Health Care Presentation December 2009 (Alligator Lasagna)

AIA Los Angeles, Committee on Architecture
for Health
From Alligator Lasagna to Evidence

Based Design
Presenters:
John
John Grounds,
Grounds, AIA,
AIA, LEED
LEED AP
AP
Carlos
Carlos Amato,
Amato, AIA,
AIA, ACHA,
ACHA, EDAC,
EDAC, LEED
LEED AP
AP
RBB
RBB Architects
Architects In.
In.
November
November 18,
18, 2009
2009
What is HCD09?
• The most comprehensive
HEALTHCARE DESIGN Conference
• Over 1000 attendees (4000 last year)
• Over 60 educational sessions
• 59 interactive roundtable discussion groups
• 11 state-of-the-art facility tours 9 pre-conference
workshops
• Keynote Speakers: Michael Graves, FAIA, Blair L.
Sadler, JD President Emeritus of the Rady
Children's Hospital & Health Center and Christine
Malcolm
• Exhibit Hall with 300 vendors
Learning Objectives
1. Trends for 2010

2. Innovation
3. Facility Tours
4. Highlights
5. Q/A
Oh Yeah! And what about the alligator?

Trends for 2010
6 Megatrends for 2010
1. Safety / Quality Revolution

2. Baby Boomers
3. Mandated Satisfaction Scores
4. Paying for Value
5. Evidence Based Design
6. Stimulus Funds
Safety and Quality Revolution
1. “Never Events”
- Nosocomial infections, hospital caused
readmissions, wrong surgery, wrong
medication.
- Federal mandate spreading to private
care
2. PHAMA & PHAMP in 2010 Guidelines
- Immobility related adverse
- Staff Injuries.
- Technology isn’t the answer.
3. Medication monitoring & delivery
4. Everything is on-line
Boomers
• By 2020 over 16% of U.S. population will be
over 65 (compared to 12% in 2007).
• Rationale for much of current healthcare
expansion, but…
Not all aging populations have an equal need for
healthcare.
Many do not have an increased need for inpatient
care.
Roemer’s law of demand:
“Supply may induce its own demand where a third
party practically guarantees reimbursement of
usage.”
Mandated Satisfaction Scores
• Increasingly a motivator of usage and a

