Welcome, everybody, to today's webinar. This is Bob Davis with Pacific Northwest National Laboratory. Today's webinar on the Nurses' Perspective on Hospital Patient Rooms is brought to you by the US Department of Energy's Solid State Lighting Program. Today's webinar is the first in a series of three webinars on health care lighting. The presenters today will include me, Bob Davis, Pat Lydon from Legacy Health, and Dr. Andrea Wilkerson, also from Pacific Northwest National Laboratory.

I'm going to introduce myself briefly now, and then I'm going to go through some introductory material before I introduce Pat and Andrea in more detail. I'm a senior staff lighting engineer here in PNNL. I direct the Gateway Program, and I lead human factors research efforts here. My experience includes working in engineering and marketing at a large lamp manufacturer and also leading product development and engineering teams with a luminaire manufacturer.

For over 15 years, I taught and conducted research in lighting as a faculty member at RPI's Lighting Research Center and in the College of Engineering at the University of Colorado at Boulder. I have degrees in architectural engineering and a PhD in cognitive psychology, where I focused on human factors and lighting.

For today's webinar on the nurses' perspective, the inspiration for this project came through a DOE-funded R&D project with Philips Research. Philips received funding to develop a new patient room lighting system, and it's an active and ongoing project.

Early in that project, Phillips asked the DOE team if we could provide input from Better Buildings Alliance members on nurses' impressions and issues with patient room lighting. That led our team to partnering with Legacy Health in Portland, Oregon to survey the nurses in different Legacy facilities.

But before we get to those details, I wanted to talk broadly about why DOE sees health care lighting as an important topic area. And it may seem a little strange, but when I tried to think about, strategically, why is health care lighting important, one analogy that came to me very quickly was The Perfect Storm. Hopefully some of you have read the book The Perfect Storm. It was first published in 1997. Perhaps if you haven't read the book, probably more of you have seen the movie that came out in the year 2000, The Perfect Storm.

The book, and the movie based on the book, were about a weather event that happened in 1991 in the North Atlantic. And of course, one of the great things about the movie was getting to see George Clooney and Mark Wahlberg terrified as they're about to be swallowed up by a huge wave.

What was the perfect storm? It's interesting to me. So looking at weather charts from that time, you can see on the bottom of this chart the date of the 29th of October 1991, and it's a picture of the weather patterns in the North Atlantic. Doesn't look like much to the untrained eye like mine.

But actually, there's three important things that were happening here meteorologically. Hurricane Grace had sort of churned in the Atlantic off the East Coast of the US. Hadn't really done anything, had stayed offshore the whole time, and it was fading up to the Northeast.

At the same time as that fading hurricane was moving that direction, there was a low pressure area, an extratropical low, up in the North Atlantic that sort of began sucking in the hurricane. It was a low pressure. And at the same time, there was a high-pressure ridge pushing down from Canada through New England pushing down on that hurricane.

So although it didn't look like much on the 29th of October, by the time November 1st came around, this is what that same area looked like. The things had just started to spin, and it created this huge storm, which was a very unusual hurricane because it had not been formed in the tropics, but it formed this far north.

One of my favorite images of that time, and I was living in New England at that time, is this image. To me, when you just look at this sort of out of context, to me it shows just a beautiful, powerful convergence of different forces of nature to form this one thing. But of course, the other way to interpret it is this is really a devastating collision of events that really wreaked havoc in the North Atlantic and that led to the book and the movie.

You might be wondering what's any of this have to do with health care lighting. And as I look at the lighting industry and the health care industry, to me, there's sort of three major forces that are also converging for us right now. And we'll replace the three meterological terms here with what I see as three important forces, and I want to talk about each of these three before we talk about the nurse survey.

So the fading hurricane that's kind of been offshore in my mind is-- I'll call it health care demographics. Health care industry is a major industry in the US. You'll see it's a major energy user. We'll talk about that in a minute. And also we have these demographics in our population of the aging population that are really critical in the future of health care.

The extratropical low kind of sitting off to the right is what I'll call solid state or LED lighting technology, that LED lighting and solid-state lighting has really sort of come into the lighting industry in a major way in the last decade and just exerting a lot of pressure on a lot of things in the industry because the technology is so new and so different.

And then the third force, sort of that high-pressure ridge pushing down from the north, the non-visual effects of light. There's so much we're learning just in the last 10 to 15 years of new things that we understand about the visual system, how light affects us in non-visual ways.

So I want to give a quick overview of each of those three forces to kind of set the stage for the webinar series that we're launching today. Let's think about the health care industry in the United States. I put down three numbers that I think are pretty interesting to think about health care.

The health care industry in the US is over 16% of the gross domestic product, which are major industry in the United States. Energy expenditures average $8.8 billion a year within the health care industry. And we saw one analysis that actually looked at, how does that break down in the typical hospital per bed?

