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Design for the times: how to select an integrated facility design team without tearing your hair out.

If you've been working in the long-term care market for a while, you know that "culture change" and "building green" are today's buzzwords You may also be acutely aware that the current physical plant of your facility is in need of upgrades--or perhaps complete replacement.

Like many people, you might do an Internet search for the phrase "long-term care design" to begin your research. You're likely to come up with The Physical Environment's Impact on Long Term Care Residents, with a link to the Center for Health Design, and a report entitled Health Promotion by Design in Long-Term Care Settings by Anjali Joseph, PhD, the center's research director. The report includes a review of 250 articles that relate the facility environment to outcomes, primarily in the areas of resident quality of life, resident safety, and staff stress.

The environment plays a key role in improving resident outcomes and staff satisfaction. This means that there is evidence available to support decisions made during the design process.

In seeking an integrated team of professionals to assist you with strategic design-making and master planning, using evidence upon which you can base design decisions is one main criterion to include in your request for proposal. Resources for research on long-term care environments include the Coalition of Healthcare Environments Research ( and the Society for the Advancement of Gerontological Environments (

What culture change means for design

When long-term care facilities were first designed, they were modeled after acute-care settings. At the time, designers missed the point that the folks being served in these facilities were not short-term care inpatients, but long-term residents.

My grandmother referred to her short-term stay in one facility as "being incarcerated." Although that may seem a little extreme, it's the unfortunate truth that institutionalization of our elders has led to outcomes that are not desirable, because those facilities feel like prison settings.

Culture change is about viewing a person as a whole human being, and clinical needs are only part of the equation. Jude Rabig, the National Director of the Green House Project and a consultant in the long-term care market, states it clearly: "You don't live with your doctor!"

Culture change is a change in care modeling. The goal is for the resident to be the central focus and for the hands-on care provider to be given responsibility and authority for the daily care of the "whole person," not only meeting clinical needs, but also providing access to fulfillment of physical, emotional, and mental needs. Some facilities have dissolved most of the middle management from their existing hierarchy and empowered their certified nursing assistants (CNA) with responsibility and authority. Others have developed self-directed teams that allow decisions to be made, seeking additional input as dictated by residents' needs.

Still other facilities have taken bits and pieces from several models and created a system what works for their residents, their staff, and the local region they serve. Another brave facility flattened its staff hierarchy completely, so all directors come together to make decisions.

What is the absolute key in starting and maintaining culture change and resident-focused models? As Kathy Oddenino describes in Healing Ourselves, there are five basic tenets to success: commitment, communication, cooperation, compassion,

Resources for hiring an architect

If you go back to your Internet search engine and type in "healthcare architects," "healthcare interior designers," and "design for aging," you'll find the following results: the American College of Healthcare Architects (ACHA), the American Academy of Healthcare Interior Designers (AAHID), and the Design for Aging (DFA) knowledge center, which is a subset of the American Institute of Architects (AIA) that focuses on designing environments for seniors.

ACHA is a certifying entity for architects, and AAHID is a certifying entity for interior designers specializing in the healthcare sector. It is recommended that you bring in interior design professionals from the beginning of the design process, as programming and space planning are large parts of the overall strategic planning process.

Green integration

The concept of an integrated team is not new and has been strongly reinforced with the sustainable green building movement. So go back again to your Internet search and type in "green building." There you find the United States Green Building Council (USGBC), which is the most well-known resource for sustainable building practices.

Sustainable, in this context, means that buildings are designed to be high-performance, energy-efficient environments. Examples of green building initiatives include the following:

* selection of materials with recycled content/renewable properties

* placement of windows and buildings that not only provides access to views, but also uses daylight for passive solar energy, creative lighting strategies, and thermal properties

* use of geothermal power as a source for mechanical systems

* use of minimal amounts of chemicals for cleaning

* availability of areas for recycling and composting

All told, it basically means being a good steward of the environment.

Currently, I am working on a project for which the desire for using green building features in the replacement nursing home is coming from the independent riving residents in the retirement community.

