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.

Home Sweet (Medical) Home

As culture shifts so, does the space that contains the activities pursued by that culture.  Health and wellness have become so intertwined with our everyday lives that we are quick to self-prescribe activities like yoga or spa visits, join a gym or adopt a fitness regimen, consult a nutritionist or seek out alternative therapies like acupuncture.  We still view our healthcare system, however as something that we need only when we are sick.  That’s all changing.

In case you haven’t noticed, the emphasis on wellness has been adopted by your local hospital, clinic and physician.  If they haven’t they may find themselves in a change or perish position.  Healthcare reform is a loaded issue and what if any of it actually gets implemented is still in question.  What is not in question is the cultural shift in care brought about by the wellness movement.  It creates whole new archetypes for us; spaces that are permutations, hybrids and creations of a new set of functions and needs.  As architects we need to be first responders and help usher in this new breed of spaces.  Some trends of the wellness movement that will impact the built environment are as follows:

It’s all about integration.  Expect to see functions like education and community gathering spaces as well as gyms or outdoor exercise areas built into medical office or hospital facilities.  Some will even feature spa and cosmeceutical services as part of an expanded dermatology practice.  On the flip side, you may start to see unlikely clients dipping a toe in the healthcare water- like big box retailers, grocery stores, and spas or fitness centers.

There will be distillation points.  While the range of services and activities may expand at a given healthcare location, expect to see the emergence of an almost concierge-like approach to care management.  The medical home is a new model that seeks to integrate primary care with specialty care, social services and alternative therapies in a single location with a single coordinator.  This helps patients to receive a more holistic treatment for their diseases or disorders and streamlines their ability to access a broader range of services.

Patients have become consumers.  We have been hearing about this trend for a while now, but as it gains momentum, a more retail-based business model will emerge, and this will affect how space is programmed and designed. Finishes and lighting will take on a level of importance previously unknown in healthcare.   Every detail from customer service to appearance and philosophy of care will be factored into their decision of one care provider over another.  See a great example of this in Domokur Architect’s execution of Dr. Darrell White’s concept for Skyvision, patterned after upscale retail environments. Also note that the brand extends beyond the building to Dr. White’s comprehensive approach to care and social media/internet presence. 

A distinct shift to outpatient care. Expect more and more services that were traditionally considered inpatient to become less invasive and performed on an outpatient basis.  This will require more specialized procedure rooms in outpatient facilities.  We’ll also start to see traditionally hospital based-specialists needing to do more than a quick consult with a patient- they now will perform many of their procedures in that same office.

So what’s the emerging archetype?

1. More multi-use and multi-purpose spaces.  Healthcare will be about delivering comprehensive wellness strategies as a part of a continuum of care as opposed to treating only a particular disease when the patient presents.  It also will be team-based instead of physician based and a broader range of clinicians and social workers may be involved in the patient’s care plan.  Therefore, there will be a need to engage patients more fully in managing their own care.  A different range of environments for meeting and working with patients will be necessary.  You may find yourself really thinking about site design and amenities, or providing child-care or library space.  These spaces may also flex to become community rooms or group education rooms.  There may be fewer exam rooms, but more procedure and consult rooms.  There is also a need to create collaboration spaces where the entire care team can meet to review a patient’s status on a regular basis and determine how to address needs as they arise.

2. Image and accessibility matter. To compete for the consumer-oriented patient, facilities will have to be more accessible.  Not only will physical appeal be important, but good marketing efforts will be necessary.  As architects, we may find ourselves much more closely aligned with graphic designers and public relations professionals to produce a seamless corporate image that reflects a well defined philosophy of care.

3. A rethinking of what a visit entails.  Patients are going to expect to see a more involved discussion of their overall health record at each visit.  The design of the typical exam room will change. While most do include a charting area, it is usually quite small and does not enable the patient and doctor to sit side by side to review either on-screen or printed information.  Many patients do not even use an exam table for most doctor visits, so it might be beneficial to have consult rooms vs. exam rooms.  The consult room could have some of the same elements as a typical exam room like blood pressure cuff, oto/opthamoscope, hand washing sink and supply/work counter.  However, instead of an exam table, the room might feature a table and chairs- allowing the doctor to do a routine check of vitals, then spend the majority of the time reviewing the results of the exam within the context of the patient’s health history and health trends.  Especially for those with chronic conditions like high blood pressure or diabetes who visit the doctor on a monthly basis, this type of room would be far more comfortable and conducive to their needs.  It would enable the patient, physician and any accompanying family member to share the events of the visit within the context of a health profile. A table would also allow both doctor and patient to bring along their own supplemental materials to share or record the events of the visit.

