Oftentimes when embarking on a new healthcare facility project, square footage and adjacency requirements will drive programming and, subsequently, design. But things were a bit different when the team from ZGF Architects LLP (Seattle) partnered with Seattle Children’s Hospital for the project Building Hope: Cancer, Critical and Emergency Care Expansion.

“Leadership, from the top down, had looked closely at all aspects of operations, care practices, and ongoing facility strategies” in advance, says Allyn Stellmacher, design partner at ZGF. “They’d set the table for where they wanted to go.”

It took a lot of work to get there, but when all the pieces came together, Seattle Children’s got just what it needed—and it was a lot less than originally anticipated.


How it all started
In 2006, Seattle Children’s partnered with ZGF on its 2030 Major Institution Master Plan, including a long-term goal to double in size by adding more than 1 million square feet to the campus sited within the residential community of Laurelhurst in Seattle. Due to the nature of its location, there are pretty tight parameters around the facility’s growth that require a lengthy entitlement process through the city. So when it was determined that additional space was needed, the organization spent 24 months working through that process. In the meantime, a lot was happening behind the scenes.

“It gave us a great opportunity to look at our strategic plans, understand our volumes forecast, and understand what our focus needed to be in terms of both operations and facilities,” says Todd Johnson, vice president of facilities at Seattle Children’s. 

The hospital hired consultant Joan Wellman and Associates and embarked on a Lean process, or continuous process improvement (CPI), to identify approaches to reducing waste and improving quality and safety. In fact, the process was so successful that a planned and designed emergency department expansion that had already cleared the entitlement phase was canceled because the hospital realized its overcrowding problems weren’t about volume but about inefficient space utilization. “That was a testament to the solution—they realized how to deliver care and save significantly. Through practice and investigation, you can improve how you think about the future,” Stellmacher says.

And soon a new challenge was brought to the table that would require an equally thoughtful solution: Hospital leadership wanted to cut the size of the proposed new addition in half. “It was 2008-2009, the market had crashed, and it was a turbulent economic time. The first read on this was that it would be a $650 million project—that’s huge for this institution. It still seemed like the right idea to move forward but at a much smaller scale,” Johnson says.

Meanwhile, a new piece of property came onto the organization’s radar. Though it hadn’t previously been addressed through master planning, an option surfaced to purchase land adjacent to the hospital. With an internal push to reevaluate scope and a piece of property that allowed innovative thinking about the placement of a new building so close to the old, the solution became clear: Seattle Children’s didn’t need to start from scratch.

“We had to ask ourselves what we needed to achieve and how much square footage it would take. The idea was to knit the new to the old,” Stellmacher says.


More with less
What was initially planned to be Phase 1 of 1 million square feet of new building space was eliminated in favor of the Building Hope expansion, a 330,000-square-foot, eight-story building housing 80 inpatient beds (with the capacity to expand to 192), a ground-floor ED, an intensive care floor, and two cancer care units.

The ability to reduce the scope of construction as well as cost was born from the idea to connect a new building back to an existing patient tower that had originally been slated for demolition. While the hospital had been constructed over years, with some areas far more outdated than others, outdated space didn’t necessarily mean unusable space. “It resolved itself by combining old and new. The older space can easily hold office, research, or less-intensive bed usage like psychiatry. It became apparent that there’s a lot of value there, a lot of synergies by connecting intelligently,” Stellmacher says.

Core services provided from the existing building include pharmacy, clinical laboratory, central stores, central sterile, outpatient services, radiology, and surgery. By taking advantage of what Seattle Children’s already had, the expansion avoided duplication and reduced initial costs by 60 percent.

And thanks to all of the CPI work that had been done, Seattle Children’s knew exactly what it wanted out of its new space, even if the scope was far from what was originally anticipated. Guiding principles included a keen focus on safety in every aspect of design, ensuring that caregivers were able to spend as much time as possible at the bedside, and enough flexibility to account for the unknowns surrounding the future of healthcare delivery.

To achieve those goals in the new space, a group of stakeholders including staff, the Lean consultants, and the design team set out to first assess the hospital’s current state through a 3P event (production, preparation, process). “They went to patient care units, followed registered nurses, hunted for supplies, went to medication rooms, looked for equipment, and recorded all of that. We had a sense of time spent at the bedside and in wasteful activity,” Johnson says.

One approach used to eliminate waste, reduce travel distances, and place key departments together was to use horizontal stacking for the new building as opposed to the more traditional vertical model. Core services are located on the same floor as inpatient beds to allow caregivers to go between inpatient and outpatient environments for a single service line (e.g., inpatient cancer treatment beds are on the same floor as outpatient cancer services).


Getting it right
While ideas for how the space could best be used surfaced, the team relied upon Lean to ensure it was right. And a big piece of that process was gaining a realistic view of what was being designed. “In Lean, you’ll hear people say that it’s about ‘learning to see.’ When you build, you’re able to see much more clearly; it’s easier than working in BIM. So we used mock-ups and simulation liberally throughout the process,” Johnson says.

