hcd_2010_inflexibility in flexible design
TRANSCRIPT
Inflexibility in Flexible DesignFactors that Can Influence
Performance of Design
Health Care Design, Las Vegas, November 13-16, 2010
Presenters
Debajyoti PatiPhD, FIIA, LEED®AP, Vice President,
Director of Research, HKS Architects
Thomas E. Harvey JrFAIA, MPH, FACHA, LEED®AP, Senior Vice
President,
HKS Architects
Jennie EvansRN, BS, LEED®AP, Vice President, HKS
Architects
Doug BazuinME, Researcher,
Herman Miller
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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Agenda
• Nine domains that impact operational flexibility
• Study question and objectives
• Study methodology
• Factors affecting design for flexibility
• Questions
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
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
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
Introduction
9 DOMAINS OF DESIGN DECISION-MAKING
THAT IMPACT OPERATIONAL FLEXIBILITY
IN INPATIENT CARE UNITS
FLEXIBILITY …
TO ADAPT
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
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
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
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
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
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
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
NN
N
C
SOFT SPACE
FOR
SUPPORT
CORE
EXPANSION/
SHARING
SERVICE
SPREAD
INTO
ADJOINING
UNIT
FLEXIBILITY …
TO CONVERT
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
`
FLEXIBILITY …
TO EXPAND
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
NN
N
C
Question
WHAT IS HINDERING OPTIMIZING
OPERATIONAL FLEXIBILITY?
Research Method
SETTING
o Four hospitals
o Recent constructions
SAMPLING
o Purposive
o Maximize variability
DESIGN
o Exploratory
o Qualitative
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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Findings
FACTORS IMPEDING DESIGNING FOR
OPERATIONAL FLEXIBILITY
OPERATIONAL
FLEXIBILITY
Systemic
Cultural
HumanFinancial
Physical
Factor Types
Systemic
o Performance benchmark
o Anticipated IT support
o Infection control
o Regulations
Factors
Cultural
o Inertia
o Physician expectations
Human
o Psychology & perception
o Cognition
Financial
o Capital cost
o Personnel cost
o Return on investment (ROI)
Factors
Physical
o Pre-existing condition
EXAMPLES
Factors within Factors
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
Operational Interventions
Human Resources
Finance
Information Technology
DECISION TO BUILD OCCUPY THE BUILDING
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
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Unanticipated Consequences of Information Technology Support
Lack of Standardized Communication Platform
Service Expansion and Inter-Unit Movement Affected
Systemic: Information Technology
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
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
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Systemic: Performance Benchmarks
Performance Benchmarks are Independent – Not Interdependent
Individual departments are measured on individual performance
Visibility and Proximity of Support Affected
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Systemic: Infection Control
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Systemic: Regulations
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Cultural: Inertia
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Human: Perception
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Human: Cognition
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Human: Cognition
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Financial: First Costs
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Financial: Human Resources
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Financial: Return on Investment
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Physical: Site Restrictions
CURRENT OPERATIONS
CU
LT
UR
E
Regulations
Design Process
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
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
Findings
WHAT DOES ALL THIS MEAN?
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
NN
N
C
Integrated Thinking
CURRENT OPERATIONS
CU
LT
UR
E
DESIGN AND CONSTRUCTION OCCUPANCY
FA
CT
OR
S
DECISION TO BUILD OCCUPY THE BUILDING
Finance
Information Technology
Design Process
Human Resources
Operational Interventions
Regulations
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….
