SEPTEMBER 19-21, 2023
Charlotte Convention Center - Charlotte, NC

Improving the Micro-Hospital Model

Renee Kubesh, AIA, EDAC | Senior Project Manager and Principal | EUA

Healthcare providers increasingly turn to micro-hospitals to deliver quality care to their communities. These fully licensed, 24/7 facilities can help patients with myriad medical issues – including critical care – within a fraction of the space of their full-sized counterparts, typically less than 20,000 square feet.

After more than a decade of operational micro-hospitals, we’ve seen recurring themes in how providers adapt them to meet their evolving needs. We also had the privilege of recently conducting post-occupancy evaluations for two buildings. We offer these top findings as lessons and recommendations for sustaining the success of this healthcare delivery model.

Finding the Right Location

Micro-hospitals can offer convenient and accessible community care when strategically positioned relative to a greater healthcare system’s network. Many existing micro-hospitals are in relatively urban areas. Still, a micro-hospital could be located to reach underserved areas or to enter new markets, even if other providers are already present.

Despite a robust network of hospitals and clinics in the United States, many communities – especially economically disadvantaged and rural areas – lack adequate access to healthcare. Some healthcare systems see micro-hospitals as a solution and a mutually beneficial arrangement: the community gets access to nearby care, and the provider introduces new patients to their system with a relatively small investment. Also, higher-risk patients benefit from connecting to a specialty care network while receiving local, stabilizing, pre-treatment care.

Staffing is vital to this approach. As these facilities are introduced in underserved areas, the municipality and health system have a joint responsibility to foster strong relationships among their constituents and improve local amenities, making the region desirable to medical practitioners as a place to not only work but also live and be part of the community.

Other providers leverage their micro-hospitals to support a “spoke and hub” model of care. Staff triages incoming patients to determine the best care location based on patient needs, staffing and bed availability. This approach works well when assets like a robust network of physicians and access to ambulatory and acute care are already in place. It is also a valuable model for municipalities seeking to revitalize their city centers, as proximity to healthcare is critical in driving downtown living and business development.

Both approaches to locating micro-hospitals have typically assumed the facility will operate as a stand-alone service. But we’ve noticed a trend of using micro-hospitals as anchors for medical office buildings or specialty care services. Patient-centered care and patient satisfaction are enhanced through convenient access to pharmacies, laboratories, radiology departments, ambulatory surgery or specialty care. This allows the micro-hospital to remain true to its core model – lean and efficient – while being able to plug into other services.

Some healthcare systems integrate their micro-hospitals to support a “spoke and hub” delivery model, allowing them to transfer patients, if necessary, to main-hub hospitals or other in-network facilities that offer specialized services.

Integrating Specialty Care

Our healthcare clients increasingly ask for micro-hospitals with more integration and flexibility. They are rightfully concerned about licensing requirements, local patient population needs, and incorporating appropriate demographic specialty care components.

The challenge is meeting those requirements without forfeiting the efficiencies of the micro-hospital model. We often caution our clients from over-engineering or over-programming; the micro-hospitals do not need to meet every patient’s needs all the time. They will still be effective, as staff will attend to patients that require immediate care while stabilizing and transferring others as needed. Over-engineering these facilities can increase the break-even point, slow patient throughput, and hurt patient satisfaction and employee engagement.

If done strategically, it is possible to integrate specialty care while still realizing a micro-hospital’s benefits. For example, one client considered pairing cancer care with the traditional emergency department and inpatient model. With cancer care as a top revenue draw – and considering the distance from the main hospital – this made sense for the provider.

To integrate specialty care effectively and preserve the micro-hospital’s efficiency, healthcare systems should identify the specific components of care early in the building’s design process and review them with the local authority having jurisdiction over the project. The facility may require separate entries, clear identification of dedicated versus shared support areas and code-delineated smoke zones.

In our post-occupancy evaluation, we found it is better to offer radiology as both an inpatient and outpatient service. Radiology for inpatient service is required for licensing, but offering it for outpatient services will increase patient access and lead to a greater return on the high-investment imaging equipment. Future micro-hospital designs should maintain separate access pathways for each type of service to maintain efficiency and reassure patients that they are receiving the care they registered for in the appropriate location.

Supporting Staff and Cross-Training

Micro-hospitals are intended to operate on a lean and efficient staffing model where doctors, nurses, and aides cross-train to provide care to the maximum ability of their licenses. This is a functional approach as long as the staff still find value in their work. Often, burnout is not the result of staff doing too much work but rather from losing touch with the job they once loved.

We’ve heard from staff that they want more time at a patient’s bedside, which allows them to own the patient’s care from arrival to discharge. While it might seem counterintuitive, in a micro-hospital setting, one nurse should provide services ranging from meals to breathing treatments, all at the patient’s bedside. The variety of work counteracts nurse burnout and increases patient satisfaction by developing a deeper relationship with one caregiver.

The hospital’s design should support staff cross-training. A centrally located nurses’ station adjacent to the medication room, lab and storage areas allows staff to help the emergency and inpatient departments during low census counts. At busier times, when both departments may have dedicated teams, the station encourages communication between them so that staff can assist each other.

A centralized nurses’ station allows staff to see what’s happening around them and ultimately deliver better care. We learned from our post-occupancy evaluation that inpatient waiting rooms must be within view of, and ideally adjacent to, the station so nurses can oversee and communicate easily with family members.

Placing the nurses’ station and other support spaces in the center of the micro-hospital makes it easier for staff to respond to patients in all departments.

Incubators for New Ideas and Systems

There is little doubt that micro-hospitals will continue to adopt more technology, and the patient experience will become more virtual. Many providers are leaning into their micro-hospitals as technology incubators because it is easier and more cost-effective to test new technology and workflows in a 10-bed rather than a 100-bed facility.

For example, consider how micro-hospitals might embrace a new registration and check-in experience. Today, patients walk into an emergency department, and the first person they see is likely a receptionist. In the future, this position will be handled by an automated kiosk that scans the patient’s identification and directs them to the appropriate waiting area. Or they may bypass the kiosk altogether; instead, there might be an automated secure door system with advanced wayfinding to support patient self-rooming. The point is that providers are much more likely to try this technology on the micro-hospital scale – with minimal investment – before implementing it in their larger facilities.

Micro-hospitals are also apt testing grounds for improved mechanical systems. We learned from our post-occupancy evaluation that more rooms should have systems that can flex to negative pressure, allowing maintenance staff to respond to potential future pandemics without re-tooling mechanical equipment.

Looking Ahead

Micro-hospitals have a bright future. The model has become increasingly attractive to healthcare systems and patients due to rising construction and healthcare costs. As we continuously look to improve the state of healthcare in our country – whether through enhanced access to care, better support for staff, or new technology – micro-hospitals are fertile ground to test and implement ideas in an already innovative and efficient model.

About the Author: Renee Kubesh believes that architecture makes a difference in people’s lives and is excited to be a part of that dynamic in healthcare. Her healthcare environments empower staff to realize their potential, welcome family and visitors in a relaxing atmosphere, and help patients take control of their treatment and wellness. Over her 30-year-plus career, she has led the creation of spaces that can flex to future needs. She values an evidence-based design approach of understanding and respecting what has worked in the past while making the design and construction process engaging and fun for everyone involved.

About EUA: EUA is best known for designing environments that elevate people’s potential. The respected 115-year-old firm specializes in several markets, including education, workplace, healthcare, senior living, student housing, mixed-use, entertainment, and science and technology. More than 250+ employees in Milwaukee, Madison, Green Bay, Denver and Atlanta demonstrate an unparalleled commitment to the markets, communities and clients they serve. For additional information, please visit the firm’s website at


Media Contact:
Sophia Lapat
[email protected]


Attendees Enjoyed Exhibitor Innovations, Inspiring Keynotes, Engaging Sessions by
Industry Leaders & Networking Connections, September 27-29, 2022

Long Beach, CA (October 10, 2022) – Last week, thousands of manufacturers, architects, designers, engineers, contractors and healthcare leaders convened at The Long Beach Convention Center for the 35th annual Healthcare Facilities Symposium and Expo, HFSE, one of the country’s largest shows dedicated to healthcare design and facilities, energized attendees, exhibitors, speakers and partners with compelling Keynote Presentations, 100+ Exhibitors, Conference Sessions, Networking Events and much more.

