Dealing with the code masters: how two facilities built for the future.

The Michigan Masonic Home and the Clark Retirement Community had both decided to take resident-centered approaches to master planning for renovation and expansion of their health centers. Old buildings, once serving residents in the manner dictated by the times, they were becoming obsolete. People wanted more space, greater privacy, and a residential environment. What's more, all indications were that these preferences would continue to drive facility design for many years to come.

Doing something about this required that both facilities challenge some long-standing regulations. Some aspects of each development process worked extremely well; others involved unforeseen difficulties. These organizations believe that by sharing their experiences--good and bad--with other potential facility development sponsors, they might better avoid certain pitfalls and create genuinely improved settings.

With this in mind, they both contributed their observations to the American Association of Homes and Services for the Aging (AASHA) Design & Code Exchange, a project created with funding by the Retirement Research Foundation. The Exchange facilitates networking and efforts to bring change to the design code process so that more appropriate settings for older persons can be built. The issues they documented for the AAHSA Design & Code Exchange are the subject of this article.

The Michigan Masonic Home

Located in Alma, Michigan and founded in 1891, this facility began its planning in the mid-1980s. A development team was set up ensuring active participation by board, staff, residents, and others involved with the Masonic Home.

During the five-year development process that followed, there was a fair amount of turnover on the board and among key members of the design and development team. Obviously, this can create awkward situations when trying to bring a project to completion; it is critical to maintain thorough documentation regarding all decisions. Much input and participation was solicited from residents, families and staff at all levels, as well as regulators, people from academia, and volunteers. During the process the planners learned that one thing that could have been improved upon was establishing at the onset realistic expectations. Nevertheless, the wish lists were challenging, and enabled the planners to more clearly identify what participants wanted. For example, the Masonic Home found the original certificate of need was too modest, compared to what was wanted. Because it was easier to apply for a new certificate of need rather than amend the first one for more space, a second one was applied for and granted.

They also found that risk-taking was essential. One risk involved planning for more square footage than the state allowed for nursing homes. Knowing that the state was considering increasing the square footage allowance, the Masonic Home was dedicated to building according to the newer, larger standards.

The corridors expand by two feet at each resident room doorway so that resident room doors recess by two feet. That gives residents a "front porch," and by enabling the doors to swing out instead of into the room, residents gain additional living space since they can use all floor space in their room up to the doorway. Even though this particular doorway design greatly enhances resident living space, it is frequently lost in states which set rigid square footage and cost limits for nursing homes. Unfortunately, those limits consider only start-up costs, and not the lifetime costs of the facility.

Most states want to contain costs in terms of cost per bed at startup. For example, a less expensive HVAC will yield cheaper startup costs, but will actually cost more money over the long run than a more expensive and efficient one with a longer life. Re-shaping bathrooms in the design process so that residents can get a wheelchair into the bathroom may add cost, but will make residents more independent and less reliant on staff help. Adding a little more space to keep supplies closer for staff makes staff more efficient. These costs often aren't factored into a cost-per-bed equation.

The Masonic Home was also committed to offering a high ratio of private rooms to semi-private rooms: 100 private rooms and 52 semi-private rooms were built for nursing care. However, the units were smaller than traditional units, each housing only 45 residents, with the area further divided into two sections of 23 and 22 residents. This meant corridors could be short and and thus more negotiable by frail elderly.

Fortunately, state authorities proved to be flexible in this case. The planners met often to consult with Michigan Department of Public Health staff and the Fire Marshall's representatives. Masonic Home staff were encouraged when they first saw the licensing officer from the Department of Public Health debating with the Fire Marshall's representative, the licensing officer taking on the role of advocate for the nursing home, knowing that its plans were in the best interest of the residents.

Code authorities may offer many challenges and cause for appeals through the design and building process, especially in the areas of plumbing and electrical, as well as the Fire Marshall. The regulators tend to say no, something cannot be done because it will violate regulations. The sponsor must know what it wants and be prepared to demonstrate how desired design plans are more responsive to residents and also be able to explain how the plans may be interpreted in keeping with the regulations.

