Advancing Healing Design to the Next Level
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What rehabilitation facilities can teach us about advancing healing design to the next level. Identify multi-sensory design strategies. Discover benefits to facility way-finding. Find synergies in contradictory needs. Support patient mobility and independence.
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Advancing Healing Design to the Next Level
- 1. Advancing Healing Design to the Next Level What Rehabilitation Facilities Teach Us
- 2. Natale Ward The Design Partnership Chris Downey Architecture for the Blind INTRODUCTION
- 3. VA Palo Alto Campus Outpatient Wing Inpatient Wing Entry and Garden INTRODUCTION
- 4. project goals & hypothesis Help patients navigate clinical environments & Support patient mobility and independence Without reinforcing a reliance on environmental crutches Multi-sensory design strategies along with the inclusion of all modalities during the design process will enable us to do this INTRODUCTION
- 5. discoveries Benefits to facility way-finding When specific disabilities are taken into account Synergies in contradictory needs When treatment modalities are addressed in tandem Treatment philosophy informs the design The design process can help to support training and treatments while helping to identify & correct obsolete protocols INTRODUCTION
- 6. a moment as a vision-impaired person Early-stage glaucoma INTRODUCTION
- 7. a moment as a vision-impaired person Notice the different world-view of someone with a disability Empathize by putting yourself in that person’s shoes Adapt through simple behavioral solutions Enjoy an environment that’s now better for you too INTRODUCTION
- 8. combat injuries Korean War: 2.8 injuries/death Vietnam War: 2.6 injuries/death Iraq/Afghan:16 injuries/death INTRODUCTION
- 10. BENCHMARKING National Intrepid Center of Excellence
- 12. BENCHMARKING VA Western Blind Rehabilitation Center
- 13. BENCHMARKING Multi-sensory navigation: A still-untapped resource Way-finding with disabilities: Landmarks within facility, or compensating with signage Synergies within contradiction: Finding strategies to combine multiple disabilities Mobility without “crutches”: Good intentions conflict with life in the real world
- 14. INNOVATIONS AND DISCOVERIES Building shape = F > < ^ Multiple pacing loops for mobility practice and orientation cognitive issues
- 15. INNOVATIONS AND DISCOVERIES Cane taps produce radar-like echo along vaulted forms Existing walkways on VA Palo Alto campus acoustical considerations
- 16. INNOVATIONS AND DISCOVERIES Transitioning from artificial to natural lighting for patients with photo-sensitivity Light patterns on floor cause confusion for some patients lighting environment: natural
- 17. INNOVATIONS AND DISCOVERIES color theory
- 18. INNOVATIONS AND DISCOVERIES Early stair design Going up: how do vision impaired find the foot of the stair? Going down: how do they find the exit? way-finding
- 19. INNOVATIONS AND DISCOVERIES way-finding
- 20. INNOVATIONS AND DISCOVERIES logistics, mechanics and adjustment
- 21. INNOVATIONS AND DISCOVERIES logistics, mechanics and adjustment
- 22. INNOVATIONS AND DISCOVERIES multi-sensory design
- 23. INNOVATIONS AND DISCOVERIES Multi-sensory navigation: Everyone benefits when other senses are engaged Way-finding with disabilities: Impairments highlight failures of plan/design clarity Synergies within contradiction: Design process helps correct obsolete protocols Mobility without “crutches”: Discernment grows when team includes disabled users
- 24. INSTITUTIONAL PROCESS institutional history
- 25. INSTITUTIONAL PROCESS reducing reliance
- 26. INSTITUTIONAL PROCESS Traumatic Brain Injury (TBI) Sensory Lighting levels Impairment Amputation Organ Damage Privacy Post-Traumatic Stress Disorder (PTSD) Security synergies between acuities
- 27. INSTITUTIONAL PROCESS toward the future
- 28. INSTITUTIONAL PROCESS Multi-sensory navigation: Reinforce therapy and training with design features Way-finding with disabilities: Utilize the training philosophy to inform the design Synergies within contradiction: Involve all modalities in the design process Mobility without “crutches”: Balance mobility with real-world design
- 29. navigation between facilities SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 30. landscape as healing metaphor Native creek bed Transition from acute dependence to natural independence Clinical core SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 31. landscape as healing metaphor Pavement color/texture reinforces directionality Backs of benches used for “shore-lining” SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 32. landscape as healing metaphor Places for celebration, introspection, privacy SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 33. landscape as healing metaphor Place-making Textured areas Variety of Fountain planting heights Greenhouse Kitchen SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 34. level 1 SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 35. navigating multi-story spaces SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 36. Reinforcing landmarks SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 37. Depth perception Contrast and personalization SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 38. level 2 SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 39. acoustically directional forms SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 40. level 3 SENSORY WALK-THROUGH: Polytrauma / Blind Rehab
