The process of design: Informing the building of a ‘healing environment’ at The Children's Hospital in Denver, Colorado
The Children's Hospital (TCH) in Denver, Colorado, consistently ranked as one of the Top 10 children's hospitals in the country by U.S. News & World Report, embarked on the design of a new 1.4 million-square-foot hospital complex which would include a design process informed by evidence-based design principles, benchmarking peer institutions, a shadowing process, focus groups, and literature reviews. The design team is composed of Zimmer Gunsul Frasca Architects and H+L Architecture.
Defining a “healing environment”
The design process was based, first and foremost, on strong hospital leadership and the organization of that leadership at the highest levels. Final approval of all design decisions were made by the TCH Board and its committee structure. The process of defining a “healing environment” clarified other key influences—the values of family-centered care; an understanding that the hospital serves children of all ages, including young adults; the cultural diversity of the people who experience the hospital; and Colorado's natural environment—in addition to the hospital's functions and operations.
Input from patients and families, caregivers and staff; hospital leadership, voices from the larger geographic region TCH serves, the neighboring campus and community, and the design team were collected and evaluated. What emerged was a set of clear guiding principles that could be used as a standard and a roadmap to evaluate all aspects of the hospital's design. These guiding principles were to provide the following: A Healing Environment; Timeless/Enduring; Clarity/Orientation; Family Friendly; Community Space; Individual Space; Focus on Learning; and Not Trendy/Timeless. A “Theme Team,” representing different perspectives of the hospital leadership, staff focused on Child Life, patient advocacy, and nursing, was charged with ensuring these principles were applied to the interior design. This team provided further definition to the guiding principles by stating, “The Experience is the Theme.” In other words, from every public space to every patient room and corridor, the interior designers were to consider how patient care and safety issues could be enhanced by art, light, color, scale, touch, sound, and spirit while positively affecting the experiences of patients, families, and staff.
Every design presentation throughout the process began with these “guiding principles” to ensure all decisions were measured against them. The guiding principles promoted a shared vision which continued to build momentum and enthusiasm, with the end result reflecting a consistency in the design at every level.
Learning from research
Guiding principles in hand, the design team embarked on a mission to understand the latest thinking in the design of children's hospitals, evidence-based design literature, outreach to family and community focus groups as well as clinical users, and their own form of objective observation of what was currently working, or not. The following research methodology was deployed.
Benchmarking peer institutions. An initial benchmarking process involved visits to a dozen children's hospitals, including Texas Children's Hospital in Houston; Doernbecher Children's Hospital in Portland, Oregon; Children's Hospital Central California in Madera; Vancouver General Hospital in Vancouver, British Columbia; Good Samaritan Hospital in Cincinnati; Vanderbilt Medical Center in Nashville; Parker Adventist Hospital in Parker, Colorado; and Children's Hospital of Omaha. Providing first-hand exposure to how existing facilities managed program elements, ranging from patient room amenities to food service; from signage to finish materials, the purpose of the tours was to help determine key healing environment elements such as location of caregivers, flow, and floor adjacencies, layout of patient rooms, and the organization of operating rooms. Moreover, these visits provided insight into the differences between single-level hospital plans and a stacked, multilevel organization of space.
The visit to Children's Hospital of Omaha, for example, demonstrated the successful incorporation of themes of nature—a concept that resonated with TCH leadership—versus more common cartoon character themes. This distinction was consistent with observations published in healthcare literature at the time.
The “Shadowing Process.” Learning more about the operations of the existing Children's Hospital in Denver was a critical part of the research that informed the design of the new hospital. The design team actively tried to place themselves into the minds of the children who would be treated, the families who would support them, and the physicians and staff providing care. To that end, a team of seven designers from Zimmer Gunsul Frasca Architects spent two intense weeks shadowing and interviewing families, patients and more than 250 hospital staff representing 27 different departments. This shadowing process not only provided an objective, real-time look at conditions about which users may not have been aware, it also instilled the design team with a sense of empathy that carried forward into the design.
