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The Leaflet Article

Featured Article:

Health Care Has Left The Building
Part I: The Imperative for Change

By Gary R. Goldberg, AIA

A. What If We're Missing An Opportunity, Because We Can't See Beyond Our Familiar Response Patterns?

I'm a Health Care Architect. For the last twenty-five years I've designed health facilities, mostly hospitals. It's a specialized body of knowledge, and a skill set that separates those of us who practice it from other architects. I'm proud of what I know, and it's ensured a steady stream of work for many like me, for a long time. The practices of health facility designers and builders seemed to be almost recession-proof, through times when other building types specialists were struggling.

But for the last several years, when I've listened to other health care architects and contractors talk about their work stream, I've heard them complain that clients are deferring major construction projects, buying time to figure out where health care reform is going to take them. The culprit, to some, is the Affordable Care Act (ACA), set for implementation in 2014.

Strangely enough, as the ACA's impact is more fully understood, relatively little of the information and opinion in the broad conversation taking place deals directly with its implications for the buildings and venues in which health services are provided. The health facility of the future can and should be something radically different from what we've been designing and building for the last twenty years. And yet, we are refining features within the tried and accepted models, instead of questioning and examining their premises or overall nature. This is not acceptable, but it is understandable, considering the cost and effort it took to develop what we have now.

Yes, we talk about smaller, leaner hospitals. We pursue energy efficiency and "right-sizing" for cost efficiency. Those vectors are universal trends, and their impact is critical for sustainability goals, but their impact on the core problems of health service operations is marginal.

Our professional peer group shares a common knowledge, and tends to keep doing what it already knows how to do.  They do, because those are the things that the market has been demanding. It wants what it knows and recognizes.  The market demands what the market understands. So that's what we design professionals continue trying to sell. The obvious path, for most professionals, is to get out there and keep providing the same thing: the known commodity. The problem is that the known quantity no longer works.

Our stalled industry is losing a competitive edge by its reluctance to reinvent what is clearly an unsustainable model.  The evidence of its unsustainability is the fact that in the 30 years ending in 2012, the cost of living doubled while the cost of health care nearly quadrupled. (Source: Bureau of Labor Statistics)

B. It's Hard To Stop A Train. It's Even Harder When It Is Loaded With Heavy Baggage: Some Obstacles To Change.

Again, the market demands what the market understands. It's as a risk avoidance tactic. Because it is easy to evaluate what is already understood, using a known model drives out risk. A recognizable product is the safest product to offer, since its success at meeting existing criteria of quality can easily be compared to other similar products. But in our current climate, attempts to strengthen future effectiveness will depend on doing the less easy and less safe thing.  Success in the future will depend on reinventing underlying models of operation. Form will follow performance.

What we've been doing is following a path of incremental refinement. The problem is that each successive improvement provides a progressively smaller degree of change from that which came before.

One primary barrier to change is in the way our regulatory rules tend to accrue around standard ways of doing things, rather than criteria that define good performance. The rigidity of the regulatory review and approval process often creates an argument for designing in a certain way. To achieve approval of a design becomes an exercise in charting a path of least resistance through reviewing agencies. For a profession that prides itself on creativity, we devote a surprising amount of energy to placing code-defined design restrictions as our first decision filters, rather than examining the fundamental issues shaping the regulation.

As we awaken to the new forms that health care will demand, we become more and more aware of the inertia that has built up around our typical response. Change is hard. 

Another serious obstacle to radical change comes up when existing facilities evolve. Clearly, core physical facilities cannot easily be remade every time they need to expand. When adding onto or remodeling an existing institution, the new work is typically viewed as an extension of the existing. But the desire to create consistency with existing conditions should be looked at critically when it is detrimental to instilling process improvement in the new work. 

As an example, there is a severe discrepancy between the design innovation cycle of equipment technology and the life span of the building envelope. While each phase of the planning, design, and construction process takes from months to years to carry out, equipment used in the clinical setting decreases in size and increases in capability day by day. From needs assessment to move-in for a new building is at best a two to three year process (and sometimes as long as six, seven, or more years). The technology landscape refreshes several times after building decisions are made, and is frequent cause of obsolescence. True, major infrastructure and systems cannot be economically abandoned and replaced with something completely different. Major investment in infrastructural systems is mandated by the legacy of what is already there. But by automatically replicating existing conditions, we perpetuate that cycle of obsolescence by viewing facility design with an eye to the past and not the future.

Finally, pressure to drive time and dollars out of budgets has led to commoditization of design work. The dollars saved, when compared to the overall costs of providing health care, are a false economy. In many cases savings in the design phases have consequential long-term costs. A case in point is exploration of alternatives and evaluation of options as a precursor to design decision-making. Theses studies can consume significant time in the early stages of design, and are tasks that no one has yet automated. But as an up-front step in design, they are essential to make the most cost-effective decisions for long-term efficiency in the enterprise as a whole. The health industry pays a price when it defaults to expedient solutions that overlook the opportunity to redesign operational features for higher quality and lower cost.

