Imagine that you are a healthcare administrator for a day. Upon entering the office, you receive a packet of information documenting the previous day-numbers that prove your success or failure to efficiently manage daily operations that result in patient care. The numbers include diversion statistics, net inpatient revenue, direct variable costs, case mix index, average length of stay, contribution margin, staffed beds, inpatient admissions, discharged emergency department patients, observation conversion to inpatient percentage, number of patients left without being seen, and the list goes on. You gaze at the numbers and try to make sense of it all. While your medical colleagues strive to keep patient blood flowing, you, the healthcare administrator, strive to keep the hospital afloat.

On any given day, your administrative responsibilities begin between 6:30am and 7:30am with a medical staff meeting-that's if you haven't already been contacted to resolve disputes. Let's imagine that you're on your way to meet with a physician group that, just as you anticipated, is not thrilled to have you join them. After chugging a cup of coffee while listening to disgruntled physicians, you're off to employee staff meetings, health planning councils, and finance meetings. Between your back-to-back meetings, a student arrives to ask you about medical advances your hospital is employing-diagnostic technology innovations, electronic medical record implementation, and changes in insurance reimbursement. You consider and incorporate these medical advances when planning departmental budgets, expanding or deleting programs, planning staff activities, maintaining organizational policies, strategizing implementation of new procedures and measuring quality assurance. But when, exactly, are you supposed to stay abreast of an industry that's constantly changing?

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Then a design team walks into your office. They're a breath of fresh air. But you're already running late and your next meeting is with your boss. Your Blackberry is experiencing e-mail overload. You are convinced that the hospital cannot afford capital improvements at this time, even though your facility desperately needs renovations to stay competitive in the market. Now, what's a charrette?

Good luck, design team.

The language barrier

Healthcare executives typically do not concern themselves with the built environment. They have countless other priorities on their to-do lists-many of which are more pressing issues. Most healthcare administrators refer to “design” as “capital improvements”; that's because administrators think in financial terms when they do concern themselves with the built environment-what will physical modifications mean for the hospital's bond rating, loan potential, or long-term financing structures? Most administrators have one opportunity, if that, to overhaul the built environment in which healthcare services are delivered; their decisions influence the community, providers, and patients for decades. The healthcare administrator is under tremendous pressure to redesign, reconstruct, and renovate our unsystematic healthcare system according to evidence-based practices; yet, most administrators have little to no training about how to approach healthcare design.

Research results

Image by Matthew J. DeGeeter

In steps the design professional.

Design professionals understand that hospital design impacts clinical ability to perform safe procedures and administer quality outcomes, organizational efficiencies, and financial performance. It's the designer's responsibility to convey these realities to administrators in terms that make sense to the client. When discussing facilities with healthcare administrators, the focus should not be the facility. The discussion ought to be centered on points relatable to administrators such as nursing retention, physician-hospital alignment strategies, and changing reimbursement rates. The designer's challenge is to communicate how administrative priorities support or inhibit the facility design process, and, vice versa, how design can aid and enhance the administrator's and clinician's abilities to perform.

The Agency for Healthcare Research and Quality produced a DVD in 2007 called Transforming Hospitals: Designing for Safety and Quality that was targeted at healthcare executives. The DVD communicates the importance of evidence-based design to executive hospital leadership and incorporates specific evidence-based design strategies through case studies. The strength of the DVD is that design strategies are conveyed by healthcare executives to healthcare executives-in other words, administrators communicate with each other in a common vocabulary about a shared vision. Design professionals, too, can position themselves to communicate in common language by utilizing available research.

Effective communication with research

Every profession has a unique vocabulary and skill set. One challenge of interior design is continual learning of the terminology and functions specific to client expertise. Designers who align themselves with the vision of the client are more likely to design thoughtful, effective interior spaces that satisfy client needs.