There were a number of direct outcomes of this shadowing process. Within the inpatient nursing units, for example, observations made clear that noise, congestion and excessive distances between caregivers’ stations and patient rooms needed to be addressed. Additionally, the design team was asked by nursing leadership to consider designs that would maximize bedside care by providing decentralized charting stations while at the same time retaining a caregivers’ “hub” for collaborative team consultations, private conversations, visitors to the unit, and administrative functions (Shepard, 2003). The resulting caregiver stations are a unique “hybrid” design, coupling a centralized station that maintains a strong sense of community and provides privacy for caregivers, with decentralized work stations that improve caregiver-to-patient contact with greater efficiency and less distraction.
Patient rooms were also impacted by the design team's observations—reinforced later by patient room mock-ups—both of which made clear that crowding, lack of storage, and inadequate sleeping accommodations for parents needed to be addressed. The result is a distinct organization of rooms into patient, family and caregiver “zones” to provide adequate space and minimize encroachment of space for clinical care functions. These observations and solutions aligned with observations by medical professionals elsewhere.
Observations in the surgery department demonstrated overcrowded waiting areas, lack of privacy, and overlap of circulation paths. What resulted is a dedicated corridor for physicians with reduced walking distances, and minimizing the crossing of paths between pre-operative and post-operative patients. A skylit interior child play area is dedicated to preoperative patients and families.
Observations in TCH's emergency department revealed that waiting areas could be chaotic and noisy, overcrowded, and stressful. The solution is a south-facing and calming waiting area with views and connections to outdoor gardens and fresh air. The layout provides a more private arrangement for check in and trauma rooms, a secured entrance and ready access to 24-hour food service.
Patient/family and community focus groups. Focus groups were also asked to discuss their experiences in the hospital. Four meetings were held with both patients and families, and additional sessions were conducted with local community groups. Patient/family group participants were asked to weigh in on 10 program elements, drawing both on their experiences in the existing facility and on their desires for the new hospital: (1) parking, (2) wayfinding, (3) patient rooms/amenities, (4) family amenities, (5) cafeteria services, (6) emergency services, (7) safety and security, (8) ICU/NICU, (9) overall atmosphere, (10) and general services.
While complaints and praise for the existing facility varied, the most common requests for the new hospital included the following: expanded parent accommodations with reasonable sleeping quarters, showers, and the ability for both parents to stay with the child; parental assistance in the form of activities, distractions, and respite spaces, both for themselves and the sick child's siblings; a 24-hour cafeteria; more storage space and lockers for personal belongings; data ports, computer terminals, and access to the Internet.
Given the hospital's large service area and the diversity of its patient population, a “cultural focus group” designed to give voice to Spanish speakers, Native Americans, and others, was convened. Of particular interest to this group was the inclusion of bilingual wayfinding measures and kiosks, as well as expanded accommodations for large families.
Literature review: The healing properties of color. Drawing on multiple sources on color theory, careful consideration was given to the amount, intensity, and value of colors used throughout the hospital. For example, research demonstrates that the color “blue” is beneficial for burn victims by its association with cool, refreshing water. Also, “green” has been shown to relieve tension and lower blood pressure, with children most responsive to lime green.
This research led to the development of five color palettes—Community, Social, Spirited, Tranquil, and Work—all influenced by the colors associated with Colorado geography, plant, and animal life, and each selected for its ability to promote a healing effect. The color palettes are, in turn, applied to program elements where their impact is most beneficial. The Social Palette, consisting of bright, rich oranges, reds, yellows, and greens, with splashes of Colorado imagery, is applied to active, energetic areas such as the cafeteria. On the other hand, the goal of the Tranquil Palette is to provide a more soothing atmosphere, so pastel colors like sky blue, mint green, butter yellow, and lavender are used in areas such as the intensive care units, respite areas, and chapel. The Spirited Palette is comprised of bold, almost tropical colors like turquoise, magenta, apple green, and sunflower yellow and is applied to clinic spaces and inpatient floors. The Community Palette represents all the palettes with strong punches of color carefully united against a neutral backdrop; this is applied to circulation areas, as well as the atrium.
