“It was the best of times, it was the worst of times,” begins Charles Dickens’s “A Tale of Two Cities.” Now, two centuries later, that sentiment strikes a familiar chord with design firm leaders who see U.S. healthcare projects in a continuing stalemate but international opportunities on the upswing, as countries around the globe look to the United States for healthcare design expertise.

That does not mean that U.S. hospital design can be transplanted directly to another country. Many large firms unaccustomed to working outside the United States are feeling the pressure to win new work by expanding their borders. When determining whether to pursue and, ultimately, accept international commissions, a team must consider how it will adapt its current processes to deliver a successful project for both the client and its own firm. Cultural, financial, and regulatory conditions vary greatly from one locale to another, even within the same country. Healthcare architects succeed internationally when they draw upon U.S. experience but tailor their designs and processes to fit the client’s situation.

Three healthcare projects in three cities around the globe provide good examples of this process. RTKL is currently developing major international medical centers in Shanghai; Jeddah, Saudi Arabia; and Santiago, Chile. Each client’s goal is to deliver state-of-the-art care in a sustainable, healing environment, but the similarity ends there. The hospitals will be designed for vastly different user profiles in cultures as dissimilar as their locations.

The scale of the projects includes a 2,200-bed medical center in China (361,000 square meters), a 600-bed specialty center in Saudi Arabia (200,000 square meters), and a 300-bed campus addition in Chile (125,000 square meters). The owner profiles range from a privately owned provider to a military organization, and the delivery systems include construction manager-driven selection to a modified hard bid. Each project brings its own collection of issues and challenges that, unless identified and addressed, could produce significant problems.


Set your CSF

For every project, there will be common, rather obvious goals that are understood. To achieve complete success, however, a design team must identify, for its client and its firm, specific critical success factors (CSF) for the project. Establishing a custom list from the beginning gives everyone a roadmap for determining how the project is progressing and achieving its ultimate success.

This is true for any project in any location, but it is much more significant when working with different cultures or in new environments. Everyone measures success through perception, and establishing that end product early ensures that the entire team is on the same path.

For the Santiago, Chile, project, RTKL established the CSF in conjunction with a defined list of deliverables during the project kick-off meeting. This allowed the team to be “product-driven” and clearly track the progress of the project through identifiable milestones using each package as an opportunity for CSF review.


Establish project timeline

Projects are always a balance of quality, time, and manpower, but certain cultures view schedule very differently. If not managed correctly, these differences will have major impacts on your firm’s established design process and ultimate profitability. 

United States-based projects are schedule-driven, but tempered with an expectation of high levels of owner input. As the process moves forward, schedules are often relaxed if the project is progressing well but the owner needs more time to make decisions and provide the necessary input.

In Saudi Arabia, schedule is viewed as almost absolute and typically drives the process, user input, and even budget. Large projects, ranging from 750-bed to 3,000-plus-bed facilities are designed and constructed in half the time typically allocated in the United States. The design team must be prepared for this expectation and must be able to respond, not only with manpower, but by redefining its process in order to move faster. 

Adding to the difficulty is the common practice of a linear approach. Many times in the United States, we solve schedule issues by “fast-tracking” product through concurrent tasking. In many cultures, including the Middle East, this is not a common practice and is definitely not used to the same extent as in North America. Schedule issues will need to be solved through faster turnover and a redefined design process. If your firm is not in a position to accept such changes, serious thought needs to be given to accepting large commissions in certain international regions.


Understand cultural impacts on space programs

Probably the most common design mistake United States-based design teams make when entering international markets for the first time is not realizing the impact culture has on physical space. When this happens, design changes forced along the way will significantly delay both the overall schedule and the labor plan.

To avoid this problem, a design team should use the programming phase of the project to develop detailed operational narratives for user expectations. What are the unique spaces required and how are they to be used? What is the family impact on specific spaces, such as the patient room, public areas, and general amenities? 

In Santiago, Chile, the patient visitation time is similar to the United States, but family size is significantly larger, requiring a larger patient room, better separation of patient zone/family zone, and a tiered system for waiting. 

In China, the impact is even greater. The family comes in mass to visit and typically stays much longer. In some regions, the family is actually considered a significant part of the caregiving team and will perform duties requiring access to support spaces. 

