For decades, residents of Johnson City, Tennessee, and its neighboring communities had been served by three hospitals that came to be an integral part of the local fabric, for both the patients who visited them and the staff members who worked there. However, Mountain States Health Alliance determined that two of them were too inefficient to maintain and opted to plan a new replacement hospital.

The health system challenged Karlsberger not only with the consolidation, but also with constructing a facility in the mountainous landscape that would achieve LEED certification.

The preliminary design and planning phases for the project began in May 2007, with the last bid package for the fast-track project going out in August 2008. The team beat its original owner occupancy date by one month, and, thanks to minimal change orders, completed the project $4 million under budget.

HEALTHCARE DESIGN Managing Editor Jennifer Kovacs spoke with Karlsberger team members Paul Carney, LEED AP, associate, project manager; Jill Grdina, LEED AP, interior designer; and Brent King, MLA, ASLA, CLARB, LEED AP, associate, senior landscape architect; as well as Bill Alton, assistant vice president, construction and facilities, Mountain States Health Alliance; and Franklin Woods CEO David Nicely about the 80-bed replacement facility.

David Nicely: We had two longstanding facilities that had very different cultures and services. North Side Hospital had been in existence for more than 30 years, and Johnson City Specialty Hospital for about 22 years. North Side offered primary care and had a very busy emergency department that saw about 80 patients a day. It did not have any operating rooms—no surgeries or women’s services were performed there. Those services—surgery and family childbirth—were provided at the Specialty Hospital.

The two hospitals were aged. They really outlived their meaningful use. So the idea was to merge the two into a brand new community hospital and really have a hospital that worked hand-in-glove with our large tertiary care sister facility, Johnson City Medical Center; but Franklin Woods would be something that served the community’s low to moderately acute patients and certainly would be very unique, very high-tech, high-touch, and also be the first green hospital in the state.

Both North Side Hospital and Johnson City Specialty Hospital had very good reputations within the community, among loyal physicians who worked at both places and among loyal followers in the area. One of the things we wanted to do in the creation of Franklin Woods was to take what was working really well in those two facilities and actually improve upon it.

Focusing on efficiency and regulatory compliance
Bill Alton
: North Side Hospital was inefficient since it was a single-story building with long corridors, which made service a bit more difficult. Service efficiency was a problem for staff, and there was no easy or inexpensive solution. The situation was similar at Johnson City Specialty Hospital. It was a two-story facility that was more efficient operationally but created energy consumption difficulties. Again, both facilities were old and expensive to operate and provide economical healthcare services. They served the community well, but it was time to combine these services into one facility that met the organization’s expectations and community needs most effectively. Energy consumption and capital demands for these two existing facilities were driving the cost of healthcare up for the organization and consuming resources. We were spending a lot for inefficient facilities, so we incorporated multiple energy-saving designs into the new facility with state-of-the-art equipment and control systems, allowing us to match the building load to demand and better meet the environmental needs of the staff and patients. We also were able to provide greater amounts of natural light, which improves healing and reduces energy costs.

Paul Carney: Originally, the plan was to pursue LEED certification at the basic level, to have the building be certified. But through the design process and through construction, we were able to bump that all the way up to Silver and were a couple points away at the very end from achieving Gold. But it didn’t make sense from a cost perspective to get those few additional points; it just wasn’t logical. Considering the original goal, Silver was certainly a noteworthy achievement.

Site challenges
Brent King
: The site was quite a bit different from the typical sites we would normally work with for a hospital of this size. There was more than 90 feet of vertical change from the top of the pinnacle rocks to the property line. It was delightfully different and had a lot of inherent opportunities we could take advantage of. There was a concept that had been proposed by another design firm to basically obliterate the top the mountain and flatten the whole thing. We thought it would be a travesty to do away with all the natural amenities that were there. We began working on a concept that would work with the land; nestle the building on the side of the mountain; tier the parking so it worked with the topography; and use gravity and bioswales for drainage. This would set up magnificent views to the valley below, preserve the pinnacle rocks, and keep the mature hardwood forest. We presented this as a concept, and the client was really happy with the possibilities and they trusted us enough to move forward.

