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.

Lost in the Trees on Wayfinding

I recently toured a newly-completed hospital and asked the architect who designed it about his firm’s approach to wayfinding.  He rattled off a series of textbook things they had done; a single point of entry, color/art themed elevator lobbies, views of the front entrance from the main point of arrival on every floor, color and art themes for department entry desks -  in other words, not nearly enough.  While I had noticed all of these elements and had no argument that they were viable wayfinding moves, I still felt disoriented in the facility.  Which way to go was not intuitive and the landmarks provided were only for major destination points, like the elevators, then I was on my own.  Even though I was being guided through the facility on a tour, I felt like I might have trouble if I got left behind and had to find my own way back.  How much more, then would an anxious patient or family member feel disoriented?

Even brand new greenfield buildings like this one suffer from deep floor plates and hallways that snake around, departments that are organized somewhat like mazes and lots and lots of walking to get to your destination.  It’s time for us to stop thinking that a few grand gestures to the idea of wayfinding are enough and start building our design around it as an infrastructure.

Many arrival points should converge at a single destination.  So often, we design fantastic front doors that open into amazing lobbies, forgetting how few of patients and visitors actually arrive this way.  What we think is a single point of entry in fact is not.  Most are coming from a parking structure that connects to the building at a point other than the main lobby.  Still more may be entering via an outpatient area or the emergency department.  Especially if the floor plate has morphed over time, these points of entry can be very remote from one another.  Creating a main circulation spine is important in order to link all of these entry points and help visitors to cognitively map the facility.   A single concourse similar to airport arrival gates that has drop off, but more importantly proximal parking along its length and immediate access to either a department or vertical transportation (which offers immediate floor access to a department) is critical to reducing distances and getting people oriented.

Design can’t stop at the public realm.  How many times have you entered a gorgeous lobby only to have your final destination be a clinic that couldn’t be more bare bones and, well, clinical in its appearance?  Patients staff and family all appreciate the lobby, but what would really make a difference is to have the clinical areas where they spend the bulk of their visit have that same attention to materiality, circulation hierarchies and amenity.  Just because you have arrived at the front door of your destination doesn’t mean that all wayfinding bets are off.  You still have to navigate this area, and you shouldn’t need an escort to find your way back out.

Getting to your destination should not be a vision quest.  Especially at large institutions, the sheer amount of walking from point A to B is staggering.  One institution I know of offers free parking for the first hour in their garages, which was laughable when it could take over 10 minutes just to get from your car to your final destination. At least at the airport they have people movers and those little carts.  In hospitals, you have to walk. For able-bodied me, this is an annoyance, for the elderly and disabled, it’s an obstacle.  For staff, it’s ridiculous- a waste of time and energy.  Being in a healthcare setting should be restorative not exhausting.  Think about how you organize departments, to minimize travel from one task/treatment area to another and about how you organize the facility to minimize travel times for joint clinics, and other modes/therapies.  You might want to consider having more multi-purpose or procedure rooms as well as larger workrooms for staff to allow services to come to the patient at a single point of care.  Healthcare institutions have to seriously factor distance into the equation and stop taking a “that’s the way it is” attitude towards expansion plans that increase travel distances or additions that create circuitous pathways.

 

I’ve discussed in a previous post on wayfinding that signage is no substitute for creating spaces that provide landmarks, zones, and mental cues to destination.  However, these wayfinding elements alone won’t fix the problem of bad spatial sequencing or poor adjacencies.  Wayfinding needs to be part of the conceptual planning of any new project, and may cause the scope of work to be tweaked to provide the most effective layout.  Until we embrace this simple fact, healthcare spaces will continue to overwhelm and confuse the people who use them-an opportunity to develop responsive design that is simply lost.

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.

