Remedies for Healthcare Design: Major industry directions you need to address

Sometimes as architects, we get so myopically focused on what we do, in the process of design and project delivery, we fail to see the biggest picture. Our clients and colleagues often suffer this same malady, leaving us in need of a new place to go to seek perspective, and get out of the healthcare design echo chamber. One of my sources of choice is MedCity News. Founded in 2008 by Chris Seper, MedCity is a clearinghouse for information on all things related to healthcare and life sciences (which I often find includes many other aspects of design as well). Precisely because of his vantage point as a journalist, not a designer, with his finger on the pulse of macro issues impacting healthcare world, Chris has some amazing insights into what we’re missing:

There’s been a lot of focus lately on the patient experience. How do you see these trends impacting healthcare spaces themselves?
Patient engagement is emerging as a big issue, as healthcare consumerism rises. This will include a bigger emphasis on wayfinding, guiding patients around the hospital, as well as designing hospitals to provide more information through integration of data and organization of the space. It is also important to make the hospital feel less institutional and more welcome. Hospitals are the least inviting of any buildings, but now they are the largest buildings being constructed in most cities. For example, when you compare past architecture and current major building projects here in Cleveland, you are comparing structures like Symphony Hall and Playhouse Square to the University Hospital’s Seidman Cancer Center and Cleveland Clinic’s Sydell and Arnold Miller Pavilion or the Medical Mart. Healthcare will sculpt the face of many of the metropolitan areas of the country, it’s where the jobs are and the donors. There is an external aesthetic, and a legacy that will be written by hospital designers, something that was not even thought of seven to ten years ago. City planners will wake up too late to understand how to integrate them into the urban context. In 50 years, these hospitals will be the historic buildings we will be looking at. It’s an unknowing legacy.


How important do you think employee satisfaction will become in healthcare? What are some ways that amenities offered in the work environment will affect this?
You hear about shortages of high quality talent, but the indicators are that this is a buyer’s market. Many physicians are running to be acquired by health systems. Nurses have suffered notoriously poor treatment and are being laid off. Unless you are a rock star clinician, most systems will treat you like a widget. Any changes to your environment will be based on how it will extract value to patients because of the emerging reimbursement model and business model. The answers for shortages are to leverage technology and increase productivity, i.e. telemedicine.


How can design work to support the technological change taking place in the way healthcare is delivered?
There’s a lot of product fulfillment going on, leveraging RFID, sensors, wireless networks, better inventory management. There needs to be a level of consideration of how you manage and supply these systems. How patients flow matters, but so does inventory management to avoid over or understocking of supplies and correct delivery of drugs. Security will also be a bigger issue. How do you design a hospital where these are no visiting hours and people come and go all day?
I was at the Digital Health Summit this year and came away realizing that there were three major issues impacting healthcare; changes to government policy on reimbursement of sick care vs. management of wellness, the food people consume or are forced to consume (i.e low income residents of food deserts), and unlocking the desire of human beings to be healthy. Most people who need health and wellness don’t seek it or can’t do it. Most people who do seek healthcare are the worried well. Therefore, hospitals are dealing with managing the seriously ill or crisis conditions, while at the same time trying to pivot their focus on wellness.

We are a third of the way at most to achieving optimal healthcare delivery. Despite the resources out there for people to manage their own health, no physician is going to trust information gathered by a patient. Technology is still in the background. Mobile apps are useless when it comes to the clinical diagnosis of your problems because the rules and regulations and ability to quickly scan or tag information is still not there. There is also still a tendency to look to a clinical solution instead of a lifestyle one. For example, they are inventing all of these high priced ways to deal with sleep apnea when the number one way to deal with it is weight loss.


As architects, we often have to place design in the context of a hospital’s value vs. cost propositions. How many of these emerging value scenarios will actually improve quality through innovation in delivery of care or process?
Innovation is the biggest challenge. If there’s one thing healthcare is panicking over, it’s how to change their innovation and interface. Motivations have changed. How do you leverage data, and keep it accurate and of high quality, much less tap into big data potential? Everything has been structured for silos. Healthcare over the past ten years has moved into a real overall ROI through cross pollination of ideas. A hospital will spin off and partner with early stage companies in ways they never would have in the past and pharmacy companies will pursue a mobile app as aggressively as they would have a molecule. The whole ecosystem is changing, but the structures have not changed with it. An triumvirate of healthcare has emerged; patients/customers, clinicians, and the B to B side. One of the things we have been able to accomplish with Med City is to provide a forum for all sectors to interact, especially the underserved B to B side of healthcare.

Chris Seper (chris @ medcitynews.com) is the CEO of MedCity Media, which publishes MedCityNews.com. Chris drives the culture, oversees business and editorial directions, and manages the governance of the company (he also writes periodically for MedCityNews.com). Chris is a former journalist turned media entrepreneur who launched MedCity Media in December 2008. He sits on the board of directors of The Civic Commons and the advisory boards of Spoke Software and Your Teen Magazine.

Games of Chance

It’s a buyers market out there in any way you want to look at it.  Got real estate to sell? Good luck.  Need a job?  Remember to rub your rabbit’s foot before you submit the next application.  Trying to win over a client?  Hedge your bets.  Trying to attract patients?  Wait.  That one wasn’t supposed to require the beneficence of Fortune.  Yet that is exactly what consumerism has brought to the healthcare market.  It’s a huge gamble for all involved- the newly empowered (or perhaps desperately overwhelmed) consumer being wooed by every stripe of service provider, the institutions looking to hit the jackpot of market demand and patient satisfaction.  This could be good news for those of us providing design services as institutions race to up the ante on one another.  It could also mean that we are forced to take on bigger risks to deliver better outcomes.  So who’s playing?