- 41. recovering one’s life Visit our booth in the exhibition hall Find the slides from this presentation on SlideShare. Search for us by name: TheDesignPartnership Or by our public profile: http://www.slideshare.net/TheDesignPartnership
Editor's Notes
- Welcome to Advancing Healing Design to the Next level: what rehabilitation facilities can teach us. Because of the high incidence of traumatic injuries sustained by today’s armed services, the VA and DOD are at the vanguard of caring for and rehabilitating patients with multiple traumas and disabilities. But the lessons of designing environments for concurrent and diverse acuities apply to the entire spectrum of healthcare delivery.This presentation will highlight the discoveries and methodologies learned in the design of Polytrauma and rehabilitation facilities across the country, including advances in: Lighting, Acoustics, Way-finding and Safety; All tailored to patients dealing with a wide range of physical, sensory and psychological injuries. The key lesson is to balance the provision of customized sensory assistance against the mission of teaching patients how to navigate the real, non-clinical world. What is needed to make rehabilitation a truly life-changing experience is a design process that partners with the sensory and mobility needs of the patient.
- I’d like to introduce our team. I’m Natale Ward, I am the planning lead, BIM lead, Job Captain, etc…for the VA Palo Alto Polytrauma & Blind Rehabilitation Center project. Joining me today is Chris Downey, who was a design consultant for this project for about a year and a half. Chris has opened our eyes, so to speak, about some of the building issues facing blind users. As a trained architect with 20+ years of experience, Chris lost his sight about three and a half years ago. He has been working hard ever since to remain in this field. We found a unique synergy between his experiences and our design effort for the new rehab center.Today, with Chris’ help we will be focusing a bit more on the blind issues as they relate to our project.
- This early design sketch for the Polytrauma & Blind Rehabilitation Center shows the concept of the two wings early on, connected by a glass lobby and entry in the middle. This was a way to break up the building façade create a transparency through the center of the building into the courtyard beyond. Some of the programs included in the building are inpatient, transitional & outpatient Polytrauma, orientation & mobility, ADL, manuals skills, computer access training, assistive technology, gait training, speech therapy and more.
- Though a project as complex as this one has many facets, we'll focus today on two of the most important goals we set out with. First, we wanted to help patients navigate the clinical environment by making the way-finding clear and the spaces comfortable. Second, we wanted to support patient mobility and independence without reinforcing a reliance on environmental crutches. This balance between supportive design and over-design was a consistent and pervasive planning and design exercise. Given the rehabilitation patient population, we hypothesized that using multi-sensory design strategies along with the inclusion of all modalities during the design process would enable us to achieve these goals.
- More than most projects, at least for me, this was an incredible learning process. While we were focused on low-vision and blind navigation, or on Polytrauma patient navigation in the space, we found that there were way-finding benefits to all users and visitors of the building. We also found some surprising synergies between multiple needs of the different patient populations, the staff and function of the building. For example, the use of automatic shading devices on the windows in public spaces and corridors helps to control lighting levels for both the low vision and photosensitive TBI patients, as well as reduce the heat gain without requiring staff to spend time controlling the shades. We also found, that working closely with staff made an important impact on design decisions, while also having an impact on treatment and training philosophies. For example, the current training program at the blind center relies heavily on the shape of the current building, which happens to be an identifiable alphabetical letter. The new design was just too large to follow suit, so the training staff and designers held sessions to discuss how the design and training program could support each other in different ways.