critical component of hospital
evaluation/marketing.
• Design implications in point of
discharge, waiting areas, ED.
• Is a perception of quality becoming
more important than actual outcomes?
Paying for Value
• New concept in the reimbursement to
hospitals and physicians:
value-based
purchasing or pay for performance
• Will impact business case for quality
improvement
• P4P changes physician behavior, ultimately
leading to improved quality of care
• Emphasis so far has been on Medicare
patients
• Medicaid and commercial payers will follow
Growth of Evidence
Defining Evidence-Based Design
• Evidence-based design is the deliberate attempt to:
Base
Base building
building decisions
decisions on on the
the best
best available
available evidence
evidence
Achieve
Achieve the
the best
best possible
possible outcomes
outcomes for
for patients,
patients, families
families
and
and staff
staff
Improve
Improve the
the utilization
utilization of
of resources
resources
• It is becoming integral to
“the process”
Clients
Clients expect
expect design
design professionals
professionals to to be
be aware
aware of
of latest
latest
information
information and
and active
active participants
participants in
in developing
developing new
new data
data
Research
Research isis becoming
becoming pro-active.
pro-active.
Patient-based
Patient-based evidence
evidence is
is emerging.
emerging.
Post
Post occupancy
occupancy evaluation
evaluation is
is key.
key.
Growth of Evidence
•• Ten Key Steps to Implement Evidence-Based
Evidence-Based Design:
Design:
1.
1. Create
Create aa multidisciplinary
multidisciplinary team & develop a clear vision that
includes
includes measurable
measurable quality
quality improvement
improvement goalsgoals
2.
2. Select
Select an
an architect
architect with
with experience
experience in in evidence-based
evidence-based design
design &
&
aa proven
proven track
track record
record of of at
at least
least one
one successful
successful healthcare
healthcare
project
project
3.
3. Identify
Identify &
& select
select evidence-based
evidence-based design design interventions
interventions
4.
4. Evaluate
Evaluate current
current practice
practice and
and develop
develop aa baseline
baseline for
for each,
each, e.g.
e.g.
infections,
infections, transfers,
transfers, employee
employee turnover
turnover (develop
(develop baseline
baseline costs)
costs)
5.
5. Set
Set measurable
measurable postpost occupancy
occupancy improvement
improvement targets
targets && get
get buy
buy
in
in from
from all
all key
key stakeholders
stakeholders –– culture
culture change
change
6.
6. Incorporate
Incorporate design
design improvements
improvements into into capital
capital &
& operating
operating
budgets
budgets approved
approved by by the
the board
board
7.
7. Widely
Widely communicate
communicate improvement
improvement targetstargets internally
internally &
& externally
externally
8.
8. Track and report progress including including Financial
Financial
9.
9. Continually
Continually incorporate
incorporate newnew evidence
evidence based
based design
design strategies
strategies
10.
10. Publish your results!
Stimulus Funds
• 9 months after the signing of the American
Recovery & Reinvestment Act, the federal
government continues to make progress on
several health care provisions included in the
federal stimulus package.
Health IT
Medicaid/FMAP
Work Force Training and Development
Broadband
Community Health Centers
Rural Health
Prevention and Wellness & Comparative
Effectiveness Research
10 New Rules
10.
10. Better Buildings Cost less over time
-- Life
Life cycle
cycle vs.
vs. initial
initial costs
costs
-- 5%
5% initial
initial cost
cost investment
investment typically
typically repaid
repaid within
within 33 years.
years.
9.
9. Become
Become Bi Bi Multi-Lingual
Multi-Lingual
-- Design
Design Professionals
Professionals are
are learning
learning to
to speak
speak the
the same
same language
language
as
as Clinicians/Care
Clinicians/Care Givers.
Givers.
-- Clinicians/Design
Clinicians/Design Professionals
Professionals need
need toto speak
speak the
the same
same
language
language as as Administrators/Finance
Administrators/Finance Officers.
Officers.
-- Administrators/Finance
Administrators/Finance Officers
Officers need
need toto speak
speak the
the same
same
language
language as as Staff/Care
Staff/Care Givers.
Givers.
-- Everyone
Everyone needs
needs to
to learn
learn to
to hear
hear the
the patient.
patient.
8.
8. Move
Move from
from Silos
Silos to
to Synergy
Synergy
-- Seek
Seek outout holistic
holistic solutions.
solutions.
-- Facilitate
Facilitate multi-disciplinary
multi-disciplinary care.
-- Remove
Remove walls
walls between
between “departments”.
“departments”.
-- Facilitate
Facilitate adaptable
adaptable care
care environments.
environments.
10 New Rules
7. Embrace Radical Transparency
- Consumers trust peer recommendations.
- Everything is available on-line.
- Accept/Admit/Own mistakes and actively seek
improvement.
6. Anticipate Disruptive Innovation

- New product, technology or service that
emerges and changes a marketplace. i.e.: Ipod
5. Create an Environment of Care that people

really, REALLY want.
10 New Rules
4. Meet and Exceed EXPECTATIONS,
not just standards
- Competitiveness is about what
customers value, not what you are
good at.
- Spaces are not passive containers.
3. Move healthcare off life support

- The “Machine for Healing” is an
obsolete concept.
2. Become an Early Adopter.

10 New Rules
1. It’s about best NEXT practice
- “Healthcare is not an end, but a means. In

and of itself it has no value.”
Don Barwick
- “Skate to where the puck is going, not to

where it is.”
Wayne Gretsky
Innovations
Innovations in Healthcare Delivery
IT’S
IT’S OKAY
OKAY TO
TO CHEAT,
CHEAT, IF
IF YOU
YOU REALLY
REALLYDON’T
DON’T LIKE
LIKE TO
TO LOSE
LOSE
• The Hospital of the Future isn’t What

You Think It Is
Part of a distributed healthcare delivery
system
Smaller
Far less costly
Sustainable
Part of a larger healthcare reform
movement
Resource effective, utilization proportionate
• The Distributed Hospital

