By: Christina Olivarria, MSPM, PMP, HACP

The construction plans are approved, the budget secured, the contractor selected, and internal resources confirmed. Everything is in place to build your next healthcare environment. Just one thing stands between you and breaking ground – the spaces you need to refurbish or demolish are currently occupied by staff. Now what?

The term “enabling” is defined as “making something possible or easier or providing whatever is necessary to achieve a specific aim.” Enabling projects in healthcare construction and design often consist of a series of steps necessary to prepare an organization to construct a new healthcare environment. To support these types of projects, it is critical that project managers understand how to effectively manage them to ensure they are completed to make way for the bigger organizational initiative. Three things to keep in mind when managing enabling projects are:

• Differences between enabling projects and traditional Transition and Activation projects
• Management skill sets to support Enabling Projects
• Baseline tools to get the job done

Understanding these items will ensure your next enabling project implementation is a success.

Differences Between Enabling Projects and Traditional Transition and Activation Projects

Before jumping into your first enabling project, it is important to understand some key differences that set enabling projects apart from traditional Transition and Activation Projects.

The first important difference is that these projects often impact staff in ways they may not expect or appreciate. For example, if trying to make way for a new tower on an impacted medical center campus, organizations may evaluate space utilization and determine which staff remain on the existing campus and which will be temporarily moved to offsite locations. Being informed of an unanticipated office relocation can be unsettling for many staff. Taking the time to develop and deliver clear messaging explaining the reasoning behind how staff were selected to move and how this supports the organization’s vision will go a long way towards engaging staff in the process. Once you begin to engage with users, it’s better to recognize this elephant in the room right away. Pro Tip: Identify an Internal Communications Resource to support messaging throughout the enabling project engagement. This will ensure staff are all receiving consistent messaging.

The next key difference is that the schedule of enabling projects is typically more compressed than those of traditional Transition and Activation projects. When planning, project managers may need to adjust how they approach projects. Thinking of each project as a sprint, managers should plan workstreams accordingly and schedule shorter meetings closer together to complete the work. Pro Tip: Work with the Project Sponsor to identify any predecessor activities required to support the compressed schedule. Is the space ready? Does someone else need to move out first?

Resources on an enabling project may be constrained compared to those of a traditional Transition and Activation project. On a hospital tower project, project managers collaborate with the same stakeholders over a longer duration, providing time to build trust and relationships. Due to the high stakes and high visibility of large construction projects, organizations often dedicate resources to ensure their success. On enabling projects, resources may be pulled to support multiple projects simultaneously, and the timeline for building relationships with impacted department stakeholders is cut short. Because of this, it is important to identify the key stakeholders required to successfully complete the project:

• Facilities, Planning, and Construction Project Manager – Supports management of space readiness and confirmation of space requirements with department stakeholders
• IT/IS – Supports de-installation and reinstallation of computers, technology, and other systems
• Furniture/Interiors – Supports furniture assessments or acquisition for new space inhabitants
• Clinical Engineering – Supports installation and calibration of medical equipment
• Signage – Supports updating of departmental and wayfinding signage
• Mover – Supports moving of boxes and equipment
• Department Stakeholder – Supports communication and requirements/information gathering from their impacted departments

Pro Tip: Having the right people at the table (in-person or virtually) will support decision-making and the overall project timeline. During each meeting, note if a specific request keeps coming up and work with your project sponsor to get that decision maker to your meeting.

Management Skill Sets to Support Enabling Projects

“A pivot is a change in strategy without a change in vision.” – Eric Ries

Have you ever drafted an agenda and ten minutes into a meeting and realized you are never getting through it because the stakeholders are discussing other priorities? How do you respond? Project managers who are successful with enabling projects are able to quickly pivot to meet the needs of the stakeholders and drive the project completion. They are adept at reading the room and determining how to change directions and priorities, quickly and decisively. Having worked on over 100 Enabling Projects of various sizes and complexities, below are key skills that the Yellow Brick team has noted as requirements for surviving the sometimes turbulent waters.

• Adaptation – Enabling projects are dynamic in nature. Due to the revolving door of stakeholders being engaged, it is safe to say that at least one of your projects will not go as planned. The ability to quickly adapt and pivot as new information presents itself is critical to the delivery of enabling projects.
• Negotiation – As shared earlier, in some instances (I would argue in most instances), the departmental stakeholders you will be working with had not planned on moving and may be resistant to the move. As a project manager, it is important to listen, know what you can and cannot negotiate, and bring reasonable requests back to your project sponsor for evaluation. Listening (not just hearing) will be important as you navigate crucial and sometimes difficult conversations.
• Organization – Due to the quicker nature of these projects, note-taking, file organization, and accountability will be minimum requirements to maintain pace. Maintaining clear records of the project is important. For example, when reviewing construction diagrams, include photos of plans with annotations in the notes to ensure there is an accurate record.
• Meeting Facilitation – Being able to command a meeting and steer the group safely to their ultimate goal of moving to a new space is a key skill. Come prepared to know what you need to accomplish in the meeting, keep an eye on the time, and be sure to summarize conversations to ensure all parties are clear regarding the next steps and decisions.
• Empathy – Like all projects, often the work being asked from the department stakeholders is often the “Other duties as assigned” part of their job description. Pay attention to facial expressions, voice tone, and nonverbal cues. Always share appreciation and recognition of accomplishments. When asking for something, ensure the requested timeline is achievable and, if possible, build time in the meeting to work together to complete tasks as a group.

