the role of the architectural environment in community health

12
The Role of the Architectural Environment in Community Health: An Evidence-Based Initiative Stephen Verderber and Joseph Kimbrell T his discussion reports the status of a 12-year program administered by a statewide health agency to strategicaiiy assess, redevelop, and monitor the architectural and facility management performance of its network of community-based public iiealth care faciiities. A protocoi, the Strategic Faciilty Improvement initiative, has directly resulted in significant improvements to the major share of a network of over 100 community clinic and clinical support faciiities In the State of Louisiana. The SFI initiative provides oversight vi/ith respect to the allocation of public heaith capital improvement infrastructural resources and has guided completion of 55 facility replacement or renovation projects to date. Its administrative mission, organizational structure, and field methodology is presented as a vehicie to significantly improve the architectural condition of clinical and ciinical support environments for underrepresented patient populations. The SFI process is discussed as an evidence-based means to foster greater systemic success in capital improvement efforts within public sector heaith agencies in the United States and in intemationai contexts, KEYWORDS: architecture, community public health clinics, evidence-based design, strategic facility planning The art and practice of constructing a building has often been described as an act of optimism. Through- out history, architecture has been viewed by advanced societies as symbolic of the highest of aspirations. Ro- rence Nightingale, in many respects the first modernist health care facility planner, viewed the layout, aesthetic appearance, and upkeep of the patient's physical envi- ronment as possessing essential therapeutic benefit— exerting a profound intluence in the treatment of sick- ness and disease. Her core principles for the design of the health care environment were disregarded dur- J Publk: Health Management Practice. 2005,11(1), 79-89 © 2005 UppJncott Williams & Wllkins. inc. ing the halcyon era of modem architecture, but have recently been rediscovered by a generation of post- modem architects. Among her many contributions. Nightingale advocated communality between the pa- tient and the natural environment and the importance of human scale in health care settings. Despite admirable intentions, the efforts of the most highly qualified and assiduously dedicated commu- nity health caregivers are too often thwarted by ar- chitecturally dysfunctional conditions experienced in hospitals, outpatient clinics, and in any setting where medical and nursing care is administered. Anecdotal evidence in history points to the symbiotic relation- ship between architecture and health care, and recent empirical evidence points to the significant therapeu- tic role of architecture in relation to human health and well-being. Research within architecture and its allied environmental design disciplines, however, has gener- ally overlooked the therapeutic and related affordances of the architectural care setting with respect to com- munity public health milieu. Meanwhile, the delete- rious effects of poorly planned, overcrowded, ill-kept clinical environments for the dissemination of public health care routinely remain overlooked or entirely dis- missed. Meanwhile, the harmful effects of these condi- tions upon health and well-being remain undetected, often, for decades.' The key role of the health care archi- tectural environment, therefore, warrants its systematic The authors thank Kevin Frank and Jessica T. Gramcko, of the Tulane University School of Architecture, for their invaiuatiie assistance in the preparation of this manuscnpt. The first author is indebted to Joan Bostick, Ph.D., Kay Burton, MA, Sylvia McKee, MSW, and Darlene Smith. MA, of the Slate of Louisiana Office ot Public Heaith, for their essentiai support and guidance. Corresponding author: Stephen Verderber, MArch, ArchD, NCARB. C/0 School of Architecture, Tulane University. New Orieans, LA 70118 (e-mail; [email protected]). Stephen Verderber. MArch. ArchO. NCARB, is a Professor. School of Architecture, and an Adjunct Professor, School of Public Heallh and Tropical Medicine. Department of Healtti Systems Management, Tulane University, New Orleans, Louisiana. Joseph Kimbreil. MA. LCSW. is Chief Executive Officer, Louisiana Public Health Institute, New Orleans. 71

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  • The Role of the Architectural Environment inCommunity Health: An Evidence-Based InitiativeStephen Verderber and Joseph Kimbrell

    This discussion reports the status of a 12-year programadministered by a statewide health agency to strategicaiiyassess, redevelop, and monitor the architectural andfacility management performance of its network ofcommunity-based public iiealth care faciiities. A protocoi, theStrategic Faciilty Improvement initiative, has directly resulted insignificant improvements to the major share of a network of over100 community clinic and clinical support faciiities In the State ofLouisiana. The SFI initiative provides oversight vi/ith respect tothe allocation of public heaith capital improvement infrastructuralresources and has guided completion of 55 facility replacementor renovation projects to date. Its administrative mission,organizational structure, and field methodology is presented as avehicie to significantly improve the architectural condition ofclinical and ciinical support environments for underrepresentedpatient populations. The SFI process is discussed as anevidence-based means to foster greater systemic success incapital improvement efforts within public sector heaith agenciesin the United States and in intemationai contexts,

    KEYWORDS: architecture, community public health clinics,evidence-based design, strategic facility planning

    The art and practice of constructing a building hasoften been described as an act of optimism. Through-out history, architecture has been viewed by advancedsocieties as symbolic of the highest of aspirations. Ro-rence Nightingale, in many respects the first modernisthealth care facility planner, viewed the layout, aestheticappearance, and upkeep of the patient's physical envi-ronment as possessing essential therapeutic benefitexerting a profound intluence in the treatment of sick-ness and disease. Her core principles for the designof the health care environment were disregarded dur-

    J Publk: Health Management Practice. 2005,11(1), 79-89 2005 UppJncott Williams & Wllkins. inc.

    ing the halcyon era of modem architecture, but haverecently been rediscovered by a generation of post-modem architects. Among her many contributions.Nightingale advocated communality between the pa-tient and the natural environment and the importanceof human scale in health care settings.