Carney: The building is integrated into the landscape, and not only does it frame views beyond, it creates exterior spaces, like the courtyards that are activated with bioswales. There are different levels of connectivity to nature, including a literal one where the building is physically embedded into the hill, which helps bring down the scale, especially at the entry points. It doesn’t have the intimidating feel of a traditional hospital. I’ve heard some say it almost has more of a spa feel in that regard. Where more visibility is needed from the major access road, the patient tower can be seen very well. It does a good job balancing those aspects.

From the outside in
: We used brick, a very traditional material, but articulated it in a contemporary manner. In particular, the patient tower set the template for the rest of the building. Each floor line at the patient tower has a continuous horizontal reveal that separates the brick wall into bands. These are punctuated with intermittent panels of metal cladding and fenestration. The effect is that a material associated with heaviness is rendered as a series of screens. Using slightly varying panel widths furthered this reading: Elements don’t stack vertically, and the expression of forces translating down a continuous masonry façade is erased. A “load-bearing” material reads like a curtainwall.

Alton: Landscape design was a big part of the facility improvement plan. The designer tried to minimize the amount of labor it would take to maintain an attractive facility by using prairie grass, wild flowers, and rocks from the site. The landscape has a unique appearance that allows everyone to enjoy the ambience as they walk the paths through the gardens and parking areas. The landscaping enhances the healing experience along with the magnificent beauty of the surrounding East Tennessee mountains.

King: I remember early on in the design process, while visiting the site, we found a tree line of significant hardwoods that were remnants from an old farm. The dominant tree in this row was a 41-inch caliper oak. It was right in the center of the site and we thought, wow, it would be a shame to remove this. So during our conceptualization, we explored ways we could preserve that tree and integrate it into a nice outdoor space. At one point in time, the building actually was defined and
pivoted around that tree, it was so prominent. It became the anchor for the healing garden. You can see it from the entrance when you come in from the road; it pops up over the top of the roof of the lobby. So that was a nice career win. Sometimes that doesn’t always work out, but this time we made it work.

Facility layout and patient room design
: On the first floor, the first thing you notice when entering the main lobby is the strong relationship to the exterior. On the left is a courtyard with bamboo shoots and rocks that are indigenous to the site and various other plant materials. Then further beyond to the south is what the community now refers to as “the tree” in the healing courtyard.

The hospital gift shop, coffee shop, administration, and pre-admission testing are all accessible from the lobby. To the east are the laboratory and emergency departments. Both the emergency department and the main lobby have excellent visibility from the street, so there’s no mistaking the emergency department entrance. The full-service imaging department supports both inpatient and outpatient volumes, and includes general radiology, fluoroscopy, ultrasound, nuclear medicine, MRI, and CT. The ED has increased capacity built in to provide services to meet future growth and includes 22 private patient treatment spaces, a large resuscitation room, and an orthopedic/procedure room.

Further south on the first floor, the kitchen and cafeteria frames a view of another rock bioswale courtyard. A dining terrace on that level cantilevers out and over the courtyard.

The building meanders back and forth to acknowledge the existing topography and to maximize daylight penetration. The chapel is centrally located at this major intersection between departments and also cantilevers out into the healing courtyard like a cube—half inside, half outside.

Continuing along the first floor, the labor and delivery department forms the south end of the building. At the entry point, the corridor opens into a waiting/reception area with another view that encompasses the southernmost space with exterior courtyards. Within the department, the touchdown or nurses’ stations are very open and approachable. They flow as part of the corridor space and aren’t separated from people traversing those corridors.

Framing the perimeter of the department are the LDRP rooms. Each patient room, and this is typical of all the patient rooms, has a window size that is about 20% of the floor area—a substantial amount of glass to facilitate daylighting, which has been proven to contribute to patient well-being and recovery. The patient tower is located at the south end of the site to take advantage of the surrounding mountain range and valley views.