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According to Deloitte Center for Healthcare Solutions, there are six types of healthcare consumers out there, each with their own behavior profile.  This might sound like a problem for hospital marketing departments, but you, architect can win big by understanding these behavioral profiles and providing designs that respond to them:

They are the cheapskates- Casual and Cautious consumers aren’t sick and don’t seek out care.  They also represent the largest chunk (34%) of healthcare consumers.  The design challenge for this group is to draw them in with services they are interested in- wellness programs, farmers markets, acupuncture and massage therapy, classes on things like stress relief or weight loss.  Maybe even a little retail therapy.  These are the people that need to have the line between healthcare and the rest of their life blurred as much as possible to get them in and get them engaged in their well-being.  The challenge?  Their loyalty to any given healthcare brand.

Content and Compliants are the true blue consumers.  They like the way they currently receive healthcare and tend to resist change.  This block, which is 20% of the healthcare population tends to follow care plans and regularly seek out care for maintenance of their health.  What do they need in a space?  Comfort and clarity.  Don’t overcomplicate with too many bells and whistles, make it easy for them to get their care and be on their way.  Think about multiple access points, convenient parking, one stop “shopping” opportunities that allow them to cluster multiple clinical visits, diagnostics, and testing and really intuitive wayfinding.

The Online and Onboard are not necessarily dissatisfied with their care, they just tend not to settle for said care as the definitive word on their well being.  This 17% of the population are avid researchers looking for alternative therapies or emerging technologies to supplement their care and won’t hesitate to bring this information to a visit.  They need to have a space that showcases the array of options offered by a provider and makes it easy for them to interface their technology- think lots of places to sit and access the wi-fi, wellness amenities highlighted with QR codes, a storefront approach to the care environment, so allow them to take in the array of offerings at a glance.

While they only comprise 14% of the healthcare population, Sick and Savvy individuals are the  biggest consumers of healthcare products and services.  This group prefers a collaborative approach to their care decisions, involving their doctor, spouse or other family member.  They need spaces that accommodate that second or third person comfortably and a format that encourages conversation and exchange of information.  This group would benefit from a consult-room rich environment that would allow their care team to engage them on a very personal and intimate level.

The “cocktailers” of the bunch, Out and About consumers are very independent and like to assemble their own combinations of services ranging from traditional to alternative therapies.  This 9% of healthcare consumers will judge you, and move on if they find anything lacking.  What they need is strong brand identity and differentiation of services. 

Price is paramount to the 4% of Shop and Save consumers out there.  They have loyalty to value alone, and are willing to put in a great deal of time seeking out their health bargains.  This group is a big user of things like retail clinics, and customized health plans that reward their thrifty ways.  Facilities that allow care to be streamlined (and therefore delivered at a lower cost) are key to compete with others working to attract this market segment. 

These insights into how healthcare consumers think and act begins to paint a picture of what the healthcare design of the future could look like.  What I see is that it’s not a one size fits all solution.  Different building types, (urgent care/storefront clinic, outpatient community center, and mothership hospital) that serve different purposes, and incorporation of amenities that are not typically associated with healthcare into healthcare spaces all need to find their way into our programming efforts.  In today’s competitive environment, we need to help our clients balance costs with services and provide true value.  While we take great pains to understand how clinicians and equipment interface, we haven’t put much effort into understanding healthcare’s consumer preferences.  In today’s market,  unless we can produce designs that respond to their expectations and needs, all we are doing is rolling the dice on the outcome.

Can hospitals cure urban blight?

They are major employment engines.  They see heavy traffic volumes of people flowing in and out at all times of the day.  They are major destination points within a community.  But how often is the hospital campus perceived as part of the urban fabric?  The urban hospital faces several challenges.  Some are located in blighted areas and need to create a strong campus perimeter to promote safety for staff and patients, even as they voraciously gobble up the surrounding neighborhood.  Others are faced with residential neighbors who view growth of the campus as infringement on their property rights and insist in walls, fences and landscaping to create a buffer zone.  In either case, this leaves the campus cut off from the rest of the neighborhood, feeling less than an accessible wellness resource. What could be achieved if instead the campus was permeable? What if the campus master plan was in fact a community plan?

As we move into a post-reform healthcare world, a greater focus on treating the whole person has come to the forefront, including comprehensive management of disease and prevention.  In addition, the level of satisfaction that a patient has with the care they receive is going to drive reimbursement. This leads to a much more multidimensional purpose for the hospital campus:

Retail therapy
We don't often view a hospital campus as our destination for gift shopping, or a lunch with friends. But we could.  In addition to capturing the huge audience of staff, patients and visitors, retail and dining venues can also be a resource for others in the neighborhood,  or even destinations on their own.  This serves to draw people in to the campus where the wellness opportunities can be prominently marketed as well as to erase negative associations that a community might have with a hospital. Hospitals become the perfect place for community wellness activities like farmers markets, fitness centers and therapeutic landscapes. Bike and walking paths and trails can add to the experience and be a resource for staff as well.