- One of the first strategies employed, was to try and put ourselves in the place of the patient populations we were designing for. The range of vision loss from slight to nearly total is substantial and well-populated. Very few people are 100% blind. What this slide is showing are some examples of the more common types of vision loss.
- The four key steps involved: Notice the different world-view of someone with a disability. Empathize by putting yourself in that person’s shoes. Adapt through simple behavioral solutions. Enjoy an environment that is now better for you too.
- As battle field medicine continues to improve, soldiers are now surviving injuries they would not have in past conflicts. As a result, the Veterans Hospitals are seeing more severe physical and brain injuries. A Polytrauma patients suffer from Traumatic Brain Injury, or TBI in combination with any number of other physical injuries including limb amputation, and sometimes multiple amputations. The Polytrauma unit in Palo Alto sees soldiers often only days after they’ve left the battlefield and have processed through Walter Reed.
- The typical blind center student is of retirement age, many have age-related, chronic illness related, or medication related sight loss. The service history tend to vary greatly among this population, and my experience so far has been that there are more female veterans in this program that in the Polytrauma program.
- We looked at a handful of centers across the country to explore how other facilities are organizing their rehab programs. What programs they have included and how they are dealing with way-finding & accessibility.1st is the Intrepid Center of Excellence in Bethesda. There were many parallels between the programs for Physical & Occupational Therapy. The most significant being the treatment gym, gait lab, vehicle simulator & family areas. By studying the modalities & equipment provided in the gym at the Intrepid, the project planners and VA therapy staff could ask important questions about services provided & possible new equipment that they may not have considered otherwise
- The next facility was Casa Colina. The value added to a project by making time to bring the user group on field trips is enormous. Some of the key comments made about this facility followed us throughout the design. For example, the VA staff had felt that the facility being so large and spread out made for very difficult way-finding. However, the large open therapy rooms with lots of nearby storage & natural light were favored, especially as compared to the current outpatient physical therapy gym at Palo Alto that is located in the basement.
- Finally, an important benchmark for us has been the current blind center at the VA Palo Alto. We will continue to discuss this facility throughout the presentation, but here I would just like to note the overall shape of the building as seen in plan. As mentioned previously, the building is shaped like an alphabetic letter, an “F”. This helps students understand the building as a whole. To further reinforce this understanding, each arm of the "F" has an alphabetic prefix to the room numbers and have a different recognizable wall color.
- We found that facilities use multi-sensory navigation techniques to varying degrees. However, most facilities rely heavily on traditional static signage, so we’ve found that multi-sensory design strategies are a still untapped resourceWe find that signage, though necessary and often very helpful in way-finding, carries with it some limitations when you begin to take certain disabilities into account. Landmarks such as nurse stations & courtyards can be extremely effective way-finding tools.Finding ways to incorporate strategies for multiple populations sharing the same facility is challenging. I believe it’s something that we struggle with in all healthcare facilities as the patient demographic shifts over time.While searching for strategies for us to implement we found that it was easy to start to over-design and create a space that no longer balances environmental aids with what the patient will find in the real world. Sometimes good intentions can conflict with life outside of the clinical world.
- Early on we realized that each floor of the new building would be nearly twice the size of the current blind center, so we could not repeat the “F” shape without creating outrageously long corridors. So, we started to look at how else the building could be organized. The increase in complexity and number of corridors was inevitable, so we determined that using significant landmarks around which we could organize the program would be the most effective way. Using landmarks is effective because they are consistently present & identifiable.
- One of the most important spaces in the building was the lobby because this was the most significantly shared space for each of the different patient populations, staff, family & other visitors. Photo-sensitivity was of specific interest because this is something that is shared by TBI patients as well as low vision patients who comprise 94% of the blind center’s demographic. We did extensive day-lighting analysis to understand what impact our building orientation & glazing would have. We found that a high level of lighting, although desired for transition between the bright exterior and darker interior corridors, needed to be even and without contrast glare. We decided to outfit our windows with automated interior shades controlled by daylight sensors. This strategy was then employed throughout to provide greater patient & staff control of lighting levels, as well as an automated building response to direct sunlight, avoiding harsh shadows & bright spots in major circulation areas.
