Design Issues for Acute Healthcare - October 2013

By Ruth Simon McRae


Huge changes are ongoing in the world of healthcare. The Affordable Care Act, with its focus on wellness, accountability and broader access to care, is encouraging the movement from institutions to communities and homes. And, as is widely reported, we are seeing a growing army of seniors moving into the healthcare marketplace.

From an interiors perspective, healthcare trends are evolving more slowly. Many different, possibly conflicting, factors influence each decision. The specifier must balance a broad range of requirements and hone in on the most important in any given situation. 

Performance, maintenance, budget and sustainability are all key drivers in healthcare flooring decisions. These requirements create the context for creative design work and color choice that bring the interior together and create a welcoming, healthy and functional healthcare facility. The deep understanding generated by both knowledge and the discovery process, in conjunction with their clients, allows designers to make the optimum decision for flooring selection. And this selection covers a broad range of products.

The past few years have seen an explosion of category mergers, with carpet manufacturers expanding into resilient materials, and the reverse. Companies understand that in order to meet the needs of healthcare and other end-uses, a multi-pronged approach is needed. Each area in a healthcare setting requires a unique approach. 

Performance remains the absolute basis for flooring selection. 

In this arena where design is always informed first by function, how and why do designers make choices for flooring? How does it fit within their overall design and planning process? And what types of products create the optimum solution for specific areas?

Aneetha McLellan, director of interior architecture at HDR Architecture, identifies a particularly effective process. Always starting with the big picture, her team begins by identifying an overall theme that aligns with the core values and vision of their client. The team proceeds to work on a high level visual concept that illustrates the theme. The next step is to translate the concept into three-dimensional space; the design becomes a study in form, shape and scale.

Material and texture research follows, exploring product options that will express the concept within the space. This is where function and aesthetics start coming together, and the specification begins.

Flooring is not the first material specified, but it is one of the most important. McLellan specifies a variety of flooring materials for acute healthcare environments and has a high opinion of carpet. 

“Carpet is a textile, with character and texture. In an environment such as healthcare, where infection control is so important, we often lose texture in the environment. There is something about being in a soft surface environment, the sound, feel, warmth, which is different from a hard surface environment.”

McLellan typically leads with carpet for corridors for its acoustical and texture perspective—that is, unless it is a situation where there are extremely immune-compromised patients, such as an ICU.

She prefers hard surface for patient rooms in an acute care facility, with seams or without seams, depending on what type of care is being provided in the room. For procedural environments (such as operating rooms) material selection is strictly about function and infection protection, so the flooring must be seamless. 

McLellan also specifies a range of resilient products, and prefers the natural visual of LVT tile and plank. “In most of North America, people assume warmth is wood. It’s a basic response. Wood is actually a texture that helps create warmth.”

As with all of the designers we interviewed, Jean Hanson, sustainable interiors manager and senior professional associate at HDR Architecture, always takes her cues from the client. “In general, in a nursing wing you really need to understand the client’s point of view and rely on the client’s experience. You need to find out what they know to be true concerning durability, cleaning, infection control, budget, indoor air quality and maintenance.”

From a design approach, Hanson prefers simplicity of design with a limited number of flooring products within one project. “I don’t like to see floor change too frequently, in order for environmental services people to be able to be successful. Consider a bigger, broader brushstroke, although change of flooring may be appropriate on a departmental scale.” In practice, she may vary color and pattern throughout a facility, but not the material. Another practical reason to limit the number of SKUs is the logistics of keeping back stock for repairs.

One place that flooring variety makes sense is in hospitality areas. Hanson sees the restaurant and café area as an opportunity to make a design statement. “It can set the stage to transport people into a different zone and take a break from the situation in the hospital.”

Sustainability is the bedrock of HDR’s practice and culture. Hanson has been deeply involved in the development of the health product declaration, a standard reporting format where manufacturers can provide information and demonstrate transparency about the content of their products and their environmental and health impacts.

It takes a team to build a hospital. Lynn Befu, principal at Stantec Architecture, sees a positive impact from integrated product delivery (IPD) on successful flooring selection. “One value IPD brings to the table for interior design is the ability to work hand-in-hand with flooring subs to better understand installation practices and where additional, unintended costs are incurred. Obviously this works best in a collaborative environment, allowing everyone—including the owner—to work to the best affordable solution in a transparent environment. It’s one thing when a designer describes intent, but when that is backed up from the owner’s perspective, the design takes on new meaning for the installer. And visa versa, to have working sessions with the installer that allow both the designer and the owner to understand what design decisions incur what costs…it’s important for an owner to understand the impact of their approvals.”

Befu has seen trends in healthcare evolve over time from an emphasis on hospitality, to sustainability, to the current emphasis on infection control. In addition to these important aspects, she anticipates the next emphasis will revolve around issues of cost.

