You Can’t Get What You Don’t Know You Want

The art of being fully present is perhaps the hardest to master for architects, who are always referencing the past and planning the future (usually under some level of duress).  We get so caught up in achievement that we lose sight of why we’re paddling so hard toward that waterfall.  There are danger signs and people shouting to get our attention, and we don’t even notice them because we are so hell-bent on accomplishing- what?  As you ponder this and take a deep breath, consider this quote from legendary conductor Ben Zander on what it takes to deliver a transformational performance, "This is the moment- this is the most important moment right now.  Which is: we are about contribution.  That's what our job is.  It's not about impressing people.  It's not about getting the next job.  It's about contributing something."

When you get right down to it, that is the essence of who we are as architects.  It’s the essence of who all people are and we function in our highest and best states when our work has meaning and makes a positive difference in the world.  Cool-eh?  Easy, not so much.  That’s because to be fully present requires trusting that the outcome will be OK even if we don’t worry about it.  To be fully present means that you have clarity about yourself and your purpose in the world and everything you do is about realizing that purpose.  It’s kind of like applying the principles of Lean design to your life.  If you never pause to plan, to ask yourself what you really want, your life’s purpose will get lost.  Here’s how to set the right goals for yourself so you can get on with living your truth:

Restore balance
If you’re experiencing dissatisfaction in your career, but can’t figure out how to jumpstart change, it’s most likely because you have lost sight of your goals, or maybe never really had any in the first place.  I’m not talking about the expectations others have for you or the things you feel you “should” be doing.  Aspirations are not true goals.  Take some time to get to know yourself better and identify what moves you as an architect:
  1. Read something inspirational about the built world each day.  You get to decide what that is, whether it’s a favorite blog (ahem), news item, or article.  The only rule is that it has to be uplifting, not anything that will upset or irritate you. Hint: It does not need to be “official architecture press.”  After a while, notice the patterns in your choices.
  2. Try to spend one hour of each day in silence, uninterrupted.  Getting off of the treadmill of what you do all day with all of its disruption and conflict allows your thoughts to settle and you to become more conscious of them.
  3. Begin each workday by sitting in stillness and set an intention for the day.  I know, I know, you’re busy, but jumping right into the fray deprives you of being able to see how the tasks before you can be used to nourish you and help you realize your goals.  Otherwise, they will create stress, which will deplete you. When you have clarity, you will express it in every action you take, which will reinforce and feed your creative identity.
Start asking
It’s hard to ask. It feels funny.  You could get turned down.  But I think the hardest part about asking is that you would have to know what you want or need and be able to clearly express that need.  We’d much rather stew about what we don’t have than figure out how to get it.  Most of us live in a haze of half-realized thoughts and our brain ping-pongs through them as we form judgments and assumptions about life.  We don’t even clearly realize our intentions much less put them out there. Do you expect others to know you well enough to just lay opportunities at your feet?  Worse, do you expect some fairy-godmother type mentor to tell you what you should do at every turn?  That passivity will at best get you what others feel is convenient for you to have, according to their purposes.  There’s a difference between saying “I want to be recognized, be a partner, win awards, get published,” and “I want to design spaces that make people better.”  One way will actually get you there.

Focus on who you are and what you bring, living in the moment taking time to know yourself and your identity as an architect and you really will change the world.

The Skinny on Lean

Forget all that stuff about firmness commodity and delight.  Today’s design drivers are Lean, Green and Clean.  If you embrace evidence-based design, you probably already find your efforts fall into these categories.  Most institutions have fairly robust initiatives related to sustainability and infection control.  It’s the third leg of the stool where things get a little fuzzy.  While every vendor can tell you how their product contributes to your sustainability and infection control efforts, can they tell you how it provides greater value by promoting efficiency and service?  Lean is a concept that most embrace in principle but have no real idea how to put into practice-ask ten people to define Lean for you, and you get ten different answers.  Yet this is such a powerful tool for improving patient satisfaction, outcomes, employee retention, reducing errors and eliminating waste that any design effort that doesn’t take Lean into account is falling short of its potential.