Although as design professionals we are trained to see deeply into a problem, and solve it as if no one before had encountered that specific problem, the scope of our problem solving is rarely defined to encompass a scope as large as the systemic complexity found in our health care system. That is a task that demands a multidisciplinary team, just as patient care, in treating the whole patient and not just the disease, is now understood to demand.

C. Here are some of the habitual responses that keep our design products from achieving the radical innovation we need.

The Hotel Model
Somewhere in our journey from caring for inpatients in open clinical wards, to the now-universally mandated private room, it was determined that for hospitals the best example on which to model the inpatient experience was the hospitality (read "hotel") model. From a customer service point of view, creating the optimal user experience is critical to marketplace success. That much is at least as true for health care facilities as it is for hotels. But modeling a health facility on a spa or high-end hotel overlooks some significant facts. Above all, hotels are filled with guests by choice, not often-reluctant conscripts for treatment. Hotel guests spend a small portion of the day in guest rooms, and unlike patients, can visit the hotel's spacious and inspiring public spaces and other amenities at will during their stay.  Furthermore, satisfaction in the patient experience is heavily dependent on minimizing the anxiety associated with the care being received, which is achieved through reassuring human contact, and only given that condition do positive environmental factors provide benefit. Also, hotel patrons have a variety of decision criteria to apply to their selection of a facility, none of which involve the input of their physician. Location, ambience, decor, price, style, if they ever enter the decision criteria list, are at the very bottom in choosing a hospital. 

None of this means that aesthetic and environmental factors are unimportant in health facility design; on the contrary, they are of critical importance. What it does mean is the hotel is a lousy model for a hospital.

Silos Of Care
As the importance of specialty medicine grew, individual specialties took on a bureaucracy to the detriment of the overall enterprise. As a result, redundancy and duplication of space and function became the norm, and still are in many facilities now being designed. When we learn to view the patient as the center of health care, and the collaboration of disciplines as the ideal, we will begin to eliminate this waste.

Pushing Patients To The Service
The biggest form of waste in the health services world is in the way that we push the patient to the service, rather than pulling the service to the patient.

Overfit in Design
The natural result of over-processing and silos of care is highly program-driven planning. Instead of seeking commonality and opportunities to combine functionality, we have sought to create environments perfectly fitted to their specific functions. The problem with that admirable goal is that environments designed in this way are useless for other functions. One trick ponies, so to speak. 

When our environments are designed to fit a unique set of programmatic requirements perfectly, they are "Designed To Be Redesigned". To borrow a term from the machine learning and predictive modeling fields, this design pitfall will be referred to as "Overfit". While not an exact correlation, overfit is described this way in data science:

"One of the main objectives of predictive modeling is to build a model that will give accurate predictions on unseen data. A necessary step in the building of models is to ensure that they have not overfit the training data, which leads to sub optimal predictions on new data." (Source: Kaggle website) 

"Overfitting occurs when a model begins to memorize training data rather than learning to generalize from trend." (Source: Wikipedia entry: Overfitting)   

Overfit, as the term is used here, describes what occurs when too many unique performance criteria are applied to a design problem. The end effect is that the result allows too few supported processes, and little generalization of use. In one sense, a highly differentiated program is a great opportunity for the design team to apply problem-solving skills. It lets them "show their stuff" in creating a unique solution. It creates tremendous waste later on, though, when it is learned that not all the detail was provided, or, when the program changes.

Loosely fit environments adapt to changing operations far more easily. We need environments more accommodating to Pull, environments that are not "tailored", as we used to say, to the needs of the client. This is especially true when a small sub part of the enterprise is misidentified as the whole client.

It's clear that we are ready to design facilities that are unconstrained in their ability to support the changing performance patterns of a dynamic discipline. Won't that same approach free them to better meet our needs as people?

In part two of this article, we will talk about:
The obstacles that generate cost without providing beneficial value to the patient
The need for new prototypes on which to build future health facilities
The power of Pull, Care Collaboratives, and Decoupling Infrastructure
The impact of "health maintenance" versus "health care"

Gary R Goldberg, AIA, is an architect in private practice in Los Angeles, California. He is a founding member of The LongWave Group, a collaborative group of industry experts who study the integration of Building, Equipment, and Clinical Operations in the service of Patient Care.

The LongWave Group's preconference workshop, to be presented at the 2013 Healthcare Symposium, is called HEALTHCARE IS UNSUSTAINABLE! How One Simple Idea Can Change Everything.

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