In 2002, the Eastern band of the Cherokee Indians executed a self- determination agreement with the federal government to assume full management responsibility of its hospital and health system, an effort to address deep financial woes that at times had left care to be rationed when budgeted dollars ran dry, says Casey Cooper, CEO of Cherokee Indian Hospital in Cherokee, N.C. “Once we stabilized finances, we started turning our attention from preventing the ship from sinking to focusing on population health.”

The Eastern Band, like many Native American tribes in the U.S., was experiencing a high rate of chronic disease, including diabetes, high blood pressure, and depression, with the prevalence of diabetes alone estimated to be as high as 23 percent. “We knew the only way we were going to improve the health of the population was to get the community to be more engaged in their own healthcare services and their own healthcare journey. We also knew we’d never get them engaged unless they had a better experience of care,” Cooper says.

The patient experience had deteriorated over time due to the organization’s financial struggles as well as the facility’s status as a safety-net hospital, which Cooper says contributed to a community perception that quality of care was low. However, when hospital leaders conducted an assessment of primary care teams, they found numerous quality measures ranking in top percentiles nationally. So Cooper and his team next turned their attention to the physical environment. “It was a nice facility in the ‘80s, but it was certainly dated. There was nothing uplifting about it. As a matter of fact, it was described by the community as being like a bunker or cave. There wasn’t much access to natural light … it exacerbated the stress that’s normally associated with a clinical facility,” Cooper says. It was also based on a provider-centric model, with patients held in large waiting queues and moved linearly through processes on a first-come-first-served basis.

Hospital leaders decided that a replacement facility was needed where the opposite environment could be created, ultimately opening the new Cherokee Indian Hospital in October 2015. But to get to that point, they first turned to Southcentral Foundation, an Alaska Native-owned healthcare organization in Anchorage, Alaska, for inspiration. Southcentral Foundation won a Malcolm Baldridge National Quality Award in 2011 for performance excellence and uses a patient-centered medical home model of care.

Cherokee Hospital staff, executives, governing board members, and tribal leaders flew to Alaska in 2012 to see Southcentral Foundation’s operational system, the Nuka System of Care, in action. The system is supported by a design concept that eliminates physicians’ offices and collocates clinical care teams, including doctors, nurses, and support staff, in a bullpen where they’re in a state of constant huddle and share access to specialists such as behavioral health therapists, dieticians, and clinical pharmacists. “The patient no longer gets a referral to go across town to enter another linear system. The system morphs and becomes what the patient needs on a particular day. That’s the heart of the Nuka System of Care,” Cooper says.

Wishing to adapt the system for their own services, the group flew back to North Carolina and got to work. “We started tearing down walls and offices and constructed an integrated care team space to do testing in a microsystem format, and we tested and tested and tested until we were absolutely certain on what we wanted. Then, when it was time to build the new building, we had a great deal of certainty about the form of the space and how we wanted it to support the new processes,” Cooper says.

Problem solving
It was that operational vision that was handed to the project team selected to make it happen, including DesignStrategies LLC as architect, interior designer, and engineer and Robins & Morton as general contractor. “By the time we arrived, they already knew the care delivery method they wanted to use … it was a real jump start,” says Ben Rook, CEO of DesignStrategies (Greenville, S.C.). “This project is really unique in how the owner prepared for the design and building program.”

The team—formed under an integrated project delivery (IPD) contract—next traveled to Alaska with organizational leaders to see the Nuka system for themselves. “We got to discuss philosophically what was applicable about the Alaska visit, how that would play forward with the Cherokee, and what was unique about the Cherokee. And because we had the full integrated care team there with us, we’d have breakout sessions in the evenings and discussions on the airplane returning, and a degree of synergy developed that carried through the project,” Rook says.

The IPD team was collocated on the project site beginning six months prior to construction start in March 2014, collaborating on Cooper’s vision as well as his conditions of satisfaction, which focused not only on getting the community engaged but identifying the problems that existed at the current facility and how the design and construction of the replacement could change those perceptions. “Those conditions of satisfaction went a long way in making sure the community was going to be happy with the end project,” says Phil Yance, vice president of Robins & Morton (Birmingham, Ala.).

In fact, meeting those expectations became a critical piece of the IPD contract itself, specifically the bonus structure, a financial incentive established for the team members if the directive was achieved. “[We said,] ‘We don’t just want you to build us a building; we want you to build us a beautiful building that the community absolutely loves, that they claim as their own, and that helps promote greater engagement from them. And as a matter of fact, we want to reward you for that,’” Cooper says. “‘It matters less that you’re on schedule and, of course, we want you to be on budget. But what really matters is the community has to love it.’ And that was the primary driver.”

To achieve that, Rook drove a community engagement process that included more than 30 meetings across every township in the tribe’s geographic area during which the team worked to glean as many details as possible on existing hassles and stressors associated with the existing campus and barriers to patient engagement, such as poor parking conditions and limited access points to the building. And if answering such requests came at the detriment of operational efficiency or an increased price tag—and it did—Cooper was OK with that. “We have more registration desks than we’ve ever had, more entrances to the building than we ever have,” he says. “But we did it because the community said they wanted to be able to have ground-level parking close to the entrance that is approximate to the service they want, and they didn’t want to snake through the building to get there.”

