In this Q&A, physical therapists and health care architects describe their experiences and offer advice. PT in Motion interviewed Colleen Borrelli; Maryam Katouzian, AIA; Lauren Lobert, PT, DPT; Scott Rawlings, AIA; Sheila Schaffer, PT, DPT; and Mike Studer, PT, MHS. See "The Participants" on subsequent pages to learn more about them.

What was your goal in designing or redesigning your space?

Schaffer: We wanted to downsize our space. It's no secret that in unregulated practice, revenues are declining. We wanted to reduce our overhead by making our space smaller.

We're an outpatient clinic and specialize in orthopedics. We don't have a pelvic program, for example. And we're usually treating in a large gym space. We needed to leverage the gym space as we downsized.

Our original space was 5,811 square feet. We reduced that nearly 1,000 square feet, to 4,829. We had a large wellness program, including locker rooms with bathrooms. Our redesign got rid of the lockers and the bench, so we were able to open up that space. We actually feel as if we added to the gym's size. Although it may not be larger, it's more functional.

Katouzian: The University of Virginia's goals were to collocate its previously dispersed orthopedic and musculoskeletal clinics, outpatient surgery, imaging, and physical therapy. The state-of-the-art outpatient center will allow patients to access comprehensive care in a convenient and patient-centered environment. The multidisciplinary facility will provide physicians and staff with a collaborative environment while supporting the training of future providers.

UVA also offers an outpatient facility that handles minor orthopedic surgeries for the "healthier" population of patients. The more sensitive cases are dealt with at the [UVA] hospital.

ZGF worked closely with UVA to refine a vision and a space program for the new building. Our team led a hands-on design process that engaged diverse project stakeholders, including administration, physicians, and staff. At the start of the project, we conducted visioning workshops to verify what the aspirations and priorities were for the project. From there, we visited UVA's multiple existing facilities to assess what was working or not working. To understand how UVA's peers had treated their facility design, we toured comparable orthopedic facilities across the nation. Finally, we brought diverse stakeholders together to define what the ideal model of care would be for the new building and what type of space would best support it.

As far as look and feel, they want this to be a high-touch facility. They don't want it to feel like a medical facility. They want a hotel feel.

Borrelli: A new CEO [for Burke Rehabilitation Hospital] was named in April 2017. He decided to create a patient experience department. A cornerstone project was to have a Caregiver Center, the strategy being that the best way to care for patients would be to take care of caregivers. We were fortunate to have the space available to convert. The Caregiver Center is 1,657 square feet.

Lobert: We moved to a new space last Labor Day. It's a 1,300-square-foot space in a shopping center that previously was a clothing store. There was no treatment room, front desk, or other areas you'd find in a clinic. We started from scratch. We had been sharing space with another business, including a shared front desk. This was our first independent space. We also were on a budget.

Studer: Northwestern Rehabilitation Associates has three different facilities. The first is our Healthy Aging and Neurology Building, built in 2009. It's important for patients to see other people like themselves exercising — sometimes even struggling, but persevering. So, in that building, we built an open gym so patients can see each other and interact.

The 2014 building has a primary orthopedic focus. Patients work one-on-one and may spend a majority of their session behind a curtain or a closed door with their therapist. There is less patient-patient interaction. One might come out into the gym for therapeutic exercise, or not. It's a more personal and boutique experience.

In 2019, we opened a sports performance and injury clinic. The centerpiece is a performance lab with the latest in technology that really keys off the facility. Patients of all ages and capabilities come to be professionally analyzed — elevating therapists as movement scientists who are instrumental in studying movement and helping people achieve fitness or athletic goals.

How did you figure out what you wanted in your space?

Schaffer: The University of Maryland Medical System has a relationship with a real estate agent, so we used them to help identify spaces we might move into. We narrowed it down to two, plus our current site. We were planning on moving. But once we prepared to give our notice, the landlord asked to have a conversation with our CFO and CEO. It all worked out; we remained here.

As part of not moving to a new space, we gained some leverage with the landlord. For example, the landlord previously hadn't wanted to redo the locker space because of the presence of air handling and other equipment. We and the landlord now negotiated on who would pay what.

