Pulling Open the Flower

On week three of our Shattering the Meme novena, we explore the concept of creativity.  Creativity cannot be forced, nor can it emerge fully formed from the depths of our minds.  Unlearning the idea that hours spent equals quality of output to force an outcome is the lesson of this week.

As creatives, it’s ingrained in us from our earliest years that we are somehow supposed to be masters of everything.  The image of the superstar sole proprietor who conquers the word is dangled before us and we’re made to feel as if we are doing something wrong if we can’t achieve it.  From those first weeks in studio classes, the all-nighter is introduced. The idea behind it is that we need to work hard, really hard, at being creative.  We are not taught techniques for collaboration, or pulling in ideas from other industries or arts.  We are not taught how to understand the needs of the people we design for.  No, Instead the message is that it all must come from within.  And if the great idea won’t just open up out of our mind and bloom, we need to start picking at the bud, much like an ant on a peony.

Sounds strangely logical, except that creativity doesn’t work that way.  The worst thing you can do is to put performance pressure on it, instead of letting it flow, to close down its sources instead of expanding its horizons.  This meme has never served anything but our collective egos as it takes our self-esteem on a perpetual roller coaster ride.

Stop the suffering
Because we have been taught the behavior pattern of hard work, it feels wrong when an idea comes too easily.  We analyze it, reconstruct it, over-embellish it, reject it.  All in an attempt to make the act of creation something that requires tremendous effort.  We need to recognize that what we have been conditioned to feel “right” about in the design process is actually only what feels familiar to ourselves and our profession.  It gets propagated as “the way.”  In fact, what really ends up being propagated is stress inducing behavior. So, we think that if we are not under stress, we must not be very creative.  This is somewhat like planting a shade-loving plant in full sun, assuming that your shadow as you constantly tend it will be enough.

Live in the now
Creativity is about being present, not trying to predict the future based on the past.  When you are in the zone and are in a state of pure consciousness, nothing except the present moment matters.  You stop imposing past limiting beliefs and letting fears about what might happen restrict you, and you just go with it.  No over-thinking, no judgement.  Just think what would happen if you gave yourself more opportunities to disconnect the outcome from possibility. You might even realize that what you or your client thought the outcome should be wasn’t the best way to solve the problem. Stop ignoring all of the other ideas flowering in the garden in your focus on the one plant that hasn’t yet bloomed.

Allow the unfolding
In our “I am enough” mentality, we believe that we can go directly from intention to outcome.  We think that we control the outcome solely through our efforts, and if we didn’t get the result we wanted, we must have either not worked hard enough or made some mistake.  Not only does this corrode self esteem, it sets us up to shut down opportunities that might lead us to an even better result. You can plant the seeds, and tend the garden, but the plant will grow at its own rate, take its own form.  Building the framework for your intent and ideas to grow and then letting them take shape organically will lead you to the best possible outcome.  Relinquish control of what the outcome needs to look like and trust that you have set the right things in motion.

Shatter the Meme:
Allow yourself to detach from the outcome and instead focus on the intent behind the work you are doing.  What opportunity for growth can you find in the problem?  What is really motivating your client to take action?  What kind of environments do people really need? By asking these questions of yourself, your team and your client, you are able to ensure you are solving the right problems and building the right framework.  Resist the need to be a control freak and remember that when you pull open the flower, you usually spoil it.  Step back and let things unfold instead of trying, in your impatience, to force the outcome.

Shattering the Meme

For the third annual novena at the Patron Saint of Architecture, I want to help you to see all of the unlimited potential you have and start putting it to work for you.  Novenas are an annual chance to look in-depth at issues that affect how we operate in the world.  In past novenas we looked at how we can truly make a difference in the world, and how to overcome the things that drain our creativity.  This year, we will center around all of the things that we may not even know are holding us back, so that you can shatter those memes and become all that you were meant to be.

