Please take the time to silence all pagers and cell phones.

1. Welcome to the 2007 PDC ConferenceTuesday, February 27, 2007 • Please take the time to silence all pagers and cell phones. • Please complete your session evaluation and turn it in to the room monitor at the end of this session. • Don’t forget to attend the ASHE and AIA Updates on Wednesday, February 28, at 8:00am.

2. New Guidelines on Acoustical Design in Healthcare David M. Sykes, panel organizer Kurt Rockstroh, AIA, ACHA Gregory C.Tocci, FASA, INCE Bd Cert Jo M.Solet, PhD, Harvard Medical School February 26 – 27, 2007 San Antonio, TX

3. 1. Overview of the session David M. Sykes, ASA, INCE • Co-chairman, ANSI S12 Workgroup 441 • Co-chairman, ASA/INCE/NCAC Joint Subcommittee (TC-AA.NS.SC2) • Liaison to GGHC & LEED HC - Acoustics EQ • Managing Partner, Remington Partners • dsykes@healthcareacoustics.org 1,2 Workgroup 44 – Healthcare Acoustics & Speech Privacy; TC-AA.NS.SC – Technical Sub-committee of the Committees on Architectural Acoustics, Noise, and Speech Communications

4. Frequently asked questions • What is it & what’s in it? • Who authorized it? • Who wrote it? • Why is it needed—now? • Is it practical, actionable information? • Who to contact for more information?

5. The panelists • Kurt Rockstroh, AIA, ACHA • Gregory C.Tocci, FASA, INCE Bd. Cert. • Jo M. Solet, PhD, Harvard Medical School • D. Sykes - Solving acoustical problems

6. Why an ‘interim guideline on acoustics’ exists Reason #1: Noise in healthcare facilities stimulated growing inquiries from HCOs, regulators, lawyers & patient groups to the professional organizations in acoustics (ASA*, INCE, NCAC). The professions needed to respond comprehensively. Our group was organized for this purpose & met with FGI two years ago to explore a response. *Acoustical Society of America; Institute of Noise Control Engineering;, National Council of Acoustical Consultants

7. Why an ‘interim guideline on acoustics’ exists Reason #2: Two separate issues—healthcare facility noise and privacy—stimulated members of Congress, WEDI-SNIP1, AIA, ACHA, ASHE, FGI, AHLA2, CHD3, AIS4 & others to learn about standards and best practices in the 100-year-old profession of scientific acoustics. This led to requests for conference papers, articles & advice by our members. *WEDI-SNIP - Workgroup on Electronic Data Integration-Strategic National Implementation Process; AHLA - American Healthcare Lawyers Association; CHD - Center for Health Design; AIS - Atlantic Information Systems.

8. Why an ‘interim guideline on acoustics’ exists Reason #3: The Facility Guidelines Institute responded to the growing interest in noise, privacy & acoustics and other specialized topics by authorizing several “interim guidelines/white papers” as a step toward including new information in the 2010FGI/AIA Guidelines for the Design and Construction of Healthcare Facilities.

9. Who wrote it? • ANSI S12 Workgroup 44 formed in 10/04 as ASA Joint TC-AA.NS.SC focused on healthcare acoustics & speech privacy • Group applied to ANSI in ’05 for recognition which was awarded in 3/06 • See: www.healthcareacoustics.org

10. Committee scope • Membership is ~350 professionals from nine constituencies including: legislators; regulatory agency heads in several countries; leaders of large healthcare organizations; lawyers; clinical research professionals; planners, architects & designers; facilities managers; researchers & practitioners in acoustical science; acoustics professionals at leading manufacturing organizations in acoustics.

11. When was it written? • 8/31/05: co-chairman met in Washington DC with FGI board & board of the 2010 edition to urge recognition of importance of healthcare acoustics • 9/2/05: FGI approved this group as drafting party for the interim guideline on acoustics • 3/06: ANSI recognized the committee as ANSI S12 Workgroup 44 • 11/06: committee leaders met with Core Committee members of the Green Guide for Healthcare, v.2.2

12. A short summary See Healthcare Design, 09.06 issue - “Evidence-Based Design: The New AIA Guidelines on Noise and Privacy” by D. Sykes, K. Rockstroh, J. Solet & O. Buxton www.hcdmagazine.com

13. 2. The need for ‘interim guidelines’ Kurt Rockstroh, AIA, ACHA • President/CEO, Steffian Bradley Architects • Board of Directors, Facilities Guidelines Institute • Co-chairman, 2010 Healthcare Guidelines Revision Committee • Board of Directors, AAH Foundation • kurtr@steffian.com

14. Why ‘interim guidelines’ have been instituted • Guidance clearly needed on several topics • Guidance is needed now, not four years from now… • “Interim” phase allows time for research, testing, validation, revision, development of new standards, etc.

