Healthcare Design Project: Greg and Stacey Renker Pavilion
Location: Eisenhower Medical Center, Rancho Mirage, CA

Healthcare designers don’t often have a chance to pursue the design of a hospital environment reflective of a luxury hotel. Designed as an evidence-based healing environment, an emphasis on privacy, convenience and personal preference are foremost. Healthcare interior architecture rarely allows for this level of attention to detail.

Healthcare Interior Design by Jain Malkin

For more information please visit: http://jainmalkin.com/html_site/case_studies/The_Greg_and_Stacey_Renker_Pavillion/hospitality-design-reception-concierge.html

Jain Malkin will be speaking at the American Hospital Association’s Health Facility Planning, Design & Construction (PDC) conference on Wednesday, Feb. 27 in San Francisco on the topic “Are There Holes in your Safety Net?”.

The Accountable Care Act (ACA) requires fundamental restructuring of primary care and the nation’s safety-net community health centers are a great model for team-based holistic care delivered in a patient-centered medical home at affordable cost and with good outcomes. This presentation challenges the traditional ways we view ambulatory care facilities and identifies best practices and evidence-based strategies.

For more information about the 2013 PDC Summit visit http://www.ashe.org/PDC/.

Asking for bariatric testing information from manufacturers producing contract seating became a “Comedy of Errors.” My experience left me confused and made me think of one of Shakespeare’s earliest farcical comedies. The topic of this blog came into play recently when one of our clients asked us to specify 25% of lobby/public seating as bariatric with a maximum weight limit of 700 lbs.

The question is, what maximum weight capacities for bariatric seating should specifiers select for healthcare facilities? Obesity is the second leading cause of preventable deaths in the U.S. after smoking and more than one-third of American adults are obese. An obese person is defined as a person with a Body Mass Index (BMI) of 30 or over. Many are familiar with the TV program “The Biggest Loser” and the heaviest contestant on the show weighed 526 lbs. One could see the struggles this person had trying to walk a few steps. Recently, CNN reported a Massachusetts doctor is now turning away patients who weigh over 200 lbs. claiming that two of their staff members were injured caring for patients of this size. The American Medical Association’s Council on Ethics and Judicial Affairs policy reads, “Both patients and physicians should be able to exercise freedom in whom to enter into a patient-physician relationship with…physicians do not give up their freedom of association by merely becoming professionals.” The Massachusetts doctor does recommend alternatives for their turned away patients such as “a local obesity center which is better staffed and has more resources than they do.” As obesity is on the rise, healthcare facilities are now scrambling to provide suitable equipment, trained staff, and bariatric seating, but is the bariatric seating we are specifying safe for obese people?

To educate myself I wanted to know how bariatric seating was tested in order to enable manufacturers to add claims “Certified to hold up to 700 lbs.” in their brochures and specifications. I sent an email to each bariatric seating manufacturer that we typically specify requesting test results. I added a suggestion for new bariatric seating weight categories, such as, referring to a seating unit’s weight capacity:

• B1 = 350 – 499 lbs.
• B2 = 500 – 749 lbs.
• B3 = 750 – 999 lbs.
• B4 = 1000 lbs. and over

Initially, I thought the responses that I would receive were going to be standard test results, but to my surprise, I received absolutely no consistency for tests they performed. Not one manufacturer matched another in how they tested their furniture in order to call it, “bariatric.” Of course the next question I had was, “Doesn’t BIMFA (The Business and Institutional Furniture Manufacturer’s Association) have standards for bariatric furniture testing?” In my review of BIMFA’s website I saw that there was no “bariatric” seating standard listed. That is why some of the manufacturers’ test results said, “BIFMA compliant” or “Passes above BIFMA.” That doesn’t make sense as bariatric seating is not and will never be the same as standard seating.

Standards for contract furniture testing currently from BIFMA’s website:

• ANSI/BIFMA X5.1-2011 General Purpose Office Chairs
• ANSI/BIFMA X5.3-2007 Vertical Files
• ANSI/BIFMA X5.4-2012 Lounge Seating
• ANSI/BIFMA X5.5-2008 Desk Products
• ANSI/BIFMA X5.6-2010 Panel Systems
• ANSI/BIFMA X5.9-2012 Storage Units

For bariatric seating, manufacturers are most likely using the ANSI/BIFMA X5.4-2012 Lounge Seating standard as a base to perform their own tests. The list below represents test types performed under this standard:

• Back strength/durability
• Arm strength/durability
• Seating impact
• Seat drop
• Structural durability
• Unit base
• Leg strength
• Unit drop
• Caster/base durability
• Swivel cycling
• Tilt mechanism
• Unit stability

Results I received of tests performed from a few manufacturers of contract bariatric seating:

• Static
• BIFMA cyclical drop test
• Drop
• Live load
• Dynamic

The above test results from manufacturers are atypical, not related, and completely confusing compared to BIMFA’s standard for the lounge seating testing. It is also confusing on what exactly the tests listed above involve or how they are defined.