Aspiration vs. Inspiration

Most of us are not unfamiliar with achievement.  On the battlefield of office politics, project expectations, and ever shifting work paradigms, we focus on scoring small victories daily.  We are also not without ego.  We want to do amazing work and have that work be appreciated and recognized.  But, with so many metrics by which our performance is judged, we can’t possibly dance to all those tunes.  How many times do you find yourself settling into a single mode, putting on, say, your sustainability hat to the neglect of managing things, or your manager hat to the detriment of thinking outside the box?  Let’s not even go to lean thinking, silo-busting, or ROI.  We’ve been conditioned to aspire, and that soon becomes our undoing.  That’s because aspirations are external motivators- other people’s ideas of success.  Attempting to please everyone muddies the waters and results in mediocrity, especially when the goalposts keep moving as new metrics get developed.  Aspiration is a treadmill, not a path.  It’s time to hit the off switch on these bad habits:

Exceeding Expectations
Implicit within this lovely catchphrase phrase is the idea that the expectations were clearly communicated and that they contained some threshold for clearly measuring success; which is not really in fact what will be considered success as you should have exceeded it.  In this economy, our clients cannot succeed if they pursue mediocrity and they hire us to access and facilitate fresh thinking.  Transformational projects never arise out of metrics.  They arise out of questioning existing patterns and habits and freeing ourselves from expectations.  Stop handicapping your vision. Instead of asking, “what now?”  ask “what if?”

Expectations are also tied up in emotion.  The fear of not meeting expectations leads everyone involved to play it safe.  That isn’t inspiring to anyone.  Instead, try pulling back to a more logical viewpoint, one that justifies thinking big by providing a path to get there. Focus on the solution and the trials and tribulations of the process will seem less onerous.

Marching into the Abyss
Of course we would like our next project to be user-centered, efficient, restorative, and transformational.  Of course we want to collaborate with the project team to leverage expertise and find innovative solutions that are faster to build, more cost effective that the traditional ones and save even more money over the life of the project.  Of course we want to attract and retain the best staff, satisfy our patients, residents or customers, and generate positive marketing. That some enterprising souls have found ways to codify these things (LEED, Lean, Evidence Based Design, organizational management, BIM, etc.) should make it easier for us - right?  Eh, not so much. 

When you try to add project expectations and tools together like a layer cake, you don’t get much real benefit from them.  Moreover, you drive yourself and your project team crazy chasing rainbows.  LEED, for example, can actually hurt the project’s overall quality *gasp* not because LEED is inherently evil or that sustainability shouldn’t matter, but because you aspired to be sustainable instead of being inspired to provide a better environment.  When we lose focus on why we are building in the first place and get distracted with “measuring up,” we start doing things that are not in alignment with the project goals or our personal ones.  We miss opportunities to enforce these goals in ways that would probably blow the doors off the LEED scorecard.
 
Chasing Proficiency
Scattered energy impacts nothing.  Trying to follow all of the buzzwords and metrics is more than just exhausting, it obscures your clarity.  Let go and start practicing with purpose.  When you know what you are all about and pause to plan how to express that in your work, you suddenly find yourself passionate, energetic and clearly communicating your vision to others.  Your inspiration leads them to be inspired as well.  This alignment of purpose and passion creates the focus that allows us to achieve the seemingly impossible. It is this distilled message and effort that leads us to mastery over mediocrity.  Mastery is what our clients crave and seek out, what the market rewards. Achievement is not about ego, which is limited by aspirations of what “should” be.  Instead, it is about having a consistent philosophy that can be understood by others. When you are functioning as your highest self, others will see you that way as well.

Simplify and pare down instead of frantically rushing to adopt whatever trend you recently read about.  Focus on the things that really matter to you and design on purpose instead of by default, allowing all the checklists, codes, technologies, requirements and strategic alliances to limit your vision then using that as the excuse for why the project wasn’t better.

Aspiration is playing into the expectations of others, inspiration is following you own path.  Do you want to get somewhere or not?

