When Cedars-Sinai Medical Center (CSMC) in Los Angeles set out to build a new Comprehensive Transplant Center (CTC) in fall 2012, the goal was to consolidate three transplant programs from multiple locations into one three-story building. However, the project presented the challenge of combining different workflows from multiple clinics into a single, efficient model within the new space, requiring the SmithGroupJJR (Los Angeles) design team to develop a solution that would meet all of the clinics’ needs while maintaining a cohesive and integrated flow.

The new CTC is a 36,500-square-foot facility consisting of administrative offices and clinic space that houses 22 exam rooms, specimen collection, infusion, consultation, and patient education space as well as pre- and post-transplant support services. Its goal is to maintain patients’ functionality, keeping their quality of life at a high level and only turning to invasive organ transplant procedures as a last resort. As such, patients with regularly scheduled appointments of varying frequencies are the CTC’s primary visitors. With this in mind, the design team set out to create a positive experience for those patients as well as a working environment that enhances staff retention and promotes collaboration.
 

Patients first 
In addition to the consolidation of programs, the new clinic required a singular workflow model for the entire transplant center, one that is more patient-centered, reflects the Cedars-Sinai brand, and meets the level of service expected at CSMC. Previously, the organization found that patients under different transplant programs had drastically different experiences. For example, at the kidney and pancreas transplant center on the main campus, patients were required to check in to the clinic, proceed to another department and waiting room for specimen collection, return to the clinic waiting room, travel to another area to have their vitals checked, and then return to the waiting room to ultimately be escorted into an exam room. In other locations, such as the liver and lung transplant center, the experience was a bit more direct with a flow from check-in to the waiting room, followed by vitals and specimen collection, and back to the waiting room before going to an exam room. The travel between spaces was confusing for first-time visitors and often tiring for patients with limited mobility, even if they knew the routine. Eliminating the patient back-and-forth between service areas and the waiting room, and creating a single-flow model for the new clinic were keys to improving processes within the CTC.

Working with the transplant clinic team and CSMC, designers developed a plan that incorporated all necessary services through a single-line patient flow from valet parking to checkout. This interdisciplinary, team-based approach prevents patients from going for one service and back to the waiting room to wait for another service. From a wayfinding perspective, patients and family also have direct access to the clinic reception area via an elevator from the parking garage. This workflow model not only improves the patient experience but also reduces wait time and patient stress, and improves staff efficiency.

Additionally, universal exam rooms were designed to be shared between different transplant programs, a key programming decision for the CTC that served as a first step in consolidating programs in one location. Initial thinking was to provide dedicated exam rooms to each of the transplant departments, which proved to be inefficient because some rooms were underutilized at certain times of the day and more total rooms were needed. Rather, a universal exam room model allows all programs to utilize any exam room and reduces the number of rooms required.

With the benefit of improved workflow and exam room scheduling, the facility’s bottom line was improved by saving additional costs associated with constructing unnecessary exam rooms, support staff, and services.

 

EBD informs design
Early in design, evidence-based design (EBD) strategies were introduced to the clinic staff and CSMC as a framework to inform how design strategies could be utilized and adapted to meet the CTC’s needs. Given the short timeframe for design, a rapid discovery period was used to demonstrate how EBD works, using The Center for Health Design’s “8-Steps of Evidence-based Design” as a roadmap. First, the team demonstrated how EBD could be used to address the project goal of reducing patient and staff stress. This included introducing support spaces for staff and areas that facilitated improved collaboration between doctors and patients.

To that end, the design team incorporated concepts from relevant research papers that address those objectives and used the research in design meetings as a basis for identifying goals. In reviewing these studies with CSMC, it became evident that even though not all of the findings had conclusive results relevant to the clinic, inclusion of some aspects could be used to develop design strategies for the CTC.

For example, the design team developed a modified version of the exam room design from one study that oriented the exam table, guest seating, and computer station in an informal configuration to help foster a peer-to-peer relationship between patient, family, and doctor. In the study model, the computer workstation is in a fixed location surrounded by seating. Although CSMC liked the layout of the study’s exam room plan, the flexibility of a mobile workstation was preferred.

Additionally, in exam rooms that don’t have access to views and natural daylight, simulated images of nature were included in the interior design to reduce stress levels in patients and staff. And, finally, staff support amenities include dedicated lounge spaces and access to a staff-only outdoor respite area located on the second-level terrace.

Throughout the design and construction process, great care was taken to protect these elements of the design from being removed by value engineering or changed drastically during the construction process. Maintaining this integrity was paramount to CSMC achieving its goals for the project. With the support of the research and white paper studies, there was a basis for why certain design choices were made that helped establish a platform for keeping them.

Faculty moved into administrative offices in July 2014 and the clinic will see its first patients in September. A post-occupancy evaluation will be conducted a year after occupancy to determine if workflow, collaboration, and design elements are meeting the desired objectives as initially outlined in the project goals. 
 

Collaboration
As the largest academic medical center in the western United States, Cedars-Sinai strives to provide spaces that promote the spontaneous collaboration of fellows, doctors, and nurses. To that end, nearly two-thirds of the CTC project area is dedicated to administrative functions, and workplace strategies not commonly adapted in healthcare office settings were explored to support teambuilding goals. For example, conference and break areas are enclosed with glass walls to promote spontaneous interaction as well as encourage utilization of these rooms as multifunction spaces rather than dedicate them to a single purpose. Likewise, an exterior terrace can be used as a multifunction space, for respite or for groups to meet for lunch, quick meetings, or an all-staff function.

Similarly, the clinic’s team workrooms, where staff consults on cases, are enclosed with glass to promote interaction with nursing staff. Two-sided caregiver workstations also promote spontaneous interaction between doctors and nurses, creating a hub where all workers can meet for a quick consultation.

 

The right fit
In the end, this journey with CSMC has led to a solution that’s been informed by experience, evidence, and a set of guiding principles that have established the context for the design of the new CTC. The design team learned that not all solutions fit all situations and not all evidence fits every project, but those tools can be used and adapted to create new solutions for each unique project. By taking what designers know as professionals and disseminating that information in a useful way to clients, successful projects can be created that also reflect providers’ unique brands, practices, and organizational objectives and allow them to make it their own.

 

Brandon R. Guzman, EDAC, Assoc. AIA, LEED AP ID+C, is an associate with SmithGroupJJR (Los Angeles). He can be reached at brandon.guzman@smithgroupjjr.com. 

 

Resources

  1. Consultation Room Design and the Clinical Encounter: The Space and Interaction Randomized Trial. HERD: Health Environments Research & Design Journal. Fall. 2009. http://www.red-thread.com/userfiles/file/The-Space-and-Interaction-Randomized-Trials-Fall-09.pdf
  2. The Effects of Presence and Influence in Nature Images in a Simulated Hospital Patient Room. 2010. Health Environments Research & Design Journal. Volume 3, Issue 3, Pages 56-69. Authors Vincent, E. http://www.healthdesign.org/chd/knowledge-repository/effects-presence-and-influence-nature-images-simulated-hospital-patient-roo
  3. Nurses and Stress: Recognizing Causes and Seeking Solutions. Journal of Nursing Management. 2013. Volume 31. Pages 638–647. http://www.healthdesign.org/chd/knowledge-repository/nurses_and_stress_recognizing_causes_and_seeking_solutions_0