    Despite admirable intentions, the efforts of the mosthighly qualified and assiduously dedicated commu-nity health caregivers are too often thwarted by ar-chitecturally dysfunctional conditions experienced inhospitals, outpatient clinics, and in any setting wheremedical and nursing care is administered. Anecdotalevidence in history points to the symbiotic relation-ship between architecture and health care, and recentempirical evidence points to the significant therapeu-tic role of architecture in relation to human health andwell-being. Research within architecture and its alliedenvironmental design disciplines, however, has gener-ally overlooked the therapeutic and related affordancesof the architectural care setting with respect to com-munity public health milieu. Meanwhile, the delete-rious effects of poorly planned, overcrowded, ill-keptclinical environments for the dissemination of publichealth care routinely remain overlooked or entirely dis-missed. Meanwhile, the harmful effects of these condi-tions upon health and well-being remain undetected,often, for decades.' The key role of the health care archi-tectural environment, therefore, warrants its systematic

    The authors thank Kevin Frank and Jessica T. Gramcko, of the Tulane UniversitySchool of Architecture, for their invaiuatiie assistance in the preparation of thismanuscnpt. The first author is indebted to Joan Bostick, Ph.D., Kay Burton, MA,Sylvia McKee, MSW, and Darlene Smith. MA, of the Slate of Louisiana Office otPublic Heaith, for their essentiai support and guidance.

    Corresponding author: Stephen Verderber, MArch, ArchD, NCARB. C/0School of Architecture, Tulane University. New Orieans, LA 70118 (e-mail;[email protected]).

    Stephen Verderber. MArch. ArchO. NCARB, is a Professor. School of Architecture,and an Adjunct Professor, School of Public Heallh and Tropical Medicine. Departmentof Healtti Systems Management, Tulane University, New Orleans, Louisiana.

    Joseph Kimbreil. MA. LCSW. is Chief Executive Officer, Louisiana Public HealthInstitute, New Orleans.

    71

  • 80 I Journal of Public Health Management and Practice

    appraisal within the community public health careequation.

    Health care organizations in the public sector have,unfortunately, infrequently adopted leadership posi-tions in terms of learning how the physical setting canhelp them attain their core goals. Frequently, architec-tural variables such as a building's aesthetic and spatialqualitiesits composition, scale, height, site planningcharacteristics, daylighting, color, air quality, wayfind-ing amenity, staff and patient flow patterns, aestheticambiance, and overall suitability to the disseminationof health care, remain unconsidered. Measures of thequality of care,, worker morale, productivity, and themeasurement of health outcomes understandably arecore concerns, although taking cognizance of the per-formance of the physical setting in relation to these fac-tors can reinforce both. There appears to be the needto do so in the United States at this time, particularlywith respect to organizations serving underrepresentedpatient populations." The dilemma of disjunctively fo-cusing on the delivery of services apart from the condi-tion of the health care setting where these services aredelivered has become highly problematic. In light ofthe many studies published on closely related aspectsof community care such as the social aspects of publichealth, the relationship between income level and thequahty of patient care received in community-basedclinical settings, and issues centered on the growing in-accessibility to health care for an increasing number ofAmericans, more research is needed on the functionsof the architectural environemnt.' Unfortunately, thepotentially direct, instrumental role of architecture asa medium of positive intervention in public health re-mains overlooked/ '

    It is well known the extent to which the health careneeds of underinsured and uninsured patient popula-tions in the United States have increased dramaticallyin recent years. Roughly 50 million Americans currentlyreceive some level of assistance from the federal Med-icaid program. Compounding matters, the conditionof the public health architectural infrastructure is di-minishing precipitously in the United States. Unfortu-nately, no national statistics exist on this trend. Despitethese trends, the dwindling percentage of increasinglyscarce taxpayer resources allocated for capital improve-ments to the public health infrastructure in the UnitedStates is likely to reach a crisis stage within this decade.New initiatives are needed to address and inven-tory the declining condition of buildings devoted tocommunity-based public health care. Although no suchinformation exists at the present time, a national facilityperformance database would be a valuable assessmenttool in strategic planning at the federal, state, and locallevel. In the past decade, an area of research in the envi-ronmental design fields knov^ m as evidence-based design

    has emerged in the United States.^ This approach is cen-tered on the systematic appraisal of the performanceof a care setting from the standpoint of the physicalsetting, as well as the systematic assessment of its oc-cupants. This information is then translated into archi-tectural recommendations and guidelines for incorpo-ration in subsequent capital improvement initiatives-Evidence-based design is a means to avoid costly, en-tirely avoidable mistakes and is no different in princi-ple from the evidence-based design movement in thehealth sciences. The work reported within this articlerepresents a major empirically based, multiyear effortto extend knowledge on this subject.

