The Affordable Care Act (ACA) is doing more than providing healthcare access to more U.S. citizens. Because the legislation affects health providers’ overall budgets, the changes trickle down to everything from staffing to facility design. So how will the new healthcare landscape alter interior spaces and ultimately influence the choice of flooring for new healthcare projects? We asked five designers from A&D firms and large hospital groups, who weighed in on some of the key issues and their design solutions.
Interestingly, each of the designers encapsulated the ACA’s effects in strikingly similar terms. Regarding budgets and the new reality, this is a “do more with less” scenario. And regarding flooring selection, it’s a question of balancing and prioritizing properties needed.
ACA REVERBERATIONS
The Affordable Care Act, signed into law in 2010, leveled a global impact on healthcare organizations and their planning for the future. More people gain access to healthcare every day, and providers now must care for more patients while raising quality but lowering costs. The ACA also promotes competition, allowing patients to shop for services, and it places an emphasis on wellness care and outreach in the communities that the healthcare providers serve.
The healthcare segment is already in the midst of major changes on several fronts, including industry-wide consolidation, changes in the types of buildings to be planned and built, and massive cost reduction efforts that are accelerating as the ACA comes into full effect.
In addition, the basis for Medicare reimbursement is moving from a focus on volume of care to quality of care. Medicare reimbursements are now linked in part to performance, including patient satisfaction, to be measured by a national, standardized and publicly reported survey known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems). Patient satisfaction is influenced by not only the staff, but by the overall hospital environment as well. Floorcovering choices can contribute in measurable ways, such as improved acoustics and traffic flow, and in less tangible ways, like attractiveness, perception of cleanliness and comfort underfoot.
With the ACA’s increased emphasis on outcomes, evidence based design (EBD) is more often incorporated into planning decisions. EBD studies offer insight into the specific methods and materials that have been tried and data on how well they work. One tool available is a checklist designed by The Center for Health Design’s Research Coalition, comparing certain performance characteristics of floorcoverings with their suitability for specific healthcare environments.
POST-ACA CONSTRUCTION
At $9.7 billion out of a total $32 billion in construction spending within the healthcare sector in 2013, acute care hospitals still account for almost a third of construction costs in the healthcare industry, according to Modern Healthcare’s 2014 Design and Construction Survey. However, as construction projects currently in the pipeline start to come to completion, hospitals’ share of healthcare construction will decline.
The trend in new healthcare construction is to decentralize, moving away from large hospitals in favor of ambulatory care centers. These centers may house community-based primary care, urgent care or specialized facilities, such as MRI and cancer treatment centers. Healthcare groups have also become creative with the repurposing of existing facilities, including former retail spaces, for the new modes of healthcare delivery. In addition, pharmacies have begun offering basic health services in clinics adjacent to their retail space. All of these changes provide more accessible healthcare in local communities rather than in large regional centers.
COST REDUCTION STRATEGIES
At the core of the ACA requirements lies a mandate for the entire healthcare industry to reduce costs to the consumer. Facilities need to cut expenses and eliminate waste, and designers have become part of the solution. Ardis Hutchins, interior architect at the University of Wisconsin Hospitals and Clinics, referring to the design process for a new hospital, said, “We are incorporating the Lean Design and Construction process, continually looking for ways to be more productive, cut out waste and streamline operations. In order to do this, we are evaluating all processes in the hospital. One objective is to reduce duplication and steps of nurses and staff. We are also creating more team spaces.”
A key tenet of Lean Design is the collaboration of multi-disciplinary teams to design and guide the process. “We are trying to be more cost-sensitive and utilize spaces to maximum efficiency,” Hutchins explained. Involving everyone who will use the space in the planning process helps maximize utility and minimize waste. Flexibility is another important aspect of Lean Design. Spaces and traffic flow must be flexible, so that the interior continues to function appropriately when inevitable changes occur.
