(Editor’s note: Colby Cavanagh leads Healthcare & Sciences Studio at Maugel
DeStefano Architects. Her design expertise includes hospital renovations, ground-up
outpatient facilities, medical office suites, labs, R&D facilities, medical devices
manufacturing, and biomanufacturing facilities. In an exclusive interview with Boston
Real Estate Times, Ms. Cavanagh talks about what is the latest in healthcare facilities
design.)
BRET: How long you have been designing healthcare facilities?
CC: I started on my first day at Maugel DeStefano Architects working on healthcare,15 years ago, and fell in love with it. I began with a smaller local practice working with Acton Medical. We’re in Harvard, Mass., and they’re just one town over. We are now their go-to architect. We’ve grown with them over the years and have designed 3 of their satellite facilities and their main office.
BRET: 15 years is quite some time. What are some of the changes you have seen in the last 15 years when it comes to designing a hospital or a small practice or overall health care facilities?
CC: As expected, all the healthcare facilities are very patient-forward, but we also consider the staff experience as well. What I’ve seen change quite a bit is the need for more patient care space, larger patient care space, more exam rooms, more of everything, really. Equipment size is changing. While we tend to think that the size of everything is getting smaller, some equipment like MRIs and other hospital-based care are getting larger. While staff experience is just as important, I think the need for a traditional medical office suite where ‘you go to the exam room and you get examined, then you move to a doctor’s office and have a one-on-one in their personal office’ is decreasing. Everything is happening in that exam room instead.
The need to have individual offices for each doctor or each practitioner has diminished; it’s now more important to have flex and shared spaces and touch-down type spaces, which benefit not only the patients, so they’re not moved around as much, but it also benefits the staff because they’re not taking as many steps in a day. Thinking about efficiency and how
that flow works is a big change from the traditional model of how they used to practice.
BRET: We are also hearing a lot about “healing” healthcare facilities.
CC: Yes. A “healing” environment starts from the moment you walk in the door. Facilities are trending toward more of a hospitality style of healthcare experience. Think about your own experience of going into a new hospital to visit someone or for your own examination. Often, you’re anxious and not sure where you’re going, so when you walk into that environment, you want to feel comfortable and settled immediately. Good wayfinding with clear signage lets you know that you are in the right building and helps you navigate towards where you need to go. Otherwise, it can be quite overwhelming.
BRET: What are the dream healthcare facilities your clients are asking you to design?
CC: Their dream healthcare facilities are state-of-the-art everything. Technology is pushing so many things forward at such a rapid pace, that a lot of the time the current built environments of hospitals and smaller medical office buildings can’t keep up with the need for that technology. It’s the desire to have the latest and greatest equipment. The convenience of technology saves time and money for both the staff and the patients they care for, but having the infrastructure in place to successfully implement it is essential: large server rooms, mechanical and electrical closets, sufficient ceiling heights, and proper structural support—all of the back-of-house systems that people aren’t necessarily thinking about.
BRET: So, it is not only medical technology, but all technologies required for day-to-day operations, right?
CC: Exactly. Waiting rooms, for example, are certainly not as needed as they used to be. During COVID, you would pull up in your car to an urgent care center and dial in to the doctor’s office to say that you had arrived. There was not a lot of waiting room downtime. I think it’s swinging back and forth a little bit, because having somebody sitting at that front desk to help you when you first arrive isn’t always something that you would want to eliminate. There’s a balance between being efficient and staffing in the right way, while also keeping up with the current technology. Many people just want to check in with an app on their phone or communicate with their doctor via an app, while others are more comfortable with in-person communication.
BRET: Now, I assume that before COVID, these remote check-ins didn’t exist. But now every facility has that type of thing. Can you talk a bit about that?
CC: They did exist before COVID, but during COVID it was difficult to keep everybody distanced within existing facilities, and virtual visits took off. For many people, it makes more sense to be able to have a conversation like we’re having right now with their doctor. They don’t need to come into the office. They can send their lab results through a portal instead of driving to see the doctor. It saves time and effort. It’s similar to what we experienced in the corporate world, with virtual meetings now becoming the norm. There are certainly instances where people need to be in-person to be examined and that has to be accommodated. However, the struggle with facilities today goes back to their current built environment and where those private conversations can happen. Making sure there are rooms with the correct technology, cameras, and sound proofing so that you’re able to have a private HIPAA-compliant conversation with your doctor is a must.
BRET: Those of us who are familiar with real estate, we have been hearing about flexible office space and flex industrial buildings. Now, this term is also becoming quite common in healthcare facilities. What are flexible healthcare facilities?
CC: We started designing flexible medical facilities quite a while ago. Back then, the term was used, for example, when we had doctors who were on different schedules and could share exam spaces and offices or when we had a series of consultation rooms or small conference rooms that could be opened into training centers or larger meeting spaces. Now, the term is used to describe a multipurpose room that can be used for exams, consultations, procedures, etc., and is shared by doctors. They’re far more flexible, but the room must work for every practitioner. It’s important to consider all scenarios for which the room will be used. For example, adult primary care is different than pediatric care and determining what is needed in each scenario will make the exam room as flexible as possible.