We did downsize some. I have a permanent office at the [University of Maryland Medical Center] hospital, and gave up my office space here. We gave up some storage where we kept medical records. Now that we're electronic we were able to clean out a lot of old stuff. We also reduced office space now that more documentation is being done on the floor. And we eliminated one closed-door treatment room.

We also went to our staff. We reduced the size of the breakroom, but we kept it because the staff wanted it. Everybody had a voice in the decision-making process.

Borrelli: We had just joined the Montefiore Health System, which had three other caregiver centers. I immediately went to see them, which was a tremendous help.

We also convened focus groups of former Burke caregivers and gathered feedback from them on everything from wanting a private place to make a phone call to having a place to charge their phone or computer. We listened carefully. Their feedback absolutely affected the design of the center.

The planning process also included Burke staff and our professional caregivers, who know our families so well. In the end, it was a combination of those sources that informed the final product.

Lobert: We wanted a big open space with a couple of rooms. I wanted it to be relatively close to where we were before. I already knew the general location, and I wasn't in a huge rush.

To what extent were architects used in developing the space or building?

Lobert: We met with an architect and a contractor to help my vision come to life, based on our needs. We decided on three treatment rooms, sized at 8 x 10 and 8 x 12 feet. I previously had worked in a facility with 8 x 8 rooms, and we'd run into the walls; those rooms were too small.

I knew both the designer and the contractor. In fact, the architect was a former patient. We were required by the city to have an architect sign off on the designs. He had to cover all the specifics on fire alarms, where exit signs would be, and so on. We didn't change anything structurally; it simply was adding non-weight-bearing walls. Planning involved a lot of standing in the space. The architect would walk me through using a measuring tape to show what the room size would be. He'd ask, "Is this large enough? Do you like this here?"

Borrelli: Our CEO had a pretty clear vision of what he wanted. We had meetings with the designer and internal people. We employed EwingCole, a full-service architectural firm in Manhattan that designed it start to finish. There were a lot of people going back and forth, and time spent sitting in display rooms in Manhattan.

Studer: We used the same architectural group, CBTwo, for our buildings in 2009, 2014, and 2019. They already had some medical experience and also retirement facility experience. They're a local company but a regional leader in medical practices and assisted-living facilities.

We consistently have looked for designs that provide traffic flow of patients into the gym and give therapists the opportunity to come up to greet patients.

We sat down with the architects. We told them the theme of the building and the type of individual who will be coming in. We tried to give the architects some latitude. For example, when they knew that the third building involved sports, they suggested using a racquetball court for a reception area. That knowledge is where working with the same architecture group can be really beneficial.

Schaffer: We didn't look at other facilities per se, but we had an idea what would work for us. When we thought we were going to move, but then chose to stay, we had to think outside the box. It took all of us to figure out how to get as close to the plan as we could. The architect would send us a plan. We'd all mark it up and send it back. By the third rendition, we felt we were getting there.

Rawlings: To develop the concept, we brought in some of our hospitality people. We held a charrette — gathering our design team and resources into an intense three-day session to generate a collection of ideas. We then brought in the client to present a lot of material that we have pinned to the walls.

Katouzian: The way we approached the building's programming and layout, we were heavily involved with the patients and the physicians. We wanted to understand their routines, their daily operations, and the way we could provide the most efficient layout. We also toured a couple of physical therapy facilities to understand their needs and how their colleagues performed.

The physical therapy suite is on the ground level of the building, and, for obvious reasons, we wanted it directly accessible to patients. Access to the outside was critical. The second area to consider was the facility's sports medicine clinic. We located this clinic on the floor above the suite, so it would be easy for patients to go back and forth. A featured staircase connecting the floors could be used as part of their physical therapy routine.

The surgery suite will be adjacent to physical therapy because, after surgery, physical therapy is often the patient's next stop. When we were laying out the pre-and post-op areas, we identified corridors where PTs could walk with patients.