Interior designers and architects are well aware of the challenges. Alison Faecher, interior design director at TRO Jung/Brannen, described the downward pressure to reduce costs felt by healthcare organizations: “These may take the form of changes in operational flow, energy savings and simplification of maintenance protocols. In design planning we are always looking for ways to simplify and streamline.”
Reduction of energy consumption can take a big chunk out of operating costs, either through broad infrastructure transformations or the simplest of changes, such as new energy-efficient lamp fixtures or components. Expenses are also being cut in the area of housekeeping and maintenance, necessitating the adoption of simpler and more effective cleaning protocols. For flooring, this can result in the decision to specify multiple products with common maintenance procedures.
THE IMPORTANCE OF APPEARANCE
With increasing competition for healthcare consumers and a new emphasis on patient satisfaction, both the function and look of a facility matter. Principal at Cannon Design, Jocelyn Stroupe says, “We are beginning to see the impact of how the facility’s appearance affects its HCAHPS scores. This is all recorded; they have to reach a certain mark for full reimbursement. So if a facility looks dirty or worn, the bottom line will be affected. It is interesting to see owners and management understanding the importance of design.”
A well-designed interior influences not only patients, but also their families. “One of the big things that has happened over the last ten years is that healthcare has become very patient and family focused,” Hutchins explained. “It is understood that the interior has an impact on healing and that sterile environments create stress. When designing an area, we often use patient/family focus groups to look at the space and the finishes during the design process.”
Noise in an inpatient unit is the number one complaint on HCAHPS. Some facilities attack this issue operationally, banning overhead paging and establishing some quiet hours. Others opt for noise-dampening flooring solutions. For hospital administrators, the choice of a rubber product rather than VCT may result in more Medicare dollars.
Healthcare consolidation can benefit facilities by creating increased buying power with purchasing advantages from a condensed group of vendors, but it creates many design challenges as well. For example, groups of facilities that have been built and acquired at various times in various locations rarely share a cohesive design plan. Branding through consistent design features has become necessary to build community awareness and consumer confidence for a healthcare group that may be scattered throughout a metropolitan area or across several small towns.
Kristine Hanson, an interior designer with HGA Architects, described the branding process with Altru Healthcare in Grand Forks, North Dakota. When another healthcare provider came into town, Altru realized that that it needed to upgrade its look. It had been a while since any renovation had taken place and the buildings had expanded over time, so there was no consistent look within or between the facilities. HGA was hired to work on branding, bringing a consistency to all their facilities.
HGA met with staff, clinicians, infection control specialists and other stakeholders to form a standards committee, reviewing culture and goals. The team devised a simple flooring solution that resulted in improved branding and wayfinding. Icons were developed, identifying elevator lobbies, nurses’ stations, etc. These icons related back to department colors and symbols, and as part of the design, the icons were laser cut into linoleum flooring.
Hanson says that a similar approach worked for a very different client. Sioux Center, a small community hospital, houses all departments, including emergency, imaging and clinic, under one roof. A “town center,” set apart with porcelain tile, contains community spaces, such as the gift shop and chapel, and “neighborhood” wings each branch off with color specific linoleum flooring. Like at Altru, an icon designates each department, and the linoleum flooring is inset with laser-cut images.
The improved design and wayfinding, in turn, improve patient and family experience as well as traffic flow.
HARD SURFACE FLOORING SOLUTIONS
According to University of Wisconsin’s Hutchins, infection control specialists set criteria for flooring purchases, determining which areas require hard surface materials and which can allow for softer options. They also evaluate all cleaning products and processes. Hard surface flooring addresses the challenges of infection control and mobility for wheelchairs and carts. Resilient flooring is the general standard for patient rooms and inpatient corridors. Sheet material—vinyl or rubber and sometimes linoleum—is typically the material of choice.
Some hard surface products specifically address the issue of slips and falls. For example, Hutchins reports that more and more manufacturers have been introducing products with embossed textures. She has noticed a trend toward more matte finishes instead of gloss in order to reduce glare as well.