Pro Tip: When onboarding new members to your team to work on an enabling project, take the time to orient and highlight these skills. Take the time to assess your approach and ask those leading successful projects what skills they find advantageous to accomplishing goals.

Baseline Tools to Get the Job Done

The next question to ask yourself is “How am I going to make this happen?” Establishing tools to support how you manage the work will allow you to adjust and refine them depending on the type of enabling projects you are delivering. Below is a list of baseline tools used to support enabling projects:

• Task List—Although your to-do list might be shorter than the hundreds of tasks required to support a traditional Transition and Activation, readiness activities need to be accomplished to ensure a successful move. Having a centralized tracking method ensures all stakeholders are aware of their assignments and deadlines. The Yellow Brick Our team leverages Smartsheet, but Excel or Lists are great alternatives to track and manage Task Lists.
• Timeline – Like any project, it is important to understand the key milestones associated with the project, including when the space is ready,  deinstall and reinstall dates of equipment, and Day 1. Once you have a handle on the timeline, create a baseline timeline that can be customized for each project based on the milestones.
• Move Roster – Develop a list of staff moving to the new space, including badge numbers and from-to office/space assignments. Be sure to include a list of equipment to ensure you have the right resources to support de-installing and reinstalling equipment.
• Orientation and Training Tools – When moving into a new environment, it is a best practice (if not a regulatory requirement) to develop educational tools to support orientation. Tools can include Welcome Packets, education modules, and vacated space checklists. Include information about parking, access, hours of operation, work orders, and staff amenities to support a smooth transition into their new home.

Pro Tip: Develop a folder structure to store project documents and provide access to key stakeholders. Include a Project Dashboard that displays key metrics, so stakeholders can understand the status of each project.

Enabling projects are the predecessor for larger, more complex Transition and Activation projects. By taking the advice shared and refining it to fit your needs, you will be on your way to successfully managing make-ready initiatives.

By Rhonda Malone​​​​ Wyskiel, RN, MSN, EDAC, LSSGB
HORD COPLAN MACHT

It was a Wednesday night in a bustling urban hospital when Sarah, a young mother, rushed her feverish toddler into the emergency department (ED). The waiting room was packed, parents with crying children, elderly patients clutching their chests, and others staring at the clock, frustration etched on their faces. Sarah’s child was eventually seen, but not before hours passed in uncertainty and growing fear. This scene isn’t unique to one hospital or city—it’s a daily reality in EDs across the United States.

ED wait times are more than just numbers on a spreadsheet. They represent moments of anxiety, missed opportunities for timely care, and, in the worst cases, preventable harm. The problem isn’t new, but it’s growing more urgent. With EDs acting as both the safety net and the front door to healthcare, solutions require more than temporary fixes—they demand systemic change, innovative thinking, and a commitment from healthcare leaders, designers, and policymakers alike.

The Scope of the Problem Nationally, EDs serve as both the safety net and the front door of healthcare. With over 130 million annual visits to U.S. emergency departments, the demand has far outpaced capacity (CDC.gov). Key contributing factors include:

• Increased Patient Volumes: Aging populations, rising chronic disease prevalence, and limited access to primary care drive more patients to EDs.
• Staffing Shortages: Workforce challenges, including nurse and physician burnout, exacerbate capacity constraints.
• Behavioral Health Crisis: EDs are increasingly serving as default care sites for patients with mental health and substance use issues due to insufficient behavioral health resources.
• Boarding Delays: Patients awaiting inpatient beds often occupy ED resources for extended periods, causing bottlenecks.

Innovative Models for Improvement Despite these challenges, hospitals across the country have implemented innovative models to reduce wait times and improve patient flow:

1. Vertical Care Models: By treating lower-acuity patients in seated areas rather than traditional beds, EDs can increase throughput and reduce bottlenecks.
2. Discharge Lounges: Dedicated spaces for patients awaiting final steps in discharge free up valuable ED bed space.
3. Observation Units: These units provide short-term care and monitoring for patients who may not require full inpatient admission.
4. Real-Time Data Monitoring: Advanced analytics platforms offer real-time insights into patient flow, helping teams anticipate and address bottlenecks proactively.

A Design-Driven Approach Physical design plays an often-underestimated role in addressing wait times, but it’s not a silver bullet. While thoughtful layouts, flexible treatment spaces, and efficient wayfinding can improve throughput and reduce bottlenecks, they cannot fully address the systemic issues driving ED overcrowding. Challenges like staffing shortages, limited inpatient capacity, and behavioral health crises require operational and policy solutions. Hospitals can’t simply ‘build their way out’ of these problems—design must work hand-in-hand with broader systemic reforms to create meaningful, lasting change. Thoughtful ED layouts that incorporate clear wayfinding, flexible treatment spaces, and separate zones for high- and low-acuity patients can significantly impact efficiency.

• Triage Redesign: Implementing rapid triage protocols reduces initial assessment time.

• Private and Secure Spaces for Behavioral Health Patients: Creating dedicated environments reduces risks associated with overcrowding and patient agitation.
• Family-Friendly Waiting Areas: Enhancing waiting room comfort reduces perceived wait times and improves patient satisfaction.

System-Level Reforms Are Essential While operational and design improvements are critical, broader system-level changes are equally necessary:

• Investment in Post-Acute Care: Increasing capacity in rehabilitation and skilled nursing facilities can reduce ED boarding.
• Telemedicine Integration: Virtual consults for non-emergency cases can alleviate physical ED overcrowding.
• Community Partnerships: Collaborations with local health services can provide alternative care pathways for non-acute patients.

