Design is Like Healthcare...

I call it the “duh” moment- when someone can frame an issue in a way that is so obvious that it inherently makes sense.  You wonder how you never came to that conclusion on your own.  I experienced on of those moments today while reading Scott Simpson’s Change of  State in A/E/C” for Design Intelligence. It compares the sea change going on in our world to the one that has and is still occurring in healthcare. Doctors and hospitals are “always” kind of things that we will never stop needing, but the particular services they provide and the way in which they deliver them has changed. Sound familiar?

The piece particularly resonated for me because I have a foot in both worlds as an architect who specializes in healthcare. Like many physicians and hospitals, our industry has been slow to move from a traditional cost-based, risk adverse model. We are annoyed that our value or expertise is questioned and rush to create defensive contracts or lobby for legislation that will protect our design processes. What we don’t do is stop to consider whether these processes even still serve us. As Simpson puts it, “there’s not much evidence that all of this management and monitoring is being used strategically to design better buildings or deliver them more efficiently, which is what clients really want.”

Simpson does a great job at projecting trends from the demise of mid-size firms to the rise of multidisciplinary project teams. It’s a futurist view, but an instructive one that I hope will inspire you to look beyond the way things are and start looking at how you can be a leader in delivering:

Architects now have to sell their expertise and value instead of their time
Outcomes matter more than the services provided, value does not equal cost. Simpson cites the example of physicians, who are the primary deliverers of care. At one time, physicians determined how they would treat patients and were paid unquestioned for the services they provided. Today, many have become employees of large health systems and the care protocols that they use are largely dictated by insurance company requirements, which are increasingly being tied to outcomes for the patient. Similarly, architects have focused on being compensated for time or as a percentage of the construction cost for producing a design product. We want our talent to act as the justifier for our decisions. Architects need to have a much broader understanding of what their clients value as well as a way to frame every decision within that context. Start framing the services and expertise you provide as a series of value-adds and tying financial incentives to your ability to deliver according to metrics that are important to the owner (lower maintenance costs, better building performance, etc.). Far from diminishing design freedom, this practice will actually justify in real terms what has in the past seemed arbitrary or purely aesthetic.

Teams, not firms, will design, document and deliver projects.

Just like the once-dominant general practitioner has now become only one member of a team (not all of them physicians) of specialists who manage a patients health, so too will the architect be perhaps the owner’s guide, but certainly not the only player in determining what’s best for a project. You wouldn’t go to a doctor who routinely performed tests without confirming with your insurance company that you had coverage, or who refused to give you access to specialists when needed. It’s the same in design. The standard focus on phases of design and bidding will become irrelevant as technology allows more sophisticated modeling of options. Into the funnel will go decisions about design, sustainability, schedule impacts, operating costs, return on investment needs, outcomes on user experience and out will come a determination of value. This will happen for multiple scenarios throughout the project and the entire team, including the owner and their stakeholders will weigh the options to select the one providing the highest value. Look for more collective contracts and increased emphasis on integration and collaboration. Better yet- suggest them and become an influencer of their content.

If you don’t lead the change, the change will lead you

Physicians have become marginalized by the business of healthcare. Although they still play a critical role, that role is no longer dominant as other players like insurance companies, government agencies, equipment manufacturers, lawyers, and the corporate structures that manage large health systems have come onto the healthcare scene. The solo practitioner with an independent practice who referred patients to the local independent hospital is a relic in today’s healthcare environment. Architects should learn from their medical counterparts that resisting change diminishes your power to shape it. My favorite quote from the piece nicely sums up the issue, “The irony is that architects, who are so good at inflicting change on others, are woefully reluctant to embrace change in their own practices.” Change or become irrelevant.

Found: How Wayfinding Trumps signage

Is signage overused in healthcare facilities?  While some is certainly needed, the reliance on it as a wayfinding strategy is a problem for many institutions. Don’t even get me started on the “tape on the floor” issue.   Patients travel long distances, often navigating several floors or changes of direction, even moving from one building to another as they attempt to reach their destination. Many of these patients are already in poor health or elderly, making it a confusing and oppressive journey.  The problem is compounded for the low English proficiency population (LEP), who may not be able to read or fully comprehend signage. 