    BackgroundIn the fall of 1990, the State of Louisiana Depart-ment of Health and Hospital's Office of Public Health(DHH-OPH) embarked upon a strategically oriented,evidence-based facility planning and design initiativeto assess, redefine, and redevelop its network of 132program sites. This network consists of administra-tively coordinated region offices, laboratories, and com-munity public health clinics. This network of programsites is structured into 9 regions, administratively. Aprotocol, referred to as the statewide Strategic Facil-ity Improvement initiative, or SFI initiative, was de-veloped. The SFI protocol has been recognized nation-ally for its innovativeness." From the dual perspec-tive of innovativeiy encompassing public health policyand architecture and its longevity, the SFI initiative inLouisiana remains a unique example of evidence-baseddesign in the United States/

    The need for the SFI arose over many years. In theyears following the demise in the early 1980s of thefederal Hill-Burton program for hospital and commu-nity clinic construction, the DHH-OPH lacked a strat-egy to guide the planning, design, and construction ofits inventory of facilities. Practically from its origins,in the aftermath of the great Mississippi River floodof 1927, the system for building public health facili-ties in Louisiana was inconsistent and at times highlycontradictory. This was in part due to a pattern of un-scrupulous political dealings dating from the era ofGovernor Huey P. Long in the 1920s. To his credit, how-ever. Long championed the construction of a number ofparish health units in communities that had been rav-aged by theGreat Flood, with the support and guidanceof the Red Cross, the US Public Health Service, andthe Rockefeller Foundation. In 1974, a state constitu-tional convention mandate reaffirmed the requirementof Louisiana's 64 parishes to provide at least one publichealth clinic within its jurisdiction. The 1974 documentconstitutionally reaffirmed these be operated by the

  • The Role of the Architectural Environment In Community HealthM

    81

    DHH-OPH. With the programs provided by the stateand the buildings built by, paid for, and maintained bythe parish, by 1990, the absence of a consistent, codi-fied pwlicy for OPH-operated facilities had resulted inan extremely uneven and jagged patchwork quilt ofclinics and regional support sites largely based on apattern of independent invention. In the worst cases,adjoining parishes embarked on capital improvementprojects for their parish health unit in virtual ignoranceof a neighboring parish's efforts, sometimes when bothwere constructing a facility at the same time.

    As of November 1990, 66% of all OPH facilities hadbeen operating in their present quarters for 30 yearsor longer. The vast majority of the facilities themselvessuffered from years of deferred maintenance and pro-grammatic obsolescence. The continued use of dilapi-dated and overcrowded facilities had been due, in manycases, to a combination of sheer lack of knowledge onthe part of local elected officials about what to do, ad-ministrative ineffectiveness on the part of the agency toprovide sustained leadership, and an inability to stim-ulate genuine grassroots interest within the parishes torectify the situation. Among staff and patients, a cli-mate of learned helplessness frequently set ina sit-uation not dissimilar from the "environmental docil-ity" syndrome employed to describe the plight of theinstitutionalized aged in nursing homes in the UnitedStates." Local communities opting to build a new fa-cility often did so with only cursory involvement ofagency personnel. This had contributed to the chronicunderfunding of new building projects. Lacking mean-ingful, sustained oversight by the agency a parish was"flying blind," proceeding in the absence of neither re-liable, evidenced-based information nor minimum fa-cility performance criteria. With so little coordinationand consistency within the network, it had become asomewhat haphazard proposition to implement newprograms with the hope of any reasonable success.

    A consulting research-based design (R-D) team (di-rected by the first author, under the direction of the sec-ond author) distributed a survey completed by clerical,nursing, and environmental health staff at 25 represen-tative program sites statewide. Following this, a full-scale survey of all 132 program sites was conducted us-ing a case study technique commonly referred to in thefield of architecture as a post-occupancy evaluation. Datawere obtained on each facility's age and appearance,condition, maintenance and repair records, annual op-erational costs, patient utilization levels, staff composi-tion, parking amenity, public transportation availabil-ity, and the Americans With Disabilities Act (ADA)compliance/noncompliance. Additional data were ob-tained on occupant satisfaction with respect to a broadrange of architectural issues, including patterns of dailyuse and environmental comfort. In so doing, minimum

    (and beyond) facility planning and design criteria werearticulated to ensure network consistency and to re-verse the deteriorating condition of the facilities.

