Ashtabula Regional Medical Center’s New Patient Tower Expands Care In Rural Ohio

For the past 120 years, Ashtabula Regional Medical Center (ARMC) has been the only full-service hospital in Ashtabula County, Ohio’s largest county, a rural community occupying the state’s northeast corner.
Having started as a one-room, wood-framed general hospital in 1904, the organization has an outsize presence there now as the largest employer in the region, the primary provider of inpatient and outpatient healthcare services, and the only place to go for patients who need the services of a catheterization (Cath) lab or behavioral medicine unit.
New specializations, clinics, and improvements have materialized over the decades as needs and opportunities have evolved. But it’s been a while since the main hospital underwent any major construction—actually, not since President Gerald Ford was in office.
Now, 50 years later, ARMC cut the ribbon on a brand-new 115,000-square-foot patient care tower in June 2024. The $86.5 million expansion project, led by Bostwick Design Partnership (Cleveland), architecture and interior design firm on the project, doubles the hospital’s footprint.
“We spent several years with the ARMC leadership, programming and planning for the appropriate replacement and expansion of key departments,” says Michael Zambo, principal, health and wellness leader, at Bostwick Design Partnership. “After a deep dive into the community’s needs, we focused our efforts on spaces that will have the most impact on local health and well-being.”
Addressing rural population healthcare needs
Ashtabula county’s population is affected by the same social determinants of health as many other rural areas, including a relatively high poverty rate, lower levels of education than state/national averages, and a lack of public transportation and broadband internet service.
Leonard Stepp, president and CEO of ARMC Health, which owns the hospital, says the organization has focused much of its attention on improving healthcare access over the past several decades, opening family health centers and other outpatient and specialty facilities throughout the region.
During that time, the main ARMC hospital building had to wait for any serious attention. In 2021, funding was approved for a new four-story patient care tower that would allow the health system to bring some much-needed improvements to the campus, such as upgrading MEP elements, rightsizing operating rooms (ORs) and exam rooms in the emergency department (ED), opening up access to daylight, and restructuring departments for more efficient operations.
Additionally, inpatient rooms could be converted from double occupancy to private layouts, while a redesigned entry experience would provide something the campus sorely lacked: a sense of arrival.
New hospital entrance
Before the addition, the hospital’s architecture didn’t present a particularly welcoming (or obvious) front door. “Visitors would go down a side road, get to a canopy, then walk through a double door straight to a small elevator lobby,” says Logan Carroll, associate with Bostwick Design and project architect on the ARMC project. “You kind of trickled your way into the building.”
Now, a solid concrete wall “floats” above the new 1 1/2 -story lobby space, creating a billboard of sorts to guide the way through a landscaped approach that leads to entrance. The traffic flow has been redesigned and improved to clear up congestion issues at drop-off, better accommodating valet service and city buses.
Textural vertical waves add interest and a sense of height to the concrete façades on the new building. Ample glass brings light into the interiors and visual lightness to the massing.
Inside, the design team picked up some aesthetic cues from the old building—wood paneling and patterned glass—and elevated them to create an inviting, cohesive environment. For example, large-format graphics on glass that depict nature photography aid in wayfinding and support a focus on biophilic design in the new tower. Light-colored wood looms large in the new lobby and other key areas, while woodgrain-patterned sheet wall protection carries the theme elsewhere.
“We wanted to introduce soft kinds of textures within the actual finishing materials to make it feel more organic,” says Carroll.
Fixing flow for hospital patients and clinicians
The new tower allowed the design team to convert all inpatient rooms to private occupancy, complete with private bathrooms and defined caregiver, patient, and visitor zones, improving both efficiency and the patient experience. Half the rooms benefit from floor-to-ceiling glass to maximize natural light; the other half look out over the adjacent Ashtabula River and the woods around it.
“Anytime we could give somebody that view, we did,” Zambo says. “All the waiting rooms, for example, are organized on the east side of the building so they can take advantage of the wonderful view.”
ARMC and the design team also dove deep into strategies to reconfigure departments to improve workflows, upgrade technology capabilities (such as telemedicine in the patient rooms), and establish the hospital as a destination for 21st century care.
The new ED features universal exam rooms; the ORs are now prepared to take on future equipment enhancements (including a recently acquired Da Vinci Surgical System) and are supported by private pre- and post-op bays.
“The connection between the ORs, ICU, and ED is much better,” says Zambo.
Specifically, an elevator now connects each department, allowing patients to quickly receive the care they require. Previously, these departments were scattered around the hospital, requiring patients to be transported through public corridors.
Addressing staffing in rural healthcare facilities
Workflow optimization, technology enhancements, and other improvements (such as ample staff lounge and locker space) play a big role in tackling another challenge facing ARMC and other systems like it: staffing.
“Healthcare is a very tough industry, and labor force is a challenge,” says Stepp. “We don’t have a vast talent pool and recruitment can be challenging, especially in rural areas.”
ARMC is looking to hire more specialists who can cover the “spectrum of expectations,” Stepp says, so that patients can get more comprehensive care without having to shuttle between multiple locations.
And for recruiting purposes, he says, “a brand-new facility is a nice draw. It’s a welcoming environment, it has all-new technology, and it speaks to the financial health of the facility. We’ve been here for 120 years, and we’re looking forward to being here for 120-plus years more.”
That message is one ARMC hopes resonates with the community at large, as well. As part of the campus renewal efforts, the organization has cleaned up the nearby bank of the river, is repaving all of the surrounding parking lots for a consistent experience and look, and plans to create more parking.
“They’re really taking a comprehensive look,” Zambo says, “and it all comes from the patient perspective. From the very beginning, this group always found a way to make decisions that prioritized what the patient needs.”
Kristin D. Zeit is a contributing editor at Healthcare Design and can be reached at [email protected].
Ashtabula Regional Medical Center Patient Care Tower project details
Project location: Ashtabula, Ohio
Project completion date: June 2024
Owner: Ashtabula Regional Medical Center
Total building area: 131,554 sq. ft. addition; 17,060 sq. ft. renovation
Total construction cost: $89.5 million
Cost/sq. ft.: $602
Architect: Bostwick Design Partnership
Interior designer: Bostwick Design Partnership
Construction manager: Independence Construction
Structural engineer: Barber Hoffman
MEPT Engineer: Karpinski Engineering
Civil engineer: Langan
Design-assist contractors: United Architectural Metals (curtainwall), Lake Erie Electric (electrical), TH Martin-HAVE (mechanical), Summit Plumbing (plumbing)
Art consultant: By owner
Medical equipment planner: VOC Associates
Large-format wall graphics: Henry Domke
Carpet/flooring: Interface, Mannington (resilient sheet flooring); Interface (resilient tile flooring); Patcraft (tile carpeting)
Ceiling/wall systems: Armstrong Ceilings, Turf
Doors/locks/hardware: Enterprise Hardware (supplier/installer)
Fabric/textiles: Maharam
Furniture—seating/casegoods: American Interiors (OFS/ MillerKnoll/Nemschoff)
Handrails/wall guards: Construction Specialties
Headwalls/booms: Skytron
Lighting: Skytron
Surfaces—solid/other: Corian and Silestone, Formica
Wallcoverings: Construction Specialties Acrovyn, Pionite, Formica
Decorative Glass Glazing: Agnora Glass, Skyline Design
Project details are provided by the design team and not vetted by Healthcare Design.
