Renee Kubesh, AIA, EDAC | Senior Project Manager and Principal | EUA

Healthcare providers increasingly turn to micro-hospitals to deliver quality care to their communities. These fully licensed, 24/7 facilities can help patients with myriad medical issues – including critical care – within a fraction of the space of their full-sized counterparts, typically less than 20,000 square feet.

After more than a decade of operational micro-hospitals, we’ve seen recurring themes in how providers adapt them to meet their evolving needs. We also had the privilege of recently conducting post-occupancy evaluations for two buildings. We offer these top findings as lessons and recommendations for sustaining the success of this healthcare delivery model.

Finding the Right Location

Micro-hospitals can offer convenient and accessible community care when strategically positioned relative to a greater healthcare system’s network. Many existing micro-hospitals are in relatively urban areas. Still, a micro-hospital could be located to reach underserved areas or to enter new markets, even if other providers are already present.

Despite a robust network of hospitals and clinics in the United States, many communities – especially economically disadvantaged and rural areas – lack adequate access to healthcare. Some healthcare systems see micro-hospitals as a solution and a mutually beneficial arrangement: the community gets access to nearby care, and the provider introduces new patients to their system with a relatively small investment. Also, higher-risk patients benefit from connecting to a specialty care network while receiving local, stabilizing, pre-treatment care.

Staffing is vital to this approach. As these facilities are introduced in underserved areas, the municipality and health system have a joint responsibility to foster strong relationships among their constituents and improve local amenities, making the region desirable to medical practitioners as a place to not only work but also live and be part of the community.

Other providers leverage their micro-hospitals to support a “spoke and hub” model of care. Staff triages incoming patients to determine the best care location based on patient needs, staffing and bed availability. This approach works well when assets like a robust network of physicians and access to ambulatory and acute care are already in place. It is also a valuable model for municipalities seeking to revitalize their city centers, as proximity to healthcare is critical in driving downtown living and business development.

Both approaches to locating micro-hospitals have typically assumed the facility will operate as a stand-alone service. But we’ve noticed a trend of using micro-hospitals as anchors for medical office buildings or specialty care services. Patient-centered care and patient satisfaction are enhanced through convenient access to pharmacies, laboratories, radiology departments, ambulatory surgery or specialty care. This allows the micro-hospital to remain true to its core model – lean and efficient – while being able to plug into other services.

Some healthcare systems integrate their micro-hospitals to support a “spoke and hub” delivery model, allowing them to transfer patients, if necessary, to main-hub hospitals or other in-network facilities that offer specialized services.

Integrating Specialty Care

Our healthcare clients increasingly ask for micro-hospitals with more integration and flexibility. They are rightfully concerned about licensing requirements, local patient population needs, and incorporating appropriate demographic specialty care components.

The challenge is meeting those requirements without forfeiting the efficiencies of the micro-hospital model. We often caution our clients from over-engineering or over-programming; the micro-hospitals do not need to meet every patient’s needs all the time. They will still be effective, as staff will attend to patients that require immediate care while stabilizing and transferring others as needed. Over-engineering these facilities can increase the break-even point, slow patient throughput, and hurt patient satisfaction and employee engagement.

If done strategically, it is possible to integrate specialty care while still realizing a micro-hospital’s benefits. For example, one client considered pairing cancer care with the traditional emergency department and inpatient model. With cancer care as a top revenue draw – and considering the distance from the main hospital – this made sense for the provider.

To integrate specialty care effectively and preserve the micro-hospital’s efficiency, healthcare systems should identify the specific components of care early in the building’s design process and review them with the local authority having jurisdiction over the project. The facility may require separate entries, clear identification of dedicated versus shared support areas and code-delineated smoke zones.

In our post-occupancy evaluation, we found it is better to offer radiology as both an inpatient and outpatient service. Radiology for inpatient service is required for licensing, but offering it for outpatient services will increase patient access and lead to a greater return on the high-investment imaging equipment. Future micro-hospital designs should maintain separate access pathways for each type of service to maintain efficiency and reassure patients that they are receiving the care they registered for in the appropriate location.

Supporting Staff and Cross-Training

Micro-hospitals are intended to operate on a lean and efficient staffing model where doctors, nurses, and aides cross-train to provide care to the maximum ability of their licenses. This is a functional approach as long as the staff still find value in their work. Often, burnout is not the result of staff doing too much work but rather from losing touch with the job they once loved.

We’ve heard from staff that they want more time at a patient’s bedside, which allows them to own the patient’s care from arrival to discharge. While it might seem counterintuitive, in a micro-hospital setting, one nurse should provide services ranging from meals to breathing treatments, all at the patient’s bedside. The variety of work counteracts nurse burnout and increases patient satisfaction by developing a deeper relationship with one caregiver.

The hospital’s design should support staff cross-training. A centrally located nurses’ station adjacent to the medication room, lab and storage areas allows staff to help the emergency and inpatient departments during low census counts. At busier times, when both departments may have dedicated teams, the station encourages communication between them so that staff can assist each other.

A centralized nurses’ station allows staff to see what’s happening around them and ultimately deliver better care. We learned from our post-occupancy evaluation that inpatient waiting rooms must be within view of, and ideally adjacent to, the station so nurses can oversee and communicate easily with family members.

