Salvatore Associates – Yale-New Haven Hospital Adult Emergency

SALVATORE ASSOCIATES
meticulously detailed
flawlessly implemented
thoughtfully envisioned
SALVATORE ASSOCIATES
Consulting
Architecture
Planning
Design
Development
Project Management
103 High Rock St.
Needham, MA 02492
salvatoreassociates.com
TEAM MEMBERS
For the YNHH Project
Alberto Salvatore
Visda Saeyan
Jansen Chang
Georges Clermont
Jill Hodson
Reynaldo Anaya
Chris Taurasi
Kaila McClead
Consultants
Civil Engineering: Tighe & Bond
Mechanical Engineering: WSP Flack + Kurtz
Construction Management: Turner Construction
Structural Engineering: Spiegel Zamenik & Shah Inc.
Landscape Architecture: The Landworks Collaborative
Interior Design: Cama Inc.
Specifications: David Lund
Hardware: Jennifer Casedy
Photographer: Rick Scanlan
Firm Overview
Salvatore Associates is a
progressive architectural firm
built on a strong foundation of
honesty, integrity and trust.
Our success is based
on bringing a “systems
thinking” approach
to an industry that
traditionally takes a
segmented, linear approach to implementing projects.
A commitment to talent and people ensures inspired, coordinated
and experienced teams of dedicated professionals proactively
addressing the unique needs of each project.
A commitment to balance, strength and flexibility ensures a
nimble process and collaboration to create elegantly simple
solutions for problems ranging from the everyday to the complex.
A commitment to aggressive project management ensures
exemplary solutions within estimated budget parameters and
projected timelines.
A commitment to an Interdisciplinary Design Team
approach ensures clients receive realistic and implementable
ideas, while always striving for the attainable ideal solutions.
What Sets Salvatore Associates Apart
Salvatore Associates is an innovative architectural firm focused
on providing clients the greatest return on investments associated
with their projects. Three essential concepts set Salvatore
Associates apart from others in our field.
• Interdisciplinary Design Team (IDT) Approach
• Evidence-Based Design (EBD)
• Environment of Care (EOC)
The Interdisciplinary Design Team
A team of committed stakeholders and professionals work
together to define the project’s goals and objectives and how
the team will measure success.
Evidence-Based Design process.
Research supports that the physical environment can contribute
to positive health outcomes. Our projects are approached
maximizing the use of this evidence and creating new evidence
that can support future projects.
Environment of Care
Beyond just the physical environment, state-of-the-art
successful projects create a total EOC that is defined by six
components: Concepts, People, Systems, Layout/Operations,
Physical Environment and Implementation. These six
components of the project, considered simultaneously, will
allow for the most effective, efficient design to be developed.
Project Overview & Process
PROJECT
Yale-New Haven Hospital
General Information
YNHH is a nonprofit, 1,008-bed tertiary medical center receiving
national and international referrals. Yale-New Haven Hospital
includes Smilow Cancer Hospital at Yale-New Haven, Yale-New
Haven Children’s Hospital and Yale-New Haven Psychiatric Hospital.
Adult Emergency Services
Adult Emergency Services at Yale-New Haven Hospital are
comprehensive and multidisciplinary. They are staffed to treat
the needs of adults with acute and urgent illnesses and injuries.
Yale-New Haven is a designated Level 1 adult trauma facility,
the first and only hospital in Connecticut to earn this status.
before
Project Objectives
The goal of the project is to create a total Environment of Care
that will reinforce the organizations’ brand and identity to the
community and to transform the existing condition into spaces
that welcome, support and nurture patients. The design should
be programmed to improve throughput while allowing the staff
to provide the greatest quality of care in an effective, efficient
and respectful manner.
Partial existing city map with project site highlighted
Proposed project site plan
after
Process
Interactive simultaneous process vs. traditional linear, independent activities
PROJECT ORGANIZATION & PROCESS DIAGRAM
CRITERIA FOR
EVALUATION
DECISION REVIEW &
APPROVAL COMMITTEE
GUIDING PRINCIPLES &
DESIGN GUIDELINES
PROJECT OVERVIEW
GROUP
WORK GROUPS
CONCEPTS
INTERDISCIPLINARY
DESIGN TEAM
PEOPLE
DEVELOP OPTIONS
SYSTEMS
LAYOUT
OPERATIONS
CRITERIA FOR EVALUATION
PHYSICAL
ENVIRONMENTS
IMPLEMENTATION
IMPLEMENTATION
Overview
• Interdisciplinary work groups focus on each
component of the Environment of Care.
• If the criteria are met, the option can
proceed to implementation.
• The outcome from the work groups is used by
the IDT to create the approved criteria for
evaluation of the project.
