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The Leaflet Article

Featured Article:

Infusion Bay Design Process, How design problems become opportunities for innovation

Daniel Livanec

Project Reference:  James M. Stockman Cancer Institute

Project Location: Frederick, Maryland

Anticipated Date of Completion:  Summer of 2017

Introduction

Just as necessity is the mother of invention, design constraints are the mother of innovation. Aggressive deadlines, tight budgets, site conditions, and a seemingly endless list of healthcare codes and guidelines handcuffs designers to predetermined methods of design and execution.

Ironically, enough constraints that would seem to warrant a generic solution require an additional level of study for the success of the work. Innovation can be a tall order in healthcare design, where the Hippocratic oath often tilts the scale towards redundancy rather than originality. Understandably, clinical staff that is tasked with implementing new strategies should be integral to the design process.

Healthcare is often late to the party in regards to contemporary design strategies, sometimes in ironic ways. A facility analysis of one particular healthcare system found two da Vinci surgical robots providing state-of-the-art technology, while clinical staff would still handwrite patient’s birthdates and medical information. This dichotomy yields a unique backdrop for design professionals that wish to challenge their clients to think outside the box.

The following case study demonstrates how a series of design constraints for a new outpatient infusion center led to a unique solution. Rather than being forced or contrived, the solution presented itself through an integrated design approach and by assigning key objectives to be studied.

Case Study

Frederick Memorial Hospital is in the process of expanding its award winning oncology program by relocating its current center across the street from the hospital to a brand new 62,000 sf, fully integrated facility.

The chosen site brought several challenges. On the property is an existing 24,000 sf ambulatory facility housing imaging and lab services. A flood plain bisects the site, forcing any new construction towards the south, which already features a significant 16-foot slope from north to south. The goal became to connect the new cancer institute with the existing building to create an ambulatory campus that would anchor the north side of town and establish a new FMH brand.

The new comprehensive center focuses on multidisciplinary care, with medical oncology, radiation oncology, surgical specialists, and support collocated. With the unwavering desire by the leadership team to collocate infusion therapy, radiation services, and medical oncology on the first floor to promote interaction between disciplines, the design team had to strike a balance between the programmatic desires of the client with a myriad of site constraints. Perimeter wall, a necessity for infusion therapy design to allow for daylighting and views for a patient population that may spend hours in an infusion chair, was at a premium. Connecting to the existing ambulatory building to the east and the sloping site that would bury the building to the south provided limited exterior wall for the infusion program.

The existing cancer center was located in a reused grocery store across the street from the main hospital. While the staff, leadership, and programs put forth at the center are exemplary, the space accommodations were lacking. Patients are seated in a nondescript room with minimal natural light or views to the landscape. Individual zones are poorly defined or nonexistent. In a space that should be a celebration of life and provide a sense of renewal, the environment was sterile and chaotic.

Design Process

An integrated team is vital to the success of a design initiative, which can include not just the design team, but the clinical staff, executive leadership team, engineering consultants, equipment planners, construction managers, and subcontractors. Each voice carries an agenda – patient safety and satisfaction, constructability and budget, aesthetics and durability.

Patients are positioned around an expansive garden space along the first floor of the cancer institute. The space boasts full height storefront glazing and 10’-0” high ceilings. The goal is to blur the distinction between interior and exterior space. The lack of exterior wall space is addressed with a double stacked approach. Careful consideration, through planning diagrams and 3d modelling, is given to allow for uninterrupted views to the garden from any seat, regardless of row or location.

A “cockpit” model was explored to solve multiple problems. First, a sloping partial-height partition curves around the back of the infusion chair, giving a sense of privacy from the circulation path but allowing clinical staff to maintain visualization of their patients. The partition then opens up towards the glazing side of the plan, permitting views of the garden beyond. The bays are angled in such a way to give each patient uninterrupted views of the garden, whether they are sitting in the first row or second.

The bays themselves are organized in zones of four to accommodate staffing ratios, a key component gleaned from discussions with clinical staff over several weeks of design meetings. While the walls work to define a space and give a sense of privacy, the spine provides a work zone for the staff. At the back of each bay is an integrated countertop and workstation for charting. At the front, a concealed opening houses the infusion cart, gloves, and sharps container to minimize the sense of a clinical atmosphere and allow patients to focus on the view to the exterior. Visual pollution is left at a minimum.

Clinical staff responded favorably to the cockpit concept because of the openness to visualize patients, the integration of their staffing ratios, and knowing that the majority of their patient population saw infusion therapy as an opportunity for socialization and peer consulting. The open design is balanced with four private infusion rooms that double as an adolescent infusion area. Rooms not adjacent to an exterior window incorporate clerestory lighting to capture some of the daylight pouring into the main spaces, without compromising patient privacy.

The finishes are thoughtful yet unassuming. The goal is to let the exterior garden be the focal point of the space, rather than overpriced finish materials. Due to this strategy, high quality renderings become a necessity rather than a luxury. Finish boards lacked the capability of telling the story of a space whose primary focus is not internal, but external – to life, growth, and renewal.

Design development took the overall layout and studied the specifics of one bay. Dedicated areas are established for the patient, family member, and staff/physician to keep the zones clean and functional. At the conclusion of design development, the construction manager engaged a casework manufacturer in a design assist format to build a full scale mockup of a bay. This allowed the staff to study the scale, height, and accessibility of the design full scale, in real working conditions. All equipment, including the infusion chair, were available to test and manipulate in the space. A list of considerations and modifications was generated and addressed by the design team. As with any modular element in a healthcare setting, a mockup provides the opportunity for testing and tweaking in advance of a multi-unit rollout during construction. Additionally, the clinical staff is given the opportunity to establish a comfort level with an unfamiliar concept.

Constructability could also be streamlined, as the mockup provides a tool for discussion with subcontractors. Once the design was approved by the end users, the design team met with the casework manufacturer to review detailing, materials, and cost saving opportunities.

The design also introduces an aspect of patient satisfaction often overlooked – control of one’s environment. Each bay includes an oversized pendant fixture that’s fully dimmable from the infusion chair. Simple yet meaningful, the ability for environmental control is a counterintuitive principle to patients that are accustomed to relinquishing control in a clinical setting.

Closing

This innovative solution to a set of design problems creates a highly functional yet unique environment for the delivery of healthcare. This innovative approach as described with the infusion suite at the Frederick Memorial Hospital Cancer Institute cannot be done in a vacuum. A variety of voices, meetings, design presentations, and technical coordination was required to establish a solution that fit the context of the initial challenges.

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