    Subsequently, a compendium of 140 evidence-basedfacility plamiing and design guidelines were created.As a means to demonstrate the validity of this lexi-con, a prototype hypothetical clinic was designed asan adaptive use of a vacant building. A 5-voIume re-port was accepted for implementation by the agency,which has since been updated annually. The first au-thor has coordinated the implementation of the recom-mendations since 1991.'' Collaboration occurs with localDHH-OPH staff, region administrators, local architects(in cases where one is contracted by the client-parish),and the contractor Planning and design services areprovided on a consultative basis including site selec-tion, preparation of program briefs outlining space andequipment requirements, design reviews of ongoingprojects, post-occupancy evaluations of existing as wellas replacement facilities, and sick building syndrt^merisk-assessment analysis. These services are providedat no cost to each parish. The SFI program is fundedand administered by the agency's central office.

    Procedural Steps In the Strategic FacilityImprovement Process

    The SFI consists of 14 separate steps. These are illus-trated in Figure 1. The steps are interdependent andare generally linear in the order with which they occur.Seven core components emphasize, first, the program'sbackground rationale and structure. The fundamentalaim is to improve the health status of the residents of allcommunities in Louisiana through the use of evidence-based planning and design knowledge in the reno-vation and construction of community-based publichealth facilities (step 1). Second, it is important to con-vey to all parties involved the nature of the SFI team'slong-term role, from a project's inception to completion,in working with in-house agency staff in a consultativecapacity (step 2). The sustained support and adminis-trative oversight provided by DHH-OPH is critical interms of providing administrative leadership and in es-tablishing capital improvement priorities (step 3). Thesolicitation of the involvement of community advocacygroups and interested local citizens in the capital im-provement process is equally important to the successof the SFI (step 4). Effective internal and external com-munication channels need to be established at the outsetwith in-house liaison agency committees as well as ef-fective communications with parish-based elected offi-cials (step 5). The creation of a project review team to as-sist local elected officials and other concerned parties in

  • 82 I Journal of Public Healtti Management and Practice

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    RGURE1. The Strategic Facility Improvement Initiative protocol.

    the implcmen tilt ion phase can be of great assistance andresult in a much more successful architectural outcomeand niore timely completion of the construction projectthan would otherwise likely bo the case (step 6). It hasproven useful to communities to be able to compare andcontrast within-state trends and to assist them in devel-oping their facility improvement strategies locally (step7). The ability to compare alternative exam room lay-outs and equipment options, for example, or the mosteffective signage system for way-finding in a clinicalsetting can save a great deal of time and effort later onin unnecessary, costly retrtifitting of a newly completedbuilding.

    Components 8 through 11 consist of key inter\'en-tional steps, each focusing on the importance of policyinterventions that identify alternative capital improve-ment options. It is important to conduct cost-benefittradeoff analyses of the benefits of new constructionversus alternative strategies (ie, renovation) and to pro-vide general guidance and architectural consul to localelected officials and agency personnel (step 8). This stepalso includes the development of functional space pro-

    gram briefs. In defining a project's mission, size, andscope, it is essential to identify and select the most suit-able site for a replacement facility. The highest and bestuse of a given site must be assessed, including selectinga site in close proximity to public transportation (step9). In many cases the consulting team is called upon toprovide schematic design services as well at this point.It is essential to maintain oversight of the entire SHIprocess, including scheduling, areas of responsibility,the monitoring of change orders, owners representa-tive obligations, and frequent review of the construc-tion budget. A post-occupancy evaluation may be nec-essary at the outset to determine whether to build newor to renovate (step 10). Regardless, every reastnablemeasure should be taken to minimize the degree of dis-ruption typically caused by a construction project. Sim-ilarly, every reasonable effort should bo made to keepthings running smoothly in an uninterrupted mannerduring the period of construction, which may last aslong as 13 months (step U).

    Components 12 through 14 consist of postconstruc-tion interventions to ensure the completed project's

  • The Role of the Architectural Environment in Community Health I 8S

    successful performance over time. These measures con-sist of the assessment of improvements made followinga 3 to 6 month "shake out" peritni, during which fine-tuning and various facility management modificationstypically occur. Atso, the facility must be in full com-pliance with k)cal, state, and federal building codes onan ongoing basis, and the needs of physically and cog-nitively challenged patients must be fully supported(step 12). It is important to assess the extent to whichthe new or renovated facility yields an increase in thenumber of patients ser\'ed daily, weekly, and monthly.Replacement fncilitios have been lound to contribute tostaff greater retention and morale, lower absenteeism,increased productivity, and in turn, a healthier com-munity (step 13). Similarly, it is important to inculcatein clinical and related program staff and in parish of-ficials responsible for site and facility maintenance awillingness to function as the stewards of their own fa-cility. Stewardship, combined with effective communi-cations between staff housed at different program sites,has had an emptiwering effect on communities embark-ing on simitar capital improvement projects becausethey know they do not need to reinvent the same wheelcountless times over (step 14).

