By Jane Rohde

Introduction

This month, Sunbrella is bringing to you; Evidence Based Design: Resources for Senior Living! Sharing resources and building the evidence is an important aspect of working in all segments of healthcare. Information from post-occupancy evaluations, research that is completed by various educational institutions and health systems, NIH, CDC, GSA, and other governmental agency research studies, and observational site visits are all resources for the design community in evaluating evidence that supports design decisions based upon the specific application, care populations, and overall goals of a project.

Unique Approach to Collaborative Design Guidelines

At the last Environments for Aging Conference, Robert Wrublowsky, Principal Architect at MMP Architects gave a presentation on the newly developed Design Guide for Long Term Care Homes (Guide). His goal is to share this as an open source resource and have others add to the research base by providing information that can be included in updates of the Guide to allow it to be a living document. This is a fresh way of looking at information as a shared growth opportunity to reach a greater saturation of person-centered settings within not just North America, but throughout the World.

Embracing a Cultural Shift for Person-Centered Care

The Guide includes Guiding Principles and provides a comparison of institutional models to small house models, including case studies. The organization of the document includes an evidence based design research topic, the use of icons to provide the associated outcomes for the research topic, an explanation of the design issue that the research topic addresses, EBD interventions and the rationale applicable to the intervention based upon a robust systematic literature search, including rating of the rigor of the research. Robert has generously allowed the Guide to be available on both the Facilities Guidelines Institute website (www.fgiguidelines.org) and on With Seniors In Mind educational website (www.withseniorsinmind.org) as an open source downloadable resource for those working in the senior living and long term care marketplace.

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The Guide was part of a recent presentation to senior living care providers at the LifeSpan Conference in Maryland. I discussed processes as illustrated within the Guide, the FGI Guidelines for Design and Construction of Residential Health, Care, and Support Facilities, and the Senior Living Sustainability Guide®(www.withseniorsinmind.org). All of the referenced resources have in common wanting to support the deinstitutionalizing of long term care, which requires embracing culture change, creating small house / household environments, operational restructuring, and following Evidence Based Design principles. As part of the programming and planning process using these various resources, our firm always holds focus groups, gleans information at the onset of a project, understands and helps develop the care models that are being considered, and discusses the goals from a person-centered perspective. Ultimately, we are continually asking for involvement by the operational team throughout the programming and design process. The interesting part of the session was the reaction by the operational and care staff in the audience. Apparently, what is the norm for asking the operational staff what works, what doesn’t work, and what is important to their residents is not actually the norm – the care managers, front line, and operational staff are being ignored and not used as the most amazing resource available to a design team! One story included a care manager that told the architect that the bed and furniture configuration that they wanted to utilize was not going to work within the layout of the resident rooms. Their comments were dismissed and ‘waved off’ by the design team. I asked, “…so, what did you do?” She replied, “we {nursing staff} just sat back and watched,” and sure enough they were definitely right, and the beds would not fit into the rooms! This was one of many stories that I have heard in the last few years about design teams “knowing better” instead of embracing the resources that are readily available to assist with making evidence based, thoughtful, and meaningful decisions that improve resident outcomes and quality of life for both staff and residents. When assisting a client with a repositioned project or building a new or replacement project, it is essential to gather information from the operational team, residents, and their families. If we design something that is decentralized, but the operational team does not provide feedback and education/training for front line staff, they will carry over the centralized, institutional model of care over to the new decentralized setting. This is setting up a new project environment to fail – the discussions upfront in the planning programming process are the most important prior to completing any design concepts or solutions. Building a framework that assists with decision-making and maintaining the framework throughout the project design process through construction allows all team members to understand the project goals that should support the resident outcomes and ease of staff to implement the desired care model.

Conclusion

Robert and I share the recommendation that all healthcare designers should read Atul Gawande’s Being Mortal – as quoted in the beginning of the Guide: “Making lives meaningful in old age is new. It therefore requires more imagination and invention than making them merely safe does”. This is our charge as designers for older adults and other potentially vulnerable populations – collaborate, share, and understand those that you are designing for – including the staff, families, and specifically the residents.

Blog written for Sunbrella.

By: Jane Rohde

There are two major certifications that have been garnering a lot of buzz lately in the health and wellness design space: WELL Building Standard® and FitwellSM. As a designer, you’ve probably heard about both. But what are they and which one might be the right fit for the work you’re doing today or your next project?

Here’s the high-level look:

WELL Building Standard is primarily medically driven
FitWel is focused on public health issues

Let’s look a little more at each.

WELL Building Standard is designed to provide guidance for health and wellness in building construction and interior spaces. And scientific, medical, behavior, and environmental health factors were taken into account during its development. Research was used to support the desired credits (versus using the research to develop the criteria).

WELL Building offers a certification that incorporates concepts that relate to air, water, nourishment, light, fitness, comfort, and mind. The credits are listed, however, as preconditions and optimizations. This means, for example, that under “air” there is an optimization credit, toxic material reduction, that uses a red list approach that deselects materials based on concern about a chemical in its pure state (as opposed to allowing materials based on their overall effectiveness, application, and final state as a finished product).

Evaluating products should use risk and exposure in conjunction with the appropriate application to better understand the overall product formulation from a life-cycle perspective. While vinyl wall covering contains vinyl chloride, for example, that chemical is harmless in the finished product. Vinyl wall covering, meanwhile, is easy to clean and an ideal material often specified for healthcare facilities.

Another challenge for architects and designers seeking WELL Building certification is that, like LEED, it’s based upon square footage. This makes it expensive to achieve and tends to be used for higher-end construction projects. The proposed 2.0 version is looking at the affordability in addition to some of the preconditions moving into optimizations (prerequisites to options).

Finally, it is important to note that although often called a standard, WELL Building is technically a guideline, in that it was peer reviewed but not developed using an all-stakeholder ANSI consensus process.

FitWel is also designed to achieve health and wellness in building construction and interior spaces. Unlike WELL Building, which takes a proscriptive approach (i.e., do this to achieve our certification), FitWel’s approach is to let you mix and match strategies to evaluate where you currently are and how to continue to improve (i.e. better public health).

FitWel was created as a joint initiative between the U.S. Centers for Disease Control and Prevention (CDC) and the General Services Administration (GSA) in conjunction with experts in public health and design. It is evidence-based guidance in that the criteria were provided by the scientists at CDC to determine what would most significantly impact public health outcomes.

This is an important distinction: FitWel is directly based upon the evidence versus developing credits and then finding evidence to support the credit after the fact. Deselection methodologies are not included in FitWel because the science is not there to support a red list approach to product selection. Fitwel was piloted by GSA on a portion of their portfolio, including rural, urban, and suburban buildings of difference shapes, sizes, and uses.

FitWel offers three levels of certification that measure success in achieving “evidence-based design and operational strategies that enhance building environments.” The 55+ strategies fall into seven health impact categories that include community health, physical activity, occupant safety, and reducing morbidity and absenteeism. In other words, using design in conjunction with operations are tools for the betterment of public health.

An example of FitWel’s approach in action is its recent partnership with lender Fannie Mae, which is aimed at encouraging healthy affordable housing. Loan recipients whose buildings achieve FitWel certification are eligible for reduced interest loans and reimbursement of the certification fees. FitWel’s affordability is another key attribute to the use of a health and wellness certification system by a larger portion of the real estate marketplace.

The article can be found on Vinyl In Design's website.