Memes, those ideas or beliefs that pervade our culture, are hard to avoid.  Like frogs in the pot, we don’t even know that they’re affecting us, they just seem to be the way it is.  As creative people we are especially susceptible to memes because there’s a certain voodoo around the act of creation.  When your work involves acts for which there is no right answer, you can only respond by evoking memes. The memes of a culture and its expectations, the memes of professional conduct, the memes of what a relationship with a client is supposed to look like.  But what if the meme is wrong? 

We can see the short-term effects of memes in viral internet content.  People get caught up in the topic, idiomatic speech may even be affected.  Then it passes.  Observing these micormemes allows us to see how something can be incredibly relevant due to factors taking place at the moment then pass away like a fad. I want to try to look at metamemes in much the same way.  That’s a lot harder to do.  Even if you can see that there may be something beyond, you might not see why it’s even in your interests to pursue it. 

Live outside the fishbowl
It’s important to realize that memes can operate on two different levels.  The horizontal level is what we absorb from our peers and other surroundings. Those memes can be, but aren’t always, easier to identify.  The more insidious memes are the ones that operate on a vertical level through cultural inheritance.  It’s what you learned about the culture of your profession from your professors and mentors, what your employers and co-workers have enforced, even what your parents thought.  If memes are all around us and have helped to form our beliefs about who we are and what’s possible in our lives and careers, that means we are not necessarily aware of them.  In this nine week series, we are going to bust through some common memes and shatter all of the limitations they hold.  I warn you, this will be both challenging and scary.  Your first reaction will be to disagree, but I ask you to sit with it and really think about why you might be unwilling to question a given issue.  We may not arrive at the same idea for shattering it, but just the realization that there could be a different approach is powerful.

Change the Equation
Believe it or not, most of us live our lives as if everything we encounter were a basic algebra problem.  We use the formulas we know to solve for x (ex. 6 + x = 10).  Unfortunately, solving for x means you have used a meme to eliminate the other variables, in our example that would be the number six or even the outcome, the number 10.  This very straightforward approach to problem solving often causes us to have tunnel vision about achieving outcomes.  If you have ever become frustrated about why you could be doing “all the right things” and still not get the desired outcome, you know what I am talking about.  I want to challenge you to think of things in a different way:  what do you really want the outcome to be?  Not the outcome you think you should achieve, but the one you really want.  Then, work backwards to see how you could achieve it.  Allow there to be more variables and less givens about the situation.  Use a little calculus, or even some differential equations.

Enter the World of Innovative Transformation
Innovative transformation is about challenging yourself to have a game-changing response to the opportunities in your life, instead of your automatic one.  How often do you start a new project the same way you start every other project?  I’m willing to bet you have all kinds of reasons why this is the best or only way to approach things.  You might be open to tweaking your process, but probably feel resistant to throwing it out wholesale.  But what if you did?  Silence all those limiting beliefs and just think about that.  What could happen?  Now think about all of the little things, the small and large decisions you make every single day.  Instead of making them on auto-pilot, start being conscious of them, and start asking yourself what assumptions are tied up in your typical actions.  Change your thinking and change your life.

For the next eight posts, I’m going to present common metamemes that we all deal with and give you strategies for looking at them in a whole different way.  I hope you’ll share your thoughts and experiences as you work to shatter each one.  The Patron community supports you and I know that you are unlimited.

What my house taught me

As an architect, it’s kind of interesting to me that I have learned several major life lessons from a

house. This structure was our family home for eight years. We bought it less than a year after relocating to Cleveland, OH from Phoenix, AZ in order to be closer to my ailing parents. Just the fact that we had relocated at all meant staring down some of my biggest fears, saying goodbye to a city we loved, good friends and professional opportunities, resigning from boards and commissions. So, I thought I’d done it. Made my big leap. But the house had more lessons in store for us. It seemed a pleasant enough house, cheerful and light-filled, with a big backyard and an attached garage. Built in 1942, it was a “newer” home for the community. But we passed it up, citing the too small kitchen and dining room. Only after looking for several more weeks and finding nothing did we come back to it after we noticed that its owners, long moved away, had decided to cut the asking price for their vacant house significantly. We bought it conditionally, with every intention of putting on an addition, adding central air, and on. Fast forward eight years, no addition or central air and we were faced with the need to relocate for work after spending several months unemployed. We put the house for sale in the worst possible market, it sat empty for a year, was broken into by a copper pipe scavenger, and finally became a rental. Two years after moving away, I think I have finally learned the final lesson I needed and am willing to let it go. This is a huge step for me because I want to at least break even, but know that whatever it costs me to be free of this house, it will be nothing compared to the cost of continuing to own it. What a great metaphor for all the things we hold on to in our lives. We are afraid of losing things we think we should want, but in truth offer us very little value.