How Has Designing For The Patient Experience Evolved In The Last 25 Years?
The Looking Back column is part of Healthcare Design’s 25th anniversary coverage in 2025. If you’re interested in contributing, contact Editor-in-chief Anne DiNardo at [email protected].
Looking back
One of the greatest impacts on healthcare design over the past two decades came from the recognition and importance of patient and family experience. For years, designers sought to convince healthcare clients that improving their physical environments was good for business.

Sheila F. Cahnman (Image: Courtesy of JumpGarden Consulting, LLC)
The industry promoted the competitive marketing advantage of having the most up-to-date amenities and hospitality or homelike environments to attract healthcare providers and satisfy consumers. Because so many factors affected healthcare choices, including physician practice patterns and insurance coverage, this strategy was successful to a point, but not readily quantifiable.
Patients’ perception of the hospital experience become a more important issue for U.S. health systems when the Centers for Medicare & Medicaid Services (CMS) instituted the Inpatient Prospective Payment System (IPPS) to pay hospitals a predetermined rate for each inpatient stay, rather than the actual cost of treating each individual patient.
Under these provisions, participating healthcare systems were required to report quality measures, or annual payment updates would be reduced.
CMS-required quality measures
One CMS-required quality measure was the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a standardized and publicly reported survey of inpatient hospital experiences that was instituted in 2012. The survey’s data collection methodology enabled valid comparisons of patient experience across hospitals.
Questions regarding provider/patient communication, cleanliness, and quietness could be directly or indirectly impacted by the physical environment.
Research also indicated that patients rated their healthcare experience higher in updated facilities. Patient experience became a top priority for the hospital C-suite due to market recognition and financial incentives.
Introduction of chief experience officers
Simultaneous with these governmental actions was a movement toward creating a culture of patient-centered care, which promoted empathy, communication, and respect for patient preferences.
Hospitals, such as the Cleveland Clinic, created chief experience officer positions focused on improving the level of service and general well-being of patients during their stay.
Healthcare design adopted new strategies including the Disney concept of onstage/offstage, intending to hide staff and support services to create a more “hotel-like” environment.
Refining patient, staff experience
Today, we recognize that providers, nurses, and support staff are under increased pressure and sometimes threats of violence that impact their interactions with patients.
Healthy, supportive communication between staff and patients and families may be the most important factor in promoting the best experience with the physical environment playing a supportive role.
There is also more emphasis on spaces that enhance staff members’ physical and mental well-being, such as tranquility/respite rooms and providing more access to natural light and outdoor areas.
With ready access to information from many sources, patients today are more informed and have higher expectations for their healthcare interactions. The ideal of the patient experience has matured, building on the lessons of the past 25 years.
Sheila F. Cahnman is president of JumpGarden Consulting LLC.
UChicago Medicine Crown Point Brings Multispecialty Care, Microhospital To Rural Indiana

UChicago Medicine Crown Point, Crown Point, Indiana
Undergoing intensive medical treatment is challenging enough without the burden of long commutes to major hospitals. For patients in rural and exurban areas, this is the reality. Market surveys from 2017-2019 showed 15 percent of Northwest Indiana residents traveled outside the area for medical services, according to COMPdata.
Amid growing awareness among healthcare providers of the importance of bringing crucial care to medically underserved areas, UChicago Medicine (Chicago) has opened a multispecialty care center and microhospital in Crown Point, Ind., designed by Perkins&Will (Chicago and Seattle).
Opened in April, the 132,000-square-foot UChicago Medicine Crown Point is the academic health system’s largest off-campus facility, designed to deliver advanced care within a personalized and family-centric environment.
Planning a microhospital
Now, patients have access to a comprehensive range of medical care provided by UChicago Medicine’s physicians and specialists, spanning fields from cancer care, cardiology, digestive diseases, and orthopedics to neurosciences, pediatrics, primary care, surgical specialties, transplant care, and women’s health.
The project team, including healthcare developer PMB (Solana Beach, Calif.), design-build partner Walsh Construction (Chicago), and Perkins&Will, the architecture firm on the project, delivered the new facility with a focus on efficiency, economy, and flexibility.
The project combines a short-stay inpatient unit with eight beds, an emergency department, imaging center, ambulatory surgery center, cancer center, and outpatient specialty clinics, all within an efficient footprint.
Exterior and interior design details
Drawing inspiration from the local architecture, the facility’s precast concrete envelope references Indiana limestone, enhanced by textured accents that create dynamic interplays of light and shadow throughout the day. Filled with natural light and surrounded by native prairie grasses, the building promotes patient health and tranquility and provides accessible green space for community residents.
Inside, the 2-story lobby serves as the central hub for patients and their families. The space features an expansive glass entry, rift white oak millwork, and Indiana limestone-clad walls to reinforce the project’s connection to the prairie site.
Wayfinding between the discrete programmatic units is enhanced through distinct color schemes and graphics inspired by Lake Michigan and surrounding prairie grass fields, dunes, and limestone quarries as well as many local varieties of wildflowers, butterflies, birds, and trees.
The first-floor radiation oncology waiting area, for example, features a wave-pattern screen to provide filtered light and privacy. Indiana limestone at the two-story elevator enclosure acts as a hearth and creates a warm neutral backdrop. A suspended art piece that mimics clouds, curated by UChicago Medicine, is experienced on both levels of the atrium.
Additional details to enhance the patient experience included sound masking in patient spaces, daylit infusion and surgical pre- and post-recovery rooms, and operable window shades in patient rooms to reduce glare and allow patients to adjust to their comfort level.
Healthy materials selections for healthcare
The project team was also mindful that the interior material selection needed to balance health with cost, procurement, and performance parameters. The project materials were reviewed against Perkins&Will’s Precautionary List and LEED’s low-emitting material standards.
The Precautionary List is a screening filter to identify materials with known human health impacts, not a banned list of substances. The tool allows design professionals to search for key substances and chemicals of concern using filters like project types, product type, and health and environmental impacts. .
Since its inception in 2008, the information contained in the list has become more comprehensive with new and evolving data including descriptions of substances, health and environmental hazards, ways in which people can be exposed (“pathways of exposure”), relevant government regulations and industry rating systems, and associated building products.
For the UChicago Medicine Crown Point project, the Precautionary List allowed designers to identify products containing chemicals of concern (those with known human health impacts) and have conversations with UChicago Medicine on alternatives. The interior acoustical ceiling tile and the exterior metal soffit ceiling system are examples of selected products that are “Precautionary-List Free.” The selection of these ceiling systems involved a careful balance of meeting acoustic requirements for healthcare environments, aggressive procurement milestones, and minimizing health impacts.
Jennifer Riddle Curley, AIA, LEED AP, is practice leader, associate principal, at Perkins&Will (Chicago) and can be reached at [email protected]. Melissa Dicaire, RID, LEED AP ID+C, is a senior interior designer, associate principal, at Perkins&Will and can be reached at [email protected]. Brad Hinthorne, AIA, LEED AP BD+C, is managing principal at Perkins&Will and can be reached at [email protected]. Andrew Sommerville, AIA, NCARB, RELi AP, is a project manager, senior associate, at Perkins&Will and can be reached at [email protected].
