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Physical Therapy Design

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I recently had the good fortune of visiting my family in Australia and attending my cousin’s wedding. However, amidst the celebration and the joy of seeing my relatives, a shadow of sadness hovered over me as I came to understand the drastic changes my grandmother has undergone since I last saw her ten years ago. At 81, gone are her impeccable posture and brisk, firm footsteps. Her back hunches over noticeably and every step is made with cautious effort. But what was most noticeable was the affect of Alzheimer’s taking over her mind.

My grandmother and I would joke and laugh as we searched all over the house looking for her glasses for the third time, her sweater for the fourth time, her slippers for the fifth time. The biggest laugh was when we went hunting for her top dentures! But hidden beneath her laughter I know there is a sense of frustration, loss of dignity, and fear. Laughter is just the best way she knows how to cope with it.

As I bid farewell to my grandmother and returned to work, what Gregg used to always repeat to us kept resonating in my head: “Don’t design a corridor that leads to a dead end. It will bring isolation and fear.” “Bring in natural light. It will help lift grandma’s mood and help her sense the passing of time and seasons.” “Of course you put a private shower in every room! Where is the dignity in being wheeled down the hall in your night gown?”

During my short stay in Australia, my uncles showed me the unwavering dedication, incredible patience, sensitivity and kindness it takes to care for my grandmother. All of this effort comes purely out of love and the hope to keep her smiling. And, as a popular animated Disney character says, because “Ohana means family. Family means nobody gets left behind. Or forgotten.” Gregg’s catch phrase “Design like you are designing for your grandmother” suddenly took on a deeper meaning.

In this season of giving thanks, I would like to extend a special gratitude to all my relatives in Australia who have done everything and more for my grandmother where I couldn’t. In a trying year for our office; (we have lost a grandfather, a mother, a brother, a sister and a friend), a big “Thank You” to all the healthcare professionals that have made the lives of our loved ones that much better. Looking around me, I see the same dedication and heart in the healthcare facilities we do work at. Every day, all across the spectrum from owners to nurses to staff, these people are working hard to restore the residents’ abilities, retain their dignity and relevance, and instill courage and happiness in our elders.

 As architects, our tools to make a difference are design and architecture, and my first design proposition is built-in denture holders with UV light at every resident night table for safe keeping of their pearly whites… just kidding! But regardless of our different job descriptions and tools of change, I firmly believe our mission within this industry is the same; to make their lives better.

May the grandmas and grandpas of the world smile on!

Learn more about “Design like You are Designing for Your Grandmother” at Gregg Maedo + Associates, Inc. - Gregg Maedo + Associates, Inc. - Healthcare Architecture and Planning.

At Disneyland, magic is found in the smallest of details. Recently, we had the opportunity to collaborate with Walt Disney Imagineering (WDI) to design safety railings for staff and guests at one of their Disneyland rides, Gadget Go-Coaster. The concept of a safety rail seems like a somewhat utilitarian, simple, and straightforward project. As we quickly found out, however, it came with its own interesting set of challenges.

When I first opened the email from WDI and saw the intent for the first time, my immediate thought was – how is somebody going to build this? To describe the project, it is a rail that looks like a popsicle stick supported by a set of golf tees, which originally was to span the entire length of the landing where it was to be installed. Working through the design with WDI, we created a set of plans and were preparing to start construction.

Tight scheduling and complicated details highlights the need for a GOOD TEAM 

About two weeks before construction was to start, we were informed that the railing would not be permitted on half of the landing because it was considered a “grabable” surface and fell within the ride safety envelope. We were then provided with a new challenge when we received an additional sketch depicting a “Tinker Toy” inspired wall for the other half of the guard rail. We soon found that in order to keep the proper scale and feel of the pieces, we would be further encroaching into the ride envelope, or into the required egress path.

In the process of finding resolution, we carefully drew and redrew the plans until we were able to find a solution that would comply with the safety requirements for the ride while still maintaining the required egress clearances. Along with these challenges, we also had to figure out how to anchor, support, and build the shapes WDI required in order to detail them properly on the plans. Due to the limited timeline for design and construction, we found that things were being built at the exact same time as we were receiving shop drawings and issuing comments. I have to admit, I was pretty nervous when I visited the site for the first time to see the progress!  

A happy ending

Finally, the rail was built and the project was completed successfully. Fortunately, WDI had put together a great team. Our coordination with the construction teamwent smoothly and the project team was happy with the results. When I complete projects, I like to think back on the process, and try to review the lessons that were learned in order to avoid repeating the same mistakes. This project taught me not to underestimate the small, seemingly unimportant details. I learned that even building elements considered utilitarian and mundane can greatly affect the experience of a facility. I am now starting to understand how attention to the smallest details can enhance the “magic” of our projects, and I will carry this thought with me throughout my current and future designs. 

Learn more about Gadget Go-Coaster Fall Protection: The Magic Is In The Details at Gregg Maedo + Associates, Inc. - Gregg Maedo + Associates, Inc. - Healthcare Architecture and Planning.