- This is my favorite image. As you heard from the audio description, there is a lot going on here. This is an intersection of two corridors at the elevator in the current blind center. This image is a great tool for talking about what is, and what is not, appropriate use of color for assisting in way-finding. In some ways the blind center is very successful in their use of color & contrast. The pattern in the floor occurs only at intersections and the contrast of color is enough to be very visible, but not so much as to appear as a step or hole. We discussed in detail with the staff which types of adaptations worked best for them and why. It was agreed that using excessive cues in the flooring was in direct opposition to their training philosophies. Students are trained to maintain good posture and look ahead since it is so easy to pick up the bad habit of looking down to find your way as you begin to lose your vision. So many of the students have been cultivating this bad habit for years before coming to the blind center for training.
- What we discovered as we progressed was that with balance in the design the extra measures to ensure that vision wasn’t our only reliance for way-finding led to a better design for all. Chris is absolutely right. As sighted architects we cannot really place ourselves in the shoes of a blind individual. We don’t understand the training required, the hardships and the disorienting effect sight loss can have on someone. With Chris’ help we were able to more successfully understand, and worked harder with our consultants to find solutions for removing obstacles.The multi-disciplinary design process helped both the VA staff, and the design staff to begin to re-organize our own processes. Building consumer group input into the process was key. The programming, planning, and design meetings provided a forum for all of the treatment modalities to be in one room discussing what is needed for all of them to provide the best patient care.By including different viewpoints, especially those with disabilities, their families and the staff, we can run our designs through rigorous testing and determine which features will really work and which will not.
- it is very challenging to strike the right balance between nurturing someone with a disability, especially if the disability is new to them, and preparing them to be able to function in the real world. We are always on the watch to make sure that we are not overly enabling the patient or student. We don’t want them to rely on special environmental “crutches” that do not exist outside the walls of the rehab center.
- What you have on the right of this slide is a sample list of the types of injuries that a Polytrauma patient can be suffering from. It could be any combination of these, or all of them. Lighting levels are just as important for Polytrauma patients as low vision patients. The need for patient privacy is universal, though an especially sensitive issue for the Polytrauma population. Security is another very important issue for these units. Although this is not a completely secure unit, there are significant elopement risks for some patients. This is why we’ve provided private courtyards within the bed units so that elopement risk patients can have secure access to the outdoors. We also have private enclosed outdoor areas off of the day & dining rooms on the unit. These types of outdoor spaces are also useful for the blind center, as there are some patients no ready to venture outside of the unit, but should have equal access to outdoor spaces.
- As we start to build this library of multi-sensory design techniques, we try to implement them across the projects in our office. We are also thinking about what’s next. A lot of what we do as architects is attempt to see into the future. We try to anticipate what will or may happen in our buildings. To do this we need the help of the clinicians, doctors and nurses at all levels to help us understand what may be in the future for them and their patients as well.
- By learning the process, either for treatment or training, we were able to help reinforce these processes with the architecture.The philosophy behind the training techniques is as important as the training itself. By utilizing this knowledge, we can design to best support the current and future patients & staff.Again, including all modalities, of which both centers have many, we can create spaces that work for all users. The model for care can provide us with insight into how we can work together to balance mobility with real-world design.
- This is an image of the Polytrauma and Blind rehab center as seen from the drop-off area. Using a combination of path lighting, lighted bollards and canopy structure, we reinforced the way-finding related to nearby parking and adjacent buildings.
- We wanted the landscape design for the building to be a metaphor for healing. To the north west of the center is a creek bed with a more natural landscape, while to the interior of the campus is primarily clinical space. We wanted the landscape through the central courtyard to provide a fairly seamless transition from clinical and manicured, to natural and wild.