Lean started at Toyota as a manufacturing process.  Apply it to the design of buildings unfiltered and a lot gets lost in translation, for example focusing on efficiency to the detriment of the human experience. The Lean Construction Institute, a non profit organization, is a great resource for helping architects and their clients work together to get a building design that supports its optimal use and generates value. I like to draw analogies to the Leaning Tower of Pisa as a mnemonic device in understanding why we need Lean:  inadequate foundations set in unstable soils and a flawed design led to a failed effort that corrective actions over it’s 177 year construction history (talk about inefficiency and waste) never did manage to put right. Lean processes help us take a step back and consider what we are really doing instead of getting swept up into the chaos of a frantic deadline:

A process about a process
A hospital can hire a Lean consultant and optimize processes without moving a wall.  As architects, our goal is to understand how design can support and even facilitate those processes. If the organization has not already done so, consider hiring a Lean consultant to observe existing conditions and help make improvements.  This allows your design efforts to be focused around the best operating conditions, not a bunch of old habits.  If a consultant isn't something the project can afford, do take the time to work with staff and understand and map the variety of activities they engage in daily to provide patient care.  You can do observations and start to notice the redundancies and waste that is built into the current system. 

Think differently about a solution 

Lean is also about empowerment.  By involving project stakeholders and coaching them through a collaborative process, you encourage them to think about how they could do their jobs better.  You also encourage everyone from the C-Suite on down to filter everything they do through the lens of whether it improves the experience of the patient.  This will inform the design in amazing ways and help you to set project goals that keep the design on track, even during value engineering.

The value proposition
Lean is, above all, a  multidimensional tool for improving value.  Value is a slippery metric.  It is not, as I’ve stressed multiple times in this blog, another word for cost.  Value may include cost, as when the lifecycle of a piece of equipment is measured against first cost and cost savings.  Value can also include intangibles, like improved satisfaction, that may generate revenue.  Still other measurements take into account indirect costs such as reduction in FTE’s or patient length of stay or lawsuits/non-reimbursement due to errors.  

Frank Zilm, Jody Crane and Kevin Roche have produced what I view as the most concise and understandable breakdown of Lean for Healthcare in their article for the Journal of Ambulatory Care Management “New Directions in Emergency Service Operations and Planning”   In their article they cite five key components:
Creating Patient Value
A value stream is a patient’s path through a set of services during a visit.  A facility will need to define value streams for all of the typical services they offer by department as well as by acuity level.  Departments then work collaboratively with leaders to identify ways to provide more value (such as shorter wait times, more amenities for family members, ease of access to the facility) or eliminate things that take value away (such as long waits for the transport team, inability to sleep well due to noise and interruptions) for each value stream they identify within their department.
Eliminating Waste
The next step is to categorize each element in a value stream as either value-added or non-value added.  The article suggests that non-value added items are one of eight forms of waste traditionally defined by Lean:
1.  Transportation – care delivery is delayed by the transport of patients, supplies or equipment
2.   Movement- staff should have supplies close at hand to their work areas, which should be proximal to the tasks/staff/patients they need to interface with. Think: right amount, right place, right time.
3.  Inventory- overstocked inventories represent capital that will potentially be wasted
4.  Waiting- this is wasted time for all involved.  In healthcare, this means less silos and territories and better utilization of resources such as exam rooms or OR’s.
5.  Overprocessing- doing more than the patient needs because of overlapping protocols
6.  Overproduction- generation of reports or materials that are not used
7.  Defects- errors or incomplete work that must be subsequently re-done.  Often there is waste generated by a lack of communication or even problems with wayfinding.
8.  Lack of human creativity- the ability to problem solve and improve processes
Promoting Flow
Study of service responsiveness within a system.  This uses tools such as queing theory to map flows from arrival through service delivery and exit, with a focus on responsiveness and system capacity.  Other ways to study flow include “spaghetti diagrams”  which track the movement of individuals through a system to identify where flow is impeded or non-linear (too much retracing of steps involved in a process).
Continuous Improvement
This is a quest for perfection that is embedded at every level of an organization.  By clearly identifying what will add value to the patient experience, staff at every level is empowered with the tools to suggest ways to improve performance. 
Developing People
Unlike traditional top-down leadership hierarchies, lean encourages a bottom-up organization that recognizes that those doing a job have the most insight into the processes involved.  By empowering staff at all levels, a more collaborative work environment is formed with a focus on delivering value over beauracracy. Resources for improvement are provided while obstacles are removed.

By working collaboratively and filtering it through the value process, it is easy to determine which strategies will make people better and which won’t.  These strategies can be reinforced through architectural elements. Focus on the value adds and drop the waste, and you’ll end up with a project a lot more successful than that famous belltower in Pisa.