Personal Insights and Reflections Early in my career, while working on ED improvement initiatives across multiple healthcare systems, I witnessed firsthand how small operational changes could lead to significant improvements in patient flow and staff satisfaction. These experiences shaped my understanding of the interconnected factors driving wait times in emergency care. I’ve observed that the most successful interventions share three common threads:

1. Leadership Commitment: Executive sponsorship ensures initiatives are prioritized and resourced appropriately.
2. Frontline Staff Engagement: Empowering nurses, physicians, and support staff to co-create solutions fosters ownership and sustainability.
3. Continuous Improvement Culture: ED performance must be monitored, and interventions adjusted based on real-time feedback.

One example I encountered was the implementation of a discharge lounge at a mid-sized hospital. The space, staffed by nurses, allowed patients cleared for discharge to wait comfortably while final paperwork and transportation arrangements were completed. This intervention reduced bed occupancy times and improved overall ED throughput.

The Road Ahead Sarah’s story isn’t just about one mother’s anxious night in an overcrowded waiting room—it’s a reflection of a healthcare system straining under immense pressure. Every delayed diagnosis, every frustrated patient, and every overburdened healthcare worker is part of this narrative.

Addressing ED wait times isn’t about quick fixes—it’s about reimagining how we design, staff, and operate our emergency departments. Hospitals, architects, policymakers, and communities must collaborate to implement sustainable, thoughtful solutions that put patients and providers at the center.

The time to act isn’t tomorrow—it’s now. For Sarah, her child, and the countless others who walk through those ED doors every day.

Input from operational roles is crucial for hospital expansion projects. They have great ideas because they see and affect everything.

By Angela Kolosky
AIA, ACHA, NCARB, LEED AP BD+C
Associate Principal, Healthcare Planning Market Leader

I recently spent time with a family member in the hospital. I was impressed with the doctors and nurses who provided excellent clinical care. But the people I remember the most are the environmental services techs who diligently tended to the room each day. Always with a smile, they would quietly enter the space, ensure all areas were orderly and clean, check that everything was going okay, and efficiently move on to the next room.

When you think about the “money makers” in a hospital, departments like surgery come to mind first. Practicalities are paramount in these spaces: do they have enough storage, supplies, and so on. But so much of surgery room performance is driven by people who aren’t the surgeons and nurses. They’re the ones who resolve how quickly a room can be cleaned and turned over. The ones who process used instruments, move supplies to sterile storage rooms, and keep the systems running optimally. The people who pick up trash and launder scrubs.

Heroes of the hospital

I call these people the unsung heroes of the hospital – the departments most patients and visitors don’t immediately think of, such as environmental services, facilities, materials management, nutrition services, sterile processing, laboratory services, and all the other staff in a busy healthcare environment. The ones helping it hum without interruption.

Their input on the operations of a hospital is a critical aspect of successful design. Whenever I get a chance to engage with these experts, I’m reminded of how much they influence workflow. What they perceive as day-to-day efficiency can influence design throughout the facility, like placing linen hampers and cabinets near the entrance of a patient room, so they can empty and resupply with minimal disruption to the patient. Small moments like this can have huge impacts on the satisfaction of patients and staff – and can be missed if we don’t include their voices early on in a project.

Big projects, big impact

Without this input on large projects or new tower additions, support service spaces can easily be underestimated and undersized. These spaces are just as dependent on patient volumes as are operating rooms and inpatient beds. Early discussions about how these areas can be right sized for future growth and appropriate placement (it’s never fun to relocate landlocked operations, like nutrition services) will save the project time and money when coordinated early.

Whenever we start a project, we bring these varied groups together to leverage all they know about supporting patient and staff safety, reducing waste and steps, and creating higher-performing spaces. One example: Our in-place renovation of Allegheny General Hospital’s new Level 1 Trauma center. Engagement from stakeholders across the facility was crucial for project success, both during construction and implementation.

At the beginning of the project, stakeholders were asked to look for success within their own services as well as their counterparts. This led to rethinking the structure of staff stations to support visibility and collaboration amongst all team members as well as strategic locations of support rooms to allow the ED to flex during various volumes without isolating support staff or creating long walks.

There’s a saying I like: “If you want to go fast, go alone; if you want to go far, go with a team.” Designing a hospital requires the input of all its team members, especially from the support services who keep the place running every day.

By: Jamie Raymond, EDAC, RID, LEED AP
Partner, Four Point Design

August is National Wellness Month, and when it comes to improving community health and wellness, caregivers play a critical role. Firms that provide architecture and interior design services for healthcare facilities should prioritize creating environments that not only consider the patient experience, but that support and enhance the wellbeing of caregivers, as well.

Inspired by personal experiences

Since its founding in 2015, Four Point Design has specialized in interior design for healthcare facilities. The firm’s partners each have unique perspectives they bring to their work—insights gained not just from past projects, but from experiences as users of the healthcare system interacting with caregivers.

For Four Point Design partner Jamie Raymond, one of her formative experiences happened when she was just 19 years old. Her mother was diagnosed with cancer, requiring a 12-hour brain surgery.

“It was traumatizing, so there’s a lot I don’t remember,” Raymond said. “I remember waiting in the lounge, but can’t really recall the color of the walls, the lighting levels, or the artwork. What I do remember was the care my mother received and the communication from the caregivers. Today, as a designer, I see the built environment as a backdrop—a supporting element that gives caregivers the tools to do their best work and allows patients and their loved ones to focus on healing.”