“On the heels of a successful 2021 Healthcare Facilities Symposium & Expo in December, 2021, we were hoping for an even bigger, and more robust 2022 edition and it exceeded our expectations with incredible growth across all facets including attendance and exhibitor participation,” said Jenabeth Ferguson, Vice President, Symposium Director. “The excitement at this year’s event was palpable, as manufacturers, architects, designers, and healthcare leaders experienced unparalleled access to industry education, cutting edge new healthcare design products and services, and networking opportunities.”

Robust Conference

The Symposium featured three jam-packed days of educational and insightful Sessions and Keynotes by top industry leaders. The sessions spanned multiple topics including Pediatrics, Behavioral Health, and Community Health. This year’s keynotes included Liz Ogbu, Founder + Principal, Studio O, Oleksii Iaremenko, Deputy Minister for European Integration, Ministry of Health of Ukraine, and closing Keynote, Jessica Gutierrez-Rodriguez, Executive Director, Facilities Management & Operations, University of Texas Health San Antonio.


“I always enjoy attending HFSE because I feel that there is more content catered to hospital executives and planning, design and construction teams. It has been valuable in connecting with peer institutions to share knowledge and expertise, especially in such a challenging post-pandemic environment. There were many great perspectives and targeted strategies shared in presentations and owner-focused meetings that I’ll definitely leverage going forward. This year’s conference was especially great, to reconnect and see so many familiar faces and walk away feeling better about our industry as a whole.” Sean Collins, AIA, LEED AP, Executive Director, Facilities Planning, Design and Construction, Cedars-Sinai


“This year’s HFSE conference was full of heartfelt inspiration.  As we continue to provide healing environments in healthcare, we are more open as professionals to lead with our hearts.  The utilization and application of generative space will continue to be at the forefront of our actions.” Jessica Gutierrez-Rodriguez, Executive Director, Facilities Management & Operations, Facilities Management Department University of Texas Health San Antonio


Expo Hall

The Expo Hall featured the most innovative products and services in the healthcare facilities industry from some of the country’s top manufacturers and providers. Many exhibitors launched new products at HFSE, getting in front of important decision makers from healthcare facilities, architecture and design firms. The Expo Floor also featured two Design Solutions Theaters where the design team galleries came alive with 15 minute mini-presentations.


“The Healthcare Facilities Symposium and Expo offers the opportunity to connect with healthcare system executives, facilities managers, architects, and designers and gives exhibitors a chance to highlight their products and make new connections.” Nick Nichols, Director of Business Development, Skyline Art


“HFSE provides an incredibly professional venue that brings everyone together around the challenges and opportunities tied to healthcare design and is a premier networking opportunity for a diverse audience. Most importantly, they provide unparalleled support to their exhibitors. We will be back next year!” Raffi Baltayan, Marketing Manager, Unicel Architectural Corp.


“I was very pleased to represent PAC/Envac Automated Waste and Linen Removal at HFSE 2022 in Long Beach, CA. The event was intimate (and fun!) and really encouraged people to meet, learn, share, consult, help, and exchange ideas.  We made several valuable connections with whom we will develop long-term mutually beneficial relationships.  Thank you to all who helped plan and organize this wonderful event!” Lynne Klosowski, Marketing Specialist, Precision AirConvoy Corporation


“SwiftWall chose to exhibit at HFSE 2022 because of the show’s attraction to the healthcare industry’s elected clientele. From facility managers, architects, designers, planners, GC’s and manufacturers, we knew the right mix would be in attendance. SwiftWall’s 20×20 booth was a great way to showcase our product in real time. FLEX Wall is our newest product for the healthcare industry and we wanted our launch to be felt with dramatic entrance at HFSE.” BettyLynn Abercrombie, Account Executive, SwiftWall


“I am so glad that I decided to participate in the 2022 Healthcare Facilities Symposium & Expo in Long Beach, California! This was our first time participating and it exceeded all our expectations. The entire event was run smoothly by the HFSE team who were incredibly organized, quick to respond to all questions, and made the process easy. We were excited about the traffic to our Expo Booth. I would say to anyone thinking about participating-do it, you will not be disappointed!” Jim Carey, Vice President, West, Krug


Symposium Distinction Awards

The annual program recognized design teams, projects and individuals who have made a profound contribution to the healthcare design industry. In addition, it recognized the best and most innovative new products within the healthcare design & construction industry. This year’s winners included: Boston Children’s Hospital Hale Family Building (Team Award), Jamestown S’Klallam Tribe Healing Clinic (User-Centered Award), Hoag On-Demand Care & Innovation Center (Adaptive Reuse Award), Tim Laboranti, Principal of Healthcare Design, BDA Architects (Individual Award), Stephen Parker, Senior Associate, Stantec (George Pressler Under 40 Award), AkitaBox Facility Condition Assessment Software (Most Innovative Product), Altro Tegulis (Most Sustainable Product) and Interface Desert Scapes™ (Architect’s Choice). New this year, the Founder’s Award was awarded to Francis Murdock Pitts, Principal of architecture+.


“I was humbled to be selected as this year’s George Pressler Under 40 Award recipient and celebrating with my Stantec colleagues from across the world who came here to HFSE. It was a wonderful experience to collaborate with my peers, consult with clients and congratulate everyone on the great designs on display throughout the conference.” Stephen Parker, AIA, NCARB, Senior Associate, Behavioral + Mental Health Planner Stantec Architecture


Networking Events and Raffle

HFSE is the place to mix and mingle with new and old friends at daily events including the Grand Opening of Exhibit Floor, Ice Cream Social, Happy Hour and the ever-popular Raffle. This year the Raffle raised $14,000 for Long Beach’s Algalita.


“Algalita was honored to participate as a charity partner at this year’s Healthcare Facilities Symposium & Expo. Using the raffle proceeds we received from the event, we will invest more than $14,000 in our environmental education programs that reach thousands of teachers and students every year. Thank you for supporting our work towards a world where plastic pollution is unthinkable!” Katie Allen, Executive Director, Algalita

For more information about the 2023 Healthcare Facilities Symposium & Expo (September 19-21, 2023), visit


The mission of the Healthcare Facilities Symposium & Expo is to create a multi-disciplinary environment that inspires you to evoke change and the advancement of a better delivery of healthcare through the physical space. Competitors, clients, and colleagues come together as friends to collaborate, share research, hear fresh perspectives and participate in the ever-changing conversation of your industry.


Champion Your Culture Strategies for Building and Maintaining a Purpose-Driven, Gimmick-Free Culture

By Robins & Morton Division Manager Eric Groat

Whether you call 2022 the “Great Resignation” or the “Great Reshuffle,” team culture has never been more important than it is now, and with good reason.

Finding qualified and committed people at every level is one of the key challenges facing the construction industry as the labor market remains extremely competitive. At the same time, our clients’ continued emphasis on speed to market, set against volatile supply chains, puts even more emphasis on teamwork.

According to a recent study by MIT, a toxic company culture is the strongest predictor of employee attrition and is 10 times more important than compensation when predicting turnover. The study identified toxic cultures by several elements that included lack of diversity, equity and inclusion; disrespect; unethical behavior; and failure to recognize and reward performance.

All those warning signs of a “bad culture” may seem easily identifiable, but are they as easy to spot in our everyday interactions? More importantly, do we recognize them in time to facilitate change within a team?

To answer this question, our first impulse may be to review the lagging indicators first. In the construction industry, these typically include the critical outcomes, such as staying on-target with the schedule, budget, profitability or employee retention. While these are benchmarks of a successful project, they’re not the first signs of trouble within a culture.

