How can an architect uncover the innermost thoughts and feelings of patients, families, and staff to create a physical environment in which every experience contributes to the transformative process of healing?

This fundamental challenge prompted our firm, Astorino, as architect for the new Children's Hospital of Pittsburgh, to seek input beyond conventional predesign planning. We are responsible for all design aspects of the 1.45-million-square-foot space, housed on a 10-acre site in Pittsburgh's Lawrenceville neighborhood. The $424 million hospital and research facility project is scheduled for completion in 2007.

Based on the firm's founding philosophy that architecture is, first and foremost, about shaping human experience, its objective for the Children's Hospital project was clear: Design a world-class, state-of-the-art pediatric healthcare facility that would anticipate and respond to the deepest needs of each and every one of its users.

Such a design must allow flexibility for changing patient/family dynamics and new technologies. Of course, economic issues are critical drivers, and some design considerations must be dictated by practical limitations. Nevertheless, in shaping one of the top 10 children's hospitals in the country, the new design had to meet and exceed the standards of quality put forth by its medical, professional, and support staff.

Traditionally, architects achieve great design through ideas that support established, relevant goals. Design elements are selected based upon the design team's experience, as well as client needs assessments, interviews, and surveys conducted during predesign. While these planning tools offer insights as a starting point for determining necessary physical attributes, they do not enable the architect to connect with the end users on a profound emotional, intellectual, or experiential level. Achieving this deep level of insightful understanding about the user experience became the Astorino design team's goal for the Children's Hospital. This required the team to integrate research protocols never before used in the architectural field, and combine them with the art and science of planning and design. Inclusion of this research evolved and refined the firm's already established Deep Design ProcessSM.

The ZMET Component in Deep Design

The process of Deep Design allows the architect to reach into the conscious and subconscious thoughts of the building's occupants to identify and prioritize how they aspire to interact with their physical environments. A central research tool in this process is ZMET (the Zaltman Metaphor Elicitation Technique), a research protocol that is grounded in multidis-ciplinary sciences, including clinical psychology, anthropology, linguistics, cognitive neuroscience, and sociology.

The ZMET approach recognizes that people think and communicate in complex ways that are not captured through traditional focus groups and surveying methods. ZMET uses various means to elicit information from research participants, with an emphasis on visual images, metaphors, and emotions.

The methodology was developed by Gerald Zaltman, a Harvard Business School professor, and is based on the premise that 95% of thought occurs in the unconscious mind and is not captured by traditional research methods. Receiving its patent in 1995, ZMET is the first market research technique to be patented in the United States. It has been used for more than a decade by Fortune 500 companies performing hundreds of market research studies, addressing topics ranging from cars and political candidates to financial services and the arts. The highly visual and emotional nature of ZMET's methodology lends itself particularly well to the archi-tect's appreciation of visual and spatial relationships; however, prior to the Children's Hospital project, it had never before been applied in the architectural industry.

Our firm's goal for using ZMET in the Deep Design Process was to gain insights that would help structure all potential design ideas and prioritize them as concepts based on the most important needs of the end users.

The Research Process

A total of 29 interviews were conducted with patients, parents, and hospital medical and administrative staff. Participants were asked to spend approximately one week before their interviews collecting magazine, catalog, and other images that described their most basic thoughts, feelings, and perceptions related to both their current and ideal Children's Hospital experiences. During individual interviews, participants discussed in detail their reasons for selecting these images and their relationships to the thoughts and feelings they represented. Working with a graphic designer on the research team, each interview participant directed the designer to create a montage that prioritized the images based on their thoughts and feelings. These metaphoric image montages and descriptions, combined with the researchers' interpretations of them, conveyed a wealth of information about the respondents' underlying needs vis-à -vis the environment.