For example, while regulations stipulated that personal items must be kept in a nightstand, the home staff and residents disagreed. They wanted personal items kept in the bathroom as people do in their homes. In keeping with the non-clinical decor that was the design goal, each resident bathroom was to have personal storage cabinets. The state had a problem with the original design for shared bathrooms having one large cabinet. The design was altered so that each resident would have his or her own cabinet, and that design was approved.

An Alzheimer's special care unit was planned and met regulatory challenges. A lounge area with an adjacent dining room was specifically designed to be open so that residents could see the area and any activities taking place. The Fire Marshall representative wanted a wall around the entire space. The Home defended its plan for open space, explaining it would better support resident functioning. The open area was approved.

That unit has 16' wide corridors so that furniture can be placed outside of resident rooms. Residents could go directly from their private sleeping rooms to an environment resembling a living room, contributing to the residential design. However, the Public Health Department and Fire Marshall's office did not want to accept this plan. They cited codes that require 8' corridors and no furniture in any corridor. The Masonic Home was able to explain that the required path for egress existed and safety would not be compromised. Again, the plans were accepted. One of the more complex regulatory challenges revolved around toilets. The Home was required to go through a very elaborate appeals process with the state's Plumbing Review Board. To meet the state's barrier free standards, toilets were required to be 17"-19" in height from the floor to the seat top. Because Masonic Home residents are predominantly short in stature, staff did not want toilets to be too high. Since standard American-made toilets are 14-1/2" tall from floor to rim, the regulations would force a facility to use a seat with a 1-1/2" to 3" lift in order to meet the minimum height requirement. Such a large seat lift raised concerns regarding stability, sanitation, and aesthetics.

Staff found a Canadian-made toilet which measured 16" from floor to rim, which with a regular seat reached the required 17". This toilet, however, had not been approved for use in Michigan, and planners went throught the process of submitting this model to the Plumbing Review Board for approval.

Their "toilet travails" were not through, however. The planners discovered that the Michigan Department of Labor had its own requirements regarding where toilet paper holders were to be placed. Even though most residents would not be able to reach the toilet paper holder if it were placed according to the Department of Labor specifications, the Masonic Home had to go to an administrative law judge for a ruling to change the position. The judge dutifully issued a four-page opinion defending the Home's desire to place the toilet paper holder closer to the toilet.

From the sublime to the ridiculous, the Masonic Home planners learned that one must be ready for anything in striving for the next level of excellence in nursing home design.

The Clark Retirement Community

A 335-resident continuing care retirement community located in Grand Rapids, Michigan, this facility was founded in 1906 by the United Methodist Church. Twelve persons reside in independent living, 164 live in the retirement residence which offers each resident a private room and congregate meals, 48 people live in the assisted living center, and 111 residents are in the skilled nursing center.

The master planning process was begun because not only were the residents aging in place, but the buildings were as well. This had started to affect census, which had always been 100%, and programming, too, which had always been regarded as excellent. A consultant with the United Methodist Church assisted with the planning, but the master planning process was primarily a board and executive director process. If they were to do it over again, the planners say, they would expand the process to include key staff. Staff are an incredible information resource, with practical experience in day-to-day operations.

The planning process led to six major conclusions. First, the accommodations at every level of care were smaller than people were looking for. In some cases they were obsolete. More and more retirement residence people wanted an apartment, not a single room, and in the nursing area semi-private rooms were small when judged by current needs and preferences.

Second, there was a need to centralize nursing areas since two-thirds of the nursing home residents were in one building and one-third in another, with the buildings joined by a tunnel. Third, there was, and is, a continuing and growing need for assisted living. Fourth, it was possible to provide additional independent living units at the present location. Fifth, though the Clark Retirement Community was well-known to the United Methodist community, it was virtually unknown to the greater Grand Rapids community. Sixth, all the changes that needed to be made--constructing independent living units, building a new health center, renovating for one-bedroom apartments, and increasing the number of assisted living residents to be served--would need to be made gradually over 6 to 7 years.