Lesson one: Never, ever settle
We had become weary of looking. I let the fact that the house was “OK” and cheap due to the price cut lure me into saying yes to something when my gut had originally said no. I passed up the house the first time because it really wasn’t what we were looking for. Instead of having faith that we would find a great house, I almost felt obligated as an architect to transform this one. We had completely remodeled our home in Phoenix, I reasoned, so why not this one? Well, for starters, the level of addition we would have needed to undertake was not financially worth it, and even if we could have done it, we would still not have had the home we really wanted. While there are many life situations that require a little extra effort on our part, there is a difference between the effort to make a good thing great and the effort to improve something that even after being improved will never be what you want. We do this not just with homes, but with our jobs, even relationships. When you invest your energy in the “good enough” opportunity, you stop being open to receive the amazing one.

Lesson two: Place yourself in situations that bring you joy
Parts of this house just downright irritated me. I shudder to think about how much negativity I carried around. Every time I had to carefully open the dining room door to avoid hitting a chair or maneuver around the too small kitchen or deal with the lack of counter space in the bathroom, it annoyed me, if even on a subconscious level. Even though we bought new high end appliances and decorated and painted, everything about the home’s limitations subliminally said to me that my life had limits, had lack, had need. I might have realized it sooner if the situation with my ailing parents, raising two small children and having a stressful and demanding job had not been looming so large in my life. Given all those things, my home needed to be a positive affirmation and regenerative environment, and yet it was only reinforcing all of the other stress. What things in your life are you “putting up” with that are actually draining you? The things in your life should feed you and affirm not only the person you are, but the one you wish to become. Choose wisely.

Lesson three: Know when to walk away
When the time came to put the house up for sale, I knew the market was bad. While I was willing to price the house aggressively, it was important for me to be able to at least break even from the sale. Although it would have been well below comps, one realtor I talked to suggested pricing the house at about $2000 higher than we owed on it to really make it move. I chose the realtor who suggested that we list at only $15,000 below our original purchase price instead (that the house had lost that much of its original value considering all of the improvements we made was shocking enough). I had tapped out all of my savings and was fearful of getting into debt. Two months in, we dropped the price another $10,000 and still nothing. I was hemorrhaging money. Debt, the thing I had been so afraid of, began to pile up. It was not sustainable to have two households, especially when one of them was vacant. Finally, a year into this ordeal, we were able to get renters, which covered the cost of our mortgage. However, it’s hard to manage a property in a city far from where you live and our maintenance costs for their months in the house have exceeded that of the entire eight years we lived there. Operating from that place of fear, I considered my self lucky we at least had the mortgage covered. What I now realize is that even if we had sold the house at a $10,000 loss and had to be in debt in order to pay off the outstanding portion of our loan, we would have been so much further ahead financially. What seemed like practical and sensible thinking was really fear in disguise. Fear costs you so much more than the risk of losing. It traps you in a situations where you can never win.

Lesson four: Question your assumptions
I had an epiphany the other day. I don’t want to own this house any more. It’s that simple. There is no value to me in being a landlord. I need to let go. I started talking to realtors and learned that the Cleveland market is starting to turn around and that people are actively home shopping again. My fears had caused me to make assumptions about the market, based on the past. Making a fresh inquiry brought me facts. While property values are still abysmal, the market is moving along briskly. I can list this house and I might actually break even or come out just a few thousand dollars ahead on the sale.