“I think we are all aware of how the cost of healthcare is impacting both our national economy and our personal wallets, and as designers we are focused on helping our clients reduce costs both in the initial capital costs and in the long-term life of the facility. Yet, as much as it costs to build a hospital, the initial cost of flooring is really minor when compared to the costs of hospital-acquired infections and work-related injuries,” two areas where flooring specifications can have a significant impact. 

On the aesthetic side, selection of flooring is a key aspect of the palette development. “An interesting aspect about flooring, even resilient flooring, is that it can help to weave in variation and bridge the gap with more restrictive materials, such as wall protection and plastic laminates that have more limited colors and textures.”

Breadth of color line is an important criterion for flooring selection. One project, Mission Bay, included three separate facilities: a cancer hospital, women’s hospital and children’s hospital. The designers were looking for an appropriate design solution for each with a minimum number of product types. The design team selected a rubber flooring with a 40-color palette; 29 were included in the design scheme. Naturally, three basic colors made up 90% of the job, yet it was the broad color range that made the interior successful.

Almost every project Befu has done in the last several years has used resilient sheet goods, primarily rubber. This is due to both its performance characteristics, such as durability and resilience, and its sustainability. Using sheet goods also creates a system where integral cove base can be used. She sees a move to avoid flooring with any non-sealed seams, especially in clinical areas. 

Befu is seeing fewer projects with carpet on the floor in hospitals, although carpet may be used in general medical office buildings (MOBs). Academic MOBs tend to have hard surface flooring due to budget restrictions.

Ashleigh Pfluger, partner at TJNG Partners, used a variety of materials to develop the interior of Castle Rock Adventist Hospital in Castle Rock, Colorado. Designed to complement the architecture and location, warm indigenous materials were selected in order to express the building’s “contemporary Colorado meets modern mountain” character. HuntonBrady Architects was the architect for this project. 

Looking out over the Rocky Mountains, the hospital interior design is clearly informed by its setting. Imagery of a topographical map of Colorado with curves of the Colorado River wind through the floor of lobby. Materials include terrazzo with insets of carpet. Commissioned art in the lobby, a sculpture evocative of abstracted aspen trees, supports the visual language. The flooring flows into the sit-down restaurant, Manna, where it meets up with porcelain tiles. (Continuing the local context and non-institutional feel of Castle Rock, the Manna restaurant has a home-like atmosphere, with a sustainable menu of locally sourced foods.)

Pfluger approached the project by exploring the choice and experiences of other facilities within the Adventist family in the area. Visiting other hospitals in the system, the team worked closely with the environmental services group to develop an understanding of its maintenance protocol.

One key influence was the environmental services’ requirement to use green cleaning products, products that were not caustic yet did the job regarding infection control. They wanted flooring that was easy to maintain and did not require stripping. They also preferred spray buff to polish.

Sheet rubber flooring was specified for the operating room, due to its “softer stand,” using the heavy duty 3 mm in the main area and thinner 2 mm in support areas. Pfluger comments, “Rubber is so comfortable underfoot that in some cases clients have removed the mat in the OR.” She finds rubber to be an easy material to maintain. Rubber flooring was also specified for the PACU (recovery, pre and post op) spaces, due to the constant flow of staff, family members and rolling traffic in those areas.

LVT was used throughout the general patient rooms and corridors. With a Gold Rush/Colorado concept, the design team selected a combination of wood looks—two tones of copper and a dark iron ore color for the floor in these areas, with coordinating sheet vinyl used for the ICU and Women’s Center.

Also inspired by the Colorado context, the LDRP (labor, delivery, recovery, post-partum) areas were designed to have a “jewel box with jewelry” look, using imagery of precious metals and elements. All finishes were intended to have sheen, sparkle and reflectivity. Examples include countertops of quartz composite and crystal chandelier-type fixtures. In this case, the aesthetics of rubber didn’t fit with the design concept. Pfluger found the perfect fit of form and function in an Armstrong sheet vinyl with a metallic print from the Rejuvenations Collection.

Two diverse trends in healthcare design play well with the use of ceramic tile. Facilities are striving to create less institutional, more home-like environments. “Bright, sterile and cold is out of favor,” comments Lori Kirk-Rolley, senior marketing director for Daltile. In areas where ceramic tile is the material of choice, this may be achieved with rustic stone or wood looks. A second direction is the spa aesthetic, with a monochromatic look and clean, simple surfaces, which naturally speaks to concrete or textile visuals as well as traditional porcelain tiles.

Each of the flooring materials discussed has its place in the acute healthcare environment. The good news is that there is a huge—and growing—variety of materials available. From a visual perspective, edges are becoming blurred between categories, and there are several options that give the same effect. Ceramic and LVT can emulate wood, stone, concrete and even textiles. Wood can be finished to resemble other species, to look old or new. Vinyl can be woven to resemble metal screen. And carpet tile is available in new sizes and geometric shapes. Together, these are the tools with which t

Copyright 2013 Floor Focus