Ryan Hullinger

Ryan Hullinger

Healthcare Partner, NBBJ
With a focus on enhanced clinical performance and adaptable hospital design, Ryan works to ensure that research-driven methodologies are at the center of healthcare design. Most recently, he has focused on a performance-based approach that leverages the transformative potential of Building Information Modeling (BIM), Integrated Project Delivery (IPD) and prefabrication. This work is yielding architectural solutions that are collaboratively developed, rapidly constructed and highly adaptable — solutions he has presented at conferences across the United States, Canada, New Zealand and the Middle East.

Six Design Strategies To Reduce Healthcare Worker Stress During The Coronavirus Pandemic

July 13, 2020

Healthcare Partner, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post initially appeared on Forbes. It was co-authored by Ryan Hullinger and Sarah Markovitz.

 

Frontline healthcare workers face enormous stressors during normal times, but especially today during the pandemic: fear of contracting the virus, concern for protecting their families, grief over watching patients die, and anxiety over resource rationing decisions. Tragically, these issues are increasing healthcare provider stress and harming their mental health, as some begin to display symptoms similar to post-traumatic stress disorder.

Even before the pandemic, levels of stress and burnout in healthcare workers were high. Fifteen percent of nurses reported feelings of burnout in a 2019 survey. Burnout is among the leading patient safety and quality concerns among healthcare organizations, as it can decrease work performance and increase risk of errors.

Although we can’t completely remove stress in the healthcare setting, changes in the environment may help boost employee resilience. Mindfulness micro practices—such as micro-breaks and a variety of respite spaces in which to take them—can mitigate stress. Meanwhile, developing resilience practices in the immediate setting where they are needed most could reinforce the impact of these practices. As the coronavirus continues, and we anticipate new pandemics ahead of us, how can we improve the experience now and for future events? We propose the following design solutions for hospitals and other healthcare facilities.

Rethink The Break Room

Taking breaks can help improve productivity and prevent burnout, yet healthcare workers may be reluctant to take them, especially in times of crisis. We need to ensure that when a break does happen, the environment is optimized for caregiver decompression, support and restoration.

One way is to transform the break room into an oasis of respite, where employees can relax and meditate. The first is to employ the power of nature to boost resilience and cognition. Research illuminates that surrounding ourselves with real or simulated green plants can lower our physiological stress response, such as blood pressure and heart rate. Break rooms with windows that face gardens, trees and other green spaces can take advantage of these critical nature benefits. Artwork or wall graphics of a forest, rolling countryside or green lawn, can help too, as can the introduction of birdsongs and other natural sounds.

Leverage Underutilized Corridor Spaces

Micro-break spaces along typical pathways, such as corridors and alcoves may decrease stress and boost wellness. For example, underutilized areas along a nurse’s route or a physician’s daily rounds can transform into a variety of calming alcoves for a moment’s rest. These spaces could include soft-cushioned chairs with ottomans and seating booths for solo rest or a quiet place to call family. In addition, corridor ends with a comfortable couch and views to the outdoors can offer a peaceful retreat, and with the addition of a whiteboard, can also allow staff to informally connect and share knowledge.

Provide Areas For Physical Exercise

Movement and physical fitness — especially high-intensity aerobic exercise — offers a host of short-term and long-term benefits, such as improved memory, a boost in mood, enhanced cognitive function and better quality of life. Walks in nature and views of green plants can help reset the harmful effects of sustained stress. Outdoor gardens can provide exercise and the restorative effects of nature.

Offer Immersive Respite Pods 

It is crucial to bring respite to those who need it most, from ICU nurses to emergency department physicians to support staff. One approach under development is called the mobile respite pod. This indoor modular system can provide a customizable and sensory experience to promote rest, relaxation and meditation. Inviting seating, adjustable lighting, calming sounds and green forest or ocean imagery may help healthcare workers recharge in their preferred way. Meanwhile UV lights engaged before and after each use could provide a convenient cleaning process. Designed to be easy to assemble and break down on site, these pods, offered in various sizes, could be installed in currently underutilized areas like waiting rooms or lobbies, or even outside in plazas or near gardens.

Decrease Stress At The Bedside

The opportunities for reducing healthcare worker stress are not limited to staff areas. In fact, many of the best opportunities are right next to the patients. We have long understood that high noise levels and incessant equipment alarms in patient areas are anxiety-producing for patients, families and healthcare workers’ communication, wellbeing and performance. Alarm fatigue is proven to decrease focus and memory, raise cortisol levels, lower concentration and even provoke a negative immune system response. Studies indicate background noise above 45 decibels can create adverse effects, and many healthcare settings are much louder than that. Simple environmental strategies like providing white noise, employing sound-absorbing materials and using smoother cart wheels are all beneficial.