Placing the nurses’ station and other support spaces in the center of the micro-hospital makes it easier for staff to respond to patients in all departments.

Incubators for New Ideas and Systems

There is little doubt that micro-hospitals will continue to adopt more technology, and the patient experience will become more virtual. Many providers are leaning into their micro-hospitals as technology incubators because it is easier and more cost-effective to test new technology and workflows in a 10-bed rather than a 100-bed facility.

For example, consider how micro-hospitals might embrace a new registration and check-in experience. Today, patients walk into an emergency department, and the first person they see is likely a receptionist. In the future, this position will be handled by an automated kiosk that scans the patient’s identification and directs them to the appropriate waiting area. Or they may bypass the kiosk altogether; instead, there might be an automated secure door system with advanced wayfinding to support patient self-rooming. The point is that providers are much more likely to try this technology on the micro-hospital scale – with minimal investment – before implementing it in their larger facilities.

Micro-hospitals are also apt testing grounds for improved mechanical systems. We learned from our post-occupancy evaluation that more rooms should have systems that can flex to negative pressure, allowing maintenance staff to respond to potential future pandemics without re-tooling mechanical equipment.

Looking Ahead

Micro-hospitals have a bright future. The model has become increasingly attractive to healthcare systems and patients due to rising construction and healthcare costs. As we continuously look to improve the state of healthcare in our country – whether through enhanced access to care, better support for staff, or new technology – micro-hospitals are fertile ground to test and implement ideas in an already innovative and efficient model.

About the Author: Renee Kubesh believes that architecture makes a difference in people’s lives and is excited to be a part of that dynamic in healthcare. Her healthcare environments empower staff to realize their potential, welcome family and visitors in a relaxing atmosphere, and help patients take control of their treatment and wellness. Over her 30-year-plus career, she has led the creation of spaces that can flex to future needs. She values an evidence-based design approach of understanding and respecting what has worked in the past while making the design and construction process engaging and fun for everyone involved.

About EUA: EUA is best known for designing environments that elevate people’s potential. The respected 115-year-old firm specializes in several markets, including education, workplace, healthcare, senior living, student housing, mixed-use, entertainment, and science and technology. More than 250+ employees in Milwaukee, Madison, Green Bay, Denver and Atlanta demonstrate an unparalleled commitment to the markets, communities and clients they serve. For additional information, please visit the firm’s website at eua.com.

By Robins & Morton Division Manager Eric Groat

Whether you call 2022 the “Great Resignation” or the “Great Reshuffle,” team culture has never been more important than it is now, and with good reason.

Finding qualified and committed people at every level is one of the key challenges facing the construction industry as the labor market remains extremely competitive. At the same time, our clients’ continued emphasis on speed to market, set against volatile supply chains, puts even more emphasis on teamwork.

According to a recent study by MIT, a toxic company culture is the strongest predictor of employee attrition and is 10 times more important than compensation when predicting turnover. The study identified toxic cultures by several elements that included lack of diversity, equity and inclusion; disrespect; unethical behavior; and failure to recognize and reward performance.

All those warning signs of a “bad culture” may seem easily identifiable, but are they as easy to spot in our everyday interactions? More importantly, do we recognize them in time to facilitate change within a team?

To answer this question, our first impulse may be to review the lagging indicators first. In the construction industry, these typically include the critical outcomes, such as staying on-target with the schedule, budget, profitability or employee retention. While these are benchmarks of a successful project, they’re not the first signs of trouble within a culture.

Instead, we should be focusing on leading indicators – Is there trust among our team members? Are we engaged in collaborating? How do we handle unethical behavior? Are team members recognized for their contributions and performances?

When we pivot toward proactively identifying indicators of a healthy or toxic culture, we’re able to determine the proper actions to either maintain that culture or reverse the negative changes we see. However, no matter its state, culture requires work.

While every industry and business is different, there are five red flags that I’ve found most universal in identifying the early stages of a toxic culture:

1. Lack of communication. It’s alarming when two people who are on the same team are working from wildly different sets of information or have a completely different understanding of a goal or outcome. It’s a clear signal that there’s a broken link in the management structure, and that the team doesn’t understand their objective. In addition to chaotic and unproductive exchanges, not understanding desired outcomes also stifles innovation, which limits the potential of the project or work product.
2. Lack of decision-making. Decisions fuel all forward progress. Developing a clear structure of decision makers and processes to tackle particularly challenging questions are foundational for a functional working relationship. When we see environments that don’t encourage timely responses to critical decisions, we could pull back the curtain and find dysfunctional relationships with managers, fear of company leadership, and team members who are unclear about the mission of their organization. Although no employee wants to make an error, positive and learning-focused environments recognize that people are fallible and will make errors. Our reaction to those errors directly reflects our culture.
3. Withholding information or support. Not all information is fit for public consumption – whether it’s unconfirmed, too detailed for most, or simply irrelevant – but there’s a difference between filtering and withholding information. Filtering is done with good intentions to provide a team member with the information they need and clarity to complete their task. Withholding information is adversarial, often used as an instrument to influence power dynamics. If a team member begins withholding information, it’s a warning sign that they don’t want to work together to solve a problem.
4. No action taken as a result of feedback. Feedback is a necessity for improving any workplace or team environment. When people place their trust in a team and provide constructive feedback, it can be a vulnerable experience. Another sign of a toxic culture is expecting team members to enter that vulnerable place with no intention of addressing their concerns.
5. No motivation to improve. The final sign of a toxic culture can be summarized into a single word: apathy. If there’s one thing we can be certain of, it’s that we’ll experience change – personally, professionally and often at an exponential pace. Without a motivation to improve, a culture will become stagnant, leading to dissatisfied and frustrated team members.

