Beyond the architecture Lesson 3: Design onstage and offstageWhat's not to love about going green?
As you are reading this, the celebration of the 50th anniversary of Disneyland has just begun. And while a myriad of recent power struggles has tarnished its once-pristine image in the business press, there is no doubt of Disney's place as the harbinger of the Experience Economy.
Disneyland was the bridge from the world of theater to the world of business for such powerful disciplines as storyboard sketching, casting, auditioning, scripting, performance, and set designing. As the world's first theme park (you may want to refer back to the first installment in this series, HEALTHCARE DESIGN March 2005, p. 20), Disneyland captivated its guests to such an extent that thousands upon thousands of businesses have come to study “how they do it.”
Disney is a tough act to follow.
Because of healthcare's standards, approaches, and industry, I sometimes hear the valuable theater lessons of Disney dismissed by healthcare executives with this somewhat obvious and defensive statement: “We're not running a theme park here; we're running a hospital.” This is reminiscent of hospitals missing, almost completely, the essential lessons that baby boomers were teaching us when they revolutionized the requirements of the birth experience. By thinking that this transformation applied only to the “happy” service of obstetrics and not the rest of the hospital, where “serious” medicine was practiced, we lost more than 20 years in getting started on the personal, healing environment movement. Think how much further along we could be if only….
So, as we reflect back on the July 1955 start of the Magic Kingdom, let's delve into its most important architectural lesson, that of onstage and backstage (sometimes referred to as offstage) design.
The associate entrance of the newly opened Banner Estrella Medical Center in Phoenix transforms the employee mind-set immediately, preparing them mentally for their workday ahead. Within this sacred space, associates are encouraged to spend a few reflective moments gonging the polished metal bells that grace the entrance. And once they're inside the doorway, they're welcomed by a stone monument that displays an inspirational poem entitled “The Caregiver Poem.” Associates are encouraged, upon finishing their shift, to take a moment and offer well wishes to caregivers coming on shift to work the next 12 hours.
Have you ever been on a Disney theme park backstage tour? If not, I highly recommend it, because the hidden Disney is almost as impressive as the visible one. An intricate set of rooms and passageways allows transportation of people, food, and merchandise, as well as staff member breaks, communication, and training, without interrupting the performances that are occurring above ground. It was understood from the beginning that “cast members” (Disney-speak for employees) dressed in Tomorrowland costumes should never walk through Frontierland; it was an unacceptable negative cue. So was Mickey Mouse taking his lunch break, or worse yet, his cigarette break in the park. The same is true of employees having onstage conversations about their personal lives or their after-work plans. (Disney feels so strongly about this one, it's grounds for immediate termination.) These observations are obvious only if you have realized that your work is theater and your workplace is a stage.
Think of our hospitals for a minute. How many times have you seen the calm of a newly created “healing environment” shattered by the harsh interruptions caused by the transporting of patients, body fluids, and trash receptacles, or the ringing of phones and the echo of overhead pages? How many times have you seen health professionals engaged in boisterous, personal conversation a few yards away from an inquiring visitor or, worse yet, a grieving family? And how often have you seen a beautifully designed and decorated patient floor deteriorate into an unsightly obstacle course of beds, IV stands, trash bins, and handmade signs within just a few months of opening?
Part of this is a culture issue. But part of it is definitely an architectural issue, because if backstage areas and transport systems have not been given priority in the design, it is impossible to make them a priority in staff behavior. (For further translation of the lessons of Disney to healthcare, you may want to pick up Fred Lee's recent book: If Disney Ran Your Hospital: 9 1/2 Things You Would Do Differently. Of particular interest to this discussion is Chapter 6, titled “Change the Concept of Work From Service to Theater.”)
So why is the concept of building a “stage” for the performance of your uniquely themed healthcare experience essential in the Experience Economy [see sidebar]? Simply put, because the success factors in experiences are different from those of either goods or services.
When the majority of people moved from farms to factories, the new management imperative was to learn how to make things in factories, instead of how to extract things from the ground. This was the heart of the products/goods economy. When services became the dominant force in the economy, management had to focus on how to deliver them in response to a real-time request—a much different set of requirements from those needed in making products and goods. Now that experiences are starting to take over, management again must learn something new, because experiences are produced and performed. In short, they are staged—and only those businesses, both inside and outside healthcare, that understand this have any chance of success.
Begin at the Beginning
Perhaps our first design requirement is to provide strong physical cues when employees are making an onstage entrance. If, in fact, we are expecting them to perform different functions in a different manner when they are onstage, as opposed to when they are backstage, the least we can do is give them an environmental “heads up” when a transition point is occurring.
Some of the best thinking in this regard is being done by those organizations that are making a thoughtful, intentional, and inspirational employees-only entrance. These spaces are meant to provide much more than a different access point for employees than the lobby that welcomes patients and families. They are intended as a transition zone from the cares and concerns of the outside world to an intense and meaning-filled concentration on the life-altering healthcare performance that is about to begin. Some hospitals provide music-laden, cathedral-like employee entrances to remind staff of the sacred nature of the work they are about to perform. Others equip staff entrances with meaningful daily ceremonial space that elicits a brief, but symbolic, acknowledgment of the importance of what is about to occur (figure 1). Still others are adding the concept of heritage halls—essentially museums of photos and artifacts—to these portals to visibly connect the work and workers of today with the legacy of all that has come before, and to remind them that today's performance will be part of the legacy passed down to future generations of employees.
