Winning the Battle and Losing the War

It’s the rare client who has the foresight to truly master plan- rarer still the one who authorizes a capital project based on forecasted need instead of waiting until renovations/expansions are way past their due dates.  When everyone’s working conditions are obsolete and overcrowded, the very way work is done is affected.  The workplace becomes the war zone with erstwhile staff in the trenches every day just trying to keep things functioning.  No wonder it’s so hard to think differently about space.  In healthcare design, we can no longer afford to keep with the status quo “adapt and react” mentality when it comes to buildings.  This mindset brings about a shortsightedness that satisfies an immediate need at the expense of truly solving a problem.  I recently had an opportunity to hear a presentation from Debbie Gregory, Senior Clinical Consultant at SSR and Nursing Institute for Healthcare Design (NIHD) Board member.  Debbie also has a background in interior design, so she understands healthcare design from multiple viewpoints and I enjoyed listening to her insights regarding what healthcare clients are looking for from their architects.  Some thoughts from the battleground:

Avoid conflation
Sometimes an expansion is definitely in order.  Others, reorganization of space is the better option.  While healthcare facilities are getting bigger in part due to larger room sizes, more equipment and the need to have more adaptability built into units, there is also the tendency for clients to ask for (and get more ) of the same space they had before just 30% -40% bigger.  All the same work habits and processes are baked right into the new space. Right size based on criteria related to flexing acuities, innovative technologies and equipment or increases in volumes, not to accommodate inefficient processes that have arisen out of the current physical features of the space.

Beware of collateral damage
Just as teaching to the test leads to peril in the classroom, designing a delivery of care model around scoring enough HCAHPS points is disastrous.  The point of metrics is to measure performance, not how well you can game the system.  If you are providing the best care, you don’t need to worry about metrics, just as a great teacher never needs to worry about how her students will score.  Learn to recognize well-intentioned policies from infection control, facilities or the C-suite as intentions that may not apply to the unique needs of your particular situation and work with them to develop a solution that meets the “spirit” of the law, not just its “letter.”

Know your enemy
The biggest enemy of innovation is the routine.  It’s very hard to break out of the way you are used to doing things, or to question why you do some things at all.  One thing I think we fail to be taught as architects is how to help our clients re-frame the problem.  Sure, we know how to turn an idea on its head, but we may not be attuned to all of the issues related to care.  We also tend to spring these “breakthrough” concepts on our clients, often to mixed reception.  What we really need to be doing is to help them walk through the process and think about what they do and why every step of the way.  Don’t create tomorrow’s problem with today’s solution. Mockups, done at a conceptual phase of the project can help to right size an element like a patient room, which will drive overall program and square footage needs.  Debbie strongly recommends that you conduct the initial viewing of the mockup as a moderated discussion in order to keep department stakeholders focussed and make sure that everyone’s voice is heard, not just the squeaky wheels or department leadership. 

Break ranks
It’s not about keeping the building as we know it, but rather making the building into what we need it to be.  As conduit for healing- the healing environment has a big role to play in patient outcomes as well as staff satisfaction.  With greater emphasis on providing value being placed on today’s healthcare providers, we must think about how buildings contribute to that equation.  The value proposition should include links of design elements to measurable outcomes, such as reduced injuries, hospital acquired Infections or satisfaction scores; recommendations related to achieving the lowest life cycle costs, and agile planning and infrastructure solutions that will respond to emerging needs instead of requiring costly and constant additions.


None of these strategies are about adapting or reacting, they rely on a great offensive strategy where the patient doesn’t end up being the casualty of our planning effort.

4 comments:

  1. David B Gardner, AIA, NCARB, ACHAJuly 7, 2012 at 9:55 AM

    Some good, subtle design advice here Angela. We need to both listen to and lead our clients, recognizing that when we say client we mean patients, caregivers of all types, physicians, support people, families, code officials, administrators, accountants, and probably a dozen others I've forgotten.

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  2. David- thanks so much for that insight!
    I agree- our client is not just the one who hired us, but those who will be served by the space we create.

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  3. Great article Angela...it looks like I have a much to learn from you!

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  4. Kevin- appreciate your interest in the article. We all can learn from each other and our clients. Keep hanging out and feel free to suggest topics.

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