    Results

    A statistical over\'iew of the SFI is presented below, to-gether with a discussion of its strengths, limitations.

    and suggestions for improvement. A summary of thecapital improvement projects completed as of Decem-ber 2i)03 is reported in Table 1. A tolal of 55 projectswere completed during the 12-year peritxi (I991-21X)3).Of these, 38 resulted in completely new replacement fa-cilities, 8 in renovations or expansions to existing facil-ities, and 9 resulted in adaptive re-use of a "new" exist-ing building for use as a community public health careclinic. The average pR>ject-planning phase from projectinception to groundbreaking was 13.0 months. The av-erage length of time required for actual constructionfrom groundbreaking lo opening day was 11.1 months.

    With respect to the amount of construction activityacross the 9 administrative regions, the average size of anew facility has been 9,224 square feet. This represented364,705 total square feet in new construction. Otherbuilding projects, consisting of renovations and adap-tive re-uses of existing buildings, averaged 5,928 squarefeet per project. This represented 121,874 total squarefeet in this category. With respect to fiscal expenditure,the average capital improvement project was S897,899(unadjusted for inflation). Total capital improvementexpenditures during the period rept^rted across the 9OPH regions totaled $53.4 million. Despite a consider-able volume of construction activity during the 12-yearperiod, it is noteworthy that a total of 25 program siteswere closed outright or consolidated with existing pro-gram sites during this period (due to administrativerestructuring efforts and state budget reductions im-posed by the state legislature).

    Statewide Strategic Facility Improvement initiatives (1991-2003)

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    'Project data reported tlirougti 12/31/03. Number In parentheses denotes total treestanding program sites tn r e ^ (with exception of sctxl-based cftnlcs)' Ceiialn protects Involve combination of eittier new avVor rsnovated or adaptive reuse strate^ss.

    S Mean across profecK reported (tn rranths].> 'New ConstTuctkm' data reported as BuikHng/Gross Square Feet (PGSf). Nurmwr in parentheses denotes total BGSF. 'Other' category consists o( renovBtton and adaptive rousaptojects, These tlala are reported as Depanrnental Gross Square Feet (DGSF) Nuinter In parentfwses denotes total DGSF.^Mean total project cost. Ificluding land acquisition, site Improvements, paiking areas, access diives, slflnags. landscaping, lumtshliigs. equipment, and building expetises flnmillions]. Number in parentheses denotes total capital expenditure in Region [In millions).'Y denotes decision to replace community pubBc tiealtti facilrty since 1990-1991 Fiscal Year (FV). Number In paraitheses dawtes tot^ number o( replacement tadttiea txiitt in

    *'A total ol 2S program sites have been dosed or consolidatad witti ensting OW-OPH tadlities s^x FY

  • 84 I Journal of Public Health Management and Practice

    The performance of the SFI program is reviewed an-nually, as is the performance of each facility. A com-posite facility performance rating is assigned, based on3 types of data: (1) firsthand appraisals by its end-useroccupants (patients and full-time staff), (2) the assess-ment of the region administrator, and (3) informationacquired in the field by the SFI coordinator. Together,this information is translated into a 4-point scale to re-flect the degree of architectural intervention required.This rating is based on 5 individual assessments: (1) thesite context and neighborhood, (2) its aesthetic appear-ance, (3) the degree of functionality from the stand pointof internal patterns of use and occupant and materialsflow, (4) the ability to adequately maintain the facil-ity, and (5) the condition and operation of the build-ing's environmental control systems (heating, ventila-tion, and air conditioning, and electrical systems). Thisinformation is compiled into a statistical profile. Withthe opening of each replacement or renovated facility, agiven program site's score typically diminishes fromthe level of urgent priority to no architectural inter-vention required at this time. The 4 levels of rankingfor priority impmvement are: (1) urgent priority, (2)high priority, (3) moderate priority, or (4) no change. InFigure 2, a between-region (R1-13R9) before/after rat-ing of each clinic and program support site in the net-work is reported at the twelve-year interval. The before

    rating, therefore, is the ^re-intervention rating (1990)and the post-intervention rating is cumulative as of De-cember 2003. This method of evidence-based facility re-view has been consisten t and has proven effective. Froma longitudinal perspective, the architectural quality ofOPH facilities has markedly improved across the entirestate during this period, with the most significant im-provements having been achieved in Regions 2,4, 5,8and 9.

    In Figures 3a-6d, 4 completed SFI projects are re-ported. Each is presented as a set of 4 images, read-ing from left to right. Tlie first column contains thefloor plan, and the second through fourth columns con-tain exterior and interior photographs of representa-tive spaces. These case studies illustrate some exam-ples within the broad range of floor plan configurationsthat are feasible within the framework of the 143evidence-based design guidelines. The first example,a 12,lX)0 square foot replacement facility built in WestMonroe, completed in 1994, was configured as a se-ries of bandwidths, with an emphasis on the architec-tural expression of each examination room as a distinct"house" (Figures 3a-3d). TTie second example, the 8,000square foot replacement facility built in Columbia, com-pleted in 1995, was configured around a courtyard. Thestaff requested a building easy for patients to navigate,one that would provide many views to the exterior.