Part of the community engagement process also included bringing on numerous local subcontractors to contribute to the project, with Robins & Morton teaming smaller companies together to qualify for the job and carving out pieces of the project for each of them. “Not only do you have community involvement in [giving] input on what it’s going to look like and the feel of the project, but also they’re the ones who built the project,” Yance says.

In the details
The final design of the 150,000-square-foot, $80 million project organizes a comprehensive service platform for the community. Although primary care is the heart of the facility, Cherokee Hospital also supports 25 inpatient beds, four of which are also used for hospice—all in a linear building layout that answers another specific request from the community: more light. The team pursued a design that breaks the facility into separate pieces, which allowed natural light to permeate throughout, with glazing used extensively on the exterior.

Once the team decided on this approach, the next critical step was creating a connection between the various structures. The solution was using a central concourse as a connecting spine along which the numerous entry doors are located. And while the approach resulted in a perimeter wall that was 25 percent larger than a traditional rectangular structure would have required, it also allowed Cherokee Hospital to separate its hospital occupancy spaces from its outpatient occupancy spaces while still tying them via the spine. “From the patient’s perspective, it’s seamless—you wouldn’t know any different. But from a design and construction perspective, it was very important because we saved money by not having the whole building burdened by a certain construction cost,” Rook says.

To reduce patient and visitor anxiety, the building operations are based on an onstage/offstage model, with circulation routes for materials, linens, food service, patient transfer, etc., kept out of sight. The emergency department (ED) entrance is on the opposite side of the campus from the other entry points so flashing ambulance lights aren’t visible. Waiting areas are open and flow into the central concourse, with ample space for families as well as fireplaces and other residential design-inspired elements used to deinstitutionalize the space.

The Cherokee interpretation of the Nuka System of Care includes the elimination of private physicians’ offices and collocation of care team members in the primary care area, with 12 total teams located in an open environment with specialists assigned to every three teams. On the acute care side, integrated care teams are also collocated and the layout introduces “talking rooms,” where family members can be educated on how to care for patients after they return home (a common practice to avoid patient transfers to larger medical centers).

“Once we made it through medical programming, we did extensive programming of cultural elements,” Rook says. As part of the process, Cooper arranged for the design team to visit with various members of the tribe, including the head of a local museum who put into terms how cultural elements should be considered in the design—a primer in what does and doesn’t appeal to the Cherokee. “We as architects are always looking for what we can do to make our buildings have a sense of place, how can they relate specifically to what our client is trying to do. And these artistic things we gleaned from the museum workshop were fantastic. I don’t think we would have designed anything the way it was ultimately designed without having these cultural ideas,” Rook says. Influences include native materials like stone and patterns that communicate rain, wind, and fire, and art elements including pottery and carvings as well as a river pattern that tells an evolution story of the Cherokee through graphics inlaid in the building’s terrazzo floor.

Additionally, to answer community requests for the hospital’s Great Smoky Mountains locale to be brought indoors, a tree form element was created to serve as the theme for the building’s central spine, with branches used in millwork on headwalls and nurses’ stations and patterns in the graphics, signage, and even in structural supports.

Results are in
After a year in operation, Cooper says the building is exceeding expectations, with collocation spaces of care teams improving performance, while patient satisfaction and employee satisfaction are improving, too. “We’re seeing the process changes, and the outcomes are soon to follow,” he says.

Some lessons were learned, too. For example, an operational method aimed at reducing the feeling of waiting by calling patients into exam rooms early hasn’t gone over as well as expected, with patients preferring to spend their time in those spacious waiting rooms with the fireplaces. The solution is having nurses avoid loading the rooms too early and better anticipating when physicians will be available. Another required tweak stemmed from adjacencies that placed radiology and the lab close to the ED, a decision dictated by adjacency scoring in the programming phase. However, it’s a long walk between the lab and the hospital’s outpatient pharmacy, an issue for anticoagulation patients who must visit the lab for testing before picking up medications. “So we’re looking at doing point-of-care testing down in the pharmacy now so we can eliminate that walk,” Cooper says.

But thanks to the pre-planning by the organization as well as a thorough engagement of staff, the usual expected design changes simply haven’t come up. “Little things like where sharps containers are located or where various items are located in rooms or along the wall—that was so carefully worked out that I haven’t had the normal callbacks that we get on projects,” Rook says.

As for the major condition of satisfaction—that the community must love it—the results are in. A scoring matrix was developed for the IPD bonus mechanism that’s based on the number of community members who were engaged in the project by attending events like a tour or the ribbon cutting, for example. Additionally, surveys were distributed to about 400 attendees of the ribbon cutting and another to elected officials and tribal leaders. “So we had good, objective data based on these surveys, and the other thing we’ve seen is a bump in our customer satisfaction scores,” Cooper says. “I don’t think there’s any question about it. The community loves it.”

Jennifer Kovacs Silvis is editor-in-chief of Healthcare Design. She can be reached at

Completion date: October 15, 2015
Owner: Cherokee Indian Hospital
Total building area: 150,000 sq. ft.
Total construction cost: $57 million
Cost/sq. ft.: $380/sq. ft.
Architecture: DesignStrategies LLC
Interior design: DesignStrategies LLC
Engineering: DesignStrategies LLC
Construction: Robins & Morton
Art/pictures: Barbara Harriman
AV equipment/electronics/software: CIC Technologies
Carpet/flooring: Spectra Contract Flooring
Ceiling/wall systems: Murray Drywall
Doors/locks/hardware: WmS Trimble
Surfaces—solid/other: Institutional Products