Most healthcare organizations maintain a strategic plan, reg-ularly updated to respond to changes in their competitive, economic, technical, and regulatory environments. As the context changes, strategy must keep pace and adapt. As more peo-ple move to a com-munity, for example, emergency visits increase, and the organization decides to expand its emergency department. All too often, these adjustments are made without an organizational perspective. Will ED expansion cause ICU backups that aggravate the situation? The physical facility can be a barrier to, or an enabler of, effective organizational performance.

Recent research indicates that organization design should be coordinated with facility design to increase the probability of successful change. Some evidence suggests that real transformation requires both physical and organizational change. The Planetree Model is an example of a fundamental shift in organ-izational culture paired with facility design supportive of the patient-centered philosophy, to create an environment that enhances the healing process. Planetree projects at Mid-Columbia Medical Center in The Dalles, Oregon, and Griffin Hospital in Derby, Connecticut, are just two examples where such transformational change has occurred with notable results.

What is behind this relationship?

A Little Organization Theory

Some authors define Organization Development (OD) as the application of behavioral-science knowledge and theory to improve organizational functioning and performance. Others simply describe it as implementation of planned change in organizations.

Although architects make useable spaces in tangible forms called “architecture,” their work produces significant changes in health-care organizations—altering structure, performance, culture, and behavior. These changes are often poorly understood by design professionals, and rarely are described as an intended part of the project brief. Architects have not been taught to design to produce cultural change or specific organizational outcomes.

An OD practitioner makes overt changes in organizations, called interventions, based on a participatory process similar to a design effort, in which goals are stated, an assessment occurs, data are gathered, findings are reported, and a diagnosis or statement of the problem is made, followed by intervention. New data are gathered following the intervention to determine whether the intended result occurred, and further cycles of diagnosis, intervention, and review take place until the desired change occurs.

Conventional OD practice includes four types of interventions: human process interventions, impacting communications, decision making, leadership, and group dynamics; human resources interventions, such as hiring and staff training; strategic interventions, dealing with development of markets, service lines, and relationships to the external environment; and technostructural interventions, relating to work design, departmental structure, organization redesign, and links between people and tasks.

One subset of the technostructural branch of organization theory constitutes socio-technical interventions. Socio-technical theory suggests that organizational effectiveness is enhanced when the social and technical aspects of the organization are jointly optimized. As Appelbaum states (see Bibliography):

Socio-technical system design is based on the premise that an organization or a work unit is a combination of social and technical parts and that it is open to its environment. Because the social and technical elements must work together to accomplish tasks, work systems produce both physical products and social/psychological outcomes. The key issue is to design work so that the two parts yield positive outcomes; this is called joint optimization.

In short, we are optimizing both the intangible and the tangible. Intangible social systems include aspects such as leadership, governance, teamwork, incentives, norms, and culture. Tangible technical systems can include the setting, technology, information systems, and logistics. The ability to “jointly optimize” both can offer the client more robust interventions that have a higher probability of success. Change supported by efforts in both areas seems more likely to “stick,” or be sustained (Figure 1).

The socio-technical model blends two complementary perspectives

Aligning Strategy, Organization, and Facilities

The ideal state occurs when the strategy, perfectly suited to the current external environment, is matched by an organization design and structure optimally suited to implementation of the strategy. Physical facilities, for their part, must be suited to producing superior organizational performance.

The ESOF model (Figure 2) illustrates the concept of alignment between the external environment (E), strategy (S), organization (O), and facilities (F). When the changing environment becomes E2, the strategy needs to adapt and become S2. Some organizations align their facilities with the new strategy, constructing an F2, but this can mean putting the existing organization (O1) into a new building, rather than redesigning the organization as O2. The new building may well be misaligned with either the organization or the strategy.

The ESOF model can be adapted for socio-technical theory.

Thinking About Organizational Restructuring

A common healthcare strategy is to develop a “service line” model to emphasize a key program, such as cardiac or cancer care, or pediatrics. Initiatives range from “lip service” to structural reorganization, or anything between. In some cases, managers with almost no au-thority have been appointed like ombudsmen, performing shuttle diplomacy between a disgruntled clinical group and a distant management team. “Centers of excellence” have been built, accompanied by distinctive graphics and promotional advertising of the “star program” in the local media. Others have funded significant capital investments in new facilities and equipment to recruit physicians and increase market share. Few, however, develop true management models in which clinical services, beds, ancillary services, and mul-tidisciplinary staff all report to a new service-line manager, who acts as a “mini-CEO” of the hospital.

That is unfortunate. How can a service line be effectively managed if there isn't distinct accountability for all lab tests, imaging services, bedside nurses, food services, supplies, housekeepers, and bookkeepers associated with the particular patient group?

All service lines are not the same, however, and don't deserve equal treatment. Cardiac patients might represent significant numbers in a particular institution, cancer patients fewer, and neuro patients even fewer. Would it make sense for the institution to have a neurosciences service line simply because other clinical services are managed on that basis?

Another consideration: Can disease-based models (cardiac, cancer, ortho, etc.) be successfully mixed with population-based models (women's, children's, geriatrics, etc.)? If female cardiac and cancer patients go to disease-based services, a women's service-line program will rapidly be diminished to an obstetrics program, and thus will be more related to one clinical segment than to the full population of female patients. Is this the institution's intended strategy?