4. More virtual access to care and medical records to allow real-time monitoring of patients’ progress.  This is not a new concept, but I am always amazed at how seldom anyone talks about HOW this monitoring will take place.  We may need to have more of a cybercafe for medical staff where they can take time to sit and do a download on a batch of patients, process the information and send back responses to them.  If a dialogue is encouraged, physician assistants need to have computer workstations where they can do a daily monitoring of patient results and respond to any emails or requests for information from patients.  It’s a much more hands-on and higher level of care than most doctors offices are used to delivering, but I see this as a trend that would also affect the physical space of an office in order to provide a private and secure location to view and respond to patient information.  Perhaps that interactive conference room space mentioned earlier might double as the data sharing area.

As you can see, the paradigm of the doctor’s office is rapidly being converted into a different type of health destination, one that supports more comprehensive, longitudinal and interactive care.  Share your experiences with recent medical offices and let me know if you are dealing with any or all of these issues.

Post-post update:  So many great thoughts were put out there on the Linked in shared version of this post that I am including them directly one the blog as comments as well.  Please feel free to add your thoughts to the mix.

Design is Like Healthcare...

I call it the “duh” moment- when someone can frame an issue in a way that is so obvious that it inherently makes sense.  You wonder how you never came to that conclusion on your own.  I experienced on of those moments today while reading Scott Simpson’s “Change of  State in A/E/C” for Design Intelligence. It compares the sea change going on in our world to the one that has and is still occurring in healthcare. Doctors and hospitals are “always” kind of things that we will never stop needing, but the particular services they provide and the way in which they deliver them has changed. Sound familiar?

The piece particularly resonated for me because I have a foot in both worlds as an architect who specializes in healthcare. Like many physicians and hospitals, our industry has been slow to move from a traditional cost-based, risk adverse model. We are annoyed that our value or expertise is questioned and rush to create defensive contracts or lobby for legislation that will protect our design processes. What we don’t do is stop to consider whether these processes even still serve us. As Simpson puts it, “there’s not much evidence that all of this management and monitoring is being used strategically to design better buildings or deliver them more efficiently, which is what clients really want.”


Simpson does a great job at projecting trends from the demise of mid-size firms to the rise of multidisciplinary project teams. It’s a futurist view, but an instructive one that I hope will inspire you to look beyond the way things are and start looking at how you can be a leader in delivering:


Architects now have to sell their expertise and value instead of their time
Outcomes matter more than the services provided, value does not equal cost. Simpson cites the example of physicians, who are the primary deliverers of care. At one time, physicians determined how they would treat patients and were paid unquestioned for the services they provided. Today, many have become employees of large health systems and the care protocols that they use are largely dictated by insurance company requirements, which are increasingly being tied to outcomes for the patient. Similarly, architects have focused on being compensated for time or as a percentage of the construction cost for producing a design product. We want our talent to act as the justifier for our decisions. Architects need to have a much broader understanding of what their clients value as well as a way to frame every decision within that context. Start framing the services and expertise you provide as a series of value-adds and tying financial incentives to your ability to deliver according to metrics that are important to the owner (lower maintenance costs, better building performance, etc.). Far from diminishing design freedom, this practice will actually justify in real terms what has in the past seemed arbitrary or purely aesthetic.

Teams, not firms, will design, document and deliver projects.

Just like the once-dominant general practitioner has now become only one member of a team (not all of them physicians) of specialists who manage a patients health, so too will the architect be perhaps the owner’s guide, but certainly not the only player in determining what’s best for a project. You wouldn’t go to a doctor who routinely performed tests without confirming with your insurance company that you had coverage, or who refused to give you access to specialists when needed. It’s the same in design. The standard focus on phases of design and bidding will become irrelevant as technology allows more sophisticated modeling of options. Into the funnel will go decisions about design, sustainability, schedule impacts, operating costs, return on investment needs, outcomes on user experience and out will come a determination of value. This will happen for multiple scenarios throughout the project and the entire team, including the owner and their stakeholders will weigh the options to select the one providing the highest value. Look for more collective contracts and increased emphasis on integration and collaboration. Better yet- suggest them and become an influencer of their content.