The project includes three resident committees, including the green committee, an Alzheimer's committee, and an aquatic center committee. Each committee completed research to share with the design team, and each chairperson is part of the design meetings, discussions, and presentations. This input is invaluable for fulfilling the needs and requests of residents, and that's to say nothing of the benefits of sharing ideas, discussing experiences, and brainstorming. The initial discussions provided an opportunity to introduce the Green House concept as a care model, which had not yet been investigated.

Videos and Web site information were shared, resulting in administration and staff looking into household models and agreeing to a workshop that provided education and information on different household models based upon training staff and evaluating all types of workers.

In addition, staff attended seminars, both in Mississippi--the site of the original Green Houses--and locally, to investigate alternative care models. The green committee has not only been important for providing ongoing input on sustainability initiatives, but it has also provided the link to administration and the other committees to challenge the current clinical paradigm. The interaction between the design team, the staff, and the residents made possible the ultimate outcome of clinical staff coming back to the design team with sustainable ideas for programming, care modeling, and the built environment.

Did you ask your residents?

Unfortunately, resident involvement in decision-making is an oft-overlooked part of the planning process--a big oversight, considering residents and staff are the end-users of the design.

In working on a strategic master plan, resident and staff input is essential to creating an environment that supports a philosophy, a culture, and operational viability. The built environment is only effective if it supports the users of a community. "If you build it, they will come" is not true. The most successful projects are those that use input from residents or potential residents and staff from all levels--not just the ones in upper management or from the segment that usually makes all of the decisions.

Another opportunity for resident input is completing postoccupancy evaluations of projects. For continued development, renovations, and care modeling to meet future needs, an evaluation completed by all users provides invaluable information for continued planning purposes. The senior living industry is anything but static, so look to others to supply ongoing input to continue to meet trends and future needs.

Selecting green design professionals

In terms of selecting design professionals with background in sustainable building practices, look for the designation LEED AP, which stands for Leadership in Energy and Environmental Design, Accredited Professional.

LEED[R] is based on a twofold certification process. Design professionals can sit for an examination to become qualified as a LEED-accredited professional. The examination is based upon the LEED rating system, which is used to certify buildings. Additional rating systems are available from the Green Building Initiative (Green Globes and Go Green Plus) and the National Association for Home Builders.

Undertaking a major renovation, multiple smaller renovations and updates, master planning, or new building construction is exciting. It provides an opportunity to reevaluate your facility, organizational culture, and care models, as well as prepare for the future.

Spend money to make money

Spending additional money up front for the planning process is money well spent. By the time construction documents are prepared, everyone has had input and the team has completed research that demonstrates and addresses the direction of your facility, care model, staffing, residents, and trends.

The process of completing construction documents usually entails the largest amount of dollars spent when taking on a construction project. With these appropriately completed, design services will move along much more smoothly because most of the questions have already been answered in the up-front planning process. In addition, using up-front planning and an integrated team has been found to lessen contract administration time and, more important, limit change orders.

For evaluating construction costs, the strategic planning process assists with establishing priorities. Once identified, the cost for each item is coupled with an associated revenue stream, depending upon the size of the project. Revenue generators are recommended as part of the up-front planning process and dialogue.

For example, if you establish a program that generates a revenue source, then there is a possible offset to the construction work being completed. Another good example is using green building strategies. These can result in lower operational costs, which means you can make a more educated decision regarding installing HVAC equipment.

The separation of first costs and then operational outcomes is not a good planning practice. Reviewing the life cycle of the building in conjunction with operations and care models is the best financial approach to take when planning a project.


Jane Rohde, AIA, FIIDA, ACHA, AAHID, LEED AP, is principal of JSR Associates, Inc., a senior living consulting firm located in Ellicott City, MD, which is committed to improving environments for seniors, their families, and staff. E-mail lane at
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Author:Rohde, Jane
Publication:Contemporary Long Term Care
Date:Mar 1, 2007
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