Enhancing Healthcare Environments Through Digital And Human-centric Innovations


Con McGarry (credit: Courtesy of Arcadis)
The progress and integration of digital healthcare, focused on technology solutions including telemedicine and artificial intelligence (AI), will play a big part in the evolution of healthcare design. Amid this transformation, an emphasis is also being placed on human-centered design, an approach that places patients and healthcare staff at the core of architectural and operational design.
These two trends may seem at odds with each other, but if digital healthcare and human-centered design can successfully converge, they can become a powerful force, driving an evolution in healthcare design that is both technologically robust and focused on enhancing the care experience.
Digital healthcare tools
Digital healthcare tools, including patient-centric wearables, fleets of autonomous mobile robots navigating the floors of healthcare campuses, and AI-enabled chatbots, are introducing innovative elements to healthcare environments. Each technology has the potential to significantly impact the design, utilization, and evolution of healthcare spaces.
For example, telemedicine propels a model of care that extends beyond the physical boundaries of healthcare facilities. This decentralization demands a rethinking of patient areas to accommodate technology-enabled remote monitoring.
Virtual care platforms, for example, require designated areas within healthcare facilities for remote consultations. Meanwhile, automation that streamlines supply chain logistics may mean less physical space is required for processing supplies, enabling the reallocation of space to better serve patient needs.
Employing human-centered design
The essence of human-centered design resides in crafting environments that prioritize human needs, experiences, and behaviors. In the realm of digital healthcare, this ethos manifests in the intentional incorporation of these principles during the development of digital healthcare tools or as a byproduct of implementing digital solutions in the healthcare environment.
For example, the integration of digital wayfinding solutions not only simplifies navigation but can also minimize the anxiety associated with traversing complex healthcare facilities.
Additionally, intelligent building controls and other digital tools that influence the built environment can be leveraged to create spaces that dynamically respond to human needs.
Heating and ventilation systems and circadian lighting that adapt automatically to occupancy and user preferences can enhance the comfort and wellbeing of occupants, aligning with the aim of creating responsive and user-friendly spaces.
Future collaboration
Deploying digital technology to tackle specific operational or clinical challenges, including managing patient flow throughout a facility, often yields efficiencies that liberate physical space, time, or resources.
Consider a scenario in which a healthcare facility adopts a fully digitized appointment, check-in, and virtual waiting room platform. This system streamlines the scheduling process, optimizes the utilization of consultation rooms, significantly enhances patient flow, and minimizes on-site wait times.
Moreover, it introduces a “wait anywhere” approach, where patients are not confined to traditional waiting areas but have the freedom to use nearby facilities or outdoor spaces. They are notified via mobile alerts when it is their turn to be seen and guided back to the facility in time for their appointment. This set up redefines the conventional need for physical waiting areas.
Guided by the principles of human-centered design, this newfound spatial freedom presents exciting opportunities. What was once a crowded waiting area can now be repurposed into a range of beneficial spaces, such as a relaxation zone, educational center to host health workshops, or additional consultation rooms to expedite patient care.
This narrative exemplifies the evolutionary journey initiated by the integration of digital healthcare tools to solve immediate operational challenges and leading to opportunities for embedding human-centered design principles within healthcare spaces.
The path forward beckons healthcare organizations to prioritize the infusion of digital innovations in their design blueprints as well as enhanced collaboration among robust project teams that involve technologists, architects, clinicians, and patients.
Con McGarry is senior consultant of digital healthcare at Arcadis (London) and can be reached at [email protected].
Fertility Clinics Embrace Hospitality-driven Design Strategies

In vitro fertilization (IVF) and other assisted reproductive technologies are credited with tens of thousands of births annually, according to the U.S. Department of Health and Human Services.
Whether couples or individuals are family planning or part of the more than 17 percent of the adult population struggling with infertility, as reported by the World Health Organization, fertility clinics offer people a chance to achieve their dreams of parenthood.
IVF is a relatively new medical sector that is currently exploding due to the increased need for fertility assistance. The first human born through IVF was in 1978, and the first American born via the procedure was in 1981.
In many cases, patients walking through the door of a fertility clinic are dealing with feelings of stress, apprehension, embarrassment, and other strong emotions. Some patients utilizing these spaces have had multiple attempts and failures, with hefty out-of-pocket costs.
Designers can help reduce patient stress and anxiety by creating a comforting environment that highlights hospitality in the space.
Rise of fertility clinics
Fertility clinics assist aspiring parents in family planning, which may consist of scientific assistance with fertility or allowing parental preference for a baby’s gender.
Functions within these clinics can include assessment of hormonal preparation for egg retrieval, sperm collection, genetic testing, creation and transfer of embryos, egg and sperm freezing, and fertility preservation.
IVF clinics began as medical laboratories within hospitals, where the focus was on creating the perfect environment for successful embryos resulting in positive pregnancies. At the time, these spaces focused more on cleanability than hospitality, resulting in a sterile and cold feeling throughout the clinics.
The evolution of IVF practices has fostered new design trends that prioritize patient well-being while focusing on operational excellence and ensuring high efficiency and technical standards for the embryology laboratory.
Hospitality-driven design strategies
As fertility clinics have grown in demand and importance, they’ve begun embracing design elements already prevalent in other healthcare settings such as hospitals and cancer centers.
Modern fertility clinics aim to provide an environment that feels welcoming, serene, and spa-like to help soothe and comfort patients during a stressful process.
When addressing the clinic layout, designers should determine patient-facing spaces such as waiting areas, phlebotomy, and consultation rooms. in the early design phases and prioritize them along the window line.
Access to natural light and a connection to nature can profoundly affect mood, blood pressure, and stress levels. Consultation rooms are where stressful and often life-altering conversations occur, and they should have natural light to provide as much emotional support as possible.
In contrast, exam rooms and post-anesthesia care unit (PACU) bays with clerestory windows allow natural light to filter in without compromising privacy. Exam rooms should be away from the window line for patient privacy.
The rise in hospitality design within healthcare spaces has resulted in more availability and breadth of construction materials and finishes to support architects and designers in creating inviting spaces while meeting healthcare-grade durability and cleanability requirements such as being bleach cleanable.
Color and material palettes can also help convey a sense of warmth and positivity as well as a connection to nature.
Desirable hues can include soft pinks, blues, greens, teals, and beige, while materials such as wood millwork and wood-plank luxury vinyl can assist in softening the design and connecting it to nature. Plants, art, and aesthetically pleasing wallcoverings can also help.
Providing patients a sense of control
Providing fertility clinic patients with an opportunity for personalization is beneficial, especially because conceiving a child is a process that may feel out of their control.
In PACU bays where women recover from local anesthesia after an egg retrieval procedure, personalized touches can include a millwork locker with integrated mirrors, dimmable lighting, and a lockable keypad to give the patient a sense that they are in their own space.
For men, positioning collection rooms in a more private location away from windows and high-traffic areas can provide the feeling of seclusion and solitude.
Collection rooms should be directly adjacent to the andrology lab, where specimens are analyzed, and include dimmable lighting and furniture such recliners or sofas to help create a comfortable setting.
Minimizing sound transmission for patient privacy and Health Insurance Portability and Accountability Act compliance is essential, given the sensitive conversations between doctors and patients.