If you don’t lead the change, the change will lead you

Physicians have become marginalized by the business of healthcare. Although they still play a critical role, that role is no longer dominant as other players like insurance companies, government agencies, equipment manufacturers, lawyers, and the corporate structures that manage large health systems have come onto the healthcare scene. The solo practitioner with an independent practice who referred patients to the local independent hospital is a relic in today’s healthcare environment. Architects should learn from their medical counterparts that resisting change diminishes your power to shape it. My favorite quote from the piece nicely sums up the issue, “The irony is that architects, who are so good at inflicting change on others, are woefully reluctant to embrace change in their own practices.” Change or become irrelevant.

Form follows...Hospitalist?

As architects, we’ve all - willingly or not - participated in a move toward practice specialization, and sub-specialization. However, in the quest to become, for example, not just a healthcare firm, but a surgery department firm, we risk losing site of the most important reason we design any type of building at all- the end user. The silo mentality that accompanies specialization fails to fully account for the interdepartmental and interdisciplinary processes that must take place in all healthcare environments. More importantly, it contributes to a lack of focus on the total patient experience.

Hospitalists, physicians who work for the hospital, in the hospital; may be the agents of change in the delivery of care dynamic. What is interesting to me is that their specialty is not disease-based, but location based. Because hospitalists act as a care coordinator for all treatment that a patient receives during their hospital stay, they have a unique perspective on the process of care delivery and how well it did or did not serve the needs of the patient.

I believe that this emerging specialty in general hospital care will drive three important healthcare design trends:
Increased focus on understanding process and promoting efficiency through design. Hospitalists are involved in hospital management and operations as they specifically relate to patient care and offer a unique perspective on inpatient flow and quality of care. Specifically, they are involved with developing and tracking quality initiatives. Proponents of Lean design, and EBD have been saying for years that the focus should be on process, streamlining it so staff can focus on providing the highest level of care to the patient with the greatest amount of convenience for that patient. This approach will only become more important as a means to optimize care delivery and quality.

Greater sensitivity to the culture(s) of patients and their families. Hospitalists’ role in the specific care management of inpatients forces them to deal with acute care situations without the benefit of having any established history with a patient. They need to deal with issues such as cultural sensitivity, and no or low English proficiency on a case by case basis and need space that is flexible enough to respond to customized plans of care as well as care management. Design implications will be greater emphasis on wayfinding, and smaller, more flexible waiting areas within each unit that can be enclosed to allow for extended family consultations.

More versatile and consistent patient space. Cooperative care is one of the hallmarks of a hospital medicine. In fact, the smaller the hospital the greater the range of duties a hospitalist will have. Because the hospitalist manages the care for a patient for the duration of their stay, they oversee a wide range of care in many different units. Therefore, it is beneficial for the design of a patient room, ICU or ED room have certain fundamental consistencies in design to allow a physician to quickly orient to patient care in a variety of departments. This also will create a greater need for more universal rooms that allow the greatest range of care in a single location and increase the decentralization of core processes such as lab and other diagnostics. We may also see hospitals develop room standards or tweak their existing standards to reflect greater consistency among units and departments.

Hospital Medicine represents a different paradigm for care delivery that may spur a different design paradigm as well. Please share your experiences and thoughts on the effect that you think the growing shift towards hospitalists will have on healthcare design.

How Was Your Stay?

First, a confession: I do not specialize in hotel design. I design, research and program healthcare projects. While hospitals have certainly tried in recent years to embrace the aesthetics of hotel design to create a more welcoming and less institutional environment, I think that the synergy between these two archetypes goes far deeper. More than imitation, this is a fusion spawned by recent trends in healthcare that creates an opportunity for both industries:

Trend 1: A hospital stay does not make you “all better”

Patients admitted to hospitals are sicker than ever before due in large part to the fact that so many procedures can be performed on an outpatient basis. You need to have had a significant illness, catastrophic accident or major surgery to qualify as an inpatient today. Simultaneously, hospitals have come under pressure from the Centers for Medicare and Medicaid services as well as insurance companies to shorten lengths of stay. Discharged inpatients therefore, may still be in a precarious state of health.

Trend 2: Both caregivers and patients are getting older.

The increase in the elderly population is also a factor in the ability of a discharged patient to function at a very high level upon discharge. All of this places added burden on the caregiver(s), who may themselves have compromised health.

Trend 3: Consumers are driving the healthcare marketplace.

Patients and their families are realizing that they have choices. They are demanding convenience, access, responsiveness and amenity from their healthcare providers. Many hospitals are beginning to provide concierge service to VIP patients. Additionally, families often want short term child care, reference libraries, and better food choices. 

