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HCD_2010_Inflexibility in Flexible Design

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HCD_2010_Inflexibility in Flexible Design

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HCD_2010_Inflexibility in Flexible Design

  1. 1. Inflexibility in Flexible Design Factors that Can Influence Performance of Design Health Care Design, Las Vegas, November 13-16, 2010
  2. 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. 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. 1 2 3 4
  4. 4. Agenda • Nine domains that impact operational flexibility • Study question and objectives • Study methodology • Factors affecting design for flexibility • Questions
  5. 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. 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. 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. 8. Introduction 9DOMAINS OF DESIGN DECISION-MAKING THAT IMPACT OPERATIONAL FLEXIBILITY IN INPATIENT CARE UNITS
  9. 9. FLEXIBILITY … TO ADAPT
  10. 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. 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. 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. 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. 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. 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. 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. 17. FLEXIBILITY … TO CONVERT
  18. 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. 19. ` FLEXIBILITY … TO EXPAND
  20. 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. 21. Question WHAT IS HINDERING OPTIMIZING OPERATIONAL FLEXIBILITY?
  22. 22. Research Method  SETTING o Four hospitals o Recent constructions  SAMPLING o Purposive o Maximize variability  DESIGN o Exploratory o Qualitative
  23. 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 123 8 7 6 5 4 3 2 1 12 11 10 3211211109121110 9 8 7 6 5 4 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 6 7 8 9 10 11 12 8 9 10 11 12 1 2 3 4 5 123456789 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8910111212345 6 7 8 9 10 11 12 1 2 3 4 5 6 7 1 2 3 4 5 12 11 10 9 8 7 1 2 3 4 5 6 12 11 10 9 8 7 6 5 4 3 2 1 12 11 10 9 8 7 6 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 123456789101112 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 8 7 6 5 4 3 2 1 2 1 11 10 9 10 11 12 1 2 3 4 5 6 7 8 3 2 1 8 7 6 5 4 3 9 10 11 12 9 4 6 7 8 5 12 1234 9 10 11 12 12 11 10 9 1 2 3 4 5 6 7 8 4 3 2 1 9 10 11 12 5 6 7 85 6 7 8 123 8 9 10 4 5 6 7 1 2 3 10 9 8 4 5 6 7 1 2 3 8 9 10 4 5 6 7 1 2 34 5 6 9 10 11 12 13 14 15 16 24 23 22 21 20 19 18 17 87654321 2526272829303132 9 10 11 12 13 14 15 16 24 23 22 21 20 19 18 17 1 2 32 31 30 3 429 28 5 627 26 25 7 8 5 6 7 8 12 11 10 9 32 1 231 30 29 3 4 28272625 21222324 17 16 1518 19 20 14 13 123 8 7 6 5 4 3 2 1 12 11 10 3211211109121110 9 8 7 6 5 4 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 6 7 8 9 10 11 12 8 9 10 11 12 1 2 3 4 5 123456789 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8910111212345 6 7 8 9 10 11 12 1 2 3 4 5 6 7 1 2 3 4 5 12 11 10 9 8 7 1 2 3 4 5 6 12 11 10 9 8 7 6 5 4 3 2 1 12 11 10 9 8 7 6 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 123456789101112 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 8 7 6 5 4 3 2 1 2 1 11 10 9 10 11 12 1 2 3 4 5 6 7 8 3 2 1 8 7 6 5 4 3 9 10 11 12 9 4 6 7 8 5 12 1234 9 10 11 12 12 11 10 9 1 2 3 4 5 6 7 8 4 3 2 1 9 10 11 12 5 6 7 85 6 7 8 123 8 9 10 4 5 6 7 1 2 3 10 9 8 4 5 6 7 1 2 3 8 9 10 4 5 6 7 1 2 34 5 6 9 10 1 24 23 2 87654321 2526272829303132 9 10 11 12 13 14 24 23 22 21 20 19 1 2 32 31 30 3 429 28 5 627 26 25 7 8 5 6 12 11 32 1 231 30 29 3 4 28272625 21222324 17 16 1518 19 20 14 13
  24. 24. Findings FACTORS IMPEDING DESIGNING FOR OPERATIONAL FLEXIBILITY
  25. 25. OPERATIONAL FLEXIBILITY Systemic Cultural HumanFinancial Physical Factor Types
  26. 26.  Systemic o Performance benchmark o Anticipated IT support o Infection control o Regulations Factors  Cultural o Inertia o Physician expectations
  27. 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. 28. EXAMPLES
  29. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 44. Findings WHAT DOES ALL THIS MEAN?
  45. 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. 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. 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. 48. Thank You …

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