With $99 billion expected to be spent on healthcare construction next year, according to Dodge data and analytics“2021 Dodge Construction Outlook,” those pursuing new hospitals will likely face a decision on what type of floor plan to use in inpatient units. Some may be looking for solutions to place care teams close to patients to enhance productivity and patient satisfaction, leading them to consider an open basic model that distributes care team work areas along corridors within patient wards. Inpatient design can support caregiver performance and well-being by increasing daylight, visibility, collaboration and reducing travel distances, while also improving the patient experience by making care teams more visible and accessible.
NBBJ He designed the first open-air hospital at Great River Medical Center in Iowa in the early 2000s. The 144-bed alternative hospital in West Burlington has developed an open master plan to create clusters of patient rooms with basic ICU support, step-down, and medical/surgical beds along a single corridor that enhances staffing flexibility and reduces the need to transfer patients when populations decline. . This approach has since been refined by several projects across the country, including the next generation NBBJ open-core design under construction. Here, ideas and lessons learned from these projects are shared to emphasize when open basic design is appropriate for the healthcare system.
What is an open kernel?
When it comes to designing the overall layout of a hospital, healthcare systems and designers have commonly used a “racetrack” design with patient rooms wrapped around the outside and backstage functions located in a central building. This decision was largely due to historical regulations from the National Fire Protection Agency that required windows in every inpatient room but not in staff support spaces. The open kernel is a fundamentally different solution. It meets window requirements but challenges the racetrack paradigm by relocating key support functions (breakrooms, staff lockers, meeting rooms, offices and all elevators) to a central hub that connects to multiple patient wards.
While most support areas are integrated into the center, some items that staff access frequently, such as medicines and medical supplies, are systematically deployed along the wings. The suites, specifically, are doubly loaded with patient rooms on either side of the central aisle. The standard 8-foot-wide inpatient corridor was increased to 16 feet to accommodate circulation on one side and a clinical area on the other; The clinical area houses the decentralized team workstations and supply/equipment rooms. Each caregiver workstation typically has two sitting positions and two walking positions that provide direct visual lines of sight to four patient rooms and increase clinicians’ view of patients and each other.
Advantages and Trade-offs
The open core concept offers distinct advantages over traditional racetrack designs in terms of staff performance, well-being and patient experience. For example, with nurse stations designed around enhanced lines of sight, the open core creates a high-performance environment that allows caregivers to see the entire ward at all times. This enhanced insight supports rapid team response during emergencies and enhances team collaboration during regular operations by making work areas and caregivers more accessible to each other.
Staff welfare, a critical factor in light of the increasing prevalence of caregiver fatigue and feelings of isolation, is an important focus of open core designs. The off-stage support areas, which are usually windowless spaces in racetrack designs, benefit from daylight and views by being on the perimeter of the building at the center of the support. Open base layouts also reduce nurses’ distance by placing patients and key supplies close to their work areas. Most importantly, the open center enables nurses to spend less time walking and more time providing direct care to patients.
Equally important, an open core can enhance the patient experience. Because care teams are more visible and located closer to rooms, patients in open core hospitals report greater confidence in their care and reassurance that caregivers are nearby.
However, the open core is not for every hospital. With these advantages come some trade-offs that hospitals need to consider. For example, although open base layouts are usually no larger than racetrack layouts, an open floorboard layout is inherently more elongated than a racetrack layout and typically requires 15 percent more external surface area than a racetrack layout. This increased outdoor surface allows more daylight opportunities for patient and staff areas, but also requires a greater investment in outdoor cladding.
Additionally, while open core projects can be accomplished using standard hierarchical layouts, the hierarchy is often transformed into a non-orthogonal grid to improve caregiver’s lines of sight. On a new construction project, the cost and return on investment (CROI) calculation for this shift varies from project to project based on building materials (such as steel versus concrete) and the types of software under the inpatient floor stack, but it can result in a more expensive structural system than a racetrack. In cases where a non-orthogonal network is used above and floors with orthogonal grids (such as operating rooms and emergency departments) are stacked below, a set of transmission packets must be combined to resolve the differences between the two network systems. Furthermore, the open core is usually not suitable for renovation projects where the network may be difficult to accommodate.
Over the past two decades, NBBJ’s approach to the design of open core hospitals has evolved by building on previous project experience and meeting the needs of specific clients. From this set of experiences come several key lessons and considerations that can be critical to the success of the model.
The Open Core introduces not only planning changes, but also important operational changes affecting the care team as well as substance management, pharmacy, diet, electronic medical records, and housekeeping. The success of the approach is linked to the effective alignment of each course of action. Using large-scale room models can help get detailed input from each department about design options for patient rooms and work areas and create business and purchasing ownership around the design direction. This can be especially useful for open core designs, where many elements may be unfamiliar to employees. For example, staff often expect that an open nucleus will not enable visualization of patients at the ICU level, but mockups can help illustrate line-of-sight performance.
With patient rooms located close to work areas, the open center also requires hospitals to review and resolve the issue of visual and audio privacy. Cabin curtains can be used for visual privacy but do little for acoustic privacy and can be a health concern unless they are constantly sanitized. Patient room doors work for acoustic privacy, but vision needs require that they be transparent or glassy. A layered approach can be an effective solution, such as using disposable compartment curtains and glass doors, doors with integrated blinds or electronic glass that can be turned opaque, to provide visual privacy.
Another major consideration in designing with an open core is the location and contents of the PPE cabinets and the amount of work in patient rooms, which will vary widely from institution to institution. The NBBJ trial has shown that having adjacent supply slots outside each patient room can reduce the accumulation and storage of supplies in and around patient rooms.
Depending on the orientation and design of the facility, the increased daylight that is a feature of the open core may require additional design measures as well. For example, matte floors may be required to reduce potential glare from additional daylight in patient wards. The use of daylight modeling during the design process can help identify these considerations.
What’s next for an open kernel?
The past 20 years of projects demonstrate the positive impact Open Core can have on employees, patients, and performance. Whether an Open Core is suitable for a particular hospital project depends largely on its location, needs, and goals—but planning has proven useful in a range of projects from community hospitals to academic medical centers to major Veterans Affairs facilities. As the healthcare landscape evolves and new projects are designed, we see the open core continuing to adapt to meet the challenges and opportunities that caregivers face.
Ryan Hallinger AIA, NCARB, is Partner and Head of Global Healthcare Practice at NBBJ (Columbus, Ohio). It can be accessed at [email protected].