HCD_2010_Inflexibility in Flexible Design

1. Inflexibility in Flexible Design
Factors that Can Influence
Performance of Design
Health Care Design, Las Vegas, November 13-16, 2010

2. Presenters
Debajyoti Pati
PhD, FIIA, LEED®AP, Vice President,
Director of Research, HKS Architects
Thomas E. Harvey Jr
FAIA, MPH, FACHA, LEED®AP, Senior Vice
President,
HKS Architects
Jennie Evans
RN, BS, LEED®AP, Vice President, HKS
Architects
Doug Bazuin
ME, Researcher,
Herman Miller

3. Learning Objectives
Understand the nine domains of design decision-making that impact
operational flexibility in acute care medical-surgical units.
Learn regarding extraneous factors that could obstruct optimization of
operational performance.
Learn regarding operational interventions that could address some of the
impediments.
Identify design process issues that could address some of the
impediments.
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4. Agenda
• Nine domains that impact operational flexibility
• Study question and objectives
• Study methodology
• Factors affecting design for flexibility
• Questions

5. Acknowledgements
 Herman Miller
 Dr. P. Phillips Hospital, Orlando, FL
 Homestead Hospital, Homestead, FL
 St Joseph Mercy Hospital, Ann Arbor, MI
 Methodist Charleton Medical Center, Dallas, TX

6. Degree
of
Success
of
Project
Owner Team
Contributions
Current culture
Change management
Transition planning
Design Team
Contributions
Know client
Lead process
Create alternatives
Communications
Collaboration
Learning Objectives

7. Degree
of
Success
of
Project
Owner Team
Contributions
Current culture
Change management
Transition planning
Design Team
Contributions
Know client
Lead process
Create alternatives
Communications
Collaboration
Learning Objectives

8. Introduction
9DOMAINS OF DESIGN DECISION-MAKING
THAT IMPACT OPERATIONAL FLEXIBILITY
IN INPATIENT CARE UNITS

9. FLEXIBILITY …
TO ADAPT

10. Peer Lines-of-Sight
 Operational issue
o Helping hand, mentoring,
socialization, de-stressing
 Affects
o Nurse, respiratory therapist
 Environmental correlates
o Caregiver work station,
corridor shape, corridor
configuration
 Implications
o Simple shape units
o Corner location of caregiver
workstation in support core
o Back-stage corridors linking
caregiver workstations
o Simple circulation configuration

11. Patient Visibility
 Operational issue
o Higher acuity, JCAHO
regulations, non-
contiguous patients
 Affects
o Nurse, nursing
administration, respiratory
therapist
 Environmental correlates
o Caregiver workstation,
medication room, utility
room
 Implications
o Multiple caregiver work
centers with proximal
patient rooms
o Unobstructed sightline to
patient rooms
o Outboard toilet location

12. MODIFIED
CORNERS =
PERCEIVED
BARRIER
Multiple Division/Zoning Option
 Operational issue
o Perceived barriers
o Assignment problems
 Affects
o Nurse, nursing
administration
 Environmental correlates
o Stairwell, support spaces,
staff toilets
 Implications
o Stairwell and support
spaces located at end of
an array of patient rooms,
or inside the support core
o Simple circulation
configuration

13. Proximity of Support
 Operational issue
o Walking distance
o Stress, fatigue
 Affects
o Nurse, nursing
administration,
environmental services,
dietary services, materials
management, respiratory
therapy
 Environmental correlates
o Patient room, support
spaces
 Implications
o Simple shape, symmetrical
units
o Distributed nursing support
spaces proximate to
distributed caregiver
workstations
o Decentralized room-side
supply cabinets

14. Resilience to Move Services
 Operational issue
o Long term census
fluctuation
 Affects
o Nurse, nursing
administration
 Environmental correlates
o Standardization
 Implications
o Standardized room
o Standardized support core

15. Inter-Unit Movements
 Operational issue
o Multi-unit caregiver
responsibility
 Affects
o Nurse, environmental
services, dietary services,
materials management,
pharmacy, respiratory
therapy
 Environmental correlates
o Vertical circulation core,
unit proximity, horizontal
access
 Implications
o Communicating stair inside
unit
o Proximal location of
vertical circulation core
o Back corridor inter-unit link
o Unobstructed horizontal
circulation

16. Service Expansion Options
 Operational issue
o Census fluctuations
o Unit-service misfit
 Affects
o Nurse, nursing
administration
 Environmental correlates
o Unit size, unit
configuration, unit
adjacency
 Implications
o Visual or geographic cues
to help unit subdivisions
o Back corridor links
between adjacent units
N
N
N
C
SOFT SPACE
FOR
SUPPORT
CORE
EXPANSION/
SHARING
SERVICE
SPREAD
INTO
ADJOINING
UNIT