Figures 1 through 5 show how these needs were expressed visually for patients, parents, and staff, and then assembled in montages indicating overall priorities. These findings expressed both surface and deep metaphors that became definitive themes among interviewees. On a surface level for example, recurring images displaying confusion and mazes pointed to individuals' wayfinding frustrations with the current hospital experience. On a deeper, more fundamental, metaphoric level, feelings about the ideal hospital emerged as a transformative experience, providing “a sense of renewal,” as one hospital employee noted. Reinforcing the fundamental theme of transformation were three supporting deep metaphors, or “Key Domains”:

Patient interview—the hospital experience. During the interview with the researcher, comments about this patient's visual metaphor included:

  • Color is very important. It sets the atmosphere for a place.

  • I put books and computer together because I do both and enjoy doing them.

  • The outside picture is another place that I like to go and have a picnic.

  • I made the dog blue because he is sad and that's the way I feel.

  • The playroom is a place that I like to be in. It is probably the most important place for me.

  • Books and a computer—they kind of get my mind off whatever may be going on.

The metaphor reinforced the emotions of sadness associated with the hospital experience, along with the needs for nature, an escape, and a desire to connect with others.

Parent interview—the current hospital experience. Isolation and a need for diversions and representations of the “real world” were apparent themes in this parent's visual metaphor. This parent added the following comments:

  • There is a blue sky—which is hope.

  • The clock shows that time stands still while you are here.

  • The chair and tree are the isolation that the family feels.

  • Ocean waves are soothing and healing.

  • You need something cheerful and happy.

  • A clean room or technology—that is what you come to CHP for.

The parent metaphor reinforces the need for calm and hope and for cheerful places to combat the feeling of time standing still and of isolation. Recognition of the necessary medical technology is also addressed.

Employee interview—the current hospital experience. Employees, not just patients and their families, conveyed feelings of isolation. The “comfort of home” metaphor was consistent across all interviewees:

  • Home is a comfort zone.

  • Children relay a sense of honesty and fun.

  • The vastness of a wide-open beach can be overwhelming.

  • The tomb represents dying with dignity.

  • The isolated ski lift conveys loneliness and no support.

  • We should aspire to make our patients feel comfortable and secure.

  • A busy city area captures how hectic our world is.

Employees understand patient and family feelings of isolation and of being overwhelmed by the chaotic hospital experience. The staff wants to provide a comforting and secure environment.

Researchers' composite—the current hospital experience. Researchers created this composite metaphoric image to represent the deep thoughts and feelings of all research audiences—patients, parents, and hospital employees. Each image in the composite was taken from individual responses about the current hospital experience. Quotes from individual interviews included:

  • The girl in the bubble is being crowded—she is confused and frustrated.

  • The paradox of time—racing against time and the disassociation of time.

  • The monotony of institutional, “one-size-fits-all” patient rooms.

  • The maze conveys feelings of frustration and of privacy invasion, the feelings of being exposed to the world.

Researchers' composite—the ideal hospital experience. This composite metaphoric image created by researchers represents the deep thoughts and feelings of all audiences about the ideal hospital experience. Research participants provided each image in the composite and its corresponding description:

  • The image shows technology and innovation next to homelike elements.

  • An environment where confusion and frustration are replaced by comfort, warmth, and a sense of belonging.

  • Normalcy must exist everywhere in the ideal CHP.

  • The lawn chair represents the need to find a space to dream and to connect.

  • On the computer screen is the beach, a frequent symbol of escape.

  • The sky symbolizes hope, happiness, and the future.

  • Control: Patients', families', and hospital staffs' need for control over their life and environment;

  • Energy: The need for energy from all sources to give people the strength and hope they need to make it through their hospital journey, whether as patient, parent, staff member, or administrator; and

  • Connection: The need to connect with the “inside” and “outside” world.

To translate these deep metaphors into design solutions, Astorino created the Deep Design Filter®. The Deep Design Filter is a patent-pending tool that Astorino uses to distill and organize the issues and ideas uncovered in the ZMET process. By mapping all issues or relevant dimensions, the firm prioritizes them according to their contextual relationship to the deep metaphors. The design team then translates these relevant dimensions, along with their activating cues, into a series of design objectives. This is accomplished through design team immersion sessions and user group interviews.

