Guide to Conducting Healthcare Facility Visits

by Craig Zimring, Ph.D. Georgia Institute of Technology

Published by The Center for Health Design, 1994

INTRODUCTION

A major medical center is building a new diagnostic and treatment center that will include both inpatient services and expensive high technology outpatient services The center is considering whether to provide day surgery within the diagnostic and treatment center or in a freestanding outpatient facility. They are facing a dilemma. If they locate the day surgery center separately, they can use lower-cost construction. If they combine the functions, they can use the spare capacity that will likely become available in the inpatient operating rooms. This is especially important as outpatient procedures become increasingly complex. The center wishes to evaluate sites that currently operate in fully separate facilities versus ones that provide separate outpatient and inpatient reception and recovery facilities, but share operating rooms.

A large interiors firm has been contacted to conduct a visit of several new children’s hospitals in the Northwest. Eager to get the commission from this major hospital corporation to renovate the interior of a large children’s hospital, the firm arranges visits of hospitals it has designed as well as two designed by other firms.

An architecture firm is renovating a large medical laboratory in an existing building which has a minimal 11-foot-3-inch floor-to-floor height. Concerned that the client may not understand the implications of this tight dimension-which means that the fume hood ventilation system can not easily be installed within this space-the architects arrange visits of other labs with similar floor-to-floor heights, change in healthcare and society is rapid and increasingly unpredictable, bringing an unprecedented level of risk for healthcare organizations facing new projects. This guide discusses a specific tool that healthcare organizations and design professionals can use to help manage uncertainty: the facility visit. In almost every healthcare project someone-client, designer, or client-design team-visits other facilities to help them prepare for the project. A probing, well structured, and well run visit can highlight the range of possible design and operational alternatives, pinpoint potential problems, and build a design team that works together effectively over the course of a design project. It can help a team creatively break their existing paradigms for their current project and can provide a pool of experience that can inform other projects. All of these can help reduce risk for healthcare organizations.

However, current facility visits are often ineffective. They are frequently conducted quite casually, despite the rigor of much other healthcare planning and design. Visits are often costly—$40,000 or more-yet they often fall short of their potential. Sites are often chosen without careful consideration, little attention is given to clarifying the purpose or methods of visits, there is often little wrap-up, and frequently no final report is prepared. Not only is the money devoted to the visit frequently not used most effectively, the visit presents important opportunities to learn and to build a design team. These opportunities are too often squandered.

This guide focuses on what a facility field visit can accomplish and suggests ways to achieve these goals. Although a facility visit may occur in a variety of circumstances, including the redesign of the process of healthcare without any redesign of the physical setting, this guide focuses on situations in which architectural or interior design is being contemplated or is in process.

SCOPE OF THE RESEARCH

The goals of this project were to learn about the existing practice of conducting healthcare facility visits, to learn about the potential for extending their rigor and effectiveness, and to develop and test a new approach. We interviewed over 40 professionals in the fields of healthcare and design from every region of the US, including interior designers, architects, and clients who had participated in design projects, and healthcare professionals who conduct visits of their own facilities. We sampled professionals from large and small design firms, and from large and small medical organizations. To get a picture of both “average” and “excellent” practice we randomly selected members from professional organizations such as the AIA Academy on Architecture for Health and the American Society of Hospital Engineers, and augmented these with firms and individuals who were award winners or were recommended to us by top practitioners. We developed a multi-page questionnaire that probed the participants’ experiences with visits, including their reasons for participating, their methods, and how they used the information produced. We faxed each participant the questionnaire, then followed up with an interview on the phone or in person. The interviews averaged about one-and-a-half hours in length. Every person we initially contacted participated in an interview. Everyone in our sample had participated in some sort of visit of healthcare facilities within the past year.

After conducting the interviews we developed, field tested, and revised a new facility visit method, which is presented in this guide. Throughout this process we conferred with select members of the Research Committee of The Center for Health Design and the Project Advisory Board.

GOALS OF FACILITY VISITS

There are many reasons for doing a facility visit and many different kinds of visits. However, visits roughly fall into three categories: specific visits, departmental visits and general visits. Specific visits focus on particular issues such as the design of patient room headwalls, nursing stations, or gift shops; departmental visits focus on learning about the operations and design of whole departments such as outpatient imaging or neonatal intensive care; general visits are concerned with issues relevant to a whole institution, such as how to restructure operations to become patient-focused. Usually, departmental and general visits occur during programming or schematic design; specific visits often occur during design development, when decisions are being made about materials, finishes and equipment.

More broadly, there are several general reasons for conducting visits: learning about state-of-the art facilities; thinking about projects in new ways; and creating an effective design team.

LEARNING ABOUT STATE-OF-THE-ART FACILITIES

Visit participants want to learn what excellent organizations in their field, both competitors and other organizations, are doing. Participants are often particularly interested in learning how changes in business, technology or demographics, such as increased focus on outpatient facilities or increased criticality of inpatients, might affect their own operations and design. For example, in Story 1, below, a UK team was interested in grafting US experience onto a UK healthcare culture. In another example, hospital personnel at Georgia’s St. Joseph’s Hospital visited five emergency rooms over the course of several weeks before implementing an “express” service of their own. According to planner Greg Barker (Jay Farbstein & Associates, CA) they “use site visits as a method of exposing the clients to a broader range of operating philosophies and methods.” This gives the clients and design professionals a common frame of reference on which to base critical operational and design decisions.