Proposal by the Advisory Board Company
Inpatient 10% versus Ambulatory 90%
• Broadening access points.
• Freestanding ED.
• Short-stay hospitals.
• Specialty hospitals.
• Specialization around
key services.
• Hospital at Home
Pioneered by Johns Hopkins in 1996
Discharge from ED to transport home with
nurse/MD.
MD/Nurse visit daily until discharge.
Statistically significant reductions in cost and
ALOS.
Limited diagnosis eligibility
results in negligible impact
UPS !!!!
on overall inpatient days. URGI
SSUR HO
CALL H
GICA
OK-- UPS
OOK
• Wearable Hospital
VA uses telehealth equipment placed in the
home to communicate with 35,500 patients.
Current system requires patient activation
to send data.
Dartmouth received $3m grant to develop
systems for monitoring by cell phone and
wearable sensors.
“Swallow the Surgeon”

“Honey, I Shrunk the Hospital”
Courtesy: Angela Burke, NBBJ Architects

Nanomedicine
•• Scientists
Scientists areare working
working nownow toto create
create nanostructures
nanostructures that
that serve
serve asas new
new
kinds
kinds ofof drugs
drugs for
for treating
treating cancer,
cancer, toto engineer
engineer nanomaterials
nanomaterials forfor use
use as
as
artificial
artificial tissues
tissues that
that would
would replace
replace diseased
diseased kidneys
kidneys and
and livers,
livers, and
and
even repair nerve damage, and to integrate nanodevices
even repair nerve damage, and to integrate nanodevices with the with the
nervous
nervous system
system toto create
create implants
implants that
that restore
restore vision
vision and
and hearing,
hearing, and
and
build
build new
new prosthetic
prosthetic limbs
limbs
•• Nanomedicine:
Nanomedicine: Future Future Applications:
Applications:
•• The
The elimination
elimination ofof bacterial
bacterial infection
infection inin aa patient
patient within
within minutes,
minutes, instead
instead
of
of using
using treatment
treatment withwith antibiotics
antibiotics over
over aa period
period of of weeks.
weeks.
•• The
The ability
ability to
to perform
perform surgery
surgery atat aa cellular
cellular level,
level, removing
removing individual
individual
diseased
diseased cells
cells and
and even
even repairing
repairing defective
defective portions
portions of of individual
individual cells.
cells.
•• Qdots:
Qdots: that
that identify
identify the
the location
location of
of cancer
cancer cells
cells in in the
the body
body
•• Nanoparticles:
Nanoparticles: that
that deliver
deliver chemotherapy
chemotherapy drugs drugs directly
directly toto cancer
cancer cells
cells
to minimize damage to healthy
to minimize damage to healthy cells. cells.
•• Nanoshells:
Nanoshells: that
that concentrate
concentrate the the heat
heat from
from infrared
infrared light
light toto destroy
destroy
cancer
cancer cells
cells with
with minimal
minimal damage
damage to to surrounding
surrounding healthy healthy cells.
cells. For
For aa
good
good visual
visual explanation
explanation of of nanoshells,
nanoshells, see see thethe picture
picture below.
below.
•• Considering
Considering thethe rapid
rapid progress
progress in in this
this field
field itit is
is hoped
hoped thatthat
nanotechnology
nanotechnology will will soon
soon bebe aa huge
huge force
force against
against diseases
diseases in in the
the
coming
coming days and it will help in wiping away the most lethal diseases in
days and it will help in wiping away the most lethal diseases in
the
the current
current era.
era.
Nanomedicine