A development blueprint
If healthcare organizations could work more closely with cities as they develop their master plans, they would be able to leverage and even influence things like locations of transit stops, streetscape design, and zoning guidelines.  Imagine being able to locate affordable multifamily housing including senior living facilities within walking distance. Partnering with the community to create land swaps can allow campus expansion that is a win for both the campus and the community.  Sustainable design initiatives can also lead to sustainable communities.  LEED credits such as development  density, alternative transportation, places of respite, permeable pavings, and percentages of landscape can also aid in helping the hospital to respond to its urban context while also opening it up as an accessible resource of wellness in the community.

Creating a unifying vision for the hospital campus within the community can also help the master plan to better reflect the hospital’s organizational goals and mission. The master plan can be linked to other development efforts within a neighborhood to become part of a community master plan that incorporates initiatives and interests of public transportation planners, city planners and even community stakeholders such as non-profits, business owners and residents.

Evaluating solutions from the point of view of the larger context allows you to integrate cultural perspectives of your healthcare customer. Tying into the neighborhood culture humanizes the hospital, allowing patients to have a more personal and contextual experience.  Growth is an inevitable part of a hospital’s existence.  Acquisition of surrounding land is key to survival, but at what cost to the urban fabric?  The hospital cannot simply act as a vacuum cleaner for blighted properties, what it does next with those properties is key to the success of the neighborhood. 

Making People Better

Being engaged as a creative person involves being willing to look outside of your own experience and give back in a way that utilizes your talents and passions.  On week three of the Change the World Novena, we look at making a difference in your community, as an individual and as a business.

Pro Bono work is not a new thing for many architecture firms.  However the desire to consistently give back to the community is something much more rare.  I recently attended a presentation called Teach a Man to Fish  at the Healthcare Facilities Symposium and Expo in Chicago because I thought it would be interesting to get the presenters’ take on how architecture could empower a community.  The session featured an intern architect named Elise Drakes, and I soon realized that she was an example of how an architect can empower people, not just through a single effort, but through the way community service is a part of the way she lives her life. 

Main Entry of the SOS Clinic

Elise, who lives in Orange County, CA, has consistently tried to find volunteering opportunities related to healthcare and architecture.  She has been a mentor for the past five years with Big Brothers Big Sisters as well as a volunteer at an art therapy program called Art and Creativity for Healing.  She realized that her efforts could have greater impact if she expanded outside of what just one person could do and so she took her interest to work.  TAYLOR, a California-based architecture firm, had done pro bono work in the past, but not to a significant extent.  Shortly after joining the firm in 2007, TAYLOR empowered Elise to take on “give back” initiatives.   At first she identified small projects, including the remodel of a child’s room for the Make a Wish Foundation.  Then came a defining moment.  Hoag Hospital, one of Taylor’s clients, contacted them and asked if they could help with a project for a non-profit organization called Share Ourselves (SOS).  Taylor agreed, and Elise coordinated the architecture effort.

Share Ourselves is a Costa Mesa based non-profit providing social safety net and healthcare services to low-income and homeless residents of Orange County.   TAYLOR joined three of the region’s construction companies and collaborated with Hoag’s Real Estate, Construction and Operations department to redesign and build a new facility for SOS.  Originally intended as a cosmetic improvement project, the team soon determined that what was needed for SOS to provide the best services to the community was a full scale renovation.  “It’s easy to drop the ball on a pro-bono project,” Elise notes.  “However, in this case it was less about what was donated than the commitment of individuals from each organization and the leadership they brought to the effort.”  Hoag provided coordination for the project as well as some of their business partner contacts so that the team could solicit donations.  They also have helped on the PR side helping to make sure that the community is aware of the resource and that they story of this effort is told. 

“This project was different from other pro bono work because it was a long term project and many of the donations were used to fund construction, not a particular item with naming rights,” says Elise.  “I was in awe of what people were willing to give both in their time and in in-kind donations.”  In addition to TAYLOR’s donation of architectural services, a local artist donated a week of his time to produce a community-based mural, and other artists loaned work to the project.  Questar stepped into the GC role while Suffolk Roel also provided contracting services and RTKL designed branding/graphics.  “I called up total strangers and asked for things the project needed and was amazed by the response,” says Elise. Their generosity was especially notable to her because, “These donations were not about recognition.  There is no donor wall.”

Elise was enthusiastic about  her efforts, but also stressed that this was something other firms can and should take on.  Her insights on how to build a successful pro bono process:

Respect the character of the organization The team looked comprehensively at SOS as an organization and provided a design response that reflects their culture and practices.  Some of the existing features that worked really well, such as the community planter garden where residents are educated in small scale gardening were prominently located at the front of the building.  It is also different in that the non-profit has collected data for exiting conditions and is using that as a benchmark for determining what design measures were successful in the new space. The team observed systems and processes in the existing facility and took steps to enhance them in the new design.  “We provided countertops in a cueing area to allow people to complete paperwork while they wait in line,” observed  Elise.

1+1 can equal 3 By looking beyond what just a bunch of architects could do in their spare time, Elise was able to successfully expand the project and involve the construction community as well as local businesses and artists.  A more comprehensive effort lent the project more credibility, which made it easier to continue to get donations. The team also told the story of the project to the construction workers to help them understand the value of their efforts.

The project doesn’t stop when construction does It’s great to help out, but to make meaningful change, you have to follow the metrics so you know what to apply to the next pro bono opportunity.  SOS tracks data on the people they serve and now can track improvements related to design elements in the new facility.  This data will continue to inform the project team on where their efforts were most successful.  Elise felt that the team was a powerful element in implementing the project and following up after construction.

