Misericordia ED will ‘care for body, mind and soul’

Jan Kroman, a Principal at Canada’s Rockliff Pierzchajlo Kroman (RPK) Architects, based in Edmonton, Alberta, discusses a project to create a new Emergency Department at the city’s Misericordia Community Hospital. He explains that development of ‘a philosophy of flow’ became a focal point ‘for a physical manifestation of a clinical plan that will likely see improved patient outcomes’.

Built in 1969, Misericordia Community Hospital is one of four major acute care hospitals currently serving Edmonton, as well as central and northern Alberta, and the Northwest Territories. Owned by Alberta Health Services (AHS), and operated by Covenant Health, the campus has been redeveloped and expanded to better suit community needs over its half century of operation. The hospital’s Emergency Department had outgrown its current space, facing overcrowding, substandard conditions, ever-increasing mechanical system challenges and, in some cases, infrastructure failures. In late 2017, a major capital project was initiated by Alberta Infrastructure, AHS, and Covenant Health to create a new Emergency Department adjacent and connected to the main hospital on the campus. More than a simple addition, this project challenged industry norms in several key ways.

Re-thinking procurement

The project’s innovation started from its inception, with the consultant team chosen via a qualification-based selection process. The methodology priorities the merits of each proponent, with fees not considered in the overall adjudication. This allows for key considerations, such as firm and individual consultant experience, team availability, and fit to drive procurement. Via this process, Rockliff Pierzchajlo Kroman (RPK) Architects was named prime consultant and lead design architect.

Upon preliminary selection, the consultant team had a limited window to further negotiate fees, scope, and the team composition (sub-consultants) with the client, Alberta Infrastructure. Due to abundant experience on both sides, the RAIC 6 contract, along with its schedule of services, became a framework around which potential scenarios were reviewed, with the document being amended to suit both parties. The process was effective in kick-starting a collaborative relationship between the consultant team and client, successfully setting the stage for the planned five-year project.

Alberta Infrastructure subsequently elected to deliver the project using a construction manager, with the contract awarded to PCL Construction. This methodology, in contrast to stipulated sum or public-private partnership, was effective in staging the work through multiple tender packages issued at strategic milestones during the project, giving the construction team flexibility in effectively scheduling the work over different parts of the campus. PCL was also able to collaborate and work with RPK’s team in a detailed, design-assist capacity. This included splitting out long lead items, reviewing scope items needing accommodation due to performance specification, and providing campus-specific insight from past project experience on the Misericordia site. PCL also incorporated these elements to prepare a highly calibrated and articulated construction and execution plan, implementing it early in the pre-construction phase. The plan clearly defined how the project would be managed with final measures of success in mind. This approach allowed work on site to be completed safely and on time, while complying with the quality and service expectations of Alberta Infrastructure, AHS, and Covenant Health.

Trade contractor input

Throughout the planning process, PCL engaged with trade contractors during pre-construction to solicit their input and unique expertise as regards the review of construction documents, constructability of key elements, durations of critical path activities, labour and equipment resources, material and equipment supply chain risks, and overall expectations and common goals. As a result, when each sequential tender package was completed and ready for public tender, an increased number of trade partners bid on the work. Sharing an accurate and realistic procurement and construction plan with the client, hospital, and potential trade partners, not only set everyone up for success, but also removed costly and time-consuming barriers, mitigated risk, and recognised opportunities with work execution to benefit the client and end-users. Overall, through these means, the project was successfully delivered on time, while also allowing for a planned and effective facility turnover to AHS and Covenant Health.

The existing Emergency Department was cramped, with a single overcrowded waiting room — a space that patients and their families would often enter multiple times (for example for triage, registration, waiting) throughout their visit. The need to streamline and avoid this type of patient cycling became a guiding principle in the new department’s design. Working with the user group and functional programmer, Resources Management Consultants (Alberta), RPK’s design team developed a model that promoted constant flow. Amalgamating lean ideology and clinical service delivery best practices, and considering a patient-centred care philosophy, the department was designed so that patients are constantly progressing in their convalescence. The goal was that patients should always feel as though they are moving forward toward the next step, both physically, and in terms of their recovery.