Nanotechnology

Robotics
•• Medical and Non-Medical Robots

Robotics

Robotics

Robotics

Robotics

Robotics

Nano-Robotics

• Cellular care delivery
If a hospital is a set of interrelated activities
intended to produce an outcome, then all activities
could be configured into multi-disciplinary care
cells capable of delivering milestone outcomes in
the care pathway.
Break-down silos (departments).
Deliver care to patient, don’t bring patient to care.
Organize line of service around patient need:
•• Intake/Diagnosis
•• Interventional Services
•• Inpatient Services
•• Administrative Services
Adaptable Environments
• Other innovative disruptors
Globalization and Medical Tourism.
Real time video communications.
•• Telemedicine & E-ICUs.
Universally accessible electronic health records.
Express care clinics. Drive Thru?...
LEAN
•• Collaborate, really collaborate.
•• Optimize the whole, not the pieces.
•• Develop a network of commitments.
•• Tightly couple learning with action.
•• Increase participant relatedness.
Innovations in Healthcare DESIGN
• How do we (planners & architects) fit in?
Seek
Seek toto design
design and
and build
build less
less expensive
expensive facilities.
facilities.
Design
Design facilities
facilities that
that are
are efficient
efficient to
to use
use and
and access,
access, and
and cost
cost
less
less to
to operate.
operate.
Design
Design facilities
facilities that
that make
make life
life easier
easier for
for caregivers
caregivers and
and
healthier
healthier for
for patients.
patients.
• Where can we contribute?
Be
Be the
the expert
expert source
source
•• Clients
Clients need
need architects
architects and
and planners
planners to
to be
be smarter,
smarter, better
better
informed,
informed, active participants in developing new concepts of
active participants in developing new concepts of
healthcare delivery.
healthcare delivery.
Adopt
Adopt healthcare
healthcare practices.
practices.
•• Make
Make decisions
decisions with
with provable
provable basis.
basis. (Evidence
(Evidence Based
Based Design)
Design)
•• Seek
Seek out
out user
user satisfaction
satisfaction data.
data.
•• Publish
Publish your
your results.
results.
•• Constantly
Constantly incorporate
incorporate new
new evidence.
evidence.
Drink
Drink from
from the
the Running
Running Brook.
Brook.
Facility Tours
Tampa General – Bayshore Pavilion
• Only Level 1 Trauma in Central
Florida
Architect: Gresham Smith & Partners

• Design Drivers / Highlights:

ED Trauma Center: Hurricane Resistant -
140 mph wind resistant structure
Incorporated PROJECT ER One Principles
Scalability for Surge Capacity
Dual use of non clinical space
Isolation Rooms pod
Tier Triage model

ER One Goals and Objectives
The
The creation
creation ofof aa specialized
specialized emergency
emergency facility
facility at
at Washington
Washington
Hospital
Hospital Center,
Center, already
already home
home toto Washington’s
Washington’s largest
largest trauma
trauma
center,
center, emergency
emergency department,
department, burn
burn center,
center, and
and critical
critical care
care
facility,
facility, will address key needs in the region and across the nation.
will address key needs in the region and across the nation.
ER
ER One
One will:
will:
Provide
Provide unique
unique emergency
emergency care care and
and response
response capability
capability designed
designed
to
to respond to a full range of threats in the Washington area and
respond to a full range of threats in the Washington area and
substantially
substantially augment
augment thethe response
response capability
capability of of the
the National
National
Capital
Capital Region;
Region;
Serve
Serve as as aa model
model andand demonstration
demonstration facility
facility for
for other
other emergency
emergency
centers
centers inin metropolitan
metropolitan areas
areas vulnerable
vulnerable toto mass
mass casualty
casualty events;
events;
and
and
Become
Become aa resource
resource forfor emergency
emergency preparedness
preparedness that that will
will offer
offer
ongoing
ongoing education
education and and training
training programs
programs nationwide
nationwide
•• Robust scalability, Specialized capability to handle contagious

and
and contaminating
contaminating illness
illness and
and injury,
injury, and
and security
security protection
protection
from
from becoming
becoming aa target
target of
of an
an attack
attack
Features/Services of ER One
Accommodate up to 2,500 patients per day
(scaling up from 250/day during routine
operations);
Accommodate up to 100 critical care patients per
day (20/day routinely);
Have all rooms equipped with negative pressure
isolation with 100% non-recirculated air;
Offer decontamination capabilities in many forms
throughout the facility;
Provide stringent screening controls to protect
hospital workers and patients;
Deploy a universal patient tracking and ubiquitous
information system;
Offer comprehensive internal and external
communications systems.
• Stats:
Only 6 feet above sea level, 30’ from sea
998 bed Tertiary Hospital
6 story addition, 340,000 SF with 64,500
SF ED.
Completed 2008




TGH – Innovative Design Features

TGH – Innovative Design Features

• Lessons Learned:
Additional
Additional upfront
upfront costs
costs will pay off
Overdesigned
Overdesigned for for day
day to
to day
day use
use
Trauma
Trauma == Controlled
Controlled “Evidence
“Evidence Based
Based Chaos”
Chaos” no
no matter
matter
how
how much
much space
space you
you have
have
Storage,
Storage, Storage,
Storage, There
There is
is never
never enough…
enough…
Hospitality
Hospitality feel
feel
Form
Form follows
follows function
function ?? Absolutely!
Absolutely!
Apply
Apply Evidence
Evidence Based
Based Design
Design concepts
concepts
Florida Hospital - Ginsburg Tower
Hunton Brady Architects