I have been thinking a lot about how architecture can play a role in creating more intuitive spaces that rely less on signage.  Many of these strategies are rooted in behavioral research and involve cueing and other psychological devices. 

Create enriched environments: 
Reinforcing a location through a theme, artwork, color palette, floor texture, music, even aromas, helps users to cognitively organize the area into a “place.” Just this simple act can create the perception of less distance to travel and reduce confusion related to having to pass through several different areas to reach a final destination.  As different people resonate more strongly to each type of behavioral cue, providing multiple cues reinforces a message and also reaches out to the greatest number of users. Incorporating natural light, plants and water features provides therapeutic effects that enhance the wayfinding measures. 

Put your urban design skills to work: 
Just like good city planning involves creating landmarks, districts and hubs, so does good institutional planning.  This is old Kevin Lynch stuff, perhaps so first-year-architecture-school obvious that we forget about it.  Providing major destination points that are visible from a distance helps users to know they are headed in the right direction.  Hubs should be designed around major vertical circulation elements and include multistory space when possible.  Doing this allows users to see their destination from the hub, which makes getting there less confusing.  Hubs also create great opportunities to create resting places.  Patients who have trouble navigating long distances need to stop often along the way.  Their stopping point should not create a break in their cognitive map, but instead occur within it.   

Avoid information overload: 
When designing, think about paths of travel and decision points- the times when a user needs to choose a direction or action.  Effective design minimizes decision points and links them for the most part with hub locations.  The fewer decision points there are in a facility, the simpler the cognitive map will be and the easier the wayfinding.  From the point of arrival on the site, information should unfold on an as-needed basis.  In her excellent article, Wayfinding: Design for Understanding, Barbara J. Huelat discusses the “airport model” for signage, stressing that providing users with more information that they need at decision points creates confusion not clarity.  This progressive disclosure simplifies the cognitive map as well.  While we want to avoid visual overload, don’t forget about auditory over-stimulation.  Be careful to design acoustically sensitive spaces that mask and absorb noise.  Loud spaces are very disorienting to someone who needs to concentrate or collect their thoughts. 

Ultimately, wayfinding is about promoting understanding and access to an environment.  The best way to do that is to think about the user’s travel path as a journey.  When you can see where you’re going, you know how to get there.

Are You an Architecture Bliss-ninny?

Do you eagerly await the next installment of your favorite design mag, have books chronicling the work of your favorite architect and actively follow you favorite firms and design blogs?  While there is nothing wrong with having heroes, appreciating good design or learning about trends or amazing ideas, there is a fine line between celebrating and sharing creativity and defining success as an architect by stylistic trends. Are we accepting the wrong premise?

If you can believe that success is not about calibrating yourself within the spectrum of your competition, but instead about you and what you contribute right now, would it matter if some other firm was bigger or had done more projects?  We need to stop defining ourselves by the terms set by others who have been successful- that is who they are, what they did, and however great an accomplishment, it does not represent the only or best answer that will ever be possible to achieve.  

Don't get lulled into conventional thinking about what design is all about.  My 16 years as a practicing architect have lead me to both moments of glory and despair about my career.  I believe that you can  keep the faith as an architect, and it is in the moments when I have done so that I have realized my greatest successes. Below are my design canons. Click the links for more in-depth information on each:
  1. Stop being rick-adverse. You lose your design magic when you lose sight of your design values and stop promoting them.  You can never take a risk if you are afraid to fail and no great innovation comes without risk.
  2. Know what you stand for as an architect.When you are engaged in what you do and really believe in it and yourself, that passion allows you to make the connections that truly move a client to believe in you as well. 
  3. It's about innovating, not about competing. Calculating and worrying as a management style leads us to view our profession as a hostile environment where we are trying to beat out competition to a few scare resources and opportunities.  This kind of mindset holds us back from our true potential and the limitless abundance that it can bring.
Know yourself and promote your unique vision, follow the heroes whose work informs that vision.  Don't just smile and nod your head in the face of the design media and profession's definition of success.

