Natalie is a principal and regional healthcare director with extensive experience in health care planning and project management.

She specializes in delivering innovative on budget solutions for complex health care projects.

From renovations to new construction, while ensuring technical excellence and strategic coordination.

And today, Natalie will present a project regarding Performance by Design, a case study in creating research driven, human centric mental health space.

So please help me welcome Natalie to that actual.

Well, thank you all very much for having me.

I'm really excited to be here today.

I'm going to talk in such general terms.

What search and practice involve design, and then I'll use a recently completed project as a case study to really explore some of those research methodologies.

And and how we collaborate with stakeholders and how we define a project's driving values, and then successfully conveying those values through the architecture.

Okay.

So again, we'll briefly touch on multiple research methodologies, that we have generally available in our designer's toolkit.

We'll walk through several mental and behavioral health as well as trauma informed design principles.

Again, we'll be using a case study to review several ways.

The methods that we engage stakeholders and how we evaluate and prioritize design.

You know, both goals and building features.

So quick, so the intersection between the model of care and the physical environment in health care, we really have perhaps the greatest chance as architects to impact health, to impact well-being and safety.

So whether that be in a high quality medical setting, like a surgical suite or an intensive care unit or, it's in an outpatient setting or psychiatric facility.

Not all projects may be able to address all of these, right?

And ideally have the ability to kind of weave together elements of several best practices to address complex design problems.

Perhaps the most important lesson to take from this today is really just how important it is to truly listen and effectively communicate, to ensure that there's trust and understanding and there's a common language in the design process.

So mental health care is a about provider AI services and a multitude of grantees.

As you can see here, when inpatient residential allocations, you know, they contain many forms.

And so beyond is also seeing an increasing awareness and an In investment in behavioral health.

And so we're seeing an increased interest in integrating behavioral health services with other spaces, whether that's other medical spaces, academic or even workplace.

So even if you don't intend to focus on specifically behavioral health settings as a designer, good design that addresses mental health issues can really benefit any environment.

So today's case study is the first project that was implemented as part of the Austin State Hospital Brain Health System plan.

And it serves a catchment area of 4.9 million people that is equivalent to the state of Washington.

In here in Central Texas.

So that is a lot of people.

And the continuum of care, as you can see, is an ecosystem, right?

It has internal and external needs, all of which need to be considered.

They need to be understood so that we can best serve Texas Health and Human Services as the client in providing improved care to perhaps some of the most vulnerable members of our community.

So the client in this case had embarked before they even got the architect involved on a multi-year process to really think about how they were changing their operation.

They were really assessing how they're funded, their short and long term development.

And then they brought us in to help look at opportunities at their existing facilities and at their 90 acre campus, shown here in north central Austin.

So the vision, is, you know, Austin State Hospital, which we affectionately call ash.

So I'm going to say that is a short, shortened version for the rest of this.

Oldest psychiatric hospital in Texas.

It's also the anchor of the 11 facility, soon to be 14 facility system of state hospitals in Texas.

And so it receives referrals from throughout the state.

It primarily serves a catchment area of 38 counties for adults and 75 counties for children and adolescents.

That'll make sure that 4.9 million individuals.

So the project vision was ambitious.

It's to really transform neuropsychiatric care through innovative, in person centered facilities and improve the delivery and quality of care.

And that vision was driven by the client, by the donor.

So it gave us a lot of room to incorporate research, to really spend the time to develop an approach that could look at what the future of modern mental health care could be in Central Texas.

So our scope was not only to supplement a large owner team for the campus plan, but then to implement that first phase of the plan, which is a new 240 bed, inpatient psychiatric hospital.

So again, we embarked beginning and throughout on a literature review.

So much of what we were doing was talking to clinicians and facilitators about an entirely new way of delivering care.

And in order to do that, you really need to understand the landscape.

You need understand how care is being delivered in other places.

You need to understand what the current research is, and you need to be able to speak to clinicians in a common language and really understand how care is being delivered.

So, there were a huge number of stakeholders that we worked with.

And and as you can imagine, the building alone is not going to be able to address all of the issues or all of the needs.