Victoria Numbers, partner at Four Point Design, also has firsthand knowledge of the healthcare experience. Her mother was an intensive care nurse for 30 years. And when Numbers had her first son, Numbers spent two weeks in the hospital, and then her new baby was in the neonatal intensive care unit for a month. She recalls breaking down and not wanting to leave the NICU late one evening.

“One of the nurses gently came over and said, ‘Don’t worry, I’ll move over to this charting station that’s right here at his window, and I’ll look after him all night; I’ll hold him,’” Numbers said. “She just put me at ease, and I gained a whole new appreciation for what caregivers do. Caregivers are with us when we’re at our most vulnerable. They not only care for your body or your family members; they also care for the whole person and their emotional wellbeing.”

Creating spaces for work and rest

Today, the team looks for any opportunity to make nurses’ jobs easier and improve their experience. For example, considering efficiencies and ergonomics helps create nurse stations that are functional and thoughtfully designed. Light-filled staff suites with amenities and a variety of comfortable seating give caregivers a place to refresh and recharge.

“The level of commitment and passion it takes to be a healthcare worker inspires me to do my best work for them,” Raymond added.

Designing schools of nursing that attract and retain

Another way to support the wellness of caregivers is to address the need for nurses and health professionals. Talent shortages put stress and strain on the existing workforce, and as aging Baby Boomers need more care, the need for Registered Nurses will only increase.

Four Point Design has experience in multiple schools of nursing, bringing real-world healthcare experience to educational spaces that provide flexibility, thoughtful adjacencies, and durable finishes. For example, Indiana University’s renovated School of Nursing facility in Indianapolis expands the size of the school to accommodate more nursing students with spaces like a new skills lab; simulation, debrief, and practice exam rooms; and informal learning spaces.

“Caregivers play a critical role in our society, and a welcoming environment can both celebrate that impact and fuel schools’ retention efforts,” said Four Point Design partner Diana Ricks. “Through our school of nursing projects, we incorporate thoughtful touches such as graphics that celebrate the rich history of nursing schools and ‘Instagrammable’ backdrops for graduation photos. These features foster a sense of pride among students.”

Whether it’s being mindful of and grateful for our own experiences with caregivers, being thoughtful to design and construction solutions, or encouraging the next generation to enter the nursing profession, we all have a role to play in taking care of the caregivers.

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By: NELSON Worldwide

In an era where healthcare dynamics in the United States are swiftly changing, the rise of community-based facilities and centers, including outpatient facilities, is reshaping the landscape. This shift is driven by various factors, including staffing changes, a return to community connection, the necessity for convenience, virus containment efforts, and advancements in medical technology like telemedicine. Community-based and outpatient facilities are becoming the preferred choice for many due to their cost-effectiveness, personalized care, and accessibility. However, their success hinges on patient-centered and data-driven design and planning.

Understanding the Shift Toward Community-Based and Outpatient Facilities

As healthcare evolves, patients are increasingly opting for remote and outpatient facilities over major hospitals, provided they receive proper care. These facilities, whether general or specialized, offer a more personalized and less intimidating healthcare experience. The COVID-19 pandemic underscored the importance of such facilities, demonstrating their critical role in expanding healthcare accessibility and business.

Focusing on Efficiency and Community Needs

Smaller facilities, including outpatient centers, excel in staffing and budgeting efficiency, tailored specifically to meet community needs, including those of ethnic communities. Many major hospitals have high costs and intimidating environments, often deterring individuals from seeking all types of care from lifesaving to treatment of simple ailments or injuries. In contrast, local clinics and outpatient centers, including emergency care and imaging centers, are far more approachable, have strong ties with the community, and even mitigate the risk of exposure to additional illnesses.

Reducing Dread Through Patient-Centered Design

To alleviate the dread associated with visiting major hospitals, community-based and outpatient facilities should be designed as inviting and less intimidating. This can be achieved with warm colors, natural light, and comfortable furnishings. Incorporating artwork and local cultural elements, simplifying navigation with clear layouts and intuitive signage, fostering personalized interactions through open reception areas and private consultation rooms, and minimizing wait times with efficient workflows are all crucial. Enhancing privacy and comfort with private consultation spaces, acoustic treatments for noise reduction, and incorporating nature through outdoor areas and views can significantly improve the patient experience.

Tailoring Solutions for Specific Needs

Community-based and outpatient facilities must address the specific needs of their populations. For example, in the community of Fishermen, Florida, healthcare facilities cater to common issues of local patients such as boating and fishing injuries, along with addressing everyday ailments. Additionally, embracing the essence and needs of the community, care centers may include auxiliary spaces to highlight local artists or areas to provide safe havens during hurricane seasons.

Regardless of serving rural or suburban areas, affluent or underserved communities, offering a range of options at a variety of scales is critical. Quick-care clinics in local grocery stores are leveraged for administering vaccines, blood pressure checks, or low-risk illness treatment. Convenience, adaptability to meet future needs, and embracing evolving healthcare technology are priorities to ensure these facilities are well-equipped to support the health and well-being of their communities.

Overcoming the Learning Curve

A significant challenge is that many people do not realize they can access local facilities, including outpatient centers, for their healthcare needs. Increased awareness and understanding that they do not need to rush to a major hospital for every health concern are contributing to the rise of local facilities.