And the number that's spent on energy per bed in the average hospital is $13,600 per bed. A lot of money going to energy. And of course, part of DOE's interest is if we can save some of that energy, that money can be reinvested hopefully in more caregivers, better care. So we can take the energy money and shift it over.

When we look at energy use in health care facilities, this chart shows across the US the energy use intensity, we measure that in thousands of Btus per square foot. So it is based on per square foot area. And you can see in this chart that hospitals are the second largest energy use intensity in the US behind only food service facilities. And outpatient health care is also down on the list.

Now, if you notice on this list, I'll point my cursor quickly, you know that most of the buildings on here are under 100 kBtu per square foot, because if we look at different health care facilities on the next slide here, we see this broken down to different types of health care. The ones in blue are sort of inpatient types. So hospitals are up there at 260. Nursing home/assisted living at 143,000 Btu per square foot. And then some outpatient things, medical office buildings and clinics.

Now, notice three of these four are over that 100 that I mentioned, that most buildings in the US are below that. So we see this big energy use intensity in health care. Obviously that's not all lighting. But there's a lot of energy is why DOE is paying attention to this.

Another graph I found very interesting was, because this is all done per square foot and because hospitals typically are much larger than most of the other building types on the list, when we just look at the per building energy use, we see this huge difference, that hospitals, in terms of the energy use per building, are just sort of dominant over any other building type in the US. So it's a big part of the economy. It's a big part of energy use in the United States.

At the same time that we have that, we can look at just lighting. So what about electricity? Those other numbers are looking at total energy. Now if we just look at electricity in typical health care buildings, according to the Energy Information Administration we see that lighting is by far the biggest electricity end use in a typical health care facility, at 43% going to lighting. So it's not just energy, but lighting obviously a big part of that.

And then when we look at the future of the health care industry, we get sort of stunned, at least I do, when I look at these graphs showing the demographics that we face, not only as a nation but really across the globe. This is a slide from the United Nations showing the century from 1950 to 2050 and the projections for what percentage of the population will be over the age of 65, sort of contrasting that with what percentage of the population will be under the age of five years old.

And I think it's fascinating that we are right now at 2016 right about at the point where the percentages match. But the 65-and-over percentage continues to climb, and the younger percentage continues to decline. So you can see that globally by the year 2050, the projection is that about 16% to 17% of the global population will be over the age of 65.

If we just think about the US, the statistics that we have show that in 2014 there were 46 million people 65 or older. By 2060, that will more than double, even more than the global population. It will be 24% of the US population. Across the world, it'll be about 16%.

So we have this major energy user in the health care industry, and we also have this aging demographic. That means there's going to be more demand for different types of health care. And it also means that the folks providing that health care are typically going to be older as well. The graying workforce in nurses and doctors is also an issue that needs to be thought about for lighting.

So that's that first sort of fading hurricane off the coast-- the health care demographics. From the LED industry, the opportunity with LED systems to tune the spectrum, to tune the intensities, to connect things, provide lots of opportunities. DOE's been looking at tunable LED systems. There's a CALiPER report that was published in August 2015 and updated in January of this year. You can get that off the Solid State Lighting website.

On the Solid State Lighting website itself, the graphic on the right is from a web page we've been building out to provide just basic educational information. So I want you to be aware that there's some information coming from DOE and will continue to come on the LED technology and tunable systems.

And then, finally, this sort of high-pressure ridge-- the non-visual effects of light. This slide's just showing a cross-section of the human brain. And we've known for decades, or centuries really, the way vision works, that we have rods and cones at the back of our eye. Those rods and cones connect to retinal ganglion cells at the back of the retina. Those retinal ganglion cells connect out through the optic nerve and back to the visual cortex.

That's how we see. And seeing allows us to do the things I've listed here, different visual tasks, not just visual tasks, but also things like enjoying architecture, appreciating things, learning, communicating. These are all things based on human vision, and we've studied that for a very long time.

Much more recently we have found out that there is a non-visual pathway from the human retina, that there are some of the retinal ganglion cells that are photosensitive. We call them the Intrinsically Photosensitive Retinal Ganglion Cells, IPRGCs. They don't connect to the visual cortex. They connect to the hypothalamus and control many different biological effects, some of which I've listed here.

We won't go into a lot of detail on these here. We'll be talking about these a little bit more in the upcoming webinars. But they are important effects that don't have anything to do necessarily with visual processing, but they do have something to do with light and specific wavelengths of light. The photic and non-photic simply means that in this non-visual channel, it's not just light that affects things. There are other influences on those factors that we've listed as well.

So those are these three kind of forces that we see affecting the industry. And what DOE is hoping is we can support health care providers as well as the lighting industry to sort of see if we can manage to get these three forces to converge together in a way that produces sort of a beautiful, powerful convergence of things and not something that would be destructive or damaging.