But the best way for us to know how to focus on what needs the building can address is to really understand the ecosystem.

So we benchmarked other facilities, and we reviewed the available literature and really just spent a lot of time evaluating industry best practices in support of this.

We also, you know, did the best we could to define the current state through use of a lot of data.

Understanding the issues, the biggest challenges, that we we can propose design solutions that are within the appropriate context that are backed by data.

So change is hard.

It can be overwhelming.

And especially for those who don't spend every day thinking about new ways to deliver care and what the role the physical environment plays in that care.

They have adapted to all facilities, that are ill suited to modern mental health care.

They may do and so hard for them often to imagine kind of supporting care in a way where the average length of stay might be shortened.

Where we can provide a stigmatized environment.

So those were the types of areas that, as designers and builders, would focus on.

So healing cannot begin in a state of crisis.

So when we talk about a bio psychosocial model, we're talking about biological, psychological and social factors.

So by truly understanding the client operations, we're, we're spending time thinking about kind of the math of the system.

Right.

And without getting into the detail of this, that loop, that crisis loop where inpatient care occurs, where crisis stabilization occurs.

That's really what's keeping our clinicians up at night.

Our administrators up at night is looking for ways to if if not eliminate that crisis loop is really reduce that as much as possible and keep people from ending up in places like jail provided behavioral health emergency departments and inpatient state provided mental health care.

We're going to skip the video for an hour and move on to the next slide.

So again, when we're talking about bio psychosocial, we're talking about multifaceted review of what really is impacted and what are the social factors in the manifest of disease.

So for us to be able to challenge and change distorted cognitive behaviors, to really improve emotional regulation and support people doing the hard work of developing personal coping strategies.

The physical environment must really move towards actively supporting cognitive behavioral therapy.

So that includes a focus on recovery, modeling the behaviors of the outside world and enhancing the interior environment.

So there are available guidelines and regulations and they're kind of catching up.

In to forward thinking evidence based care models.

And they provide some guidance in evaluating and prioritizing environmental features for these types of buildings.

And there are a few notable resources from researchers like Roger Ulric and Mardell Shapley that offer guidance on environmental psychology issues and design features that reduce stress and aggression.

So Roger Ulric, Leonard Belgrade and Stephen London studied and tested nine key features that are known as the stress reducing bundle.

So they tested this bundle for a control comparison of three Swedish hospitals and measured the outcomes through documentation of both chemical and physical restraint use.

And these design features have really kind of become the standard for model mental health environments.

Things like single patient rooms, views and access to nature, lower social density.

The importance of acoustics, flexibility and then staff observation and safety.

And then Mardell Shapley and Samir Pasha published a book called The Design for Behav Mental and Behavioral Health, and they highlighted 11 environmental psychology issues.

And as you can see, they're very closely related to that previous nine bundle.

So, you know, they're really largely in line also with the prevailing health care design research of the last couple of decades.

And so you're seeing a lot of common themes and if you look at this and you read through and you think, okay, well, that's just good universal design for the most part, right.

Access to nature, to daylight, high quality, well-maintained environments, flexible room layout, environmental control, etc.. And despite the fact that you might think is common sense and yes, these are great universal design, it's really important that we continue to reiterate that we repeat that we study it and put data behind it, because we constantly need to be kind of reproving to ourselves and our client what good design is, because that's how we continue to move design forward in the health care environment.

So this is the Austin State Hospital patient unit milieu.

And I've kind of highlighted here several of the multiple principles that are exemplified and integrated into the care environment.

So the space is designed to maximize daylight.

And it's really, really improving patient and staff visibility.

So there's lots of glazing in the space.

We're looking at high quality, durable materials that have been tested for behavioral health environments.

We also have high acoustically absorptive materials where we can, which is a challenge in behavioral health environments and health care environments in general.

Often infection control provides us with very, resonant materials that can make it a very loud space.

So we do what we can, for instance, in the ceiling and in some of the furnishing materials and in some of the treatment of the sheetrock, to absorb sound as much as we possibly can.