Elise’s passion as an architect is operations impacts (she’s currently working on an MBA).  Forming a community partnership to benefit area hospitals was something that she was happy to take on, although she was surprised that more firms are not already doing this type of thing.  She hopes that by sharing the SOS story, more will.  “This can be done by everyone,’ she stressed “It’s all about the people and the passion they had,  That’s what let us keep going on this project.” 

Elise Drakes, Assoc. AIA is a project coordinator at TAYLOR and a passionate advocate of bridging the industries of architecture, healthcare and non-profit organizations. She is involved in all aspects of hospital projects at TAYLOR, from schematic design through construction administration. Additionally, Elise is extensively involved in the community. She has engaged with non-profit organizations such as Art and Creativity For Healing, Big Brothers Big Sisters, Project Tomorrow, Make-a-Wish Foundation, and ACE Mentoring. In 2011, she received the Tomorrow’s Leaders scholarship at Chapman University and is now pursuing her MBA with an emphasis in finance. She is a co-founder of The Benefactor Foundation, a non-profit corporation established to create college scholarships for deserving students. Elise’s role in The SOS Project as a designer and project manager was an opportunity to make a significant impact in her community. The positive life change that each team member experienced was an unforgettable gift.

Power to the People: Unleashing User Insights

Patient centered design has been around for a long time. From Planetree, to LEED for Healthcare  and Evidence Based Design, the importance of the environment to outcomes has been advocated, documented and linked to design and operational decisions. The Beryl Institute is devoted solely to the cause of improving the patient experience. It’s great to have all of these resources. Even better as an architect to have healthcare clients embracing the needs to address the issue. But something gets lost in translation as we go from intent to implementation. Healthcare environments tremendously impact their users, who often have little opportunity to control them. We need to know we are getting it right, not just designing and building attractive surroundings based on precedents.

That’s why I was excited to read about a project recently launched by Penn Medicine in conjunction with the Wharton School of Business. Called “Your Big Ideas Challenge,” the effort reached out to staff throughout Penn Medicine’s system to present their innovative ideas for improving patient care. The top ten will be selected and presented at a town hall meeting. There were many compelling ideas, but what I was most interested in was the process. By empowering staff to think about how they can better serve patients, they were free to do more than air grievances or whine about needing more space. Instead, they could influence the change. Just think about how powerful this process could be when it’s time for the next design project:

Unlock information
There is only so much time at traditional design meetings and only so many staff usually allowed to attend. When you couple that with the fact that most of these people are not adept at reading plans or processing the information we present, counting on meeting feedback is actually a very bankrupt model for design. Instead, after discussing goals for the project with stakeholders, we should frame those goals in the form of questions back to a much more comprehensive cross-section of staff and empower a little innovative thinking that can lead back to either discrete design decisions or the development of design elements that will support an operational change. For example, if you develop a project goal that you want to create a less stressful environment for families, you might ask staff about how they would address commonly encountered family issues or complaints.

Cut a wide swath
Many times, we develop “departmental myopia” on our projects. We forget about just how much impact related departments or core process (lab, housekeeping, maintenance, food service, social services) or groups like infection control and facilities have on a space. Make sure to get the insights of these staff as well. The interchange of things that we don’t even realize happen in a space is often the area most ripe for a design intervention. These extra-departmental folks can provide the lowdown.

Re-integrate Information
So if you follow these suggestions, you now have a bunch of data. Hopefully, you also have a lot of ideas germinating as well. The last and very crucial step in getting the most innovation (and generating the most value) possible, is to re-integrate it back to the project. Invite key players from the extra-departmental group and a more robust sampling of staff from your departmental group to the next design meeting. Provide a recap of the results and how you are planning to use them in design. This allows the innovations to give way to some collaborative discussions, which will give the design team the most useful feedback possible going forward.

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.

Can prototypes help you think outside the box?

It seems like a good idea at the time- if you are going to build something more than once, you should develop a prototype.  In theory, your standard can then be tweaked with lessons learned from each subsequent project, allowing the ultimate in efficiencies for design, construction (hello purchasing power), maintenance, even optimizing the efficiency for staff, patients, customers, vendors, you name it.  However, the idea of a prototype is very different from realities on the ground: this project, in this location, with this demographic and these codes.  I used to do a lot of commercial retail projects (where prototypes reign supreme) and I think I only ever once built anything straight out of the box.  That was in a really small town where the community was happy for any development at all and the city planner was also the plan reviewer and the building inspector.  I also got a building permit in less than 24 hours, so that should tell you something about THEIR standards.  If you think that developing a prototype is a shortcut, a way to circumvent the design process, it’s time to take another look at your motives:

The standard with no standards

Architects and their clients alike are guilty of developing prototypes based on the lowest common denominator in an attempt to build more,cheaper, and faster.  Elementary schools with no windows that got replicated over and over in two rapidly growing school districts who shared a facilities manager is a distasteful (yet sadly real) example that comes to mind.  Sure, the buildings were practically indestructible and went up in record time, but the staff and students were placed in an environment that was one step below prison requirements.  I’ve also worked with prototypes that were so low-budget that the building essentially served as a billboard and nothing more.  How much time and money (including architect and landscape architect fees) do you think got wasted every time the cheap, somewhat gaudy prototype exterior had to be upgraded to pass muster with a local planning department?  Avoid unintended consequences that cost you time and money by having design goals for your prototype that extend beyond the desire to save time and money.