• Options that fail to meet the criteria
will be modified or discarded, necessitating
the IDT’s creation of additional options.
• These criteria will be the measurement of
success of the options created by the IDT.
• Should the criteria prove to be unachievable
within the project’s guidelines, new criteria
will have to be established and approved
prior to further option development.
The Interdisciplinary Design Team approach to project delivery
engages all of the participants
All stakeholders will be involved in development of the vision and
implementation of the project from the inception of the process.
This powerful approach allows for clear definition of the “real problem” that should be addressed by the project and ensures that the
consequences (economic, social, environmental, scheduling and
others) associated with decisions that are made along the way are
identified by involved stakeholders, allowing informed decisons to
be made in a timely fashion.
This approach is consistent with the ideal implementation of
the Evidence-Based Design process
The client’s goals are identified relative to how evidence will be
used or created throughout the design process. This understanding is used as a basis for a business case to develop realistic
budgets, considering both first costs and potential return on
investment associated with the proposed evidence-based design
interventions. This process is also instrumental in going beyond
the traditional development of a new building or addition and
renovation project, which is only concerned with the physical
environment, to create a total Environment of Care.
The concurrent integration of these components throughout
the process is transformational
Understanding the relationship between the EOC components, so
that each component continuously impacts the others, results in
much greater efficiencies in the design and construction process
as well as the overall functional operation.
Innovations
Graphic Programming vs. Traditional Programming
If functional programming is undertaken as a mathematical
exercise alone, it usually results in space allocations that may
not support the actual functions that are envisioned to be
supported in that space. Our graphic programming process
produced diagrams that identified the physical requirements
and relationships for typical and specialized spaces. Graphic
programming allowed a true understanding of the functions
that can be accommodated in the available space.
For Example:
The Health Insurance Portability and Accountability Act of 1996
(“HIPAA”) always receives a great deal of attention. The functional
program must therefore include spaces that allow for patient
privacy. Space must be envisioned in the project that is visually
and physically separated from the general population to allow for
confidential conversations. This space was diagrammed in the
programming process, and this resulted in the confidential,
physically separated, private, visually screened area, as seen in
the adjacent photograph.
Since the functional program directly impacts the project’s
planning, design, construction cost and ultimate outcome, it is
imperative that this document be as accurate as possible to
increase the likelihood of an improved outcome.
Innovations
Art-Enhanced Wayfinding
Emerging evidence suggests that creating memorable moments
in the physical environment will help you recall how to get to
where you need to be and back again. The impact may be even
more significant if the art portrays natural settings with
landscapes of regional significance.
Innovations
Visual Triage/Registration Based on the Emergency
Severity Index
The physical environment was designed to support the proposed
functional operation. Three triage/registration stations were
incorporated, based on the projected volume, to visually assess
all who present. Critical patients and patients of lesser acuity are
escorted directly to the appropriate areas. If there is a question
about the acuity level of a patient, he or she is taken to the triage
room behind the triage desks for examination to determine which
area and level of medical attention is appropriate.
Innovations
Open Clinical Core
The Open Clinical Core concept in the treatment areas is designed
to enhance staff communications and patient visualization
and safety.
By simply observing the activity levels in any particular area of the
unit, the care teams can see and know where additional staffing
or attention may be required.
The care teams have the space, centrally located, to share and
obtain the required information to bring the appropriate level of
care to all the patients in the unit. Additional patient supplies
and medication are also centrally located to efficiently support
the care teams’ work.
Glass-walled consult areas in the center of the units allow for
private consults between medical professionals without
compromising the visual openness of the unit.
Innovations
Chair-Centric Care Delivery Option
The chair-centric clinical care delivery model for appropriate
patients allows for increased volume while reducing space
requirements. Preliminary findings indicate this approach reduces
patient stress and medication levels while increasing patient
satisfaction and throughput.
Should a stretcher be required, that option is available in the
same general environment.
The design of this area also maximized visual access to nature,
with the availability of natural light and views through the large
windows above the headwalls. Advance planning allowed the
medical gasses and other support services access to be kept low
enough to manage both the direct clinical functions and the
additional benefits of stress reduction for patients and staff,
orientation, positive distraction and increased patient
satisfaction that come with access to nature.
Innovations
(conceptual diagram sketch)
Summary — The Ideal Solution
As this project included new construction and renovation of
existing spaces, traditionally one would approach this project
by building the new space as an independent project and then
move the functions that will be renovated into that space prior
to beginning renovations.
That approach might allow for a more efficient implementation,
but it would force an inefficient overall solution. It is ultimately
short-sighted, in that there will be initial savings in logistics but
the inefficiencies of the implemented layout and project as a
whole would be there for the next 20 years — and so would the
additional costs to staffing and overall functional operation.
