Healthcare’s Evolving Delivery Needs Change the Design Process

Long before the ribbon is cut … before the very first rendering is unveiled … the real work of today’s healthcare design typically begins in a boardroom with a list of thought-provoking questions and a notepad.

While ‘form follows function’ has been a design staple for many years, the architectural commandment has traditionally focused on crafting the optimal space within a single facility to meet a client’s needs. Yet, the changing healthcare delivery landscape means architects now must consider not only what happens inside the four walls of a healthcare structure but also how that facility must interact and function within the larger community.

Jim Easter, MArch, FAAMA, senior vice president and director of planning for Hart Freeland Roberts (HFR) Design, said his firm has invested in the belief that the design process is changing and evolving. Recently, Brandon Harvey, MArch, CDT, joined HFR as an intern architect/planner to focus on the connections between health facilities and the broader community. Harvey holds both a bachelor’s degree in urban planning and a master’s degree in architecture from the University of Tennessee – Knoxville.

“Brandon has joined us to help define, with our architects and our firm, how healthcare facilities will be developed as part of the urban fabric of a community … not just as stand-alone facilities,” Easter explained.

With an emphasis on preventive care and population health, new reimbursement models that pull together providers across the continuum, a focus on patient engagement, enhanced technology needs, increased connectivity and changing demographics, Easter said the expectation is that clinics, medical office buildings, outpatient facilities and acute care hospitals will increasingly need to partner with each other and plug into the communities they serve.

As a result of health reform, Easter said there is an increased need to deliver spaces very tailored to the specific clinical services provided and supportive of the push to streamline processes and increase efficiency.

One example has been HFR’s work over the past year in analyzing the effect of the Affordable Care Act on emergency services. Working with Todd Warden, MD, the founder and president of Emergenuity, the design team has used performance metrics to create the physical plant to support streamlined clinical pathways. As Easter explained, the idea is to ‘batch’ consumers into appropriate areas of care so that a senior presenting with stroke symptoms, a parent with a sick child, and an adult with substance abuse issues access the ED in different ways. “We make sure people are in the right pathway for the right reasons. What this system is designed to do is to allow care to be delivered quickly, efficiently and in the most appropriate manner,” he said.

So how does that knowledge fit in the larger context of community? Harvey noted, “We’ve defined a lot of urban dynamics. One of those urban dynamics is public policy and how that affects planning and design. The Affordable Care Act is a forcible vehicle for pushing the healthcare industry in the direction of patient centered care rather than just volume.”

That, he continued, changes how you envision accessing care and designing and locating spaces to fill needs within a community. A project in Carthage, Ill. underscored the need to think about delivering services differently. Harvey noted it became clear some services needed to be decentralized to better serve patients. Breaking memory care out of the critical access hospital allowed the design team to deinstitutionalize the feel of the new facilities to care for early Alzheimer’s and other dementia patients. The result is 10-bed residential cottages that feel and function much more like a home than a hospital with places for walking, reading, exercising and visiting with family.

“The healthcare industry needs to follow urban trends,” Harvey said. “Now we live in a microwave society where everything is about convenience. It’s changing the dynamics of the way healthcare can and should be delivered in the future.”

Harvey added more suburbanites are beginning to move back into urban areas, leading to the creation of a lot of mixed used developments. Perhaps that means accessing healthcare in the same place consumers access retail outlets and dining venues. Perhaps, as in Dallas, it means creating a major light rail transportation connection point actually on the hospital property.

Designing for a ‘big picture’ world has forced the creative process to shift and expand. “In the old days, you’d sit down and design an office building or sit down and design a hospital,” Easter said. “Now, it’s not that simple. We’re doing a full analysis.”

When working with a hospital campus or health system, Easter noted the first step in the process is to assemble a group of professionals including those with expertise in strategic alignment, architecture, engineering, finance, urban planning and market analysis to assess how the current alignment does or does not meet the needs of the community. Steps include:

Assessing the current situation.

Determining a strategic direction based on market need and workload requirements.

Assessing current facility conditions and future facility needs. “Most of our hospitals are way too big in spaces that are not well defined,” Easter noted.

Creating a composite redevelopment of an area-wide plan, which Easter said is taking what you know and redistributing it to meet population needs.

Scheduling and pricing that redistribution.

Building consensus with stakeholders and seeking specific design input. However, Easter and Harvey said this is actually a recurrent step integrated from start to finish.

Developing a phased implementation plan.

Measuring the overall economic development impact factors and considering regional implications.

Considering the full continuum of care including patient transitions from inpatient to step-down or home-based care and how technology impacts those moves.

As for when the design process begins, Easter said time constraints demand incremental decisions be made along the way with heavy design lifting occurring about halfway through the steps.

“We still believe form follows function, and you can’t begin to design a building until you first know what the function is going to be and how process improvements enhance the design,” Easter concluded.