Instead, we should be focusing on leading indicators – Is there trust among our team members? Are we engaged in collaborating? How do we handle unethical behavior? Are team members recognized for their contributions and performances?

When we pivot toward proactively identifying indicators of a healthy or toxic culture, we’re able to determine the proper actions to either maintain that culture or reverse the negative changes we see. However, no matter its state, culture requires work.

While every industry and business is different, there are five red flags that I’ve found most universal in identifying the early stages of a toxic culture:

  1. Lack of communication. It’s alarming when two people who are on the same team are working from wildly different sets of information or have a completely different understanding of a goal or outcome. It’s a clear signal that there’s a broken link in the management structure, and that the team doesn’t understand their objective. In addition to chaotic and unproductive exchanges, not understanding desired outcomes also stifles innovation, which limits the potential of the project or work product.
  2. Lack of decision-making. Decisions fuel all forward progress. Developing a clear structure of decision makers and processes to tackle particularly challenging questions are foundational for a functional working relationship. When we see environments that don’t encourage timely responses to critical decisions, we could pull back the curtain and find dysfunctional relationships with managers, fear of company leadership, and team members who are unclear about the mission of their organization. Although no employee wants to make an error, positive and learning-focused environments recognize that people are fallible and will make errors. Our reaction to those errors directly reflects our culture.
  3. Withholding information or support. Not all information is fit for public consumption – whether it’s unconfirmed, too detailed for most, or simply irrelevant – but there’s a difference between filtering and withholding information. Filtering is done with good intentions to provide a team member with the information they need and clarity to complete their task. Withholding information is adversarial, often used as an instrument to influence power dynamics. If a team member begins withholding information, it’s a warning sign that they don’t want to work together to solve a problem.
  4. No action taken as a result of feedback. Feedback is a necessity for improving any workplace or team environment. When people place their trust in a team and provide constructive feedback, it can be a vulnerable experience. Another sign of a toxic culture is expecting team members to enter that vulnerable place with no intention of addressing their concerns.
  5. No motivation to improve. The final sign of a toxic culture can be summarized into a single word: apathy. If there’s one thing we can be certain of, it’s that we’ll experience change – personally, professionally and often at an exponential pace. Without a motivation to improve, a culture will become stagnant, leading to dissatisfied and frustrated team members.

While some of these signs may sound familiar, the good news is that it’s never too late to course correct. Here are a few tactics that have been successful in my experience:

  1. Provide a platform for feedback. Creating a mechanism for feedback is the first step to building trust with your team. Provide several avenues for team feedback such as performance reviews for one-on-one conversations, team health assessments, and companywide people satisfaction surveys. No matter how the feedback is collected, holding ourselves accountable to be transparent about what we received and how we plan to address it is essential to maintaining culture.
  2. Get the right people in the room. When working to address cultural problems, we naturally gravitate to having hard conversations with those whom we already have the greatest rapport. While those conversations may serve as a great sounding board, they’re unlikely to result in meaningful change. Only when we engage everyone and commit to healthy conflict among the team members who can initiate changed behavior can we truly expect an improved outcome.
  3. Hire and promote emotionally intelligent leaders. People will always be any organization’s greatest resource and having leaders who can navigate interpersonal relationships will make the difference when facing a culture crisis. One way to support this within your teams is to ensure you’re providing growth opportunities, and the only way to know what that may look like for a team member is by getting to know them. Establish a review structure for all team members, ensuring every employee has a structured touchpoint with their manager, at least twice year. There are also specific mentorship programs within the company that can help them reach their professional goals. However, most team trust is built in the day-to-day conversations – it’s why we emphasize the importance of teambuilding activities. All of these elements will help you get to know the strengths of your existing team members, and you can build a strong management structure as a result.
  4. See red flags for what they are. It’s easy to categorize a challenging interaction or an undesirable outcome as a one-off, but harder to admit when it may be a sign of a more significant problem. However, we’re better positioned to tackle incremental change than an entire cultural shift. Surfacing an incident before it becomes a long-term issue is a proactive solution to reduce the red flags, one by one.
  5. Pursuing partnerships that are culturally aligned with your organization. Business can be a lot like marriage. The phrase “opposites attract” isn’t often the case – two married people may have different hobbies or social batteries, but it’s rare that they have a completely different value systems. It’s a similar quandary in construction, with numerous long-term project partnerships. Inevitably, there will be friction between teams that don’t share collaborative and transparent practices. Projects are at their best when teams share critical values. While every business partnership won’t be a perfect match, prioritizing working with companies that share fundamental cultural characteristics has a greater opportunity for success.

Although there is no one-size-fits-all approach to developing and maintaining culture, its building blocks are grounded in respect for people – respect for your employees, your business partners and your community. Using that as your culture’s guiding principle can assure a successful foundation for your team – no ping-pong table required.

Eric Groat is the Division Manager of Robins & Morton’s San Antonio office. He has more than 20 years of experience managing complex construction projects and is an advocate of Lean construction principles. Groat believes that an emphasis on culture, partnership and respect for people is key to revolutionizing the construction industry.

Agency, Blossoming, Better Tomorrows, and YOU

By Dr. Wayne Ruga, FAIA, FIIDA, Hon. FASID

In our world that is circumscribed by histories, beliefs, and biases – our true heritage – the natural human agency, to express ourselves freely, that we were each born with, gets increasingly constrained as we progress in our development, an inescapable paradox that most of us are blind to. ‘Structure’ – such as norms, rules, and policies – is the insidious and ever-present constraint to ‘agency’, and for many of us, reproducing and producing more limiting structure is what we unknowingly become practitioners of, and rewarded for, rather than drawing upon our own natural agency to liberate ourselves, and those around us, to become more of who we were originally born to be.

At the Seventh Symposium, our Keynote Speaker was Bernie S. Siegel, a surgeon, who encouraged us to examine how this ‘agency-structure paradox’ creates limitations in our ability to achieve greater personal health, deliver more compassionate healthcare, and live our lives in ways that are more fulfilling. The theme of his presentation was captured in a compellingly simple photographic image, that he presented, of how nature is unstoppable in its pursuit to express its agency – even in the face of the most severe limitations of structure.

Dr. Siegel’s image was of a dandelion that had forced its way up through a newly paved and striped urban roadway – a road where the asphalt was still shiny in its newness and the yellow painted center line was, as yet, untrodden by vehicles – and this dandelion was the only natural element in this sterile urban setting, beaming triumphantly in the rays of the sun, having become the brilliant dandelion that it was created to be. Of course, the point of the image was to encourage us to each become like this dandelion.

Anais Nin expressed this same point with breath-taking eloquence, when she said – ‘And the day came when the risk to remain tight in a bud was more painful than the risk it took to blossom’. Through these simple words, we can begin to see the fact that we do have a choice – it’s not an easy choice – but it is a choice that is available to each one of us. Do we choose to remain as a bud – constrained by structure, or blossom – as an expression of our natural agency?

Of course, since we all want to choose to blossom – why is it so challenging and difficult? To suggest that it is simply a matter of beliefs is to oversimplify the situation. However, our beliefs are key to what we choose. For example, in The Doctor and the Soul, by Viktor Frankl, we see a dramatic example of how the power of our believing that we have a choice, and making it, can profoundly inform our experience – even in an extreme situation where pain is involved. In Viktor Frankl’s chilling personal account of being tortured, he describes how he chose to be triumphant over his situation, drawing a direct parallel to Dr. Siegel’s brilliantly radiant dandelion image.

Now, in its 35th year, the Symposium has a proud legacy of being a highly fertile field, providing the essential conditions that enable its participants to blossom – the extreme opposite of the newly paved urban roadway or the torturous conditions that Frankl survived. The Symposium is a unique place with an established history of supporting positive beliefs in our ability to improve the world, supporting our choosing to blossom, and actively encouraging our blossoming because of the invigorated agency that our courageous Symposium community supports our access to.