Our approach ensures that the programming and planning outcome is the most efficient and effective possible. The available
space for new construction and renovation were combined and
envisioned as one large blank slate. Only the existing conditions
that could not be disturbed were considered to be constants.
Many layout options were considered and held up against the
pre-established criteria for evaluation until the most efficient and
effective outcome was selected. The resulting outcome exhibits
clear circulation and flexibility of use relative to volume and
staffing, with the functional operation coordinated and
supported by the layout.
Enviornment of Care
Address All The Components of the EOC at the Same Time
The Family Support Area is infused with natural light, natural
materials/color and nature in the form of plants designed into the
casework to enhance the patient experience.
Curvilinear forms and a regionally specific art program provide
positive distractions, wayfinding clues and a strong sense of
place. Various seating arrangements allow for different groupings
of patients, visitors and family to find a comforting space.
All the seating clusters and related seating areas have USB and
power outlets to support the users’ needs.
Patients’ safety, security, and privacy are incorporated into the
design of the whole project. This has been coordinated with the
envisioned functional operation of the space.
As one enters this environment and approaches the triage/
registration desks, the first person encountered is a nurse.
Security personnel are located adjacent to the registration offices,
with a direct view of everyone entering the space through the
glass vestibule just inside the exterior glass curtain wall system,
so they can quickly identify any potential threat prior to their
access to the space, which is reassuring to staff and patients alike.
Safety is especially important in urban healthcare settings.
There is always a fine line between providing the patients,
families and staff with a safe, private and confidential
environment and creating one that is welcoming, comforting
and supportive.
Evidence
How Will Evidence Be Used?
At the initiation of the project, the IDT agreed that wherever
generalizable evidence could be used to enhance the likelihood of
an improved outcome, it would be incorporated into the design
via the associated design intervention. The team also agreed that
a research project, creating an opportunity to collect evidence,
would be incorporated into the proposed project. The chair-centric
care delivery approach was one of the design interventions that is
planned to be studied to hopefully substantiate its potential for
increased volume while reducing the required square footage.
The design for the Environment of Care included working
with staff to develop the future functional operation of the
environment and the casework to identify the care centers from
which care would be delivered. These casework pieces were
meticulously detailed to support the functions, technology and
interactions that were envisioned to occur there. Materials were
selected to ensure ease of maintenance, durability, warmth,
elegance and grace.
Visual Chaos and Clutter Are Known to Increase Stress in
Patients and Staff
Horizontal datum were established and carried throughout the
care zones to organize the visual environment. Supplies for
attending to patients are stored in similar locations within the
standardized exam room layouts to allow staff to focus on
the patients.
Evidence
Gathering Evidence
The Evidence-Based Intervention in this area considered the
hypothesis that one could increase throughput, increase
patient satisfaction and provide the highest quality of care while
reducing square footage associated with exam rooms. This would
be implemented through the use of chairs that could recline if
necessary, which did not require the same space clearances that a
stretcher would. Data will be gathered over the next year that
will allow us to determine if this hypothesis will be supported
or questioned.
Design
Design Supports the Guiding Principles
Reinforcing the organization’s brand and identity to the community
was one of the guiding principles for the design.
This design took a dark and foreboding entrance to the existing
Emergency Department and added natural light, natural materials,
a feeling of openness, and visual access to nature and their
surroundings for patients, visitors and staff.
The glass canopy structure stands tall, proud and strong, like a
sentry, creating a sense of comfort and security. As dusk turns to
night, the new Adult Emergency Environment of Care becomes
a beacon of light that assures the community that, should the
need arise, they will be comforted and provided with the
highest quality of care.
Design
Enhanced Ambulance Access and Entry
The new ambulance entry allows direct access from Howard
Avenue to the new ambulance discharge areas. This area is
located under cover with appropriate lighting and localized heat
for the most effective, efficient transfer of patients to the facility.
The glass exterior curtain wall enables visualization for both the
emergency medical technicians/paramedics who are stabilizing
and transporting the patients and medical staff waiting to
receive them.
The overall site access is designed to create a physical and visual
separation between the ambulatory drop-off area, where valets
will park vehicles for all who present there, and the ambulance
transfer area, where immediate access to the facility is required.
Design
Chest Pain Observation and Testing
This specific zone within the emergency Environment of Care
is specifically designed for observation. Patients presenting with
chest pain will be triaged directly to this area, where they will be
tested and observed for various heart issues. This zone is
designed with a centralized care center to allow visualization of
each of the six observation areas. A treadmill and nuclear camera
are located within this zone to allow testing without leaving
this area.
Transformation
THE
Project
Yale-New Haven Hospital