Trend 4: A greater emphasis on wellness and prevention has emerged

Many healthcare systems are now offering alternative and complementary therapies such as massage, yoga and acupuncture. They are also expanding campus design to include things like on-site walking or fitness trails, and community education rooms within the facility.

Many major hospitals are served by nearby hotels, including some franchises directly owned by the healthcare institution and located on-campus, and I see an opportunity do more than provide accommodations for families during a hospital stay or a convention venue. As a building type, hotels are consumer oriented and focused on the total guest experience. Designers of hotel environments as well as their clients understand the value of positive distraction and captivating guests during their stay.

As healthcare clients shift their focus from purely functional spaces to ones that incorporate evidence-based design strategies, the connection between the environment and the health of patients and performance of staff is undeniable. Market trends have also necessitated a re-evaluation of traditional business models and rethinking of the spectrum of services provided. Healthcare design teams are working with owners to create spaces that are relaxing and comforting, perhaps even inspirational, instead of clinical. Collaboration with hotel designers could produce inspired hybrid architecture that also results in construction and operational savings for both due to the ability to share spaces and create operational efficiencies. Hotels already know how to offer excellent amenities that can seamlessly integrate with the goal of a healthcare institution such as wellness services and alternative therapies for both patients and families, in spas, gyms and grounds, venues for educational an community classes, and possibly even providing a transitional environment for discharged inpatients who may not be fully ready to return home. An inpatient room and a hotel room are not that dissimilar after all.

Biophilic Design: More Than a Distraction?

When you first started your architecture education, you were no doubt exposed to concepts tying the built and natural environments such as the chambered nautilus, bi-lateral symmetry, golden section, and of course Le Corbusier's Modular Man.  It seemed like cracking the code of nature would give some kind of magical solution to any design problem.  Then you probably forgot all about that stuff as you began a career and had to deal with real program requirements and code constraints.  Nature-inspired design is back, and this time its about more than just proportion or organic shapes a la Bruce Goff. It's also more than just putting up some twinkly LED lights in the ceiling or an illuminated photograph of a natural scene to simulate an outdoor view.

Incorporating evidence based design principles, biophilic design looks to meld the materials, process and cycles of nature into architecture.  It links our health, job performance and well being directly to the built environment. Design that takes into account natural processes and cycles feels better to inhabit. And now, it has evidence behind it.

In his popular book Biophilia, Edward Wilson, a biologist and social researcher describes a connection that humans innately seek with other living things.  The deep psychological connections that we have formed with nature influence us in primal and subconscious ways.  As behavioral psychologists began to study biophilia in greater detail, the applicability to healing environments became evident. Roger Ulrich has shown direct correlations between connections to nature and reductions in pain and depression, both of which lead to fewer complications and faster recovery. His work in particular seems to indicate that the most beneficial type of stimulation comes from evoking nature, as in artwork, or through actual exposure to nature itself. The growing amount of research into the impact of biophilic concepts on the built environment has included work with actual patients and hospital staff, such as the Ambient Experience created by Phillips, focused on building systems that provide a multi-sensory environment for patients, families and staff.  

This seems intuitive.  However, what exactly to implement in each type of space you are creating is not.  Your game plan:

1. As part of your space program, create a column for what you are trying to promote in each space.  In corridors, you may want to promote wayfinding and reduce noise; in staff work areas, reduce errors; in patient rooms, promote healing; and reduce stress in procedure rooms.  
2. Look at existing research on what will best produce the desired effects in each space.  For example, stress and anxiety contribute strongly to high pain levels.  Views of nature create a  positive diversion that helps to keep people focused on things other than pain or anxiety and promote healing.
3. Brainstorm as a team about ways these effects can manifest themselves in each space- can you provide views to a landscaped area?  Should artwork of natural landscapes be a focal point? What about lighting and acoustics?  What opportunities are there to get natural light, especially sunlight, into the space?  Can the space adapt to the time of day or season?  Are there opportunities to actually bring nature inside through plants or water features?
4. Determine how you can measure the results of your strategies and incorporate them into your evidence-based design plan.

Why does it work?  Some speculate that reducing anxiety is all about distracting people, but I think it goes further than that and taps into a primordial state of balance that helps inhabitants to feel calmer, more focused and invigorated.  Being in a biophilic environment is enriching and by stimulating our senses, we stimulate the soul.  