Starting with tabletop exercises using pieces cut to scale, users were asked to move those pieces around to decide on things like adjacencies, proximities, and shapes with a focus on seven flows of medicine—patients, families, providers, medications, supplies, equipment, and process engineering. The next step was to take the results and create mockups on the roof of the hospital’s parking garage.

With details kept to a minimum, the mock-up consisted only of exterior walls to get a feel for the space configuration. And it worked—the team realized the right angle in the middle of its L-shaped wings caused a pinch point. They opted to tweak the design to bring more of a curve to the wing.

Next came the big event. The team rented a 70,000-square-foot warehouse in Seattle, where a cardboard mockup of an entire 32,000-square-foot floor was built. Influenced by previous design events, the mockup included established ideas for univer
sal patient rooms, support areas, and a concept for “care team porches” outside patient rooms, to get a feel for them at scale.

Patients and families were among those taken through the space, with about 50 to 60 people overall involved in the process. But there was a large focus on staff, from nurses to housekeeping supervisors, who simulated their activities on the mockup floor in as real-life a fashion as possible. Daily rounds were conducted, travel distances were measured, and all the data collected was compared against a baseline to ensure tweaks were making things better.

“The whole goal was to improve operations while also building a new space,” says Mark Gesinger, principal at ZGF. “It was our task to synthesize all of that architectural information knowing their aspirational goals.”

Once out of the warehouse, a final phase of Lean design homed in on refining the patient rooms, with more mockups built—this time with real materials and equipment, where care delivery could be simulated and the design tested. Overall, Johnson says, he saw the Lean effort as a consensus-driven process that refined divergent views to create a single approach. “We would use data and anecdotes out of the simulation to help us get the full spectrum of information,” he says.

For ZGF, taking the information provided and keeping it on track with project goals was a critical piece. “We were charged with helping the facility document direction, evaluate, and figure out best models to facilitate that,” Stellmacher says.

Johnson adds that having an integrated team, including ZGF and general contractor Sellen Construction (Seattle) involved throughout provided much-needed counsel to ownership on what ideas would also fit the budget. “The process doesn’t focus users on how much things cost. There has to be a safety net so you don’t decide on something you can’t afford to build,” he says.


Core concepts
When all was said and done, the Lean process identified a number of design approaches to support Seattle Children’s goals for a safe, efficient environment of care, starting with eight-bed patient room neighborhoods in 16-bed units designed around an extremely narrow building core.

“In a traditional outpatient unit, you would have a core taken up with storage of items, and here the core is taken up by people functioning in different ways, interacting,” says Anita Rossen, senior interior designer at ZGF. The narrow core not only offers open and closed collaboration spaces but provides short travel distances to patient rooms and allows daylighting to cross the unit while offering easy visibility, too.

When nurses aren’t at the bedside, their next point of contact is the care team porches, small workstations adjacent to patient rooms. The spaces are also used to store supplies, charts, equipment, and medication, and to support just-in-time supply delivery. “It really becomes this multifunctional space, but it’s visually right in your path of travel, which is impactful for families and staff,” Rossen says.

To support both safety and future flexibility, patient rooms are universal and capable of being flexed between acute care and ICU, or to other modalities as necessary over time.


After its April 2013 opening, the organization talked to users at the 90-day mark to see how the space was working, says Johnson. And outside of requests to add a few hooks and move some clocks, the feedback was largely positive. “They said nurses had been spending 40 percent of their time at the bedside before and now are spending 60 percent,” he says. Improvements have also been noted in family experience surveys, with satisfaction trending upward alongside staff satisfaction. While goals weren’t met in every instance, improvements were seen against the baselines.

Building Hope, though largely scaled back from what was originally thought to be the next move for Seattle Children’s, is also a first step toward a greater plan. Over the next two decades, it and other additions will replace the current hospital. And, currently, two floors of shelled space in the Building Hope expansion are being built out for an additional acute care floor and critical care floor.

ZGF is currently doing a master plan of Seattle Children’s east campus, which was previously occupied by the primary services lines that have moved into Building Hope, to be completed in 2014.

The Building Hope experience provided a new perspective on creating an appropriate facility without overbuilding—essentially, providing a client more value by designing less. “It’s been a sea change in discovering how much more effective we can be. It puts a large responsibility on Seattle Children’s to seek change, to organize, and find value that may be beyond what they anticipate,” Stellmacher says. 

Jennifer Kovacs Silvis is managing editor of Healthcare Design. She can be reached at jsilvis@vendomegrp.com.

Project details:
Completion date: April 2013

Owner: Seattle Children’s

Architecture: ZGF Architects LLP

Total building area: 330,000 sq. ft.

Total construction cost: $136.32 million

Interior design: ZGF Architects LLP

Construction manager: Seneca Group

General contractor: Sellen Construction

Lean design: Joan Wellman & Associates Inc.

Engineering: Coughlin Porter Lundeen (structural, civil); Sparling (electrical, technology, security, acoustic and vibration); Affiliated Engineers (mechanical)

Artwork: Amy Ruppel, Lab Partners

Medical equipment: Design Works Inc.

Lighting: Pivotal Lighting

Signage and wayfinding: Studio SC

Landscape: Site Workshop

Furniture: Garrison Design