To clarify, here are some definitions of manufacturer test responses:

• Drop Test—weight dropped from 6” above seat (simulates the impact weight of when person first sits down)
• Dynamic Test (live load)—combines both the weight and the motion of sitting to represent a more realistic situation
• Static Test (dead load)—single large weight on chair for a set period of time with no additional force or movement applied. Not very realistic.

In conclusion, it is “theatrics” in the world of contract bariatric seating testing. It seems farcical and leaves us, as commercial designers, questioning if there will be a “To be or not to be,” bariatric seating standard implemented by BIFMA sometime in the future. I am hoping for “to be” as you can see above, we need this. We have gone way too long to not have these standards established in the time that manufacturers started producing this type of seating.

BIFMA….are you listening?

Many new hospitals are bland, having little color and few design amenities especially in patient care areas.  The lobbies are beautifully detailed but, after leaving the lobby, many buildings resemble the “pre-Planetree” 1970s and early 1980s with an institutional ambience—lots of “infinity” corridors with white walls, lay-in acoustic-tile ceilings, standard fluorescent luminaires and incidentally, poor wayfinding, since where you are standing looks just like where you’ve been and where you will be going.  How did this happen after all that we have learned about the importance of creating settings that reduce stress? And why does this matter?

Patient Room at the Indu & Raj Soin Medical Center, Beavercreek, OH. Designed by Jain Malkin Inc. and HOK

Stark white walls, harsh lighting, noise, and an overall lack of comfort are incompatible with a healing, nurturing environment.  It’s interesting to note that the brain perceives the environment consciously and subconsciously causing it to increase or decrease the concentration of physiologically active hormones that have the capacity to negatively impact the healing response.  Consider this:  even when a person is not consciously thinking about the interior design and comfort level of the setting, the brain is responding to it subconsciously.

According to neuroscientist Dr. Bruce Rabin, stress impacts coping skills and the inability to cope results in the increased use of medications for pain, sleep, and anxiety.  When sleep is interrupted, muscle tension, blood pressure, and heart rate increase in response to stress.  Stress-reactive areas of the brain become activated resulting in elevated levels of stress hormones in the blood.  There is relatively little in a hospital that does not cause anxiety and stress therefore the built environment needs to be designed to mitigate the negative impact of it.

Nurse Pod at the Benjamin & Marian Schuster Heart Hospital, Kettering, OH. Designed by Jain Malkin Inc.

Think about the spaces you design.  Are you carrying design details from the lobby into areas where patients spend their time?  Into nursing units, patient rooms, procedure rooms, diagnostic imaging?  Are you selecting art images that exemplify the best research as to what is restorative?  White walls are great for museums, but not for hospitals.  Color is the elixir of life, it energizes us, makes us feel good.  Don’t be afraid of it!

Elevator Lobby at the Benjamin & Marian Schuster Heart Hospital, Kettering, OH. Designed by Jain Malkin Inc.

Rabin: “From PsychoNeuroImmunology to PsychoNeuroArchitecture.” Keynote address: Healthcare Design 04, Houston, TX. November 9, 2004.

Rabin, B. 1999. Stress, immune function and health: the connection. New York: Wiley−Liss.

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Photo by Jack Journey | © Tumbleweed Tiny House Company 2008

Who knew? There are people who are choosing to live in teensy houses built on trailer platforms about 100 to 130 square feet. Imagine that! Ideal for people who want to live more simply, for retired couples, or for those who want to live off the grid. These are architecturally quite interesting. This is definitely not a good housing option for hoarders.

Sarah Susanka author of The Not So Big House is credited with starting the Small House Movement after her book was published in 1997. Susanka opened the door for designers like Jay Shafer, owner of the California-based Tumbleweed Tiny House Company. According to Alec Wilkinson, staff writer for The New Yorker, Jay Shafer “builds the most stately and sleek tiny houses.” Shafer, who specializes in sustainable architecture and urban planning, lived in his first tiny home, just 89 square feet for 5 years.

Greg Johnson, author of Put Your Life on a Diet: Lessons Learned from Living in 140 Square Feet says, “what excites me the most about simple living is how micro decisions can have a macro impact.” Johnson is founder and Director of Resources for Life, an outreach and public interest organization based in Iowa City, Iowa. Visit resourcesforlife.com for more information about the organization and the Small House Society.

Photo by Jack Journey | © Tumbleweed Tiny House Company 2008

Photo by Jack Journey | © Tumbleweed Tiny House Company 2008

Photo by Jack Journey | © Tumbleweed Tiny House Company 2008

© Tumbleweed Tiny House Company 2008

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Medical and Dental Space Planning: 3rd Edition by Jain Malkin

Another book!  After Jain vowed she would NEVER write another book John Wiley & Sons said it was time to do a 4^th edition of Medical and Dental Space Planning:  A Comprehensive Guide to Design, Equipment, and Clinical Procedures.  The current edition was published in 2002.  This is still the principal reference book on this topic, so here comes the new edition with lots of new material.  Well…don’t expect to buy it until maybe 2015.