In fact, in support of our belief that we can each improve the world by making better tomorrows – we have compelling evidence that the Symposium accomplishes precisely what Dr. Siegel encouraged us to do: by providing the conditions that support our liberated expressions of agency, the Symposium enables improvements to our personal health, it has championed a more compassionate delivery of healthcare, and has enriched a vast number of human lives. Rather than contributing to the already-too-much-structure, the Symposium supports expressions of agency – bold agency, courageous agency, agency that enables our community of believers-in-better-tomorrows to actually create better tomorrows, day after day, and year after year – in the face of the ever-increasing structure that continuously attempts to constrain our expressions of agency.

As an original creation – unlike anything that existed before it – the Symposium was created to be a community of like-minded individuals. It was intended to be an annual ‘place’ to learn from each other and to share resources. The very name, ‘Symposium’, was carefully chosen to express the value of ‘discussing together’ – the non-hierarchical and inclusive activity that gives its flourishing community an infusion of vitality and a taste of the splendor of openly expressing our uniquely individual agency. As active participants in this experience of ‘discussing together’, we can feel the warmth of acceptance and a valuing of difference.

One of the original hallmarks of the Symposium was its open invitation to all stakeholders in health, healthcare, and design to engage in a new, and very different kind, of collaborative discussion – to provide this new and ever-expanding global community with the opportunity to hear new voices and different perspectives, to learn new ways, as well as for your voice to be heard and appreciated, for you to be seen and recognized, for your ideas to be openly expressed, for your resources to be shared and valued, and for you to learn in ways that open your mind to new possibilities.

The Symposium is a place for YOU to blossom: as an attendee in the 3-day long annual event, with ongoing discussions with Symposium community members between the times of the annual event, through the special relationships that develop through these discussions, and through the positive reinforcement that being in community with like-minded colleagues – those who believe in making better tomorrows – can encourage and support.

As this year’s 2022 Symposium returns ‘home’ to California, the state of its ‘birth’, YOU are invited to return ‘home’ to the fertile conditions of the annual Symposium where you will be encouraged to blossom, and to re-discover being the triumphant active agent that you were born to be. I am looking forward to our further blossoming together in Long Beach, in September.

Telemedicine: Comparing Facility Design Models

By Jenni Eschner AIA, EDAC, LEED AP

Telemedicine as a mode of patient care delivery is here to stay. With the $1.5 trillion Consolidated Appropriations Act, 2022, coverage has been extended for telemedicine services, sending a message of support to ensure better healthcare access. Over 80% of surveyed physicians agree that patients have better access to care due to the availability of telemedicine (AMA 2021 Telehealth Survey Report).

Increasing professional satisfaction, telemedicine has allowed providers to find better work-life balance. According to a 2019 survey by American Well there is a correlation between physicians’ interest in using telemedicine and physician burnout. Specialists are among the most burnt out and are also most willing to practice via telemedicine.

Patients like it, too. A Jones Lang LaSalle surveyshows that seventy-six percent of all respondents who have had a telemedicine visit since July 1, 2021 would prefer to use this option in the future. For parents with multiple children, not having to find childcare or not having to take both healthy and sick children in for a clinic visit is a huge satisfier. The ability to do a virtual visit after hours and not have to take time off work for minor illnesses saves precious paid time off.

Architects are asked to help our clients figure out effective and affordable ways to implement this care model. What are best practices when designing telemedicine spaces? It depends on the situation.

Two Scenarios: Care Team Integration

To ensure the continued success of telemedicine, it needs to be integrated into the care team continuum. While technology allows us more mobility and flexibility, it needs to be deliberately planned, tested, and implemented.

Two scenarios need to be considered.

One telemedicine version is where a patient is in-person at a healthcare facility and interacts with care givers at a different location, either on or off site. This might be a visit with their provider and additional care team, such as social workers, pharmacists, psychologists, and other coordinated care. FGI 2018 Guidelines provides requirements for this scenario which include acoustics, lighting, finishes, patient orientation and equipment placement. These will be expanded in the upcoming FGI 2022 version.

The second telemedicine option is when a provider and/or staff interact with a patient and either the patient or both patient and caregiver are remote. According to the AMA 2021 Telehealth Survey Report, 80% of physicians are in a clinic during a virtual visit, while 64% are at home. 95% of patients typically connect from their home setting.

Three Models: The Comparison

There are three programmatic areas architects plan with clients to achieve this integration.

Model 1: Existing Exam Room

This option gives providers the ability to do both virtual and in-person clinical visits within the same work period without having to physically relocate. The same support staff is available to the provider during these visits and the same clinical supplies and tools are also available without duplication. This is a familiar and branded experience for the patient since the visual background they see is the same as during an in-person visit.

There are downsides to using an existing exam room. Renovations may be required to provide the right environment and infrastructure for connectivity. This might mean that additional equipment such as a microphone or camera would need to be added. Using an existing exam room also ties up space that could be used for in-person visits. And our clients are sharing that it can be challenging for providers to switch back and forth between a synchronous virtual visit to an in-person visit. The fact that you don’t need as much physical space for a telemedicine visit also makes this an inefficient option for a healthcare facility from a $/SF standpoint. Along with the size of the room, a virtual visit would not require the same medical equipment/amenities in the existing exam room for telemedicine.

Model 2: Dedicated Telemedicine Room

A dedicated room can be smaller and simpler, so organizations don’t overspend on equipment, millwork, and plumbing. Having these rooms also frees up traditional exam rooms so that more care can be provided at the same time. As with using an existing exam room, the same support staff and supplies are readily available.

What gets omitted from projects when clients can’t afford everything they want? Often, it’s staff support areas. We’ve been riding the prioritization wave of “patients’ needs first” for the past 15+ years in healthcare planning. There is now a shift to a more holistic systems approach, in which the entire life cycle of providing quality healthcare is considered and prioritized. When not in use as telemedicine space, these rooms can flex as multi-purpose use, small meeting, dictation, off-stage or staff respite space.

While simpler and less expensive, in an existing facility there is still the cost of space reallocation and renovation in creating dedicated telemedicine rooms. These rooms are ideally near the provider. In a new project, this can change the planning module of the department and add additional space to the overall footprint.

Model 3: Separated Space/Call Center

The final option we look at with our clients is a separate or off-site facility. This can range on a spectrum of one provider working out of their home to a large call center type of office space. The lower cost of construction and overhead for this space type makes it worth investigating and it (or the provider) can be located anywhere. This is a big advantage for facilities with a limited footprint, as they can prioritize available square feet for higher acuity care.

Another benefit to a physically separated space is that it can more easily adjust to varying volume demand. When rent is cheap and lease terms are short, it is not difficult to relocate. Because of this scalability, healthcare organizations can more easily increase quantities of providers and potentially reach new patients, even outside of a demographic area.

However, expanded access of virtual care to a wider population increases the responsibility of healthcare organizations to ensure their providers’ licenses and credentials are in good standing (“Managing provider licensure amid expanding Telehealth” April 2022). During the Public Health Emergency of COVID-19, all 50 states waived state licensure requirements. Now that most states have reinstated them, healthcare systems that want to use a large call center to reach patients in various states need to monitor that their physicians on staff are licensed in those locations.

The demands of technology on an organization can be a barrier to having off-site virtual visit locations. A healthcare system’s IT department may not be set up to manage the demands that arise, especially when it occurs in a provider’s residence.

Another drawback to a separated virtual visit model is that the support team and resources are not all in the same location. It may not be practical to use a synchronous care team approach (MA + Physician in one visit) from a staffing and scheduling standpoint. This could lead to additional work for staff. There is also the risk of less oversight and accountability.

And finally, patient experience might be diminished if there are too many steps or transitions in the virtual visit process or if it feels disconnected from the healthcare organization. Sure, it is convenient to be able to speak with a physician at 9:00 p.m. while they are in their living room. But doesn’t it feel just a little weird and unprofessional? For this reason, health systems need to work hard on the technology piece to make sure it feels familiar and consistent with the quality of care one would get during an in-person visit.