We were hands-on with the different teams involved in the project. A couple months of our process involved going to UVA for week-long work sessions with users. These were three-to four-hour sessions with different groups who would be housed in the building. We asked them how their workday went. We toured their existing facility. Then we'd put pen to paper and try to do a first pass. Our turnaround time was three to four weeks. We'd have the same people refine the design. We focused on adding value rather than just recreating their existing spaces.

We went through a four-month programming phase, understanding and defining the layout of the rooms. After that came design development — such as what goes into an exam room — and refining that with users.

Representatives of the physical therapy team attended the meetings. They were decision-makers who'd give us their feedback. We also had a core group of surgeons and UVA representatives who'd make the final decision on the spaces.

ZGF helped integrate the detailed requirements of the diverse users into the design while also maintaining focus on UVA's broader project aspirations. Through multiple week-long, onsite work sessions, we maintained regular engagement with UVA stakeholders. As the design developed and our focus shifted to defining how the building would be laid out and the specific design of each room, we continued to explore, test, and refine options with UVA.

Were there some things you knew you wanted?

Lobert: Owners often end up with fancy offices. I didn't want to be closed off from the clinic. So we opted for a documentation station. We decided to put it behind a half-wall. We have desks, so when we sit down the patients can't see us. But we can hear patients come in and out and what they say to the front desk. I like that in-between setting. Some practices have a desk in the middle of a clinic. You never get your work done. So we decided not to do a full office, but it's not totally open, either.

Studer: Flow is important and is the commonality in all three buildings. Flow means ease of movement for patients and therapists: patients getting in and beginning treatment, and therapists moving up front to coordinate with the front desk staff or to meet clients. Without that ability, functionality inside the clinic is inhibited. Essential communications won't happen if the PT doesn't have convenient access to the front. This flow works out extremely well for all involved.

We also made the decision to reinvest in the environment. We have photovoltaic panels off the grid. But we're not doing the smart building technology yet. We're not sure it's where it needs to be, and we're getting better benefit from the photovoltaic panels.

Rawlings: We always want to understand more about how our client approaches their patient, operationally. How do they provide optimal care and how does that model define who they are? Architecture can inspire and raise the level of what we do each day, but it needs to be focused on creating a better environment for each individual operating model to be fully supportive.

How did the demographics of your patients and clients influence your design?

Studer: Our initial building — Healthy Aging and Neurology, constructed in 2009 — is designed to look like a two-story home. Remembering the age of the patients we're working with, it's good to have a large home appearance. Our second building is more contemporary: 5,000 square feet spread out on one story. The color scheme in the second building is bold, while the first one is more muted. As these buildings are only 200 feet from each another, we kept our same logo and branding to have a consistent thread throughout — a campus feel.

We opened a sports performance and injury clinic in 2019. The centerpiece is a performance lab with all the latest in technology that really keys off the facility. We want everyone to come in, regardless of their abilities. We drove a track all the way through the building to make things visually pop. That makes it apparent that we're doing athletics there. The track is two lanes, 70 meters down the middle of building. It's literally an indoor-outdoor track — 30 meters inside and 40 meters outside. It's bisected by a garage door that we can open. Here again, the architectural lines and colors are very aggressive, athletic, and sleek.

Lobert: We see the whole lifespan of patients. We've had five-year-olds and 90-year-olds. We even have patients whose goal is to take their grandchildren to a zoo. It's a good mix. We just want patients who want to get better and who are happy to see us. We have a chalkboard wall that patients sign when they "graduate." We like to see patients who are motivated, who want to be here, not just because their physician told them to.

Rawlings: Speaking more broadly about designing for demographics, when we're approached regarding a physical therapy center, our first response is to get very specific about patient mix and demographics. Rehab has become very specialized and very wide-ranged at the same time.

As we move from baby boomers to the younger generations — Gen X and millennials — we look more to sports gyms for design inspiration. These generations are used to this type of space, and social interaction, as part of their daily lives, so it resonates with them. The days of sterile spaces lined with equipment and tables in the basement of a hospital are over. Natural light, easy access, views to nature, and inspiration design is key.