So we're trying to take all of those features of, of smart design, of, of good research driven design and incorporate them into an environment that supports care.

So I'm just going to run kind of really quickly through those 11 features and kind of give some examples.

These aren't all from the state hospital.

They're from from different facilities.

But so patient support spaces, you know, when you think about it, especially with children's health care, it's really extraordinarily disruptive, whether it's mental health or medical health care.

They're being taken from their daily life.

They're being taken from school.

And so thinking about the types of spaces you need to provide that, that kind of provides some regularity and some normalcy and allow people to address medical health care, mental health care in in tandem with daily life, really helps people as they continue, beyond the inpatient space.

A neighborhood layout is really important.

So if your design can kind of resonate the neighborhood layout, it can then offer privacy and the social needs and the environment of stimulation for patients.

That that can kind of mimic life outside of the hospital.

Then the other benefit of neighborhoods, especially in a mental health facility, is that each neighborhood can have its own identity, you can have its own access.

And so that helps, operationally separating, separating some of the service access, some of the staff back of house, from the patient environment, even flexible room.

I think you're just giving up.

So control the environment.

This is really important.

Obviously in different types of health care environments where we're limited in different ways, in behavioral health environments is something that we've struggled with for a long time, is how how can we provide the maximum amount of control to patients as possible?

Because it's really important.

In a situation where you might be in crisis, you are somewhere you maybe don't want to be.

You are not in control of a lot of what's happening to you, but you can control the environment that you're in the room.

And, and historically, they haven't been able to control remotely lighting or control their own lines or control even what's happening on a TV in the day room.

But if we can take that step to provide that control, I can do a lot to, provide a stabilizing and normalizing environment that shows the patient a level of respect that helps can be conducive to, health and well-being.

Flexible room layouts is true in any kind of health care environment.

Obviously, people, when they come into a health care environment could have multiple issues co-occurring.

And so thinking about how you can best serve, issues that patients may be coming in with in a flexible room means you're disrupting people less by having them move them to different spaces.

You're bringing the care to them, rather than having them move around the facility.

And it really can create kind of a better environment for, say, family being involved in the health care as well, which is really important for long term adherence to treatment.

And then family support spaces, even outside of the bedroom, really important, especially in pediatric environments.

So, you know, really thinking about amenities like dining spaces, outdoor activities, lounges that can be offered with patients and families in mind.

Nature in daylight, which I skipped by accident.

Outdoor spaces, healing gardens, activity playgrounds, patio areas.

Even if you can't provide access, providing views at minimum can be really key for kind of allowing exercise, reducing aggression.

It can be a key component for calming and behavioral environments and allow, an ability for patients to kind of get energy out.

Safe haven designation.

This is really important, especially in medical, behavioral health as well.

The bedroom in and of itself, if you can really have that, be a safe haven away from the harder work of other cognitive behavioral therapy, the harder work of, of, you know, being poked and prodded in a medical environment.

If that's not happening in the bedroom, that's better.

That provides patients a place to retreat to feel safe, to be able to kind of deal with and process the things that they're having to go through on a daily basis.

And their therapist.

And then positive distractions, these are really key in really any environment.

We often use these in educational academic environments as well.

And thinking through kind of what are the age ranges of people that you're trying to provide positive distractions to, because this could take on a lot of different, a lot of different features.

So this is a sensory space for people who have severe disabilities, often are on the spectrum.

This is actually in an academic environment, non-medical environment.

But they are students with high medical needs.

This could look different in a different facility.

So the behavioral health facility might be a sensory space that has very soft furnishings and lighting control and music.

It could even be, a high tech media space if you're talking about adult patients.

Just an ability to have a way to get your mind off of the things that you're going through.

From a medical sense.

And then physical security, this is really important in any health care environment.

Probably the most important in a behavioral health environment.

It's a necessary precaution.

But what I will say is that there's a balance when integrating observation and privacy.

And so that should really be something that's discussed in a really detailed way when performing your projects.

Risk assessment with the end users, with the clinical, with the clinical folks.

