This year has, unfortunately, seen a sea change for the architecture/engineering/construction field, as unemployment grows and postponed and cancelled projects continue to mount in a troubled economy. Adding to the uncertainties for healthcare are the mega-debates over healthcare reform. With all these major forces converging, what's happening with healthcare design, and what lies ahead? Two well-connected HEALTHCARE DESIGN Editorial Board members-one a nationally known interior designer, the other a recognized pioneer in healthcare design education and training, engaged in a lively conversation about this recently, prompted (and sometimes participated in) by Editor Richard L. Peck.

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Richard L. Peck: Recently at the Academy of Architecture for Health (AAH) Leadership Summit, hospital financial consultant Kenneth Kaufman of Kaufman Hall laid out a “perfect storm” of changes impacting the healthcare design field: a weak economy, a capital crunch, and healthcare reform. George, you were there-what did you think about that?

George J. Mann, AIA: Yes, that was quite a “double whammy,” and it's creating a hesitation in the marketplace that is unfortunate but understandable. It used to be that my phone was ringing off the hook with firms looking for graduates. Now it's ringing off the hook with graduates looking for jobs. Clearly, with 47 million uninsured people, we've created a healthcare system which fewer and fewer can afford healthcare. Often uninsured people use the emergency room for minor ailments such as colds, generating huge costs for Medicaid. The healthcare system is skewed-costs, manpower, technology, and facilities need to be realigned so that they are accessible, affordable, and of high quality.
George J. Mann, AIA

George J. Mann, AIA

Jain Malkin: Interesting, because we've been busier than ever. We have people working 60- and 70-hour weeks and the stress is unbelievable, but it's apparent that these healthcare systems are looking beyond the immediate crisis and are still trying to analyze their markets and stay ahead of the competition. There's no doubt that some hospitals have been hit by lack of funding, and medical office buildings have practically ground to a halt. But many of these hospital projects were funded before the crisis fully hit.
Jain Malkin

Jain Malkin

Peck: Kaufman maintained that hospitals are going to become more financially demanding of designers and looking for more specific value for the money. Are you finding this to be true?

Malkin: Frankly, I wish clients would be more like this. We're imposing financial restrictions on ourselves that help us be good stewards of their budgets.

Mann: I think there is a movement toward lean and mean-and fast, with very tight deadlines!

Malkin: We're seeing a huge emphasis on speed in delivering drawings and getting projects up-projects are being delivered these days in time frames that were previously unthinkable. What is interesting is hospitals are paying financial incentives for this. I am familiar with one in which the opening had been set for December but the hospital planner said that, with oncoming flu season and the Swine flu, they were to open three months ahead of schedule. And they were paying an incentive to the contractor for this.

Mann: It's hard to generalize about an industry as large as this one, but we do know that many healthcare reform proposals are emphasizing more community-based primary care and prevention. Hospitals are also looking at new strategies for growth by emphasizing prevention and early detection of disease. In the past we've emphasized and built expensive hospitals practicing expensive curative medicine. We will always need these. However, the acute care hospital will become the critical care hospital. We will have more in the way of special-purpose diagnosis and treatment facilities, such as cancer and heart centers, trauma facilities, ambulatory clinics, women's and children's facilities, men's health centers, and acute care facilities geared more toward the elderly. And tertiary care facilities will certainly still be with us.

Malkin: I know with current hospital projects we are seeing a readjustment in the way of more shell space being built rather than fitted out, saving money and preserving flexibility. Also, along the lines of George's remarks about special-purpose, we're also seeing a trend toward freestanding emergency centers spreading out through multiple city neighborhoods, and extending the hospital's market reach in that way. ER patients in need of hospital follow-up are ambulanced to the facility.

Peck: Are you seeing much in the way of renovation, which is often, though not always, a cheaper way to go?

Malkin: Yes, there is a lot of that going on, although renovation always has to cope with code restrictions that make things difficult. Quite frankly, I'm still seeing a lot of new inpatient beds being built, even with the increase I mentioned in ambulatory centers.

Mann: There's no question that hospitals are still playing catch-up to meet inpatient demand. I talk to people in the field every day and hear about this.

Malkin: We're still going to need massive expansion of primary care networks and facilities. One thing that the healthcare reform debate has made clear is that our system is seriously out of whack, with more than twice as many specialists as primary care physicians. This has to be rectified. Also, with 47 million Americans someday finding coverage, there will be a huge increase in volume.

Peck: Let's get back to this added value question that Kenneth Kaufman raises-don't you think this will change the language that designers speak to project sponsors?