- What we have here is on the clinical side of the building. This is a plaza in front of the building south of the drop-off. As you can see we created pockets of seating using benches that are solid for easy “shore-lining” for those with canes in the main circulation areas. Also provided are trees for shade, a therapeutic labyrinth and a vegetable garden.
- Here we have a view of the main courtyard. Some of the more formal areas exist towards the lobby side and as you move toward the back of the building it’s broken up into walking paths and small seating areas. On the left you see a stage area with a fountain wall backdrop, to be used for special occasions and ceremonies. To the right we have the enclosed dining area for the Polytrauma inpatient unit which satisfies the need for security and privacy, but provides access to natural light and fresh air as well.
- The second level courtyard provides unique places to sit alone and reflect, or sit in small groups and visit. A walking path is provided with the seating areas separate to provide for easier navigation with a cane. Shade trees and a fountain create additional privacy and separation for the seating areas. Also located with access onto this space is the greenhouse, and a training kitchen. By allowing direct access the students can experience the outdoors as part of their everyday training before they learn the necessary skills to travel downstairs and venture out into the campus.
- Here we have the floor plan for level 1. This level is comprised of the Polytrauma inpatient beds with immediate staff support spaces. Also on this floor are the outpatient PM&R programs including exam rooms, a gait training lab, vehicle training, PT/OT Outpatient gym & hand clinic. The 24 bed unit is laid out as two adjacent 12-bed units with shared courtyards and a main street circulation where the social space occur, the day room, dining room and staff meeting spaces. The organization of this floor laid the groundwork so to speak for the whole building. The required space for a Polytrauma unit is larger than the typical acute care setting with bedrooms at 300 SF, but by organizing the north wing of the building as a 24 hour wing and moving all daytime only services to the south wing, we were able to reduce patient & staff travel distances, also creating easier evening & weekend supervision for nursing staff. This organization was also set up a framework for overall building energy savings.
- This next slide shows an interior view of the lobby space as seen upon entering the building. As touched on earlier, navigating this two level space was an important concern for us during design. A number of the considerations we discussed earlier were incorporated into the design and are shown here in the rendering. First, the blind center needed to have a presence in the lobby from the first level. The stair serves as their front door. The base of the stair is now located adjacent to the reception desk, which is directly across from the entry doors. The circulation path through from north to south into the celebration room, is reinforced in a few ways. First, the path is flanked on either side by waiting areas with a contrasting flooring (both in color and material). Second, the plinth at the base of the stairs provides a straight edge to aid in directing cane users towards the celebration room. The celebration room doors are of obvious contrast to the surrounding area. And finally, the area below the bridge has been acoustically treated so that it is clear when you are underneath it. This also serves to quiet the lobby space for the reception staff and TBI or psychologically compromised patients.
- The next space we have is the nurse station. The client had wanted to be consistent floor to floor, so we were again designing this to work for all units. It needed to be a clear landmark, in a multi-sensory way. It needed to provide privacy & supervision of the unit for the nurses & do this while evoking a sense of hospitality not institution. Some of the design features utilized to start tackling these criteria include; an extended drop ceiling into the corridor for increased visibility of the nurse station from the patient corridors. We matched the outline of the dropped ceiling with a change in floor color as well. We provided a combination of indirect up-lighting at the soffit and drop task lighting for the nurses. We incorporated the wood paneling on the wall & the ceiling for aesthetics & acoustics.
- The corridor design should provide an ease in perceiving depth by using contrast and variation in the plane. Between each two rooms there is a sub-charting / equipment alcove that is lit differently and painted an accent color. Personalization is also important, especially for patient populations that may have memory issues or difficulty finding their way back to their room. We have provided a signage type at the patient rooms that includes panel that can be personalized. This way a patient can verify that the room they’ve found is their own before entering.
- This is a plan for level 2, the Western Blind Rehabilitation Center. This level is organized essentially in the same way as level 1. The north wing is the residential wing, with adjacent orientation & mobility services as well as 24 hour accessible computer training. The south wing has the day treatment spaces including optometry, manual skills & living skills, as well as the level 2 courtyard.