Nine Steps to Great Healthcare Design
Woman's Hospital in Baton Rouge, Louisiana, took an innovative approach when designing its new $300 million project. Rather than using the normal design process of presenting and representing various options, HKS designers listened and watched as more than 100 staff members, physicians, and leaders at Woman's Hospital, as well as representatives from the community, used a variety of materials-from colored dots and Velcro boards with moveable pieces, to actual furnishings and equipment, to design and physically mock-up the optimal hospital layout and determine the exterior and interior vision.
Designers-in real-time processes-documented and tested the overall visioning process; the exterior and interior design; planning, blocking, and site utilization options; patient room and bed unit configurations; circulation alternatives; and patient mock-up rooms. All participants' voices were heard and incorporated into the final design thinking.
The result is an inclusive design that will offer an excellent family experience from arrival through departure when the Woman's Hospital is opened.
To get there, nine distinct steps were taken:
Step 1: Visioning
The first design activity for the new hospital was to convene a group of 64 people representing patients, administrative leaders, nurses, support leaders, clinical leaders, community leaders, physicians, and staff in a facilitated, three-day process. Over the three days, the participants discussed and made decisions about the services and facilities to be located on the new campus and the experience to be created for patients, visitors, employees, and physicians (figure 1).
A group of 64 people convened to discuss the hospital's vision in a three-day, facilitated process
At the end of the session, the group agreed to areas of common ground and issues to be resolved (figure 2). The visioning session yielded a two-part result: First, a clear direction was developed for the project's planners. Second, the process generated 64 excited and powerful advocates within the hospital, as well as the community.
A compilation of thoughts following the Woman's Hospital visioning session
Step 2: Exterior and interior charrettes
All of the participants of the previous visioning session and a number of Woman's Hospital employees were invited to participate in a charrette-type process to determine the exterior and interior design concepts (figure 3). Architects selected and displayed interior and exterior imagery depicting traditional, transitional, and modern architectural styles. Participants were given 15 voting dots to place next to images (figure 4). They could place the dots in any quantity they preferred, all on one image or distributed among several. This allowed for strong feelings to be represented. The images with the most dots (votes) were discussed by the whole group and ranked for incorporation into the design.
Participants of the initial design charrette were given 15 voting dots to be placed next to architectural images that represented options for the hospital's new design
Participants of the initial design charrette were given 15 voting dots to be placed next to architectural images that represented options for the hospital's new design
This process allowed the design tastes of a large group of people to be expressed, discussed, and incorporated in a quick and comfortable manner.
Although hospital staff predicted that the community would favor a traditional design, modern interiors and exteriors won overall. The group preferred open spaces and atriums, as well as broad expanses of glass that allow generous light and views. They agreed that the hospital should appear modern, as well as warm and inviting. The concourse, or mall-like concept of including activity along public corridors, was also universally embraced. The community placed value on architectural designs that drew visitors into the entrance and provided simple and intuitive wayfinding.
Step 3: Planning and blocking
Planning programming meetings were held with members of departments within the hospital and the design team. Once the departmental programs were developed, a blocking and stacking meeting was held with physicians and representatives of all hospital departments.
For that meeting, the design team created scaled foam core pieces for every department and placed 4′ x 8′ boards along the walls (figure 5). One board represented horizontal relationships within the two main buildings, while the other represented vertical stacking of the buildings. The participants, divided into service groups, were led through a discussion of their work needs. Regrouping as a combined team, the group laid out the hospital vertically and horizontally in real-time using tools created by the design team.
The design team created scaled foam core pieces for every department and placed them on boards along the wall for discussion
Designers and workshop participants quickly developed complete blocking and stacking diagrams for the entire hospital-a complete hospital, blocked and stacked with full consensus in just four hours. Several beneficial arrangements arose from the exercise, including placing the oncology floor on the top level to maximize views to nature and separate it from busier units, as well as locating labor and delivery, surgery, and intensive care all on the same floor.
Step 4: Site utilization
Site utilization meetings included the developer, key Woman's Hospital management, civil engineers, and HKS representatives.
With a greenfield site of more than 200 acres and a desired hospital area of 60 to 80 acres, the design team was challenged with siting the hospital to capture inspiring views to nature, maintaining a park-like setting around the hospital, and allowing well-planned commercial development surrounding the hospital, as called for in the visioning step.