I’ve moved on in my life to a great new career in a city I love. No need to be tethered to anything that might limit me. The sales agreement will be my diploma. It’s time for my house to teach a different pupil. Lessons learned!
You don't always have to learn the hard way.  My new book Career Crisis helps you to uncover the fears and assumptions you may be making in your own life so you can unblock them and move forward to what you really want.

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?

see larger image

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.

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.

Liberation: six steps to set your creativity free

Does your thinking always default to “fault?” Are you trapped in an endless game of “gotcha” with yourself?  Have you imprisoned your creative spirit in a cage of self doubt? As someone who expects perfection out of myself I can relate to the fears and desire to overachieve and exceed expectations that hold creative people back.  I recently read an excellent article on letting go by Tony Schwartz that got me thinking about how we can set ourselves free of things that don’t serve our highest self in order to make room for the things that do.  Sounds like a scary proposition- but it’s not.  What it is is nothing short of liberation.  Just as fear of failing can immobilize us and keep us stuck in a rut, letting the perfect be the enemy of the good causes us to aim low, and apologize for taking chances.  It causes that judge and jury in our heads to consistently level a guilty verdict. This is my list of six common creative prisons and recommendations for breaking out:

Shackled to the past
Maybe it took you a while to really get the hang of model building, or a design program.  Maybe you got some harsh criticisms of your work.  Maybe that first internship was a bit rocky as you learned the ropes.  Maybe, just maybe you learned from all of this and are now competent.  However, you got used to viewing yourself as inexperienced and mistake prone.  That self-image no longer is a true representation of the architect you are today.  Like the person who’s conquered a lifelong weight problem, and can’t stop seeing themselves as fat, you are locked inside your initial years as a fledgeling architect. Re-write your resume, update your LinkedIn profile, do something to affirm the architect you are today and keep celebrating that in order to change your self image so that you can feel empowered to make decisions from the point of view of who you are, not who you were.

Confined by busywork
No one ever says on their deathbed that they wished they’d worked more.  If anything they probably wished they’ed enjoyed life more and made more of an impact.  No, you can’t blow off deadlines, but you can prioritize.  Are you letting your to-do list be your excuse?  Whether it’s deadlines at work or personal projects, not giving yourself permission to move forward is not only silly, but it makes you feel so uninspired that you probably won’t actually get all those tasks done anyway.  You eat a pie one bite at a time.  At the beginning of each day, look at what parts of your life goals you can accomplish on that day.  It may be a single task and that’s fine because it advanced your agenda.  Contract, distill and excel.  When you say no to the expansive opportunities before you in order to scratch off some (insignificant in a global view) task, you are really saying no to your own expansion.

Locked into Entitlement
Do you brood about what’s not right or not fair in your career?  The client who treated you poorly, the promotion you didn’t get?  Do you beat yourself up over every real or imagined misstep?  The root of those feelings is an unyielding and harsh view of yourself as all or nothing.  Like a teenager, you believe that you deserve certain things and that life is lived at the extremes of always and never.  As your mother probably told you then, “life’s not fair.”  She was right.  Life’s not just about you.  The people you interact with have their own motives- you are far better served when you focus on understanding them because what really matters is the result and how you respond to a situation, not all the things that happened along the way to cause it.

Energetically in Isolation
You might think you took the high road by not telling your boss off, or giving that unappreciative client a lecture on the value of your service.  But you are still holding on to the resentment and it colors all of your future interactions not only with the individual in question but with others in your professional and private life as well.  Realize that by being non-confrontational, you are choosing to make yourself invisible- no wonder you aren’t on these people’s A-List.  Think about your passion for what you do as a ball of energy that lives at your core.  The more expansive the energy, the further out the glow extends.  Other people are attracted to that glow and want to work with you.  The greatest architects have such expansive energy that people will crowd into lecture halls to hear what they have to say, buy their monographs and wish they could work for or with them.  When you can’t let go of all of your resentments or regrets, you diminish your energy.  Think about that glass-half empty colleague or friend  How drawn to that person do you (or clients) feel?  Then realize that, at times, we are all that person.  Choose to be aware of when you are letting your anger, doubts and fears diminish your energy.  Then take steps to let go.  Stop suppressing your emotions and instead think about whether you actually made your point of view heard.   Calmly and with an open mind approach the person and ask them to recount their decision/actions from their point of view.  You may be surprised at what you learn.