The Architecture of Wellness

As architects, we seek to inspire those who move through the environments we create.  It’s also our job to understand how the space will be used and create elements that support that use.  The last leg of the stool, a part we often overlook, is the need to make buildings that support wellness.  Even architects who design healthcare buildings often forget about this one as they work to meet many other challenges related to budget, program, operational  and code requirements.  Maybe it’s because wellness is such a slippery term.  Much like the term “green,” “wellness” is often bandied about, a buzzword that makes some aspect of a product, design or organization sound like it’s good for us. So how do we know if it really is- much less translate that into design elements?  I have been thinking about this issue for a while and even found an interesting website devoted to defining wellness complete with helpful questionnaires. 

I’ve come to the conclusion that true wellness is multidimensional and positively impacts our physical, mental and social state of being.  With that in mind, I have also observed that, as a profession, we kind of, sort of, dip our toe in the waters of designing for wellness.  We embrace sustainable building standards, evidence-based design, lean design, even socially conscious strategies.  However, these are just quantifiers.  Building blocks of the wellness leg of the architecture stool, but not enough as stand-alones.  True architecture of wellness must incorporate all of these measures, but spring from a much deeper intent.  I have listed below some additional more global considerations:
 
Design for the whole person
I have been in some buildings that gave me a headache.  Not in sick building syndrome terms but in the quality of lighting, colors used and claustrophobic environment.  Some work spaces are so dreary, my heart goes out to those who have to toil there daily.  It might not seem like an obvious connection, but many studies across various industries confirm that the way someone feels in a space, can affect their performance.  Quality of life should never have to be suspended by any building user.  I like to ask  myself as I work on a design: ”how will this make people better?”  Thinking about small details that contribute to wellness like the degree of control someone has over their physical environment, ease of wayfinding, ergonomics and proximities that facilitate their activities pays rich dividends.

Wellness is a journey not a destination
We never stop having to actively cultivate wellness.  As architects, we need to respect the fact that wellness is a process and support through behavioral cues things that will help those who live work and play in our buildings to make life-enhancing choices.  What if there were walking paths and outdoor areas of respite?  Stairs could be prominently located while elevators are tucked away.  Interior finishes could provide a marker of distances traveled during the day, break or relaxation rooms could feature relaxing color and material choices and subdued lighting.  Nature could be introduced through atria, patios, roof gardens or outdoor landscaping.  Acoustics could be appropriate to the setting and activities.  These al seem pretty obvious, I’m sure you’ve read countless articles on the subjects, but what have you done to actively introduce these issues as design concepts in the predesign phase of your project?

Design for diversity
We all know that building types have different types of users, but within each user group, there is also diversity.  Create a profile of likely building occupant and work with your clients and colleagues to “test run” your design ideas using  a scenario based on each profile.  For example, how is the experience of your building different for a 30 year old nurse vs. a 55 year old nurse?  What do different demographic groups need from the spaces?  You might be surprised at what you learn.

Silos, Tunnels and Lanes: Navigating Healthcare Culture

Shattering silos is a big buzzword these days.  Everybody is against hierarchy (at least in theory) and in favor of a collaborative team approach.  So why is it so challenging to let go of the org charts and departmental boundaries and produce designs for healthcare that make the best use out of resources and provide the best patient experience?

According to a recent research report from the Beryl Institute, The State of Patient Experience in American Hospitals, most focus on the patient experience is coming from leadership initiatives, but culture change is still a challenge.  Although a common strategy is to form cross-departmental committees to address the issue, the biggest obstacle is that hospitals are still organized in departments.  The success or failure of employees in each department is measured in metrics developed specifically for that department and often may be at cross purposes with the metrics for other departments whose work intersects.