There is no one-size-fits-all solution for telemedicine. My recommendation is that as stewards of our clients’ buildings, we should “be flexible but stick to [our] principles” (Eleanor Roosevelt). Design spaces so they can adapt to new technologies and uses, but don’t overbuild. Work with your clients to help them figure out what will serve their needs best. If one thing has become clearer over the past couple of years, it’s that we are scrappy and resilient and need to do more with less. And we can!

Design through stories: Experience-based design in pediatric healthcare

By Laurena Clark, Tim Eastwood, and Natalie Petricca

A story can mean so much. Hearing about the experiences of patients and family members can affect us deeply, injecting us with focus and propelling us forward as we design with a particular end user in mind.

Experience-based design is more than just understanding the clinical flow or asking patients for input on design decisions. It’s looking at the experience of an event. It’s hearing the stories that patients carry with them, and the impact of their experience on all five senses. While it’s important to design a functional healthcare space, it’s also vital to maintain a human touch. How can you combine function and experience? Patient experiences are sensitive and personal, so how do you gather and apply these experiences of patients and their families to design spaces that improve experiences?


We’ll share some lessons learned from a rewarding project in our hometown of Toronto, Ontario. Adopting an experience-based design approach to healthcare design – especially on pediatric projects – can have a big impact on the healthcare experience.

Blood and marrow transplant/cellular therapy unit

We incorporated experience-based design while working on the redesign of the blood and marrow transplant/cellular therapy (BMT/CT) unit at The Hospital for Sick Children (SickKids), which provides care for patients from across Ontario and Canada’s Atlantic provinces.

This unit is home to some of SickKids’ most vulnerable patients, who stay in isolation rooms for weeks to months at a time and require stringent infection control measures because of their compromised immune systems. In the unit, children can receive treatment for leukemia, lymphoma, aplastic anemia, sickle cell disease, and other conditions.

Staff on the BMT/CT unit have delivered care in the current space for 25 years. Patient rooms are small and require upgrades to support new technology, individual washrooms, physical therapy, and comfort for patients and their families.

During the beginning stages of our redesign of the unit, which took place prior to the COVID-19 pandemic, we had the opportunity to use one larger patient room as a prototype. We used the room to sample different technologies and materials, and enabled care teams to think about how they might work in the new space.

This project gave us the opportunity to engage with end users – children, youth, and their families – which provided a key element of the design process. The experience of patients or caregivers in this type of environment is critical because the extended hospitalization allows people to think about how they might change the space. We knew we needed to hear their perspectives.

Engagement: Learning about experiences

When it comes to experience-based design in pediatric healthcare environments, you need to approach the engagement process carefully. Aside from being empathetic – especially when working with current patients and their families – here are some ideas to consider, taken from our work on the BMT/CT unit:

  • Journey mapping: Can you learn about milestones before the engagement starts? Before meeting with users, we asked care team members about the major milestones of a patient’s experience, from arrival to discharge. This provided us with a structure for our interviews with users, where we could later walk through a patient’s journey. Then, we placed posters on the wall with five different steps in a patient’s journey, asking questions like, “What was the experience like? What would you wish was different about the experience? What were positives and negatives about the experience?” Patients and families wrote their experiences on sticky notes and attached them to posters.
  • Preparation: Before you begin your sessions, make sure you have materials ready for people to describe their patient journeys. Bring samples so users can pick their favorite tiles or floor materials. Provide paper and drawing tools for users to illustrate what their experience was like or to sketch out an ideal room design. For some children and youth in our SickKids session, we asked how they’d design a new patient bedroom for the next patient that needed treatment.
  • Dual format: It’s useful to conduct interviews via a dual format, where you book appointments with some people but also provide an open, drop-in session. This provides a hybrid of structured and unstructured engagement and gives options.
  • An invitation to share: You may not even need to ask many questions during an engagement session – it’s more about inviting people to share their experiences in an informal way. Be prepared for some emotional moments. While working on the project, it touched us to hear some of the sacrifices that caregivers made for their children, including caregivers that slept over for months or traded shifts with their partners so they could maintain their jobs while their children were in hospital. Caregivers told us they didn’t want to leave their child’s room because they didn’t want to miss important information from a doctor.

From stories to design details

After conducting your engagement, you can look at ways to enhance your design with the feedback you have received. Dive deep and immerse yourself in that experience. Imagine every possible way you can make the experience better for patients and the family members (whose wellbeing is so important, given the important role they play in the care of their child).

For example, rather than just painting a wall, could you add a marker board for children and youth to doodle during their stay? Your design decisions can help create something more than a space of healing.

A well-rounded process

In pediatric healthcare, an experience-based approach to your design can lead to a well-rounded process that reflects the unique needs of young patients and their families. We’re driven by the balance between leaning on our technical knowledge and incorporating stories we hear from families. While working on the BMT/CT unit, we always put ourselves in the position of the people we were designing for – such as the child and caregiver staying in the hospital for weeks.

When projects like these, it’s all about listening. And the more you listen, the better you design.

EvaClean unveils PureExcellence for True Infection Prevention Partnerships

Braintree, MASeptember 2021 – The vision for proactive infection prevention has been realized in the EvaClean solution with proven processes and safer, more effective cleaning technologies. Over time, EvaClean has also become a trusted advisor for infection prevention units and environmental service teams in hospitals, health systems and long-term care facilities, as well as in colleges and universities. Ultimately, the unique needs of these industry sectors inspired EvaClean to create PurExcellence.

EvaClean’s PurExcellence is a progressive program built on six key pillars—Assessment, Standardization, Education, Safety, Sustainability and Guaranteed Cost Savings—which establish a roadmap to true infection prevention partnerships with healthcare and higher education.

The first step in the quest for PurExcellence entails a complete site assessment of current protocols, chemistries and applications based on a number of factors specific to each facility.

Kurt Wong, Chief Experience Officer at EarthSafe, EvaClean’s parent company said, “The data is used to develop a comprehensive chemical analysis, then compared against a more standardized approach using safer chemistries, which invariably yields cost savings of at least 30%.”

However, these benefits can’t be realized without ongoing targeted education that ensures proper procedures are implemented on a consistent basis.

“One of the most critical components of PurExcellence is customized training for the life of the partnership,” said Rich Prinz, Senior Vice President of Sales. “Perennial education helps ensure higher levels of safety, compliance and productivity to achieve better outcomes.”

Safety has always been one of EvaClean’s primary pillars. That’s why PurExcellence is standardized around EvaClean’s PurOne®NaDCC cleaner and disinfectant. Not only does PurOne have the first EPA registered biofilm bacteria kill claim, it also eradicates over 55 organisms on 12 EPA lists, including multi-drug resistant and emerging pathogens. To mitigate cross-contamination, PurOne can also be used with EvaClean’s disposable environmental surface wipes or, alternatively, the wipes system can be used to augment existing programs.

Yet, high level efficacy is only half the safety equation. In addition to protecting patients, students and staff, solutions must also protect the environment. EvaClean’s advanced chemistries are HMIS rated 0/0/0 with a neutral pH, as well as biodegradable and fully OSHA, NIOSH and JCAHO compliant.

CEO Steve Wilson said, “Long-term sustainability is another important aspect of PurExcellence. Our technologies were specifically designed to deliver both environmental and economic benefits.”

Because PurOne and PurTabs®, EvaClean’s electrostatic sprayer disinfectant, dilute to different strengths for multi-purpose solutions and are highly effective at lower parts per million (ppm), it takes less chemical to accomplish more. The tablet format also requires less packaging, translating to less shipping, emissions and environmental impact. When strategies include electrostatic disinfection of all touchpoints, chemical consumption is even further reduced.

The six pillars of EvaClean’s PurExcellence initiative are a proactive formula for the prevention of infectious outbreaks and HAIs, which adds up to higher quality care and lower associated costs of at least 30%–guaranteed.