A good example of this outside healthcare is Carlson Companies, the Minneapolis-based travel conglomerate that owns a variety of name-brand hotels, restaurants, cruise lines, and travel agencies, as well as its own relationship-marketing firm focused on growing the loyalty of Carlson's customers. To get to the elevators off the lobby in its corporate headquarters, employees walk through a Carlson history area that celebrates all the milestones and unique company aspects that have made Carlson what it is today. Similarly, 3M has a gallery in a high employee-traffic area that celebrates all the products it has invented. You'll notice that the inspiration is taken to where the people are, not stored in some out-of-the-way destination that requires a special trip.
These intentional areas create a different context, one that transforms mundane space (what is still, after all, just a door and a hallway) into a memorable place.
Attention to Every Detail
The sense of onstage and offstage can't stop at the entry; it should be woven into every detail large and small. When Wilson Mertens, MD, director of Cancer Services at Baystate Health System based in Springfield, Mass., got approval to build a new cancer center that would bring together all of the oncology specialists and support services formerly scattered throughout the Baystate campus, he was determined not to perform “the old play in a new theater.” He changed the model of care from a disjointed physician-centered one to a collaborative patient-centered one. And when it came time to design the building embodying this, he made sure that every detail reflected the new philosophy. The feeling throughout the D'Amour Center for Cancer Care is one of calm, peacefulness, and support. It is obvious that great care was taken to ensure that grim clinical reminders or institutional ugliness did not intrude on the healing environment. For example, when sitting in the family counseling area, you are struck by how the windows perfectly frame a row of trees. It is only when you stand, and inspect more closely, that you realize that the frosted glass on the top and bottom of the clear glass band screens out the parking lot (effectively putting it backstage) where the trees are planted.
Furthermore, the D'Amour Center for Cancer Care takes a mundane hallway and puts it memorably onstage. The second floor of the center is inspirationally illuminated by a building-long skylight that “performs” dancing light patterns on a dramatic wooden wall throughout the day (figure 2). But what about the first floor—is it cut off from the performance? Hardly. An opaque glass path overhead not only lets the light shine down, but it also adds a silhouetted footprint element as people walk down the hall above. This strikingly dynamic image subliminally reinforces the “Partners on Your Journey of Well Being” theme that directs the whole experience. In short, exquisite attention to detail is the hallmark of a place that has learned the lesson of onstage/backstage performance.
Architecture as a Training Program
At its best, onstage/offstage architectural design is woven together with staff training so seamlessly it is impossible to determine where one stops and the other begins. Mid-Columbia Medical Center in The Dalles, Oregon, is world famous for its breakthrough patient experience, driven by the operating theme “Personalize. Humanize. Demystify.” (More than 1,300 site visits from all over the world attest to its significance.) One of the keys to its success is a weeklong university that teaches “the Mid-Columbia Way” to every employee. So important is the concept of onstage/offstage performance that Mid-Columbia's training facility has been built as a theater stage. Each employee's first experience of the training program is to enter through a door in the back of the room, pull back the curtain, and suddenly realize he is, literally, onstage. The medium is the message.
Academic medical centers, with their focus on research and teaching, have even more difficult traditions to overcome than community hospitals in finding success in the Experience Economy. That's why the work at the University of Colorado Hospital (CU) and its new Anschutz Inpatient Pavilion is so remarkable. CU studied the Disney approach and extracted many of its theatrical lessons, such as casting, rehearsal, and onstage/offstage “set” design (figure 3). Passion for the guest experience is an unusual goal in academic medicine, but it can be felt throughout this organization, from how people are recruited and trained, to appealing backstage areas where employees can relax out of the view of guests, to onstage areas designed to be free of phones, supplies, and patient transport interruptions. And the results of the newly opened hospital are already remarkable. Patient satisfaction has rocketed from scores below 10% to scores as high as 80%.
Expansive windows, skylights, and translucent glass panels along the ceiling and floor (at the D'Amour Center for Cancer Care in Springfield, Mass.) allow sunlight to stream into the building, bringing with it the positive physical and psychological effects of natural light. This clever design feature beautifully takes a mundane hallway and puts it memorably onstage.
The University of Colorado Hospital's new Anschutz Inpatient Pavilion in Denver was designed with Disney-inspired lessons throughout the building. Based somewhat on Disneyland's underground tunnel concept, private offstage spaces were intentionally designed into the Anschutz building, such as the light-filled employee entrance, separate elevator bays, secluded walkways, and private “decompression” spaces allowing employees to spend a few moments of quiet reflection before walking through the doors to onstage areas.
So what does all this mean? One thing is clear: Unless the design of the new healing environments has onstage/offstage principles at its core, it will never reach its full potential. So after 50 years, the lesson is as new and vibrant as ever. Thanks, Walt! HD