As architects, we fall prey to the same thinking: we approach the design of each department rather myopically, when perhaps we should challenge the need to even have a department at all. Taking away the silo does not in itself produce change unless you also understand the tendency for "tunnels," what I call unrecognized links/connections that might be reinforcing the old culture and practices, are also identified.  We need to envision the hospital as more of a highway dedicated to the flow of patients with various cars pulling alongside them to deliver needed services.  Thinking in terms of lanes instead of tunnels and silos enables us to envision greater permeability and fluidity in design:
Destinations instead of locations
Certainly there are some functions that work best when patients are grouped in a single location (surgery, ED) But there are many others that, if we abandon our old ways of thinking, really are decentralized and coming to the patient (respiratory therapy, lab, some imaging).  So, is there really a benefit to having a department called "Lab" when we could instead consider staff dedicated to bedside care or certain specialty procedures such as anatomical pathology as part of the departments where they work?  This can be supported spatially by providing satellite areas within or between major departments as well as collaborative work areas to allow staff to feel they are part of the total care team.

Decentralization of equipment, services and staff
Perhaps core processes should be evaluated in terms of how they enhance each department they touch instead of stand-alone entities.  A therapist or transporter who is part of the "ED team" is a lot more invested in the overall workings of the department and understands better how their part in the care of a patient affects the healing experience than does one who is simply paged as needed.  The same is true for physicians, who need to view themselves as part of an overall care team that includes everyone from clinicians to administrative and support staff. 

Multitasking and all purpose environments
Thoughtfully designed multi-functional, easily adaptable types of spaces with plenty of rooms for group interaction of the care team both with each other and with patients and families provided in key departments can go a long way in supporting the kind of culture change necessary to provide truly patient-centered care.

Shattering silos and eliminating tunnels means creating relationships among departments (or satellite departments) that mirror the flow of a patient through the space.  All the other relationships and barriers that have evolved over time have contributed to a rigid us vs. them culture where everyone feels beleaguered. A more permeable lane-based concept allows the attention to really be where it belongs- delivery of care.

Alchemy and Architecture: How rich is your perspective?

What’s your point of view? How is it the same as or different from that of the users who will inhabit your design? How is it perhaps still different from that of your client?

In quite a few recent posts, I’ve discussed the idea that architects need to provide a value beyond just our traditional scope of services in order to stay relevant. This value often comes with the ability to harness and master data from its collection to application on the project. However, as we go boldly forward with integrated project delivery, evidence based design and quantifications of value associated with sustainability (green) and productivity (lean), it is all too easy to feel that creativity must emerge in spite of - not because of - these constraints. No, you are not off the hook in terms of shifting your practice model to incorporate the aforementioned value streams. You are being challenged to be more than an information generator and processor (overwhelming and boring). Too much of our time and energy is wasted feeling besieged yet unchallenged and uninspired.

The value of the architect in today’s world lies in his or her ability to synthesize. An excellent series of articles by Jon Kolko for Fast Company based on his book, Exposing the Magic of Design, caught my attention because they address precisely what makes us creative, as well as how we can allow our creativity to get lost in translation by being overly concerned about process and data. Kolko uses the term “sensemaking,” which has its roots in behavioral psychology, even going so far as to term the act of design as applying bias. We’re conditioned to view it as a four-letter word, but it’s impossible for anyone not to process the world through their individual filters. Bias represents the personal perspective of the individual designer, and the more interesting their perspective, the more likely they are to bring an exciting design solution to the table. Neutralizing your bias is the equivalent of dumbing down your work. Allow yourself to value the explorer inside of you, to question the status quo and to feel that pushing the envelope is not just OK but necessary.

Being creative begins with being inspired. Being inspired comes from allowing yourself to ask what if? That’s a scary concept, and when we don’t know where to begin, we start following all the rules of design and allow constraints to eliminate creativity by a depressing process of attrition. We fail to approach the subject with fresh eyes, disgruntled that we are doing “another” (fill in blank) and have clients that only care about getting the most amount of building for the least amount of cost. How could anything innovative ever hope to arise out of this attitude?

While budget is certainly a serious concern on every project, our clients want to build the best buildings they can, not the cheapest or most adequate. They want a solution that works for them and supports the activities that need to take place. They understand the difference between cost and value, but they will also uphold cost as a determinant when design seems too wayward and devoid of value. They are relying on your vision to take a quagmire of facts, needs, data and requirements and start to connect the dots to form a solution. That is the alchemy of architecture, to transform a bunch of information into a design strategy that supports an underlying project mission. To apply your vision and design the spaces that make people better.