Consider The Return On Investment

As we addressed in an earlier Forbes column, hospital systems currently face extraordinarily difficult financial challenges, so every solution needs to be carefully vetted in terms of costs and benefits. While some of the proposals above would have very little cost impact, others (like the respite pods) would require a larger investment. It is important to note, however, that the cost of not responding to provider stress is perhaps the highest of all.

Last year—even before the COVID outbreak—healthcare organizations on average faced 17.8% staff turnover. This came at a huge cost, averaging more than $60,000 for replacing a registered nurse and $500,000 for replacing a physician. Decreasing staff turnover by just 2% could save the average hospital over half a million dollars per year, and could quickly offset the construction cost for many supportive environmental solutions.

Our society has rightly reframed healthcare workers as heroes, who are sacrificing so much of their own security every day in order to save others. It is our hope that this new-found societal recognition will not be squandered, but will instead generate unprecedented advocacy and investment in the emotional safety and well-being of our nation’s devoted front line staff.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Frank Oudeman.

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Getting Hospitals Back on Track: Safely Bringing Healthcare Back Online

How to Prepare Our Hospitals to Balance COVID and Non-COVID Care

May 21, 2020

Healthcare Partner, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post initially appeared on Forbes. It was co-authored by Ryan Hullinger and Sarah Markovitz.

 

Since the middle of March, nearly all elective surgeries and medical procedures in America were postponed to create capacity for the first wave of Covid-19 patients. While the curve has started to flatten and many facilities are reactivating their procedural platforms, there is still hesitation in patients seeking in-person care for fear of inadvertently exposing themselves to the virus. As a result, many patients with both chronic and acute conditions are putting off necessary health maintenance and avoiding trips to the hospital.

For the healthcare industry, this is devastating both in terms of its impact on patient care and its bottom lines. Hospitals — especially non-profit hospitals — historically operate on extremely narrow financial margins. With so many departments sidelined, the average American hospital has seen an estimated average drop in operating revenue of 40 – 45%, resulting in significant furloughs. These actions take a huge emotional toll on staff, many of whom were bracing for battle only a month ago and are now suddenly without a job.

America can’t afford to continue putting its wider healthcare system on pause in the likely event of another patient surge in the summer or fall. So what solutions could help keep appointments and procedures on track? And how can we ensure that they are performed in a safe manner?

All entrances, lobbies and screening processes should look calm and well-organized to assure patients that the facility is in control of the situation and safety is the number one staff priority.

There are many design changes that can make this happen and many of them begin before patients set foot on hospital grounds. Hospitals should use their websites to present clear communications with patients so they are aware of the safety precautions and instructions for their arrival.

Inside the hospitals, there needs to be legible signage that communicates cleaning and disinfecting processes for the facility. For example, many hospitals have existing digital signage outside of rooms that previously communicated room occupancy. This can be repurposed to communicate cleaning frequency and efficacy. This can be as simple as something like “This room was cleaned three minutes ago and is ready for use.”

Thoughtfully planned wayfinding will be equally important. These need to demarcate separate pathways for those with and without Covid-19 symptoms entering the site, covering the patient journey from the parking to the entrance to the treatment areas. Wayfinding solutions could use unique colors and shapes – such as the color pink or a triangle shape – to help messages stand out.

Planning hospital flow for optimal safety

Accommodating coronavirus and non-coronavirus patients in the same hospital requires thoughtfully planned and clearly delineated processing and treatment zones. The Centers for Medicare & Medicaid Services recommends establishing distinct zones for each group. In the coronavirus care areas, symptomatic patients will be identified, screened and receive appropriate medical guidance and contract tracing efforts. Where possible, these areas should be physically separate from other hospital services — this could be a different building, a dedicated room/floor with its own entrance, or pop-up tents adjacent to the hospital.

For patients with Covid-19 who come for treatment of other issues and conditions, a bespoke multidisciplinary clinic can be set up to address their needs. For patients who have yet to be screened, administrators can work together to plan uni-directional flows throughout hospitals so those coming in and going out don’t cross paths with one another.

This will also require consideration for features like elevators to ensure they don’t become contamination zones — potentially by having designated staff operate them, reducing the number of persons allowed in at any given time, and identifying separate elevators for coronavirus and non-coronavirus patients.

Rethinking the waiting room

Balancing care for coronavirus and non-coronavirus patients in parallel may require rethinking the traditional waiting room entirely. Hospitals are designing new patient experience systems to alleviate patients’ anxiety by limiting the amount of time in the hospital outside of direct appointments and treatment.