About EvaClean

Originally developed by EarthSafe Chemical Alternatives® in 2016, EvaClean® has become the preeminent infection prevention solution. In addition to a portfolio of advanced electrostatic technologies and safer, more sustainable chemistries, EvaClean provides customized protocols and ongoing training to simplify processes and improve outcomes. Founder and serial entrepreneur RJ Valentine, together with an exceptional leadership team, have built EvaClean into one of the leading authorities on healthier disinfection across all industry sectors. Learn more at www.evaclean.comand follow us on LinkedIn, Facebook and Twitter.

Progressing Beyond the Rubicon

By Dr. Wayne Ruga, FAIA, FIIDA, Hon. FASID

This article is about the future – yours, mine, and everyone’s. It is a ‘call’ to courageous progress.

Background: The expression, ‘crossing the Rubicon’, is meant to evoke a decision to a significant course of action – an irrevocable action where there is no going back, as in 49 BC, when Julius Caesar crossed the Rubicon River and the events leading to the rise of the Roman Empire unfolded. In the 1970s, Thomas Kuhn developed the concept of a ‘paradigm shift’, with a similar meaning. Today, it is common to hear the expression, ‘let’s get out of the box’, a metaphor meaning much the same. In all three of these cases, radical progress is harkened – a systemic improvement over the status quo – one that requires courage to advance into the ‘beyond’.

At the 2017 30th annual Symposium, in Austin, we commemorated this milestone event by drawing upon the image and legend of Janus – the Roman god of transitions. The image portrays Janus as a left and a right profile – with a straight-on portrait between these two profiles – to mean that, as we progress into the future, we should inform our journey with learnings from the past. At the 30th Symposium, as we discussed progressing into a future informed by learnings from the past, none of us could have imagined the arrival of the Pandemic on our doorstep, about to challenge everything we thought we knew.

Foreground: As we make our preparations to return to Austin for this year’s 2021 Symposium – having completely skipped a Symposium for the first, and only, time in the history of the event – to be certain, during the last 20 months, we have all been required to cross the Rubicon, shift numerous paradigms, and get ourselves out of many a box. In my roles as the Symposium founder, healthcare and design innovator, pioneer of new futures, and teacher, I am frequently asked to comment on what we’ve learned through the challenges of this pandemic that will have a lasting, positive impact on how we create our future.

In this regard, the Sankofa – the mythical bird of Ghana – offers useful guidance. It is an inspired legend that reminds us of Janus, with the additional dimension of ‘wisdom’. The native Akan tribe, the source of the Sankofa legend, believe that the past should guide us in how we plan our future – and, that it is the wisdom from this learning that enables us to make a stronger future likely. In the tradition of Socrates – I turn the question to you: what have you learned during these 20 months, what wisdom have you gained, and how will this wisdom inform the decisions you will make as you progress into the new future?

My own view on this question – what have we learned – has multiple dimensions: (1) how can the Symposium impact the new future; (2) what impact can I (the collective ‘I’) possibly have on the new future; and (3) how can ‘I’ contribute – positively – toward creating a new, and better, future? How each one of us addresses these dimensions is profoundly crucial, in terms of how our collective new future will unfold.

For example: How can the Symposium impact the new future? First-time attendees may get the impression that the Symposium is a conference – although it contains many of the same elements that a conference does, it has so much more to offer. The Symposium can be better understood as a crucible, a vessel where transformation is forged. Each year, radically new ideas are presented and discussed that are carried by the attendees further into the world to advance progress. Whether these ideas exist as information, knowledge, or wisdom – it takes courage to learn new ideas and use them to improve the status quo, as Symposium attendees have done for decades, as inspired and courageous agents of transformation in health and healthcare.

The Symposium, as a crucible, has an established pioneering legacy of fueling the transformation of the individual lives of its attendees by providing direct exposure to: new, and often – very different – ways of thinking; new connections, support, and resources from meeting and engaging with like-minded individuals; and new business opportunities. There is no other healthcare facilities design event that has so profoundly improved lives around the globe, because of this transformative function – the lives of patients, families, staff, and local community residents.

To find ourselves asking, ‘what impact can I possibly have’ is to overlook the many unique opportunities that have opened up because of this unprecedented moment in our history. Every single individual has a significant, unique, contribution to make towards the creation of a new and better future – although it is not always so easy to see that, and to have a clear idea of what we each can do. This is precisely why we must reach into the ‘beyond’ – the beyond the Rubicon, into the new paradigm, and get ourselves out of the box. As Hillel the Elder said. ‘If not now, when? If not you, who?’. Now is the time.

The question: ‘how can I contribute – positively – towards creating a new and better future?’ is not a simple question with a simple answer. It is an inquiry that each one of us has the opportunity – and responsibility – to engage in. Why do I make this bold assertion that we each have the ‘responsibility’ to consider this question? My view is that we are all leaders – some of us are highly visible and recognized leaders, with ‘leader’ written in all capital letters; many more of us are leaders, written simply with a capital ‘l’; and – most importantly – every single one of us is a leader in lower case letters: the leader of an enterprise, called ‘my life’. As the leader of this personal enterprise, we are the CEO, and we have sole leadership responsibility – as the CEO of our life – just as the CEO of a major organization has. In this role, we have the responsibility to discover how our inherent personal, unique, agency can find purchase – and traction – to advance our own enterprise.

Of course, advancing our enterprise does not necessarily mean that we will contribute positively towards creating a new and better future – so, I qualify my comments by drawing upon the words of Reinhold Niebuhr, author of the ‘Serenity Prayer’: ‘God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference’. From this prayer, I highlight the words, ‘courage’ and ‘wisdom’. The Sankofa enabled us to appreciate the value of wisdom in informing our future with learnings from our past – a new understanding that the teachings of Janus were silent on.

‘Courage’, however, is a new aspect – one that the Serenity Prayer contributes to our inquiry: a personal exploration of considering what things can I actually change? In our modern times, definitions and understandings of ‘courage’ have emphasized brave and fearless actions, particularly when faced with adversity. Examining the origins of ‘courage’ provides us with a further understanding – ‘courage’ is derived from the Latin root of ‘cor’: of the heart. When ‘courage’ is used in this original way, it encourages us to discover and to speak openly of truths from our heart, as opposed to brave and fearless actions, which have their origins in our brains.

As we further consider the root of ‘courage’, we must each discover a personal way to understand our heart in a new way – not merely as a mechanical pump for the purpose of circulating blood, but – rather – as the center for our ability to gain access to unique intelligences that – amongst their far-reaching capacities, enables each one of us to pursue courageous self-expression. Neibuhr’s Serenity Prayer invites us to use our ‘wisdom to know the difference’ – a profound opportunity to learn how to clearly distinguish the wilful volition of brain-driven actions, from the more subtle and elusive callings of our hearts, and – as a result – access personal expressions of ‘courage’ that can move mountains and transform futures.

What have we learned? If it isn’t as obvious to you as it is to me – old habits are hard to change, and ‘necessity is the mother of all invention’. It is surprisingly easy – more than we imagined – to try doing old things in new ways, and – presto – the outcomes are improved. What about making a really big stretch, and also discovering how to do new things in new ways?

The September / October 2021 issue of Harvard Magazine has a feature article, ‘The State of the Pandemic: Lessons Learned from the Continuing Confrontation with the Virus’. It discusses a range of lessons learned – some of which call to us to create futures that – heretofore – were unimaginable. For example, the article reminds us that the Pandemic is a global challenge, and we have not yet developed the global structures to adequately withstand future health threats – or the resources. In our current era, the wealthiest countries can have the best outcomes, while our less wealthy relatives have less robust defences – is this the future we really want for our children, and their children?

The article mentions the built environment, and some of the health challenges that our current inventory provides – such as closed and ventilated buildings, and insufficient intensive care capacity for future epidemics. As a community of leaders, with a passionate interest for improving health and healthcare facilities, we can expect that the Symposium will inspire novel remedies to these deficiencies that will contribute towards improving the resilience that we rely on our essential services to have, and to continuously upgrade.