Another trend: To appeal to the younger generations, more forward-thinking systems are moving these spaces off campus. They are looking for locations near sports fields, recreational areas, and parks. You're not going to a hospital and starting from a sick environment. You're starting from a place of wellness.

When we start to conceptualize these spaces, we consider retail spaces and sports wellness venues, not hospitals. The younger generation is much better at using social media to research and select their preferred health destinations. They don't see health care as simply existing in hospitals.

Katouzian: Every aspect of the building was designed with the patient group in mind, and we sought to create an environment that is easily accessible for all users. The layout of the building minimizes the number of steps patients need to take to access the clinics and services. ZGF also focused on selecting materials that would not create hazards or barriers. For example, when we specified items such as walk-off mats, we chose materials that will not present a challenge for wheelchair users.

How did you incorporate branding into your design?

Lobert: I'd gone through the entire branding process with a graphic designer to design my logo. That really helped define what the business meant to me: bright and aggressive. Having already done that, it was easier to convey the brand in the physical space. Our logo color is a ruddy bright orange. I went to the space with my card and a Pantone [color sample] book. We have 2 walls painted that orange color. The other walls are bright white. The floor is black. That's all based on our branding.

Studer: We put an underwater treadmill in each of the buildings. The underwater treadmill gives us a "branding" feature that's unique and not fad-like — unlike modalities, some of which will come and go. The treadmills will be something that people around town can talk about. Aquatics is something we can do for any type of rehabilitation. It allows us to diversify the people we can serve and increase the intensity of the intervention.

Katouzian: UVA branding is incorporated throughout the building's architectural and interior design. Through its materials and form, the exterior expression of the Ivy Mountain Musculoskeletal Center is inspired by the traditional style of architecture common on campus. On the interior, branded navy blue and orange elements — UVA's colors — help celebrate the client's reputation as a top care provider. We also focused on branding when it came to developing the identity for each of the specialty clinics. Although we sought to promote cohesion among the clinics and services, it was important that we retain identity for each to promote clarity for patients moving through the building.

How were PTs, PTAs, and others at your facility involved in the process?

Lobert: My front desk was really helpful letting me know what they needed — how much desk space, how much storage space. We moved so that we could grow, so the question was: What will we need a year from now? Two years? I learned a lot from talking to my employees about their preferences for making the environment work the best for us.

Borrelli: We definitely sought the input of PTs and PTAs. It was vital because of their intimate familiarity with the facility and their working with the families of the patients. We'll see therapists bringing patients through the center.

We received input from board members, senior staff, and the clinical team. Our tendency was to be very inclusive. They thought of things we hadn't. For example, another hospital with a caregiver center had a tiny room with a massage chair similar to what you'd see at a nail salon. We presented that to our caregivers. They responded: "Not like the chair at a nail salon!"

We thought about installing a television. Everyone had the same reaction: There would be potential disagreements on channels and news coverage. So we did not include a television. Someone said it was important to have healthy snacks. We also have two private rooms: One is upbeat with vibrant colors. The other has dimmer light. We put those in because caregivers said it was important to have a place to make a private phone call or have private discussions. There were many times, caregivers said, when it was necessary to deliver very personal news.

How can the design of the facility help motivate patients?

Rawlings: The space should be motivating, to encourage people to do the work.

Because people are more goal-oriented now and digitally savvy, patients and clients want to see the steps in their improvement. So we design facilities to visually give them an idea of progression.

For example, we finished a project at UPMC, which has one of the top rehab programs in the country. Included with the new facility will be an extensive outdoor garden, with differing pathways and stimuli to allow patients to work on their ability to navigate changing situations. In the past, we would have simply set up an area with three for four separate stations to visit. With this design, we were challenged to develop the garden as a progressive pathway that also could support the visually impaired. This allowed us to rethink how people with different conditions recognize space. We created a single pathway, still incorporating the traditional material and elevation changes, but included multiple sensory points. Patients moving through the garden will experience different sounds and smells. Using planting and sensory sculptures such as wind chimes, visually impaired patients can begin to navigate the space with alternate senses, using these "point identifiers" to navigate a complex pathway. There will be a true sense of accomplishment when they finish.