15. Four subjects covered in the first group • Acoustics – completed 10/28/06 • Oncology – in process* • Bariatrics – in process* • Imaging – in process *will be reviewed by FGI/HGRC in April ‘07

16. What is their status before the 2010 edition? • Significant need now for expert, authoritative guidance • Never before codified for HCO’s--so information is highly useful as a digest of expertise & professional best practices • Interim guidelines set benchmarks that can be tested through research & field trials

17. Why did the acoustical document appear first? • Noise/privacy are big, growing concerns • Paucity of organized guidance available • Large group of qualified, willing & well-organized professionals • They completed this one first

18. Next steps in approval process • ASA/INCE peer review (6/06–10/06) • HCO peer review (11/06–8/07) • Appointment of HGRC Workgroup (4/07) • April HGRC “all hands” meeting (4/17-20/07) • Proposal to HGRC (8/07) • Public review period (11/06–8/07 & 1/08–8/08) • Integration into 2010 edition • Send comments to: www.fgi-guidelines.org

19. 3. Overview of the ‘Interim Guideline on Acoustics’ Gregory C. Tocci, PE, FASA, INCE Bd Cert • President, Cavanaugh Tocci Associates, Boston MA* • Co-chairman, ASA/INCE/NCAC Joint Subcommittee • Co-chairman, ANSI S12 Workgroup 44 – Speech Privacy • gtocci@healthcareacoustics.org *Consultants in sound and vibration

20. Document parameters • Title:Interim Sound and Vibration Design Guidelines for Hospital and Healthcare Facilities – Public Draft 1 (Nov. 1, 2006) • Practical approach covers retrofit & new construction in 36 pages • Drafting group - 34 professionals actively participated in drafting with review by the full 350 members of both committees

21. Document parameters • Intended to be comprehensive • Completed peer review by engineering community 10/28/06 • Peer review by healthcare profession began 11/1/06 • Obtain a copy: www.healthcareacoustics.org • See “Documents” • $30 – credit card orders • (view-only on FGI website)

22. Six topics covered 1. Site exterior noise* (5 pages) 2. Acoustical finishes and details* (3 pages) • Room noise levels (2 pages) • Sound isolation performance of constructions* including speech privacy (4 pages) • Paging & call systems, clinical alarms, masking systems & sound reinforcement (2 pages) • Building vibration (2 pages)

23. 1. Site exterior noise *sound transmission loss (STC) rating

24. Site exterior noise

25. Example 2: Acoustical Finishes Average absorption coefficient ( )

26. Ex.2: Acoustical Finishes & Ex.4: Sound Isolation

27. Example 4: Speech privacy Special consideration required Special consideration required

28. 4. Speech Privacy

29. Regulatory compliance • ‘Interim Guideline’ is based on existing standards from recognized standards authorities & on widely accepted professional best practices • Certification?—standard analyses & tests can be performed in design & tested in-situ to show general conformance to the established criteria specified in the Interim Guideline • For HCO’s, this may be useful & desirable for inspections (e.g., JCAHO, FDA, etc.)

30. Goal: common sense “The character and magnitude of the sounds in a building should be compatible with the intended use of the space.” William Cavanaugh Architect,FASA, INCE Bd. Cert., & 2006 recipient of the Wallace Clement Sabine Medal

31. 4. The medical perspective:Acoustics matter Jo M. Solet, Ph.D. • Clinical Instructor, Harvard Medical School • Cambridge Health Alliance, Behavioral Medicine • Member, 2010 Healthcare Guidelines Revision Committee • Commissioner, Cambridge Historical Commission • joanne_solet@hms.harvard.edu 2007 International Conference and Exhibition on Planning, Design and Construction™

32. Evidence-based design meets evidence-based medicine

33. The stakeholders • Patients and Families • Caregivers and Staff • Federal and State Governments • Hospital Boards and Management • 3rd party payers

34. Acoustics & clinical outcomes: mechanisms of influence • Stress response • Lost privacy • Sleep disruption • Impaired communication • Clinician “burnout”

35. Stress response • Arousal • Trauma • Pain • Lack of control • Inability to interpret experience

36. Adapting the Neonatal Intensive Care Environment to Decrease NoiseJohnson in J. of Perinatal & Neonatal Nursing 2003 Noise Effects: • Lower oxygen saturation • Higher respiratory rate • Higher blood pressure • Faster heart rate • Lower weight gain • Impaired sleep

37. Influence of ICC Acoustics on the Quality of Care and Physiological State of Patients 2004 Hagerman, Rasmanis, Blomkvist, Ulrich, Erikson, Theorell, in Internatl. J. of Cardiology • Poorer acoustic environment = higher re-hospitalization rates • Sickest patients showed the most reaction: Acute MI and unstable angina patients had raised pulse amplitudes, greater sympathetic arousal • Quieter environment elicited higher patient quality of care ratings

38. Physiological Changes Memory and Cognition Epidemiological Evidence Sleep disruption

39. Consequences of poor sleep Impaired Attention and Reaction Time Risk of Injuries, Falls Insufficient or Disordered Sleep Incidence of Pain Decreased Memory and Concentration Weight Gain Worse Mood; depression Diabetes Impaired Task Completion Increased Consumption of Healthcare Resources Cardiovascular Disease Psychosocial difficulties

42. Privacy protection and speech intelligibility • HIPAA 1996 Health Information Portability and Accountability Act • PHI= Protected Health Information • Patients with families & friends • Caregivers with each other

43. Interactions among patients, families & friends

44. Purpose dedicated environments

45. Scanners

46. Examination rooms

47. Accurate communication: nurses’ stations

48. Celexa anti-depressant Lamicil anti-fungal Propecia hair growth stimulator Klonipin anxiolytic Celebrex anti-inflammatory Lamictal anti-convulsant Precose glucosidase inhibitor Clozapine anti-psychotic Pharmaceutical “homonyms”

49. Avoiding medical errors

50. Quieter work environment • Lower stress levels/decreased sympathetic activation • Greater control in high demand situations • Increase in speech intelligibility • More sustained attention for careful decision-making = fewer errors • Respectful of workers and their mission • Less burnout/staff turn-over