We've initiated a number of projects to try to make that possible, and we're going to be talking about three of those projects in this webinar series. So I put this slide in just to remind you of what's coming up. Today, we're going to talk about the nurses' perspective.

On October 4, we'll be reviewing the findings from a recent literature review we collaborated with Clemson University on and Professor Anjali Joseph-- Evidence-Based Design for Health Care Lighting, looking at what's in the published literature about the evidence for different aspects of health care lighting.

And on October 18th, we've been partnering with folks at SMUD, the Sacramento Municipal Utility District. And we'll be presenting with Connie Samla on a project done in Sacramento at a senior care center with tunable LED lighting.

So with that, let me introduce the nurse survey speakers for today. Pat Lydon is the Sustainability Program Manager for Legacy Health, a 1000-bed, six-hospital integrated delivery network serving the Portland, Oregon and Southwest Washington region.

Pat's responsible for developing and implementing cost-effective strategies for sustainability programs, including water and energy resource management throughout the 4 1/2 million square feet of building space operated by Legacy Health. He's also responsible for developing Legacy's energy acquisition plans, and he currently serves on the board of the Northwest Industrial Gas Users and the Association of Energy Engineers Columbia River Chapter.

After Pat speaks, Dr. Andrea Wilkerson will come on. Andrea's a lighting research engineer here at Pacific Northwest National Lab, focusing on the evaluation of emerging lighting technologies and the development of lighting system solutions in support of the DOE SSL program.

She earned her doctorate from Penn State and her BS and MAE degrees from the University of Nebraska in the respective architectural engineering programs. Andrea serves on the IALD Education Trust board of directors and on several IES committees. With that, I'll let Pat take over to tell you a bit about Legacy Health. Pat.

Thank you, Bob. So as Bob mentioned, I work with Legacy Health. We're a nonprofit, locally owned health care delivery network based in Portland, Oregon. We serve the Oregon and Southwest Washington areas, but concentrated mainly around the metropolitan Portland area. So that's where most of our hospital presence is.

But as is the case with many health care systems, we're also growing our clinic presence throughout the region on an expanded basis. We have six hospitals listed. You can see them listed here. I'm not going to read through each one of them, but you can see they all serve the Portland metropolitan area. And we've actually recently merged with a seventh hospital, Silverton Health, which is down near Salem, Oregon. All totaled, before that merger we had about 4 1/2 million square feet, excluding clinics.

Our approach here to institutionalize energy efficiency, which we see as a very important element of our sustainability program, is we leverage programs like the Energy Trust of Oregon's Strategic Energy Management Program. So that program helps us focus on operations and maintenance opportunities. Basically what we're talking about there is anything that involves site assessments, constant review of our monthly energy consumption, tuning, retrocommissioning, those kinds of activities.

We also have an element that looks to our master planning and our design and construction and capital upgrade cycles. So we anticipate, what can we do to improve our overall efficiency through equipment upgrades and investments in the future? Today, energy efficiency tends to be a secondary priority. The vast majority of the emphasis in that process is on patient safety, patient comfort, clinical technology, and we're leaders in delivering clinical care.

But my role in sustainability is to remind everybody that's involved in those processes that we have huge opportunities to improve our energy efficiency at the same time. So I'm working with our facilities and design and construction staff to integrate the energy-efficiency aspects into that planning cycle.

And as I point out here, we have more room to improve. We need to get a better focus on total cost of ownership, investment quality for the buildings that we're designing, building, and remodeling and make sure that we're not overlooking the financial side of the opportunity in addition to the energy efficiency and carbon footprint reduction opportunities that exist in that cycle.

And then, lastly, we have an employee engagement thrust in our sustainability programming specifically around energy efficiency and other areas of sustainability. I regularly present every week at our new employee orientation, and one of the areas that I emphasize in those presentations is the connection between energy consumption and health and how when we reduce our energy use, we're also making a direct contribution to our mission to improve health in our communities. That's not a well-understood or intuitively obvious connection, so I like to take that opportunity to let people know when they're coming in that there is a very clear connection there.

Recently I've started working with some other staff here at Legacy that are responsible for physician engagement in a number of ways. And I learned we have a physician portal that I can get access to and get some sustainability and energy efficiency and health-connected related information on that portal. So I'll be working on that next.

And then we also have a thrust to figure out how to recruit more nursing involvement to our Sustainability Committee, which will then present me with an opportunity to engage with our nursing community and help them understand how their decision making and their actions in performing their duties can contribute to energy efficiency.

And that last item right there really is our connection to this nurse survey. By engaging with our nurses and asking for their input on the lighting that exists in the facilities today, it opens up a great communication channel to follow up and to work with them to figure out how do we do a better job of designing lighting that not only meets their needs for clinical care delivery, but also is energy efficient.