The ground floor is the backbone of the hospital. Starting from the north, where the staff entrance is located, employees walk through another courtyard called a strolling garden as a way to decompress. To the east of that entrance is the central energy plant, which runs the hospital and is sized for future expansion. Upon entering the hospital, there are staff locker rooms close by, mechanical spaces along the west perimeter where grade is highest, and back-of-house functions like facilities, biomedical engineering, and pharmacy located where grade is lowest to provide daylighting opportunities.

The second floor stacks vertically so the surgery department is directly above imaging and emergency. Central sterile is adjacent to the surgery department, with pre-op and post-op bays accessible through the surgery reception area that in turn connects back to the public elevator. The surgery department provides six operating room suites, each the same size and configuration for maximum flexibility. Supporting spaces were also standardized for flexibility based on patient activity needs.

The remainder of the building to the south on the second floor is the patient tower with two nursing units for med/surg. The footprint is similar to the floor above and below, where corridors are located with the support services on one side, the open area touchdown stations occur at corridor intersections, and patient rooms frame the perimeter.

The third floor is comprised of only the patient tower volume, which includes the ICU department, half of which is shelled space with rough-ins in place for expedited fit-out, as well as the physical therapy department. The mountain range to the south and east of the hospital is pretty spectacular at this elevation.
The room size and configuration in 80 of the patient rooms are identical, though equipment varies by room type. The LDRP rooms are the most unique to accommodate the birthing process. Patient room amenities are high-tech but not visible: Med gases are hidden behind casework in LDRP rooms, and all rooms utilize a get-well network for education and provide multiple lighting options for comfort. The typical layout includes ample space to accommodate a sleep chair or daybed for a family member, as well as a built-in desk, bench, and wardrobe unit.

All patient rooms are private and include a private toilet room with shower, sink, and toilet. Patient toilet rooms are typically in-board, except at the ICU where out-board toilet rooms are used to maximize borrowed-lite wall space into the patient room. The patient room and toilet room layout mirror back and forth in pairs; however, the caregiver and family zone remain constant.

Interior design choices
Jill Grdina
: One of our challenges for the interiors was to find products that would meet LEED requirements, remain within the budget, and be easily maintained by the facility after it opened. Linoleum flooring is used throughout most of the patient areas. It has recycled content and is rapidly renewable, but also doesn’t require the waxing and the maintenance that other floors might have. We used low-VOC paint throughout the facility that is easily maintained and budget-friendly. The carpet, used in the waiting areas and offices, has recycled content and is a low-emitting material, but it’s also solution-dyed so it’s easily maintained by the facility.

Another goal included blurring the line between the interior and exterior, and bringing the exterior design language into the building. We used the sandstone, brick, and the wood-clad soffits for wayfinding to identify specific areas that were more important than others.

When developing the color palette, we wanted to bring in colors that were from nature, and specifically from nature in the Johnson City area. The pops of color are from wildflowers you would find in the area. Also, the signage and furniture fabric draws in graphic elements that refer back to nature.

While incorporating nature and sustainability, our main goal was to reflect the community in the interiors. The hospital had a great opportunity to bring in local artists and photographers to provide a large majority of the artwork that is around the hospital. Much of the artwork reflects local nature and was a great way to give back to the community. 

: We accomplished about 95% of everything we intended to do, including the patient healing environment, the feeling of bringing the outdoors to the indoor area—all of that has been phenomenal. Our patient satisfaction scores are in 99th percentile in the Press Ganey database that we use.

I think there are a couple of things we could have done differently. One is the wayfinding signage—we’re tucked away into a medical and industrial park, so you really have to know your way around that park in order to find the hospital easily. There are pretty strict covenants in the park regarding the types and heights of signage that we can use. Then the building does meander, so there are some lengthy walks for some of our folks. We made signage additions for about the first four months just from listening to our family members and our community telling us
some of their issues with wayfinding. The other thing I would have loved to have is a separate entrance for our family birth unit. We’re missing that. It’s located at the furthest point from the main entrance as you’re walking. Some of our moms come in needing care quickly.

These are small things, though. Again, all of the key elements in our mission have really been met from the LEED/green aspect to the serenity of the environment and regarding the healing gardens.

It was a stellar accomplishment of design. HCD

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