In April, I had the opportunity to attend the Healthy Aging Summit, hosted by Keiro Senior HealthCare at the Ethel Percy Andrus Gerontology Center at USC. The Summit presented the idea of “Healthy Aging”, a principle that I have thought about quite extensively throughout the many years I have worked in the field of nursing home design. If before, this concept was one of the many considered in the healthcare industry, it seems that “Healthy Aging” is gaining momentum. With the help of companies like Keiro Senior HealthCare, who truly are committed to the wellbeing of their residents, the “Healthy Aging” approach is beginning to resonate loudly throughout the senior care community.

What is “Healthy Aging”?

When we think about the process of aging, we often think of a growing frailty in our bodies, the slow advancement of illness, and the increasing need for medical monitoring and care. Our thoughts are primarily focused on the realm of treatment; after a problem has been identified is when we begin action to solve it. The concept of Healthy Aging can be briefly summed up as a function of prevention. After all, studies have shown that 70% of chronic illness is behavior driven. If we shift our way of thinking and implement beneficial lifestyle changes, even our genetic predispositions are able to be modified.

Healthy Aging and Building Design

What does this mean for architecture? How do we design and manage our buildings to encourage and exercise the many necessary elements of prevention? This is no simple task. Aside from adjusting dietary, activity, medical, and other facility-driven factors, we must consider the environment in which our seniors live. A new report from the Centers for Disease Control and Prevention recognizes three major factors that the patients’ environment must offer. First and most obvious is the concern for safety, specifically preventing falls. Falling often leads to a swift deterioration of both health and independence in seniors, which in turn is sometimes followed by depression and mental decline. This is perhaps the easiest factor to deal with by making the floors non-slip, eliminating awkward corners, spacial transitions, etc.

Improving Cognitive Function by stimulating the senses

The second factor of prevention expressed by the CDC is maintaining cognitive function and preventing its decline. To do this, we must provide an environment that stimulates the senses, evokes positive emotions, and helps relieve stress. This is a much more complex concept that may incorporate many different elements of design. Some ways of providing this stimulation are experimenting with natural light, colors and textures, water features, vegetation, and other experiential elements. However because we are designing for a healthcare environment, we must also be acutely aware of the effects these things might have from the perspective of the resident. To a visitor passing through, lights casting shadows on a wall through a screen may look pleasing. To an elderly patient with early onset Alzheimer’s, that same light may be confusing and disturbing. We must always work from this position of consideration for the resident, as it is their home we are designing.

Better Circulation Layout Encourages Physical Activity

The third factor the CDC recommends is the prevention and delay of disease or disability through the creation of an environment that encourages physical activity. Not only is this a huge aspect of health, but also arguably the most difficult to accomplish in an environment such as a nursing home, where most patients either need a lot of assistance, or are bedridden. In this case, I believe the best way to encourage physical activity is twofold: create places where people will want to go, and places where people will want to go through. The path that residents travel is just as important as the place they are going to. If the experience of getting somewhere is pleasant, it increases the chances of residents to actually start moving. This places a huge importance on corridors, walkways, and other paths of travel, not only in the sense of aesthetics, but also in intelligent planning of the building itself and the interrelationship of spaces to each other. A design method that strongly supports this concept is the incorporation of the outdoors with the indoors. For example, courtyards that are visible through glassed corridors provide that interconnection of space and visually urge residents to walk through them. Of course the destination spaces are also important, and the more dynamic the design of the space, the more interaction a resident can have with the room and the people in it. This naturally leads to both more physical activity and mental stimulation.

Ultimately, it is our responsibility as a society not only to take care of our elderly in sickness, but also to work hard to prevent that sickness from ever occurring. It is these and other ideas of “Healthy Aging” organizations such as Keiro Senior HealthCare are beginning to explore and implement. Keiro specifically takes this approach to heart. Founded in 1961, Keiro is the largest non-profit organization serving the Japanese-American community. With several facilities located throughout Los Angeles and its surrounding areas, Keiro implements what is known as “Genki”, or healthy and energetic, Living. Through their own Institute for Healthy Aging, Keiro has established this model of care throughout their facilities, and serves as a great example of what “Healthy Aging” means.

If you would like to learn more about Keiro Senior HealthCare or Healthy Aging, please visit: http://www.keiro.org/healthy-aging

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One of the biggest mistakes currently being made in the Nursing Home design is the new trend of following the Hospitality Model. It has become popular to abandon the Medical Model and take a literal turn toward designing a Skilled Nursing Facility like a hotel. It is understandable where the roots of this trend come from, as medical buildings have always carried the reputation of having a sterile, cold quality. Making a Nursing Home more like a hotel and mimicking the aesthetics does theoretically create a more inviting atmosphere.

Unfortunately, this approach is a mistake. Even though conceptually, a Nursing Home and a hotel may have similarities in terms of balance between public vs. private space, the hospitality design lacks the underlying medical support that composes the actual function of a Nursing Home. There have been several hospitality companies that have attempted to translate their expertise to nursing homes, and have consequently failed. They created a space that was beautiful, but ultimately dysfunctional.