Similar to the blocking and stacking exercise, designers used movable pieces of all site elements-main hospital, support services building, medical office buildings, central plant, parking, and other structures-on a site diagram to explore possible configurations. The diagram illustrated the site boundary, topography, vegetation, travel distances and times, major streets and highways, and the desired buffer zones surrounding those.
To mitigate vegetation loss on the mature site and the expense of fill to raise the site, the design team considered the influence of cut-and-fill options on the placement of buildings. One pivotal outcome was the creation of an 18-acre lake spanning the hospital's perimeter, providing a picturesque frame and buffer from the nearby highway and economical fill (which would have cost several million dollars).
Today, the patient rooms are designed with views to nature and a pastoral landscape, a key goal of hospital staff and community design participants. In concert with regional planners, the design team also created a site plan configured to accommodate additional uses to support the hospital including retail and residential to maximize land value and preserve the park-like setting.
Steps 5 and 6: Patient rooms and bed units
These two steps, which were conducted simultaneously, incorporated a series of meetings that included key Woman's Hospital management staff, HKS representatives, and a cross-section of staff from labor delivery, gynecology, oncology, mother/baby, anti-partum, NICU, and maintenance, totaling more than 100 people (figure 6).
HKS designers watched and listened as more than 100 staff at Woman's Hospital moved panels, furnishings, and equipment to mock-up the optimal patient room
To support efficient nurse-patient staffing, hospital leadership had already decided to use clusters of 12 rooms rather than a racetrack design for bed units. They also recommended that all adult rooms be sized and shaped the same. Staff brought in everything used in an LDR room-from the patient bed to medical gasses and guest furniture. Using an open area, they worked together to place each item where it would best accomplish the ideal work environment for delivery of care to Woman's Hospital's patients. The last step was to use moveable panels to create walls for the room. HKS designers listened and watched as staff at Woman's Hospital moved panels, furnishings, and equipment to physically mock-up the optimal patient room in a large and open conference room.
Nursing and staff from other departments were invited to suggest alterations and modifications to accommodate their needs. The groups investigated same-handed rooms, inboard versus outboard toilets, and racetrack unit configurations. They also discussed universal room design tenets and the specialty function of each unit and department.
Once the patient room was designed, a similarly inclusive process was used to create the design and relationship of the patient units. During the sessions for both the patient room and the bed units, designers, in a real-time process, used AutoCAD to document and test the various configurations while the staff at Woman's simulated the actual activities.
The team was able to design a universally adaptable room that allows any type of patient care-from ICU to acute care-and provides ultimate flexibility and surge capacity for Woman's, a critical issue for the hospital following Hurricane Katrina.
The final room design was neither rectilinear nor orthogonal, making an efficient and economical configuration of the bed unit challenging (figure 7). Designers crafted a unique unit configuration with nursing stations at the intersection of two oblique corridors. The result was high visibility and access between the nurses' stations and patient rooms, a compact plan, and a building massing of visual and architectural interest.
A rendering of a typical patient room at Woman's Hospital
Step 7: Circulation discussions
Representatives from administration, various nursing units, physician and provider groups, and maintenance attended several comprehensive workshops to consider and define circulation for patient travel and care delivery.
First, the group developed a rank-ordered set of guiding principles for circulation, focusing on the patient journey from arrival to discharge. Establishing these guiding principles began with important questions such as:
How do we provide security for newborns, as well as provide easy and welcoming access for family and visitors?
Can we configure the discharge of mother and newborn in a way that celebrates the joy of such an occasion without causing anguish to families and patients dealing with issues such as cancer or lost pregnancy?
Can materials and staff move between departments quickly, easily, and without crossing public circulation?
This discussion was closely followed by delineation of circulation paths involving dock to food preparation; central sterile, lab, and imaging to surgery; assessment to imaging and surgery; and pharmacy to patient care delivery points. To ensure a comprehensive and efficient plan, the participants gave considerable thought to often overlooked circulation realities, such as flower delivery, vending machine restocking, and express mail delivery.
Through this process, the group developed basic circulation paths that the design team refined. These ideas generated several innovative architectural designs, including a two-story, naturally lit entry, an arced concourse with integral screening devices that evoke curiosity and intuitively propel visitors forward, and vertical circulation elements that lead guests forward by increasing light and view as they ascend.