And then ideally, if you have a patient or family worker, this part of your project is.

High quality environment is obviously what we're all striving to provide.

Right.

You know, in behavioral health, well tested building products, fixtures, furnishings are really important.

And really what we're trying to endeavor to do is not only create an environment that will will hold up to the activities within, but we're trying to communicate to the people using these spaces that we care about you.

You're going to be receiving very high quality care here.

That's not just for the patients, but for family members as well.

And then finally, social interaction.

So it's really important to have choice around social density, especially in behavioral health environments.

So opportunity for small, medium and large gatherings, but also individual contemplative and quiet activity should be included in the program at the facility.

And then finally, you know, trauma informed design is really more of a recent focus is following in the footsteps of trauma informed care.

And what what this does is it really acknowledges a need to understand an individual's life experiences in order to deliver effective services.

And it has the potential to improve engagement, treatment or protocol adherence and health outcomes, as well as staff wellness, which is a really important focus, especially in behavioral health environments.

So you can see many of these considerations for trauma informed design really do mirror those that we just discussed in the Ulric and Shapley materials.

And so, you know, safety obviously of high priority trust, choice, a holistic approach to the individual person, equity and inclusion as well as social connection.

This is an area where we're seeing a lot of opportunity to continue to further research in health care design.

So looking at stakeholder engagement, before we even start in on the design, like I mentioned, they had put together as a client, multiple stakeholder groups to really think through how and how they were going to revise their whole health system.

So we kind of built on that.

And, had, them continue involvement throughout the design of the facility.

And it was really important that we find multiple ways of communicating the design, so that we could really get meaningful feedback from the users.

Not everybody can read a floor plan.

Not everybody's going to interpret a rendering the same way or understand the space the same way.

So we were fine.

We were trying to find multiple ways to communicate our proposals, so that we were really making sure that the clinical staff understood what we were suggesting, and could imagine how they would provide care in that space, and therefore provide us meaningful feedback to make modifications to that design.

So most of the folks, in the early work groups were from all kinds of backgrounds.

They were not just health care providers because behavioral health touches a lot of other areas.

In particular, there's a large justice footprint in behavioral health care that's really important to understand and think about and be really meaningful in how that connects to your care environment and how it doesn't connect to your care environment, and what that means for kind of the future.

At the intersection of these two things.

So each group had their own area of focus and obviously their own kind of drivers for success.

Right.

So it was paramount that we continue to involve them throughout, and then and then really give them an equitable platform for providing feedback.

And that might look different for each group.

Right.

Equitable is not necessarily equal.

So we had different approaches for different experts, different ways to communicate ideas to different groups depending on where they were coming from and what type of, kind of footprint they wanted to have on the project.

So moving more into kind of what we do as designers are really the meat of what we do.

So, in addition to studying the care continuum, studying the operational model, we assessed the Austin campus, we looked at in detail and concluded, which was not a surprise to anyone, that the existing facilities were really unable to support the desired operational model.

In fact, they were really going to be a significant barrier, to, to research driven treatment.

So looking at the existing facilities and, first, you know, there are urgent safety issues.

The hospital was operating under a continued, conditional ligature psych citation from CMS, and that had been going on for three years when we started design.

That's a really expensive, expensive staffing activity.

And it results in the exclusion of vital services.

For instance, they couldn't have private family visitation because in their family visitation areas, they were using a drop ceiling and they didn't have the funding to replace that with something more secure.

So they weren't able to offer the types of services they want to because they didn't have the environment to support it.

Within the existing facilities, the transition was really not possible.

For for several reasons.

There's really not enough space.

So coping self-soothe is not available.

They only have three options and places to be.

You're in your room that you share with three other people.

There are no private bedrooms.

You're in the day room.

You share with the entire unit.

There's no additional breakout spaces, or you're in the courtyard.

The single courtyard that's shared by three units.

So there's no choice in social density.

There's no opportunity to really practice your coping, or self-soothing in this environment.

And then the physical state of the facilities was really far beyond a reasonable building life cycle.

In many cases, some of these facilities are 100 years old, a more than 100 years old.