Katouzian: We focused on creating a patient-centered environment that reduces stress, promotes safety, and helps normalize the health care experience. The site itself in Charlottesville serves as motivation. It's a beautiful, layered site, with hilly and flat portions that we can use to our advantage. We created a flatter area of the site directly accessible from the gym, so doctors and patients can get outdoors. We also have weaving trails through the site, with different levels of difficulty to allow patients to engage in physical therapy outdoors. To reduce stress, the building's interior design will more closely resemble a hotel or spa than a traditional clinical environment.

How long did the process take?

Borrelli: The process was one year from planning to ribbon-cutting. The planning process probably took about three months. Other centers told us: "It's a tremendous goal, but it's just not possible" to do it so quickly. The architects and Burke's internal team were very anxious for that initial phase to happen on schedule, and I pushed for that.

I'm glad we did it that way. Our CEO felt, especially because our patients are becoming more neurologically complex, that he didn't want to wait longer to give them that support. We also received an unanticipated donation that helped us jump in "whole-hog."

Schaffer: Ours was a three-phase plan. The contractor provided a schedule, but there was something I wasn't aware of. Phase One addressed one area. We thought Phase One would be completed before we went to Phase Two. That wasn't how it worked. Maybe having a construction manager on our team would have helped. You're always a bit in the dark. Maybe if someone had looked it over and asked some questions [we could have avoided those misunderstandings].

The schedule was 12 weeks. It actually took about 16. We treat from 7 a.m. to 8:30 p.m. and we're open on weekends. The construction crew worked in the evening and we agreed to close for two weekends.

Lobert: You have to start early, as when you're buying a house. The remodeling process is going to take time, and the lease-signing process took a while. It was six months from when I made an offer to when we were able to open. My advice: Start six to 12 months in advance. One issue we ran into is that many master electricians have wait lists of up to four months.

Katouzian: We won the project in the spring of 2017 and kicked it off in early summer. We went through the design process and through the programming schematic. That took us until spring of 2019. We broke ground in the summer of 2019, clearing out the site, including demolishing an existing building. We are currently maybe 25% through construction. The facility is scheduled to open in fall 2021.

Studer: Based on our three buildings, it generally takes us slightly over two years. It begins with the land acquisition, then initial plan design and into a pre-application process with the city, presenting what we want to build. Different cities have different political processes dealing with city planning. There often are development costs — for instance, putting in new sidewalks. Or they may require some improvements with the street or the sewer, require an environmental or a traffic study. All of these line up right after the preapproval process. Then, we approach the bank and begin the process for loan approval and begin to put the final design out to bid. Construction begins, typically with a construction loan that converts into a permanent loan. It's a two-year process, minimum.

What sort of surprises or unexpected challenges did you encounter?

Schaffer: Communication is critical. I had told the contractor that our cleaners would still come in. They thought our cleaners would clean up after their construction crew. The first day after construction, we came in and there was dust everywhere.

They were much better cleaning up after that. Every morning, I'd meet with the construction manager. I would ask, "How long will this hole be in the ceiling?" Or mention something that needed to be corrected for patient care.

One thing that happened: After the second weekend, they moved electrical panels out of the locker room area to the outside wall. I didn't see that anywhere in the plans, and it interfered with our plans to put equipment on those walls. We gave them an additional day to make the change and we shared the cost.

Studer: The biggest surprises are the increasing city development costs and the time it takes to get the project moving. The time has increased exponentially with each of our buildings. The reason — and this isn't isolated to our city — is that when a new tax is proposed, such as to improve the streets, it's much easier to get the funds from a corporate resource than to add more taxes onto the backs of individual citizens. A business only has one vote. If you've levied an additional tax on the business, it's not going to be opposed as strongly as if those taxes were put on the general populace, where it'll be opposed by thousands of voters. Taxing businesses is the path of least resistance.

Lobert: One surprise was that the rubber I chose for the flooring was a pain to put down. I love it now, but it wasn't easy to install. Another surprise was the cost of electricians. To pass inspection, we needed to change fixtures. The electrician moved a few lights and it cost approximately $7,000.