Hospitality Model vs. Medical Model

The fundamentals of hospitality design are vastly different from those of Nursing Homes. In hotels or resorts, guests voluntarily come to rest and distract themselves from their travels or everyday lives. Most of these visitors tend to be mobile, relatively fit, and healthy. They do not require assistance and are there for a short time. A hotel is a place of entertainment, relaxation, and comfort. Guests leave their rooms for the day and return in the evening. The architectural design for this type of use is based heavily on aesthetics, to be more attractive than the competition. Since people come to hotels by choice, they have the option to choose between thousands of companies. Often, the design aesthetic becomes one of the driving forces hotels used to attract these customers.

The people who occupy nursing homes are typically not there by choice. They are sick, elderly, frail, and weak. They are by definition residents, not guests. The nursing home is in fact their actual home, as they rarely leave the premises, let alone even spend time outside. They need a strong foundation of medically trained staff to support their daily activities. Unlike visitors to hotels, they tend to stay for a longer period of time and have less options of leaving.

A major area that suffers in a Skilled Nursing Facility when it is designed to copy a hotel is the corridor. Guests, residents, staff, clean and dirty linens, medicine, food, and trash are funneled down the same linear path. These competing elements are then forced to co-exist together, all for the sake of a misguided design. In a well run Nursing Home, the corridor is the heart of the facility in terms of being the social center. Residents in wheelchairs travel from their bedrooms to public spaces, interacting with staff and each other. It is a welcome respite from being alone in their rooms, and they feel like a part of the community. In a hotel, a corridor is simply a means of getting from one place to another, and lingering or socializing there warrants suspicion.

The Best of Both Worlds

Our belief at Gregg Maedo + Associates is to design Nursing Homes by using the medical model as the fundamental foundation, and then breathing life into the design by incorporating the best elements pulled from hospitality, restaurant, and residential architecture. It is time for a new paradigm shift in Nursing Home design, as we move beyond the stereotypical medical model but do not seek to mimic that of hospitality. We also provide a unique perspective, pulling experience from the many things we learn by working with Disney. The “Happiest Place on Earth” has a lot to teach all of us about creating pleasant, inspiring environments. Ultimately for us at GM+A, the true measure of excellence is not the accolades that a design receives, but whether it stands the test of time. There is no easy formula to achieve this result, but a combination of experience, talent, knowledge, passion, and a vested interest in the care of our most respected citizens.

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We are often asked how we reconcile our Entertainment Projects, mainly Disneyland work, with our dedication to our core Healthcare Projects. Our answer is simple: we use what we learn and experience from these unique Disney projects and apply the concepts and design elements into our healthcare projects.

While putting myself through architecture school, I worked at various jobs at Disneyland. I noted what I experienced each day while working at the park to incorporate the concepts into my design projects in school. Now, many, many years later, things have not changed. Our office still uses what we learn at Disney and apply it to our Nursing Home Designs. The metaphoric imagery used, the subtle sensory language spoken, and the subliminal messages of happiness conveyed are all extracted from our Disney work and translated into our Healthcare Designs.

Joy in Nursing Home Design

The fundamental concepts that shape good Nursing Home Design and good Disneyland Design are different. The priority and focus of good Healthcare Design is linked to an underlying understanding of medical support based on efficient function and technical execution. This focus is fundamentally different from that of Entertainment Design, where happiness, joy and fun dominate the essence. That said, we often see how Nursing Home Design becomes so focused on the absolute necessities of existence, and as a result we overlook that there is a life involved and living needs to occur. Our aim is to not forget this lesson and use the concepts learned and developed at Disney to fill in and expand upon those critical voids in Healthcare Design.

Our Unique Position

After completing many projects at Disneyland, we feel we are in a highly enviable position in the Healthcare field, as we have the opportunity to learn from the thousands of hours of research, experimentation and knowledge that the Disney team spends to create the magic of this unique atmosphere. The underlying design spirit of Disneyland is the creation of happiness, joy and excitement. Many elements contribute to this endeavor and make Disney “the happiest place on earth”.

One of the most unorthodox but arguably most effective strategies the Disney team implements in the execution of their projects is full-scale building. They know that the only way to truly experience the space and its design is to actually build it, to full size, and then make any necessary changes to it as the project develops dynamically in the field. We recognize that not all clients will have the resources or time to work in this fashion, but we understand that this is the best way to design, and strive to embrace this type of thought process.

Ironically our Healthcare experience has helped us with our work at The Disneyland Resort, (DLR) because Healthcare requires us to be strong in our technical expertise. In order to properly execute the complexities of Healthcare projects, we must have innate technical knowledge, and this same knowledge strongly supports our Disney projects. The projects at DLR are also often times highly technical, requiring us to manage and understand complex systems, special effects, robotics, and cutting edge technology amongst other systems to properly coordinate a project. Ultimately, it is the work we do with their very talented design team, Walt Disney Imagineers, that provides the “magic” to the projects and the creation of the elements that we seek to transfer to our work.

As we reflect back to our unique experiences of working in the Healthcare and Disneyland fields simultaneously, it amazes us how two fields that seem so completely different and independent of each other can be so complimentary and mutually supportive. Disney serves the Healthcare field well as it provides many of the aspects that are so often missing in Healthcare.

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