Enhancing Facility Amenities
Beautifying Without Breaking the Bank

By Kathy Dix

With competition growing fiercer in the marketplace, ambulatory surgery centers (ASCs) are upgrading their looks to draw healthcare consumers into a welcoming, less sterile-looking environment. However, cost is a significant consideration when determining what changes can fit into the facility budget.

“The owner’s desire to limit the overall ‘front-end’ capital costs of a project usually result in high-end finishes being limited to the waiting room and reception desk areas and possibly the hotel-room-like extended recovery rooms (if they’re a part of the project’s program),” says William R. Massingill, AIA, chief operating officer at Polkinghorn Group Architects. “In the waiting and reception desk areas, carpet flooring, stained wood base and crown moldings, rich wall coverings, decorative light fixtures and integrated furnishings can create an ambience that is often more attractive and comfortable for patients and family members than the traditional hospital or physician office environment.”

Massingill continues, “In patient care areas where more clinical surfaces are necessary (such as vinyl flooring, cleanable painted wall surfaces, and sturdy cabinetry), color selection can go a long ways towards creating an ambience where patients feel less uncomfortable and staff feel better equipped to providing better care towards those patients. Effective color and pattern selections for cubicle curtains, laminates on cabinetry, and even staff uniforms can contribute to an overall environment of efficient and patient-oriented delivery of a facility’s services.”

Massingill references a healthcare-related school of thought, PlaneTree Principles, which several healthcare organizations incorporate into their facilities. “These principles are oriented towards establishing a multi-sensory ambience of wellness in facilities, and encompass such aspects as architectural design, exterior and interior landscaping, sounds (music, fountain-type water features, etc.), artwork, aromas, family member activities (while a patient is in the care of the facility), and other means of developing a ‘non-traditional’ healthcare delivery environment.”

However, ultra-luxurious surroundings at an ASC may also cause the patient to wonder if he is, in essence, paying for the improvements if he brings his business there. “It makes you wonder if they’re not overcharging, even if the insurance pays for it, if their prices are not competitive,” points out Gayle Evans, RN, MBA, CNOR, CASC, president of Continuum Healthcare Consultants and Quality Surgery Centers.

When determining what improvements to make to an existing ASC, Evans says, consider the patient population you wish to draw. Is the community rural, with a main patient potential of farmers, or will the clients be from white collar business in a commercial area? Mesh the image the physician practice wants to convey with that of the surgery center. “Are we conservative? Contemporary? A farming community? What is the age of the patient population? Certainly a 70-year-old farmer is not going to look for a glamorous-looking ASC. They’re going to look for what makes them feel at home. They don’t want the sterile environment look; that’s why they’re coming to a surgery center. It makes you feel at home for the time you’re there, makes you feel comfortable, alleviates the anxiety,” she affirms.

One facility Continuum is currently working with has physicians who are outdoorsmen, active in hunting in fishing. The colors at this rural ASC lean toward camouflage tones — not a camouflage pattern, but colors incorporated in that material. “It’s beautiful,” Evans says. “So the patients will walk in and there’s a warm feeling to the center, but also very comfortable.”

Another facility in Atlanta treats many cataract patients. After surgery, one of the first colors these patients can differentiate from others is blue, so the facility began with the color blue. “We have patients who are senior citizens, in their late-60s and early 70s, but there’s still a bit of a farming community, or a blue collar worker. In this facility, it’s a bit contemporary. We’ve got blue, purple, and green in the surgery center, but we’re using tin throughout the surgery center, so the patients can relate to the color and textures. Surgery centers don’t need to be ‘sterile.’ As far as decorating, they don’t need to cost a lot of money if you put color into them,” she adds.

Color can convey luxury without being costly; paint can be used in many cases instead of wallpaper, and thus respect the budget. Chair-type recliners instead of beds in a recovery area are amenities that can convey a more homelike feeling to the ASC, as can televisions and music. And allowing family members to be present in the recovery after less invasive procedures can also contribute to that “homey” atmosphere. “But you also have to remember — in doing all of this, the patient stay has to be minimized, so you don’t want them to be too comfortable, so much so that you can’t discharge them,” Evans quips.  “Some people provide nourishment, but here again, you have to be careful because of the length of stay in doing that.”

