By Dan Hounsell, Senior Editor

Healthcare facilities have been in a constant state of flux for years. from evolving compliance and security requirements to the challenges created by the COVID-19 pandemic. One element of these facilities that has begun to come under greater scrutiny is the way healthcare executives and facilities managers view a critical element surrounding their buildings — landscapes. 

"Originally, people were almost entirely focused on the experience of the outdoor environment from more of an aesthetic standpoint," says David McCullough, principal landscape architect with McCullough Landscape Architecture, citing healing gardens and memory care gardens as examples of that approach. “The conversation has changed. We're still having some of the same conversations about designing and building healthy spaces for people. But it also has become mixed with a stronger discussion about resilience and using less water, for example, and working with materials that grow naturally in the region or the climate that they're in.” 

For healthcare facilities managers, the renewed attention on the role of landscapes in the mission of the organization and the larger community are creating new kinds of challenges. 

Rethinking landscapes  

One event that has led to a reconsideration of healthcare facilities is the COVID-19 pandemic, which changed not only the way patients enter and move through healthcare facilities. It also changed the way staff protect themselves from airborne diseases and the way they interact with surrounding landscapes. 

“A heavy, heavy part of the conversation is, 'How does the outdoor space support the staff of the facilities?'” says Trygve Hansen, landscape architect with HGA, an architecture and design firm. "We're really thinking about the outdoors and landscapes as being an opportunity for respite and stress relief and exploration for staff. It makes a lot of sense because they are the population that is there all the time." 

Healthcare organizations also are making greater efforts to connect the benefits of natural landscapes to the facilities’ mission of patient care and healing. 

"There is a continued and increasing interest in biophilic design as healthcare organizations evolve their understanding of the best ways to treat their patients,” says Eric Hoffman, vice president and healthcare sector lead with Project Management Advisors, adding that healthcare facilities are emphasizing the need to design for mental health and emotional and spiritual wellbeing, which can affect recovery. “Studies continue to show that biophilic design, natural light and access to the outdoors are integral in the overall wellbeing of patients, families and staff.” 

Re-thinking landscapes also more often incorporates concepts of resilience, which involves ensuring facilities and communities are connected in ways that ensure their survival and long-term performance in a rapidly changing climate.  

"People are really concerned about the regional impact their facility has, as opposed to just the site-specific concerns that we've been having discussions about,” McCullough says. “A lot of these people, even though their world is their facility, they're thinking a little bit more broadly about the impacts of their facility from a site standpoint to the community and region as a whole.” 

Ground-level challenges 

The changing views on the roles and potential benefits of landscapes around healthcare facilities are creating ground-level challenges for facilities managers who oversee their maintenance and care. Consider the example of installing and maintaining biophilic elements, such as plants and water features. These features require an added level of care. 

“Depending on the installation, the initial cost is often capitalized with the project, and the ongoing maintenance becomes an operating expense,” Hoffman says, adding that to be effective in the long term, crews need to maintain these elements regularly. “Interior installations will need a multi-disciplinary team made up of security, safety, infection control, environmental services and facilities personnel involved in the planning, installation and maintenance. The elements of the installation, including water features, planting mediums, environmental controls and cleaning protocols, also need to be aligned as part of the design.” 

Organizations also are rethinking their choices of plant materials going into landscapes. In some cases, the new approaches are prompting managers to update landscape practices that have been used for decades. 

“No matter where you're at, whether it's California or Boston, there are certain materials that in the past 100 years have become standard materials people use,” McCullough says. “But they're not necessarily the best things for those areas. What's happening is that a result of this need to be a little bit more regionally conscious and think more about sustainability, people are starting to really focus on regionally available material.” 

The increased interest in the role of landscapes in healthcare facilities also is prompting a growing number of healthcare organizations to include facilities managers earlier in the planning stages of new construction projects. The challenge for managers in such discussions is balancing the benefits of healthier landscapes with the overall needs of the facilities. 

"The building has to operate and operate right — the power, all these kinds of things,” Hansen says. “That can take away from the capital, the time, the effort that can reflect in the landscape and the outdoor spaces. The building and the rooms are a must. 

“But we always advocate and realize and sell that you know the site and that the landscape is always the first impression of the experience. It's a balance from our end and from everyone's end.” 

That need for balance extends to the oversight of landscapes after the facility opens, when the manager’s hands-on role can continue providing benefits to patients and staff. 

"One of the conversations that we always try and try to engage in early is understanding if the grounds and the landscape is going to be managed in house or by a third-party contractor, a landscape company,” Hansen says. "A challenge with the third-party operation is that it's a transactional exchange of how the maintenance and operations happens. When we have facility managers that are very involved, whether they perform the services or not, if they're doing it or closer to doing it themselves, there's a labor of love and pride.” 

Protecting the organization’s investment in landscapes and ensuring its long-term performance extends beyond the facilities manager’s involvement in big-picture decisions. It includes communicating with front-line workers caring for landscapes, who often use materials and methods out of habit. 

"They're basically just doing what they've been told, and if things have just been passed down through generations with one person telling another person how to maintain these materials, then it's not always really beneficial and effective,” McCullough says. “One thing we've done recently is to engage with the people actually doing the work because the people that are building these facilities or even some of the upper management folks that attend the meetings during the construction or design process are completely different than the people that are maintaining it. We really make up a point to make sure that those people are engaged in the conversation early on so that they understand.” 

What lies ahead 

The landscape challenges facing healthcare facilities managers will only expand as organizations and surrounding communities pay greater attention to such big-picture issues as sustainability and resilience. In some cases, the challenges are even expanding to involve issues related to diversity, equity and inclusion. 

"There's a very strong renewed interest in and demand for spaces that allow for diversity, equity and inclusion,” McCullough says, citing California’s growing efforts to mandate the accessibility of outdoor spaces to make sure everybody has equal access to every part of a facility, especially in healthcare. “What people need to be prepared for is those codes and rules and regulations, which are mainly driven federally by the American with Disabilities Act, will continue to evolve and get even more aggressive to the point that there literally is universal accessibility.” 

In addressing these emerging and evolving issues, managers must keep in mind the traditional challenges of facilities management. 

“The overall theme for facility managers today is the continuing pressure on staff, budget and time as organizations continue to prioritize the patient, family, staff experience with natural, flexible installations that offer a sense of well-being and comfort,” Hoffman says. 

They also need to remember that even though they might successfully address one challenge involving landscapes, more are certain to arise.  

“My observation is that healthcare campuses, especially those developed a long time ago, are constantly go going under additions and renovations and upgrades, and the pressures to balance new designs, old existing landscapes and all these different things can be very challenging,” Hansen says. 

Dan Hounsell is senior editor for the facilities market. He has more than 30 years of experience writing about facilities maintenance, engineering and management.