OK. We'll go ahead and get started. So thank you again, Pat, especially for your considerable effort in making this happen. Lots and lots of emails and lots of perseverance on your part in order for this survey to occur.

So part of the reason, as Bob mentioned earlier, there's a broader reason that the Department of Energy is interested in health care, as well as our team's focus on patient room lighting. And one of the goals for the survey was really to help determine the characteristics of optimal patient room lighting systems. And then also to identify, what are the opportunities for increasing energy efficiency?

So this survey was a 17-question survey with about eight demographic questions and then the remaining questions were really focused on the nurses' perception of the lighting in the patient room that they most often worked. And the nurses that participated were located at four hospitals. Three of those hospitals were older hospitals, urban and suburban, and then one of those hospitals was newer and was a children's hospital.

As you can see from the photos on the slide, the patient room varies quite a bit in terms of layout and lighting. And so we're not going to try and dive into the particulars of a patient room. But we're really just going to take a broader look at, where are areas for improvement in general regarding patient room lighting?

And thankfully, we had 252 nurses who provided plenty of feedback and well over 600 comments on patient room lighting, and so we will be reviewing that today. A little bit about the nurses. Who are they? At all the hospitals, we had a range of ages participating in the survey voluntarily.

And you can see the darker shaded area at the bottom of each bar, and that's indicating the number of nurses that worked the night shift. So there's between 27% to 42% of nurses at a given hospital that work in the night shift. And that's probably not surprising is that the percentage of nurses working the night shift decreases as the nurses' age. So something, again, that's important to take into account when you're designing a lighting system.

Also, what department were they working in? So in general, the nurses who responded to our survey were working in the medical surgical unit. But you'll see at the newer, children's hospital, there were quite a few nurses also working in the ICU, and we had a variety of departments that participated, which we are happy about.

Also probably not surprising that 95% of the respondents were female. And we were really pleased to see that 67% to 80% of nurses that responded from a given hospital had worked at that location for more than five years. So they were providing some experience when they were answering the survey.

So the survey design. We kept reiterating with every question that we wanted the nurses to focus on the patient room in which they most often worked. And we asked them to rate and rank the impact of different attributes of the lighting system. And then we also asked them to rate the different areas of the patient room.

And looking at how they rated and ranked different attributes in areas as well as reviewing and scoring all 600-plus comments, we felt like the results that came out of the survey and comments really were pretty clear as to what are the high-level takeaways that the nurses were communicating through the survey.

The first was light level. So we asked the nurses to rate these different attributes. And we asked them to rate on a scale of strongly hinders, moderately hinders, neutral, moderately helps, and strongly helps. And so when they were doing this rating and then when we weighted these ratings, controls came up at the top as one of the most important attributes for performing their duties. And then followed by light level, color, the pattern of light and dark areas, flicker from the light fixtures, glare from the light fixtures, and shadow from people and objects.

So after they rated these different areas, and again, they could have chosen strongly hinders for all of those attributes, or they could have chosen neutral, so they weren't required to really choose between two. But with the ranking, we asked them to pick what were the most important attributes. They could only pick one attribute that was ranked as number one.

And so light level came out at the top when we were asking them to specifically rank those attributes. So really we see, based on the results, light level and control were prominent in the survey, of prominent importance. And then color was a distant third.

And some of the comments from the nurses regarding light level. And so there are many, many comments about using a flashlight and that being necessary for catheters when there's no adequate over-the-bed light and just in general. And one nurse commented that she would like a bright, adjustable light fixture attached to the ceiling. Another nurse had a comment about whoever came up with the idea of not having direct overhead lighting has obviously never worked as a nurse.

And another commented that overhead lighting would really help them improve their ability to perform their duties as an IV nurse and how that relates to patient satisfaction. And even anecdotally, I'm sure you've heard people complain before about how many times it took for the nurse to get the IV in. But after reading all of these comments, makes me realize that their task is really quite hard. And oftentimes they just don't have the lighting that they desire to perform those duties.

And another thing that really surprised me was the emphasis on the overhead lighting. I had never thought too much about just how important that light on the bed would be, especially when they're working at the end of the bed.

So moving on to controls. I mentioned there were over 600 comments. And I went through and scored those comments and marked if they discussed controls, if they discussed dimming, daylight, color, the bathroom. There were several different categories that if they mention those, then I would score them, and then I summed up those comments. And so over 400 nurses commented on controls.

And we asked specific two questions about what is best about the patient room lighting and what needs improvement. And so you can see again, looking at the number of comments related to controls compared to daylight and the bathroom, controls were definitely on the nurses' minds, with a lot of nurses indicating that was the best thing about the lighting in the patient room, and other nurses wanting more controls.

