Signs of the new: A panel discussion by the jurors from SAGE

Carpenter: One of the questions we asked of participants this year involved their use of green design. Several of the answers were interesting and showed growing involvement with this. I recall one participant noting that the trees that had been removed from the site were milled and used for the wood flooring, for example.

Green: Another entrant had installed a windmill next to a pond both to generate energy from wind and to clarify the water.

Carpenter: Yet another project indicated that while there was a 6% incremental cost for green design, this was recouped in 3.5 years.

Calkins: Which means operators are making money on the building over the course of time.

Carpenter: Research has also shown that there's a lot you can accomplish with green design without incurring large upfront costs. Improving indoor air quality could be an example. There are several easy methods that can be implemented, such as construction sequencing. Schedule a two-week time period at the end of construction when the building can be aired out to vent noxious fumes before the occupants arrive. This doesn't cost anything, especially in nursing buildings that already have a system to provide 100% outside air. Also, install all of the wet materials and allow them to off-gas before installing carpets and furniture so that noxious fumes don't get trapped in the fuzzy materials. One wonders why more people aren't taking a first step like this.

Pace: Well, although more people are thinking about these things—and I'm glad that we asked the question—sustainable design is still not foremost in many people's minds as they design new projects.

Carpenter: We're finding in our experience that more residents of CCRCs are asking about green issues, so it's going to evolve to become an important marketing issue.

Brown: With the specific “green” issue of stormwater drainage, many projects worked closely with regulators and dealt innovatively with this. Results like these validate the SAGE philosophy that collaboration with regulators leads to a better product.

Calkins: I think I saw more projects than ever before commenting on having a close working relationship with regulators.

Pace: It reflects an underlying fact, in my view, that regulations have begun to change in a direction that reflects the principles of SAGE. I think we should feel good about that.

Gregory: However, we recently reviewed regulations nationally and found that about half are very similar to each other—similar, for example, in space requirements for resident rooms. There appears to be a “common ancestor” for all these regulations and I think it's in the Southeast. This may have arisen because these states generally had a large population of elderly and adopted the Hill-Burton amended requirements that were used for licensing hospitals. In 1950, most states licensed hospitals because the Hill-Burton Act required it, but few licensed nursing homes. The 1950 amendments to Hill-Burton for the first time required states that received federal matching funds to create standards to license both nursing homes and hospitals. The common ancestor was the Hill-Burton standards for hospitals which were simply adopted and, over time, somewhat modified to apply to nursing homes. So the nursing home design standards were originally based on a medical mode and, unfortunately, have not been updated since the 1960s or ’70s. For example, nursing stations are very obviously nursing stations in facilities in these states. Even though we now have the technology to upgrade these areas, we continue to be stuck with an antiquated model based on the old Hill-Burton standards.

Calkins: It's interesting. The federal guidelines say nothing about nursing stations, but the state requirements vary quite a lot from state to state. An informative place to check on these issues is the Nursing Homes Regs Plus Web site,

Steinhauer: But the regulatory environment overall is dictated by the legislative environment, and we as a field haven't done enough to educate legislators or consumers.

Carpenter: Some states do work with us. But others shut the process down and go strictly by the book.

Pace: Different regulators can interpret the same things differently. Local officials, such as fire marshals, can take very different stands from state officials as well. We have to remember that we're not just preaching to the state regulators. We have to go up the ladder to their bosses in the state legislatures.

Steinhauer: And I'd have to say there has been an overall failure by the long-term care industry to demand change at the state level. SAGE workshops are very useful, but while we sit here and talk about how regulation is subjective and often ties our hands in trying to advance technologically, if you talk to professional provider associations about whether they are actively involved with state codes in the culture change that's needed to bring about reform, the answer is no. Little or nothing ever happens.

Yes, it took Wisconsin 17 years to change because it took that long for everything to line up properly, but there's no real reason why we should have any regulation of this type in the United States that's more than 10 years old. The overall lack of progress with state administrative codes is inexcusable.

Bonn: It's very difficult to change the rules. Doing so is political and painful, and confronts a lot of people who maintain an interest in the status quo. Certainly they don't look forward to regulatory updates.

Gregory: That's true. It is extremely difficult, and often there isn't enough time for regulatory reform to work hard on this. It's difficult even to work upgrades into a three- or four-year cycle. In Florida we do have guidelines for healthcare construction but, although we adopted a hospital construction guideline in 2001, we haven't been able to do the same for nursing homes because of issues over enforceable language.

Carpenter: But is residential skilled care in Florida any different from what it is in Utah or Wisconsin? They all have the same needs. Why can't we have something like the international building code, i.e., one standard of regulation for every nursing home in the United States?

Gregory: There's no particular direction toward this in the existing code and, as Bill [Bonn] mentioned, there will be resistance. This is a problem for the Health Guidelines Revision Committee to take up.

Green: I'm one of two AAHSA representatives on the Health Guidelines Revision Committee of the American Institute of Architects, which is striving to develop a uniform set of nursing home standards that could be adopted by all the states. AAHSA, I'm told, didn't want to get involved with environmental regulations until recently because they didn't support the concept of any type of assisted living regulation. Now, though, AAHSA accepts that we have to look at healthcare facility design guidelines as an agent of change.