And, you know, the challenge really for, for maintenance was just the breadth of needs across the facility.

It was stretching them so thin it was overwhelming.

And then ultimately, you want to try to keep maintenance staff out of the patient environments as much as possible.

That poses a significant safety risk.

Maintenance is going to have to bring tools, and tools can be weaponized.

Maintenance staff, when you don't have a lot of places to bring patients to, it's hard to remove patients from the environment for maintenance staff to come in.

So it's really just a logistical challenge to work with in their existing facilities.

So, we looked at doing mocap and simulation as part of this because they have their huge campus space.

We were able to do this.

We worked with the contractor to build a high fidelity patient bedroom, an absolute bathroom mock up, because there were 240 of these in the facility.

We knew we wanted to get this right.

In behavioral health, the patient bedroom a bathroom is the highest risk environment.

It's one of the only places a patient is left alone for any significant period of time.

So getting this right was really important.

They also had never operated with private bathrooms and bedrooms before in their existing environment.

So having the staff really understand what this was going to look like and what this would mean for them was really important.

So this gave us away.

In addition to the 360 degree renderings, in addition to all of the other things that we had done to really get everybody into the same space, understanding the environment at the same.

So we were able to do construct ability reviews, you know, not just with clinicians, with maintenance, but with the contractor and their trade partners helping them understand what the difference is for a behavioral health environment over any other type of construction.

And it helped us work through some construct ability issues and modify details before construction began.

Based on the installation of the mock up.

You can see an example here with a ligature resistant toilet, mounted flush against the back wall.

We modified the base detail to better support that installation.

We also looked at maintenance.

In many cases we validated some of the design proposals and maintenance had been concerned about.

So the secure ceiling in the corridors and how you would access that.

They weren't convinced.

We built a mock up of it.

They tested it.

And as maintenance will do, they beat the crap out of it and were convinced like, yes, this works.

We like this.

We can put this in the facility.

So this is the way our ceilings are designed and altercation units.

And then we were able to make some other modifications to the platform bed for Eva, how that platforms installed Hounsfield and how the millwork is detailed to allow for proper cleaning was modified with the Eva staff in place.

And then we did, additional mock up and testing, on the exterior so that right there is a human impact test that we devised with the, contractor to test the custom window installation.

Because we weren't able to put something in there was off the shelf that had already been tested.

We had to test it on site.

So that and, ligature testing were consistent throughout, submittal reviews throughout punch box and throughout the design.

And then probably the biggest thing that came out of the mock up, that was the biggest change that we had discussed it a lot in design, was a visibility concern.

So if you look at the floor plan on the very left here, there's a blind spot.

When you're at the entry door to the bedroom, you can see behind the bathroom where the nightstand is.

There's a bit of a blind spot.

We talked about that a lot in design.

We did 360 degree renderings, and we walked through what that might mean, and the staff felt comfortable with it.

They're like, I to you know, it's okay.

I mean, if if I can't see them when I walk in the room, I'm reasonably certain that's where they are.

You know, it's not too much of a concern.

I can talk to them and walk in and mitigate the situation.

But then once we did the physical mock up and they understood kind of what that nightstand construction was, which is extraordinarily robust.

They understood somebody could stand on this nightstand in the corner and not be seen from the door.

And as a patient, as a staff member comes into the room, they have a height advantage, not just being hidden.

And so that felt very uncomfortable for the staff.

So they decided, okay, we we do need to do something about this.

And by having this as a physical mockup, we were able to bring in some additional materials.

We brought in some big foam core and we put we put it against the wall and we angled it out and we said, okay, well, what can we do in the mock up?

So this is the mock up where it was.

This is how we were testing it on site.

What was the balance between still providing space at the hand wall for the patient and, decent nightstand, but allowing the close off of that corner so that if a patient does want to hide in that corner and stand on the nightstand, the staff can see their feet.

They can see a part of them from the door, and so they can know they're there.

They can try to mitigate that situation by talking to the patient before walking into that room.

So suffice it to say, big fan of mock ups.