While some of these signs may sound familiar, the good news is that it’s never too late to course correct. Here are a few tactics that have been successful in my experience:

1. Provide a platform for feedback. Creating a mechanism for feedback is the first step to building trust with your team. Provide several avenues for team feedback such as performance reviews for one-on-one conversations, team health assessments, and companywide people satisfaction surveys. No matter how the feedback is collected, holding ourselves accountable to be transparent about what we received and how we plan to address it is essential to maintaining culture.
2. Get the right people in the room. When working to address cultural problems, we naturally gravitate to having hard conversations with those whom we already have the greatest rapport. While those conversations may serve as a great sounding board, they’re unlikely to result in meaningful change. Only when we engage everyone and commit to healthy conflict among the team members who can initiate changed behavior can we truly expect an improved outcome.
3. Hire and promote emotionally intelligent leaders. People will always be any organization’s greatest resource and having leaders who can navigate interpersonal relationships will make the difference when facing a culture crisis. One way to support this within your teams is to ensure you’re providing growth opportunities, and the only way to know what that may look like for a team member is by getting to know them. Establish a review structure for all team members, ensuring every employee has a structured touchpoint with their manager, at least twice year. There are also specific mentorship programs within the company that can help them reach their professional goals. However, most team trust is built in the day-to-day conversations – it’s why we emphasize the importance of teambuilding activities. All of these elements will help you get to know the strengths of your existing team members, and you can build a strong management structure as a result.
4. See red flags for what they are. It’s easy to categorize a challenging interaction or an undesirable outcome as a one-off, but harder to admit when it may be a sign of a more significant problem. However, we’re better positioned to tackle incremental change than an entire cultural shift. Surfacing an incident before it becomes a long-term issue is a proactive solution to reduce the red flags, one by one.
5. Pursuing partnerships that are culturally aligned with your organization. Business can be a lot like marriage. The phrase “opposites attract” isn’t often the case – two married people may have different hobbies or social batteries, but it’s rare that they have a completely different value systems. It’s a similar quandary in construction, with numerous long-term project partnerships. Inevitably, there will be friction between teams that don’t share collaborative and transparent practices. Projects are at their best when teams share critical values. While every business partnership won’t be a perfect match, prioritizing working with companies that share fundamental cultural characteristics has a greater opportunity for success.

Although there is no one-size-fits-all approach to developing and maintaining culture, its building blocks are grounded in respect for people – respect for your employees, your business partners and your community. Using that as your culture’s guiding principle can assure a successful foundation for your team – no ping-pong table required.

Eric Groat is the Division Manager of Robins & Morton’s San Antonio office. He has more than 20 years of experience managing complex construction projects and is an advocate of Lean construction principles. Groat believes that an emphasis on culture, partnership and respect for people is key to revolutionizing the construction industry.

By Dr. Wayne Ruga, FAIA, FIIDA, Hon. FASID

In our world that is circumscribed by histories, beliefs, and biases – our true heritage – the natural human agency, to express ourselves freely, that we were each born with, gets increasingly constrained as we progress in our development, an inescapable paradox that most of us are blind to. ‘Structure’ – such as norms, rules, and policies – is the insidious and ever-present constraint to ‘agency’, and for many of us, reproducing and producing more limiting structure is what we unknowingly become practitioners of, and rewarded for, rather than drawing upon our own natural agency to liberate ourselves, and those around us, to become more of who we were originally born to be.

At the Seventh Symposium, our Keynote Speaker was Bernie S. Siegel, a surgeon, who encouraged us to examine how this ‘agency-structure paradox’ creates limitations in our ability to achieve greater personal health, deliver more compassionate healthcare, and live our lives in ways that are more fulfilling. The theme of his presentation was captured in a compellingly simple photographic image, that he presented, of how nature is unstoppable in its pursuit to express its agency – even in the face of the most severe limitations of structure.

Dr. Siegel’s image was of a dandelion that had forced its way up through a newly paved and striped urban roadway – a road where the asphalt was still shiny in its newness and the yellow painted center line was, as yet, untrodden by vehicles – and this dandelion was the only natural element in this sterile urban setting, beaming triumphantly in the rays of the sun, having become the brilliant dandelion that it was created to be. Of course, the point of the image was to encourage us to each become like this dandelion.

Anais Nin expressed this same point with breath-taking eloquence, when she said – ‘And the day came when the risk to remain tight in a bud was more painful than the risk it took to blossom’. Through these simple words, we can begin to see the fact that we do have a choice – it’s not an easy choice – but it is a choice that is available to each one of us. Do we choose to remain as a bud – constrained by structure, or blossom – as an expression of our natural agency?