• Design Drivers / Highlights:
“Visually
“Visually Arresting”
Arresting”
“Recognition
“Recognition ofof Soul
Soul and
and Spirit
Spirit
of
of Location”
Location”
Second
Second Opinion
Opinion Process
Process
(Hospitality,
(Hospitality, Hotel
Hotel design,
design, Walt
Walt
Disney
Disney Entertainment,
Entertainment, TheThe
Center
Center for
for Health
Health Design,
Design,
environmental
environmental psychologists,
ambient
ambient environments,
environments, clinical,
clinical,
systems,
systems, and
and specialized
specialized HC
HC
designers
designers with
with expertise
expertise in
in
Emergency,
Emergency, CV CV services
services and
and
EBD.
EBD.


• Stats:
$163 Million, 656,000 SF expansion ($250
/ SF
15 Story Building
6 Shelled floors (Overall building flexibility)
New pkg garages for over 1,700 cars
New Central Plant
50 Bed ED, with dedicated Peds ED
160 seat conference auditorium
440 private beds with CV focus



EBD notes:
Staff lounge, is at the midpoint of the
floor
Round Spire at the end of the tower is
a Conference / Education Rm.


Florida Hospital – Design Innovation



FL dollars go a longer way than they do in
CA (Any guesses as to why?)
Ode to thy public spaces
Implement a real Art program
Hospitality feel to the max
Think long term
Capitalize on ext. and int. first impression
Embrace the contrarians or “Two minds
are always better than one”
Florida Hospital – Memorial Medical Center
Design Drivers:
• Maximize vertical
design expression
• Strong physician
accessibility
• Integrate views of
nature
• Flexible nursing
units
• Future growth
• Greenfield site

• Stats:
$170 Million, 600,000 SF ($280 / SF)
New 12 Story Facility
Structure designed for vertical expansion
• Additional 8 story tower with 300 beds
135 acre Greenfield site
277 Beds, 82 critical care
Connected 5 story MOB

First Floor

Second Floor

Third Floor

Fourth Floor

Fifth Floor

Patient Floors

Administration

Iconic design statements have value
Cost savings is not a substitute for smart
design
Advanced technology may be optional
Need to Embrace the Contrarians
Take Away Concepts
Questions?
Selected References
• HCD09 Conference Proceedings
• Blair L. Sadler, JD, Healthcare Estates Welsh Conference &
Exhibition
Exhibition 2004
2004
• Angela Burke, 2030
2030 Nanotechnology
Nanotechnology inin hospitals:
hospitals: Is
Is the
the future
future
smaller?,
smaller?, NBBJ
NBBJ Architects
Architects
• Gary Burke and Terrie
Terrie Kurrasch,
Kurrasch, Ratcliff
Ratcliff Architects
Architects
• David Chambers, Sutter Healthcare
• Nanotechnology, nanomedicine and nanosurgery. International
Journal of Surgery (2005)
RBB ARCHITECTS INC

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AIA Los Angeles, Committee on Architecture

From Alligator Lasagna to Evidence

1. Trends for 2010

Oh Yeah! And what about the alligator?

1. Safety / Quality Revolution

• Increasingly a motivator of usage and a

6. Anticipate Disruptive Innovation

5. Create an Environment of Care that people

3. Move healthcare off life support

2. Become an Early Adopter.

- “Healthcare is not an end, but a means. In

- “Skate to where the puck is going, not to

• The Hospital of the Future isn’t What

• The Distributed Hospital

“Swallow the Surgeon”

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Courtesy: Angela Burke, NBBJ Architects

Architect: Gresham Smith & Partners

• Design Drivers / Highlights:

Architect: Gresham Smith & Partners

•• Robust scalability, Specialized capability to handle contagious

Architect: Gresham Smith & Partners

Architect: Gresham Smith & Partners

Architect: Gresham Smith & Partners

Architect: Gresham Smith & Partners

Architect: Gresham Smith & Partners

Architect: Gresham Smith & Partners

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

Hunton Brady Architects

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