One size does not fit all

Other organizations try to create prototypes for finishes and standard room types.  The goal is to circumvent a lengthy design process, including extensive user input.  This use of prototypes is especially prevalent in the healthcare sector, but you can also find it in the residential market in the form of subdivisions offering a choice of models.  Theoretically, the prototype has been carefully researched and will provide the most efficient and “best” layout for each type of space.  In practice, users customize their space as soon as they begin using it because it doesn’t really work for how they need to use it.  Standards for colors and finishes may also need to be modified if they project the wrong image to a community because there is a culture clash related to how the organization is perceived.  You are not necessarily even saving time and money when the prototype for a room or department has to be applied to an existing building or unique use and therefore requires modification.

So is there ever any circumstance where prototypes are good?  While a bit of a slippery slope, a prototypical design can be used as a tool to enhance the user experience, and learn more about operational goals and the specific design elements that can help achieve them:

Prototype as Pilot

It’s really exciting to think about a project as a test lab for all an organization wants to achieve with a particular space.  That can’t happen if the prototype isn’t constantly in question.  Not only should extensive mock-ups (including finishes) be constructed, but input from staff in all departments, at all levels, patients, customers, other community members should be sought.  Once a prototype design gets the green light, a thorough post-occupancy evaluation of the space should be conducted to learn about what worked and what didn’t BEFORE this prototype is used again.  Lessons learned need to be examined as part of the design process for the next project where the prototype will be used.  Don’t forget to collect data related to demographics of your building occupants; you may start to notice some patterns that cause your prototype to evolve into options over time.  You need to have a very clear set of goals for the project and each element of the prototype should be carefully researched to contribute to those goals.  When an element fails or underperforms, it needs to be analyzed in the context of those goals to determine whether the cause is a design or an expectation.

Prototype as module

There are many different scales of prototypes: master plan, building, department, room.  It often makes sense to have a prototype just for room types and finishes.  Sometimes, it is more important to map ideal processes and flows that you want to standardize and develop modules that can be applied with a greater degree of flexibility to an individual project. Prefabricated construction can often do more than prototyping to help you build cheaper, better and faster, without compromising a solid design approach that applies evidence based design and enhances the environment.  This module can be easily fit into a multitude of existing conditions, and has the flexibility to adapt over time.  Modularized prototypes give you a kit of parts that allow an open and honest dialogue with user groups about what needs to happen in the space to ensure that the standards of care are supported, not circumvented by design.

We’ve all certainly seen plenty of badly applied prototypes.  However, even in your own experience, there are design elements and combinations that work and that get used over and over in projects (although we don’t label them as prototypes).   These can represent just as much of a closed circuit as the officially sanctioned prototype and lead to equally banal and unresponsive design.  Saving time and money can be accomplished in a lot more interesting and effective ways than cookie cutter architecture.  The important issue is to constantly upgrade your knowledge based on a thorough assessment of how a design performs and to apply what you learned to consistently raise your design standards.

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.

How Does your Garden Grow? The role of Therapeutic Landscapes in Design

What does landscaping mean to you?  Most likely, not nearly enough.  Too easily, we view it as decorative, a “nice to have” part of a project.  However, as we learn more about salutogenic design and the effects of the environment on wellness (everything from healing to better job performance), landscape starts to become a critical element, one which should form the basis of design.  With this in mind, I asked Naomi Sachs, Founder and Director of the Therapeutic Landscapes Network (TLN http://www.healinglandscapes.org) to share some insights on the power of nature.  Naomi is a landscape architect and recognized expert in therapeutic landscape design, and part of the Center for Health Design’s Environmental Standards Council working on expanding the Environment of Care section of the 2014 Guidelines for Design and Construction of Health Care Facilities.  Rather than helping afflicted people to feel less bad, her goal is to use landscape to make them feel good:
Usually, when architects think about landscaping, we think about outdoor rooms or ways to enhance areas like building entries or parking lots. What are your suggestions for getting more landscaping inside of buildings?
Nature needs to be viewed as a part of the built environment.  While being out in nature is best, bringing it indoors with interior gardens, atria, or even potted plants is the next best thing. A great recent example of nature incorporated within the building is the Stoneman Healing Garden at Dana Farber’s Yawkey Center for Cancer Care. Providing windows is an excellent way to allow visual access to nature, which is especially important when people can’t go outside. Allowing for views out also lets natural light in (one study found that patients in east facing rooms who were exposed to morning sunlight did better than other patients), and “advertises” the garden, which then encourages use.  Research has also shown that while images of nature, like artwork or videos, do help people, they are not as effective as views of nature through a window or – best yet - an experience of real nature. Using natural materials (wood, stone, etc.) is another way to “bring nature in” to an indoor space.

In terms of facilitating access to the outdoors, transitions from one to the other are critical: Architects must design to minimize barriers (providing flat thresholds, doors that are easy to open, etc.) and allow for transitional spaces, such as a paved area with an awning where people can enjoy the outdoors close to the building, even in inclement weather, and can get a sense of the space before they venture out into it.

How do you explain the link between nature and wellness?
Biophilia – our innate attraction to life and living things - is intangible, but research is working towards measurable results. The book Healing Spaces: The Science of Place and Well-Being, by the neuroscientist Esther Sternberg, addresses the role of nature not only in reducing stress, but also in eliciting positive psychological and physiological responses.  For example, Sternberg documents how seratonin receptors in the brain, when exposed to positive sensory stimuli, light up. She posits that being outside creates multiple positive stimuli (and therefore more seratonin) because it’s a multi-sensory environment.  You can hear the birds, feel the sun on your face, smell flowers or freshly mown grass.  Being outdoors also enables exercise, and tends to facilitate social connections because people are more relaxed. At the San Diego Hospice, the nurse leading my tour of the facility observed that people shared more about themselves and their situation when outside. 