So one nurse commented that it would be nice to be able to turn or adjust the lights remotely. And that you can be all set up to do a procedure, but then you might realize that you need a little bit more light. And with technology advancements, and this is something I think that is definitely possible in the near future.

Also, a nurse commented on how challenging it is to get the appropriate amount of light. And that even when you use a spotlight to get more light, then it can skew skin tone, creates glare, creates a blind spot, and it just takes a lot of adjusting and readjusting.

There were also comments related to location of the controls. So in this instance, the nurse would like to see bathroom light switch outside of the bathroom so that the patients don't have to fumble around for it inside the bathroom. And again, that might not be the best solution either, but just at least acknowledging that there's an issue here with the bathroom light switch not being easily accessible.

And then, again, placement of light switches is not always obvious. Some nurses commented on how it seemed to be there were 100 different light switches in 100 different places. So again, something that I think needs to continue to be a focus when designing patient room lighting.

And so taking it one step further beyond controls, a lot of nurses actually commented on dimming. And so you can see, I just highlighted the bottom portion of that bar, and there were over 150 comments from nurses just related to dimming.

And then if we break down what the comments were related to controls, some of those comments were just general, couldn't really be categorized. But a lot of the comments could be categorized as dimming. So they loved dimming, or they really wanted dimming. So that's where that best comes in. The best thing about the patient room to them was dimming, or the thing that needed improvement was the fact that they wanted to be able to dim.

So a few more comments on dimming-- the over-bed light is obnoxiously bright. More dim light options are needed. And that the bright over-bed light is painful for the patient's eyes, but that it's needed in order to do any sort of care in the lower body area. Also, one nurse commented on the fact that being able to adjust the light would allow for some therapeutic benefit for the patients, as well as could provide better visibility for the staff if they could increase it when they needed to do lab draws or exams.

And then another interesting comment was how the variance of natural and artificial light is difficult. And remember, this is in the Northwest, so we're not exactly known for having a lot of natural light. But I think it's something, especially as architecture trends increase the amount of daylight coming into a space or give people a view, also taking into consideration what that means in terms of how the daylight will interact with care, with what's going on in the space.

And another comment is that-- a few nurses actually commented on this-- that there wasn't enough shading on the windows. So at night you would get the bright city lights shining into the room even with the shades drawn. So something else, when you're trying to incorporate daylight, it's important to take into account other consequences.

And then we also had, as I mentioned earlier, the nurses rate the different areas of the patient room. And so they rated these excellent, good, neutral, fair, poor, or not applicable. And again, they could choose all excellent if they wanted to. They could choose all good. They weren't restricted in that regard.

And one of the things that really stood out from this was the fact that new hospital, old hospital, across the board, that nighttime navigation had one of the lowest ratings. So computer monitor, equipment monitors were rated best, with bathroom and entrance rated in the middle. And worst were patient bed, guest area, and then this nighttime navigation.

So looking at some of the comments from the nurses regarding nighttime navigation. The lighting is often too harsh to complete my exam in the middle of the night. One nurse commented that flashlights were very necessary and that she needed to change out the batteries in her flashlight each week.

A few nurses actually made this comment-- the best thing about the lighting being that they could turn on the bathroom light and close the door, and that would provide a low level of light at night. And definitely think that's one of those areas for improving efficiency and coming up with better solutions. Also, one nurse commented that she uses the scanner to shine on the computer so she can see what she's doing in the dark without turning on the lights.

And then one last question for the patient room in which you most often work-- do you require additional lighting? So we asked this question and were a bit surprised. 32% said no, but 68% said yes and sometimes. So the main source of supplemental light was a flashlight, with over 60 nurses indicating that's what they used, also a task spotlight or exam surgical light.

And all these nurses are using the supplemental light at night. And two of the tasks that require them to use the supplemental light include catheterization and IVs. Again, just going back to how many nurses commented on the difficulty with seeing at the end of the bed, and there's a considerable problem with catheter infections. And then also just the fact that oftentimes people, once getting out of the hospital, will complain about how many times it took the nurse to get the IV in.

So these are just small things. But you start to think about how just having a little bit more light may help that patient experience in the hospital and also just help the nurses to be less stressed when completing their daily activities.

So a few comments about the supplemental light. Pulling the top light down is helpful, but it's not adjustable enough if the bed is elevated. So you can see in the photograph or you can imagine if that bed was elevated, how that would change the distribution of light across that bed. And you can already see that there are pretty distinct shadows coming from just that light at the top of the bed. And so if you can imagine trying to examine something at the foot of the bed, that would be pretty difficult.

Also, one nurse commented that they turn the harsh room lights off, and they do their care by a bathroom light, a flashlight, or an otoscope. And then another nurse commenting on catheters, that they need a light that shines from the foot of the bed. And then one nurse saying that currently there are not patient rooms available with optimal lighting for IV starts.