Malkin: We recently responded to an RFP wanting five specific examples of value delivered. We're really getting data along these lines in unsolicited comments from clients bearing directly on value-for example, from two projects you'll be publishing soon, Richard, in HEALTHCARE DESIGN. An emergency room we did for the Eisenhower Medical Center in Rancho Mirage, California, saw its Press Ganey satisfaction scores go from 71 to 96-a nearly unheard-of level-in one month! The ER's staff and healthcare delivery protocols haven't changed, so they're attributing most of this to the new environment. The Carol Ann Read Breast Health Center we recently completed in Oakland, California, has led to the CEO telling us of his astonishment that this inner-city facility is now attracting high-income women from the San Francisco suburbs. What's more, it has generated substantial referrals for D&T and surgery for the local hospital by an order of magnitude-considerably exceeding their business plan targets. This isn't just esthetics or patient/staff morale we're talking about, this is money. It's the type of things designers are going to have to demonstrate in the future.

“We spend more than any other country on earth for healthcare, but our world standing in health outcomes is not first, and does not live up to these huge expenditures.”

-George J. Mann

Peck: Let's talk about trends specifically within the design field-for example, use of building information modeling (BIM). Comments?

Malkin: It's being used in every project we're involved in. We don't use it ourselves in interior design, and we've yet to do an actual walkthrough of a completed project that has been using this, but knowing some of the problems that typically do come up during construction-for example, having to lower a ceiling and redesign the lighting-can hopefully be avoided. BIM should provide an excellent way to foresee this sort of problem and head it off.

Mann: Everyone I speak to sees BIM as an effective tool for better project delivery.

Peck: What about integrated project delivery (IPD)?

Malkin: Of course Sutter Healthcare has been a leader in this and we are working with them on a new hospital using this system. There are an incredible number of large meetings upfront with IPD-they call them Big Room Meetings-and it's clear from the start that everyone's needs are your needs. It's like a marriage, with everyone making promises to everyone else. It's a totally different way of delivering projects, and it makes a lot of sense.

Mann: In these modern times, the “master builder” is an integrated team that fosters collaboration on complex projects from the beginning. Those who will not and cannot function as an IPD team will be swept aside.

Peck: Have you seen any areas of healthcare design where there's been a notable lack of progress?

Malkin: That's one reason I felt forced to write my book (“A Visual Reference for Evidence-Based Design,” published by the Center for Health Design, 2008). I visited three hospitals that had recently been completed, and except for the lobbies they looked like throwbacks to the 1980s. Totally institutional-white floors, white doors and walls, no differentiation in terms of esthetics or wayfinding cues between the main artery public corridors and the service/gurney corridors. And patient rooms were “plain vanilla,” with no footwall design, flying in the face of everything we learned from Planetree. Why is this happening? I suggest it's because hospital leadership is simply not paying attention to these issues or not asking the right questions of their architects during the design phase. They don't realize how barebones everything is going to be until it's completed and it's too late.

Mann: From my standpoint the shortfall has been this major disconnect in our system between needs and wants, and the gap between the insured and the uninsured. We, as designers, have been subject to the criticism that we're not aligning our designs with real healthcare needs, that we're functioning as technicians and missing the broader picture. We need to understand disease patterns, causes of illness and death, and come up with innovative design strategies to help prevent, detect, diagnose, and treat illness. Effective strategies here can lower the costs of healthcare tremendously.

Malkin: It's also becoming clear-for example, from the recent X3 conference sponsored by The Center for Health Design and The Vendome Group-that we're not designing adequately for IT, which is much more broadly defined these days. It should be addressed in detail in visioning sessions upfront and should involve national consulting firms and not just left to the hospital CIOs. Another need: innovative nursing unit design based on the groundbreaking research by Ann Hendrich and Marilyn Chow on how nurses spend their time. What we're seeing right now is pretty much rearranging the deck chairs on the Titanic. There's plenty of room for innovation in these areas.

Peck: Do you think projects are getting enough input from patients or consumers?

Malkin: In all honesty, whenever we try to elicit this input from a patient group, we find out, at the meeting, that they have no concept of the built environment and seem completely unable to discuss it. We did a session recently with 40 patients and they kept directing the discussion to do issues such as parking lot lighting and the meal service, but the concept of the built environment didn't seem to register. There is one exception, and that's with pediatric facilities. The example that comes to mind is Hasbro Children's Hospital during Bruce Komiskey's tenure. During design development, a parent on the planning committee requested during design sessions that bathtubs be provided in patients' rooms so that they could perform the normal daily activity of bathing their kids. They did this and it's worked out beautifully. This is something that no planner or designer would have come up with on their own.

Mann: We are not paying enough attention to what patients and consumers have on their minds. If we did, we would have come to understand that one of the major issues the consumer faces relates to the escalating costs of healthcare, and the escalating costs of building and operating our hospitals and health facilities. We spend more than any other country on earth for healthcare, but our world standing in health outcomes is not first, and does not live up to these huge expenditures. We have to address this great disconnect and find out how other countries are doing a lot more with a lot less. HD

Healthcare Design 2009 November;9(11):24-28