Effective communication which is essential for a positive design process is linked to vocabulary and syntax. Designers recognize that their decisions impact client livelihood and user comfort (patient, family, and staff). In healthcare, design decisions affect the quality of care, staff performance, and retention, as well as patient recovery. Thanks to research and evidence-based design, the impact of design decisions are being quantified and disseminated. Research empowers designers with knowledge to justify costs for single patient rooms, and more durable finishes that protect against infection and sustainable practices. All of these design decisions speak to administrative priorities.

Healthcare clients understand numbers, figures, and return on investment. Thus, the most positive response may result from a designer who delivers measurable impact that is evidence-based. For instance, if the nursing unit configuration is designed to reduce walking distance for care providers and consequently increase the amount of individual attention patients receive, there may be a measurable return on investment: the patient may feel individually cared for and satisfaction ratings may increase. In this example, nursing unit configuration research served as a tool for communication of design decisions and integration of best practices.

Design solutions may be justified when communicated in terms that make sense to hospital administrators. For instance, a patient fall costs a hospital $10,000 on average, without a lawsuit. A hospital-acquired infection costs $4,000 on average per patient. Hospital administrators naturally relate to design solutions that develop a less hazardous healing environment that is safer and healthier for patients, family, and staff.

Designers can help administrators realize shared goals by communicating research-based design decisions. A seemingly simple task of comparing flooring materials can develop into an in-depth research opportu
nity (see figures 2 and 3). Here, a significant body of research was visually communicated in a client presentation by compiling information about various flooring products and evaluating the products according to attributes prioritized by the client.

Flooring matrix, data

Flooring matrix, graphic

The role of evidence-based design is increasingly important to the design process. Using research to inform design, the client can see that design does have an impact on the bottom line as well as patient care. Building on research from previous projects, designers can positively influence the project at hand, thereby, increasing the value of the design process for both the client and field of design. Communicating research is one method of engaging the client in the design process and encouraging the client to play a part in innovative design thinking, which ultimately leads to improved project quality. Ideally, the client uses research to better understand and value the design process.

Adding value

Every project is an opportunity for an interior designer to increase the value of design. Through a mutually beneficial partnership between the client and designer, the designer learns about the client and the client has the opportunity to become more educated about the value of design. This outcome can be achieved through increased communication in the form of shared research.

The value of a project can increase as more information is gathered about the results of design solutions. Comparative analysis of the facility pre- and post-design adds to the return on investment of the project. Quantitative analyses of infection control rates, staff retention, and/or patient satisfaction, for instance, provide valuable information and lessons to both the client and designer. Results from informed design solutions can help shape future design solutions and ultimately add value to the design profession.

Design professionals can measure success of research sharing communication strategies by studying the number of return clients, positive feedback, and project references for more design work.

Conclusion

Each project is unique to the client and their organization. The same holds true for the designer; design is a personal process and communication is a relationship building process. From effectively communicated design, a connection is established between client and designer that extends beyond physical space needs.

Although a new building is almost always a monumental project in the eyes of the client, it is only one piece of a hospital's long-term plans and one component of a designer's portfolio. As the perception of design emerges into a research-based process with measurable results, design can assist in changing the state of the current healthcare system. Instead of thinking about the problems at hand, designers and hospital administrators can be visionary pioneers of the hospital's future, redesigning a system founded on evidence-based infrastructure. HD

Matthew J. DeGeeter, Allied Member ASID, Associate IIDA, LEED AP, is a designer in the healthcare market sector at Perkins+Will in the Washington, D.C. office. Mr. DeGeeter was selected and served as a national juror on the HEALTHCARE DESIGN 2010 program design team. He can be reached at Matthew.DeGeeter@perkinswill.com.
Carrie R. Rich, MS, EDAC, is a healthcare specialist at Perkins+Will also based in the Washington, D.C. office. Ms. Rich holds an adjunct faculty appointment at Georgetown University, School of Nursing and Health Studies, Department of Health Systems Administration. Ms. Rich can be reached at carrie.rich@perkinswill.com. Healthcare Design 2010 April;10(4):28-33