And so this brings us back, really, to the beginning when I mentioned that really our overall goal was to better understand the characteristics of an optimal patient room lighting system. And so light level controls and dimming really came across as three areas where the nurses felt like it was important that they could adjust the light, that they would be able to control the light, could change it from bright to dim as needed. And that nighttime navigation, another area where they had to resort to flashlights or turning on the bathroom light, as well as supplemental light.

So hopefully in the future, with advancements in patient room lighting systems, we can get rid of some of the need at least for supplemental lighting, and it may never go away. But one of the nurses commented that there is no light that is helpful for placing catheters, some of which may be true.

But I also think that is an opportunity for the lighting industry to really collaborate with the medical community in order to determine how we can better serve the medical community with lighting systems. And so hopefully we can continue collaboration in the future and figure out ways to improve lighting systems.

And to end, it's also important to keep in mind that sometimes change, there's some resistance to it. So one nurse commented that she hated the new ideas about lighting. So again, I think this is where collaboration is necessary to make sure that we're addressing the needs of both the younger nurses and-- in this case she mentioned that she was an older nurse, and she felt like she needed to be able to look at color and that she struggled with contrast, going between dark rooms and bright computer screens and bright hallways.

So it's really trying to take into account the variety of ages and backgrounds and departments of these nurses, and I definitely think there's a role for collaboration in the future. So with that, I'll turn it back over to Bob. Hopefully you guys have some questions that we can answer.

Great. Thanks, Andrea. Thanks, Pat. Very interesting to get those direct quotes coming from nurses. We do have time for a question and answer period. So feel free to send your questions in. I have a few here that can help us get rolling. Then we'll see how much more discussion we have.

One question that came up is just about getting more details on this nurse survey and the results, and I can answer that one. We really focused this webinar on the kind of open-ended responses. There were, as you saw from what Andrea shared, we had rating scales, and we had different ages, different hospitals.

We were frankly surprised at how much the nurses wanted to share. When you design a questionnaire like this, the usual thing is you got to keep it short. They don't have much time. And so we didn't expect the level of thoughtful, detailed, open-ended responses. We were gratified at that and found we learned a lot from those. And so in this webinar we focused on that.

We are also working on all the quantitative data, and we'll have a full technical report that goes through those rating scales and what we learned about the different hospitals and things. So that will be coming out later. If you're signed up for the DOE updates and Postings, you'll get updates on that. And I guess, Andrea, just to follow that up, questions about, did you notice any important differences, one, based on the ages of the nurses, and then two, based on the differences in the different hospitals?

And that could be a really long-- well, I could give a really long answer to that one. But just a couple quick comments. So age differences, we did notice there was a difference in how highly they ranked glare as an issue as they aged. So as the nurses aged, they were more likely to rank glare as being more important over the other attributes listed.

And then between hospitals, there was definitely some difference too in regards to bathrooms. That was one that kind of stood out. There was the one hospital where the bathroom got quite a few poor ratings. And we just haven't dived into those differences as much as we would have liked by now, but they're definitely worth exploring.


And Bob, do you have anything to add to that?

No, I think that's good. I think I wanted to shift to Pat, because I think what we saw, as Andrea mentioned, in the different hospitals, there were definitely big differences in age of the hospitals, some older versus newer. And it seemed like, from our survey, the newer hospitals were definitely going the right direction, right, that the responses were much more favorable with the newer hospitals, which you could tell a lot more care had gone into the design, not just the lighting, but the overall design.

And I guess, Pat, that sort of leads to a question that came up. When you have this mix of older buildings and then newer buildings, how do you sort of balance that mix? What are the drivers to update the older buildings? You mentioned your drive to increase engagement with the caregivers. And so how do you balance off the sustainability and energy goals that your department has to the things that affect care?

Well, obviously our best opportunity is to catch that during new construction planning, to make sure we're thinking about the best way to design lighting in new construction projects. So if I could get a seat at that table early enough in the design process, I'd bring that kind of thing up.

Then often those new construction projects lead to movement of units and departments. So they vacate space, and sometimes that can present the opportunity you want to find to do some remodel work and to consider how to improve lighting based on what will move into that space. But the bottom line is, if those two activities aren't happening, it's much harder to do it because obviously you're talking about patient rooms.

And it's very difficult to take down blocks of patient rooms at any point in time to do this kind of work, because obviously, in many cases, you're going to be disturbing the ceiling plane, or it's going to be pretty disruptive, and the room's going to be out of commission for a while while you're doing it. So I think our best opportunity is to really think about how we integrate this kind of improvement with new construction and any subsequent remodel in vacated space.

Good. And Pat, a related question that just came in on that is-- just a general question of, who decides or who makes the lighting design or the purchasing decisions, I guess, at least for Legacy? Is it sort of a centralized thing, or is the individual hospital making the decision? Is it facilities? Is it the administration?