Faecher sees healthcare clients increasingly looking at the big picture from a flooring lifecycle cost viewpoint. “From a flooring perspective, we are steering away from products that have low capital cost and high full time equivalent (FTE) cost over time, such as VCT. Our clients are finally moving away from the wax-strip-reseal regimen, which is ultimately very expensive.
“We are specifying a lot of rubber flooring now,” Faecher adds. “Clients are willing to invest in the product. They typically use product with a thickness of 3mm to 3.5mm and above, and product with a little luster is preferred. Rubber requires lower maintenance over time. This may allow the facility to get FTE hours down and possibly reduce maintenance staff.”
Rubber is the standard for operating rooms at University of Wisconsin Hospital, in part due to the comfort underfoot for staff who may be standing on their feet for long stretches of time, and also due to its durability and beneficial acoustical properties.
Stroupe reports seeing more epoxy floors specified for operating rooms and emergency rooms as well. Epoxy floors may also be used in patient toilet rooms. A product from Stonhard with rubber chips, for instance, offers some comfort underfoot, but from an acoustical perspective this material would be less sound absorbent than rubber flooring.
Sandra Kaye Raak, interior design coordinator for facilities at Lee Memorial Hospital System, believes that there is a need for a balance of finishes. Carpet is often perceived as warmer and more inviting, yet the hospital system has found certain resilient products, especially wood looks, which also seem warm. All of the stakeholders, housekeeping in particular, have been pleased with a Teknoflor wood grain sheet vinyl with a slightly embossed texture. This product requires no waxing or buffing and incorporates a nano-silver sterilization technology.
Lee Memorial is using LVT in some off-site ambulatory care centers. Unlike hospitals, which operate around the clock, ambulatory care centers can shut down during flooring installation. In certain circumstances budgetary restraints still mandate the use of a VCT product. This would only occur in buildings with wider corridors able to accommodate a riding machine for waxing, striping and buffing.
Installation methods are another important issue to be considered in efficient design. In some renovation scenarios, The University of Wisconsin Hospital System has been using systems such as EnviroStix, an applied poly-acrylic adhesive system with embedded scrim, as opposed to the traditional high-fume mastic. With EnviroStix, the flooring manufacturer ships the sheet vinyl to the adhesive company, which attaches the system and ships the roll goods onto the job site.
Hutchins mentioned similar installation solutions, such as Interface’s TacTiles system, with its 3-inch adhesive squares, and Nora’s Noraplan nTx, a pre-applied adhesive that can be added to any of the Noraplan roll line. These systems are fume-free, which is extremely important for renovations in a healthcare environment. Mastic is a much less expensive option, however, and continues to be the standard for new construction or for facilities that can close during installation.
SOFT FLOORING SOLUTIONS
In general, carpet provides superior acoustics by absorbing sound. It also helps avoid slips and falls, and if a fall should happen, the patient is less likely to be injured. Although rarely specified for areas in the urgent care environment, such as inpatient rooms and corridors, high performance carpet may have the perfect combination of attributes for other areas.
Carpet is typically found in waiting areas, lobbies, conference rooms and administrative and consulting areas. University of Wisconsin uses only carpet tiles in the hospital, no broadloom, because it likes carpet tiles’ ease of installation and the ability to replace soiled tiles from attic stock as well as the inherent sustainability with less waste. According to Hutchins, the products they prefer use merge-able dye lots, so that when tiles need to be replaced, it is not as noticeable. She observed, “Modular styles are getting prettier and prettier and are available in different shapes, which offer added flexibility and creativity.” Although University of Wisconsin uses sheet vinyl in its patient corridors, carpet has been used in some corridors around the Neonatal ICU for its acoustical properties. This particular carpet was tufted of solution-dyed yarn so it can be bleach cleaned.
Sioux Center Hospital uses some carpet tiles in the clinic, waiting rooms and patient corridors. The hospital likes the ease of maintenance and the ability to pop out and replace soiled tiles. A Lees product was selected due to both its style and its fiber system—type 6,6 Antron Duracolor.