17. FLEXIBILITY …
TO CONVERT

18. Adjustable Support Core
 Operational issue
o Supply and equipment
storage
o Shape and size of rooms
 Affects
o Nurse, nursing
administration,
environmental services,
dietary services, materials
management, pharmacy,
respiratory therapy
 Environmental correlates
o Cabinetry, support room
shape, support room size
 Implications
o Modular, movable
compartments or cart
system for storage
o Minimize walls with MEP
elements

19. `
FLEXIBILITY …
TO EXPAND

20. Expandable Support Core
 Operational issue
o Operational changes over
time
 Affects
o Nurse, nursing
administration,
environmental services,
dietary services, materials
management, pharmacy,
respiratory therapy
 Environmental correlates
o Adjacent functions
 Implications
o Soft program adjacent
spaces
N
N
N
C

21. Question
WHAT IS HINDERING OPTIMIZING
OPERATIONAL FLEXIBILITY?

22. Research Method
 SETTING
o Four hospitals
o Recent constructions
 SAMPLING
o Purposive
o Maximize variability
 DESIGN
o Exploratory
o Qualitative

23. Research Method
 PARTICIPANTS
o Nursing, RT, Materials
Management, EVS,
Pharmacy, Dietary
 TOOLS
o Gaming
o Semi-structured interviews
 ANALYSIS
o Transcription
o Content analysis
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24. Findings
FACTORS IMPEDING DESIGNING FOR
OPERATIONAL FLEXIBILITY

25. OPERATIONAL
FLEXIBILITY
Systemic
Cultural
HumanFinancial
Physical
Factor Types

26.  Systemic
o Performance benchmark
o Anticipated IT support
o Infection control
o Regulations
Factors
 Cultural
o Inertia
o Physician expectations

27.  Human
o Psychology & perception
o Cognition
 Financial
o Capital cost
o Personnel cost
o Return on investment (ROI)
Factors
 Physical
o Pre-existing condition

28. EXAMPLES

29. Factors within Factors
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
DECISION TO BUILD OCCUPY THE BUILDING

30.  Unanticipated Consequences of Information Technology Support
 Hands-free Technology Conflicts with Regulatory Agency Requirements
 Hands – free Technology not available for all staff
 Visibility and Proximity of Support Affected
Systemic: Information Technology
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
 Clearly identify the problem
 Thoroughly map operational use in various
situations
 Failure Mode Effect Analysis (FMEA)
DECISION TO BUILD OCCUPY THE BUILDING
Information Technology
Operational Interventions

31.  Unanticipated Consequences of Information Technology Support
 Lack of Standardized Communication Platform
 Service Expansion and Inter-Unit Movement Affected
Systemic: Information Technology
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
 Clearly identify the problem
 Failure Mode Effects Analysis (FMEA)
 Identify return on investment
DECISION TO BUILD OCCUPY THE BUILDING
Information Technology
Operational Interventions

32.  Unanticipated Consequences of Information Technology Support
 Assumptions are not implemented in time
 Visibility, Proximity of Support and Support Core Affected
Systemic: Information Technology
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
 Understand how technology affects workflow
 Design for interim model of care
 Plan IT implementation concurrent with
building occupancy
DECISION TO BUILD OCCUPY THE BUILDING
Information Technology
Operational Interventions

33. Systemic: Performance Benchmarks
 Performance Benchmarks are Independent – Not Interdependent
 Individual departments are measured on individual performance
 Visibility and Proximity of Support Affected
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
 Identify the return on investment
 Create interdependent organization – wide
benchmarks
 Create culture to eliminate the waste
DECISION TO BUILD OCCUPY THE BUILDING
Operational Interventions

34. Systemic: Infection Control
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
 Call for more empirical evidence
 Identify and communicate case studies of
other facilities
DECISION TO BUILD OCCUPY THE BUILDING
 Lack of Standardized Infection Control Guidelines
 Infection Control Guidelines are not consistent
 Visibility and Proximity of Support Affected
Operational Interventions

35. Systemic: Regulations
CURRENT OPERATIONS
CULTURE
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
 Identify downstream regulatory restrictions early
 Plan for future building growth
 Plan for flexible use of space
DECISION TO BUILD OCCUPY THE BUILDING
 Certificate of Need Restrictions
 Restriction of Service Growth
 Service Expansion Affected
Operational Interventions
Human Resources
Finance
Information Technology
Regulations
Design Process