Designers can reduce sound transmission by placing automatic door bottoms and gaskets on doors, which minimize the transmission of sound, air, and light under the door. Ceiling insulation can further dampen sounds, while the playing of white noise or soft music can create another layer of comfort.
Back-of-house efficiency
While patient-facing areas focus on comfort, back-of-house spaces should strategically focus on optimal functionality and efficiency, with centrally located lab spaces that reduce the time and effort required for staff to move between different areas.
Embryology and andrology labs should have a standard 10-foot layout, similar to a galley kitchen, with two people working back-to-back for efficiency.
Project teams can gather insight from staff on their processes, including retrieving, analyzing, and combining eggs and sperm, to guide the strategic placement of equipment to guarantee the most efficient lab.
The embryology lab, where technicians work with the eggs and sperm, must meet specific temperature, pressurization, and humidity requirements and standards. Because the lab technicians are extracting materials out of the body that are not conditioned to be outside of it, the internal conditions of the lab need to mimic the conditions inside the body.
For example, outside air intake locations are determined based on the building’s surrounding environment and should be far from a busy street due to automobile exhaust and fumes.
Because embryos can be damaged or lost if the power goes out or the environment changes, labs need robust emergency backup power, medical gas connection points, and a 24-hour mechanical system. Backup for lights, mechanical systems, and electricity should be at least 24 hours.
One of the biggest concerns in the embryology lab is the presence of volatile organic compounds (VOCs) in materials. VOCs are directly toxic to embryos and negatively impact IVF success rates. Project teams should specify materials such as paint and construction adhesives that have low or no VOC emissions.
Like other bio labs, the surfaces, flooring, and walls need to be easily cleanable, and there should be minimal spaces where dust can collect.
Growing demand for fertility treatments
As demand increases for fertility treatments, clinics will need to expand and adapt, often increasing in size to accommodate the growing number of patients.
Expansions typically include additional exam rooms and collection rooms, larger staff break rooms, and new PACU bays, transfer rooms, and offices for doctors and nurses. These additions not only increase capacity but also improve the overall patient experience.
It’s essential that, while expanding, the clinic remains up and running. In some cases, clinics set patients up on the same cycle, called batch cycling, which can allow the andrology and embryology labs to close for 28 calendar days.
During a project for Pearl Mini IVF in San Diego, Ware Malcomb (San Diego) first transferred the less invasive spaces such as consultation rooms and PACU bays to the new location, followed by additional phases to continue the expansion and eventually move the exam rooms and labs.
Providers also sometimes incorporate smaller satellite locations for noninvasive procedures such as collecting urine samples, blood draws, or consultations, while the central clinic focuses on labs, retrievals, and transfers. Satellite locations help make the primary clinic’s patient spaces more manageable.
Flexibility for change
Because the IVF field and its associated equipment are constantly improving and evolving, laboratories must be flexible to change.
For example, countertop incubators are quickly replacing stacked incubators and hold more specimens in a smaller footprint. Facilities are also removing plastic laminate counters and material storage for movable benches.
Additionally, robotic storage is becoming a popular solution, replacing bulky specimen dewars that take up valuable square footage. Robotic storage can hold the same number of samples as 12 specimen dewars.
Dewars should always remain at the main clinic instead of alternative satellite locations and be incorporated within or near the embryology lab to ensure a controlled environment and efficiency of procedures.
As fertility practices expand and evolve, the demand for thoughtfully designed clinics will grow. These spaces help individuals achieve their dreams of parenthood and set a benchmark for future clinic design.
Heather Moore is project manager at Ware Malcomb (San Diego) and can be reached at [email protected].
The Case For Financially Driven Design In Healthcare

Kirk Rose (Headshot credit: Courtesy of HMC Architects)
The healthcare industry is caught in a perpetual struggle against escalating costs—in patient care, staffing, services, and construction. Consider California: Even before the pandemic, the state’s hospitals operated on razor-thin margins, with an average profit margin of 2 percent to 2.5 percent.
Forty percent of California hospitals were incurring losses. This precarious financial footing was exacerbated by the pandemic, with major hospital systems suffering staggering losses that are still being overcome several years later.
Skyrocketing inpatient facility construction costs, now $1,600 per square foot or more in California according to cost estimators (excluding design and equipment), add to the financial strain. Delays in project initiation and extended timelines compound these costs with material and labor escalation.
Traditional architectural approaches often neglect the critical importance of financial viability in project planning and design, leading to inefficiencies, inflated expenses, and missed opportunities for revenue generation. The need for a financially driven approach to healthcare design is more pressing than ever, and architects must lead this movement by considering economic factors in every stage of master planning and design.
Think like a hospital CEO
A hospital CEO once told me: “I told my architect I have $200 million, and he keeps drawing a $500 million project.” Architectural approaches that fail to consider clients’ financial models often result in projects that aren’t cost-effective to build and fail to optimize revenue and throughput potential for patient care. Such projects are not likely to be approved for financing by hospital boards.
Architects frequently spend months programming and designing their ideal combination of buildings before submitting plans to a cost estimator, only to learn that the cost is too high.
Adopting a CEO’s mindset can inject financial savvy and agility into every stage of programming, master planning, and design. Architects can create facilities that meet functional requirements and serve as strategic financial assets by aligning project decisions with revenue generation and cost optimization goals. Through rigorous evaluation and innovative techniques, the design team can optimize program net-to-gross ratios and building layouts while maximizing client investment returns.
Temecula Valley Hospital’s cost-effective planning
For example, for Temecula Valley Hospital in Temecula, Calif., HMC implemented Lean design principles and strategic planning to create California’s most area-efficient (lowest building gross square foot per bed) and cost-effective greenfield hospital. The project achieved significant space savings with a reduced-circulation plan, which eliminated 3,000 square feet per floor without impacting patient capacity.
The plans for Temecula Valley Hospital introduced a universal care unit (UCU) model that enabled shared spaces across departments, further eliminating space and reducing costs. Additionally, the more compact plan was more efficient to staff and operate, highlighting how careful planning provides substantial financial and operational benefits.
In projects at Henry Mayo Newhall Hospital in Valencia, Calif., and Harbor-UCLA Medical Center in Torrance, Calif., HMC successfully built to tight budgets while achieving high program efficiencies. One key strategy employed was “wedding cake” stacking, reducing floor plate sizes from bottom to top, which allowed placement of air handlers on several levels of the building, nearer the spaces they served. This strategy lowered costs on mechanical systems by reducing duct run lengths.
Where to begin
Taking a financially linked design approach starts with asking clients for a business case focusing on revenue-generating patient care spaces and how much financial investment in the building the business case supports. The architect can then model initial programs and costs over time before drawing the project, allowing for early financial modeling of project options. Using spreadsheets for initial design options and cost analysis provides a clear picture of the financial landscape and ensures that design decisions are grounded in economic reality.
This approach involves close collaboration and open lines of communication with the C-suite and cost consultants, and a knowledge of achievable stacking configurations and planning ratios for efficient space utilization. By minimizing unnecessary space, architects can maximize patient care throughput and revenue.