Kuo and Taylor have published several studies that measure the positive impact of green settings in reducing ADHD symptoms, and the correlation of trees in a neighborhood to reduced domestic violence, lower crime rates, and higher self esteem.  These studies show, empirically, that people in environments with nature do better.  Research by Whitney Gray presented at Greenbuild 2011  focused on sick building syndrome.  Gray looked at sick days, turnover, stress, and ability to concentrate; when access to nature was provided, there was a measurable improvement in all of these factors. Debajyoti, Harvey, and Barach showed that nurses who had a view of gardens over those who just had access to natural light, or no windows at all, were better able to concentrate and had less long-term stress. When you think abut the fact that it can cost around $60,000 to train each new hire, the economic benefit of providing access to nature is huge. (Full citation is below)

Maintenance is always a concern when it comes to landscaping- I’ve actually worked with healthcare clients who wanted nothing but grass in the areas they “had” to landscape for ease of maintenance.  What kind of recommendations can you make to landscape skeptics about using plantings?
Access to nature just makes good business sense. Studies by Roger Ulrich, confirmed by others, have demonstrated less need for pain medication, improved patient satisfaction, faster recovery rates, and many other examples of improved outcomes for patients and staff. When you really look at the benefits of providing access to nature, the return on investment (ROI) justifies the initial cost and lifetime maintenance.  Hospitals need to see landscaping as a strategic investment in the same manner they would the purchase of a new MRI.

Sure, a lawn is better than no landscaping at all, but when you consider the benefits of gardens and more designed landscaping, you can make the argument for the cost of maintenance. A study by Matsuoka showed that students viewing just lawn vs. a more varied view that included trees and shrubs performed better. Access to a lawn is often restricted; it may be wet or uneven, and wheelchairs cannot travel on it.  Lawns are best as one element in children’s play areas, since they – especially visiting children - need to run around and blow off steam. [In case you want the full citation: Matsuoka, Rodney (2010). “Student Performance and High School Landscapes: Examining Links.” Landscape and Urban Planning, Vol. 97]. Incidentally, lawns actually take a LOT of money to maintain: They need regular irrigation, fertilization, mowing, leaf-blowing, etc. Facilities that are using alternative landscapes such as native meadows and rain gardens are finding significant savings after the initial investment. And at the same time, they are sending a very positive message about their commitment environmental as well as human health. It’s all related.

That being said, the landscape architect needs to know the resources and capabilities the client is willing or able to put into the project – up front and for the future - and design around that. Your typical “mow and blow” crew is not qualified to handle anything more than routine maintenance, so there needs to be a funding strategy in place for an annual maintenance budget. It’s also a good idea to create a maintenance manual for staff or an outside landscaper to follow.
Some healthcare facilities, usually those with a horticultural therapy program,  integrate gardens into physical and occupational therapy.  This is a great way to provide benefit to patients while keeping the garden expertly maintained. The gardens at Legacy Health, in Portland, OR, are excellent examples of this strategy.
Healing gardens can be easy to raise money for because they are “warm and fuzzy.” The institution can also use the space for social events and to generate PR (promotional materials, events, press releases, etc.). The likelihood of assisted living facility resident referrals has been shown to increase with the quality of the grounds.


What is the difference between landscaping and a garden?  Is it only about habitation?
In general, I would say that a “landscape” is any outdoor space, wild or designed, and a “garden” is a designed space. A restorative landscape is simply an outdoor space that makes you feel good when you’re in it. To me, “landscaping” implies decorative elements like a lawn, shrubs, some trees, and is not necessarily intended for interaction.  A therapeutic (or healing) garden is a space designed for a specific population (children, cancer patients, people with Alzheimer’s) and a specific intended outcome (stress reduction, positive distraction, rehabilitation). This is not to say that landscaping isn’t important. Well-designed and maintained landscapes communicate to patients and their families that they will receive a high level of care, and this can happen from the moment you cross the property line.  Even areas such as parking lots can utilize landscape to provide and reinforce the overall image and mission of the facility.

What is landscaping’s role in wayfinding?
This goes back to the importance of views outside from indoors. As a wayfinding tool, a garden stands out as a strong landmark, something people notice and remember.  Plantings - indoors and out - can also provide visual cues or themes for a space.  Again, when well-integrated with design, views to a garden can also act as advertisement for that space.  So often, gardens are underutilized because people (even staff!) don’t know they exist.  Signage can help, but creating direct views to the garden is the best way to ensure that people use it.

Landscape is a blanket term that includes plantings, water feature, site furniture and hardscape elements like pavers and walls. How does your ideal therapeutic garden utilize these elements?
My ideal garden would focus on the needs of the user population (patients, visitors, staff) and would be designed based on evidence, but also with a heavy dose of empathy and inspiration. As with any good design, there are parameters, but we can never just tick off boxes on a checklist. All landscape elements – overall layout, paths, seating, hardscape, plantings, water features – should facilitate health and well-being. Two useful theoretical frameworks are Ulrich’s Theory of Supportive Design, in which a space supports the users by reducing stress; increasing a sense of control; encouraging social support; and facilitating physical movement and exercise. And Stephen and Rachel Kaplan’s theory of environmental preference, which calls for an emphasis on coherence, complexity, legibility, and mystery. I would add that especially in the healthcare environment, outdoor spaces must be safe and comfortable, and should provide a marked contrast to “the hospital,” which is often perceived as a very cold, alien, intimidating environment. Finally, all of the elements should contribute to that positive multisensory experience we talked about earlier to help people feel not just “not bad,” but instead “good.” That is true salutogenic design.

