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Creating environments for modern care

March 1, 2008
by Timothy M. Rommel, AIA, ACHA, OAA
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Effective designs maximize patient care and provide real-world experiences

During the past century, behavioral healthcare has undergone a tremendous transformation. Yet the facilities in which treatment—particularly inpatient care—takes place have aged, and many now need to be replaced. At the same time, inpatient stays are shortening due to, among other reasons, reimbursement constraints. Thus, patients' time in inpatient settings must be maximized, and patients must be prepared for the environments and situations they'll encounter after discharge. Fortunately, architects have found ways to address these issues by creating efficiently organized patient care units and “normalized” environments.

Efficiently Organized Units

Inpatient stays averaging from four to six days are not uncommon. During this time, clinicians must stabilize the patient, diagnose him/her, begin a treatment program, observe/document the patient's progress, and develop a discharge plan. During a six-day stay, clinicians have about 84 hours for patient contact and treatment, assuming a patient will spend 10 hours a day sleeping and engaging in normal personal/hygienic activities (leaving the remaining 14 hours to active patient interaction and treatment).

The design of patient care units can significantly impact how efficiently staff can use the limited time they have with patients. An effectively designed patient care unit ensures that when patients leave a treatment area, they pass through an area monitored by clinicians; without such a design, patients could spend more time in their rooms—and less time in therapeutic activities. The “ABCs of Patient Care” is a design concept that helps designers and planners ensure that clinicians maximize their contact with and treatment of patients. The ABCs represent the essential building blocks of the patient care unit.

  • “A” represents the Activity zone—any space that promotes or enables active interactions among patients, clinicians, visitors, and family members. This also is referred to as the unit's “daytime” zone.

  • “B” represents the Bed zone—space commonly associated with patient bedrooms. This includes bathrooms, toilet rooms, shower facilities, laundry facilities, and supply rooms (e.g., linen storage). This zone also is referred to as the “nighttime zone.”

  • “C” represents the Clinician zone—space clinicians occupy without direct patient contact, such as the on-unit medication room, charting area, staff conference room, team center, staff break/locker room, etc.

These three zones can be organized to greatly increase the efficiency of patient treatment. For maximum unit effectiveness, zone C must be in direct contact with zones A and B. Ideally, zone C acts as a buffer between A and B, allowing staff to maximize the time patients spend in direct care. Figure 1 displays the zones in patient units at several behavioral healthcare hospitals.

Figure 1. The ABCs of Patient Care: A = Activity zone; B = Bed zone; C = Clinician zone

Normalized Environments

Much has been written in healthcare design publications about creating a homelike environment. Such qualities may be desirable in a patient bedroom but certainly are not appropriate for an entire behavioral healthcare facility. Other areas of behavioral healthcare facilities should reflect settings patients will encounter once they leave the hospital. This is called creating a “normalized” environment.

In this design concept the hospital is organized to create the experiences a patient will encounter after discharge. This is not a “stage-set” approach but rather a much more inherent way of organizing the facility.

The hospital is conceived as a town or village, with its components and departments reflecting services or functions in a town (figure 2). This town-planning approach serves as a blueprint for organizing and planning the hospital. Just as towns create zones for residential, commercial, retail, educational, and industrial uses, a behavioral healthcare hospital can include similar zoning (figure 3).

Figure 2. At the Whitby Mental Health Centre in Ontario, a 1,500-foot-long, two-story enclosed corridor (“The Street”) suggests the overall metaphor of a village or town. Photographer: Patrick Kennedy/East End Studios

Figure 3. The Lindner Center of HOPE in Cincinnati (opening later this year) creates a normalized environment by offering patients different environments and experiences throughout the campus.
The residential zone is comprised of patient care or nursing units. Each unit is likened to a neighborhood in a town with patient rooms representing individual homes.

The commercial zone is comprised of treatment departments that become destinations for patients, both physically and in terms of their treatment objectives. In this zone are areas for behavioral, medical, dental, occupational, physical, and other treatments and therapies. These departments are where patients' “9-to-5” activities take place.