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    (16/14) (16/12) (10/10)Regions 1-9

    1990-1991 Fiscal Year2003-2004 Fiscal Year

    FIGURE 2. Statewide capital improvement prior-ity rankings" 'Four-point assessment scale: 1 =urgent priority; 2 = high priority; 3 = moderatepriority; 4 = no modification required at time otassessment. ^FJrst number in parentheses de-notes number of freestanding program sites inregion in 1990-1991 fiscal year (FY). Secondnumber denotes number of freestanding programsites in 2003-2004 FY (figures reported do not in-clude 16 school-based clinics).

  • The Role of ttie Architectural Environment in Community HeaWi I 86

    3a 3b 3c 3d

    4Q 4b 4c

    r lEB

    : * . : . r -

    5a 5b 5c

    Iflllffi*

    5d

    6a 6b 6cFIGURES 3a-ad. Representative case studies.

  • 86 I Journal of Public Health Management and Practice

    thereby establishing a direct connection to its woodedsite (Figures 4a-4d). These two facilities were designedby the first author's firm {R-2ARCH), in a joint venturewith Hugh Parker and Associates. In both of these fa-cilities, the staff requested large windows and a signifi-cant degree of transparency within the building, and be-tween "public" interior spaces and the exterior environ-ments. In the third case study example (Figures 5a-5d),the renovation of a 5,500 square foot, 2-leveI interna-tional style, modernist clinic in Metairie, completed in2004, required gutting the entire interior and rebuild-ing it in a phased manner. The site was deemed toovaluable to abandon, although the parish had offered tobuild anew on a site in an area remote from the core con-stituency of patients. This building will be eligible forplacement on the National Register of Historic Places in2012. Tlie renovation was the work of R-2ARCH in asso-ciation with Cusack and Cusack Architects, The fourthexample is the replacement facility built in Lafayette,designed by Architects Southwest, based upon closeconsultation with the SF! team and the guidelines. Tliisbuilding, completed in 2003, is the anchor within a new12-acre civic services campus, configured as a collegecampus in layout and its pedestrian scale. The build-ing is configured as a "street" with various waiting andsubwaiting rooms arrayed along a central circulationaxis, leading from a main reception counter resemblinga small vessel (see Figures 6a-6d).

    The evidence-based findings drawn from the field-work and the guidelines may be summarized as a setof 8 provisos: (1) there is no single, optimal floor planconfiguration, (2) clinical areas should be clearly sepa-rated from nonclinical zones and waiting areas shouldbe zoned to centralize patient Bow (including the ran-dom movements of cliildren) and to minimize noise,(3) natural daylight is desired by patients and staff andwas found to afford therapeutic amenity; views of na-ture were found to be Wghly preferred, (4) residentialimagery is highly preferred and is perceived as creatingan inviting atmosphere, (5) flexible spaces that allow fortwo or more functions at different times are highly pre-ferred, (6) children should have their own spaces withinthe building and the on the site, with the entire facilitydesigned to be attuned to their physical and sensoryneeds, (7) patient confidentiality should be maximizedwithin the total care environment, and (8) clearly identi-fiable entrance, parking areas, and interior way-findingsignage should be provided.

    In 2000, the original statewide survey from1990-1991 was re-administered with one significantmodification.'" This centered on expanding the surveyrespondent group: in 2000, the respondent group wasgreatly expanded to a total of 1,143 full-time DHH-OPHpersonnel. This longitudinal strategy made it possibleto discern broad trends and, in many ways, reaffirmed

    the progress made across the decade. Also, these datahave since been of use in consort with post-9/n anti-terrorism programs initiated by the Centers for DiseaseControl and Prevention in Louisiana and the recentlycreated Federal Office of Homeland Security.

    Discussion

    The SFI initiative has been a success from the stand-point of improving the delivery of care and the qual-ity of the public health care architectural environ-ment in Louisiana. Nevertheless, a number of publichealth clinics in Louisiana continue to urgently needmajor improvements, expansion, or total replacement.To date, no instances have been reported of the SFIprotocol having had an adverse impact on the qual-ity of or the untimely completion of any capital im-provement project. In many respects the SFI protocolis not significantly dissimilar from a CDC~sponsoredinitiative developed to monitor and reduce diabetesin inner urban communities." The SFI initiative, inthe broadest sense, is therefore not dissimilar from re-lated efforts to reduce the incidence of chronic diseasesin communities, as it similarly endeavors to expressthe needs and aspirations of patients, their families,direct care providers, agency administrators, locallyelected officials, statewide elected officials, and advo-cates for health improvements among disadvantagedpopulations.'- A building's occupants, the end-users,possess an undeniable wealth of pragmatic knowledgeacquired through experience. There is no way that an ar-chitect, acting alone, without meaningful consultation,can respond to an end-user's complex sets of functionalneeds. A second group, the building's intermediate-users, consist of individuals who may typically spendlittle or no time in the building on a regular basis yetmay have a profound influence on matters of financ-ing. This constituency includes local elected officials,agency administrators, and other policy makers. Giventhis situation, these constituencies may, knowingly ornot, set conflicfing agendas and policies. It is hopedthat the SR has contributed to an improved dialoguebetween end-user and intermediate-user constituen-cies. Regardless, some avoidable pitfalls are worth men-tioning for the benefit of public health administratorselsewhere.