After being screened for Covid-19 at a triage tent, patients can wait outside the hospital until they receive a text that their doctor is ready to see them, at which point they are taken straight into a treatment room to promptly be seen by their provider. By using mobile communication tools, these hospitals are decentralizing and streamlining the waiting room experience.

For the majority of Americans who access hospitals with their own vehicle, cars could become the new waiting room. For those living in more urban settings, hospitals can consider converting larger and more spacious rooms like cafeterias and conference rooms into waiting areas. This would allow for greater distance between patients waiting to be seen. Reconfiguring furniture for appropriate spacing, leaving signs on chairs and tables after they’ve been cleaned, and using markers to establish appropriate distancing for any lines are all immediately actionable solutions.

All of these considerations will change as PPE supplies, Covid-19 screening, antibody testing, and tracing programs continue to evolve. By closely aligning thoughtful and innovative hospital programming and operations with solutions that project a sense of safety and care, we can start to reconfigure our hospitals and healthcare facilities to operate within this new reality.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Benjamin Benschneider.

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We Need More ICU Beds. Rethinking America’s Individualized Healthcare Mentality Can Help Get Them

With Prefabricated, Open Ward-Style Treatment Spaces We Can Rapidly Scale the Number of Beds

April 16, 2020

Healthcare Partner, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post initially appeared on Forbes. It was co-authored by Ryan Hullinger and Bryan Langlands.

 

For years, America’s healthcare industry has operated from an abundance mentality, with hospitals assuming access to virtually unlimited resources. But we are just a month into the United States’ COVID-19 crisis and hospitals across every corner of America are finding themselves in the midst of a threefold lack of resources — of appropriate space, of healthcare workers needed to address the crisis, and the necessary level of personal protective equipment (PPE) to keep frontline staff and patients safe.

Though the outlook feels bleak, the current pandemic is a chance for the healthcare industry to reevaluate deeply held beliefs around patient care and comfort. Most notably, the primacy of private patient rooms and specialized nursing units as across the board solutions. Both healthcare professionals and the general public need to forego the ideal patient experience as a primary focus for the American healthcare system. Instead, it is imperative that they move to an emphasis on patient safety and survival.

It sounds like a paradox in the midst of an infectious outbreak, but augmenting single-patient rooms with prefabricated, open ward-style treatment spaces ensures we can rapidly scale the number of beds in our country. While some hospitals at the forefront of the crisis are beginning to adopt versions of this model, the scale of this crisis requires solutions that are more integrated, faster to build, and easier to deploy across geographies.

One solution is pre-fabricated ICU units: a process that builds the components offsite to allow easy assembly onsite, saving time and money. Developed recently for use in future hospitals on the East Coast, these ICU units can be integrated into unorthodox and temporary treatment areas inside hospitals like cafeterias, clinics, conference centers, and parking structures. It can also be used beyond the hospital in civic spaces like arenas, schools and community centers.

Hospitals can arrange these temporary units in modules of 12 to 18 beds that come pre-fitted with essential ICU functions like regulated gasses, air and data. Grouping beds into larger modules maximizes caregiver sight-lines and allows nurses to oversee a greater number of infected patients in a smaller area, minimizing the staff required to care for patients. These groupings also have the potential to extend the average length of use for some PPE by reducing the need for staff to don and doff protective equipment repeatedly, as they do in typical nursing units each time they enter and exit private patient rooms.

Specialized medical equipment manufacturers have been developing and producing key elements found within the ‘plug and play’ solution for years as a part of the nation’s hospital building boom. By marrying the two together — the “plug and play” ICU unit and redirecting existing units intended for construction projects — we may be able to help quickly offset some of the stress on today’s hospital systems.

Now we must shift that energy to respond to the crisis today. Doing so means that, at least temporarily, we must focus less on the individualized and specialized care model that has been a hallmark of American healthcare, and more on the infrastructure and solutions that will save the most lives.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Frank Ooms/NBBJ.

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How Modular Construction Can Supply Beds in the Coronavirus Crisis

Advancements in Rapidly Deployable Inpatient Architecture Are a Key Solution as Hospitals Scale Up

March 24, 2020

Healthcare Partner, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them however we can as they courageously care for the sick. So we’re posting design ideas based on work with several clients across the U.S., in the hope that we can to contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

 

The unprecedented challenge of the COVID-19 pandemic puts tremendous strain on healthcare infrastructure in the U.S., with staff and patients at elevated risk. A recent study found that in a moderate outbreak scenario, hospitals in 40% of American markets would not have room for all COVID-19 patients, even if they emptied all beds of other patients. While authorities are responding with strategies to address the national bed shortage, such as New York’s plan to create 8,000 new hospital beds in two weeks, there will be an ongoing need to increase inpatient surge capacity nationwide.