Design in the Age of the Prosumer

Ah, the good old days...it seems like there was once a time when clients trusted their architect implicitly and accepted their design and recommendations with little pushback.  It it just you imagination, or have things changed?   If you feel like only a necessary evil on your projects, you're not alone and you're not paranoid either.  Access to information has led to the rise of what has been called prosumerism, a term first introduced by futurist Alvin Toffler that implies that consumers are well informed, experienced and confident enough to challenge the producer of what they consume.  There are many variations on the origins of this word, from professional consumer to producer-consumer.  I like to think of it as proactive consumer,  This merger of professional and consumer roles leads to marginalization of the corporate producer (in our world the architect) and threatens to reduce our services from value-added to commodities. Some prosumer trends that have arisen and thoughts on how to use them to the project's design advantage:

1. Hiring of in-house professionals like registered architects and engineers to oversee and manage the work of the contracted design team for a project.  The in-house professionals often complete smaller projects without seeking to hire outside help.   

TIP: The insider is your friend.  They understand your point of view. Work with them and collaborate on strategies and they will be a trusted advocate at your next meeting with the rest of the team.  Remember, part of their job is to make sure that you are doing yours, so including them in the process allows them to report back favorably while shutting them out leads to critical comments when they review the set at the end of a design phase.

2.  Development of standards for room design and finish types/colors/materials.  These prototypes are the result of considerable time and effort on the part of the owner and changing them is not usually welcomed.

TIP: There is no such thing as one size fits all and every prototype has some capacity for adjustment to project-specific needs.  Having in-depth discussions on the rationale for each element in the prototype or standards can go a long way towards understanding where a proposed change makes sense and where it doesn't. Standards can help a client to establish a brand identity and level of quality without having to go through the process of reinventing the wheel for every project.  Additionally, it can take certain sticky design issues off of the table with user groups.  This is a case where the spirit of the law will trump the letter of the law, so do your homework before presenting different approaches and work within the framework.

3. Requirements that certain criteria or standards be incorporated into the design (like sustainabiity measures) in a defacto manner without acknowledging impacts on schedule, budget or fees.

TIP: For the most part, it's exciting not to have to sell a client on adopting a good practice, but boy are you both about to get some sticker shock if the right approach isn't followed.  You are designing a building, not baking a layer cake.  Before the first design meeting, maybe even in your proposal or the interview, you need to make it clear to your client that the old rules of project management and approach are out the window.  The square peg will not fit in the round hole.  Show them your true level of expertise by discussing precisely why these requirements will lead you to approach the project in a way that is smarter and better.

4. Rise of alternative project delivery methods to get things built faster.

TIP: Many architects bristle at the introduction of more chefs in the kitchen, from the Owner's Representative, to the Design Builder, to the increased legal implications. What actually happens, if you allow the process to work, is that we are making other parties more accountable, which takes some pressure off of us to spell out every little thing on drawings and develop painstaking details for every joint and drain.  Have you ever looked at a set of drawings from 40 years ago and been surprised by how thin the set was?  Go back 80 years and there is even less detailing of the functional stuff.  Those old drawings showed design intent, not how to fasten screws. Means and methods is something that should be the contractor's problem.  We had ourselves painted into a corner of over-detailing to avoid liability.  See this as a liberation.

I think designers can welcome the emerging prosumer in their clients because we can also show them that their patients/users/customers are prosumers too.  Everybody can use some good design to get a competitive edge.

The Design and Construction Game: Whose side are you on?

The built environment has many factions- team Design, team Owner and team Construction.  Recent trends in sustainable design and evidence based design require buy-in from all sides and a cooperative effort to carry concepts through into completion and operation. The rise in popularity of design-build and integrated project delivery attempts to balance responsibility and risk more evenly.  

Can we really transition successfully from an "us vs. them" mentality?  Or are we hardwired to struggle between achieving design goals, achieving profitability goals and achieving operational goals?  We are living through a paradigm shift that is both neutralizing our individual silos and adding responsibility to our effort.  But with this come a greater opportunity to stop competing and start collaborating.  Can we all be on the same team and realize that these goals are mutually dependent, not mutually exclusive? 

Hopefully the real winners are team End Users.

Are You an Outlier?

What does it take to be truly innovative?  The most succesful innovators actually redefine the staus quo and move the bar for the rest of the design world.  These outliers and their seemingly fringe ideas catch on and displace  established expectations and ways of doing things.  They find a way to create new synergies between things that previously seemed unrelated.  They define issues that others just worked around as actual problems and work to solve them.    It's always a risk to be an early adapter http://www.valuebasedmanagement.net/methods_rogers_innovation_adoption_curve.html because you might ride that wave head first right into the sandbar  but, really to make a difference as architects, we need to embrace our status as outliers.