How does this play into prospect/refuge theory in biophilic design?
It is really important to design with this in mind.  People like to survey the space from a protected vantage point.  Creating transitional space like a covered patio at the entrance to the garden is important, especially for elderly people who may not feel safe going directly outside.  Those with certain psychiatric issues, including autism, like to be “read” a space before immersing themselves in it.  Good designs create transition spaces throughout including shade to sun and walking and seating areas, and “nooks” or nodes where people can feel a sense of security and even privacy.   

It’s not unknown for a project to get landscape elements value engineered out due to budget concerns. What’s your advice for architects regarding how to work best with landscape architects and really integrate their work into the design so that the landscape elements become less expendable to the client?
Bring the LA in right away! Landscape architects are valuable members of the interdisciplinary project team [or A/E team] and they need to be included in the conceptual design phase. LAs have so much more to offer than simply “putting the parsley around the meatloaf.” Their site planning expertise can be a great asset to preserve open space, maximize views, create walking paths, take advantage of existing natural amenities, and to create that “healing experience” that starts at the entry drive, not just in some tucked-away “healing garden” courtyard. They can assist in design of the building to maximize visual and physical access to nature, both indoors and out. They can also best address EPA standards and maximize LEED and Green Guide For Healthcare points and help make sustainable measures like stormwater management or green roofs into design features.

It is important to use a landscape architect trained in healthcare design for healthcare projects (the TLN has a directory of designers and consultants who specialize in this field). They know the research and requirements for each specific user population; they have the experience in this particular area and so they know how to do pre-occupancy evaluations and talk to the various stakeholders: Healthcare providers, facilities and maintenance staff, the C-Suite, board members and donors, patients and community members. They can be allies in your design efforts because they have the experience, examples and precedents to share with clients regarding the sustainable or evidence-based value of a design decision.

Can you talk a little bit about the book you are working on with Clare Cooper Marcus?  What kind of issues are you looking at?
Healing Gardens: Therapeutic Benefits and Design Recommendations (Eds. CLare Cooper Marcus and Marni Barnes, with eight contributing authors including Naomi Sachs) was published in 1999 and is still considered to be the "bible" on this topic. Our new book, to be published by John Wiley and Sons, NYC in 2013, will be a shorter companion volume with different material and format, and will address many of the issues we’ve talked about in this interview. The heart of the book will be design guidelines that are applicable to all patient populations and settings, as well as guidelines for specific users (hospice, cancer care, children, etc.). We will be drawing on many examples of built works to illustrate theories and practice. Other chapters will focus on history, theory, and definitions; the interdisciplinary design process; funding; planting design and maintenance; sustainability; and more. Clare and I are both very excited, and from the feedback we’re getting, others feel the same way.


I encourage all of you to explore the wonderful resource that is the TLN site (http://www.healinglandscapes.org). You don’t have to be a landscape architect to take advantage of the TLN as a springboard for your sustainability and evidence based design research or as a resource for finding a great landscape architect specializing in healthcare.  How will you harness the power of  landscape and gardens on your next project?

*Citation: Debajyoti Pati, Tom Harvey Jr., Paul Barach (2008). “Relationships Between Exterior Views and Nurse Stress: An Exploratory Examination.” Health Environments Research & Design Journal, Vol. 1, No. 2, pp. 27-38.
Exterior views of nature decreased stress and increased alertness in pediatric nurses.
Abstract: 
Objective: Examine the relationships between acute stress and alertness of nurse, and duration and content of exterior views from nurse work areas. Background: Nursing is a stressful job, and the impacts of stress on performance are well documented. Nursing stress, however, has been typically addressed through operational interventions, although the ability of the physical environment to modulate stress in humans is well known. This study explores the outcomes of exposure to exterior views from nurse work areas. 
Methods: A survey-based method was used to collect data on acute stress, chronic stress, and alertness of nurses before and after 12-hour shifts. Control measures included physical environment stressors (that is, lighting, noise, thermal, and ergonomic), organizational stressors, workload, and personal characteristics (that is, age, experience, and income). Data were collected from 32 nurses on 19 different units at two hospitals (part of Children's Healthcare of Atlanta) in November 2006.
Results: Among the variables considered in the study view duration is the second most influential factor affecting alertness and acute stress. The association between view duration and alertness and stress is conditional on the exterior view content (that is, nature view, non-nature view). Of all the nurses whose alertness level remained the same or improved, almost 60% had exposure to exterior and nature view. In contrast, of all nurses whose alertness levels deteriorated, 67% were exposed to no view or to only non-nature view. Similarly, of all nurses whose acute stress condition remained the same or reduced, 64% had exposure to views (71% of that 64% were exposed to a nature view). Of nurses whose acute stress levels increased, 56% had no view or only a non-nature view. 
Conclusions: Although long working hours, overtime, and sleep deprivation are problems in healthcare operations, the physical design of units is only now beginning to be considered seriously in evaluating patient outcomes.

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.

How Agile is Your Space?