The design team will need to represent a diverse skill set, combining medical planning, engineering, and an understanding of construction methods and sequences, as well as regulations. Establishing interdisciplinary teams that include financial experts alongside architects will foster a holistic approach to project planning. Leveraging knowledge of contractors for both cost and schedule issues will help mitigate cost by including procurement, phasing, escalation mitigation, and buyout strategies.
Additionally, investing in training and professional development to enhance architects’ financial literacy and strategic planning skills will be essential for driving industry-wide change.
Role of architects in delivering financially viable projects
Owners can be easily swayed by eloquent architects discussing patient care, wellness, hospitality-like environments, and the latest trends. While compelling, this perspective represents only part of the equation. Integrating business-oriented design thinking with patient-centric approaches is essential.
Architects play a pivotal role in ensuring projects are financially viable. The architect’s goal should be to create beautiful and feasible designs, which get funded and built, serving our communities.
As healthcare organizations navigate cost containment and revenue optimization, architects should lead the way by championing financially viable master planning and design.
Kirk Rose, AIA, DBIA, is the healthcare practice leader at HMC Architects (Los Angeles).
Improving Surgery Efficiency With An OR “Megafloor”


Gina Chang (Image credit: Beth Coller, Courtesy of CO Architects)
An academic medical center hospital must accommodate a large spectrum of surgeries, from the most acute and high-risk to more “tried and true” procedures.
Each surgery uses different tools, nurse ratios, and requirements for prep and recovery. As medical technology advances, surgeries that used to be allowable only in a hospital setting are now possible in an outpatient setting, and this increases more and more every day.
The under-construction University of California Irvine (UCI) Health – Irvine campus in Irvine, Calif., features an innovative platform to improve surgical efficiency and flexibility: a “megafloor” that connects inpatient and outpatient operating rooms (ORs) between two buildings.
The solution allows the hospital to perform any surgery anywhere by altering the workflow and space designation as decided each day by the surgical department.
Surgical megafloor features
Implementation required reconciling the different jurisdictions, seismic requirements (if applicable for code compliance) and required separations between the hospital and outpatient buildings to make them seem like one building.
For example, the buildings are separated by a 4-hour fire barrier, designed to be invisible by implementing magnetically held, open-rated doors and hidden fire separations.
The 56,000 square-foot suite has 18 standardized operating rooms designed for seamless flow from one building to the other. This set-up allows the surgical team to determine how to use any room or block of rooms for ease of use for the providers and safety for the patient.
Furthermore, by grouping inpatient and outpatient ORs, the supply chain and sterilization operates as a single large-scale operation, with strict quality and safety checks and an optimized flow to ensure that instruments and case carts are always ready and checked.
This high level of quality control reduces errors and waste in a streamlined process. It also allows quicker turnover, and each OR can be used for either inpatient or outpatient procedures based on demand.
Megafloor planning and design
To bring this concept to realization, CO Architects’ Los Angeles-based architecture and interiors team, working in conjunction with design-build project leader Hensel Phelps, built the megafloor virtually in a computer model and ran it through a year of simulated operations to eliminate bottlenecks and test any imaginable scenario.
UCI Health’s director of surgery oversaw the “virtual year” and made modifications to the workflow, which were then also simulated and proven out.
With the final design, surgical operations at UCI Health – Irvine are taken to the next level of adaptability and quality, allowing this academic medical center to push the boundaries of surgical performance.
The project is on track for completion in October 2025.
Gina Chang, AIA, EDAC, is a principal and healthcare team leader at CO Architects (Los Angeles) and can be reached at [email protected].
Ohana Center For Child And Adolescent Behavioral Health Creates Welcoming Spaces For Mental Health Care

Ohana Center For Child And Adolescent Behavioral Health, Monterey, California
Benefiting from a gift of nearly $106 million from philanthropist Roberta “Bertie” Bialek Elliott (Warren Buffett’s sister), the Ohana Center for Child and Adolescent Behavioral Health was poised for attention even before breaking ground along a serene hillside in Monterey, Calif. Owner Montage Health wanted something unique for the design of its new facility, which would provide innovative outpatient care and interventional programs with a family-centered focus.
For inspiration, designers from NBBJ’s Los Angeles office spent two days on the site even before the firm had won the job, hanging out under the oaks and wandering the grounds at different hours of the day, sketching. After getting hired, they worked closely with Montage leadership; Ohana’s newly hired executive director, Dr. Susan Swick; and a neuroscientist to rethink what a mental health building could be.
“It’s a beautiful site, with a lovely view across the valley to another hillside,” says Jonathan Ward, firmwide design leader and design partner at NBBJ. “Connecting to nature is something that optimizes brain function, and we wanted to integrate that throughout the whole care process.”
The 55,600-square-foot campus, which opened in November 2023, features curving walls of glass and mass timber, stepped terraces, winding paths, and aromatic gardens. But the connection to nature is just the beginning. “Ohana” is a Hawaiian term meaning “extended family,” and that concept, combined with transparency and a sense of learning and discovery, embodies the center’s philosophy.
“We want this building to be a place that sparks curiosity for everyone in our community,” Swick says. “We really thought about the way it’s designed, with private and public spaces, including a family resource area and conference center. There’s nothing to be ashamed of here. Shame is the enemy.”
Ohana’s built-in support
The first-line approach to therapy at Ohana, Swick says, is to help children and adolescents learn new skills to manage strong feelings, impulses, and interpersonal relationships.
“It requires tolerating a lot of failure and discomfort,” she explains, “but fortunately, kids—more than adults—are wired to be super-curious about novelty and staying with something new in the pursuit of mastery.”
The facility is designed to “activate” that curiosity and instill a sense of anticipation rather than fear of the unknown. For example, Swick says, “almost the entire building is marked by curved hallways. So you’re perpetually sort of thinking about what’s around the bend.”
Gently curving walls, Ward adds, work against the institutional, cold, and hard-edged stereotype of mental health facilities. “We learned through our research that hard-edge forms are perceived as threatening deep down in the brain,” he says. The curves work in concert with other design elements meant to convey honesty and transparency, supporting Swick’s “nothing to hide” philosophy. Walls of windows everywhere offer not only extraordinary views of nature, but sight lines to other areas of the campus, allowing patients and visitors to stay oriented and reminding them they’re part of a community.
The interior architecture reveals the natural expression of materials. “We didn’t plaster everything over with drywall,” Ward says. “The structural purposes aren’t hidden. A column is a column, the ceiling is a ceiling.” For example, following the project’s simplified materiality approach, the timber ceilings and columns throughout the facility are left exposed, supporting the idea of transparency and honesty.
A community art program with works from more than 160 contributors pervades the facility and includes commissioned pieces by visual artists, poets, and student photographers. The variety of artworks, abstract and figurative, is another way to spark curiosity, but the pieces can also play a more direct role in treatment.
“When you’re in a space where you’re ruminating or worrying, seeing something vivid, unexpected, or colorful can draw you out of your head,” Swick says. “Even if it’s just for a moment, that can be enough.” Therapists will also use the hallway art—as well as a looping path in the outside courtyard—to get restless patients up and about, giving them something to respond to and discuss.
Campus lay-out
The serpentine building coils around a large, walkable courtyard and an outbuilding with a gym and cafeteria. Spaces are organized around the severity of patients’ conditions, with the most public and lowest-acuity areas on the top floor and the highest-acuity residential program at the base. The middle floor contains therapy spaces.