Literature review: Natural light and connections to nature. Studies strongly support the benefits of bright natural light in reducing depression and agitation, improving sleep and circadian rest-activity rhythms, reducing pain and the need for pain medication, and even shortening the length of stay in a hospital (Ulrich, 1992).
Accordingly, at TCH, windows and “light wells” bring natural light to patient rooms, corridors, staff areas, and offices, and an interior courtyard and six-story atrium maximize daylight shining into the center of the inpatient building. Additionally, the front of the outpatient building is comprised of floor-to-ceiling glass and several interior roof terraces further harvest natural light to enhance interior spaces. In addition to natural light, the TCH design accesses the outdoors and nature-inspired themes, drawing connections to nature wherever possible, particularly evidenced by the hospital's art program.
Unique features and the power of art
From the beginning, TCH's leadership viewed art as essential to promoting a “healing environment.” Art was to serve as an integral part of the hospital's design, not merely as an add-on. It was also important that the art be “ageless”—that it would appeal to children without being childish, to young adults, and adults, alike. The art was intended to reinforce connections to nature and the Colorado region, foster a sense of optimism, and provide distraction. Given the extended stays and repeated visits of many patients and families, it was also intended to provide a constant sense of discovery and education.
The art program also assisted with wayfinding. Works of art can be found throughout the hospital including: colored glass panels with Colorado imagery such as snowflakes, skaters, and trout; terrazzo flooring which incorporates butterflies, birds, and other familiar images, plus a maze, traversing the entire atrium; photographic images of rustic Indian paintbrush, marsh marigolds, and colorful aspen leaves applied to flooring tiles and etched onto glass panels and walls.
Other unique features designed and executed were based on the research and feedback gathered. The design team paid close attention to patients’ and families’ desires for a variety of escape zones. Outdoor spaces are easily accessible and abundant for those in need of fresh air, sunshine, and the sounds of nature. There are several options for families who want to remain close to their child during his/her hospitalization, including custom-designed sofa sleepers for two family members, gliders, recliners, and sleep chairs within rooms; separate sleep rooms on each inpatient and critical care floor; or the Family Center featuring private sleep rooms and lounge space. In addition, each patient floor includes family lounge, kitchen, and laundry facilities.
A large, sun-lit 24/7 cafeteria, with adjacent outdoor patios plus a gelato and espresso bar, is adjacent to the atrium. A 3,000-square-foot teen-only “hot spot” features a movie theater, pool table, basketball arcade, computers, music/reading room, a kitchenette, and a private telephone booth. Numerous Child Life spaces where children can play are located throughout the hospital, and a Creative Play area, available for siblings, offers respite for parents. Multiple amenities are also provided for hospital staff—lounges, staff showers, employee workout facilities, inside bicycle lock, conference spaces, and a beautiful staff-only terrace—to give caregivers places of respite from the stresses of their workdays.
The final analysis
As one of The Center for Health Design's Pebble Projects, The Children's Hospital is currently performing research to determine if their new facility meets and surpasses key objectives that promote healing, aid in recruiting and retaining staff, and reduce operating costs. A research study entitled “Evidence-based Design: Evaluation of a New Children's Hospital” will measure and assess areas including family and staff satisfaction levels, infection rates, and correlations between private/semiprivate rooms and clinical outcomes. Another study will assess the use and benefit of family sleep rooms.
Since its opening in October 2007, the performance data already appears to be positive on all fronts. Three months after the new hospital opened its doors patients and their family members were already reporting greater satisfaction in seven categories of service, including the appearance of the patient rooms, accommodations and comfort for visitors, comfort of overnight facilities, and cheerfulness of the hospital. The category of service showing the greater increase in patient and family satisfaction was the comfort of overnight facilities, increasing more than 10 points between the old and new hospitals. The hospital has had a net increase of 500 employees, 100 of which are nurses, during a time when nursing shortages are still prevalent. Census figures have increased well above expectations from 170 Average Daily Census in the fourth quarter of 2007 to 214 for the first three months of 2008. The staff has experienced the challenge of adapting to a new building with inpatient beds fully occupied. Even with these challenges, the patient/family satisfaction scores, although still early, reflect high levels of satisfaction with the new Children's Hospital. HD