There’s a Lowe’s commercial that depicts a woman dashing around and adapting her space to various life stages just by ripping away one surface, rolling up another and (my favorite) sliding back a wall to reveal new French doors.  While it would be beyond cool to have buildings adapt to change that easily, the commercial did get me thinking about all of the ways we can design for adaptability and flexibility that we either shy away from like emerging technology, or don’t pay enough heed to such as good planning strategies. Especially when designing a building that will continue to grow as well as adapt in use over time, like a hospital, agility is a crucial feature.  But you already know that.  The next step is to actually make that a priority in your next project:

Build yourself a cushion: Design to provide pocket shell space surrounding key growth areas to allow departments to expand without major renovation having to take place. There’s nothing worse than the unfortunate addition of ten thousand square feet or so on a single story to accommodate the urgent growth of a department.  That bump on the side of your building will just create roadblocks to future, master planned (ahem) expansions.  Also look at ways to organize the department to expand capacity through utilization and operational changes before you have to consider more built space.

Balance the peaks: Speaking of organizational strategies, it’s already common within a department to have flexible space, such as surgery bays that can be used for either prep or recovery.  But what if you thought about departments less as silos and more as all part of the same set of resources? Those same perioperative bays could become an observation unit or ED overflow after surgery volumes dwindle down in the late afternoon. 

Cluster for conversion: placing related functions together can allow spaces such as an interventional room to be converted to an OR easily in the future if volumes change.  Again, this challenges prevailing notions of department and silos and requires thinking more about properties of a space and patient flows.

Modularize the Master Plan: Think beyond today’s project, even if you are just dealing with the need to expand one department right now.  Immovable, difficult or expensive to relocate items such as structure, vertical circulation, shafts, stacked IT, Data and electrical rooms should be kept to the perimeter to allow maximum flexibility within the floor plate for reconfiguration.  Also think about circulation as part of a master plan- expansion should extend the route, not distort it or create dead ends that are confusing to navigate.  Modularized construction allows technology and infrastructure to be plug ‘n play, easily extendable and expandable. 

Recalibrate your metrics: Too many organizations measure performance and outcomes by department, reinforcing competitiveness and policies that make one department’s numbers look good at the expense of another’s.  Unless your goal is to have competition within the facility equal to or greater than the one you have with other facilities, this is a problem. Foster a more team-based, collaborative approach by setting institutional goals, not department based ones and challenge staff to determine ways they can work together to achieve them. 

What does this have to do with design?  Well, maybe one day soon, architects won’t be designing emergency departments, surgery departments and interventional departments, but instead patient intake areas that will route patients through a series of procedures leading to either their admission or discharge.  Maybe one day there will only need to be one access point for patients where they can access all services conveniently.  Maybe form can follow flow, not just a presumed set of functions.

What We Really Learn from Benchmarking

It’s typically one of the first steps taken when designing a new healthcare facility.  We look at data from facilities modeled similarly to what our client wishes to consider.  There may even be tours, surveys or interviews with staff from the comparative institutions.  This knowledge ostensibly helps our user groups to understand clearly the pros and cons of a given design model and sharpen their own vision for the project at hand.  But....benchmarking is relative.  Unless you presume to be in the prototype business and use post occupancy analysis and benchmarking to keep improving your model, nothing you look at with a client will be exactly like what you design for them. To avoid going astray with your efforts, observe the following benchmarking protocol:

Determine what "best" really means
The idea of benchmarking is rooted in comparison- ideally you find the best performer in the industry and look at ways to compare their results to your own.  Where you are lacking, you look to the means and methods applied by the benchmark and try to incorporate them into your model.  In the design world we have a small problem with that idea- who is really the best?  There are so many variables that might make a given hospital a good performer that may be unique to their circumstances. These same strategies may fail miserably if applied within your client’s market and culture.  Make sure that you spend time defining the needs and wants of your client and developing a discrete list of objectives. Place only institutions that dealt with these issues in design and operations on your benchmarking list.  Because you can learn from failure as much as success, it is important for your benchmarking to be based on a set of predefined criteria that has been addressed by every hospital you study. 

Understand your extrapolation
It’s unlikely that you will literally copy design features straight from another facility. You will be instead applying elements and concepts to your design problem.  Make sure that you understand what made something work for the benchmark facility- was it a combination of placement and protocol?  If you don’t understand the dynamic behind the result, you can copy design elements and not achieve the goal. Create a matrix that lists facilities across the top and then contains rows of your client's design objectives. In each cell, discuss specifically how a particular facility dealt with that client objective.  Leave room at the bottom to expand the objectives if a particular benchmark inspires the client to change or add a priority. 

Don’t exploit the process
Many times, we want so badly to sell our client on a given design solution. If they are not on board, benchmarking of similar institutions is used as a brainwashing technique.  Ethics aside, you may be very sorry later when the design you ramrodded down the client’s throat doesn’t perform well for them.  It’s equally as important to not allow administration or staff to become enamored by a facility and want to emulate it if it won’t provide similar benefits for their organization. Use facility tours to look at trends and filter out what will have lasting benefits vs. quickly becoming outdated. 

Benchmarking is a useful tool, but only after clear needs, goals and priorities are set by the client.  It is about setting standards for best practices, and that can be a highly subjective undertaking.  The Evidence Based Design process embraced by the Center for Health Design champions benchmarking as part of the initial research needed to define the problem.  I agree that benchmarking belongs firmly in the learning phase of the project, a source of information and a contributor to how the design problem at hand will be defined.  How have you successfully used benchmarking on a project and how did you work to remove bias from your facility selections and review of data?  Please join the discussion and share your thoughts.