A ‘Call to Courageous Progress’: Pablo Picasso famously said, ‘I am always doing that which I cannot do, in order that I may learn how to do it.’ No doubt, if Picasso was still alive, he would have been a notable Symposium Keynote speaker, and a regular attendee. Although the richness of the distinctly different Symposium attendees is invigorating, Picasso’s quote provides a fascinating snapshot of the key characteristics that weave their way through the global Symposium community – a commitment to regularly and consistently doing the impossible, and continuous learning. And, as a Picasso scholar might explain to us, Picasso’s quest to be ‘always doing that which I cannot do’ was driven by his courage – in translating the wisdom of his heart and learning to create from this source – much as each one of us might do, as we courageously progress on our respective leadership journeys, in creating a new and better future for the many generations to come.

In conclusion, this ‘call’ is a thundering shout: now is the time to draw a line in the sand, beyond which is a new and much better future than our recent past (50 years?). Let’s all discover and draw from our wisdom, learn from our journey, and invest our precious life force into courageous demonstrations of our unique agency – the gifts we were born with, the legacy that our ancestors bequeathed to us, and the dreams that inspire each one of us to leave this world better than when we arrived.

Wayne Ruga can be reached at: [email protected].

Rapid Adaptation: Redesigning a VA Senior Living Center to Contend with COVID-19

By Jay Pelton, RA, LEED AP, & Morgan Young

In 2019, the Lebanon, PA Veterans Affairs (VA) Medical Center tapped Miller Remick and Array Architects to design and construct a Community Living Center (CLC) that follows the VA standard small house modelfor their campus. Little did the team know that the pandemic was about to fundamentally change how age-in-place environments are designed. In this article, we’ll review strategies to adapt existing designs to meet new guidelines by exploring how the design team addressed MEP and operational challenges posed by the pandemic.

Project Overview

The existing CLC is located inside the 1940s H-shaped historic nine-story inpatient building on the sprawling campus. Each floor plate was only 30-40’ wide, with the structure and double-loaded corridors limiting each resident room to be no more than about 15’ wide.

Phase one of this project consisted of a full master plan to move their current beds into
small houses to be constructed on campus. This aligns with the guidance of the new small house model, which includes four 14-resident CLCs and one town/community center which will interconnect all residents. During the master plan, the team determined we would need to relocate 56 beds, so the CLCs evolved into four small house models – all connecting to one central town hub through a series of connecting corridors.

The team had completed the CLC’s schematic design when March 2020 arrived. As the pandemic took hold, the VA remained steadfast in protecting their residents with new HVAC solutions in the inpatient hospital. The VA learned a lot at that time, often acknowledging that sealed shut windows were a very difficult obstacle.

Questions and Downstream Implications

The team began their re-evaluation when the building was at 35 percent completion. At this stage, the building was designed with mechanical and available infrastructure efficiency in mind and was equipped with geothermal heat-pumps and a single air handling unit. Working with the VA, Array and Miller Remick looked at what could be done to improve the residents’ outcomes should the pandemic happen again, after the future CLC was occupied.

The first decision was determining how far to take the protection. Would we need to treat each small house separately? Would we need to treat each connected community differently, or address each individual on a case-by-case basis? Would staff need to don and doff equipment differently? How would the normal course of meals and daily resident life be altered? Would they be able to share in the planned small house amenities?

The team first looked at the plan to determine what would create the most versatile solution. We explored how we could prevent airborne virus spread most effectively. The current VA approach to protecting the veterans inside their hospital rooms naturally influenced our thinking. The team considered this approach within the context of the floorplan layout. If we needed to boost our HVAC system, we had to start over, and knew we had to begin with the level of protection necessary to provide residents and staff protection during a pandemic. Our floorplan was a Y-shaped spine and two wings. Each wing contained seven rooms.

Re-assessing Floor Plans

The team looked at the plan for how to limit airflow among all spaces. Originally, there was only one air handling unit (AHU); the building was designed efficiently with geothermal pumps producing a majority of the conditioning with a lower air delivery. The team determined that if there were COVID-positive residents, one AHU will no longer be sufficient because it would make the whole building ‘hot,’ or contaminated. Our design was now at risk and we needed to determine how to revise the HVAC system. But first, we needed to tackle the transmission problems. We established rules for three categories of residents: those who were in contact with COVID, those who were not and those who might have been. In looking at residents who were, the agreement was to limit room air exposure recirculation.

Working with the VA, we developed a series of options. When we compared an isolation room-type scenario to these air delivery needs, it quickly became evident that these rooms needed to be 100-percent exhausted. Along with the design community at large, we learned that contact tracing would not be able to definitively identify the residents with COVID in time for them to properly isolate. Therefore, we needed to treat everyone who went to their own room as if they had COVID. We also needed to designate safe areas for the staff to continue to support residents, both in and out of the hot zones. Very quickly, we decided to limit the access to the resident corridors with closeable doors from the main spine and treat the rest of the rooms as if they were clean.

Determining New Needs

Now that we identified a layout and compartmentalization strategy that accomodates occupants during a pandemic, the next step was to assess the new needs of the mechanical system. We determined that one geothermal-fed unit would not have sufficient capacity for new air requirements because the air changes per hour (ACH) would go from two to a minimum of six per residential room. In order to redesign the system, the team implemented a plan to provide multiple chilled water air handlers, one for each wing’s distribution, plus a 100 percent exhaust system.

Key Takeaways for Updating HVAC in Age-in-Place Environments

Selecting the right HVAC system for age-in-place environments is important to ensure your facility is future ready. Here are five key takeaways from our experience to guide your decision:

  1. Select an HVAC system that provides conditioned air by a Variable Air Volume AHU. By doing so, our team was able to provide the VA a “Pandemic-mode” for the resident wings which prevents recirculated air within the building and meets the minimum six ACH per hour.
  2. Ensure the AHUs are capable of negatively or positively pressurizing each resident’s room to isolate infected patients from the remaining population. In our case, three AHUs – one for the central core/spine, and one each for the two resident wings – were needed.
  3. Specify for versatility. At the CLC, the HVAC system feeding the residents’ rooms will allow for the rooms to be convertible from normal condition, nearly pressure balanced with respect to the adjacent corridor, to a negative pressure condition. This will be accomplished by increasing the air flow of the supply air valve serving each of the resident rooms so that the rooms will go positive relative to the resident bathroom and the adjacent corridor. Additional back-up of natural ventilation can be achieved through operable sashes in the windows.
  4. Adopt advanced air purification equipment. For this project, our team used Genesis Air as a basis of design, which utilizes photocatalytic oxidation to reduce infection and improve the indoor environment in hospitals. Data shows that hospitals with this equipment in critical care areas have a significantly lower MRSA standard infection rate.

In Closing

Rapid adaptation is possible to a design-in-progress for an age-in-place environment like this Veterans Affairs Community Living Center. When retrofitting a facility or modifying a design, weigh how the layout can be reconfigured to safely compartmentalize patients as needed, and identify the most critical planning elements that must be addressed. Working in tandem with a skilled MEP firm, select and specify the right HVAC system, one that allows for negative and positive pressurization, appropriate AHUs, versatility and air purification.

Prior to the publication of this article, the FGI offered draft guidancefor designing resilient healthcare and residential facilities to adapt to emergency conditions, including pandemic response.

Downloade the high-reg images found in this article by clicking here.

About the Authors

Jay Pelton, RA, LEED AP
A Principal and Project Architect at Array, Jay Pelton is passionate about delivering projects that offer sustainability, energy efficiency and environmental harmony. His technical focus ensures a proper coordination between building engineering elements, the established building program, and the aesthetic goals of the institution.

Morgan Young
An Architectural Designer at Array Architects, Morgan Young is inspired by the opportunity to drive positive change in people’s lives through the built environment. His experience includes work with clients across the mid-Atlantic, and he has earned awards and co-edited grant publications rlating to his design savvy and expertise.