That's a great question, and it's one where we still have room to improve, like many health care systems probably do. We are a system, so we do have a centralized administrative office, which is what I work out of. And we have centralized oversight of construction and major remodel projects.

But nevertheless, there are still a lot of decisions that are made at the site level based on the individual hospital president and the individual facilities management that exists at that site. Sometimes it's actually tied to who the strongest relationship might be with the electrical contractor.

So in many cases, there may be a relatively long-term relationship with an electrical contractor that knows that facility very, very well. And because they have such a strong presence there, they may be the ones who are making suggestions on fixture selection and that kind of thing and lighting remodels. And that's not always the best way to go, because they may not be the most informed, the most current on that information.

So that kind of ties into my involvement with you, Bob, and with the Department of Energy's Better Building Alliance, and specifically the health care sector. One of the things I focused on quite a bit over the last few years was really educating myself on lighting in particular and how to get a better idea of how to leverage the new LED technology in clinical care.

So as I've been able to do that and build relationships with our facilities and our design and construction staff, I'm kind of getting a reputation for having some information about lighting. So more and more people are coming to me with questions, which is good because that's the desired outcome.

That way we can have more of a thoughtful process about how to go about making the selections instead of just letting existing vendors tell us what we should get based on what they push and what they have sales incentives on. So it's another one of the gradual changes that's occurring as we do a better job of integrating sustainability thought process into all of these other existing processes.

And that's good. I think from my perspective, one of the observations with Pat and Legacy Health, but also we've seen at other health care systems and also, frankly, with things like school districts, is sort of that tension between the central corporate goals and then the individual locations and their desire to have some autonomy, whether it's a principal of a school or an administrator at a hospital.

And so I know it's kind of that balancing act of letting the facility control some of their things, but also making sure the overall goals for the whole organization are being met. Andrea--

Yes, go ahead, sir.

One other thing on that, Bob, is, is even if we do have a thoughtful process on a project, particularly new construction, there's always the value engineering element that creeps in somewhere in the process, where somebody may propose equivalent, but less expensive, fixtures or lighting.

And I think that's where the DOE lighting specifications can be really useful. If we can offer up the opportunity to propose a value engineering element in a project, as long as it adheres to those specifications, I found that to be really helpful.

Good. Andrea, a couple questions just on some specifics you mentioned. Someone says, can you speak a little more about the importance of the overhead lighting? Did I understand that most nurses liked the overheads or didn't like the overheads?

So based on the comments that we received, most nurses liked the overhead lighting. Although I can't remember exactly the word, but one nurse was definitely not too happy with just how bright it was and not having the ability to adjust the brightness.

Got you. And then another couple of different questions, Andrea, came up about-- great to have the nurses' input. Were you able to do any surveys directly with patients, or is there any way to get input from patients? Do you want to comment on that?

Yeah. We actually-- and I didn't talk about this today specifically, but part of our survey was asking the nurses about their perspective of what the patients seem to complain about the most. But the hard thing is that we're still getting the nurses' bias in those responses.

And asking patients is pretty difficult just in terms of protocols. We'd need to get institutional review board approval, and then we'd have to take into account patient privacy. So we didn't get to ask patients their perspective in this survey. It was really from the perspective of the nurses. And again, it is confounded with a little bit of the nurses' bias.

Right, yeah. And I think just to be clear, we did have to use institutional review board even to question the nurses. So that was all done. The privacy issues got to be pretty large. It's more from the hospital's standpoint of protecting patient privacy.

We've had similar things on other projects not in health care, even working with a project at a hotel and wanting to be able to survey the people staying in the hotel. And there's just so much concern about privacy that crossing those lines can get to be difficult from the end user standpoint, which we certainly understand.

A couple questions here that I can just answer directly. Were most of the lighting areas surveyed LED or fluorescent? All of the areas we surveyed were fluorescent. There were no LED systems. Someone else asked about, do we know of any examples, or have you been involved in any hospitals where the whole hospital has kind of gone all in and a complete LED system for the whole hospital?

We have not been involved in any of those projects. Most of the things we are seeing right now are more limited trial installations or using LEDs in public areas, but not yet in patient care areas. Now, I should qualify. This is all for kind of the general architectural lighting, not things like surgical lights and other specific applications where LEDs are well established. So if anyone in webinar land is aware of a major health care facility that's going all in on LED, we would love to hear about that.

Bob, this is Pat. We actually have one of our hospitals, Legacy Meridian Park, we just enrolled in the Interior Lighting Challenge because--

Oh, good.

--they have converted all their troffers to LED. All their exterior parking lighting is LED. Their parking structure lighting is LED. And any can lights in there are pretty much LED. So that hospital has gone pretty far.