In Saudi Arabia, the separations between male-only and family zones, along with the need for prayer areas and mosques, not only will impact net areas but also influence circulation concepts and access to public zones.

In every case, a team’s initial project in any new region will be impacted by a learning curve, but good preparation in the pre-design stage will help keep the entire process on schedule.


Define state-of-the-art

Hospital design and technology planning go hand-in-hand. Today’s facilities are advancing faster towards the truly smart building, and as this trend continues, our design teams become more reliant on technology systems designers to work concurrently and develop intelligent designs. The timeframe established for this part of the team and its work, similar to architectural design, is based on past experience, and any changes to its base assumptions can significantly impact the workflow and schedule.

It is this set of base assumptions, usually defined by U.S. standards, that must be questioned and clearly defined early in pre-design. We overuse the term “state-of-the-art,” but its relevance in international work makes it more important than ever. What is “state-of-the-art” for your pro
ject region? What standards are your clients expecting, and is there the structural backbone to support their dreams and your design parameters? More important, is there a clear definition of how far your design work will need to extend to complete their expectations? 

RTKL offers integrated healthcare design teams, employing architectural, systems design, and medical equipment technology planning under one roof. This has helped our team scope the overall needs of the client early and avoid major issues common with other large international projects.

Each region will require a customized approach to technology planning, and it must be identified and planned for accordingly. As an example, in the Middle East, RTKL established full-time teams on the ground in Jeddah, Saudi Arabia, and Dubai, United Arab Emirates, to handle technology planning given the challenges faced on these very large projects and the demanding schedule expectations of the region. 

Whether your team has these capabilities on staff or through pre-established relationships, a solid approach to scoping and implementing data/technology planning from pre-design through field observation is critical to the success of a project and firm.


Sustainable approach

For most large-scale international work, sustainable design is not a fad nor an added layer of service, but an integrated part of any successful building or master plan. Just as cultural changes impact our process and space planning, energy and resource planning varies from one region to another. Elements, such as water conservation or reuse, considered an added benefit here in the United States, is an absolute basic service in the Middle East. Energy conservation and land use planning, again considered advanced design here in the United States, are common expectations in Shanghai. 

United States-based firms, when pursuing international commissions, need to understand the basic expectations for sustainable practice for each individual region and have the necessary expertise. In Santiago, Chile, given the recent earthquakes and general approach to land use, significant seismic planning and energy conservation planning are common practices. A process and fee structure needs to be in place as part of basic services to cover more complex structural systems combined with structured underground parking and high-performance buildings. 

In Shanghai, the RTKL Changzheng project is designed for an extremely high level of energy performance, water conservation, and alternative energy capture. While extraordinary in the United States, this level of service is an expectation on projects of this magnitude and by this client. Again, the lesson is “be prepared.” Additional expertise and manpower can be required to design for and implement levels of sustainability considered normal in many international regions. To be successful, a firm must be willing and able to deliver these services under tight timeframes and for expanded scopes.

In themselves, hospitals are the most complex building type most architectural firms will ever attempt to design. The coordination needed to seamlessly create a healing environment while integrating the needs of patients, visitors, users, and technology is difficult under optimal conditions. Even greater are the challenges of accomplishing the same tasks across a worldwide platform, honoring different cultures, meeting the expectations of different value systems, and incorporating technologies and sustainability practices perhaps even more advanced than those in most U.S. hospitals.

Overall, being prepared to successfully accept and complete major international commissions in different regions around the world comes down to a firm’s willingness and ability to be ready for change. Each firm’s design process, as unique as a fingerprint, is an iconic attribute. Running it smoothly and flexibly is critical to success. Your ability to perform internationally will rely on your team’s ability to decipher the  cultural differences between your established market and the targeted one, identify necessary changes in process, and establish with the client new methods that support its needs and your firm’s as well. Once this level of expertise is achieved, large international commissions can be both financially successful and personally rewarding. HCD


Scott Rawlings is Vice President and an International Design Director for RTKL Healthcare. He is based in Washington, D.C., and can be reached at srawlings@rtkl.com. Gregory Stackel, AIA, LEED AP, is a Principal with RTKL Associates in the firm’s Healthcare Practice Group. He can be reached at gstackel@rtkl.com.