Leveraging Expertise for Community-Centric Care

Our Healthcare Practice is at the forefront of this transformation, ensuring that community-based and outpatient facilities effectively serve their populations through strategic, data-driven design and planning. By engaging with local leaders and organizations, we accurately address specific community requirements and challenges. Furthermore, we focus on designing adaptable facilities that can evolve with technological advancements. Our expertise ensures that community-based and outpatient facilities are not only more efficient but also more attuned to the needs of the populations they serve. By leading this charge, we are helping to shape a future where healthcare is more accessible, affordable, and personalized.

By embracing these principles and strategies, community-based and outpatient facilities can redefine healthcare delivery, ensuring compassionate, patient-centric care that meets the evolving needs of diverse communities.

For more information on NELSON Worldwide visit https://nelsonworldwide.com

By Michelle Wendler, AIA, Principal, Watry Design, Inc.,

The opening of the new outpatient clinic at Fred Hutchinson Cancer Center in Seattle ushered in a new era of care in the areas you would expect, with expanded facilities and state-of-the-art medical equipment, but also somewhere you might not: parking.

Parking in medical centers can be a stressful experience. In addition to confusing layouts with different specialists in different locations, patients often have more physical constraints than the general public. Often, the parking structure is separate from the facility where they will receive care, requiring additional mobility from patients who are highly likely to have mobility limitations. Sloped floors can also pose a hazard to patients at high risk of falling, which creates safety concerns in addition to the mental and physical stress of getting to the right location on time for an appointment.

At Fred Hutch, however, a combination of factors allowed designers of the recently opened outpatient clinic to explore new ways of overcoming these challenges in the form of a fully automated parking system that removes many of these barriers.

What is a Fully Automated Parking Structure?

Many types of mechanical and automated parking systems exist, from simple mechanical lifts to fully automated systems, such as the system found at Fred Hutch. As each project is unique, there is no straightforward formula to a successful selection. Choosing the right solution requires careful study, expertise and innovative thinking.

While fully automated parking systems come in many different forms, they all share one notable thing in common: a transfer cabin. The vehicle is driven into a transfer cabin outfitted with sensors. The driver then exits the car and follows a set of instructions to engage the system. Once the door to the transfer cabin closes, no further human involvement is necessary to park the car. The system itself is completely responsible for selecting a space, storing, and later retrieving the vehicle. In the case of Fred Hutch, a robotic shuttle system in the form of a rack and rail system retrieves the car from the transfer cabin and delivers it to an available parking space. What this means for patients is a streamlined, simpler parking process. There is no searching for a space or navigating a large parking structure on foot. Patients deliver their vehicle to the transfer cabin via a valet and can then proceed directly to their care destination.  At Fred Hutch the system is further enhanced because the patient leaves their car outside the transfer cabin for the valet to load into the system so they do not have to park in the automated system at all.

Why Fred Hutch Chose Automated Parking

Automated parking typically becomes viable when site constraints exist that make traditional parking impractical. Deep subterranean excavations, high water tables, and constrained footprints  are all factors that can make automated parking worth exploring.

When the new outpatient facility was under design, early plans called for it to be interconnected to an existing building on the upper floors with a continuous underground layout that would include parking. However, code restrictions made this approach cost prohibitive, which resulted in a very constrained building site. An alley between the planned and existing building contained utilities that could not be relocated. To fit within the available footprint, a traditional parking facility would not only have been saddled with an extremely inefficient layout, but it also would have been difficult to achieve the 160 spaces required to meet the needs of Fred Hutch’s patients without a much deeper excavation. Therefore, the design team turned to automated parking as a possible solution.

This approach solved the space constraint problems by utilizing the available volume to park more cars in the same amount of space and offered the opportunity to create a safer, more user-friendly parking experience to relieve some of the stress patients face when visiting a care facility.

To ensure that the facility design succeeded in meeting patient needs, Fred Hutch engaged a patient care advisory committee to review the project development – including the parking. “The big topics that we got a lot of feedback on concerned ease of use, patient safety, and navigating mobility limitations,” says Alyssa Stein, an associate with ZGF Architects, who designed the project. “Patients were generally in favor of any technology that helped their experience.”

Selecting a System

Deciding to pursue an automated system is only part of the journey. Selecting the right one to meet a project’s unique needs requires a great deal of careful consideration, from both a design and operations standpoint. Engaging parking experts who have experience with these unique systems can help navigate these challenges and ensure they effectively integrate into the building.

From a design perspective, different systems have different requirements, from the number of transfer cabins required to how cars are stored and retrieved and the density of the parking. Adequate queuing and loading areas also need to be considered.

For example, several systems evaluated by the design team required more lift bays than the site could accommodate. Many systems are produced overseas, which introduces other complexities such as coordinating international shipments into the construction schedule and field certification that components make a compliant UL system.

From an operations perspective, a number of logistics had to be taken into account. Unlike traditional parking, in which users can go straight to their car and drive away, automated parking systems have limitations on capacity and throughput, or how many cars a system can handle and how quickly they can be retrieved. Therefore, everyone needed to be on the same page regarding performance expectations at peak times, and how that would impact the patient journey. This included designing lobby areas with ample seating to ensure patients were comfortable while waiting for their car.

Automated parking systems also have ongoing maintenance considerations that need to be factored into both ongoing budget and operations plans. This includes how to handle unexpected system outages, annual costs of preventive maintenance and logistics of repairs. “Fred Hutch took a strong interest in this, because they would ultimately be responsible for maintenance,” Stein explains. “If something breaks, how does it get fixed, and how long will it take?”