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The clinic focuses on family practice, internal medicine, OB-GYN, pediatrics, and dentistry. This health and wellness center offers a model of coordinated care that is lacking in much of our primary care system in that it is a holistic approach­─during one appointment the patient may be seen by a number of providers (physician, nurse practitioner, nutritionist, psychologist, social worker) who all share information and insights. The goal is to do as much as possible for the patient as well as any children who may be tagging along at that one appointment. The clinic makes sure all vaccinations are up-to-date, that women have mammograms and PAP tests, as appropriate, and that chronic diseases like diabetes are being well managed. An on-site pharmacy, a café that serves healthy food, and a large community meeting room used for educational events compliment the clinical services.

Women’s health services include a WIC clinic to bring educational training to nursing mothers so that they and their babies can be healthier.

An interesting aspect of the project is its location on the periphery of a community college campus and close to a new light-rail line. Students pursuing medical arts degrees can do their internship at the clinic, a benefit to both the students and Adelante Healthcare.

Join us for a stimulating panel discussion about this project at the 2012 Healthcare Design Conference, November 3-6 in Phoenix and also register for the tour.

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A divided exam room is a variation of the standard medical exam room that is drawing interest in clinic space planning. This design model is appropriate for medical practices that choose to provide concierge care in which patients (sometimes called members) pay an annual fee for the opportunity to have easier access to a physician and longer appointments with a wellness focus. It is also ideal for integrative medicine practices where more time is spent with each patient discussing lifestyle modifications. Actually, Mayo Clinic was the first to initiate a combined consult/exam room referred to as a “Mayo room” many years ago.

This multi-use space has all the features of a traditional exam room and also includes an area for consultation, counseling, and education. A divided exam room may be a multi-room suite or condensed into a single room with dual-use for examinations and consultation.

Dual-use Exam Room

The most basic divided exam room is simply a larger than average exam room divided into areas by use. One side of the room will contain the exam table, diagnostic equipment, sink, storage cabinets and clinical supplies while the other side is designed for comfort and to facilitate discussion. The consultation space may consist of two lounge chairs in front of a large monitor or simply a table with comfortable guest chairs for the patient and physician to sit and talk. The consultation space should be comfortable and inviting. The seating should be arranged to promote communication between the patient and physician. The monitor may be used to review medical records, educational material, or to display stress-reducing nature images. The consultation area may also include a wardrobe, display shelves, art, magazines and diagnostic equipment. The design team may choose to make the consultation area visually different through use of materials to reinforce the purpose of the space.

Divided Exam Room Floor Plan

Multi-room Suite

If space allows, an exam room and consultation area can be divided into two rooms, separated by a door, offering the patient a more relaxing environment to encourage discussion. In this configuration the patient waits in a private consultation room with access to a TV monitor with educational programming, music, reading material and wireless Internet. The healthcare provider sits side-by-side with the patient in comfortable lounge chairs facing a wall-hung monitor to review lab reports, radiographs and to view medical images or videos if necessary. Vital signs are documented in this room and electronically uploaded to the patient’s health record. Once the consultation ends the exam continues in the adjacent exam room.  This configuration also includes a private toilet and designated nurse station.

Multi-room Exam Suite Floor Plan. Designed by Jain Malkin Inc.

Exam Suite Features

Consultation Room at Cisco LifeConnections Health Center, San Jose, CA. Designed by Jain Malkin Inc.

1. Lounge Seating
2. TV Monitor
3. Magazines & Art
4. Diagnostic Equipment
5. Comfortable Lighting
6. Entry to Exam Room

Pros & Cons of the Exam Suite Model

Designing a suite-style exam room can be beneficial in many ways but may not be the answer for every clinic.

1. Perceived wait time may be reduced. The consultation space is private and comfortable with a variety of positive distractions offered to the patient to reduce stress. They can watch TV, research medical questions, work on their laptops or flip through a magazine without distraction from other patients.

 

2. In the dual-room model the consultation space is self-contained accommodating spouses, elderly parents or children comfortably. Some clinics are even providing Xbox or PS-3 so the kids (or dads) can keep themselves entertained.

 

3. Space is usually at a premium. The most obvious draw-back to the suite design is that it takes up a lot more space. A traditional exam room is 8’x12’ or 10’x12’ while an exam care suite may be 12’x12’ or 12’x30’ if a true two-room suite is created. This concept essentially creates a private waiting room for each exam.

Seeing more patients in less time is the goal in our current healthcare system as reimbursement keeps spiraling downward but when physicians are incentivized to keep people healthy and focus on prevention, longer appointments in a dual-use exam room makes sense.

Scripps Center for Integrative Medicine, La Jolla, CA. Designed by Jain Malkin Inc.

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