Not your same-old hospital: How design is responding to new priorities in health care

West: We need to be good stewards of their dollars and make sure that we're developing and designing facilities that can be the most efficient in delivering care to the patient.

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Interviewer: I'm here with Pat West who's the Senior Vice President at Gresham, Smith and Partners, which is an Architectural, Engineering and Planning Firm. One of the things that probably isn't as obvious as we talk about everything that's changing in healthcare is how the design of buildings are going to need to respond to new delivery systems, new priorities, and new incentives. So maybe you can us about some of the issues and some of the solutions you're creating in architecture to respond to those changes.

West: Probably the most important thing that we're doing is responding to the client in regards to efficiency. We need to be good stewards of their dollars and make sure that we're developing and designing facilities that can be the most efficient in delivering care to the patient. So we practice architecture by using a lean process improvement factor to drive the planning units within a hospital to determine the departmental needs in the design of the building.

Interviewer: You said that the systems are not set up in the most efficient way, the most lean way and that comes out in the planning process. Talk a little bit about that new role you're having to play.

West: We've been using process improvement for several years, but now it's more heavily accepted by the client. Just as they're delivering care efficiently to their patients, we also need to deliver the architectural process in the most efficient way. What we do is bring together what's called multi-disciplinary study teams and I'll use the ER as an example. It's just not those people that are working in the ER, it's also the people that connect with the ER: housekeeping, lab. So we bring all those teams together and look at the process of how they're delivering care now and then look at the ideal process. And then that process frames the design of the building or that particular department.

Interviewer: It seems like there's a lot of opportunity for, I guess, disagreement in a way. Do you find that as a little bit of tricky territory?

West: I don't know if it's so much disagreement. It's that "uh-huh" moment where one person is thinking a process is delivered in one manner and it's really not. And another person is thinking, "Oh my." That's what's really happening.

Interviewer: Interesting. And you mentioned that you've learned a lot from other industries, like the aviation industry. Talk a little bit about in the standardization of care because rooms and operating rooms and all sorts of systems are set up completely different, which would make it hard for the provider, I would imagine.

West: Yes, about 10 to 12 years ago we designed a facility in West Bend, Wisconsin, St. Joseph's Hospital. That was the first patient safety hospital. We took about 10 months just going through a planning process and understanding safety attributes that we could bring to the building. We engaged people from Nassau, from the aeronautical industry and nuclear power plants to look at their safety elements that they put in place within their industry.

For instance, in aviation, if you go in any plane in a 747 or a Cessna and the cockpit's the same. Why shouldn't the patient room be the same? So in that particular case, in St. Joseph's West Bend, we went ahead and all patient rooms are truly identical. And then we also went through a process of failure modes effect analysis and looking at different processes and where the breakdown could be. They were prepared not only in delivering care, but we were also prepared if there were any particular failures within the building that we could correct. If it was lighting, if it was noise, interruptions that interrupt patient care.

Interviewer: So variation is a huge problem within healthcare. Do you ever see a moment where every patient room across the country might be designed the same?

West: No, it's still up for discussion. Some see it as being very effective. Some people see that it's at a high cost. But I think when you start standardizing and standardizing the casework in the patient room and the plumbing, costs start coming down.

Interviewer: And a lot of the buildings that were designed several years ago maybe were designed more to attract new patients. For patients that attraction now, cost is a much, a much bigger driver in Healthcare. Systems seem to be designing more for efficiency. Have you seen a change in the way that you're designing buildings over the past several years?

West: Absolutely, efficiency and delivering care is the number one element that's in the mind of our client. How efficient can that building operate probably with the lowest number of FTEs without sacrificing patient care?

Interviewer: You know incentives are something that are just a moving target in healthcare and have been misaligned forever. You mentioned a few ways that you're bringing the architect into the incentive process. Talk a little bit about that.

West: Well, there's a delivery model out there that's called Innovative Project Delivery that actually originated in California. Typically, that delivery method, the contract is one contract with the hospital. But a lot of states legally will not allow you to do that. So we have done several projects under IPD Lite, where they're contracts held separately, but we all play in the same sandbox together. We're a fully integrated team, along with the owner.

Sometimes, there are some incentive programs, not only for the architect, engineer, and contractor but also for the owner to reap benefits where we've been able to have several different cost savings during the design of the project either influenced by efficiencies of the contractor or the subcontractor and that we all benefit in that. The owner usually defines what goals they want to meet in order to have that incentive package pay back to all parties involved.

Interviewer: And so some of those incentives, talk about what they included. HCAP scores in some instances, what were some of the others?

West: One particular client wants to measure the outcomes of what the architect, engineer and contractor did based on their data of two years out as far as falls or hospital-acquired infections.

Interviewer: If you were to describe an impossible problem in the intersection of architecture and healthcare, what would it be?

West: I don't know if it's an impossible problem, just being able to reap the best benefit for the hospital under today's healthcare reform. Just like they're trying to do more with less, we need to do almost more with more innovative solutions for the hospitals.

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