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Holistic Medicine

Physicians have come to understand the importance of treating patients holistically, of understanding not just issues of the body, but those of the mind and spirit. We also know that it is not the strength of any one of these entities that leads to better health, but the right balance of all of them.

We at Callison Architecture approach the design of the 21st-century acute-care unit with the same attitude. The business of sustaining patients is too complex to design from only one viewpoint.

In the last decade, there has been an important move toward creating more humane, comforting surroundings for the patient. This stems from the realization that the environment has a quantifiable effect on healing. Many facilities have cosmetically upgraded patient care areas to look more like homes or hotels than institutions.

Family wait and support areas have often been designed or retrofitted to be more comfortable. Many facilities have upgraded their food services to include well-presented, flavorful food. Some have moved to a room-service approach rather than just delivering the same thing to all patients. Still, this humanizing trend does not go far enough.

True patient-centered care requires equal consideration of patients, caregivers, and the materials that support them. A patient's experience will not be satisfactory if the caregiver is too stretched to respond appropriately. Even the coziest patient room cannot make up for a nurse's stressed attitude.

Nurse!

On Callison's staff is Kerrie Cardon, RN, AIA, an architect and a registered nurse with 14 years of clinical experience. She uses her expertise to investigate hospital operations from both perspectives, analyzing patient, process, and materials flow, reviewing staffing issues, and evaluating facility layout to improve staff efficiency, patient care, space effectiveness, and customer service.

For example, information gathered regarding medical/ surgical nursing unit operations for the Providence Campus of Swedish Medical Center in Seattle resulted in a design solution that alleviated two major causes of stress for the nursing staff: fatigue and isolation.

The hybrid solution combines centralized and decentralized nursing. Room-side charting stations disperse daily nursing activities and trim trips for supplies and other tasks by as much as 50 percent on the 36-bed, 14,000 square-foot (1300-square-meter) floor. Three new "care-ports" — nurse stations designed to accommodate three nursing teams — help maintain critical contact with colleagues.

No Givens

To understand the assembly of systems that support the activities of an acute-care unit, we need to revisit the fundamentals of the work being performed there. Assume there are no givens. For each user, ask the question: What does it take to do your job effectively? Patients, caregivers, physicians, materials managers, housekeepers, and owners all have differing needs. Balancing them is the key to better results.

Consider storage. For years, the response to the chronic shortage of storage space has been simple: build more. Yet nurses continue to squirrel away equipment and supplies. Why? Experience tells them it may be the best chance of saving precious minutes in an already stressful day.

Maybe the real problem isn't the lack of storage but that nurses don't trust the delivery system. In that case, working through the materials management issues can provide maximum support when and where the caregivers need it. Given today's scarcity of nurses, investing in better delivery systems may be a cost-effective solution to attracting and retaining them.

Operational improvements like this can have a big influence on the bottom line, not only through improved staff and patient satisfaction but also by reducing costs, shortening lengths of stay, and improving throughput.

For instance, staffing analyses can identify strategies to improve "census management." This term refers to the difficult task of coordinating the highly variable flow and quantity of patients through the facility.

An example of an architectural response to census management problems is in an observation unit in which patients can be monitored by appropriate staff for a short period of time (less than a day) rather than being admitted into a nursing unit.

Many patients, such as those with undefined chest pain, need to be monitored while a diagnosis is being made and lab tests are being run. Admitting them into a nursing unit during observation has inherent inefficiencies: they are potentially with inappropriate staff for specific monitoring needs; they may be put into a reimbursement category that may not make sense (and may actually lose money) once the diagnosis is made; and they take up valuable bed space that could be occupied by an appropriate patient.

By understanding these operational issues, architects can recommend and design spaces that create effective adjacencies, promote operational efficiency, help reduce stress for caregivers while allowing more quality time with patients, and improve bed capacity and room-use rates.

Balance, Not Compromise

For Callison, rethinking the nursing unit means finding strategies that give the new facilities more options for supporting their long-term health. Think balance, not compromise.

The goal is not only to address the web of issues that influence healthcare now, but also to create an integrated model that can flex more readily in response to changes in technology, economics, policy, and social structure.

Including all viewpoints, from operational planning and materials and process flows to patient needs and caregiver requirements, is the most important step in opening our minds to new possibilities.

Janet Faulkner, AIA, a principal of Callison Architecture, Inc. in Seattle, leads the firm's Healthcare Studio and is a specialist in the design of healing healthcare environments.

Callison had nurses replicate procedures in a full-scale model of a patient room to identify the best placement of medical gases and other key room elements. Photo: Chris Eden The evolution of acute-care nursing units illustrates problems solved and problems created. In the 1940s, a long rectangle ensured light and ventilation for patient rooms but made long distances from the nurse station to patient rooms at end and provided inadequate support space and storage. Image: Callison Architecture, Inc. Better support space in the 1950s also limited visibility from the nurse station to some patient rooms and elongated nurse travel distances. Image: Callison Architecture, Inc. Cross-shape floor plates in the 1960s improved expansion potential, but hurt staffing flexibility and placed the public entrance at the center of the patient care zone. Image: Callison Architecture, Inc. Circular configurations of the 1970s shortened travel paths for nurses, but limited the potential for architectural adaptability. It also meant inadequate support space and storage. Image: Callison Architecture, Inc. Triangles of the 1980s again shortened travel paths, but limited support space, storage, and architectural adaptability. Image: Callison Architecture, Inc. Patient clusters of the 1990s promoted the perception of nurse isolation from other caregivers. Image: Callison Architecture, Inc.   Click on thumbnail images to view full-size pictures.