings with maximum adaptability is the essence of this design theme, and it is an investment in a long-term strategy for change.
In part, this goal can be achieved by establishing a clinical core. This core is constructed with a minimum 28-foot column spacing and a minimum floor-to-floor height of 14 feet, thus creating a universal grid. The core should house a majority of the building program with only required interior interruptions. Components such as auditoriums and atria that do not conform to the universal grid are extracted from the core and placed around its perimeter (Figure 4). If a particular space has an inherently inflexible characteristic, it should not be located within the core, to avoid interference with future building adaptations.
The clinical core, indicated in yellow wire frame, has minimal obstacles within it and contains a majority of the building program. Inherently inflexible components, such as the aquatic area and atria, are extracted from the core and placed in the periphery, creating the ultimate opportunity for future building adaptations that are less disruptive.
By their nature, wellness centers consist of several inherently inflexible components: the auditorium, natatorium with lap pool, warm-water therapy pool and whirlpool, and walking track for cardiovascular exercise. At the HSC, these particular components were separated from the clinical core and attached to the periphery of the building. Simultaneously, offices, treatment rooms, and locker/dressing facilities were retained in the universal grid space. In the future, if an entire area requires renovation to accommodate a growing program, large obstacles such as an auditorium will never be in the way.
Partitions within the clinical core should be standard steel-stud, drywall construction with sufficient above-ceiling space to import different configurations of HVAC ducts and other infrastructure for new technologies. Conversely, the more permanent natatorium enclosure walls should be constructed of concrete masonry to resist moisture. This design theme sets up a system to provide built-in adaptability. However, it also has great impact on building massing and, therefore, must be used within a thoughtful overall design methodology. This subtle, yet powerful, concept carries with it both architectural and long-term cost-saving implications.
Creative Problem Solving
Each project has the potential for unique and innovative problem solving. Because healthcare is constantly changing, opportunities to positively evolve the architecture that houses it will always exist. Although there are great advantages in using tried and true methods, there are always opportunities to expand the horizon and seek new ways to solve problems. The challenge is to find a balance between conservatism and innovation.
A critical component to the success of wellness centers is the inclusion of education and access to information. With the constant advent of new technologies, both can now readily be obtained via the Inter-net. The challenge is to find an innovative way to unite access to this information with the users of the facility.
At the Health Services Center, a Health Information Resource and Media Center is at the heart of the building. Taking a cue from Frank Lloyd Wright's notion of the fireplace hearth being the place in the home from which all other spaces radiate, the Media Center is located at the base of a tower that acts as an external and internal wayfinding beacon. The Media Center is a primary focal point immediately adjacent to the front door and main reception desk, and next to the public elevator core. One simply cannot use the building without being exposed to the Media Center.
The innovative aspect of this concept is that the Media Center is not simply a room; instead, it acts more like the Internet itself, providing access to information from multiple points within the facility. For example, there will be tel-data ports throughout the lobby concourse so that, at some point, users in seating areas there will have access to PC terminals and health information. With kiosks and data outlets, the Media Center will transform the lobby from a simple circulation and gathering space to a health information center, with interactive opportunities for the users (Figure 5).
Symbolically indicated as a circuit board, the first-floor plan of the HSC is shown superimposed with a line diagram, indicating a network of intrabuilding connections. The lobby, kiosks, and terminals, as well as several other spaces, are connected to the Media Center in an effort to unite consumers with valuable information about their health.
The concepts of wellness and the success of providing wellness services are linked to current and anticipated forms of reimbursement. In fact, institutions have to decide whether to invest in these facilities, based on a myriad of governmental and market-driven changes. It is difficult for healthcare institutions to invest capital into facilities that are designed to keep people out of their hospitals, while simultaneously struggling to get paid for their efforts. That is the bad news. The good news, however, is that although wellness often is not reimbursed through traditional channels, it can nonetheless be quite profitable, depending upon the community. The fact that people pay out-of-pocket for these services can actually increase profitability, because the fastest-growing component of U.S. healthcare expenditures is “other,” which includes complementary therapies and, yes, the basic philosophies prescribed by wellness centers.
Each facility will have unique requirements, but through utilization of the themes we have described, the risk on investment can be reduced. Using these themes during the design process will inevitably influence the architecture, helping to generate important criteria for most healthcare institutions. It is essential to understand, however, that these themes do not constitute a design philosophy unto themselves, but instead are components within a larger design methodology. Therefore, it is crucial that they be derived from stated goals of the healthcare institution. In an ideal world, incentives would exist for healthcare providers to develop more of these types of facilities. As exemplified here, the methods by which they are designed already exist. HD
Robert W. Hoye, AIA, is president and CEO of TRO/The Ritchie Organization. In addition to serving as architects at Stamford Hospital, TRO provides architecture, planning, engineering, and interior design services to many of the country's most visionary healthcare facilities. The firm has offices in Memphis, Birmingham, and Sarasota.