The Ohana campus incorporates day programs, individual and family therapy services, group therapies, music and recreational facilities, and a 16-bed, short-term-stay residential unit. It’s not a high-acuity locked facility; there are no involuntary patients.
From the main lobby at the top level of Ohana, patients and visitors can look out across the courtyard and into open-air hallways and clinic waiting rooms. “It looks a little bit like an ant farm, where you can see people moving through different parts of the building,” Swick says.
Prioritizing safety and privacy
Still, safety and privacy considerations needed to be balanced against the otherwise open and transparent ethos. “We did a very detailed diagram of the entire building with the staff there,” says Daphne Corona, senior associate and project manager, NBBJ. “Looking at the licensing requirements, our best practices, and Montage Health’s practices, we diagrammed the safety features in every single space, then did a lot of cardboard mock-ups and testing.”
The short-term residential unit is sited in a way that provides added privacy and has its own entrance and courtyard (not visible from the lobby); Swick describes the atmosphere as more of a retreat.
Throughout the facility, windows in treatment areas and some of the meeting spaces are frosted glass. “We’ve created spaces where we’re not forcing people to be more exposed than they’re ready for,” Swick says. “The message we want to deliver is: There’s nothing to be ashamed of, but we’re happy to walk alongside you at your pace.”
Keeping caregivers healthy
As important as it was for the building to support the therapeutic programming and emotional needs of patients, it was equally critical for its design to boost cognitive skills and well-being for the center’s clinicians and staff.
To that end, the ample daylight and access to nature serve staff and patients alike; other design elements, like triple-sound-insulated “chill rooms” (as Swick calls them) with dimmable lighting and calming artwork, are available to staff as well as patients who may need them to take a break.
Dedicated staff areas also include spacious, private patios on the top level of the building, looking out over the courtyard and beyond. “It’s a chance to get fresh air and sunshine with other staff, but there’s also plenty of space so you can take a solitary break, listening to headphones or reading a book,” Swick says.
Dr. John Medina, a developmental molecular biologist and NBBJ research fellow, worked with NBBJ on the initial planning to consider design elements such as these that could improve executive function—a skillset that helps people control behaviors and other cognitive abilities. “He challenged us to invert the design focus,” Ward says. “Usually, you put your energy into the patient, but Dr. Medina asked us to focus on the caregivers, which then leads to an even better space for the patients.”
Community outreach
Swick is pleased at how much interest Ohana Center for Child and Adolescent Behavioral Health has gotten from families and the greater community. “There’s been a great sense of curiosity and enthusiasm,” she says. “The building has created a feeling of ownership and pride that is itself very destigmatizing.” She adds that more than 200 local residents have expressed interest in volunteering.
It’s exactly what Swick and the design team hoped to achieve. “For a child to do what they need to do, they often need the support of family around them,” she says. “But for the family to do what they need to do, they need to be connected to a supportive community.”
Kristin D. Zeit is a contributing editor at Healthcare Design and can be reached at [email protected].
Ohana Center for Child and Adolescent Behavioral Health project details
Location: Monterey, Calif.
Completion date: November 2023
Owner: Montage Health
Total building area: 55,600 sq. ft.
Total construction cost: Not disclosed
Cost/sq. ft.: Not disclosed
Architect: NBBJ
Interior designer: NBBJ
General contractor: South Bay Construction
Engineers: Integral Group (MEP), Fast + Epp (structural), Whitson Engineers (civil)
Art consultant: Susan Krane
Carpet/flooring: Shaw Contract, Bentley, Nanimarquina, Chilewich
Doors/locks/hardware: Ives, Schlage, LCN
Fabric/textiles: Carnegie, Maharam, DesignTex, Knoll Textiles, Kvadrat, Geiger
Furniture—seating/casegoods: Steelcase, Coalesse, Keilhauer, Andreu World, Pineapple, Bernheardt, Bolia, Hightower, Buzzi Space, Watson, Viccarbe, Muuto, Diversified Woodcraft, Stylex, RS Barcelona, Hay, Janus et Cie, Naughtone, Davis, Herman Miller
Lighting: Tom Dixon, Alphabet, Finelite, Zero, Kirlin, Visa
Surfaces—solid/other: Corian, Plexwood
Wallcoverings: Carnegie
Project details are provided by the design team and not vetted by Healthcare Design.
Tackling Maternal, Infant Health Disparities Through Healthcare Design

The Centers for Disease Control and Prevention report that Black women have a pregnancy-related mortality rate more than three times higher than that of white women. Related data show that infant mortality rates in the U.S. follow a similar unsettling trend. These stark maternal and infant health disparities indicate broader underlying social and economic inequities embedded in our culture.
Given that social and environmental factors such as neighborhood quality, healthcare access, and community resources contribute significantly to health outcomes, architects must critically examine how healthcare built environments can be designed to better support maternal and infant well-being for women and children of all races and ethnicities.
Additionally, it’s important to consider that, sometimes, the best practices used to design for one community may not hold when designing for another. For healthcare design to be equitable, designers need to balance generalized planning and design recommendations with contextual insights from the communities they serve, recognizing that these may not always align.
Social inequities that drive health disparities
The stark disparities in maternal and infant health outcomes are deeply rooted in social inequities that permeate our healthcare infrastructure. As such, healthcare built environment factors may contribute to discrimination within the healthcare system and further complicate maternal and infant health. Healthcare designers must recognize these issues and strive to create nuanced spaces that address the needs of diverse patient populations.
In healthcare design, health equity is sometimes equated with access to care. For example, building a hospital or clinic within a community may enhance residents’ access to care through closer proximity.
However, research tells us that proximity is only one of numerous factors—many beyond the realm of facility design—that affect care access. Within the realm of design, it’s not enough just to build this space. Rather, the goal should be to create a culturally sensitive facility that is not only conveniently located but also designed to reflect a community’s values and meet the diverse needs of its residents.
Difference between equal and equitable
Designing with health equity in mind requires a fundamental understanding of the difference between equality and equity. While equality involves treating everyone the same, equity focuses on providing individuals with the specific resources and opportunities they need to achieve similar health outcomes.
In the context of maternal and infant healthcare, this means recognizing and addressing the unique circumstances and challenges faced by each patient, such as education level, language preference, pre-existing or chronic health conditions, poverty, and structural racism and sexism.
Healthcare design can play a role in enhancing health equity. Design should focus on patient dignity and privacy, support patient- and family-centered care, and accommodate individuals with diverse needs, including those with physical disabilities, limited mobility, or sensory impairments.
Materials and design practices that contribute to a healthy indoor environment, such as good air quality, natural light, and noise control, are essential, too. Furthermore, healthcare design should consider the entire patient journey, from home and back. This includes ensuring that transportation options and parking facilities are accessible and convenient for all users.
It’s also important to consider who is included in the planning and design process, and how to measure design outcomes. Reaching out to the community for input and feedback is essential, but how we solicit that information affects what we hear.
How do we ensure that we gain feedback from people who are representative of the whole community? Is enough incentive provided for someone to miss time from work? Can we provide childcare, adequate transportation or easy access to technology, and translation services? A welcoming space that feels inclusive and judgment free? If not, we may not have the right people in the room.