Those voices you hear are the angels in the architecture, and you have to let them sing.

Treat[ED]: Shifting the Emergency Department Paradigm

I’ve designed quite a few Emergency Departments, from large to small and concepts from zoning, to universal rooms to interior nurse cores and observation units. I have even participated on a team developing standards for one of the nation’s most prominent health systems. While all of these efforts focused on the patient experience and the standard of care, what we have really been doing is rearranging deck chairs on the Titanic that is the ED. ED volumes keep increasing at a pace that no expansion strategy could ever really address. Patients are not getting better access to care, in spite of our efforts. I guess that’s what happens when you treat the symptoms instead of the problem.

I have had some recent exciting conversations with Dr. Todd Warden whose work on implementing aggressive processes to improve ED throughput is a game-changer.  An article detailing his work

explains how we have traditionally been using not only the wrong metrics to project volumes during programming, but also the wrong paradigm for processing patients. As architects, we love a good form follows function argument and Dr. Wardens’ insights into ED function create some very interesting implications for design that I share with you here:

The ED is not a hopeless case

“I think the ROI benefits of strong new ED processes tightly integrated with complentary design bodes well for future of ED. I am working with a revenue cycle company Besler, who is interested in the impact of ED improvements on increased revenue and decreased cost of operations.” To help us better understand how this works, Dr. Warden focuses on some specific patient statistics. “The moving parts are Left Without Being Treated (LWOTs), elimination of Diversions, and over time increased volume due to improved patient satisfaction.” These variables can be significant when you consider the following example for a typical ED that sees 50,000 patients per year. “LWOT’s, if at 5% for a 50K volume ED is $400-500 for every patient that walks out and about 10% of those patients would be admitted, representing a loss of anywhere from $1 to 1.5M.” There is also a tendency to over-focus on the external causes of ED overcrowding, including efficient interface with other departments and the ability to get patients who will be admitted out of the ED. Dr. Warden’s concept for managing ED throughput challenges traditional process in order to deliver a more efficient outcome from within the department. This might seem like a management or operational exercise, but it is actually supported by the built environment:
1. The patient shouldn’t own the bed
Dr. Warden’s approach begins with a challenge to the way we program space. His study of departments has indicated that the way we typically calculate a peak ED volume actually does not account for the amount of fluctuation between the highest and lowest daily volumes and therefore provides an underestimation of the number of patient spaces needed. Further, we typically understand one patient space to mean one patient bay or exam room. In fact, many patients who come to the ED do not require a stretcher or a private room or bay at all. Even those who do may not need to be in such a space for the entire length of their stay. “By adhering to the idea that the patient owns the bed, we create a lot of needless crowding and bottlenecks”, says Dr. Warden.
2. Integrating process with Design
Two areas that Dr. Warden focuses on are capturing the true measure of volume and efficiently moving that volume of patients through the department. Interestingly, building more rooms is usually not the answer he recommends. “I really see three levels of intervention. The first is completely process-driven. By getting the ED staff to work more efficiently, they can get patients in and out of the department quicker. The second level involves renovation to create a better space for handling patients who are not ready for discharge but do not require a bed. Sometimes, giving up a few ED rooms or a section of waiting are can create this space and allow more patients to be treated. The final intervention occurs at facilities that must add additional space in order to manage their volumes. In these cases, I actually recommend that they build a space called a Rapid Evaluation Unit or REU. More importantly the additional volume created with a high-performance method such as the REU allows the additional volume to be absorbed usually without needing additional staff so most falls to the bottom line. By applying these principles to design, the ED unit is about a third of the construction cost of a typical unit but provides double the annual capacity of the same number of traditional ED beds.”

Read more similar content in an article by Dr. Frank Zilm, FAIA and FACHA on New Directions for the ED

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.