Entry points were arranged hierarchically from main public and service entries to secondary entry and exit points to allow trouble-free delivery of flowers and vending stock. Hierarchical entries also separated patients and visitors who might be bereaved from those experiencing the excitement of leaving with their healthy newborn.
Step 8: NICU-specific design
Mothers of previous NICU patients attended discussion-and-design sessions, along with key Woman's Hospital administrative staff, neonatal physicians and nurses, and HKS representatives.
Woman's wanted to explore the use of single-family NICU rooms exclusively in the new hospital. This potential shift from group to individual-room care demanded extra attention. The hospital hosted several meetings that allowed the moms, designers, and hospital staff to discuss their concerns and desires for the new facility (figure 8). They were also able to participate in a frank and sometimes emotionally intense discussion with the mothers regarding their experiences and the conflict between the families' need for privacy while also being fully supported by staff.
When Woman's Hospital wanted to explore the use of single family NICU rooms, they met with mothers of previous NICU patients
After the meeting with the moms, HKS staff met with NICU doctors and nurses. Several options for patient care delivery were considered, including open space with pinwheel bed configurations, all single-family rooms, and shared rooms. Designers and hospital representatives also discussed the goals for the general architectural environment and interior theme for the NICU.
The team determined that an all single-family rooms approach would result in the best clinical outcome for the patients. Because of the NICU's size, it was necessary to divide it over two vertically integrated floors, with the most critical babies on one floor and less critical babies on the other. This arrangement of spaces allowed the best possible delivery of care and movement of supplies and equipment. The location of comfortable observation alcoves at each patient room and the nurse stations allows visual communication to the patient rooms and improves patient care and eases the anxiety of parents and families.
Participants also set the unit's interior design theme based on the hospital's overall theme of elements of nature: earth, water, fire, and air. Water elements were incorporated into the NICU design evoking calmness and reflecting the intrinsic elements of Louisiana's rivers and bayous. Using art glass, natural-colored woods, and subtle blues and greens, the designers created a unique healing environment while complementing the overall hospital design.
Step 9: The mock-up rooms
At various stages of development, former patients; physicians; and key nursing, administrative, and maintenance staff were invited to review the physical mock-up of the patient room design (figure 9). Full-scale mock-ups of an adult patient room, NICU patient room, and an operating room were fabricated in warehouse space provided by the hospital. These mock-ups were built in stages to allow each iteration to be tested.
Full-scale mock-ups of an adult patient room, NICU patient room, and an operating room were fabricated in warehouse space provided by the hospital
The first stage was intended to validate room size and configuration. This was followed by progressively developed stages that added windows, doors, millwork, casework, and cabinetry. Next, the design team added finishes, colors, equipment, lighting, and furniture.
After each change, the appropriate nursing staff reviewed the mock-ups and simulated various procedures to test the rooms' appropriateness.
The mock-ups and simulations resulted in critical and beneficial changes to room designs. These changes were based on evolving criteria such as maneuvering space, emergency activities, ease of access, family accommodations, privacy, and views. For example, following the mock-ups, the angle of the NICU bed was shifted to allow more space for families and caregivers. Changes also occurred in the location of the delivery cart from the bedside to under the counter. This change reduced the potential for contamination in the sterile field and accommodated accessibility for caregivers. Moreover, the mock-up process allowed caregiver staff to participate in the process, providing feedback on process improvement and buy-in on the new design.
Participation, especially by large groups, is often avoided and thought to be time-consuming and difficult to manage. The participative processes used by the design team on Woman's Hospital defied those beliefs. Large group processes combined with liberal doses of involvement resulted in a design that will offer an extraordinary experience from arrival through departure.
Throughout the process, potential problems were uncovered and corrected prior to construction. The owner gained an informed expectation for the final product and members of the hospital staff and community were essential to the design process, giving them ownership in the design of their new hospital. HD
Stanley F. Shelton, MSOD, is Senior Vice-President of Woman's Hospital. He can be reached at
firstname.lastname@example.org, or visit
http://www.womans.org for more information. Jeffrey Stouffer, AIA, is Principal, and Jack M. Ford, AIA, IDSA, is a Project Designer/Vice-President at HKS, Inc. They can be reached at
email@example.com, or Visit
http://www.hksinc.com for more information. Healthcare Design 2009 September;9(9):64-71