In the May 2004 issue of HEALTHCARE DESIGN (“Lessons From Both Sides of the Pond,” pp. 23-28), Derek Parker wrote about the similarities and differences between healthcare architecture in the United States and the United Kingdom. In this issue and one to follow, we want to focus on aspects of healthcare architecture that are unique to each of them. Although we have found some differences between the two countries in space programming and physical planning for healthcare facilities, we have chosen in this piece to look at process and culture in the making of healthcare architecture— focusing, most particularly, on our experience in the United States with the visioning process. While many aspects of healthcare design are becoming standardized, the visioning process and the resulting image—or brand (a popular concept in the United States)—reflect the culture of a specific institution, as well as of the larger society.

It has been our experience that visioning helps get our clients and our design team on the same page. As we plan and go through the process, the client/architect team is formed and the foundation for the design process set. Whether encompassing a one-day session or a series of events, visioning has helped us understand our clients’ highest aspirations for what might be their once-in-a-lifetime opportunity to build their “ideal facility.” Moreover, when we worked with an organization that had a new CEO, the visioning process allowed the client's key stakeholders to hear each other's ideas and hopes for the future and helped them get aligned around a unified goal. As they build a common vision together, our clients are laying the groundwork for a project that will reflect their overall preferred future.

Who's Involved?

It is automatic for us to consider visioning as part of the project kickoff process. As architects, we organize the agenda, the participants, the guests, and the outcomes as a result of working in close partnership with our client. The participants are the organization's stakeholders, who typically include physicians and key staff, administrators and board members, patients and families, and community representatives. For big healthcare institutions, we have often retained the services of a consultant that specializes in large group facilitation. The facilitator helps us shape the agenda, suggests engaging activities and techniques to elicit open participation, assembles a record of the proceedings, and advises us on presentation of the outcomes.


Bringing in a neutral party who has neither a rigid approach nor a preconceived result encourages all participants to share their views. Many facilitators use similar questions and techniques, but whether the group comes away with a sense of shared purpose and resolve depends largely on the facilitator's skills and “fit” with the group's cultural style and dynamics.

We have noticed that large groups also benefit from using the services of a professional graphic recorder. This is a consultant who documents specific comments and overarching themes in a visual format on butcher-papered walls; this is useful because pictures are interesting, attention grabbing, and immediately accessible. In addition, we have often invited one or two experts to report on future trends that may impact healthcare and who are provocative and focused on stimulating participants’ thinking.

Before You Begin

Preliminary planning meetings with the facilitator are essential in setting up the process. We invite key project leaders to work with us. After these preliminary meetings, the facilitator and graphic recorder can create a “start-up chart” in preparation for the first full session. Hung on the wall for all to see as they enter the session, the chart will tell everybody the agenda for the meeting, the roles of the people involved, a proposed set of ground rules, and the desired outcomes. Putting up the agenda at the beginning helps everybody buy into the framework for participation. Ground rules are reviewed and can be amended by the participants. We've seen the following rules included in many of the sessions in which we've been involved:

  • Share responsibility for success of meeting.

  • Explore and examine differences.

  • Respect time constraints.

  • Think outside the box.

  • Respect each person's input.

The desired outcomes can be revised, if necessary, but are usually broad in nature. Typically, they include developing key attributes to guide the project's development, creating excitement and gaining support from major constituencies, and agreeing on the next steps.

Logistically, it is beneficial to hold sessions at a venue outside the institution to help clear peoples’ minds of the pressures of their immediate responsibilities and tasks. We have held visioning retreats at local hotels, resorts, or country clubs, all places with a strong ambience of hospitality. Organizing people in groups of eight to ten at round tables, where everyone can see the whole room, encourages participation both in whole-group discussions and in more intimate small-group breakout exercises. We have found that it is wise to have the client decide on specific seating assignments, however, to avoid disruptions and promote synergies.

Expert Presentations

An effective way to stimulate peoples’ thinking about their own future is to present them with an expert's broader perspective. As mentioned, we have invited healthcare futurists to speak on the challenges facing the healthcare industry in the near-term, as well as in a predicted future based on today's trends. We have seen experts in specialty areas such as family-centered care or integrative medicine also effectively deliver “food for thought.” These guests should be carefully chosen with the specific interests of the institution's culture and strategic plan in mind.

