Marcus Terry, AIA, Project Manager

As healthcare design professionals, what are the opportunities to bring value to a project? Knowledge of clinical operations? The ability to design to a budget? The skillset to provide well-detailed and complete construction documents?

Certainly, all the above are true. But at the center of our services is the process of design: How we engage with our clients and lead them through the daunting and monumental task of defining what the project should be and informing the design with the right information to create the appropriate physical environment. This process creates the foundation from which a successful project can be built.

The most accurate description I have ever heard of what the design process is was from Kurt Neubek. He defines it as “an organized way to make a million decisions.” That’s all it is. And it’s maybe one of the most important and incredibly challenging parts of our job as design professionals. We must engage staff, provoke thought, inform discussions, collaborate with team members, and facilitate direction on how to address the messy details, and these are the things they didn’t teach you in Architecture school. Below are nine things to keep in mind when taking on this challenge based on real lessons learned over several years of practice.

1. We Are All Smart but in Unique Ways

In most cases, information is gathered in a collaborative process we call User Group Meetings. In these meetings the design team can engage with the end users to ask questions and create a forum for discussion. Staff invited to these meetings include nurses, physicians, department directors, and ancillary department staff. Although our clients are intelligent people, we shouldn’t assume that they inherently understand what we need from them and what we are showing them. Floor plans are commonplace for us, but to them it may be just as foreign as an X-ray would be to us.

2. Choose Your Own Adventure

Because the process is less about design and more about facilitating a series of decisions, it’s important to remember that all decisions build upon each other. Decisions made at the beginning of the project — like program, budget, and location — cannot be changed once the next series of decisions that inform layout, equipment planning, and material selection are made. It’s like a Choose Your Own Adventure book. Each decision leads the project in a particular direction. If decisions made several steps back are revisited, the entire story is rewritten. That may not be a bad thing, but it will likely require additional design fees. If decisions were made with either faulty or incomplete information, this could be a difficult pill to swallow for the client.

Another way to look at it is to think of the popular game Jenga. The stack of bricks is the series of decisions. As you poke out blocks at the base of the structure, the tower eventually falls and you start all over again.

3. Identifying the Decision Makers

During the design process several groups are identified to inform the process and design. This usually comprises an executive leadership team or steering committee; end users who include nurses, doctors, and other staff; and representatives from ancillary groups such as EVS, infection control, pharmacy, materials management, and clinical engineering. It is important to confirm that the right people are in the room when making decisions. If they are not and decisions are made in their absence, these decisions are subject to change and the integrity of the information gathered is threatened. A classic example would be discussing finishes with a group of users and obtaining a consensus of what works for them in a particular space, only to find out later that the facility has standards that supersede staff preferences. Know who you should be asking from the start, and don’t ask questions to people who are not authorized to make the decisions!

4. Establishing the Goals for the Project 

Project goals are important to measure success and track progress. Functionally your goal may be to improve patient flow, increase private bed counts, or expand a department. More importantly, we are interested to understand what metrics will be used to measure the success of the project. What is key? Coming in under a specific project budget? Improving patient satisfaction scores? Speed to market? Understanding these metrics helps the entire team from the design team to hospital administration know what matters most when making decisions about design.

5. Communicate the Process and Expectations

Generally, a series of User Group Meetings will be scheduled to facilitate a progressive set of decisions that will inform the design of the project. During these meetings, the staff gathered to contribute to the process are generally willing and able to help; however, they likely are not familiar with design and construction and are not clear about what is expected of them. It is important to let the users and staff know what will be asked of them and when. This helps them be prepared to answer questions and possibly bring people to the table who wouldn’t otherwise have been invited to address specific items. If the staff comes in cold, more often than not questions will not get answered but will be tabled as action items that must be answered at a later date. Unfortunately, we have just wasted the staff’s valuable time and delayed important decisions that inform the process.

6. Provide All Pertinent Information

It is the burden of the design team to ask the right questions but also to furnish all the necessary information to inform the decisions. Many times, a decision must be based on several factors. A certain material may look wonderful and be approved but ends up being more expensive than the budget can afford or has a six-month lead time because it is coming from China.

7. Understand the Difference Between Best Practice and Personal Preference

Two perspectives inform how a department or space should be laid out, what material should be used, or what type of equipment should be purchased: best practice and personal preference. It is tempting to appeal to a physician’s or nurse’s personal preference when informing these decisions, but it’s important to understand that positions move and change. The people making decisions on the design may not be there when it is all said and done, and preferences differ from one person to the next.  It is always best to move toward best practice whenever possible.

8. Document the Decisions and Discussion

Each discussion is documented with meeting minutes to record the decisions that were made, not only to list the items decided upon but also the items decided against. This is important for several reasons. As stated above, positions change, and new people who want to introduce their own ideas are added to the project all the time. It is important to have a record of the decision-making process up to that point.

Additionally, after the project is built and occupied, it is natural for staff to have questions about why we did this or that. Good meeting minutes would document all the decisions and identify what was agreed to as well as what was not agreed to and why. So, when someone says, “Why didn’t we do it this way?” the record shows that it was in fact discussed and was decided against for these reasons. These meeting notes are an Owner’s best friend.

Lastly, inevitably some staff members have selective memory and take issue with design details in the final hour when it is costly to address. Good meeting minutes help the Owner demonstrate who participated in the decision-making process that led to the current design and challenge them to explain why a change at this point is important.

9. Obtain User Signoff

At the conclusion of the design process, all participants are asked to sign off on the drawings that have been developed as evidence that they informed the process and agreed on the outcome. To some, this may bring motive into question, but the truth is that signoff is important to all involved. It is a record that you as a key stakeholder participated in the process and the design has considered everyone’s contribution and input. It is meant to be a record of the design phase and inform the next phase of the process: Another building block to the next step.

Final Thoughts

Our objective as design professionals is not only to bring value to the project through good design and a robust knowledge of healthcare. We are providing clients with an experience and a forum to inform a design solution to an operational challenge. We are the facilitators of this process first and foremost, not the leaders. At the end of the day, the client and key stakeholders should feel confident and have ownership of the process to make the decisions stick. If the decisions stick, the foundation of the process will stand the test of time.