Borrelli: We really struggled with whether to permit patients to enter the caregiver centers. We're patient-centered and it seemed strange for a caregiver to go into this gorgeous space, and then go and describe it to the patients. Most focus group participants, though, said the area should be exclusively for caregivers. So we compromised and allowed patients when accompanied by their caregiver. We're still struggling with that.

What's been the feedback from your various stakeholders?

Borrelli: Staff love the caregiver centers. Some centers allow staff to use those areas, but we don't. Some caregivers said they'd feel uncomfortable. Our nursing team would say it has positively impacted their work. It's a place to send a caregiver with a social worker there to talk to them. The staff feels that it helps them because of what it offers to families. Our senior administrators are huge fans. There's no one who doesn't think it's a good idea now.

As we're open longer, our center director is looking to expand the programming. We'll offer a "Burke 101" class for new caregivers, showing videos on certain topics. We'll have complimentary mini-massages. All those offerings will elevate it to being more than just a beautiful space.

People are using the facility and getting out of it what we'd hoped. We're learning every day from our caregivers. We're tailoring things as we go on. We'll have special celebrations in there — birthday parties, a proposal (a caregiver proposed to his girlfriend who was there as a patient), a 50th anniversary celebration.

Schaffer: The patients have been very pleased. For years, there had been a gym membership available to patients after finishing therapy. The gym/wellness members were disappointed with the removal of the lockers. But we did install some cubbies, and we do allow people to go into a curtained area to change clothes if they need to. We were able to keep some equipment, and it feels so spacious. And we added a softer floor. The response was phenomenal.

Therapists love the space as well. It looks so modern. And we now have a wheeled cart with laptops and desks at which the therapists can either stand or sit with fixed computers. They felt that everything they needed was retained, and we now have adequate space for functional activities that we were a bit tight on before.

Katouzian: We have heard from stakeholders that they are thrilled to see their vision for this project come to fruition. There is tremendous excitement for how transformative the building will be in providing patients with an entirely new level of care and convenience, in addition to educating the next generation of providers.

What advice would you offer to others considering a similar project?

Rawlings: On many projects, clients request site visits to other similar facilities. Not every client needs tours in person, as this can be time-consuming and expensive for the institution. Much of what needs to be seen can be accomplished with virtual tours and case studies, but for this type of facility, we advise them to find a few facilities that are operating similar to their business model and accomplishing similar goals. So much has changed over the past decade with digital environments, tools, and new thinking in motivation. Clients really need to see what's out there, and they often come back with an entirely different idea of what they want to build.

Borrelli: There isn't a lot that we wished we'd done differently. The best thing we did was involve our own staff and former Burke caregivers in the process. Maybe other facilities or clinics don't have the luxury of being close to other centers. But we looked and saw things we wanted to do, and things we didn't.

Studer: You need to know your brand, your customer base. You need to build to reflect that. And plan ahead for technology and growth. Initially, we needed Ethernet lines, then Cat5 cable technology, wireless routers, and Bluetooth-compatible equipment. Now it's Cat6. You need to be thinking ahead. For example, include access panels and conduits to thread through new wiring. You never know what you don't know.

Schaffer: Assess the needs of your space and your patient clientele so you can retain what you absolutely need. Then determine what you can sacrifice if you're downsizing. Have someone with construction experience on your side of the table. A daily startup meeting with someone from project management was very helpful for us.

Lobert: We were sharing space with another business, with a shared front desk. So this was our first independent space. We were on a budget. We bought a lot of used equipment, but we bought high-low tables because we do a lot of manual therapy. I don't think a ton of equipment is necessary. We got the basics — including a rower, bike, and leg press. But not large equipment. After a few months, we talked about what else we really needed. We weren't in a rush to fill the space. If you start with the basics, once you're there it'll all make sense, rather than [guessing] and buying equipment you won't use.

Katouzian: One size does not fit all, and it is worth the effort to develop a unique solution around your organization's culture, aspirations, and patient population. Taking the time to include diverse users and stakeholders in your visioning and design process can make all the difference.

Donald E. Tepper is editor of PT in Motion.