The Clark Retirement Community selected an architect who understood the need to work closely with staff as part of a design team. The architect asked the director of nursing for her vision of the health care component. She felt the health care center needed to be at the very center of the campus and, therefore, the center of operations. She knew that availability of health care services is a key factor for people in deciding to move to a retirement community. They want to be assured they can receive quality health care if and when they need it. This was an innovative concept, in that usually the tendency is to place health centers where they cannot be seen when one first enters a community.

Continuing development of the health care center plans brought resident concerns to the forefront, and required challenging some longstanding codes. All on the design team agreed that the health center must be like someone's home rather than someone's hospital. Privacy is important, and they found that people preferred small private rooms to large double rooms. The plans therefore called for 75 private rooms and 18 semi-private rooms. The large number of private rooms was made possible by providing for the bathroom to be shared by two rooms. Since bathrooms are very expensive, this arrangement allowed the planners to stay within budget and still deliver privacy to future residents.

Keeping units small-scale was key, and led to an innovative design that met with resistance from state regulators. The design team was aware of the importance of enabling relationships to be developed between residents and staff and between residents. They knew that this cannot be achieved if staff perform tasks and then leave residents to return to a nursing station. Based on that concept, the architect designed a unit that eliminates the traditional long corridor that ends at a staff work station. Instead the unit is designed with clusters of 8 to 10 private rooms that surround an activity, living, and dining area. There are twelve clusters throughout.

Knowing that this plan was well-thought-out and acceptable to the organization, all involved in the development process were confident that it would be acceptable to the bureaucracy. The architect submitted the plans to the state Fire Marshall. The Fire Marshall saw things he liked, but raised the key issue of the furniture being located in the central cluster areas, which he viewed as the corridor. Though the required corridor space existed, having the additional square footage with furnishings was a new concept to him.

He allowed that he was willing to accept the plan if Clark Retirement Community would bolt the furniture to the floor. He wanted the furniture to remain in place permanently to provide a consistent path of egress. That was not acceptable to the facility. They explained to the Fire Marshall that his plan likened the facility to a McDonald's, where immovable furniture did not allow people to slide into their seats. Their intention, on the other hand, was to create a homelike setting.

Seeing that the Fire Marshall would not budge, the planners took the issue to the state Fire Safety Board with a formal appeal. The board was convinced that fire safety precautions had been taken care of structurally and operationally, and therefore granted its approval.

After the Fire Marshall issue was resolved, CRC received letter from a Department of Public Health employee who was disturbed that he had not been contacted earlier to review the plans. He implied it didn't matter, since the Fire Marshall wouldn't approve the plans he had seen. The facility then informed him that the Fire Marshall had indeed given his approval, and then responded to his series of questions and concerns. The Public Health employee felt that a sponsor's only concern was for the building, and it was his job to look out for the residents. Unfortunately, too many bureaucrats believe that "looking out for the residents" means enforcing outdated, hospital-based codes.

The facility always maintained that residents were the central issue and concern throughout the planning process. The fact is that the staff's commitment to the residents was the driving force that enabled them to take on bureaucrats unfamiliar with new and better design for the elderly. Clark Retirement Community did not begin the project with the thought of being innovative. Innovation occurred as the planners responded to the question "how do we best serve the residents?" They saw that development and design are not about regulations--they are about mission.

Formerly CEO of Masonic Home, Roger Myers directed the building process at Masonic Home and is currently President of Presbyterian Villages of Michigan. Robert Perl is Executive Director of Clark Retirement Community. The American Association of Homes and Services for the Aging (AAHSA) Design & Code Exchange sponsors a 24-hour helpline [phone] to share information, advice and successful strategies for navigating the building process