The unique maintenance needs of these facilities means that they require a specialized maintenance provider. Understanding who will service and maintain the system, expectations for response times, turnaround time on repairs and how parking will be managed during an outage are all questions that need to be addressed before committing to a system. As Fred Hutch desired valet service to further elevate the patient journey, a valet vendor was selected and trained to operate the system as efficiently as possible.

Ultimately, WÖHR Multiparker 730 was selected to provide the 160 spaces needed to support the project, with the goal of retrieving up to 100 vehicles in an hour with a maximum recall time of 150 seconds.

Design Challenges

While automated parking systems are common elsewhere in the world, they are still relatively new to the US, which poses a number of design challenges, starting with code. “Code requirements are limited in their coverage of fully automated parking, so a lot of communication has to happen in order to get everyone on the same page to build it,” says Stein. Due to the project’s complexity, Watry Design was brought in as a mechanical parking expert to review the design and help navigate the approval process.

One example of the complex code requirements the team tackled was intake and exhaust requirements. Garage ventilation requirements  were created around the needs of traditional parking, in which cars operate within a structure that must also accommodate people. Fully automated systems, however, are designed so that when a car enters the system, it is turned off and unaccompanied by a human, making air change needs minimal. Therefore, the team worked closely with the city, including sharing case studies of similar projects, to find a middle ground that would meet design and budget needs while also satisfying city requirements.

Another common design challenge faced by automated parking is whether or not lifts get classified as elevators. Elevator codes are designed around human safety, however a human never rides in a lift in a fully automated parking system. Therefore, the life and safety considerations typically associated with elevators may not apply. Design teams need to carefully define project terminology to ensure the code interpretation appropriately meets the building needs without triggering unnecessary design criteria. Watry Design and ZGF worked closely with both Fred Hutch and the city to review the design early and keep the approval process as smooth as possible. “We had a lot of conversations with the city to interpret the code and decide what was required,” says Stein. “Ultimately, I think everyone was satisfied and comfortable with where we landed.”

The contractor  also needed to navigate  the constructability of the system with the  mechanical parking vendor and steel subcontractor. A rack and rail automated parking system like the one installed at Fred Hutch utilizes a shuttle that moves along a set of tracks on each floor. The vehicle lift moves vertically to bring the car to each floor. The movement and speed of the lift and shuttle is controlled by lasers that need to be carefully calibrated to ensure the smooth transfer of vehicles from the transfer cabin to the rail system to the vehicle lift. The concrete floor levelness and placement of hundreds of steel embeds had to be meticulously coordinated with little room for error.

This level of design, however, is what makes the system so effective. “The complexity of the design is fascinating,” Stein says. “The palates are so well-engineered that they rotate with just a gentle push of the hand. It’s really special.”

The End Result

The new outpatient clinic building at Fred Hutch opened in March of 2023. When patients arrive, they deliver their vehicle to a valet who then delivers it into the transfer cabin and initiates the parking sequence, taking the stress and logistics of parking away so they can focus on what’s most important: their care.

In addition to convenience, the structure also offers a few extra perks. It is one of the first fully automated parking systems to offer EV charging pallets. Ten of the 160 parking spaces are equipped to autonomously charge electric vehicles, with the ability to expand to additional spaces as needed.

Despite the automated system being closed to people, you can still get a glimpse of it in action. “We realized during construction that this system functioned entirely behind closed doors, which felt like a missed opportunity,” Stein says. “So we designed a viewing window that would let people watch the system in operation. It’s one of the most appreciated parts of the project.”

Looking to the Future

While fully automated parking systems pose many advantages, they are not a blanket replacement for a traditional parking facility, and still face a number of challenges. Each project requires a dedicated review of its programming needs to determine the right parking system, and parking experts with detailed knowledge of how these systems work are invaluable for selecting the right approach.

However, when the conditions are right, they can offer a groundbreaking, innovative solution, and not just for medical centers. These systems are being integrated into residential buildings, public parking and even university housing, and the more common they become, the fewer barriers they will face.

Photography credits: Ben Benschneider.

Capitalizing on Opportunities to Capitalize Costs

By Jeff Agner, MPH

The delivery of most healthcare services requires regular upkeep, periodic renovation, and the occasional new construction of physical facilities and infrastructure. Construction projects allow a healthcare organization to remain compliant, competitive, and operationally efficient. A formal project is established to plan and execute the work, and the necessary time and resources are allocated. When the cost is high and the useful life of the resulting asset is long (typically more than 10 years), the project is considered to be a “capital project.” Even though these projects likely require a financial investment (often referred to as “capital”), the term “capital” in this context refers to the fact that the resulting asset can be capitalized. Capitalization is an accounting method that allows an organization to break up the full cost of building or purchasing assets into smaller expense activities over the expected life of the asset through processes known as amortization and depreciation.

When an organization can record such a large investment as an asset on its ongoing balance sheet versus an expense on its annual income statement, the financial health of the organization is seen as far more favorable. This means that the organization has greater freedom to borrow money, attract investors, and conduct business. This article will further explain the concept of asset capitalization and will explore its applications in a healthcare construction project.

When can costs be capitalized?

The capitalizable costs of a healthcare project include the amount paid for constructing, acquiring, and/or improving an asset. As expected, this includes the design and construction labor, materials, and fees necessary to deliver the project, but it can also include expenditures for utilities, interest on debt during construction, and other resources engaged in putting the asset into service. In many cases, these costs are not part of the construction budget but are included in a separate Transition and Activation Budget related to the capital project. Regardless of how the activities are funded, a plan to address the accounting requirements is critical.