By refining the design objectives and supplementing them with conceptual images in this way, the design team is better able to shape the architectural design. For instance, the domain of Energy—derived both from people and the environment—pointed to a need common to all hospital users: the need to recharge and rejuvenate. Without the benefit of the ZMET findings and the Deep Design Filter, however, while the domain of Energy might have been identified as a high priority for patients, it might not have been rated as high for families and staff. The activating cues of “giving staff and families a place to charge their batteries” led to design solutions that include more lounges for family and staff, a fitness center, and the Healing Garden, a natural extension of the enclosed atrium that provides the restorative powers of nature for children and their families.

While the domain of Control—over one's life and the environment—had already been recognized as an important program element, the research findings uncovered dimensions of Control that had not yet been prioritized. We learned, for instance, that the need for personal space, including private patient rooms, separations within them for privacy/family areas, and fabrics and colors that are more homelike, should take precedence over some other design options. Figure 6 illustrates how these expressed needs were translated into design of a patient room.

Proposed patient room. Design solutions were prioritized based on both patients' and families' desires for each of the key domains of Control, Energy, and Connection. All elements support the theme of transformation:

  • Daybed and window seat valences; inset area carpet tile

  • Sleeper lounge chair

  • Separation for privacy and family area

  • Table for games and dining

  • Moveable work area and hidden medical gases

  • All fabrics and colors more “homelike”

In a focus group setting, the design team might have heard superficial responses to suggested colors, but the ZMET findings provided specific color palettes, based on deeply held thoughts and feelings about how color contributes to the healing process. Thus, bright, yet soft, colors are used throughout both the interior and exterior of the building. This was in response to the domain of Connection and its corresponding dimension of “escaping” through color. By working from a broad palette that includes hues such as Grass Green, Robin's Egg Blue, and Sunshine Yellow, different tints and intensities can respond to both the need to be stimulated and the desire to relieve stress. In line with this, colors in the palette will appear in softer, calming shades within the ICU and chapel, for example, but will be much more vibrant and energizing in playrooms and waiting rooms.

To support the fundamental theme of a transformative healing experience, dynamic design solutions are incorporated throughout the hospital. The building exterior communicates that Children's Hospital of Pittsburgh is a facility that is dynamic and alive, and water features and a kinetic sculpture have been added to the front entrance (Figure 7). Upon entering the hospital, patients, visitors, and staff will travel through the main “Transformation Corridor,” which expresses the evolution of healing through design elements suggestive of the four seasons. The walkway starts, therefore, with autumn-like tones, textures, patterns, and materials for the floors, walls, ceiling, and lighting. It then illustrates a sense of transition by moving to cooler, winter design elements, then into a mood of revitalization with a softer, spring-like feel and, finally, into a vibrant, balanced environment evocative of a brilliant summer day.

Elevation prior to ZMET in Deep Design ProcessSM. Prior to incorporation of the ZMET research in the Deep Design Process, the initial design for Children's Hospital was a contextual study that fit within the community

Revised plan incorporating findings. While not yet final, current designs for the hospital are introducing deep, rich colors that are not seen typically on buildings in the region. The transformative process of healing is reinforced through elements such as a water feature and kinetic sculpture at the front entrance. Colors, forms, and shapes illustrate a building that is alive and dynamic


The Deep Design Process, with its ZMET research component, has become an evidence-based tool that is assisting our firm in making earlier and more effective facility design decisions in response to the aspirations of end users. For Children's Hospital of Pittsburgh, the result is a healthcare facility that begins in the hearts and minds of its patients, families, nurses, physicians, and hospital staff. Each aspect of the design contributes to shaping an experience of transformation, as desired by both the healers and the healed. HD

Louis D. Astorino, FAIA, founded the architectural and engineering firm Astorino in 1972 and serves as chairman and CEO. He is responsible for the firm's architectural design quality reviews, strategic planning, business development, and executive leadership. He is the regional representative for the AIA College of Fellows and a past president of AIA Pittsburgh and Pennsylvania.

For further information, contact Astorino at (412) 765-1700 or visit To comment on this article, please send e-mail to

Healthcare Design 2003 November;3(4):12-17