Of course, since we all want to choose to blossom – why is it so challenging and difficult? To suggest that it is simply a matter of beliefs is to oversimplify the situation. However, our beliefs are key to what we choose. For example, in The Doctor and the Soul, by Viktor Frankl, we see a dramatic example of how the power of our believing that we have a choice, and making it, can profoundly inform our experience – even in an extreme situation where pain is involved. In Viktor Frankl’s chilling personal account of being tortured, he describes how he chose to be triumphant over his situation, drawing a direct parallel to Dr. Siegel’s brilliantly radiant dandelion image.

Now, in its 35th year, the Symposium has a proud legacy of being a highly fertile field, providing the essential conditions that enable its participants to blossom – the extreme opposite of the newly paved urban roadway or the torturous conditions that Frankl survived. The Symposium is a unique place with an established history of supporting positive beliefs in our ability to improve the world, supporting our choosing to blossom, and actively encouraging our blossoming because of the invigorated agency that our courageous Symposium community supports our access to.

In fact, in support of our belief that we can each improve the world by making better tomorrows – we have compelling evidence that the Symposium accomplishes precisely what Dr. Siegel encouraged us to do: by providing the conditions that support our liberated expressions of agency, the Symposium enables improvements to our personal health, it has championed a more compassionate delivery of healthcare, and has enriched a vast number of human lives. Rather than contributing to the already-too-much-structure, the Symposium supports expressions of agency – bold agency, courageous agency, agency that enables our community of believers-in-better-tomorrows to actually create better tomorrows, day after day, and year after year – in the face of the ever-increasing structure that continuously attempts to constrain our expressions of agency.

As an original creation – unlike anything that existed before it – the Symposium was created to be a community of like-minded individuals. It was intended to be an annual ‘place’ to learn from each other and to share resources. The very name, ‘Symposium’, was carefully chosen to express the value of ‘discussing together’ – the non-hierarchical and inclusive activity that gives its flourishing community an infusion of vitality and a taste of the splendor of openly expressing our uniquely individual agency. As active participants in this experience of ‘discussing together’, we can feel the warmth of acceptance and a valuing of difference.

One of the original hallmarks of the Symposium was its open invitation to all stakeholders in health, healthcare, and design to engage in a new, and very different kind, of collaborative discussion – to provide this new and ever-expanding global community with the opportunity to hear new voices and different perspectives, to learn new ways, as well as for your voice to be heard and appreciated, for you to be seen and recognized, for your ideas to be openly expressed, for your resources to be shared and valued, and for you to learn in ways that open your mind to new possibilities.

The Symposium is a place for YOU to blossom: as an attendee in the 3-day long annual event, with ongoing discussions with Symposium community members between the times of the annual event, through the special relationships that develop through these discussions, and through the positive reinforcement that being in community with like-minded colleagues – those who believe in making better tomorrows – can encourage and support.

As this year’s 2022 Symposium returns ‘home’ to California, the state of its ‘birth’, YOU are invited to return ‘home’ to the fertile conditions of the annual Symposium where you will be encouraged to blossom, and to re-discover being the triumphant active agent that you were born to be. I am looking forward to our further blossoming together in Long Beach, in September.

By Jenni Eschner AIA, EDAC, LEED AP

Telemedicine as a mode of patient care delivery is here to stay. With the $1.5 trillion Consolidated Appropriations Act, 2022, coverage has been extended for telemedicine services, sending a message of support to ensure better healthcare access. Over 80% of surveyed physicians agree that patients have better access to care due to the availability of telemedicine (AMA 2021 Telehealth Survey Report).

Increasing professional satisfaction, telemedicine has allowed providers to find better work-life balance. According to a 2019 survey by American Well there is a correlation between physicians’ interest in using telemedicine and physician burnout. Specialists are among the most burnt out and are also most willing to practice via telemedicine.

Patients like it, too. A Jones Lang LaSalle surveyshows that seventy-six percent of all respondents who have had a telemedicine visit since July 1, 2021 would prefer to use this option in the future. For parents with multiple children, not having to find childcare or not having to take both healthy and sick children in for a clinic visit is a huge satisfier. The ability to do a virtual visit after hours and not have to take time off work for minor illnesses saves precious paid time off.

Architects are asked to help our clients figure out effective and affordable ways to implement this care model. What are best practices when designing telemedicine spaces? It depends on the situation.

Two Scenarios: Care Team Integration

To ensure the continued success of telemedicine, it needs to be integrated into the care team continuum. While technology allows us more mobility and flexibility, it needs to be deliberately planned, tested, and implemented.

Two scenarios need to be considered.

One telemedicine version is where a patient is in-person at a healthcare facility and interacts with care givers at a different location, either on or off site. This might be a visit with their provider and additional care team, such as social workers, pharmacists, psychologists, and other coordinated care. FGI 2018 Guidelines provides requirements for this scenario which include acoustics, lighting, finishes, patient orientation and equipment placement. These will be expanded in the upcoming FGI 2022 version.

The second telemedicine option is when a provider and/or staff interact with a patient and either the patient or both patient and caregiver are remote. According to the AMA 2021 Telehealth Survey Report, 80% of physicians are in a clinic during a virtual visit, while 64% are at home. 95% of patients typically connect from their home setting.