On the chain gang of Trying Too Hard
Are you trying to make your clients like you more by practically wiping their noses for them?   Score points with your boss by being a workaholic?  Being a doormat diminishes your expertise and loses any respect people will have for you.  A project is a partnership and all involved have to understand their roles and responsibilities.  Decisions and directives (or lack of them) have consequences.  Don’t try to sweep client driven issues or office problems under the rug and cheerfully try to compensate by doing others work for them.  So often, we try to just make our situation work and do it all. You never want to put yourself in a position of being held accountable for an outcome in an areas where you have no responsibility. Your boss and your client’s main objective is to have a successful project.  If they aren’t giving you what you need to accomplish this, the greatest service you can provide is one of coaching them on how they can help make the outcome a success. 

Rotting in the dungeon of the Status Quo
What’s good for General Bullmoose is not necessarily what’s good for you.  If you are trying to live up to the expectations of your family, co-workers, society, you are engaged in conformance.  Conformity erodes creativity.  I am not suggesting that you have to be an angry, angry artist who rejects the world in order to be successful.  I am telling you that you need to know yourself and make decisions because they are right for you.  Unfortunately, we’re all likely to hit cruise control when we feel that our lives are basically going in a good direction.  It usually takes some disruptive event to create a breakthrough.  Why?  Because being shaken out of your status quo stupor makes you refocus on what really matters to you.  In the disruptive state, you reject limits and question rules.  Make bold, purposeful moves in your life and you will fail, but you will also succeed beyond your wildest dreams.    When you take actions with purpose, not just because you can or should, miracles can happen.

Who caged your creativity? Who cares?  What’s important to remember is that you hold the key to your own creative freedom. Unlock your own liberation.

NIMBY and the Unintended Consequence

Is it fear of change, or actual aversion that causes us to rally against new ideas? Not in My Backyard (NIMBY) is the bane of most planners as well as anyone who’s had to go through a public hearing process.  Concerned neighbors worry about the impact that a proposed project, change of use or zoning might have on their property and they speak up loud and clear at public hearings, becoming influencers of opinion and striking fear into the hearts of approval boards.  Rightly or wrongly, they bully their concerns into prohibitive restrictions or even outright banishment of a proposed change.  It’s easy to be judgy as architects and planners who understand (or think we do) that the pros outweigh the cons and know (or think we do) that all those feared unintended consequences are no more likely than a child’s fear of monsters under the bed.  We become almost pedantic in the face of these obstacles to change.

However, NIMBY is a double-edged sword.  It’s not only the narrow-minded, bigoted, or greedy who take issue.  Sometimes, those people in the trenches can run through scenarios we never envisioned that could in fact lead to disaster.  The designers and social workers behind Pruitt-Igoe thought that they were counteracting blight and providing a better social alternative to housing for the poor.  Their revolutionary design concept didn’t take long to implode, figuratively and then literally, when the project was demolished just 17 years after construction was completed. 

What’s good for the goose...
At it’s heart, NIMBY-ism is rooted in support for a concept in general, but an aversion to taking the risk of having this experiment played out as a specific where it could affect us.  How many times have you designed a project from on high, imposing what you believe is best on its users? How many times have you been part of a panel or commission who tried to mold policy around practices you deemed to be the right answer? Good intentions aren’t good enough when we are talking about things that influence real lives. We can only do that by really understanding the needs of our users, by seeing though their eyes and being willing to experience what we are asking them to live with.  The best projects do that - they are not so focused on playing to the lowest common denominator or influencing behavior that they stop being spaces that people want to inhabit.

