Five years ago, Clarian Health Partners elected to try a design experiment in its soon-to-be-constructed cardiac critical care unit. Spearheaded by nurse executive Ann Hendrich, RN, and taking its lead from The Center for Health Design, it signed on as one of the first Pebble Projects to implement and test elements of a healing environment. The Pebble Project image of a small stone tossed into a pond and spreading ripples far and wide is apt: The success of Clarian's CCU design made waves in its own backyard. Clarian Health Partners decided to employ many of the same design principles in creating a new, 76-bed community hospital called Clarian West Medical Center. It is a full-service hospital, offering emergency, med/surg, radiology, oncology, pediatric, and women's services. Opened in late 2004, Clarian West employs Clarian's CCU design innovations on a much larger scale, producing promising operational and clinical results. Details were discussed by design principal Norman Morgan, AIA, of the firm HKS, Inc., and hospital President/CEO Al Gatmaitan in interviews with HEALTHCARE DESIGN Editor Richard L. Peck.
Morgan: “Ann Hendrich was the visionary with her ‘Four Cs’ project (comprehensive cardiac critical care unit), which was developed in collaboration with physician leadership and offered many intriguing new elements. Al Gatmaitan added an operational perspective in developing a healing environment on a hospital-size scale.”
Gatmaitan: “Our approach is a credit to Clarian Health Partners, which could not wait for the healing design concepts to be widely documented or accepted because of project timelines. The lessons learned from the Pebble Project cardiac unit and experience concerning what was not working well in traditional hospital environments provided enough insight to support the risk related to this very significant investment. In expanding these concepts to the hospital level, the key was integrating three ideas: a healing physical environment, the work of healthcare and the technology needed, and the relationships that must develop among patients, families, and staff for healthcare to work well. We consulted with Jain Malkin Inc. and Maregatti Interiors to come up with a unified process, and the result does more than take advantage of natural light, colors, materials, and elements of nature—it adapts the hospital form to comfortably fit healthcare function.”
Morgan: “With 70 acres to work with, we had ample acreage for design. The building was height-limited to three stories, so essentially it is spread out and horizontal, with lots of ‘pockets’ here and there. The building is laid out racetrack-style, with an inner courtyard featuring a waterfall, rocks, and native plant materials that we call the Indiana Garden. On the exterior grounds we've created a lake, alongside which are a rose garden and meditation garden. Rooms on both the outside and inside walls of the building have beautiful views of either the Indiana Garden or surrounding countryside through larger-than-usual windows. Because the patient rooms are larger than the industry standard (see ‘Patient Rooms’ below), we were faced with the challenge of having a larger perimeter for the building. We've modified this by angulating the exterior façade to create niches within the landscape.”
Morgan: “These are all-private rooms, about 320 square feet each including the patient bathroom. The space includes a work zone that is workable; Clarian insisted on this. The patient areas feature flat-screen TVs and refrigerators built into the casework, and the headwalls have been placed to give patients a convenient view of the outdoors through the floor-to-ceiling windows. There is a nursing alcove between every two rooms.”
Gatmaitan: “We put a lot of effort into figuring out how the technology would fit into the room without being obtrusive. Computers and monitors are carefully placed for both patient and staff convenience, and the support/supply functions are hidden behind doors. Physicians and nurses can work comfortably without necessarily having to stand and can easily engage in conversations. We also use the ‘onstage/offstage’ approach in corridor and room planning so that patients and families never see equipment and supplies being wheeled around. We try to put the intense work involved in delivering healthcare out of sight and out of mind.”
Morgan: “We wanted to give families a choice of spaces in various corridor alcoves and throughout the building. One alcove might be set up primarily for kids to play in, another for TV watching, and another for quiet reading and meditating—and some of them have working fireplaces. Family members can move around the facility if they so choose—from alcove to garden to cafá or dining area. The dining area is carpeted, with lots of wood, acoustic paneling, and a large fireplace.”
Morgan: “Aside from the comfortable work spaces inside the patient rooms, we have what we call ‘clinical service centers.’ These are glass-enclosed rooms where physicians and nurses can discuss cases with some privacy, but are still visible to patients and families for reassurance. We also have staff break rooms that are surrounded by views to the campus's parklike setting, a replenishment room for lying down and relaxing, and a staff meditation retreat overlooking the lake and rose garden. There is also a physician retreat, which includes exercise equipment.”
Gatmaitan: “This hospital was built based on the idea that we provide care through our caregivers, and we know that the same things that affect the patients affect the staff. Healthcare makes for a stressful environment for everyone, but we don't want staff exhibiting that in front of patients. We want them to have someplace to go to have candid conversations about patients, exhibit emotions, and relax. In line with this, the view from the nurses' lounge is probably the best view in the hospital. We've had nurses express a great deal of satisfaction with the work environment here; many say they feel much better at the end of the shift, and 30-year nurses are saying that it has extended their careers. We've had no difficulty over the past several months recruiting nurses, and often it's through word-of-mouth about the working conditions.”
Morgan: “I've heard people ask how this could be a hospital, because it looks so much more like a hospitality resort. There has also been positive feedback regarding the use of natural lighting throughout the building; the design team gave much consideration to incorporating natural lighting wherever possible. For example, public concourses on each level host views to the exterior, allowing intuitive wayfinding and providing positive distractions. In addition, each patient bathroom has its own small window, contributing to the healing environment.”
Gatmaitan: “We completed our first formal customer satisfaction survey in February, and we have a lot of anecdotal evidence and suggestions of progress. Aside from patients describing the hospital as ‘beautiful’ and ‘welcoming,’ we've had some promising preliminary clinical results. For example, our incidence of patient falls per 1,000 days and of nosocomial infections is virtually nil, and compares very favorably with other Clarian hospitals with which we've benchmarked. From a business standpoint, we believe that the incremental cost for implementing a design like this—and it can be fairly significant, as much as 10 to 15% more—will be amortized to virtual nonexistence over the anticipated 30-plus-year life of the building and have a minimal impact on an annual income statement. Then there are the cost savings that occur when incidence of falls and infections are minimal. We also anticipate improved revenues from enhanced referrals and reduced costs for staff recruitment and retention.
“We've been open only 13 months, and only time will tell whether these trends will hold true. But it is our bold bet that they will.” HD