Three Models: The Comparison

There are three programmatic areas architects plan with clients to achieve this integration.

Model 1: Existing Exam Room

This option gives providers the ability to do both virtual and in-person clinical visits within the same work period without having to physically relocate. The same support staff is available to the provider during these visits and the same clinical supplies and tools are also available without duplication. This is a familiar and branded experience for the patient since the visual background they see is the same as during an in-person visit.

There are downsides to using an existing exam room. Renovations may be required to provide the right environment and infrastructure for connectivity. This might mean that additional equipment such as a microphone or camera would need to be added. Using an existing exam room also ties up space that could be used for in-person visits. And our clients are sharing that it can be challenging for providers to switch back and forth between a synchronous virtual visit to an in-person visit. The fact that you don’t need as much physical space for a telemedicine visit also makes this an inefficient option for a healthcare facility from a $/SF standpoint. Along with the size of the room, a virtual visit would not require the same medical equipment/amenities in the existing exam room for telemedicine.

Model 2: Dedicated Telemedicine Room

A dedicated room can be smaller and simpler, so organizations don’t overspend on equipment, millwork, and plumbing. Having these rooms also frees up traditional exam rooms so that more care can be provided at the same time. As with using an existing exam room, the same support staff and supplies are readily available.

What gets omitted from projects when clients can’t afford everything they want? Often, it’s staff support areas. We’ve been riding the prioritization wave of “patients’ needs first” for the past 15+ years in healthcare planning. There is now a shift to a more holistic systems approach, in which the entire life cycle of providing quality healthcare is considered and prioritized. When not in use as telemedicine space, these rooms can flex as multi-purpose use, small meeting, dictation, off-stage or staff respite space.

While simpler and less expensive, in an existing facility there is still the cost of space reallocation and renovation in creating dedicated telemedicine rooms. These rooms are ideally near the provider. In a new project, this can change the planning module of the department and add additional space to the overall footprint.

Model 3: Separated Space/Call Center

The final option we look at with our clients is a separate or off-site facility. This can range on a spectrum of one provider working out of their home to a large call center type of office space. The lower cost of construction and overhead for this space type makes it worth investigating and it (or the provider) can be located anywhere. This is a big advantage for facilities with a limited footprint, as they can prioritize available square feet for higher acuity care.

Another benefit to a physically separated space is that it can more easily adjust to varying volume demand. When rent is cheap and lease terms are short, it is not difficult to relocate. Because of this scalability, healthcare organizations can more easily increase quantities of providers and potentially reach new patients, even outside of a demographic area.

However, expanded access of virtual care to a wider population increases the responsibility of healthcare organizations to ensure their providers’ licenses and credentials are in good standing (“Managing provider licensure amid expanding Telehealth” April 2022). During the Public Health Emergency of COVID-19, all 50 states waived state licensure requirements. Now that most states have reinstated them, healthcare systems that want to use a large call center to reach patients in various states need to monitor that their physicians on staff are licensed in those locations.

The demands of technology on an organization can be a barrier to having off-site virtual visit locations. A healthcare system’s IT department may not be set up to manage the demands that arise, especially when it occurs in a provider’s residence.

Another drawback to a separated virtual visit model is that the support team and resources are not all in the same location. It may not be practical to use a synchronous care team approach (MA + Physician in one visit) from a staffing and scheduling standpoint. This could lead to additional work for staff. There is also the risk of less oversight and accountability.

And finally, patient experience might be diminished if there are too many steps or transitions in the virtual visit process or if it feels disconnected from the healthcare organization. Sure, it is convenient to be able to speak with a physician at 9:00 p.m. while they are in their living room. But doesn’t it feel just a little weird and unprofessional? For this reason, health systems need to work hard on the technology piece to make sure it feels familiar and consistent with the quality of care one would get during an in-person visit.

Takeaways

There is no one-size-fits-all solution for telemedicine. My recommendation is that as stewards of our clients’ buildings, we should “be flexible but stick to [our] principles” (Eleanor Roosevelt). Design spaces so they can adapt to new technologies and uses, but don’t overbuild. Work with your clients to help them figure out what will serve their needs best. If one thing has become clearer over the past couple of years, it’s that we are scrappy and resilient and need to do more with less. And we can!

By Laurena Clark, Tim Eastwood, and Natalie Petricca

A story can mean so much. Hearing about the experiences of patients and family members can affect us deeply, injecting us with focus and propelling us forward as we design with a particular end user in mind.

Experience-based design is more than just understanding the clinical flow or asking patients for input on design decisions. It’s looking at the experience of an event. It’s hearing the stories that patients carry with them, and the impact of their experience on all five senses. While it’s important to design a functional healthcare space, it’s also vital to maintain a human touch. How can you combine function and experience? Patient experiences are sensitive and personal, so how do you gather and apply these experiences of patients and their families to design spaces that improve experiences?

We’ll share some lessons learned from a rewarding project in our hometown of Toronto, Ontario. Adopting an experience-based design approach to healthcare design – especially on pediatric projects – can have a big impact on the healthcare experience.

Blood and marrow transplant/cellular therapy unit

We incorporated experience-based design while working on the redesign of the blood and marrow transplant/cellular therapy (BMT/CT) unit at The Hospital for Sick Children (SickKids), which provides care for patients from across Ontario and Canada’s Atlantic provinces.