OK. That's great. And that was all sort of retrofit LED products in that case, right? Yeah, good.


Andrea, there's a series of questions about color. One person says, I was surprised to hear so little about color, which might factor into task requirements and assessment of the patient. Do you know what's the preferred color temperature by nurses and patients, which color rendering for proper examination and diagnosis discussed? So if you could just comment a little bit more about color and why color didn't seem to come out that high in the nurses' concerns perhaps?

Yeah. Actually, I was surprised by that as well and the lack of discussion, especially when you compare it to all the talk of color tuning and health care and all these cool, new things we can do. Color just wasn't as much on the nurses' radar. You can see it a little bit. A few nurses definitely brought that up, or they also brought up daylight. They appreciated the ability to be able to examine the patient under daylight.

And I guess, again, I would just say that-- well, there's no specific color temperature that we were able to glean, and we didn't try to glean that from the survey. And as far as color rendering goes, again, that's not something we were trying to achieve. We were just really trying to understand, what are the major issues from the nurses' perspective? But I do think color rendering is important and that there is some work that still needs to be done in that area.

Another thing that I didn't mention was just also this idea of color tuning and controls, and do you give the nurses control of being able to change the color of the light? And some nurses did bring this up. And some knew, they understood sort of the health implications, potential implications, of light on health.

But also some didn't understand. One nurse commented that she would like to have blue light that she could turn on at night to calm the patient. And so that aligns with color theory, but doesn't align with what we know about non-visual effects of light.


And so there definitely needs to be more discussion about color, color rendering, especially if color tuning becomes part of the conversation. And I think actually color tuning and this light and health issue being raised will hopefully help, too, with more discussion regarding nighttime navigation and how do we better design spaces taking into account the nurses' need to be able to see at night but also take into account the non-visual effects of light.

Yeah, good, good. Well, we're right at 11:00, 11:00 Pacific that is. Let me do a couple more questions, and then we'll wrap up. Someone asked if the newer facilities got a better score on controls and/or light level. And the short answer is yes. There's one hospital that we surveyed that is about three years old, and that was the hospital that got pretty much the highest scores overall, and particularly on those two questions of light level and controls and also nighttime navigation.

And again, it was just you could tell that it was a thoughtful design that Legacy led that had more navigation elements in wall step lights and things like that. So that was handled better. So definitely the newer facilities seemed to be going the right direction from some of the ones that were, I think, Pat, 30 or 40 years old, right?

And Pat, kind of related, I'll let you think about this one. This question is interesting because it sort of ties into the idea that it's not just-- the aging demographic doesn't just mean that more and more of us need health care, but also that your workforce is an older crowd.

And so someone asked, from a controls standpoint, if you have a room-level control system with a touch screen or an iPad or something like that, is that just too challenging for the older generation of nursing staff? And do you find barriers from kind of the graying workforce to implementing some of the newer technologies?

Yeah, I don't have any specific feedback on that myself, but I could see where that could be an issue. And I think there's a variety of ways you can implement controls like that. One, of course, is what you just described-- a touch screen, menu-driven kind of approach, which could be a little more complicated and may need to have some supplemental instructions posted with it.

I've seen that in some of our conference rooms where we've gone to complete digital audio/visual presentation systems. They usually have a touch panel-enabled control system, and they still need to have supplemental instructions that most of us use regardless of our age.

But I think if you look at the slide, the picture of the controls we see there, which are more of an older sort of analog switch type but are still probably connected to digital controls, there are ways to simplify the control interface. So maybe that's something that needs thought as well.

Yeah. That's good. And I guess I'll wrap up. There were a few questions about that this content has really identified a lot of needs, but not offered much solutions. Will the other webinars do that? And the answer is yes. And some of the other things that came up in terms of some specifics. In the nurse survey, we weren't going in to do detailed measurements of the lighting itself. It was more about understanding what was important to the caregivers.

But in, specifically, the third webinar is a case study at a facility where we did very detailed measurements of lighting, a trial installation of LED, compared it to the fluorescent, and can provide a lot more details on specific solutions and how those seemed to work out.

And someone else also asked things about, did we get anything from the nurses about patient falls or trips or some specific issues that come up? And the first webinar in October we'll talk about what's in the literature about some of those things and the effect of lighting on some of those. And then also in the case study in the third webinar, we have some data from the facility there about what happened after the changes in terms of some of those direct patient impacts.

So tune in, I guess, on the two webinars in October. Sorry we didn't get to all your questions. Thank you. I know at least one person sent in a kind of a tip on a facility that's done some large LED installations in a health care facility. So thanks for that.

Thanks for attending. US Department of Energy's Solid State Lighting Program appreciates your attendance here and hope you can participate in the next two webinars on October 4 and October 18. Thanks again to Pat and Andrea. And thanks to everyone for listening in.