Customer service can be improved by continuity — allowing one nurse to accompany the patient from the pre-op experience through the procedure and the post-op period. Nurses enjoy that continuity because it allows them the opportunity to get to know the patient, Evans relates. “Sometimes these facilities get to be looking too much like an assembly line, because you truly are moving them in and out because of the limited amount of time that it takes to pre-op, do the procedure and recover them. You want to make sure that while that patient is interacting with staff, there is that bonding that occurs, and that they don’t feel like they’re rushed, because you get some satisfaction surveys back saying that the patient felt rushed.”

“We’re definitely getting more advanced as it relates to patient satisfaction,” says John Marasco, AIA, NCARB, principal at Marasco & Associates. “In several recent facilities, we have integrated water features into the waiting room, and on a couple occasions, we have actually been able to get approval from the state health department to put a water feature in the step-down lounge. The reason is to bring in more of a soothing, relaxing environment, and even an acoustical environment.”

Another feature used frequently is due to the layout of most ASCs. “The nursing station for the prep and recovery area tends to get more buried internally to the project,” Marasco explains. “Either having skylights or clerestory windows — taking a piece of the structure and pulling it up so there are windows on the side instead of straight up — lets natural light in.

More importantly, what we have found from our users is their desire to have a connection to the exterior as it relates to weather — is it raining, snowing, light or dark? It tends to make them more relaxed to know what’s happening outside, so instead of burying these people in a windowless environment for hours at a time, by adding those features, you can help bring some of that external to them.”

Some operating rooms have windows as well, conveying a less “sterile” feel to the space. Some locations have had mountain views, which were readily incorporated into the operating room windows — enhancing the patient’s experience before he is sedated for the procedure. Windows with integral blinds — sandwiched between the two layers of window glass — can be utilized, thereby eliminating blinds as a sterility issue. These blinds can remain open to offer the view, then closed when more controlled lighting is necessary for a procedure.

“What you have to be careful of in that case is the view patterns,” Marasco cautions. “You don’t want people looking into the operating room, so in most cases these windows tend to be high in the space. There are other ways to deal with that — reflective glass, so there isn’t that situation. However, in many communities, that is frowned upon, because it reflects sunlight onto somebody else’s building, so that can’t always be done.”

Greenhouse-like waiting areas are also an option — however, the room should not be south-facing and thereby building up massive amounts of heat from the sun exposure. High ceilings are another choice, bringing a sense of spaciousness to the room. “Most of our surgery centers have vaulted ceilings in the reception area, so it goes up a story and a half or even two stories, to open up that volume,” Marasco says. Walls and ceilings with a curved look as opposed to austere right-angles can convey a more natural feel to the space. And, he adds, “The concept of the concierge environment is very popular these days.

“What we’re trying to avoid is having that traditional glass enclosure where the receptionists are behind glass, and the patients feel like numbers as opposed to patients. We like an open, airy, friendly, concierge-type of environment. The downside to that is you also need to provide some sort of private enclosed interview area, so if you do have a patient and you need to talk about private information (because of HIPAA regulations), you require some space where you could have a more private face-to-face sit-down. We have found what works well is an alcove to the side of the front desk, so you can move a patient there, but it’s the same receptionist dealing with that individual but this time in a more private environment,” he says.

The actual design of the interior — as opposed to constructing the architectural “shell” of the building — can be much more costly than the building or the expansion. “The sheer physical volume of the space as it relates to the architecture of the space generally does not have as significant an impact as the level of quality of the finishes that go into that space,” explains Marasco. “The higher level materials that go into a space can have significant impact on the cost. That’s often what surprises clients. In reality, the cost to put a marble floor in or stone countertops may be equal to if not more than a volume upgrade.”

Randal Kiemnec, ASID, president of RMK Design Associates, Inc., has worked with Marasco on approximately 50 ASCs. “What we’ve typically tried to do is soften them up so they can compete with the hospitals, because a lot of the hospitals have better budgets,” Kiemnec clarifies. “If we do upgrades, we try to do them in areas patients are going to see the most — obviously the waiting area, maybe a bit in the prep/recovery space. We’ve done wall covering borders and small sheet vinyl insets in the ORs where the patients are cognizant, and add a bit of color to distract them from all of the technical, medical equipment in the rooms.”