Often the presentation is most useful as a catalyst for discussion. Even if the participants disagree with the presenter, certain trends that will inform the vision are likely to emerge from the stimulation of the group and subsequent discussion. Some recent topics we have observed as relevant to our clients include impact of biotechnology on medicine, staffing shortages, and safety issues in the healthcare environment. If the participant group is large, it is helpful to break into smaller groups for the discussion and then bring the results back to the whole group.

Historic Time Line

Institutions that have been in existence for a long time each have a history that plays a critical role in developing a vision. A useful task is to assemble the institution's time line, highlighting important defining events as well as including milestones in the healthcare industry as a whole. This institutional “memory exercise” requires a fair amount of preparation on the facilitator's part, but it can be useful in bringing diverse stakeholders together to understand their common legacy and shared future.

After the historic time line has been constructed and displayed as a large poster, it is a good idea to discuss what was revealed in reviewing the institution's history. Participants are invited to add key milestones and important events. There probably will be a balance of negative and positive comments. For example, participants might remark on what they have endured in terms of discontinuity or the need for more strategic vision in the future. On the other hand, highlighting their accomplishments over the years—easily forgotten in the details of day-to-day challenges—can rekindle a sense of pride. This exercise is engaging, enlightening, and helps everyone build the foundation for their future.

Starting the Visioning

The above notwithstanding, groups don't always have time to create a historical time line, and sometimes the “expert presentation” is only an article to read the night before the session. In these cases, we have found it helpful to break into smaller groups and work on determining the values of the organization. This approach gives participants the opportunity to share what really matters to them as an organization.

The first step is to investigate what the term “visioning” means. An experienced facilitator will share some quotes or inspirational statements to assist the participants in forming a bond as they sort this out. One inspirational quote used in two different sessions in which we participated was, “Everything that is possible now was at one time impossible. When we look forward with hope and expectation, it is an act of creativity that empowers and creates the present we want. So, we must learn to speak out and say, ‘Yes, this is where we prefer to go.’” We have found it helpful for breakout groups to develop their own inspirational comments about “what is possible.”

Warming Up

One of the most interesting and fun exercises in which we've participated was part of the visioning for a children's hospital replacement project. Small groups were invited to imagine that their newly completed hospital is featured in a cover story in a major national publication like TIME, The New York Times, or The Wall Street Journal. A graphic template was provided that included mock-ups for the cover, headlines, quotes, and sidebars, as well as a place for images. Many of the covers and story ideas that emerged revolved around a few key themes important to the institution. These helped people identify the values expressed by their new building for which they wanted to be recognized and remembered. For example:

  • Clinical and research intersections (bench-to-bedside advancements)

  • Recognition for healing (e.g., Nobel Prize)

  • Community revitalization

  • Worker satisfaction

  • Combination of high tech/high touch

Like stretching before jogging, all of these exercises help limber up the imaginations of the stakeholders in a hospital project. By “thinking big,” they are ready to determine the key vision state-ments that will lead to their “Guiding Principles.”

Guiding Principles

Sometimes we compare the first part of visioning to being at 30,000 feet, because we are encouraging our clients to dream of their ideal scenario. To bring things closer to earth, and eventually to a building, participants refine those broad ideas into three categories: vision, goals, and planning principles. It is not unusual for us to bring the boards on which we captured these ideas to all the client meetings through the schematic design phase. They are a constant reminder for the entire team not to lose sight of the big picture, and they serve as a guide when hard decisions need to be made. For example, the outcomes of the visioning session for one of our recent ambulatory specialty care centers were captured on three boards, as follows:

Key Ideas and Their Implications

Some large medical centers continue with more complex visioning steps that elaborate on their key principles. A long list of ideas about issues such as technologic and scientific trends, patient care continuum, and design for efficient staffing and operations is linked to implications for physical planning. These are documented and used as guides in asking the important questions that influence both large-scale and detailed planning and design.

A few relatively simple vision statements eventually lead participants to discuss topics that number in the hundreds and will have a profound influence on the building's design. Indeed, if you look carefully, you can often see the key vision statements reflected in the finished building.

That's our goal.

Building the Brand

The branding process—a U.S. obsession, actually—often occurs at the same time as the visioning process but is frequently led by different consultants. We have advocated that the visioning and branding processes intersect and that the architects be present at both. In a future essay we will explore how the visioning process might inform the branding discussion, and then how the resulting healthcare building reflects the brand. HD

As part of this series of articles that look at U.S. and U.K. experiences, the next article will take the U.K. perspective and look at that country's Private Finance Initiative (PFI).

Annie Coull, AIA, ACHA, is a Principal at the San Francisco office of Anshen+Allen Architects.