Quick Response with Rapid Inpatient Units

A rapid-response inpatient unit can be set up in a range of converted spaces, including military bases, schools, dormitories, office spaces, and arenas. Additionally, temporary structures such as tents, modified shipping containers and even purpose-built semi-trailers/RVs can be utilized. One such approach, the U.S. military’s Deployable Rapid Assembly Shelter, provides a turnkey system combining portable enclosure and high-output HVAC provisions. These and other mobile approaches are particularly compelling for virus response because they enable a healthcare structure to be delivered precisely to the point of greatest need, and can be moved from one hotspot to another in direct response to viral transmission patterns.

Yet in many ways, the building enclosure around a temporary ICU is the easier part to construct and deploy. The more challenging step is the construction of the life-support medical engineering systems that support patients within that enclosure.

Using Prefabrication for Increased Adaptability, Configurability and Speed

One solution may be an unconventional approach to ICU unit design and construction that maximizes the potential of prefabricated patient room components. These components act as a highly adaptable chassis for an ICU’s most complex engineering subsystems, including the life-support headwalls that deliver data, power and medical gases via a highly adaptable “plug-and-play/motherboard” framework. Rather than building these components conventionally at the job site, the modules can be prefabricated in a dedicated off-site assembly plant and then delivered and installed with significantly improved schedule, precision, cleanliness and efficiency.

Prefabricated building components can be installed up to 50% faster than similar conventional construction methods; the speed afforded by this prefabricated approach has clear applications for rapid crisis response. Our research in this field benefited greatly through a partnership with the Ministry of Health in Christchurch, New Zealand, after the devastating earthquake there in 2011 required the design of a state-of-the art replacement hospital. And the research was pushed further still in response to the Ebola crisis in 2015.

With these global events acting as a catalyst for innovation, headwall components can now be developed for prefabricated delivery, as well as for life-cycle demountability, enabling continuous reconfiguration and redeployment. In a conventional healthcare setting this flexibility allows caregivers to calibrate their work environment more precisely to need, and in a crisis situation — like COVID-19 — it could enable rapid ICU fit-out for a variety of temporary enclosures. These systems achieve their increased flexibility by incorporating features such as quick-connect fittings, flex piping, scalable technology management, adaptive leveling and panelization (rather than relying on conventional wet-joint sheetrock). Overall, the design leverages a great deal of manufacturing logic from the demountable furniture systems incorporated in corporate workplace projects.

The capacity issues that face the healthcare sector in the current crisis are daunting and cannot be addressed by conventional approaches and thinking alone. Modular construction offers one potential path forward, which may help hospitals respond more rapidly and effectively to the challenges ahead.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Sean Airhart/NBBJ.

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Let’s Make Obsolete Hospitals Obsolete

Prefabrication Can Make Healthcare Resilient and Sustainable. Here's How.

February 5, 2014

Healthcare Partner, NBBJ

Healthcare today is changing like never before — practice models are evolving radically, medical technology is advancing at an unprecedented pace, and healthcare’s financial infrastructure has become extremely volatile, especially due to recent steps toward insurance reform. Each of these issues has the potential to significantly affect how a new healthcare facility will be used in the future, and too often these drastic changes in use have led to premature obsolescence in hospital design.

Today architects invest tremendous effort in designing hospitals that are sustainable in terms of energy performance and near-term environmental impact, but unless we specifically address the threat of premature obsolescence, our hospitals are destined to be inherently wasteful in the long run. Once a healthcare facility becomes obsolete, it will either be overhauled, demolished, or worse yet, left in place for decades as an underperforming workplace that frustrates staff, diminishes patient care and squanders resources. These are not sustainable outcomes. At the societal scale, this wastefulness has afflicted trillions of dollars of healthcare spending.

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A New Approach 

In order to prevent obsolescence and ensure that a medical facility’s enterprise value will endure, architects are now developing strategies that maximize a hospital’s ability to accommodate unforeseen change. These strategies are based on a new design thinking that moves past the traditional view of a building as a static container, and instead explores opportunities for designing a building as an open-ended framework of prefabricated components. By developing a component logic that is highly standardized, demountable and multifunctional, key areas within the framework can be repurposed, reconfigured or replaced as performance requirements evolve. Eventually this allows for a massive reduction in waste because it significantly increases the probable lifespan of the entire project and ultimately leads to a future where medical facilities are designed to be transformable rather than disposable.

In a new age of clinical sustainability, can we make “Replacement Hospitals” a thing of the past?

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