BRET: I know that budget is a big issue in many hospitals, and we have seen that some hospitals in Massachusetts have gone through tough times. When it comes
to budget, how willing are these hospitals or healthcare organizations are to really make these improvements?
CC: They’re all very willing, if they can make their bottom-line work. That’s where my heart breaks for them. They are all trying to do their best for their staff and the patients they care for. But sometimes, the budget is just not available. There are times where we must come in and say, ‘Alright, well, this year, everybody needs something. Each department is asking for improvements, but which one is the most critical and where are we seeing the most problems?’ In emergency departments, they’re just overwhelmed, and they have behavioral health cases that do not turn over as quickly. Healthcare organizations are desperately trying to find solutions to stop the bleeding in the most critical areas first and still address as many needs as possible within the fiscal year.
BRET: In the context of the budget and the desire to improve the facility, how often do you or your clients struggle with whether they should stay and renovate their facility or just move to a brand new place? And what do you recommend, renovation or moving to a new facility, if they can afford it?
CC: It’s unique to every client. Obviously, working with the big healthcare networks, they’re not going to be moving their hospitals anytime soon. Often, their questions are, ‘Do we add an addition? Do we add an extra floor? Are we moving departments off-site to a new facility and in-filling and expanding within our existing facility?’ I see the last option chosen more often in the larger hospitals that use a new satellite medical office building as a “one-stop shop” for urgent care and patient services, women’s health, pediatrics, and primary care, taking demand off the hospital.
We’re working with Woburn Pediatrics, who’s a wonderful client, and they went through this struggle when we first started with them years ago. They loved their location, but their building didn’t feel big enough. They have a large practice and needed 40 new exam rooms. We looked at many buildings in search of a new facility. Some of them were outside of Woburn, which they didn’t love because “Woburn” is in their name and that’s where they are located. They ended up staying in their existing location because they couldn’t find a better alternative. We showed them how they could fit in their space and how we could create flexible spaces to get the number of exam rooms they wanted. It came down to budget for them as well.
We often create a master plan for our clients and workshop ideas to uncover their true goals. It’s not just about the built environment for healthcare organizations; it’s also about their community, how far someone must travel to get to their facility and staying true to their trusted reputation for quality of care. There are also challenges to staying in an existing location, because you’re trying to work or stay functional in a construction site. Phasing in these types of projects becomes key. You must ensure that they never go below a certain number of exam rooms, so they can serve their population. It’s even more critical when you’re working in an operating room or another critical part of the hospital that there is minimal disruption. You can’t have unexpected shutdowns at any time of day— everything’s critical.
BRET: Initially, there were talks about converting office buildings into multifamily, which seemed a little bit more challenging. Now, I am hearing about converting some of those office buildings into hospitals, or outpatient facilities. What is your take on that? What do you think of that idea?
CC: I think it’s a great idea. I certainly see the need for it, especially in the behavioral health sector. There’s a huge need and desire. We worked with Advocates, Inc., in Framingham, Mass., on a community-based behavioral health center and crisis stabilization unit. They’re helping that community immensely. The challenge of trying to transform any existing building into something it wasn’t originally built for is making sure there is enough ceiling height and the proper infrastructure to support the new use. Traditional office buildings don’t have the electrical and mechanical requirements that hospitals require. You’d lose much of your square footage just trying to get those systems in place. It can be done, but it’s certainly a challenge. It’s easier to take a medical facility and flip it into an office than it is to go the other way.
BRET: Is it possible, especially in Boston?
CC: Boston certainly has the infrastructure to bring the power and the sewer lines and all the non-pretty things that you don’t think about that come into the building. They have the infrastructure to be able to expand in that way.
BRET: I keep hearing about the staff experience and the patient experience. If you can just talk about how as an architect, you are able to help the healthcare facilities create a better experience for both?
CC: I think both are equally important. I think that’s where we want input from patients and staff. For instance, at Woburn Pediatrics, we started with a survey that went out to their staff and patients to understand how they felt about the current environment: what they liked, what they thought could be improved, and things they may not have considered. The feedback showed that they loved the care they were getting, but the exam rooms were too tight, too small and not as flexible as they would like. We gathered as much information from both sides and then really looked at a lean, efficient model of how everybody worked, traveled and interacted. It was as simple as ‘what’s the patient’s path throughout their time in the facility: from coming in the door, checking in, waiting, going to the exam room, coming back around, and checking out’, to ‘where is the staff coming through and how are they communicating’ and making sure there’s flow and efficiency on both sides. No one wants to run halfway across the office to restock their exam room during the day. We want to have everything at everybody’s fingertips as much as possible.
BRET: Earlier, you mentioned briefly about the signage and wayfinding to navigate through the facility. Please talk a bit more in detail about the color and the signage as well?