This unit is home to some of SickKids’ most vulnerable patients, who stay in isolation rooms for weeks to months at a time and require stringent infection control measures because of their compromised immune systems. In the unit, children can receive treatment for leukemia, lymphoma, aplastic anemia, sickle cell disease, and other conditions.

Staff on the BMT/CT unit have delivered care in the current space for 25 years. Patient rooms are small and require upgrades to support new technology, individual washrooms, physical therapy, and comfort for patients and their families.

During the beginning stages of our redesign of the unit, which took place prior to the COVID-19 pandemic, we had the opportunity to use one larger patient room as a prototype. We used the room to sample different technologies and materials, and enabled care teams to think about how they might work in the new space.

This project gave us the opportunity to engage with end users – children, youth, and their families – which provided a key element of the design process. The experience of patients or caregivers in this type of environment is critical because the extended hospitalization allows people to think about how they might change the space. We knew we needed to hear their perspectives.

Engagement: Learning about experiences

When it comes to experience-based design in pediatric healthcare environments, you need to approach the engagement process carefully. Aside from being empathetic – especially when working with current patients and their families – here are some ideas to consider, taken from our work on the BMT/CT unit:

• Journey mapping: Can you learn about milestones before the engagement starts? Before meeting with users, we asked care team members about the major milestones of a patient’s experience, from arrival to discharge. This provided us with a structure for our interviews with users, where we could later walk through a patient’s journey. Then, we placed posters on the wall with five different steps in a patient’s journey, asking questions like, “What was the experience like? What would you wish was different about the experience? What were positives and negatives about the experience?” Patients and families wrote their experiences on sticky notes and attached them to posters.
• Preparation: Before you begin your sessions, make sure you have materials ready for people to describe their patient journeys. Bring samples so users can pick their favorite tiles or floor materials. Provide paper and drawing tools for users to illustrate what their experience was like or to sketch out an ideal room design. For some children and youth in our SickKids session, we asked how they’d design a new patient bedroom for the next patient that needed treatment.
• Dual format: It’s useful to conduct interviews via a dual format, where you book appointments with some people but also provide an open, drop-in session. This provides a hybrid of structured and unstructured engagement and gives options.
• An invitation to share: You may not even need to ask many questions during an engagement session – it’s more about inviting people to share their experiences in an informal way. Be prepared for some emotional moments. While working on the project, it touched us to hear some of the sacrifices that caregivers made for their children, including caregivers that slept over for months or traded shifts with their partners so they could maintain their jobs while their children were in hospital. Caregivers told us they didn’t want to leave their child’s room because they didn’t want to miss important information from a doctor.

From stories to design details

After conducting your engagement, you can look at ways to enhance your design with the feedback you have received. Dive deep and immerse yourself in that experience. Imagine every possible way you can make the experience better for patients and the family members (whose wellbeing is so important, given the important role they play in the care of their child).

For example, rather than just painting a wall, could you add a marker board for children and youth to doodle during their stay? Your design decisions can help create something more than a space of healing.

A well-rounded process

In pediatric healthcare, an experience-based approach to your design can lead to a well-rounded process that reflects the unique needs of young patients and their families. We’re driven by the balance between leaning on our technical knowledge and incorporating stories we hear from families. While working on the BMT/CT unit, we always put ourselves in the position of the people we were designing for – such as the child and caregiver staying in the hospital for weeks.

When projects like these, it’s all about listening. And the more you listen, the better you design.

Braintree, MA – September 2021 – The vision for proactive infection prevention has been realized in the EvaClean solution with proven processes and safer, more effective cleaning technologies. Over time, EvaClean has also become a trusted advisor for infection prevention units and environmental service teams in hospitals, health systems and long-term care facilities, as well as in colleges and universities. Ultimately, the unique needs of these industry sectors inspired EvaClean to create PurExcellence.

EvaClean’s PurExcellence is a progressive program built on six key pillars—Assessment, Standardization, Education, Safety, Sustainability and Guaranteed Cost Savings—which establish a roadmap to true infection prevention partnerships with healthcare and higher education.

The first step in the quest for PurExcellence entails a complete site assessment of current protocols, chemistries and applications based on a number of factors specific to each facility.

Kurt Wong, Chief Experience Officer at EarthSafe, EvaClean’s parent company said, “The data is used to develop a comprehensive chemical analysis, then compared against a more standardized approach using safer chemistries, which invariably yields cost savings of at least 30%.”

However, these benefits can’t be realized without ongoing targeted education that ensures proper procedures are implemented on a consistent basis.

“One of the most critical components of PurExcellence is customized training for the life of the partnership,” said Rich Prinz, Senior Vice President of Sales. “Perennial education helps ensure higher levels of safety, compliance and productivity to achieve better outcomes.”

Safety has always been one of EvaClean’s primary pillars. That’s why PurExcellence is standardized around EvaClean’s PurOne®NaDCC cleaner and disinfectant. Not only does PurOne have the first EPA registered biofilm bacteria kill claim, it also eradicates over 55 organisms on 12 EPA lists, including multi-drug resistant and emerging pathogens. To mitigate cross-contamination, PurOne can also be used with EvaClean’s disposable environmental surface wipes or, alternatively, the wipes system can be used to augment existing programs.