Architecture in the Age of Ideas

Now that we've kicked the first decade of the 21st century, it's a good time to reassess how we work, from the generation of ideas to the way we communicate them.  The digitalization of life has spawned an age of conceptualization- a unique opportunity for ideas to be communicated and valued as never before possible. Information of all sorts is readily available to anyone who can use a search engine.  This can lead to frustration on the part of architects, we feel that our clients think they can do our job for us, that our services are being cherry-picked away by owners representatives and contractors.  It makes us want to turn inward, draw a line in the sand and try to create value for our work through exclusivity.  And that would be a big mistake.

Sure competition for what we traditionally defined as our services has increased while perhaps value has reacted in inverse proportion.  But what do those traditionally defined services have to do with being an architect anyway?  Ask any child what an architect does and you'll get the heart of the matter- we deign buildings.  Who really cares that at some point someone created phases of design and structured contracts around those phases?  Maybe they don't make sense anymore.  Maybe we can do better and be more fulfilled if we stop being competitive and instead focus our main reason for doing this at all- designing buildings.

What our clients need more than anything is someone to take the overwhelming amount of information that exists out there and distill it down to apply to their situation and solve their problem.  They need fresh thinking and innovation- someone willing to synthesize seemingly unrelated issues into a cohesive whole. No owner's rep or contractor can do that.  I challenge everyone not to hoard their knowledge, but to share it.  Make it free and easy to access your ideas, knowing that the more people are aware of them, the more powerful they will become.  Change the world.

Form follows...Hospitalist?

As architects, we’ve all - willingly or not - participated in a move toward practice specialization, and sub-specialization. However, in the quest to become, for example, not just a healthcare firm, but a surgery department firm, we risk losing site of the most important reason we design any type of building at all- the end user. The silo mentality that accompanies specialization fails to fully account for the interdepartmental and interdisciplinary processes that must take place in all healthcare environments. More importantly, it contributes to a lack of focus on the total patient experience.

Hospitalists, physicians who work for the hospital, in the hospital; may be the agents of change in the delivery of care dynamic. What is interesting to me is that their specialty is not disease-based, but location based. Because hospitalists act as a care coordinator for all treatment that a patient receives during their hospital stay, they have a unique perspective on the process of care delivery and how well it did or did not serve the needs of the patient.

I believe that this emerging specialty in general hospital care will drive three important healthcare design trends:
Increased focus on understanding process and promoting efficiency through design. Hospitalists are involved in hospital management and operations as they specifically relate to patient care and offer a unique perspective on inpatient flow and quality of care. Specifically, they are involved with developing and tracking quality initiatives. Proponents of Lean design, and EBD have been saying for years that the focus should be on process, streamlining it so staff can focus on providing the highest level of care to the patient with the greatest amount of convenience for that patient. This approach will only become more important as a means to optimize care delivery and quality.

Greater sensitivity to the culture(s) of patients and their families. Hospitalists’ role in the specific care management of inpatients forces them to deal with acute care situations without the benefit of having any established history with a patient. They need to deal with issues such as cultural sensitivity, and no or low English proficiency on a case by case basis and need space that is flexible enough to respond to customized plans of care as well as care management. Design implications will be greater emphasis on wayfinding, and smaller, more flexible waiting areas within each unit that can be enclosed to allow for extended family consultations.

More versatile and consistent patient space. Cooperative care is one of the hallmarks of a hospital medicine. In fact, the smaller the hospital the greater the range of duties a hospitalist will have. Because the hospitalist manages the care for a patient for the duration of their stay, they oversee a wide range of care in many different units. Therefore, it is beneficial for the design of a patient room, ICU or ED room have certain fundamental consistencies in design to allow a physician to quickly orient to patient care in a variety of departments. This also will create a greater need for more universal rooms that allow the greatest range of care in a single location and increase the decentralization of core processes such as lab and other diagnostics. We may also see hospitals develop room standards or tweak their existing standards to reflect greater consistency among units and departments.

Hospital Medicine represents a different paradigm for care delivery that may spur a different design paradigm as well. Please share your experiences and thoughts on the effect that you think the growing shift towards hospitalists will have on healthcare design.