This philosophy manifested itself, in part, through the formalisation of five pods — intake and assessment, general treatment, mental health, clinical decision unit, and acute — responding to varying levels of patient acuity. Internal waiting areas were also developed within each area. Fundamentally, this configuration means that patients potentially only have to ‘touch down’ once (if at all, depending on acuity) — at the arrival/triage area, and then move into a corresponding pod where, at an internal waiting area, they can start to receive care prior to proceeding into an examination or procedure space. From the examination room, patients progress forward, either leaving the Emergency Department, or being admitted to an applicable hospital department. In the case of the largest department with the least acute cases (intake and assessment), there is another lounge for patients that may be waiting on diagnostic results prior to discharge. Of additional note is the incorporation of emergency medical services (EMS) stretcher bays on the perimeter of the intake and assessment waiting room, connecting EMS teams and their patients directly into the flow of the department.

Carefully designed patient arrival

As part of the constant flow philosophy, the patient arrival area was carefully designed, restructuring all requisite elements. Like all Emergency Departments, the space contains triage, registration, a volunteer welcome station, and security and seating, and is the initial touch point for all patients and visitors. The welcome desk, staffed by volunteers, has been located so that it has a prominent role, while security is tactfully obscured via a tiled feature wall and mirrored glass. Universal stations have been designed to facilitate both triage and registration functions so that staff, rather than patients and families, can move from station to station to accommodate processing. Although well-appointed, the waiting area itself is smaller than might be expected, as it is anticipated that patients will move quickly into smaller individual waiting areas within each pod. It is believed these changes will improve patient outcomes and aid in the throughput of the department, although this will need to be proven by studies of the operational department. Current anecdotal feedback from staff has been positive.

As part of the design process, a narrative structure was 
developed by RPK to engage with stakeholders in the development 
of qualitative attributes. Initial discussions led to the synthesis of a distinct mission for the Emergency Department to be a space that is efficient, welcoming, warm, and safe. This vision was then further augmented, with the building’s design elements reflecting several key aspects of the site’s and Covenant Health’s history, both overtly, and in subtle ways.

The building was designed to blend into the remainder of the existing campus, rather than stand out. Its vertically-orientated white metal cladding, organised in horizontal bands, together with the white brickwork on the front facade, reflect the materials and geometries of the original hospital building, with the large ’emergency’ sign and arrival area glass delineating the entrance.

Courtyards ‘carved’ into the footprint

An additional layer of meaning has been created through the courtyards that are carved into the building’s footprint, each associated with an internal patient waiting area or other specific programmatic element (mental health courtyard and family room). The exterior walls that form the courtyards are clad in copper, an acknowledgment of the chapel that was demolished to accommodate the department. These copper-clad walls have been left to patina, transitioning from bright orange to brown, and finally to green, a reminder of what once stood on the site. As a naturally oxidising material, these walls lend further interest to the courtyards that serve to provide visual respite and connection to the outdoors in the patient waiting areas.

In addition to reflecting the immediate history of the site via the copper cladding, the design team incorporated symbolism relating to Covenant Health’s history. Realising that lanterns represent hope for the organisation, they were reinterpreted as a design motif for the department’s wayfinding indicators. Each pod entrance is identified with a backlit wall, subtle colour, and rectilinear lantern motif. Although the symbolism may not be obvious for all visitors, it weaves a story and sense of pride for staff, reinforcing their mission of caring for the whole person — body, mind, and soul.

Opened in November 2023, the Misericordia Community Hospital Emergency Department renovation is exemplary of how novelty in procurement methodology, functional planning approach, thoughtful design, and quality construction, can create a project that truly elevates a patient’s experience. Alberta Infrastructure’s approach to the initial procurement process created a groundwork of trust from the very beginning. The subsequent development of a philosophy of flow became a focal point for a physical manifestation of a clinical plan that will likely see improved patient outcomes, while the weaving of organisational and site-specific details into the interior and exterior design elements has created a rich tapestry of meaning that serves to elevate the building’s purpose. Indeed, it seems that to go with the flow is a good thing.

Acknowledgment

• This article, titled ‘Form flows from function’, first appeared in 
the Summer 2024 issue of Canadian Healthcare Facilities, the official magazine of the Canadian Healthcare Engineering 
Society (CHES). HEJ thanks the author, CHES, and the magazine’s publisher, MediaEdge, for allowing its reproduction, in slightly edited form, here.