But when those discussions are ready to happen, it’s important to listen deeply to what these individuals share about their experiences and needs, setting aside personal assumptions, and making sure those insights influence the facility goals and design process.
How unconscious bias impacts design and process
Unconscious bias, or implicit bias, refers to the negative attitudes or prejudices individuals hold unconsciously against specific social groups. This bias can subtly influence various aspects of life, including the design and planning of hospitals and healthcare environments.
While buildings do not possess biases, how they are designed, planned, and utilized can reflect and perpetuate social inequalities—a concept known as spatial (in)justice.
Political geographer Edward Soja defined spatial justice as the “fair and equitable distribution in space of socially valued resources and opportunities to use them.” This concept emphasizes the importance of representation and acknowledgment of a range of users within a given space.
The underrepresentation of people of color in design professions may contribute to the perspectives and needs of communities being overlooked in the design process, which can lead to healthcare facilities that do not adequately serve or reflect the cultural preferences and sensitivities of minority communities.
Historically, underprivileged communities have suffered from a lack of investment in critical infrastructure, including hospitals and healthcare facilities, contributing to disparities in care access. Even when facilities are established in lower-income or minority communities, their design often mirrors predominant cultural or industry standards rather than the actual needs of the communities they serve.
Choosing the right design strategies
Evidence-based design (EBD) strategies, which are intended to improve healthcare outcomes, may not always be appropriately applied in these contexts due to significant knowledge gaps in the literature and in understanding of how best to implement the principles.
For example, the use of single-family rooms in the neonatal intensive care unit (NICU) at Parkland Memorial Hospital in Dallas hypothesized various patient benefits based on EBD best practices at the time. These benefits included greater parental presence and involvement in the care of their infants, including more opportunities for skin-to-skin contact and breast feeding, which can help reduce stress levels and lead to higher satisfaction with their child’s care due to the private, quiet environment.
The single-family rooms were also expected to help control infections by reducing exposure to others.
While these NICU rooms provided some families the privacy and care they were seeking, they also presented challenges and disadvantages for others, such as:
- Isolation: Not all parents are able to spend extended periods in the hospital, limiting the potential parental involvement benefits of single-family rooms for infants.
- Reduced Peer Support: Parents, and single mothers in particular, may have fewer opportunities to interact with other families experiencing a similar situation, limiting social support, connection, and shared experiences.
- Staff Challenges: Physical separation can make it harder for staff to communicate with families and each other. A larger unit layout can increase staff travel distances, and single-family rooms reduce staff visibility of patients compared to open-bay NICU designs.
At Parkland, a public safety-net hospital, not all patients come with their own social support network or resources to benefit from single-family rooms in the NICU.
Additionally, the 2020 article, “Single family room neonatal intensive care unit design: Do patient outcomes actually change?” published in Journal of Perinatology, found no significant changes in infant length of stay, time to first oral feeding, or incidence of sepsis due to the single-family room NICU design.
These findings emphasize a need for careful examination when implementing specific design strategies and the importance of distinct patient populations.
Delivering inclusive, supportive healthcare environments
There is no one formula to achieve equity in healthcare design. While sustainability rating systems are evolving to incorporate social equity into their schemes, the manner and degree to which systems engage equity concerns varies widely.
Three key dimensions of equity are as follows: Recognitional equity involves consideration and recognition of community context and history. Procedural equity pertains to affected groups’ involvement and influence on the decision-making process. Distributional equity attends to how potential benefits and harms or risks of a program or project are allocated.
For example, fostering engagement and understanding with community members may support recognitional equity, involving community members in decisions supports procedural equity, and careful consideration of siting, access, and cultural sensitivity may affect distributional equity.
Based on an analysis in the 2023 article, “Social equity in sustainability certification systems for the built environment: Understanding concepts, value, and practice implications,” published in Environmental Research Infrastructure and Sustainability, there is no guarantee that following one prescribed process or achieving points for a certification will lead to real-world equitable outcomes.
Importance of community input
While broadly generalized EBD strategies can provide helpful direction as well, they may not be optimal for all groups or communities. When designing healthcare environments, context is key. To meet the needs of all patients, especially in the realm of maternal and infant health, design teams must engage deeply with the communities being served, including credible and representative community-scale research where possible.
A prime example of this approach was a series of focus groups and workshops with recent mothers at the Texas Health Resources Center for Women in Denton, Texas, which provided designers with invaluable insights into patients’ needs and preferences and allowed them to understand what these mothers wanted in their maternal experience.
This community engagement revealed the value of privacy and comfort in the birth process to support family bonding, a strong need to feel fully supported rather than judged, and a positive influence of intuitive adjacencies and clear wayfinding. These findings were integral to development of patient pathways, birth spaces, and interactions with staff.
Historically, women, particularly women of color, have been underrepresented in the design process, with a male perspective often being the default. Such a lack of inclusion can result in healthcare environments that do not fully meet the needs of all women.
To address this issue, it is crucial for project teams to include team members with local knowledge of community needs and to improve representation, recruitment, and development within the industry. Equally important is engaging communities in the design process to ensure that projects reflect their values and meet their needs.
Fostering trust through partnerships
While community engagement can help foster a wider representation of voices in the design process, several barriers can also hinder community engagement, including lack of trust in the healthcare system and environment, past negative experiences, resource and power imbalances, misaligned incentives and goals, lack of familiarity, community capacity, funding, time, and language or cultural barriers.
Overcoming these challenges requires a long-term commitment and a concerted effort to build trust and foster meaningful partnerships.
As healthcare providers and systems strive to provide culturally appropriate care, designers must also re-evaluate their own practices.
Creating inclusive and responsive environments that support the health and well-being of mothers and infants through the lens of equity means listening to our communities about their needs and setting aside assumptions about what works best.
Francesqca Jimenez, M.S., is a senior social scientist at HDR (Seattle) and can be reached [email protected]. Melissa Templeton, Ph.D., is a senior research coordinator at HDR (New York) and can be reached at [email protected]. Jeri Brittin, Ph.D., is director of social and behavioral sciences at HDR (Boise, Idaho) and can be reached at [email protected].
HCD Expo Preview: For more on this topic, the authors will be speaking in the panel session “E64 – Equal Is Not Always Equitable: Understanding Equity in Maternal and Infant Health and the Implications for Healthcare Planning,” at the HCD conference + Expo, Oct. 5-8 in Indianapolis. For conference and registration details, visit hcdexpo.com.
Site-of-Care Shifts Are Impacting Emergency Department Design

The narrative pushed to hospital administrators and strategic and facility planners for years is that site-of-care shifts are causing emergency department (ED) use rates to decrease—and will continue to do so for the foreseeable future.
These projections are based on the idea that as alternative immediate care options such as urgent care centers and retail clinics proliferate, lower-acuity ED visits will shift to the new, lower-cost settings, potentially resulting in a need for less ED space.
Despite the well-documented rise of immediate and urgent care sites, data from the National Ambulatory Medical Care Survey (NHAMCS) and American Hospital Association show that ED use rates are increasing, though year-over-year growth is slowing.
Based on this trend, emergency departments will require either more space, more patient care positions (assigned places where ED patients are seen) and/or more efficient operations to accommodate higher volumes in an equivalent space.