Per generally accepted accounting principles for new construction, project costs can be capitalized if at least one of the following conditions are met:

• Costs contribute to the value of the asset
• Costs enhance the use/value of the asset
• Costs ensure or extend the useful life of the asset

Additionally, to qualify for capitalization, these expenditures must occur prior to the asset being put into service.

What costs are typically capitalized in a construction project?

Each organization must abide by its specific capitalization policies and procedures and comply with state-level mandates or requirements. The following table lists some common costs encountered during a facility renovation or construction project and whether or not they can typically be capitalized. Final determinations of cost capitilization must be made by the financial leadership team.

Manage and track opportunities to capitalize project costs

Once a Transition and Activation Budget is developed, the healthcare organization’s financial leadership team should evaluate all expected costs and categorize them based on their capitalization potential. Separate cost centers can be established if there is no easy mechanism to flag capitalizable costs as they are incurred so they are not mistakenly accounted for as an expense. All costs should be tracked closely and documented clearly so that the accounting treatment can be applied at the conclusion of the project. Once the new space is operational, the organization’s balance sheet should be updated to reflect the full value of the completed capital project as an asset. This action must be performed within a few months (typically 90-120 days) of the asset being put into use; otherwise, taxes and other financial penalties may apply.

Take advantage of the full value of your investment

The purpose of capitalizing costs is to align the cost of using an asset with the length of time in which the asset is providing a benefit to the organization (aka generating revenue). Finance industry and government-level capitalization policies guide organizations on items that should be capitalized versus those that should be expensed on large construction projects. This guidance is intentionally general in nature to be as broadly applicable as possible. It is up to the organization to understand and comply with its specific guidelines to maximize the financial benefits of capitalization when renovating or constructing a healthcare facility.

Elements of Effective Lighting Design in the Behavioral Health Facilities

By: Ellie Motevalian- Lighting Designer, LC, LEED GA and Toranj Noroozi, Lighting Designer, LC, P2S, a Legence company

Lighting design plays a crucial role in creating supportive environments in behavioral health facilities, promoting well-being, and facilitating healing journeys.

Beyond its technical aspects like anti-ligature and vandalism, lighting serves as a companion, subtly influencing wellness. Join us as we explore how this understated element, with its artful touch, profoundly shapes the healing experience in behavioral health facilities.

Biophilic Design:

Biophilic design is an architectural and interior design approach that seeks to reconnect people with nature within the built environment to encourage them to co-exist with it. Rooted in the idea that humans have an innate connection to the natural world, biophilic design incorporates elements and features inspired by nature to enhance the well-being and productivity of occupants.

There is much research supporting the hypothesis that biophilic design will enhance physical, mental, and cognitive health and has positive impacts on stress relief, cognitive skills, and sensitivity both in children and adults.

There are various ways lighting can be incorporated into the biophilic design:

• Light Therapy
• Natural Daylight
• Circadian Rhythm through Artificial Lighting
• Shapes, Finish and Pattern

Light therapy, also known as phototherapy, has emerged as a crucial tool in addressing Seasonal Affective Disorder (SAD), which is characterized by symptoms such as low energy, mood fluctuations, and a general sense of lethargy. Light therapy involves exposure to a bright light that mimics natural sunlight, stimulating the production of serotonin and regulating melatonin levels to alleviate symptoms of depression. Beyond SAD, the importance of light in treating mental health issues extends to various conditions, as exposure to natural or artificial light influences circadian rhythms and affects neurotransmitter levels. Light therapy has shown promise in treating other forms of depression, bipolar disorder, and sleep disorders. The role of light in regulating mood and overall mental well-being underscores the significance of incorporating light therapy into comprehensive mental health treatment strategies.

Exposure to natural light has been consistently linked to improved mood, enhanced cognitive function, and regulation of circadian rhythms. Integrating daylight into these spaces creates a more pleasant and uplifting environment, reducing feelings of confinement and fostering a sense of connection to the external world.

By introducing daylight, as much as possible into the architecture through windows, light wells, skylights, and clerestories, the therapeutic impacts of natural light can be harnessed to create a supportive atmosphere for individuals seeking behavioral health services.

Given the constraints within architecture and construction, coupled with varying durations of time users spend within interior spaces, the thoughtful integration of architectural lighting becomes pivotal for the enhancement of circadian rhythms. Not all architectural designs allow for abundant natural light to penetrate indoor environments, and users may find themselves exposed to artificial lighting for extended periods. In such cases, leveraging architectural lighting becomes a strategic tool to simulate the effects of natural light on the circadian system. The usage of a diffused indirect lighting approach as an expansion and continuation of daylight perception into the interior space provides an opportunity to integrate biophilic design with architectural lighting.

In applications where the users are deprived of receiving enough natural light throughout the day incorporating human-centric lighting within the architectural lighting to provide the blue wavelength (490nm) for maximum daytime circadian impact is essential. The sky-blue wavelength which mainly lies within the invisible spectrum can be provided for several hours depending on the technology used to balance the circadian rhythm through Melanopic and skin pathways.

Quality sleep plays a crucial role in maintaining good mental and behavioral health. As the sun sets, much of the blue light is scattered, signaling to our bodies that it’s time to wind down and prepare for sleep. In residential and relaxation spaces, lighting can be strategically utilized to promote healthy sleep patterns, particularly through the use of “zero-blue” light fixtures. These fixtures eliminate the blue spectrum of light to mimic the natural pattern of sunlight. Additionally, during nighttime hours, it’s recommended to use amber night lights to illuminate pathways for safety while still supporting the body’s natural sleep-wake cycle.