I know that they take a lot of additional work, but even if you can do it in place as part of your construction with your contractor, there is a huge amount of education.

And, specific knowledge that comes with behavioral health environments.

And this is a great vehicle for being able to train new staff members that are coming on the project train, train partners, and really have everybody understand what the impact in these spaces on.

So I was going to finish with another video which may or may not work.

But this is just some of the additional kind of finish.

That's the finished bedroom there.

And then one of the 11 secured outdoor patient courtyards that they provided here.

And with that, I mean.

Any questions?

Well, wonderful.

Thank you so much.

That's amazing project.

And how long has the building being occupied so far?

So they moved in in October.

So they've been in for about four months now.

We've been hearing really great feedback so far.

Very few issues.

What we're hoping to do in the next few months is meet with the superintendent and the director of clinical care and start gathering data from the existing facilities, incidents and things that occur there, and then be prepared to do the same after they've been in for a year in the new facility, to understand where some of the metrics might have changed if the average length of stay has reduced and then put together some qualitative surveys from both the staff and the patients, and we can really kind of close the loop and get that feedback and see if any of the hypotheses that we put out there actually made a difference, actually are doing what they're meant to be doing.

It's the first of multiple projects we're doing with the same, client.

So we're doing another 225 bed hospital in North Texas and 75 that hospital in Amarillo.

And so, as much as possible, we're taking lessons learned from this project, feeding that into those projects and trying to make sure that every time we do a new behavioral health facility, whether it's with this client or with another, that we're always improving and proving out some of the things that we believe to be good design and making sure that that it really is good design for that.

It really is making impact and is worth the investment for the donor.

I think that's the big thing that often is there is.

The kicker is we need to be able to convince the owner.

Not only do they need to invest in this particular design feature, but there is a return on that investment.

That's really important for us to move positive health to the design for.

Wonderful.

Thank you so much.

That was a great presentation.

And we have some time for, so Julia and Julie, that is one of my scenes in, the studio.

And we are working on a price stabilization.

Isn't it great?

Hi.

My name is Julie.

I have to run actually, after this, because I have an interview with some of your colleagues, and a few minutes ago, my question was, Mike also went through and research for my 10th class.

My question was, what are some of the problems or limitations that you run into in trying to provide patient autonomy?

And then what you mentioned about the patient control and their environment, while also maintaining, safety and security.

And should those two things be seen as like one concept or intertwined with each other, or should they be seen as more separate at times?

I think it's a challenge.

It's a good question.

And it's something that we struggle with consistently on these projects is really taking the time to understand and that balance.

And I'd rather use the word integration than balance.

Right.

Because it's not that you're giving up one thing for something else is what we're trying to do is achieve both.

We're trying to achieve safety, but we're trying to also provide a destigmatize to normative environment where patients have more control.

A big part of what has made that hard in the past has been the lack of investment.

From an industry standpoint.

So very few furniture manufacturers, very few, new building materials were available when I started offering them.

How many years ago?

They, we had to choose fixtures and furnishings out of, prison catalogs, unfortunately.

And you can see seeing some of these pictures of this facility, that's not what it looks like anymore.

Thank goodness.

Right.

But that's only because manufacture are making these products to feel more normative to to not just be stainless steel, to not, look and feel like oftentimes folks that are provided that are being provided mental health care are interfacing with the justice system.

So if as much as possible, we can try not to replicate any features of that environment, then we are not retraumatizing, we are destigmatizing and we are showing a level of sensitivity and respect.

And that's only really possible because we have lighting manufacturers that are providing us and get your safe nightlights that touch back to your hand so you can sit in your bed and read a bulb and you can turn the light on.

You weren't able to do that as a behavioral patient before.

So it's the little things like that that have made a really big difference.

In some other cases, we still have to be kind of creative, right?

We have to think, okay, how can we get this done?

There's not a product out there that will do it.

We really want patients to be able to do this.

And you, you work together and you try to do mock ups and testing.

So we oftentimes, as part of behavioral health projects, require our manufacturers to provide us their fixtures long before, construction.

So that we can test them in our office.

