Mission-Oriented Design: Two Views.

Strategy is usually thought of as a management tool, but it is also important to use strategic thinking in other areas, such as design. In constructing new healthcare facilities or in remodeling older facilities, the planning phase should consider the organization's overall mission. This should include strategies that will meet foreseen challenges in the future, such as growth of the facility, environmental and community changes, regulatory expectations and technology issues. Yet planning must be flexible enough to accommodate change.

Universally, designing space for a physically compromised population must support the clients' ability to function as independently as possible. The treatment areas must also incorporate the needs of the staff. In sum, design should support the staff's ability to provide treatment while encouraging the resident's independence. This establishes a critical design challenge: how to create space that enables clients to function as independently as possible and support the staff in facilitating the achievement of that goal.

Another critical challenge involves the limitations set by the licensing and regulatory agencies that, although unintentionally, can act contrary to enabling independence.

Recently, in an effort to better understand how providers are meeting these strategic challenges, I spoke with some who have had recent firsthand experience in participating in the design and remodeling of their respective organizations:

Leslie Larson, MA, administrator of the Centre for Neuro Skills in Los Angeles, California, which serves clients who require rehabilitation for brain injury or other related conditions and who are learning skills for re-entry to home and community.

EliPick, CNHA, CAS, CEO of Ballard Healthcare in Des Plaines, Illinois, which offers a continuum of post-acute care services.

Hyatt: In your experience, what areas present design/architectural challenges for the patient population that your organization serves?

Larson: This really hits home, as they say. The clients we serve experience difficulties both where they live and where they work. Such things as durability of steps and railings, the height and strength of countertops, wheelchair accessibility, the size of doors and the utility of shower stalls, bathrooms, kitchens and hallways all present daily challenges. The reality is that few homes or older structures, which are often used for assisted living, meet the new American Disabilities Act (ADA) space/design requirements. In many instances, it just is not economically feasible for the owners to comply.

Pick: We face unique regulatory and client/staff issues in the healthcare industry. We are over-regulated, and some of the regulations for post-acute care are not always in the clients' best interests. When we were designing our environment for rehabilitative care for our skilled nursing facility at Ballard, we contracted with Guynes Design of Phoenix, Arizona, to develop Our [Town.sup.TM] as a unique feature that provides simulated settings for clients to practice their everyday activities. This includes a bank, grocery store and varied walking surfaces, as well as an apartment that includes a fully functioning bathroom. The state health department required that we conform to the institutional guidelines, which differ significantly from standards used in most private homes. We tried to clarify to them that while the institutional requirements made sense for those who were most limited in functioning, those clients would be the exception in our facility, and that our goal of providing training for clients wh o would need less assistance would be compromised. However, the lowest common denominator is the focus of the regulations, and we had to comply in order to receive approval for the design of the unit.

The ability to adapt the design to meet the regulatory requirements and still enable clients and staff to use the space appropriately is the challenge. Therefore, we worked with the designers to develop an approach that enabled staff to utilize removable aids that are specific to the needs of the client. This satisfied the regulations and still allowed the program to adapt to individual clients.

Hyatt: What is the impact of architecture/design in your service area?

Larson: Home- and community-based brain injury rehabilitation is a daily challenge for newly disabled clients who are re-entering their homes, residential care such as assisted living, their communities and their workplaces. If the client is wheelchair-bound and resides in an older home or apartment, chances are he must maneuver through a narrow doorway in which some wheelchairs will not fit. Or if he is a larger individual and uses a wide walker, he will have to hop sideways to get through. Many clients and their families find this too difficult to cope with, so they set up the bed, commode and all other needs in the living room in hopes that the client will recover quickly and these architectural barriers won't be a factor. Attendant care is often necessary in these situations.

Other clients are institutionalized because the home or residential living environment is not safe enough for them without major remodeling.

Most home bathrooms are too small and do not allow any room to maneuver a wheelchair to the toilet, sink or bathtub. With a bathroom this small, it is not uncommon for a client who has suffered a spinal cord injury to use a rolling commode chair to get in and out of the bathroom. This often requires attendant care to move the chair and to transfer the client from the toilet or to the tub and out. The risk of falling is very high.

Other clients are able to walk but might have depth perception or visual deficits from their injury. In those cases, jutting staircases or angled hallways or cabinets can be a hazard and a challenge.

Cheap, flimsy building materials appear to be popular in many apartments and buildings. Some brain-injured clients lose their ability to fine-tune the weight of their steps or might lean on countertops too hard, resulting in rapid deterioration of steps and countertops. Our organization has had to assist clients in getting stairways rewelded and replacing countertops and railings.

Clients with behavioral issues as a result of the traumatic brain injury (TBI) require shatterproof glass, industrial-strength low-nap carpeting and rounded corners on all furniture.

Clients who participate in acute rehabilitation at a hospital will probably be regaining function in an environment with ADA specifications of architecture. But the real challenge occurs upon discharge, when the client has to relearn to cope with his home, community and place of work.

Soothing colors are another important element during the recovery process and are often used in rehabilitation clinics. Beyond that, though, the "real world" is a kaleidoscope of color. Having progressed through the recovery process, the client is taught to adjust to the community. The same applies to coping through problem solving with the lack of elevators and small doorways, bathrooms and kitchens.

Pick As our organization has developed specialized programs that meet the needs of a diverse population, different client populations and their visitors now compound the design challenges. The age groups are extremely diverse and have very different needs and interests. The desire on the part of these populations to not only have specific programming, but also to have dec11cated space that is individualized to them, is very high on their priority list.

Hyatt: When choosing a design and/or architectural firm, what factors influence you the most?

Larson: There are many good architectural and design firms available, but we look for only those that have experience with our particular type of population in building to ADA specifications. We expect the architectural company to utilize contractors who are timely and use durable and high-quality building materials. It is crucial that they build to our specifications and the regulatory specifications.

Pick: The firm must, first, be familiar with the codes and/or regulations that govern the activity. If it is skilled nursing or assisted living, for example, there are significant differences in space requirements dictated by federal and state codes. This might be the result of assisted living facilities being non-licensed in most jurisdictions, while skilled nursing facilities must comply with federal and state regulations. Selecting a firm that has a working relationship with the governing agencies in that jurisdiction helps facilitate the process of approvals and minimize the amount of time spent on reviews.

To conclude, strategic planning for design should present another opportunity for providers in all areas of healthcare to revisit the goals and mission of their organizations. The organization must have a very clear concept of its goals in order to enable the architect/designer to plan a space that works in concert with the organization's overall mission.

If you have suggestions that you think would be helpful to others working in the area of post-acute care, please forward them to Laura Hyatt, MBA, Hyatt Associates, 2956 Kelton, Los Angeles, CA 90064.

Laura Hyatt, MBA, is president of Hyatt Associates, Los Angeles, California.