"Designing for Health" is a monthly, web-exclusive series from the healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environments.
A critical access hospital (CAH) is a small community hospital in a rural setting with 25 or less acute care beds, providing 24-hour emergency care to the catchment area and located more than 35 miles from the nearest hospital. Congress created the Medicare Rural Flexibility Program in 1997 in order for small community hospitals to be designated as critical access hospitals and receive funding through a special reimbursement model; in essence this allowed community hospitals to remain open and maintain financial viability. An important component of the legislation required that hospitals assess and provide community services. With a sounder financial footing, the legislation paved the way for hospitals to expand their health services and community engagement. The small rural community hospital is typically one of the larger community employers in addition to providing crucial medical services. The hospital also tends to be one of the larger civic structures, so a replacement hospital project is an important event—a design opportunity for and by the community.
For the last five years Perkins+Will has been an integral part of the programming, design, and construction of three critical access hospitals for ValleyHealth, based in Winchester, Virginia. Early in the process the team reviewed a study commissioned by the U.S. Department of Health and Human Services that explored the concept of a prototype for a critical access hospital. This study provided a baseline for typical CAH services: emergency, diagnostic imaging, surgery, lab, and acute care, as well as the physical plant and public space. Due to the cost reimbursement for CAH services under Medicare, the non-reimbursed public space is kept to a minimum and planning efficiencies are critical for staff utilization.
Perkins+Will first developed the Valley Health Critical Access Hospital prototype with the War Memorial Replacement Hospital in Berkeley Springs, West Virginia. The prototype sought to address the typical issues confronted by critical access hospitals—low staffing, a fluctuating census, and high outpatient volumes—and was the result of an extensive planning effort with the hospital administration and staff, ValleyHealth, and the architectural team. As the model was transposed to communities in Romney, West Virginia and Luray, Virginia, the team found that the prototypical plan had to be modified to respond to each facility’s unique needs. Localized requirements for care and regional culture influenced design and final planning was responsive to these needs. However, within the shifting prototype, we successfully retained key design concepts for public space, wayfinding, and community engagement.
Due to the cost reimbursement model and limited resources available for public space, a strategic design element utilizes reimbursable space as an extension of the public zone. At War Memorial Hospital the dining room is not a separate room in the food service department, but a large area adjacent to the main corridor connecting the hospital to the adjacent medical office building (MOB). A community education room is at the other end of the corridor, and the outdoor courtyard adjacent to both creates a much larger public zone, with the dining area doubling as an extension of the community space. All three hospitals connect to an MOB and are cornerstones of the concept of a “health campus” in their communities.
Integrating a community education and meeting space in the planning was a core component for the facilities and ties into the CAH model envisioned at the federal level. Providing an exterior courtyard adjacent to the community room creates more options for education and community venues, as well as expanding the public space of the hospital.
The high tourist volume at Page Memorial Hospital in Luray, Virginia, drove the planning requirements for distinct main and emergency waiting rooms, and provided a different public space opportunity. We designed a central registration block between the two waiting areas and along the main public corridor. A secondary corridor connecting the registration stations provides privacy and allows staff to easily flex between the two waiting areas as demand dictates. The registration block, with natural stone walls, is a focal point between the two waiting areas and expands the public zone by creating a larger waiting zone, rather than two completely separate spaces.
Clear separation of staff and public zones is another key concept carried through the facilities; this leads to better clarity of services, wayfinding, and staff maneuverability. The design of the public space is characterized by corridors filled with natural light and views to gardens or nature. Within departments, natural light and views at the end of corridors is highlighted and brought into staff zones wherever possible. While assisting with patient wayfinding within departments, the natural light heightens staff satisfaction.
The public zone also provides the opportunity to incorporate regional features into the architecture. At Page Memorial, the mountains and caverns of the Shenandoah Valley provided inspiration for the design. Regional materials such as stone, expressed as an exterior element, continue into the interior spaces and mark key access points. The healing power of the Berkeley Springs is reflected in the floor patterns in the corridor of War Memorial: a stream of water running along the edge and “pooling” in the dining area. On the acute care unit the pattern of a water drop radiating out gives a unique character to each corridor and room in the department. In all the facilities, the local material palette is used an indicator of department entries and staff stations, and connects to local palettes initiated in public zones.
Experience with three CAH facilities suggests a new prototype concept for small community facilities: one based on broad design concepts rather than specific planning modules. These broad concepts can more easily accommodate facility requirements, and respond to community in the creation of a new civic space reflecting regional character. Neil McLaughlin, CEO of War and Hampshire, has said, “The needs of the community are well served by a new facility with modern healthcare standards, however the function of the hospital goes deeper than that. The community is proud of their new hospital and the local character imbued in the design makes it a welcoming place to visit.”
Tatiana Escobar, AIA, is an Associate with the Perkins+Will Washington, D.C. office. She is the project architect for a variety of healthcare projects, with a focus on Critical Access hospitals. Tatiana can be reached at firstname.lastname@example.org.
Flex Monitoring Team Briefing Paper No. 14 “Exploring the Community Impact of Critical Access Hospitals,” January 2007. University of Minnesota, University of North Carolina Chapel Hill, University of Southern Maine.
“Critical Access Hospitals Payment System,” paymentbasics October 2007. Medpac. Washington, D.C.
Past installment of "Designing for Health" include (click on the title to access the full article):
The Ancient Feng Shui Philosophy in Modern Healthcare
The True Family Women’s Cancer Center
Physician Shortages and Implications for Design
Designing for an International Standard of Care in Transforming Global Cultures
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