CC: That’s where we work in tandem with signage companies and with graphics and art. It shouldn’t be an afterthought where the signage company comes in after construction and starts to put graphics on the wall. I think that we’ve all experienced that feeling of walking into a large facility and asking directions, and someone replies, ‘take a left and another left and then a right, and then the elevator is around the corner to your left.’ Halfway down, you’re not sure if you went the correct way. So, we use wayfinding elements like color, patterns on the floor, and strategically placed graphics that designate what floor you’re on, what’s on that floor, and what wing you’re in. It’s very easy to get turned around, especially if you don’t have a view of the outside—which we always try to maintain at some point, particularly in circulation spaces. But color is an important element. For example, at a pediatric office, we used very calming blues and purples and green jewel tones throughout the exam rooms. But their checkout area is bright orange, and their waiting area is yellow so that it catches your attention and brings you back to where you started and to checkout.
BRET: And what about some of the other non-health-related facilities like the cafeteria, the bathrooms, or cafés? How does that play out?
CC: We’re designing more hospitality-style spaces that feel more like a hotel than a hospital. There’s more soft seating. There are times, especially in cancer centers with families waiting for a long period of time, or even in a pediatrics office, where having five standard-size chairs in a row doesn’t really help families whose kids want to sit on their laps. We create different levels of seating such as benching and high and low options, so it’s more comfortable. We also create smaller areas and nooks for more privacy. Breaking down larger environments and waiting rooms into smaller pods has been successful for our clients. Also, we are conscious of complying with all the HIPAA regulations during check-in to create a sense of comfort as soon as patients walk in. In the cafeteria, we’re doing more high barstool-type seating where people get a chance to sit and see the outside. Or places to sit and use a laptop while eating. There’s a mix of spaces and a mix of furniture, nooks, and banquette seating. Bathrooms are key. You need them everywhere. They should be well marked, in obvious locations, clean, and accessible to all.
BRET: If you can also talk about master planning of healthcare facilities.
CC: We do master planning with all different healthcare organizations, but hospitals are really where we do the most. An example is the work we did with Sturdy Memorial Hospital. New regulations came out for their inpatient pharmacy, and we needed to make it larger. They wanted to upgrade their central sterilization processing suite to gain another OR and improve their pre-operative and post-operative areas. Initially, they came to us with two separate issues. After an intensive information gathering exercise that included multiple departments, our findings showed that while these two departments needed to grow, the labor and delivery department had excess capacity. As a result, we undertook a multi-phase, seven-year project which relocated each department to a space better suited for their needs. It was extremely helpful to be able to move and expand the pharmacy to better serve the entire hospital, as well as expand their central sterilization, which was placed next to the OR, creating better flow and better disease and infectious control.
It’s essential to fully understand the big picture of the hospital’s ecosystem to be successful. You can’t just zone in on an immediate problem and try to solve that in isolation. We expand our view and always look at what we can do to make the whole facility better. Doing so, creates a positive domino effect and we’re able to help our clients bring the best possible experience to their patients, staff and visitors.
BRET: What about Net Zero and sustainability issues in the hospital setting, because these hospitals consume a lot of energy?
CC: It’s tough. It is a great goal, but so many hospitals have old steam plants or old infrastructure that need to be completely upgraded to get to net zero. We are helping facilities navigate that process, and we’re all navigating the new energy code in Mass., For facilities that haven’t been consistently upgrading their infrastructure, it’s going to be difficult. We’ve been hearing about the challenges from facility departments, in particular. I just attended a conference where they were speaking about this issue: sustainability goals are wonderful, but the cost implications to get there can be daunting and overwhelming. We’re all trying to navigate the best practice and determine the best way forward to meet those goals—and be on the leading edge of it.
BRET: What are the five things that are important in healthcare design and cannot be ignored?
CC: Wayfinding is very important, especially in larger facilities and smaller facilities with multi floors. It has such a big impact on the immediate comfort of a patient walking through the door.
Circulation and organization would be my number two. Efficiency lets the doctors, nurses, and staff do their job and care for their patients the best they can. So, designing a lean process is essential. We understand they are the experts in what they do on a day-to-day basis, and we design the built environment to give them the best experience patient-wise and staff-wise.
Number three would be implementing for the 50-year solution, not just the five-year solution. You never know what technologies are going to come along. We need to think about how we’re going to use this space now and how we want it to flex or change in the future. If you ever wanted to, for example, have a consultation room become an exam room in the future, then let’s put the plumbing behind the wall now. So, thinking about, and sometimes challenging, the wants and needs list of our clients to uncover their true goals is important.
Four, creating calming, comfortable, beautiful spaces for not only patients, but the staff as well. Staff retention is vital. There’s a huge need for more nurses, more staff, and more facilities. Each facility is now hiring and trying to bring in skilled staff. The ability to offer amenities and a beautiful space to work is just as important as retaining patients. It goes hand-in-hand with their experience.
Lastly, just keeping up with technology. Personally, I like to see a person when I walk through the door, but I also love being able to fill out forms on my phone and not have to sit with the pen, paper and clipboard in a waiting room. Finding a happy medium between the human experience and the virtual experience is going to be the challenge of the future for healthcare facilities.
