For North Carolina, replacement beats renovation
During the late 1990s, in the midst of planning a single project to replace one of four psychiatric hospitals operated by the State of North Carolina, an ambitious idea emerged. Rather than address obsolescence one facility at a time, why not design a prototype facility and replace all four state-operated psychiatric hospitals? By 2001, the idea had started becoming a reality.
Of course, the problems were not uncommon. Just as in many other states, North Carolina Department of Health and Human Services (DHHS) administrators faced aging and inefficient hospital buildings (some dating back to the mid-1800s), which reduced the ability to deliver desired outcomes in a patient-friendly environment. Energy costs, maintenance headaches, security challenges and technology shortcomings only exacerbated the other challenges.
The hospital replacement strategy, supported and funded by the North Carolina General Assembly, called for the phased replacement of four existing regional psychiatric hospitals with three new state-of-the-art facilities. The design of each of these new regional hospitals consolidates patient care services using a treatment mall model. The prototypical design offers patients a safe open, day-lit environment that fulfils four key DHHS priorities:
Enhancing the healing outcomes for patients
Improving patient and staff safety
Creating operational and energy efficiencies
Delivering durable, adaptable facilities.
North Carolina anticipates that this investment will have a total design, construction, and up-fitting cost of approximately $423 million. However, it will also provide measurable return on investment through improved patient outcomes, reduced operating costs and closer integration with community-based service networks.
Shaping the therapy prototype, gaining consensus
Planning and design of the prototype facility began by establishing a leadership committee comprised of representatives from each of the four hospitals, DHHS administrators, behavioral healthcare experts, patient advocates, and the design team.
Workshop sessions helped to define the philosophical approach for therapeutic care and program requirements for each of the new prototypical facilities. Members of the leadership committee met regularly over many months, visited other facilities around the country and reached consensus around the use of a “treatment mall” concept featuring a “Main Street” lined with patient services and outdoor spaces.
The concept was advanced into an integrated flexible, scalable and affordable design standard, resulting in three new psychiatric hospitals designed to provide consistently high-quality environments for patients across the state-a landmark departure from the aging conditions of physical environment and therapy resources of the existing hospitals.
Designing a “linear village”
North Carolina's comprehensive reinvention and replacement program incorporates lessons learned from the experience of other states replacing aging facilities. Key features of the design program include:
An emphasis on community living within a regionally based campus-like setting and a strong connection to the outdoors
An abundance of natural light, with outdoor views and access to landscaped courtyards and outdoor seating areas throughout the facility
Patient care units (PCUs), occupied by 18 to 24 patients, located along the building perimeter. These PCUs are connected, allowing additional flexibility for the ebb and flow of different categories of patient populations
Patient rehabilitation and interaction occurring daily on a treatment mall, allowing patients to move from the patient care units to the mall as a part of their normal routine. The treatment mall is comprised of classrooms, dining areas, a gym, physical therapy, outdoor courtyards and other activity areas
The entire hospital functions as a linear village, providing multiple levels of independence and supervision
Beyond the treatment mall and PCUs, each hospital is supported with facilities for administration, clinical services, admissions and support services. Bed quantities were determined based on historical data projected forward, taking into account the shift toward community-based care for most patients requiring mental healthcare services. The hospitals target populations not effectively served in their local community, but that remain geographically proximate to their portion of the state.
Transforming the patient experience
The first hospital opened under the statewide initiative was the Central Regional Hospital in Butner, N.C. The 432-bed, $130 million facility was constructed on a sloping green field site located across the street from the John Umstead Hospital, one of the two aging hospitals that Central Regional replaced.
Patients relocating to the new 470,000 square foot facility saw a dramatic change in surroundings. The older, multi-building hospitals were designed as secure facilities, characterized by fluorescent lights, windows with detention screens, institutional grade finishes and furniture, and limited access to the exterior environment.
The facility includes full-height windows with unobstructed views of trees, green fields and landscaped courtyards. Inside: increased freedom of movement, open and day-lit common areas for socialization, natural finish materials and comfortable furniture.
Patients particularly appreciate the easy access to amenities provided in the new building. They no longer have to be escorted or transported to other buildings to utilize the gym, learning resource center, or their therapeutic services.
The natural slope of the site allowed for the hospital to be developed with public and private sides of the 470,000 square foot building. The treatment mall is located on the second of three levels of patient care units, which keeps vertical travel to a maximum of one flight of stairs.
Adapting two future hospitals
Construction of the eastern region facility is scheduled for completion in 2012, while the western region facility is expected to be completed the following year.
Each will integrate changes to reflect the patient population and cultural distinctions surrounding patient care in these more rural areas of the state. Each will also benefit from physical improvements arising from the experiences and recommendations of staff, administrators and patients at the Central Regional Hospital.
The new Cherry Hospital, serving the eastern region of the state, is located in Goldsboro, N.C. This building uses public and private sides organized around a treatment mall. Outdoor courtyards were elevated to allow for programmatic space beneath the courtyards and give patients a view of the agrarian landscape.
The new 476,000 square foot Broughton Hospital is being built in Morganton, N.C. Naturally, various adjustments and improvements were able to be incorporated into the Broughton design, but the planning principles remained the same-with public and private sides, organized around a treatment mall and featuring a single flight connection to all levels of the PCUs.
Compiling key lessons learned
With the benefit of three years of patient care experience in the Central Regional Hospital, combined with the insight associated with design refinements developed for other two facilities, some valuable lessons have emerged. Among them:
Replacing obsolete facilities is a far better option than renovating. While there may be some building types where extensive renovation can deliver a favorable result, this project has shown that economic and social factors can strongly favor new construction. It allows for the integration of new technology and the ability to plan infrastructure for ongoing changes, and minimizes the impact to current patients.
Phased replacement allows for essential planning and logistical steps to be choreographed in a practical, efficient way. When projects are phased sequentially, financial impacts can be spread over a number of years, operational procedures (administrative and physical) can be anticipated in each newer facility, and lessons learned can be incorporated. Consensus-building and integration of cross-disciplinary ideas is crucial to a successful design program. The best results come from engaging as many stakeholders in the planning as feasible, and allowing these stakeholders to be invested in the decisions reached.
Creating a true healing environment relies on many factors beyond physical hospital space. Providing an open, spacious environment with plenty of natural light and outdoor views, combined with ready access to amenities and outdoor courtyards, contributes significantly to improved patient outcomes.
Terry Hatcher, PE, is Director, Property and Construction at the North Carolina Department of Health & Human Services. Timothy F. Winstead, AIA, LEED AP, is Vice President at The Freelon Group in Durham, N.C.