It is possible to hypothesize that a service-line initiative should be planned only if it fits with the healthcare organization's overall strategy, which should suit the organization's regulatory and competitive environment. The facilities must be aligned with that strategy. Organization design and facility design should be congruent, support each other, and be aligned with a sound organizational strategy.

Some Examples of Facility/Organization Change

Harbor Hospital in Baltimore achieved transformation through a dramatic culture change, combined with an upgrade of its renovated facility (Figure 3). An organizational consultant worked in tandem with the architectural team for this project. The change to a patient-centered model of care involved a philosophy change for everyone at the Harbor Hospital. Taking the care to the patient meant, for example, that the pharmacist went on rounds with physicians on the patient units. Also, support space was provided on the units, which meant that less inpatient-related space was needed downstairs for cardiology, physical therapy, or admitting. The project initiated a financial turnaround and significantly improved patient satisfaction.

The central nurses’ station at Harbor Hospital, Baltimore, is replaced by decentralized satellite positions and a multidisciplinary team workstation serving the growing list of professionals who come to the unit for a portion of their work.

St. Michael Health Care Center in Texarkana, Texas (Figure 4), retained a strong Catholic culture, but work redesign was combined with facility replacement, resulting in extraordinary financial success. Diagnostic and procedure centers were altered to simplify the way patients are processed. Outpatients arriving at the diagnostic center have access to multiple departments through a single reception and appointment desk. Similarly, outpatients arriving for a procedure come to a single entry point and are prepped in a private room with easy access to surgery, endoscopy, cath, or infusion, as needed. Secondary recovery also occurs in a private-room environment. As a result of these physical and organizational changes, St. Michael Health Care Center experienced a dramatic increase in market share and high levels of patient satisfaction.

Patient-centered care at St. Michael Health Care Center, in Texarkana, Texas, has led to financial success and increased patient satisfaction.

Valley View Medical Center in Cedar City, Utah, is a replace- ment facility that radically redesigned its organization. Twelve consolidated departments replaced the original 35. Such reorganization could not have been possible in the old facility, because the building itself would have been a significant barrier. The locations of existing departments in an outdated building would have limited potential for the consolidation and staffing efficiencies available through work redesign, cross-training, and overlapping responsibilities. The major organizational redesign and significant efficiencies Valley View achieved would not have been possible without the new facilities (Figure 5). It must be acknowledged that some hospitals have encountered numerous stumbling blocks in attempting to correlate design and organizational change without strong follow-through:

At Valley View Medical Center, Cedar City, Utah, the concourse provid-ing outpatient access to diagnostics and procedures is shared between the hospital and physician offices.

  • A hospital in Idaho recently embarked on a major project but is finding that the new facilities planned may not solve its culture problem entirely. The hospital has exceptional technology but needs to overcome the community's perception of its “lack of caring.” Redesign of the new facilities may be necessary to achieve the desired organizational results.

  • A teaching hospital in Houston failed to orient the staff to a new building designed for a different model of care delivery. As a result, it continues to experience staff dissatisfaction and has not yet reached the organization's potential.

  • A hospital in Connecticut purchased a competitor and continues to experience a lingering “us versus them” mentality among staff. The leadership feels it may take a replacement project, paired with a competitive, transformational shift to a family-centered model, to change the new organization's culture.

  • A relatively new merger in Denver has yet to perform effectively, and continues to deal with culture and consolidation issues associated with system formation. With the exception of some financial and information systems, the organization struggles with systems and facilities that continue to perform independently. The promise of efficiency and savings through consolidation and rationalization of services has not yet materialized.

Organizational Assessment as Insurance

Because the benefits are great and the stakes are high, healthcare organizations considering a major, multimillion-dollar capital project should invest in an organization assessment to determine whether the elements of environment, strategy, organization structure, and culture are aligned. Such an assessment is an inexpensive “insurance policy” against an expensive investment in a dysfunctional duplication of the existing organization. The hospital of the future shouldn't be a shiny, new box that contains the organization of the past.

As an example, The Methodist Hospital in Houston has used such an assessment in conjunction with the master planning and programming process. They intend to design their project with an eye to supporting a service-line organization model and to reinforcing their goal of performance improvement, with focus on the consumer. The hospital sees this as protection against major expenditures that ignore important organizational and cultural issues.

A Collaborative Consulting Model

Architects must learn that organizational issues are more complicated than asking a client how to make a new building more efficient than the current design. Ideally, they should collaborate with experienced organizational consultants to prepare designs that jointly optimize the technical components of the facility design and the social and cultural aspects of the organization. In preparation for this, architects would do well to devote time to the study of organization and management theory.

Similarly, organizational consultants should recognize that facility design can be a planned “intervention,” as they define it, and can be yet another effective tool for the change-management process. OD practitioners need to collaborate with experienced healthcare architects to extend their capabilities in this regard.

Finally, healthcare organizations and their leaders should recognize the important synergy available to them through encouraging a collaborative model in which organization design and facility design are developed in tandem. HD

Founding Principal with Watkins Hamilton Ross Architects in Houston. He is past-president of the American College of Healthcare Architects and president of the nonprofit Center for Innovation in Health Facilities. Also past-president of the AIA Academy of Architecture for Health, he is a member of the board of directors of The Center for Health Design and the Coalition for Health Environments Research. He has authored and edited three books on health facility design and is currently working on a new book about evidence-based design for critical care. He has recently completed a master's of science degree in Organization Development at Pepperdine University.

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