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.

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?

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.

Pre-Fab is Ab-Fab

I remember playing with Legos as a kid. The bricks were modular and contained prefabricated specialty elements, yet I never felt that my creativity was threatened by these constraints. Why is it then that as grown-up architects we bristle at the idea of modular and prefabricated construction? We think “trailer park” and wide load trucks on the freeway. We think that all design has been taken to the lowest common denominator. In reality, the prefabricated industry has evolved into a highly sophisticated range of projects. While you can buy the cringe-inducing whole house, you can also buy pre-engineered systems that are your kit of parts to make amazing buildings. Prefabricated elements can also be a more planet-friendly solution.

One of my favorite sustainability sites, Inhabitat, had a recent article on a prefabricated house built in Seattle by Greenfab and designed and assembled by HyBrid Architecture. The model home is working towards LEED Platinum and qualifies as restorative with it’s net zero footprint and ability to generate its own power. While Greenfab makes a kit of modular parts, they also can work with clients to create custom design or just to reassemble their offerings in new ways. There is also a great article in ED+C magazine by Dru Meadows that details how by reducing waste on the front end, prefabricated construction can outperform other downstream efforts using the more traditional reduce, reuse recycle method. It’s a dramatic difference. Enough to make all of use reconsider prefabricated and modular construction as a matter of conscience.
Prefabricated elements have better quality control and produce less construction waste. They also allow a higher degree of integrated elements like smart technology, LED systems or materials that contribute to the design or flexibility of a component. I myself have always dreamed of a “walls on wheels” concept that truly allowed one to adjust the spaces to your individual needs. The one thing we know about the spaces in our world is that they need to support ongoing change of needs and function. Another plus of prefab: pieces and parts can be adaptively re-used to suite the needs of the occupants over time and easily dismantled and recycled at the end of the house’s life. Because they can be delivered to the site 80% installed, the actual construction time on site is greatly reduced.


So what changes? As a designer, you should develop a relationship with either a pre-fab constructor or manufacturers of pre-fab elements so that you can collaborate with them. I have also pulled together some advice to help you channel the modular mindset (you can also visit the Modular Building Institute to learn more):


1. Know your team. The fewer players, the fewer points of accountability, which is always a good thing. Many modular construction companies will also provide the option of constructing smaller commercial or residential structures as part of their package, which further enhances the design-build relationship.

2. Understand the kit of parts, what is considered partially custom and fully custom. Don’t be afraid to bring your imagination along. Because the modules are factory built, you can develop prototypes to get the design to work perfectly.

3. Design mindful of how each element can be a variation on a theme. The more repeatable modules you can use, the greater the efficiency of construction and lower the cost. This can be an especially effective strategy for large buildings like hospitals that contain many repeated elements like headwalls that are found in some form across many different departments.

 4. Think more about how the building will be used and how each element will support that use. A module doesn’t have to be as dumb as: wall, 10 foot high stud with drywall. Instead it can be: wall 10 foot high with built-in light source and touch activated media.


Far from being a limit on your design sensibilities, prefabricated and modular elements can actually set your imagination free and allow you to do things that would not be possible or feasible with traditional construction methods. Please share your thoughts and experiences with modular construction. I'm interested to hear the good, bad and ugly as well as how you got over any negative stereotypes about this construction method.

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

When Green Isn't Enough

Sustainable healthcare design is a strange beast.  It's not just about saving energy, but about providing a better quality of life for the users of the building.  A handy source for melding the two is the Green Guide for Healthcare, which acknowledges some of the distinct issues facing sustainable hospitals, and begins to take it one step further, weaving in elements of evidence based design (EBD). Other sources I like to consult are Practice Greenhealth, Healthcare without Harm, and the treasure trove of information on EBD that is the Center for Health Design.  Emerging mateirals such as the UL Environment hybrid standards and CSI's new GreenFormat also can help filter through a wide range of data in multiple formats. 

The best way to pursue sustainable goals is to understand that most of what they are working to accomplish can either lay the foundation for or amplify other goals that an Owner aalready has.  By taking the time to identify and codify Owner Project Requirements (OPR), they can be matched to green goals.

Being sustainable as a matter of conscience or energy savings is nice, but healthcare organizations should view it as a prerequisite to meeting their infection control requirements, staff retention goals, and patient satisfaction plans as well as a tool to improve the overall outcomes for cases.  When you look at green measures through an EBD lens, you get a whole different game plan for your project.  As my diagrams below illustrate, there are parallel paths for both sustainable and EBD strategies, which helps strengthen the argument for any measure that satisfies both aims:

These diagrams illustrate sustainable strategies (some linked to multiple LEED credits) and parallel EBD strategies with outcomes listed for both. As this comparison shows, many sustainable strategies also lead to direct EBD gains-a win/win/win result for your project.


Integrating EBD and sustainability into the project from the planning and conceptual stage encourages Owners to select strategies that support and inform their design goals for the project. To get you started on the visioning path, consider these strategies:
1.  Stepping back to look at the big picture from a “whole building” point of view
2.  Master planning infrastructure not just buildings- systems expandability
3.  Making bold moves for big results
4.  Incorporating redundancy and reliability into the sustainable plan

Go forth and be life-sustaining, not just sustainable.

Cheaper, Better, Faster: The Case for Entreprenurial Marketing

The increasing pressure to design and construct buildings cheaper, better and faster can seem like the surest path to a landscape of mediocre, throwaway buildings.  Architects prefer to look at projects as a factor of the dependent variables quality time and budget, explaining to a client, that meeting a low budget might compromise quality and perhaps argue for building a better, but smaller design.  Those relationships are weakened by market forces such as fewer resources or shorter client timetables to effectively launch a project and build, maintain or increase their market share. Clients demand that they want it all and want it now.  And there's a business theory for that.  Called Entrepreneurial Marketing,  Len Lodish, a Professor at the Wharton School of Business argues that smaller businesses need fast results with minimal investment.  Even the largest institutions in our industry operate much like small businesses, which is why I find this idea so compelling.  

To help get inside our client's head, let's focus on making the business case for ideas:

It's hard to focus on the long term when you have an immediate need that will likely exhaust your capital budget.  That's why so many large institutions look like they have tumors of one story buildings growing out of them and are a wayfinding nightmare. Schedule and budget concerns may be non-negotiable, but your client didn't hire you to smile and nod your head.  They hired you to think about the problem in ways that they can't.  As long as you have truly listened and respected their concerns, presenting a less literal solution than the one they asked for will gain their respect and produce a better project. 

There is also an implicit assumption on the part of the client by playing its safe, they know what they will be getting, and that the project will proceed more quickly and cost less.  Looking for proven solutions, they may be a little hesitant to explore innovative design practices, cutting edge research or sustainable tactics.  Or, they may  require integrated project design or minimum LEED certification without really understanding what is involved.  

Innovation does not have to come at a premium, and sometimes, the payback on implementing a cutting edge technology , unconventional method or research makes its own compelling argument. Architects are not necessarily known for their financial wizardry, but by presenting a strategy in terms of its return on investment, the conventional understanding of cost, schedule, and budget are transformed.  design time frames can become more elastic, with more time spent in pre-design and schematic design in order to brainstorm and then vet options as a team.  When we view a building project over its lifetime, the way that the problem is framed and eventually solved becomes more dynamic as well, leading to what the client wanted to achieve most- value.