PlanningThe human element
Designing a health care space that keeps the patient and staff in mind
By Stan Chiu, AIA, LEED AP
President Obama's director of the office of management and budget recently stated that the study of human behavior should play a more vital role in economics and medicine than mathematics. "Too many academic fields have tried to apply pure mathematical models to activities that involve human beings," David Orszag recently told National Public Radio. "And, whenever that happens—whether it's in economics or health care or medical science—whenever human beings are involved, an approach that is attracted by that purity will lead you astray."
Orszag's philosophy reflects a paradigm shift we've recently experienced in the health care design profession. Health care planners must not only play designer, economist and financial analyst when evaluating target value costing and other data, but also anthropologist as they analyze the flow of people, materials and information.
Lean methods—first popularized by Toyota in the 1960s—present us with an exciting opportunity to wear all of these hats. Applied to operations, lean principles impact the flow of health care delivery by reducing wasted time and improving efficiency. Applied to design and construction, lean changes the way a hospital project is delivered by reducing the time to design, permit and build. In the end, lean methods can help today's hospitals lower operating costs by decreasing the amount of space used by up to 30 percent and using up to 25 percent fewer natural resources. Yet, those metrics only tell you part of the story. What about the human element?
The optimal process
By observing how a patient flows through a hospital, architects can design a modern health care environment that eliminates wasted time, reduces operational costs and ultimately leads to less mistakes, backflows and waiting. The key is to understand the current process flows prior to design, analyze these flows and create the ideal future state flows, adjacencies and spaces that provide the best functionality for each process, department or organization.
In the optimal process, before any design or space layouts are created for a health care project, architects create a map of key daily activities inside the hospital. If part of a client's objective is to design a more functional and efficient space, it is essential to know the current process flow as well as the ideal flow, so that spaces can be designed accordingly. This can be accomplished through interviews with staff or by directly observing all of the actions required from the time a patient is admitted, through diagnosis, treatment and discharge as well as follow-up. The map can be incredibly detailed and fine-tuned for specific users. For example, what are the steps of an inpatient fluoroscopy scan? How does the physician enter the system? How is the patient transported? Arguably, the only part of the process that adds value is when the patient is in the scanner, however, there may be 20 or more steps involved in an inpatient fluoroscopy scan. There are many aspects of this process flow that can contribute to designing an inpatient fluoroscopy scan layout that reduces waste and improves efficiency. Questions asked, and answered during this observation process may include: What is the sequence of activities? Which activities add value to the process? What activities add waste? How can they be eliminated? What is the travel distance between these activities? What are the desired adjacencies based on the ideal flow? The answers are to be found in changes to people, processes, space or technology.
 Hospital staff map out daily activities on post-it notes during the pre-design process. |
Even when a current process is working for the client, it doesn't necessarily mean it is the best design for a particular process, department or organization. "Workarounds" created by intelligent, resourceful staff mask waste—which contributes to inefficiencies or quality compromises. At a recent site visit to an emergency department, for example, numbered tags were observed taped to the wall of the corridor. These makeshift ED stations addressed a space need at an enormous cost to patient experience and quality of care.
Understanding how a process flows enables the creation of new health care facilities that are not only architecturally pleasing, but also functional and efficient for those utilizing the building. This pre-design observation process is incredibly instrumental for all parties involved because it gives the designers, staff and health care provider an opportunity to identify the values that are most important to them.
Observing the flow of traffic through a physical space contributes to the flow of knowledge during the design process. An opportunity for true collaboration and patient satisfaction is born through this process, as architects work in tandem with healthcare providers and staff to understand their ultimate goals. Patient experience sessions between hospital clinical programs and internal service providers may be set up in order to brainstorm ideas that will better serve patients. It is a team culture, where egos are checked at the door and words like "I" and "me" take a backseat to "us" and "we." Through these discussions, we may generate sets of alternatives and engage in a multi-disciplinary integration of events. The architects, staff and client are empowered to make decisions that support innovation, creativity and ultimately, the hospital's core values. The pursuit of knowledge overrides the singular pursuit of metrics; because through that knowledge, the metrics will follow.
Example of success
The Barlow Respiratory Replacement Hospital in Los Angeles demonstrates how the collaboration and observation process presents an opportunity for designers to reduce waste, improve efficiency, and increase innovation. Two seemingly incompatible goals for the 56-bed, 78,000-square-foot project included: 1) creating small scale neighborhood clusters in order to make the best use of a very tight site within Elysian Park, and 2) needing the flexibility of a more typical continuous beds racetrack layout. Thanks to highly collaborative user groups and a creative design team, both tasks were accomplished. The team's process analysis paired this solution with distributed supplies to create specialized nursing units that respond to Barlow's unique culture. Additionally, the team's process engineer predicts a profound increase in efficiency as well. Estimated to be completed in 2013, the new hospital aims to include 48 long-term acute care beds, eight ICU beds, surgery, imaging, a respiratory therapy and pulmonary function lab, pharmacy, clinical lab, medical and administrative offices, gift shop, dining and support services.
 For the future Barlow Respiratory Replacement Hospital in Los Angeles, designers created small-scale neighborhood clusters in order to maximize space and develop efficiencies for nursing staff on a very tight site within Elysian Park. |
By understanding the current state activities and flow as part of an in depth patient experience analysis, the designers created a more efficient and functional architectural plan that met the specific needs of Barlow Respiratory Replacement Hospital. The results will be better patient care and higher performing staff. Patients will be able to get the care they need in a timely manner, and the staff will be able to spend more time with patients and less time walking between departments or doing other non-value-added activities.
Emphasizing people
Defining success in the world of new health care facilities does not simply come down to cost numbers, figures or diagrams. It is about the people behind the hospital's design, and the people who will fill its corridors everyday. By placing emphasis on the human element—the patient experience—we are essentially flipping the traditional design model. This process leads to a new kind of purity—a purity of knowledge—where healthcare delivery is streamlined, non-value-added steps are eliminated and value-added steps associated with each resource in the process are improved.
Stan Chiu, AIA, LEED® AP, is vice president and lead designer in the Los Angeles office of HGA Architects and Engineers, one of the nation's leading firms specializing in lean design. He can be reached at schiu@hga.com.