The grand utopian vision is wearing blinders
I think that it is critical that we not feel pressure to have all the answers.  We are taught to be utopians, the examples of masters LeCorbusier, Frank Lloyd Wright and Baron Haussmann held up for their bold, irreverent approaches that got people to live in a modern (read appropriate) way. An arrogance is cultivated within us that just because we do our research and have conviction, we can improve the life of the average slob.  No wonder that average slob is so damn suspicious of our ideas, hatched behind their backs and forced down their throats like a good dose of castor oil.  No wonder they say “NO WAY is that happening in my neighborhood!”

The New Urbanists are on to something, whether you like them or not.  They started asking, “how do people really want to live in their cities and neighborhoods, and how can we facilitate that?”  There’s a reason that high modernism never took off and most housing developments are based on traditional references.  Oh yes, there’s an unintended consequence for the lack of design and vision, defensive planning and zoning statutes, and pandering to nostalgia that plagues most cities.  But those consequences were born out of the design and planning world’s inability to listen, understand and give vision to lives that people really want to lead.

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.

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.

Because Someone Had To: The Flawed Thinking of being a Trouper

In the last three weeks of our novena, we are focusing on transformation. Last week we looked at our career path and how to make the necessary adjustments to achieve maximum potential.  In week eight, we do the same for our work process.

At my old firm, there used to be a mantra uttered by the staff whenever confronted with an impossible situation.  “Get ‘er done,” frazzled architects and interns would say, as if a results-oriented approach would make the crushing deadline, impossible budget, or demanding client seem less overwhelming.  The objective was to hunker down and focus on the most streamlined path possible to meeting the objective, then put your nose to the grindstone and crank it out.  There was a certain pride, even, in the ability to be uberproductive in the face of such odds.

How many times have you found yourself faced with a problem for which you were ill-trained, understaffed and poorly equipped and just muddled through and made up a way? Woe to anyone who dare criticize the final product, means, or method, so proud are you to have accomplished the task.  If you feel like an innovator in situations such as these, you’d be right, but only in a can’t-see-the-forest-for-the-trees kind of way.

You feel proud of yourself for accomplishing something in a jerry-rigged half-assed way- because someone had to.

Perhaps it is our experience of studio instruction, where professors try to avoid placing too many parameters on the task at hand in order to encourage individual exploration.  We are just a little too comfortable as architects with working with an ill-defined problem and making the best of it.  A lot too willing to make sacrifices in order to get the job done (hello, all-nighter mentality). The trouble is we are diverting our creative energy to dealing with procedures instead of devoting it to design.  We make managing the schedule and the budget the design problem, not the design issues.  We’re rewarded for this flawed thinking when the metrics of success for a project are: 1. On Time and 2. On Budget and the people assessing our performance have taken those two measures completely out of the context of design.  It’s time to realize that being a trouper means only that you were willing to be put in a box and not complain about it.  What kind of team player does that really make you?  How to break free:

Don’t accept the premise.  Dealing with impossible design parameters is exciting, challenging and opens the door to innovation. Dealing with impossible demands from clients, co-workers and bosses is draining, stressful, and leads you to keep recycling the same solutions over and over again because you know they will work.  Do not confuse the two. 
1.  Schedule, budget, and aesthetics are interdependent variables of the design problem. They are not design problems in and of themselves. 
2. Use the pre-design phase to determine design parameters that will meet schedule and budget goals.  3.  Stay focused on the design problem, knowing that these are addressed. 
4. Start saying no to the things that aren’t about solving the design problem.  These things are not only distractions, but they affect all of your variables, therefore compromising the design itself.
5. One you define the problem to be solved, don’t dilute your efforts by allowing others to introduce new problems.

Always take time as a team to revisit the view of your project from 35,000 feet.  This helps everyone understand the goals and big design ideas and stop obsessing about the details that are actually off the reservation.  It's easy to get distracted by concerns crises that seem critical to one or more team members, but responding to panic with panic sends the project off on a tangent.  Instead, ask how a given change in direction or new area of exploration will help meet the overall goals.  If it doesn’t, then it’s a waste of time and money.  How’s that for meeting those on-time/on-budget metrics?

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.

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.