Stroupe also supports the use of carpet in certain spaces. “As often as we can, we use carpet tiles in waiting areas. It creates a softer, quieter environment. We also like to use carpet tile in team stations. Carpet tile provides an acoustical advantage where we are able to use it, although it is not always possible. We are using carpet in the corridors of the neonatal ICU because they need it to be quiet. Emerging research on the importance of quiet environments for children in a formative state is very compelling. It overrides the facility’s concerns about cleaning and maintenance issues.”
TRO Jung/Brannen never uses carpet in patient rooms or inpatient corridors. Although carpet is a good choice acoustically, spills are considered the real issue. This is true even for carpet with moisture barrier backing, since clients will often not get to the spill quickly enough.
Lee Memorial hospitals have some corridors with carpet and some with resilient sheet flooring, depending on the type of patient care area. Their carpet standard is typically carpet tile. Six-foot roll goods are purchased as a base in these areas. In areas where vinyl sheet is used, vinyl base is specified.
Many healthcare systems are devising creative solutions to expand their portfolio of care delivery options. For example, the University of Wisconsin Hospitals and Clinics has recently purchased a hotel in order to house visitors. A section of the hotel may be expanded into a halfway house, where a patient can receive outpatient treatment at the hospital during the day, and stay in a nurse-supervised room at night without hospital admission. This facility would benefit a patient who lives at a distance from the hospital and needs daily treatment for a period of time. Both the hotel and outpatient wing could utilize a less performance-oriented type of flooring, such as broadloom carpet.
Community hospitals tend to use more carpet, whereas university and city hospitals utilize more hard surface flooring overall. Their environments generally take more abuse and more traffic, and they generate more frequent spills. The move away from hospitals and toward outpatient facilities may increase the use of carpet in healthcare, since ambulatory centers tend to use more soft flooring.
NEUTRAL PALETTE
Most designers prefer a classic approach to color for healthcare facilities. As Faecher described, “We try to tie together main items to form a series of complex neutral palettes, as these items may be in place for ten to 20 years. Where money is tight, we are definitely trying to make responsible choices.” Durable materials likely to be chosen in neutrals include laminates, solid surface flooring, stone, porcelain tiles, wall protection, etc. Accent color, which is more trend-based, is chosen for items that can be more easily changed, such as paint, upholstery and artwork. For carpet color, Faecher says she never starts at lighter ranges. She prefers medium to deep colors with a bit of complexity to hide the tile edge.
Pattern trends have clearly shifted away from the hospitality approach of five to eight years ago. Heavily patterned product, like as the swirls and organic designs that were popular in the ’90s, now seem very dated. Current products are more subtle and textural, some with a soft geometric. “There are a lot of linear patterns right now, so that has made its way into our facilities. Often we use them in plank formats, possibly woven into a larger texture,” explained Faecher.
LOOKING FORWARD
Designers are approaching the changing healthcare landscape with thoughtful, informed choices, assisting facilities in their efforts to become more streamlined and consumer friendly in the wake of ACA legislation. We will see growth opportunities for all categories of flooring as facility types evolve and the healthcare consumer base increases, both from improved access and an aging population. Products offering innovative solutions to the increasing challenges in the healthcare environment will be in high demand. Now more than ever, a balance of beautiful design and true innovation with quality and cost efficiency holds the key to a product’s success in the healthcare market.
ASSESSING FLOORING FOR HEALTHCARE
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Specifiers can use a checklist offered by The Center for Health Design and available online to evaluate existing flooring or to choose new flooring in a healthcare setting. The checklist resulted from a study that compiled the implications of research findings, industry standards and best practices related to floorcoverings. The following eight categories represent specific areas of concern, including those linked to Medicare reimbursement under the ACA.
1. Reduce slips, trips and falls
2. Reduce patient and staff injuries associated with falls
3. Reduce noise levels
4. Reduce staff fatigue
5. Reduce floor surface contamination and infection risk
6. Improve the patient experience
7. Improve indoor air quality
8. Represent best return on investment
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