Bowersox: I remember approaching AAHSA about this as part of a group of designers in 1986 and AAHSA telling us that they didn't want to get involved with regulations for environments. Cheryl Riskin is the person who got things started at AAHSA in the early 1990s when she was in charge of a project to evaluate the impact of regulations on nursing home design. She was an initiator of SAGE. She did research showing that nursing home models went back to how hospital beds were laid out during the Civil War! We've made a lot of progress since 1986.

Green: But it's still not easy. I recently spent hours going through existing nursing home environmental guidelines in the 2006 edition of the book produced by the HGRC and writing up proposed changes for the 2010 edition just to get them considered by the committee during this revision cycle. SAGE should be getting involved in proposing revisions for the next four-year guidelines revision cycle, which begins in 2011.

Calkins: Getting back to the project designs, I was impressed with how much bigger and better the bedroom designs were generally this year. I was not impressed with the bathroom designs in virtually any of the projects we saw.

Bonn: I did see sliding-type barn doors used more in bathrooms, and that is a trend I support. A barn door is a surface-mounted sliding door and is preferred over a pocket door because it typically has larger hardware and is much easier to maneuver. They are also easier to maintain, easier to install grab bars near, and do not require a pocket that may be uncleanable. Finally, they don't require the floor maneuvering space that a swinging door would.

Calkins: Another positive I saw this year was an apparently growing recognition that we need to be designing shared rooms less and less and private rooms more often.

Gregory: After three years of intense debate, we in Florida are seeing fewer shared rooms planned for hospitals because of a general acknowledgment that single rooms are better for patient safety. That consensus is apparently starting to grow in long-term care, too.

Wilson: Speaking of safety, I saw a lot of mentions in these projects of high-tech wanderguard-type devices, automatic lock-down arrangements and other technologies for resident safety. What does everyone think of these?

Calkins: I remember one project noting that residents didn't have to wear tags because they had designed a secure perimeter using remote monitoring. I think most organizations could function comfortably with a secure perimeter of this type.

Pace: There's always the concern, though, especially in colder climates, that residents could get out of the facility and end up freezing.

Bonn: Elopement is definitely a serious problem. In Utah we have people wandering off and freezing to death, sunburning to death, or getting run over by trains every year—maybe one or two elopement deaths a year, compared to zero deaths from fire over the past 21 years. It's a very serious issue.

Green: The key to addressing elopement risk is to be able to focus on the individual and to develop a care plan for that person to enhance his or her safety without affecting the quality of life for everyone else.

Calkins: That individualized approach you describe can work if you have the staff that Evergreen Retirement Community has, but if you have 70% turnover, then to maintain continuing responsibility for residents’ safety, you probably need something else.

Green: But if you don't have the right facility design, it isn't going to work no matter what your staffing situation. The physical environment does determine behavior—indeed, it's a major factor.

Calkins: In my experience, some facilities don't have sufficient security options, so they end up obstructing the movement of individuals in general. For example, they have doors that are locked so that no one can come and go. I think that, with today's technology, there's no reason to design a system like that.

Another positive trend I saw was the design of more and more courtyards which do give residents more of an option to move about.

Pace: Interestingly, among public spaces, I only saw one project offering a “main street” concept. “Small Town USA” may or may not appeal to residents—in fact, it might be demeaning and have no real relevance to life as they know it.

Carpenter: One project did have a mall concept, but it didn't look like Small Town USA. It was used more as an organizing principle for resident access to services. As such, it worked quite well.

Weisman: I remember an award winner last year who did the mall concept in a rather elegant way.

McLaughlin: Yes, it was designed to attract both residents and people from the surrounding community.

Weisman: We also saw many more household schemes this year—indeed, enough variations on the household to satisfy a full-time student of them. That is quite a change from years’ past. D

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Perhaps it's a sign of a market in full bloom, but the panelists judging this year's DESIGN showcase seemed to focus more than usual on the new trends and innovations they saw emerging with the 37 projects they accepted for DESIGN 08 review. Whether it was sustainable—or “green”—design, an opening up of facilities and landscaping to a new sense of freedom for residents, or a growing push to reform state regulations, the panelists offered several observations. What follows are excerpts from their discussion.

Members of the DESIGN 08 review panel. Top row, left to right: Jack L. Bowersox, Manager, Life Wellness Communities Development Company, LLC; John E. Pace, AIA, Pace Hart Design, Architects; Margaret Calkins, PhD, President, IDEAS Inc., and Board Chair, IDEAS Institute; David A. Green, Executive in Residence, Center for Community Partnerships, University of Wisconsin–Oshkosh; Second row, left to right: William J. Bonn III, AIA, Utah Department of Health; Charlie Wilson, Vice President of Operations, Buckner Retirement Services; Russell R. McLaughlin, AIA, Architect, AG Architecture; Michael J. Steinhauer, OTR, MPH, FAOTA, Principal, The Steinhauer Group, LLC; Third row, left to right: Addie M. Johnson, Organizational Change Agent, Jewish Home & Care Center–Milwaukee, PhD in Architecture Student, University of Wisconsin–Milwaukee; Amy T. Carpenter, AIA LEED®, Associate, Wallace Roberts and Todd, LLC; Jerry Weisman, PhD, Professor of Architecture, Director, Institute on Aging and Environment, University of Wisconsin–Milwaukee; Kaye Brown, PhD, Adjunct Associate Professor, Biological Anthropology & Anatomy, Duke University; Fourth row, left to right: Susan Torgrude, MS, Environmental Researcher/Planner, Boelter Design Group, Inc.; Skip Gregory, NCARB, Bureau Chief, Office of Plans and Construction, Agency for Health Care Administration.

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