Yet, high level efficacy is only half the safety equation. In addition to protecting patients, students and staff, solutions must also protect the environment. EvaClean’s advanced chemistries are HMIS rated 0/0/0 with a neutral pH, as well as biodegradable and fully OSHA, NIOSH and JCAHO compliant.

CEO Steve Wilson said, “Long-term sustainability is another important aspect of PurExcellence. Our technologies were specifically designed to deliver both environmental and economic benefits.”

Because PurOne and PurTabs®, EvaClean’s electrostatic sprayer disinfectant, dilute to different strengths for multi-purpose solutions and are highly effective at lower parts per million (ppm), it takes less chemical to accomplish more. The tablet format also requires less packaging, translating to less shipping, emissions and environmental impact. When strategies include electrostatic disinfection of all touchpoints, chemical consumption is even further reduced.

The six pillars of EvaClean’s PurExcellence initiative are a proactive formula for the prevention of infectious outbreaks and HAIs, which adds up to higher quality care and lower associated costs of at least 30%–guaranteed.

About EvaClean

Originally developed by EarthSafe Chemical Alternatives® in 2016, EvaClean® has become the preeminent infection prevention solution. In addition to a portfolio of advanced electrostatic technologies and safer, more sustainable chemistries, EvaClean provides customized protocols and ongoing training to simplify processes and improve outcomes. Founder and serial entrepreneur RJ Valentine, together with an exceptional leadership team, have built EvaClean into one of the leading authorities on healthier disinfection across all industry sectors. Learn more at www.evaclean.comand follow us on LinkedIn, Facebook and Twitter.

By Dr. Wayne Ruga, FAIA, FIIDA, Hon. FASID

This article is about the future – yours, mine, and everyone’s. It is a ‘call’ to courageous progress.

Background: The expression, ‘crossing the Rubicon’, is meant to evoke a decision to a significant course of action – an irrevocable action where there is no going back, as in 49 BC, when Julius Caesar crossed the Rubicon River and the events leading to the rise of the Roman Empire unfolded. In the 1970s, Thomas Kuhn developed the concept of a ‘paradigm shift’, with a similar meaning. Today, it is common to hear the expression, ‘let’s get out of the box’, a metaphor meaning much the same. In all three of these cases, radical progress is harkened – a systemic improvement over the status quo – one that requires courage to advance into the ‘beyond’.

At the 2017 30th annual Symposium, in Austin, we commemorated this milestone event by drawing upon the image and legend of Janus – the Roman god of transitions. The image portrays Janus as a left and a right profile – with a straight-on portrait between these two profiles – to mean that, as we progress into the future, we should inform our journey with learnings from the past. At the 30th Symposium, as we discussed progressing into a future informed by learnings from the past, none of us could have imagined the arrival of the Pandemic on our doorstep, about to challenge everything we thought we knew.

Foreground: As we make our preparations to return to Austin for this year’s 2021 Symposium – having completely skipped a Symposium for the first, and only, time in the history of the event – to be certain, during the last 20 months, we have all been required to cross the Rubicon, shift numerous paradigms, and get ourselves out of many a box. In my roles as the Symposium founder, healthcare and design innovator, pioneer of new futures, and teacher, I am frequently asked to comment on what we’ve learned through the challenges of this pandemic that will have a lasting, positive impact on how we create our future.

In this regard, the Sankofa – the mythical bird of Ghana – offers useful guidance. It is an inspired legend that reminds us of Janus, with the additional dimension of ‘wisdom’. The native Akan tribe, the source of the Sankofa legend, believe that the past should guide us in how we plan our future – and, that it is the wisdom from this learning that enables us to make a stronger future likely. In the tradition of Socrates – I turn the question to you: what have you learned during these 20 months, what wisdom have you gained, and how will this wisdom inform the decisions you will make as you progress into the new future?

My own view on this question – what have we learned – has multiple dimensions: (1) how can the Symposium impact the new future; (2) what impact can I (the collective ‘I’) possibly have on the new future; and (3) how can ‘I’ contribute – positively – toward creating a new, and better, future? How each one of us addresses these dimensions is profoundly crucial, in terms of how our collective new future will unfold.

For example: How can the Symposium impact the new future? First-time attendees may get the impression that the Symposium is a conference – although it contains many of the same elements that a conference does, it has so much more to offer. The Symposium can be better understood as a crucible, a vessel where transformation is forged. Each year, radically new ideas are presented and discussed that are carried by the attendees further into the world to advance progress. Whether these ideas exist as information, knowledge, or wisdom – it takes courage to learn new ideas and use them to improve the status quo, as Symposium attendees have done for decades, as inspired and courageous agents of transformation in health and healthcare.

The Symposium, as a crucible, has an established pioneering legacy of fueling the transformation of the individual lives of its attendees by providing direct exposure to: new, and often – very different – ways of thinking; new connections, support, and resources from meeting and engaging with like-minded individuals; and new business opportunities. There is no other healthcare facilities design event that has so profoundly improved lives around the globe, because of this transformative function – the lives of patients, families, staff, and local community residents.