Patient-related demographic variables
Some ED volume may be shifting to alternate locations, but that change is largely being offset due to other variables such as age, insurance coverage, race, facility location, and unmet demand for specialized care, such as behavioral health services. Segmenting the data by demographic segment reveals that some population cohorts are driving higher emergency department use while others are decreasing their ED use.
Age: in the past decade, most age cohorts have shown decreasing ED use rates, with the exception of two groups: patients under age 15 and those ages 45-64.
The largest absolute trend change was in the under-15 cohort, where ED volumes increased at a rate of 6.3 visits per 1,000 children per year. In the 45-64 cohort, ED volumes increased at a rate of 3.4 visits per 1,000 adults per year.
Of note, while the ED use rate for older adults and the elderly (65 years and older) is declining, the rapid population growth in this age group continues to drive high ED utilization, which can be expected to continue.
Insurance type: Emergency department use in the United States is shifting from a mixed population of privately and publicly covered patients to primarily publicly insured patients.
Based on the NHAMCS data, from 2008-2020 the percentage of ED visits paid for by private insurance decreased from 42 percent to 30 percent while the percent paid for by Medicaid/CHIP increased from 24 percent to 37 percent. (In this same time period, visits paid for by Medicare increased from 18 percent to 22 percent and visits without insurance decreased from 15 percent to 8 percent.)
Race: Segmenting ED use rate by race reveals yet another instance of the inequity present in the U.S. healthcare system. The NHAMCS data reveal that emergency department use by Black Americans is double that of white Americans and quadruple that of other races.
Visits by Black Americans to the emergency department account for a disproportionate share of all ED visits when compared to their share of the population, and their use rate is growing five times faster than that of white Americans.
Geographic area: With most urgent care centers located within metropolitan areas, the growth in use rate in these areas, while still positive, has been controlled over time and is less severe than in areas where other alternatives are less readily available. In non-metropolitan areas, the ED use rate is much more variable from year to year and has generally experienced more rapid growth.
Higher-acuity care demands in EDs
At a high-level, two other factors are shaping the needs and considerations for ED facility planning: acuity and mental health.
Post COVID-19 pandemic, a widely realized trend is that patients who are seeking care at the ED are much sicker than in the past. This could be a result of the low-acuity volume filtering out to alternative sites of care or perhaps it is being driven by choices to delay care during the pandemic.
Either way, the ramifications are being felt in the emergency department and culminate in increased lengths of stay as higher acuity patients require more resources for treatment such as additional tests, imaging services, or procedures.
Finally, while upticks in visits were seen prior to 2020, the pandemic exacerbated the volume of patients arriving to the ED seeking mental health emergency care.
According to Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, unprecedented increases were seen especially within pediatric and adolescent populations—with the proportion of mental health-related visits increasing 24 percent and 31 percent, respectively.
The specific needs of behavioral health patients present opportunities for improved ED planning and design that can stand to benefit both medical and behavioral patient cohorts.
The trends outlined above drive the need to think about emergency department design in new ways, including:
Rightsizing the ED
Often the ED is the largest contiguous space needed on a campus and drives projects when expansion is needed. Therefore, it is crucial that the planning team thoroughly research and use all available data to accurately inform how much space is needed.
Demographic assessments, competitor analyses, and historical volume trends pulled from electronic health records (EHR) are the starting point for forming volume projections.
However, arriving at the right number of future care positions also requires a critical look at current-state operational performance—namely the average length of stay—gleaned through EHR data.
The planning team should not rely on the status quo if it is not meeting benchmarks. Alongside emergency department leadership, current operations should be critically analyzed to determine areas where adjustments can be made that can improve length of stay.
These targets can be combined with future-state volume projections to inform the total number of positions, and therefore square footage, needed to accommodate the planned scenario.
Alternative triage layouts
The conventional triage model looks like this: after a patient arrives to the ED and checks into the waiting room, the patient is triaged by a nurse and then returned to the waiting area. Once called, the patient is placed in either a large or small room/bay and remains there for the duration of their stay.
While this model has served healthcare well for many years, it may no longer be the best model for the increased volume of higher-acuity patients as it can be error-prone in busy settings
Several health systems are implementing other ED triage options such as basic split flow (patient moves from check-in to horizontal or vertical care areas), split flow with hybrid triage, rapid assessment zone (large room with recliner bays), and pull to infinity (patients receive initial vitals and move to a triage recliner zone for assessment and treatment or care trajectory assignment).
These models are employed to achieve faster decision-making, more efficient sorting of patients and distribution of resources to the most acute cases, and more rapid initiation of the treatment process, especially in high-volume emergency departments.
Several of these approaches use nontraditional, and often smaller, key planning units to better leverage scarce space resources. Designing the operations and the physical space in tandem can allow for more patient care positions in the same square footage.
Structuring EDs for flexibility
Related to the triage process and the mix of patient acuity within the ED, flexibility can be built into the space by incorporating both vertical and horizontal positions.
While the right balance needs to be determined by understanding a facility’s specific acuity mix, vertical positions offer multiple benefits. For example, by conducting triage in recliners, care advancement can begin immediately.
These positions also allow a more seamless flow for low-acuity patients who may not need to be in a horizontal position during their stay. Finally, because these positions take up less space than beds (requiring about one-third less space), they can increase capacity when expanding the physical footprint of the ED isn’t an option.
It is essential that these positions are planned for in advance, with proper space—around 80 net square feet per recliner allocated—so that they don’t interrupt flow through the department and hinder care processes.
Additionally, flexibility needs to be built in to overcome staffing challenges, especially in departments that experience wide variation in volume. A pod design can allow staff to oversee all patient positions from a central nurses’ station.
However, if the pods are physically separated, it can limit the ability to expand and contract open positions because staff cannot see from one area into another. Instead of creating physical barriers, designing along a central, unified chassis and then operationalizing that into “zones” gives flexibility to open new positions without waiting for an entire pod to be sufficiently staffed.
Dignified models of care
Nearly 15 percent of all ED visits are behavioral health related, according to Virtuity, a physician-owned healthcare organization, but traditional emergency department design is not as conducive to treating these types of patients.
While these patients wait for care in the general emergency department, treatment is often not initiated until placement in an inpatient bed/facility is possible.
The inherent risks and stressors of the ED, such as potential access to objects that can be used for self-harm and the cacophony of alarms and other patients/providers can exacerbate their conditions.
Psychiatric patients can occupy emergency department beds for a considerable amount of time since they are often subject to psychiatric holds and because there is a deficit of appropriate inpatient options to transfer these patients to for care. As a result, mixing medical and behavioral populations often results in increased lengths of stay for both patient types.
The creation of dedicated spaces—such as crisis units in an adjacent or dedicated section of the ED or an EmPATH (Emergency Psychiatry Assessment, Treatment, and Healing) unit, which delivers acute interventions for emergency behavioral health patients in a therapeutic setting—can help to better serve these patients while reducing the burden on the entire department.
Investing in ED planning
The ED often serves as the front door to the hospital, making the design of these spaces one of the most crucial elements to get right on a facility project.
A planning process that incorporates knowledge of the most up-to-date trends, empirical data, and departmental leadership and perspectives can help to ensure that the resulting facility provides all patients with the best healing environment.
Jill Barbaro, MHA, is a strategic planner at Array Advisors (Conshohocken, Pa.) and can be reached at [email protected].