Another way the lighting can be part of the biophilic design is through effects and forms. One example is in interior nature spaces, by creating lights and shadows, lighting will enhance the vibrant nature-like environment.

In addition to the quality of light and its impact on the space, the shape, form, and finish of the light fixtures are influential design factors in the mental and overall emotional state of the occupants. One of the main driving factors is to implement lighting to create a calm, inviting atmosphere that provides a sense of safety and tranquility. This can be achieved by the implementation of light fixtures that offer soft edges and earthy color tones, with more of a hospitality aesthetic. By opting for fixtures with gentle curves and natural finishes, the overall design can further enhance the soothing ambiance of the space. These fixtures not only provide functional illumination but also contribute to the overall design cohesion, promoting a harmonious environment.

Figure 1 Example of lighting in common spaces, using indirect sources of light to reduce glare, providing multiple layers of light including vertical illumination, in addition to using nature-inspired finishes and shapes.

Shaping serenity: optimal visual comfort and glare management

In the behavioral health facility setting, where individuals may already have higher sensitivity and emotional challenges, the importance of creating a visually soothing environment should not be ignored. Effective lighting design is characterized by glare reduction, flicker-free illumination, and appropriate color temperature selection. The overall lighting effect should be continuous, soft, and even to minimize any discomfort or agitation. Harsh patterns and shadows created by light should be avoided, as they can exacerbate feelings of anxiety and disorientation. It’s also important to eliminate dark corners and avoid extreme contrasts between light and dark spaces, which can induce feelings of unease. To create a more dynamic and therapeutic environment, it’s recommended to incorporate various layers of light, including vertical illumination and accentuating features and materials.

Indirect lighting, edge-lit light fixtures, and fixtures with louver and diffuser can minimize the harsh glare. One of the metrics to evaluate the light fixture glare is UGR. Many lighting manufacturers provide fixture UGR information on their cut sheets or IES files. Based on some of the standards like LEED Well, UGR below 16 is considered a low-glare fixture and can help with visual comfort in behavioral health facilities. Choosing the appropriate lighting color temperature (in most cases warmer CCT in the patient area) contributes to creating a calming atmosphere that facilitates relaxation and promotes a sense of security for the user.

Some conditions such as autism spectrum disorder are more sensitive to lighting fixtures flicker. Providing flicker-free lighting solutions minimizes visual disturbances that could decrease anxiety and stress levels among the patients. Several key aspects warrant consideration to minimize light fixture flicker, including High-quality drivers with higher frequency, compatibility of the driver and light control, and light fixtures with certifications like Energy Star.

Figure 2 Example of corridor lighting, using an indirect source of light as a continuation of natural lights, to minimize glare and enhance visual comfort, providing even illumination on horizontal and vertical surfaces.

Balancing safety with patient autonomy (independence)

Effective lighting design should consider the specific needs of patients, ensuring adequate visibility for staff while minimizing potential hazards like sharp objects or ligature risks. At the same time, providing patients with control over their environment can significantly reduce their stress and anxiety levels, increase their self-esteem, and improve the patient’s mental well-being.  By collaborating with healthcare professionals this delicate balance can be achieved in the design, and it will enhance the overall quality of care and patient experience.

In high-risk areas of the facility like patient rooms, anti-ligature light fixtures can be considered. Using this type of fixture can reduce the risk of self-harm and ensure the patient’s safety. Design strategies such as using tamper-resistant fixtures, avoiding protruding elements, and selecting durable materials are critical to mitigate the risk of ligature-related incidents.

There are no specific codes or regulations governing anti-ligature fixtures. While various organizations offer guidelines and recommendations, there is no mandated standard applicable across all jurisdictions. One commonly referenced source is the New York State Office of Mental Health recommendation that many lighting manufacturers rely on to design anti-ligature fixtures. Designers can use this reference when selecting fixtures for high-risk areas.

While utilizing anti-ligature fixtures in high-risk areas is critical for patient safety, the design should still provide patients with a degree of control over their environment.  Examples of these controls can be:

• Adjustable lighting settings to allow individuals to customize the light fixture brightness based on patient preference.
• Personalized bedside reading light fixture with dimmer switch.
• Natural light control options like adjustable blinds or curtains.

Figure 3  Typical lighting design for patient room.. Access to daylight, dimmable anti-ligature reading light, and low glare recessed downlight. Tamper-proof dimming switch for controlling the lights.

In conclusion, the careful orchestration of lighting design elements explored in this paper underscores the pivotal role played by environmental factors in shaping the healing process within behavioral health facilities. By embracing the principles discussed above, the designers can craft spaces that enhance the well-being of the users and empower individuals in their recovery journey. As we advance in our understanding and implementation of lighting design strategies, designers must remain vigilant in implementing evidence-based practices to foster environments that nurture both physical and psychological healing.

References:

• S. Department of Veterans Affairs (2021), Design Guide for Inpatient Mental Health And Residential Rehabilitation Treatment Program Facilities.
• New York State Office of Mental Health, 30^th edition (2023), Patient Safety Standards, Material and Systems Guidelines.
• Perkins , Deborah (2024), How Designers can Use Flicker Safe Dimming.
• Amber Roguski, Philipp Ritter, Daniel J. Smith – Sensitivity to light in bipolar disorder: implications for research and clinical practice (2024. Published by Cambridge University Press on behalf of the Royal College of Psychiatrists)
• Bios Lighting. (2024). Technology – Bios Lighting. Retrieved from https://bioslighting.com/architectural-lighting/technology-2/