To find ourselves asking, ‘what impact can I possibly have’ is to overlook the many unique opportunities that have opened up because of this unprecedented moment in our history. Every single individual has a significant, unique, contribution to make towards the creation of a new and better future – although it is not always so easy to see that, and to have a clear idea of what we each can do. This is precisely why we must reach into the ‘beyond’ – the beyond the Rubicon, into the new paradigm, and get ourselves out of the box. As Hillel the Elder said. ‘If not now, when? If not you, who?’. Now is the time.

The question: ‘how can I contribute – positively – towards creating a new and better future?’ is not a simple question with a simple answer. It is an inquiry that each one of us has the opportunity – and responsibility – to engage in. Why do I make this bold assertion that we each have the ‘responsibility’ to consider this question? My view is that we are all leaders – some of us are highly visible and recognized leaders, with ‘leader’ written in all capital letters; many more of us are leaders, written simply with a capital ‘l’; and – most importantly – every single one of us is a leader in lower case letters: the leader of an enterprise, called ‘my life’. As the leader of this personal enterprise, we are the CEO, and we have sole leadership responsibility – as the CEO of our life – just as the CEO of a major organization has. In this role, we have the responsibility to discover how our inherent personal, unique, agency can find purchase – and traction – to advance our own enterprise.

Of course, advancing our enterprise does not necessarily mean that we will contribute positively towards creating a new and better future – so, I qualify my comments by drawing upon the words of Reinhold Niebuhr, author of the ‘Serenity Prayer’: ‘God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference’. From this prayer, I highlight the words, ‘courage’ and ‘wisdom’. The Sankofa enabled us to appreciate the value of wisdom in informing our future with learnings from our past – a new understanding that the teachings of Janus were silent on.

‘Courage’, however, is a new aspect – one that the Serenity Prayer contributes to our inquiry: a personal exploration of considering what things can I actually change? In our modern times, definitions and understandings of ‘courage’ have emphasized brave and fearless actions, particularly when faced with adversity. Examining the origins of ‘courage’ provides us with a further understanding – ‘courage’ is derived from the Latin root of ‘cor’: of the heart. When ‘courage’ is used in this original way, it encourages us to discover and to speak openly of truths from our heart, as opposed to brave and fearless actions, which have their origins in our brains.

As we further consider the root of ‘courage’, we must each discover a personal way to understand our heart in a new way – not merely as a mechanical pump for the purpose of circulating blood, but – rather – as the center for our ability to gain access to unique intelligences that – amongst their far-reaching capacities, enables each one of us to pursue courageous self-expression. Neibuhr’s Serenity Prayer invites us to use our ‘wisdom to know the difference’ – a profound opportunity to learn how to clearly distinguish the wilful volition of brain-driven actions, from the more subtle and elusive callings of our hearts, and – as a result – access personal expressions of ‘courage’ that can move mountains and transform futures.

What have we learned? If it isn’t as obvious to you as it is to me – old habits are hard to change, and ‘necessity is the mother of all invention’. It is surprisingly easy – more than we imagined – to try doing old things in new ways, and – presto – the outcomes are improved. What about making a really big stretch, and also discovering how to do new things in new ways?

The September / October 2021 issue of Harvard Magazine has a feature article, ‘The State of the Pandemic: Lessons Learned from the Continuing Confrontation with the Virus’. It discusses a range of lessons learned – some of which call to us to create futures that – heretofore – were unimaginable. For example, the article reminds us that the Pandemic is a global challenge, and we have not yet developed the global structures to adequately withstand future health threats – or the resources. In our current era, the wealthiest countries can have the best outcomes, while our less wealthy relatives have less robust defences – is this the future we really want for our children, and their children?

The article mentions the built environment, and some of the health challenges that our current inventory provides – such as closed and ventilated buildings, and insufficient intensive care capacity for future epidemics. As a community of leaders, with a passionate interest for improving health and healthcare facilities, we can expect that the Symposium will inspire novel remedies to these deficiencies that will contribute towards improving the resilience that we rely on our essential services to have, and to continuously upgrade.

A ‘Call to Courageous Progress’: Pablo Picasso famously said, ‘I am always doing that which I cannot do, in order that I may learn how to do it.’ No doubt, if Picasso was still alive, he would have been a notable Symposium Keynote speaker, and a regular attendee. Although the richness of the distinctly different Symposium attendees is invigorating, Picasso’s quote provides a fascinating snapshot of the key characteristics that weave their way through the global Symposium community – a commitment to regularly and consistently doing the impossible, and continuous learning. And, as a Picasso scholar might explain to us, Picasso’s quest to be ‘always doing that which I cannot do’ was driven by his courage – in translating the wisdom of his heart and learning to create from this source – much as each one of us might do, as we courageously progress on our respective leadership journeys, in creating a new and better future for the many generations to come.

In conclusion, this ‘call’ is a thundering shout: now is the time to draw a line in the sand, beyond which is a new and much better future than our recent past (50 years?). Let’s all discover and draw from our wisdom, learn from our journey, and invest our precious life force into courageous demonstrations of our unique agency – the gifts we were born with, the legacy that our ancestors bequeathed to us, and the dreams that inspire each one of us to leave this world better than when we arrived.

Wayne Ruga can be reached at: [email protected].