We can test them for durability, we can test them for weaponization.

We can tell them from the teacher.

And that's an extensive process.

But it's really important because it can allow us to put things in a behavioral health environment that you might not otherwise.

The other factor in that is like really working with your client in your conditions to understand what are their risk avoidance measures, what are they trying to what are their take off between providing a more normative environment that may reduce aggression, be safer for patients, for staff?

This is often what we talk about with open or closed nurse stations.

Nurses are uncomfortable with an open station.

And we talked about that quite a lot during design.

We had a really fabulous period of family work with with, a lot of the peer counselors work in the facility, family members of current patients and former patients.

And one of the former patients we talked to on that specific item said, if you close off the nurse station, there's a big barrier between me and the staff.

You're telling me you don't trust me?

You're you're maybe challenging me to do something about it.

He admitted that his issue, one of his major issues going into the hospital was, was anger and rage.

And so he would see that as a challenge, and he would do what he could to try to damage that station.

But he said, if you had an open nurse station and I could be face to face with a staff member, I feel more respected.

I feel like I'm trusted and I'm far less likely to actually do something damaging.

And we've heard that story.

A number of different ways, and sometimes it's a different feedback.

But, we have that conversation on every project, and, and a lot of times it's just about understanding where the clinician stand, because they're the ones that are going to have to offer you this facility for the next 20 years.

And what are they willing to accept as far as my skills and what are they willing to, compromise as far as environment or patient care goes in order to receive that safety?

So there is a balance there.

But I do prefer the term integration, because then I feel like you're trying not to give up one to, sounds like a change.

You know, our culture of things, right?

Largely, yes.

So what kind of codes are they?

They life support?

Yeah, it is largely cultural and we've had very different experiences on different projects.

So this one in particular, they were coming in from a leadership down approach of trying to question everything and move to really future, thinking modern mental health care.

And that's not what every client wants.

And so, yeah, it's always a conversation you need to have.

And in behavioral health projects, you start by doing what's called a safety risk assessment.

And it's really important to have those conversations during that process and then revisit those conversations as you go through design.

To remember, Parker mentioned the North Star was people first on this project.

We kept going back to that to remind everybody, yeah, maybe you had an incident on Unit and it's coloring.

How you reacting in this meeting right now.

But let's reset and remember why we're here and then think about what the hospital of the future can be.

So it's definitely it's a culture thing and it's a conversation.

We want to have one answer my question.

So the fact and invite my question is that, you know, how much takes the time you put on, you know, on the research phase and then the, clients or other stakeholders like this.

Is there any pushback on standard farrier for other projects?

Right.

So, yeah, I think we run into that barrier a little more often in, medical health care projects because I think there's an and it's assumption that we all we know everything already.

And you're not necessarily trying to change the way you're providing intensive care in an ICU, ICU.

And so there's less appetite for research and there's less appetite to pay designers to do that research.

In mental health, I think we still have an appetite for it because we're in such a transitional period still, of what?

When current mental health care provisions are around a really, really wide range.

Right?

There are still some that are being provided in cinderblock environments that are really unfortunate.

And then there are some that are being provided in really nice environments and everywhere in between.

And so there's a lot that needs to be done to encourage and prove to staff and hospital administrators that what we're recommending will work.

And you do that by having that research, by having the benchmarking.

So probably the easiest part of of the research phase for us to get the clients to agree to is benchmarking, because they want to go visit other hospitals.

They want to go see what everyone else is doing.

And that's probably the most powerful way for us to convince them to do something is for them to talk to their colleagues at another facility that have already gone through this change and has it's proven out that it was worth the the pain and worth the challenge and worth the the difficulty for the results.

We can't sell that nearly as well as a clinician that's already working in the work environment.

Right.

That's wonderful.

Thank you so much.

So Natalie is going to stay until 2 p.m..

So those of you who have questions you can understand tough.

Ultimately, we're gonna, wrap up, the session right now.

So thank you so much again for joining us.

It was such a pleasure meeting you again, having you join us in College Station and hear about this amazing project.

And so thank you so much.