36. Cultural: Inertia
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
 Commitment to ensure adoption
 Early change management for all stakeholders
 Education stakeholders on impact of non-
conformance
DECISION TO BUILD OCCUPY THE BUILDING
 Lack of Adoption of New Technologies
 Interdependence of team requires team adoption of technology
 Visibility and Proximity of Support
Operational Interventions

37. Human: Perception
CURRENT OPERATIONS
CULTURE
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
Design Process
 Education regarding effects of odd shapes on functionality
 Checkpoint at conceptual level for operational functionality
 Keep design process fluid by exploring alternatives
 Provide time to evaluate design options
DECISION TO BUILD OCCUPY THE BUILDING
 Some Shapes Attract More Than Others
 Curves Attract!
 Visibility, Proximity, and Adaptability Affected
Design Process

38. Human: Cognition
CURRENT OPERATIONS
CULTURE
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
Design Process
 Create unit mock-ups
 Preferably with walls and equipment
 3D – visualization of rooms and units
 Create virtual reality model
DECISION TO BUILD OCCUPY THE BUILDING
 Cognition of Non-Designers
 Translation of 2D to 3D
 Peer Line of Sight, Visibility, Multiple Division Affected
Design Process

39. Human: Cognition
CURRENT OPERATIONS
CULTURE
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
Design Process
 Mock-up “pods” or groups of rooms
 Tape OK – walls better
 Create virtual reality model
DECISION TO BUILD OCCUPY THE BUILDING
 Cognition of Non-Designers
 Scaling UP from Architectural Drawings
 Visibility, Proximity of Support, Inter-Unit Movement Affected
Design Process

40. Financial: First Costs
CURRENT OPERATIONS
CULTURE
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Information Technology
Design Process
 Value stream map flow of materials, waste, linen,
patients
 Create early study (not DD) of cost of material and
people flow
 Identify return on investment for people movement
Finance
DECISION TO BUILD OCCUPY THE BUILDING
 Vertical and Horizontal Connections
 Location and Number Matters
 Inter-Unit Movement, Service Expansion Affected
Finance
Design Process

41. Financial: Human Resources
CURRENT OPERATIONS
CULTURE
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Information Technology
Finance
Design Process
 Identify human resource changes early
 Identify first costs with performance
benchmark improvements
 Implement a culture to eliminate waste
DECISION TO BUILD OCCUPY THE BUILDING
 Personnel Cost
 Right People Doing the Right Job
 Proximity of Support Affected

42. Financial: Return on Investment
CURRENT OPERATIONS
CULTURE
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Information Technology
Finance
Design Process
 Focused attempt to calculate Life Cycle
Cost
 Identify new performance benchmarks
DECISION TO BUILD OCCUPY THE BUILDING
 Missing Life Cycle Cost
 Similar to Sustainability Challenges
 All Domains Affected – Healthcare Design Could Change
Finance

43. Physical: Site Restrictions
CURRENT OPERATIONS
CULTURE
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
Operational Interventions
Human Resources
Finance
Information Technology
 Identify downstream implications of site challenges
early
 Verify master plan assumptions
 Explore alternatives to optimize functionality of design
DECISION TO BUILD OCCUPY THE BUILDING
 Form Dictates Function
 Site Restrictions Require Particular Shape
 All Domains Affected
Regulations
Design Process

44. Findings
WHAT DOES ALL THIS MEAN?

45. Summary
9 Domains of
Operational
Flexibility
Factors that
Inhibit
Flexibility
Tactical
Solutions
• Flexibility to Adapt
• Flexibility to Convert
• Flexibility to Expand
• Systemic
• Physical
• Financial
• Cultural
• Human
• Identify Life Cycle Costs
• Breakdown Silos
• Value Stream Mapping
• FMEA and 5Y
• Identify downstream risks
N
N
N
C

46. Integrated Thinking
CURRENT OPERATIONS
CULTURE
DESIGN AND CONSTRUCTION OCCUPANCY
FACTORS
DECISION TO BUILD OCCUPY THE BUILDING
Finance
Information Technology
Design Process
Human Resources
Operational Interventions
Regulations

47. Process Rethinking
 Establish Clear Goals
 Ensure Compliance with Goals
 Identify Metrics for Evaluation
 Identify Strategic Checkpoints for
Operational Review (metrics)
 Perform Functional Facility Reviews
Post Occupation
 Begin Change Management At Decision
to Build or Before
Finance
Human
Resources
Information
Technology
Operations
Design
Process
Regulations
Integrated Project Delivery for Operational Planning….

48. Thank You …