Waiting areas typically have wall coverings introduced, both for aesthetic purposes and durability, Kiemnec comments. “That may be something as simple as a type 2 wall covering or exotic as an inexpensive olefin, which has the look and texture of a linen but is a petroleum product, so it’s not as expensive and it’s very durable. If we’re careful as to what we specify, we can keep the price relatively low.”

Olefin comes with its own challenges. “It’s harder to install — the installers literally go through a blade every time they cut it,” he explains. “Typically, wall coverings will be 54 inches wide and the paperhangers will cut the edges on the material because it’s selvage, a rough edge, so they have to cut it to get a good seam. But on olefin, they have to do a new blade for every cut, so it’s a little bit more labor-intensive. But cost-wise, it can be fairly close to a type 2 vinyl. We try to specify heavier vinyls so that they hold up. The vinyl on the walls initially is more expensive, but over the life of the paint or the wall covering, it’s less expensive, because maintenance, repainting, is going to be more labor-intensive over time.”

Other options are wood accents — wood trim, a wood chair rail, or wood detail at the reception counter, which is the first thing patients see upon entering the ASC. Hard surface flooring like a tile at the entry can also improve the look without being too costly, while still improving durability in the high-traffic area. “There are a lot of manmade products that look very natural,” Kiemnec points out. “There are porcelain tiles that are not too expensive, as long as we keep the square footage down, and we can add a nice entry tile, maybe the same color with a different size or direction, so we can create a little inset pattern with the tile.

“In the waiting areas, we’ll introduce multiple fabrics for the seating so we have some variety in the patterns. Alot of the surgery centers now have nourishment counters in the lobby for family members — maybe just a counter with a sink, with coffee or tea or soft drinks, and we make that into what looks like a residential credenza. It’s already going to be there, so let’s just make it look like a sideboard in a dining room,” he adds.

Artwork communicates a more luxurious feel but can be quite costly; to counteract this, Kiemnec suggests utilizing poster art but with nicer frames and matting. “We may try to do a few nicer pieces in the waiting room, and then as we get back to the prep/recovery area, it may be a less expensive frame, just to bring in some color and variety to the space.” However, he observes, “the biggest part of the punch is the waiting area, then the patient education or the interview rooms or consult rooms where family members meet the physician or the patient meets the physician. Once we get back into the prep/recovery area, it gets much more clinical — the carpet’s gone, the majority of the wall covering is gone, so a lot of times, the prep/recovery area typically has a control station in the middle. Marasco will try to do that as one control station for both areas, and so we will accent just that center core space with wall covering, just to give it a little color. Typically, we don’t use a lot of accent paint, because it’s harder to maintain, and if we do an accent, we try to do it in vinyl covering, because it’s more bulletproof. Marasco will do a built-in cabinet at the prep/recovery station so the gurney will basically bump into a counter where there’s monitor equipment on the counter, and maybe a shelf below, where they can put linens or storage, and the center will be a blank panel where the gurney will bump into. Sometimes, we’ll accent that back wall with paint because it’s protected by the cabinetry.”

Pre-manufactured silk florals are also a nice touch, and even one arrangement can make a difference in the appearance of that core control station. Signage for the facility is color-coordinated with the rest of the ASC to provide continuity, and flooring can be customized with small patterns on vinyl tile or sheet vinyl. Sheet vinyl is more expensive, but is better in the prep/recovery area because it has fewer seams. Although most of Kiemnec’s facilities are ASCs, they have worked with some specialty hospitals that had full PACU rooms. “In those rooms, we’ve done carpet, wood trim, wall covering, and wood grain sheet vinyl for flooring, if they want it more durable. There is some great wood grain sheet vinyls out there that add a lot of warmth, but that is a cost factor. It’s more expensive than your standard sheet vinyl, so you have to be careful there,” he adds.

For 2006, the American Institute of Architects (AIA) and the Facility Guidelines Institute have proposed changes on the AIA’s existing guidelines for design and construction of hospital and healthcare facilities.

Space does not permit publication of all these recommendations for various outpatient facilities — which include outpatient surgical facilities, freestanding outpatient diagnostic and treatment facilities and gastrointestinal endoscopy facilities — but the guidelines may be viewed at www.aia.org/SiteObjects/files/chap%2009%202006.pdf.¹

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