    Early intervention vis-^-vis the SFI process has, byand large, yielded tremendous dividends.^^ This is be-cause the establishment of the construction, furnish-ings, equipment and land acquisition budget, and theselection of the "best" site is a critically important deci-sion and this typically occurs early on, often, beforethe architect is hired. The major decision that mustbe made prior to the determination of the project's

  • The Role o( the Architectural Environment in Community Health I 87

    scope and budget is whether to build or not to buUd,or to renoi'alf. I'rior to 1990, in numerous instances,communities had prematurely opted to keep and reno-vate their obsolete existing building instead of adoptingthe more sensible strategy of total replacement. Simi-larly, deferred maintenance is seldom the best courseof action over the long term. Secondly, develop poli-cies to encourage the meaningful involvement of theend-users as well as the intermediate-users. Do not de-vote an excessive amount of attention to any one con-stituency at the expense of others. Everyone will benefitfrom open and unfettered communication, lmbalancedor biased communications usually results in a lessthan fully supportive care setting (ie, improperly sizedRX)ms with poor adjacencies to one another, difficultto maintain wall surfaces, institutional-looking fur-nishings, and pcKir internal flow. Tliird, articulate theproject's mission statement early on.'"* The necessaryhomework should be done by experienced profession-als with regards to the establishment of the total budget,the definition of site amenities, and the incorporation ofrecent innovations in building design and technology(ie, assistive technologies such as redundant-cued di-rectional and room ID signage for the visually impaired,new types of lighting, emergency egress systems, assis-tive systems for the hearing and visually impaired, andLEED certification Ithe US Green Building Council'sprogram in Leadership through Energy Efficient Envi-ronmental Design]).'"^ To date, the health care indus-try in the United States has significantly lagged behindother building types and their clients in this respect.

    The question may arise: "Don't all thoughtful andskilled architects who work in the arena of health careengage in evidence-based design?" Simply put, the an-swer is no. This approach requires the systematic as-sessment of precedent, a willingness to revisit one'spast projects, and an investment of time and resourcesto leam what others have done. Perhaps it may comec^ some surprise, but relatively few architects in theUnited States or elsewhere have been trained to con-duct this type of work and still fewer provide evidence-based design as a professional service. Does it cost toomuch? Absolutely not, particularly in the case of a largenetwork of interrelated program sites operating underthe umbrella of a single statewide or municipal agency.The knowledge to be gained from one community andone building can be applied to 40, or 100, or others.As mentioned, there is no need to continually reinventthe same wheel. Architecturally, actively learning frompast mistakes as well as past achievements is, therefore,invaluable.

    From an administrative perspective, remain cog-nizant of the time-tested adage out of sight, out ofvtiud}^Be involved at key decision points. Fifth, persevereagainst the odds. The layers of bureaucracy in the pub-

    lic sector at times can have a paralytic effect on a capitalimprovement project. This is compounded by the sheerlength of time required to plan, design, and constructa process itself that can be slow and painstaking. Evena fast-tracked project may take two or more yearsfrom start to finish. Nonetheless, organizational resolveand determination are prerequisites to surmount polit-ical hurdles, intricate building code issues, and relatedconcerns. Sixth, build upon the organization's past suc-cesses, establishing a track record of successfully com-pleted capital improvement projects.'" And finally, es-tablish a culture whereby mechanisms are put in placeso past costly architectural mistakes are not needlesslyrepeated.

    A carefully sited, planned, and designed communitypublic health care facility functions as a civic symlx>l,not dissimilar from the "civicness" expressed in the lo-cal public library. It functions as a source of pride andaccomplishment, and this alone resonates throughoutthe entire communit)'. However, its impact can be evenmore far-reaching. One effect in Louisiana has been aheightened appreciation of the value-added benefits ofarchitecture as a meaningful part of the total paletteof public health services. Over the course of the pastdecade, the quest to replace aged, obsolescent facilitieshas in fact become a part of the public health cullure inLouisiana. Parishes in many instances have sought to"keep up with the Joneses." A new clinic facility in aneighboring community sparks interest. The construc-tion of so many new community care program sitesresultetl in a positive ripple effect thmugh the agencyas more and more replacement facilities opened for theprincipal use of underrepresented and historically dis-advantaged patient populations.