Mandatory Vaccination: Meddling with the Golden Triangle?

By Aarushi Jain

Concerns related to ‘job security’ are being raised worldwide at a time when various countries are considering mandatory vaccination for workers. The United Kingdom is considering making vaccination mandatory for care home staffwhereas Saudi Arabia is taking a position as hard as ‘no jab. no job.’ A similar stance has been taken by countries like Italy and Serbia for healthcare workers.

The issue that needs to be dealt with in detail is the impact of mandatory vaccination on various fundamental and basic human rights of an individual. The recent judgement of the Meghalaya High court in Registrar General, High Court of Meghalaya v. State of Meghalayaon the validity of the order made by the Deputy Commissioner of Meghalaya mandating vaccination for vendors, shopkeepers and others before resuming their businesses, held forceful vaccination to be unfounded in the existing jurisprudence. The major aspects dealt with in the judgement include Article 21, Article 19 and the related arenas.

In the historic case of Maneka Gandhi v Union of India, the Supreme Court of India held that Article 21 cannot be read in isolation and all the procedural requirements under this article are to be tested for possible contraventions with Article 14 and Article 19. This judgement opened up a new gateway for the legality test of every law on the basis of a ‘Golden Triangle’ of Article 14, 19 and 21. This Golden Triangle provides complete protection to an individual from infringement of their fundamental rights.

Perusal of the Golden Triangle

The right to equality enshrined in Article 14 of the Constitution of India, has been recognized as a part of the basic structure of the Constitution with the conceptof reasonableness and non-arbitrariness running through the whole fabric of the Constitution.

The Epidemic Diseases Act, 1897 under Section 2A and the Disaster Management Act, 2005 under Section 62 provides powers to the State Government to prescribe temporary regulations and to the Central Government to issue directions to the Union Ministries and State Governments, respectively. The above-cited authorities indicate that the Government possesses sufficient power to prescribe compulsory vaccination. A specific phrase mentioned in Section 2A “prescribe such temporary regulations to be observed by the public or by any person or class of persons as it shall deem necessary” indicates that specific guidelines for a ‘class of persons’ (workers in the present situation) stand within the given authority of the Government.

However, any administrative action made for intelligible reasons, must be measured according to the legal standard of reasonableness. A new dimension of Article 14 was laid down in E.P. Royappa v. State of Tamil Naduwhere the Court stated:-

“Where, an administrative action is challenged as ‘arbitrary’ under Article 14 on the basis of Royappa (as in cases where punishments in disciplinary cases are challenged), the question will be whether the administrative order is ‘rational’ or ‘reasonable’ and the test then is the Wednesbury test.”

Further, the principle of proportionality, which is considered as a part of ‘Wednesbury test’ has been applied as a part of Article 14 in India. The ‘Doctrine of Proportionality’, adopted by the Supreme Court of India in Om Kumar v. Union of India, is a principle here a major concern of the court is the process, manner or method in which the priorities are ordered by the decision-maker to reach a conclusion or arrive at a decision. The conditions for the principle of proportionality as laid down in the landmark case of KS Puttaswamy v Union of India include:-

  1. Legislative action must be sanctioned by the law
  2. Rational (reasonable) connection to a legitimate aim
  3. Existence of no equally effective less restrictive measure

In the current scenario, even if the first condition of “the action being sanctioned by the law” is fulfilled, the other two conditions are not satisfied. ‘Irrational’ most naturally means ‘devoid of reasons’ whereas ‘unreasonable’ means ‘devoid of satisfactory reasons’, as explained by the House of Lords in R v. Secretary of State for the Environment. This indicates that any administrative action must be based on satisfactory reasons or else the doctrine of arbitrariness and in turn proportionality can be invoked.

The Statutory power provided to the executive extends only to “prescribe regulations and issue directions” in the interest of general public. However, there exists a marked distinction between the “regulation or governance” of a trade and the “restriction or prohibition” of it. A fine line was drawn between “regulation” and “restriction” by the Orissa High Court in Lokanath Misra v The State of Orissa:-

“Restriction may be complete or partial and where it is complete it would imply absolute prohibition. The dictionary meaning of the word ‘restriction’ includes ‘prohibition’ too…the word ‘reasonable’ implies intelligent care & deliberation, that is the choice of a course which reason dictates…”

The complete prohibition of the workers from going to work without vaccination indicates a failure on the part of government to base the action on rational and satisfactory reasons. Thus, invading the rights guaranteed under Article 14 as well as Article 19 of the Constitution.

While Article 19(g) assures the right to trade and profession, Article 21 is inclusive of the right to live with dignity which is ensured by the right to adequate work and livelihood. The right to livelihood has been accepted as a part of Article 21 by the Supreme Court in Olga Tellis and others v Bombay Municipal Corporation and others. Mandatory vaccination is a step that is compelling instead of boosting people up to get vaccinated. The concept of bodily autonomy concerned with the right to make decisions for one’s own life and future has been recognized by various international rights agreements such as the Convention on the Elimination of All Forms of Discrimination against Women and recognized by India through the landmark case of KS Puttaswamy v Union of India. It was held in Munn v Illinois that the expression ‘life’ means “not merely a person’s animal existence, but a right to the possession of each of his organs-his arms and legs, etc.”

Additionally, the right to informed consent has been recognized in Samira Kohli v. Dr. Prabha Manchanda & Anr. The Delhi HC while reviewing a noticeregarding compulsory vaccination against Measles and Rubella in children, held that such a requirement without permitting the parents of such children to give informed consent stands in violation of Article 21. Even the right to refuse medical treatment has been recognized by the court in Aruna Ramchandra Shanbaug v. Union of India & ors.

The right to bodily autonomy, to refuse medical treatment, and to informed consent and choice are facets of the right to privacy. The right to privacy is a part of the right to “life” and “personal liberty” enshrined under Article 21 of the Constitution. It has been recognized as a basic human right by Article 12 of United Nations Declaration of Human Rights, 1948and by Article 17 of the International Covenant on Civil and Political Rights, 1976.


There is an imminent need to strike a balance between the severity of the threat and the intensity of the response. The principle of “least restrictive means” (third condition of the principle of proportionality) needs to be upheld while protecting the population. The Government, instead of imposing mandatory vaccination capriciously, shall encourage people to get vaccinated voluntarily by creating maximum awareness and providing incentives just as Russian authorities tried to cajole people to get the shot by offering sweeteners, such as free cars and circus tickets. Social distancing and lockdowns are a kind of preventive measures that require the voluntary application of such rules.

The obligation of the State recognized under Article 21 in State of Punjab and Others v Ram Lubhaya Bagga has been further reinforced by Article 47which provides a basis for the right to health. The right to health and medical care has been recognized as a fundamental right under Article 21 read with Articles 39(e), 41and 43. Just as such Directive Principles of State Policy cast a positive obligation on the Government to protect the public health, there is a pressing need at this time to remind citizens of their fundamental duties enshrined under Article 51-Aof the Constitution. Citizens are expected to adhere to the basic norms of civilized conduct, respecting the protocols and the honest observance of duties.

Considering that COVID-19 is an infectious disease, the erroneous conduct of the citizens such as a sizeable number of foreigners found living in one place in Delhi testing positive for covid or the reverse migration of a large number of migrant laborers from cities to villages, might jeopardise the efforts of the government to contain the spread of the virus resulting in damage to the society as a whole, raising fundamental questions about their responsibility as a citizen. Education and awareness are thus, the major instruments that need to be combined with discipline. A joint response by the Government at the global as well as the citizens at an individual level can allow for effective vaccination drives.

Author’s Information

Aarushi Jain is an undergraduate student at Dr. Ram Manohar Lohiya National Law University, India. She finds her interest in Human Rights and Public health policy. She can be contacted through her LinkedIn.

This piece was previously published by TheLawExpress.

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