The recent Environments for Aging Conference included a different approach to education versus death by PowerPoint. A gerontologist, two interior designers, and an architect formulated the team to do a live demonstration of the functional programming process.
The team of presenters realized that often the buzzword "functional program" is found in design sections of healthcare licensing code language and healthcare design reference materials, and utilized during the strategic master planning process. However, as much as this is discussed in theory, it is not often clear how this process is completed in practice.
Julie Bessant Pelech, a gerontologist from Toronto, was the programmer and facilitator; Betsy Brawley, an interior designer and author of two books on designing environments for residents with dementia, role-played a resident with dementia; Sandra Harris, a mission-driven and person-centered senior living interior designer, represented the different design disciplines; and I was "all staff." This was a bit schizophrenic, but by utilizing different characteristics, tones of voice, and facial expressions pulled off everyone from C-Suite administrators to food service chefs to facility and homemaking staff to nursing caregivers, the process was effective for the audience. (Albeit the Julia Childs interpretation came out more like the Chef on the Muppets.)
Prior to the two hour pre-conference session, a survey was sent out to registered attendees in hopes of determining who was building environments as a design-centric project versus an operationally-driven, supportive environment. Twenty-five percent were "driven by design" while 82.4 percent were placing “operations, care model, and functional programming" at the head of the class. Interestingly, only 58.8 percent had actually completed a functional programming process prior to starting the design work for a senior living setting.
Interdisciplinary teams in action
Based upon positive attendee reviews, most felt it was helpful to actually see a role play "in action" to realize the benefit of interdisciplinary teams, their interaction, and the positive impact on the completed design. The physical environment design impacts and requirements were recorded during the role play by Sandra Harris, as the discussion about care model, decentralized dining, care staff needs, and resident desired outcomes was completed.
The top discussion points of interest to the audience were formulated by going through a “Day in the Life of a Resident,” played by Betsy Brawley and facilitated by Julie Bessant Pelech. An example for illustration includes the following dialogue around the “waking process”:
Betsy prefers to get up a bit later than the other residents. She likes a cup of coffee and then joins one of her friends for a late breakfast. She prefers to be dressed when she goes to breakfast, so she needs some assistance in the morning in getting up, toileting, bathing, and dressing. Physical program discussions and ramifications centered around the following points:
- Decentralized dining services that provide opportunities for staggered meals to be prepared and coffee/tea to be readily available hospitality style
- Clothing storage to be accessible within resident room to allow resident to gain access to clothing and selections from a wheelchair
- Bathroom to be fully accessible for wheelchair and transfer assistance by staff (sometimes two care givers)
- Ceiling lift and/or other types of lifts utilized by staff to provide resident assistance
- Structural needs, as well as storage requirements and types of lifts best suited for residents with dementia
- Triggers a Resident Safety Risk Assessment (RSRA) that includes evaluation of mobility and transfer, resident fall, and resident dementia and mental health risks (found in detail within the new Guidelines for Design and Construction for Residential Health, Care, and Support Facilities at www.fgiguidelines.org)
- Types of showers, storage of personal care items that are reachable by the resident, and independent utilization of shower controls when seated in a shower seat
- The desire to utilize a favorite mug for coffee (personal control)
From the rehearsed program, the interdisciplinary team had agreed to the following assumptions, so that a design concept could be presented to the audience to gain their input and feedback:
- Decentralized household model (smaller number of resident rooms grouped with living, dining, residential kitchen, and smaller “home” type spaces)
- Hot bulk (commercial kitchen) to finishing in warming/catering kitchens for each household
- Restorative/therapy decentralized within each household
- Diverse dining experience (mixture of tables)
- Connected households for sharing staff and resident interaction and socialization
- Hybrid decentralized/centralized medication (providing medications in resident rooms, as well as centralized for any narcotics and when residents receive certain medications during a meal time)
- Decentralized personal laundry
- Contracted or centralized linen service
- Centralized and decentralized activities in a mixture of spaces: living room, sunroom, dining area, parlor/private dining room
- Decentralized bathing and spa available within the household
- 80 percent private rooms/20 percent shared rooms (alcove style/shared bathroom)
- Stacked: urban model
- Outdoor space: terrace space
The team also provided some concept renderings based upon the plan above that demonstrates what happens to an interior of a space when a resident has visual impairments. The aging of the eye requires higher levels of lighting for residents to be able to see and reduce fall risk and improve independence. Floors require reduction in value contrast, whereas higher contrast is required between floor surfaces and walls, and grab bars/handrails and adjacent wall surfaces.
Overall, the presentation style and resulting design concept provided the audience an interactive way to see how a functional program can be utilized to improve the project design, as well as improve resident and staff satisfaction. The process demonstrated the positive aspects of upfront informative discussions and interactions with the entire resident, operations, design, and organization teams.
No one size fits all solution
An important closing dialogue highlighted that there is a lot of discussion in the marketplace about cultural transformation and person-centered care. However there is not a “one size fits all” for care providers. If the functional program process reveals that there is not a commitment to complete decentralization and re-training of staff, then this needs to be acknowledged by the integrated design team in the beginning of the project planning and design process.
Designers want to encourage the embracing of new ideas and culture change, but in order for a project to be successful, there needs to be an identification of limitations as well as desired goals. If a care provider decides to centralize some or all services for whatever reason, person-centered principles can still be utilized, but the physical environment needs to support the care model. Providing a small house or household design for skilled nursing is not going to be successful if it is being operated like a traditional centralized model. The physical environment has to support the care model, operations, and resident desired outcomes to sustain identified person-centered goals.
The Facility Guidelines Institute, ASHE and the Center for Health Design have been working on educating designers, providers, and authorities on the importance of the functional programming step in the planning and design process. As a follow-up to the ASHE Summit Plenary Session held earlier in the year with moderator Ken Cates and panelists Alberto Salvatore, Deborah Smith, Brent VanConia, and myself, the American Hospital Association has requested a second debut at their annual EXHANGE Conference for the Association for the Healthcare Environment. We will present “Maximizing the Benefit of The Functional Program” on Tuesday, September 23, 2014 from 1:15 to 2:15 pm in Tampa, Florida.
The opportunity to utilize and have feedback from clients and end users demonstrates that maximizing the functional programming process improves the overall design and success of projects. Brent VanConia, president at SSM St. Mary’s Health Center, pointed out the benefits of the interdisciplinary team and the results for a successful replacement of a 370,000 square foot, 178 bed hospital and 65,000 square foot medical office building.
The total project cost was approximately $220 million, and the cost to develop the functional program for all aspects of the hospital and MOB was approximately $1.5 million (less than 1 percent of the project cost). VanConia demonstrated it completely worth it in his evaluations of the resulting efficiencies, design success, and patient satisfaction. The triple win!
About the author:
Jane Rohde is the founding Principal of JSR Associates, Inc. located in Ellicott City, Maryland. She champions a global cultural shift toward de-institutionalizing senior living and healthcare facilities through person-centered principles, research and advocacy, and design of the built environment. Clientele includes non-profit and for-profit developers, government agencies, senior living and health care providers, and design firms. Jane speaks internationally on senior living, aging, healthcare, evidence based design and sustainability. For more information or comments, please contact Jane Rohde at firstname.lastname@example.org.