    On a daily level, these renovated and new facilitieshave resulted in what perhaps might be best describedas a "haJo effect.""* On average in Louisiana, replace-ment facilities have experienced an increase in utiliza-tion by patients of as much as 20% in the first year afteropening. It no longer was acceptable to engage in adhoc attempts to get by with doing less. The stark, win-dowless, industrialized metal clinics erected as recentlyas the late 1980s have became passe. A core aim of theSFI protocol has been to demonstrate how an evidence-based architectural standard is achievable without be-ing prohibitively costly. With this said, the goal has beento do more tlian what is minimally ret]uired, architec-turally, and to do so without significantly increasingconstruction expenses. This public policy position hasitself reaffirmed the community care clinic's status asa genuine ciWc amenity, in a reprise of the status ac-corded these places in the aftermath of the Great Floodof 1927.

    Some limitations of this process are worthy of men-tion. Critics may assert it is entirely loo self-referential

  • Journal of Public Health Management and Practice

    (ie, based too much on a finite universe of possibilitiesthat may exist only within Louisiana). In point of fact,similar outpatient community care clinics built else-where and examples of this building type publishedin professional journals, are a continual source of in-formation. Programmatically, it has been modeled inmany aspects upon Healthy Communities national pro-gram initiatives, although these precedents are not "ar-chitectural" per se. A second limitation is the impossi-bility of asking the occupants to rate their new facilityagainst their old one without invoking some version ofthe Hawthorne Effect. It is plausible to expect this typeof halo effect whereby one's new quarters engender alingering positive biasing effect on one's impressions ofit. It becomes impossible to completely divorce, isolate,or cogrutively separate the old from the new in one'sconsciousness. It has been found that after a period ofone year of completion the occupants are significantlymore adroit in realistically comparing their old to theirnew environment. A third limitation is the problem ofobtaining a representative occupant sample of the postoccupancy assessment of a given facility's performance.This is largely due to staff turnover, busy work sched-ules, and at times a laisez faire attitude that since onenow has new quarters, one need not feel obligated toshare this knowledge with others elsewhere who cangenuinely benefit.

    Conclusion

    Increasing the value-added amenity of architecture isa worthwhile civic investment. This will, however, re-quire the establishment of a learning curve in the pub-lic health policy-making arena. Administrative lead-ers within state and local public health agencies arewell advised to make site visits to recently opened clin-ics within their purview prior to embarking on a newproject. Agency representatives and local elected offi-cials are encouraged to hold town hall meetings to en-sure broad community input. Agency representativesand consulting professionals need to meaningfully en-gage local civic advocacy groups.''' Such meaningfuland sustained engagement in the planning and designof civic institutions, public health facilities notwith-standing, can result in a heightened sense of commonpurpose.'^" In Louisiana, a state which chronically ranksat or near the bottom in national health statistics, it hasbeen possible to establish for the first time a consistentevidence-based yardstick to measure the performanceof each community public health program site. This hasocairred in light of at times divergent regional politicalagendas within a state fiercely proud of its local cul-tural traditions. Architecturally, the SFI initiative hasactually respected and sought to further this cultural

    diversity by treating no two projects or communitiesalike.

    In for-profit health care organizations the patient isincreasingly viewed as a health care consumer. Intensecompetition now exists between institutions operatingin the same market. This results in costly marketing,public relations, and media campaigns. One by-productof patient-centered, consumer-focused health care hasbeen an increase in capital expenditures on architec-ture with the aim of attracting more patients and highquality staff personnel. The outpatient community carefacility is seen now more than perhaps ever before asa marketing tool and as a means to achieve this. Bycontrast, not-for-profit public health agencies have tra-ditionally not been subjected to these types of compet-itive market forces because they have not been forcedto do so.'' The underlying reasons for this situation aretoo numerous to discuss here, although in recent years,it has been the exception rather than the rule for tliepublic governmental sector to take full cognizance ofthe potential contribution of a well-designed architec-tural environment. It has been demonstrated that well-designed outpatient care environments can improvethe delivery of community public health care.^ Unfor-tunately, too many underrepresented patients and theircaregivers continue to receive and provide care in over-crowded, dysfunctional clinical environments."

    With this said, capital improvement challenges facedby public health care agencies in the coming years por-tend to be no less daunting than at present. The pressureexerted on public health leaders to curtail expenditureswill likely continue to escalate in the future.-"'-^ '^ Theproblem of chronically under financing buildings builtfor public health is, therefore, also likely to escalate,particularly in underrepresented communities wherefiscal resources make it is nearly impossible to build atall in the first place. A breaking point will be reached asmore and more states and local jurisdictions face criticalbudget shortfalls. Despite this less than rosy scenario, asustained commitment to the building of high quality,evidenced-leased architecture for public health care isneeded more than ever at this time. Due to their train-ing as problem-solvers serving, by professional defini-tion, the "public health, safety and welfare," architectsare ideally positioned to help society attain its high-est aspirations as more and more architects receiveuniversity-level training in evidence-based design. Thiscall to action on the part of the architectural professionnot coincidentally parallels current widespread callsfor an evidence-based medical and allied health profes-sional landscape.-"^ A genuine spirit of architectural ad-vocacy in public health in the United States and aroundthe globe can yield tremendous benefits in the comingyears as the world's population continues to increasedramatically.

  • The Role of the Architectural Environment in Community Health

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