STORY 1

William Headley, North Durham Acute Hospitals, UK

Traditionally, hospital design in the UK has been established centrally, with considerable emphasis placed on standard departmental areas and on a standardized planning format known as “Nucleus.” The 20-year-old Nucleus system is based on a standard cruciform template of approximately 1,000 square meters housing a multitude of departments, which can be interlinked to provide the nucleus of a District General Hospital.

Durham wished to develop a hospital that in its vision would meet the challenges of the 21st Century, and produce a custom-designed hospital solution built to suit the needs of the patient, not just individual departments.

The brief has, therefore, to be developed from a blank sheet of paper and not from standard guidelines. It is also the Trust’s objective to have the brief developed by staff from the bottom up. The purpose of the study tour was to allow frontline staff the opportunity to experience new ideas firsthand and talk to their medical counterparts about some of the philosophies of patient-focused care and to input their findings into the briefing process. We acknowledged the differences in the US and UK healthcare systems, but were interested in ensuring that best US practices, including the patient focused approach, facilities design, and the use of state of the art equipment, was studied and subsequently tailored to suit the new North Durham hospital.

THINKING ABOUT A PROJECT IN A NEW WAY

Participants who are currently engaged in a design or planning project are concerned with using visits to advance their own project. They use a visit to analyze innovative ideas and to help open the design team to new ideas. At the same time they are interested in building consensus on a preferred option. In Story 2, below, a hospital serves as a frequent visit host because it shows how special bay designs can be used in neonatal intensive care, and participants can consider how these designs apply to their current project. Other visit organizers see a visit as an opportunity for focusing the team on key decisions that need to be made, or to help the team focus in a systematic way on a range of strategic options and critical constraints. The visit exposes each team member to a variety of ways of accomplishing a similar program of requirements and thus starts the debate on how to achieve the best results for the facility being designed.

STORY 2

Georgia Brogdon, Vice President Operations, Gwinnett Women’s Pavilion, GA

We get visitors at our facility about once per month. Right now the NICU (neonatal intensive care unit) is the most frequently visited location. The main reason is that Ohmeda uses our unit as a showcase for a special design of NICU bays. People want to see it because most think that Hill Rom is the only vendor of this type of equipment.

Early on, we were also one of the only state-of-the-art LDR facilities around. So if people wanted to visit an LDR unit, they had little choice but to come here. Now, however, people come to see us because we are a freestanding yet still attached facility. Over time the visits have evolved away from the design of the facility and more into programming, services, and operational issues.

We give three types of visits: 1) overview visits for lay people who just want to come see the area; 2) functional visits for other hospital people or architects who want to see the LDR design, mother/baby floor, NICU design, etc.; 3) operational flow visits to learn how the LDR concept impacts operations. In general, we start the visitors wherever the patient would start in the facility.

To arrange a successful visit of our facility, we need to know the interests of the visitors; then we can focus the schedule on that. Also knowing who they are bringing is helpful. You need to have their counterparts available. The types of information needed to conduct facility visits are: 1) what specific operational information to ask for in advance-size, number of rooms, number of physicians, staffing, C-section rate, whether they are a trauma center; 2) how to prepare for the visit; 3) who to bring. We’ve found that periodically the visitors are disappointed because they didn’t bring enough people. Better to have too many than not enough.

CREATING AN EFFECTIVE DESIGN TEAM

Participants use visits as an opportunity for team building. Many visits are conducted early in a design project by a team who will work together for several years. The visit provides participants a useful opportunity to get to know each other and to build an effective team. As Story 3 illustrates, clients often look to a visit to see how well designers can understand their needs; designers use it as a way to learn about their clients and to mutually explore new ideas. A visit can also provide an opportunity for medical programmers to work with designers and clients. This is particularly important if programming and design are done by different firms.

Many visit participants focus on interpersonal issues: spending several days with someone helps build a personal relationship that one can rely on during a multi-year project. A visit also provides the opportunity to achieve other aspects of team building: clarifying values, goals, roles and expertise of individual participants; and identifying conflicts early so they can be resolved. One result for some teams is that it establishes a common vocabulary of operational and facility terms translated to the local healthcare facility.

STORY 3

Bing Zillmer, Director Engineering Services, Lutheran Hospital, La Crosse, WI

Conducting a facility field visit is an opportunity to have that one-on-one contact and find out if the architect “walks the talk or talks the walk.” The biggest benefit is in finding out how the visit team of the architectural firm has been assembled: to see their level of participation, and how they have interacted with and listened to the clients and the hosts. What we look for in a consultant is not a “yes man”; we look for someone who knows more about existing facilities than we do. Our key concerns are how the team worked together, how they listened.

Dennis C. Lagatta, Vice President, Ellerbe Becket, Washington, DC

The main reason for conducting a visit is to settle an issue with the client. The clients usually have only two frames of reference: the current facility and the one where they were trained. These two frames of reference are hard to overcome without a visit. We conduct visits to help settle an issue between various groups within the institution. The visit process tends to be a good political way to illustrate a problem or a solution to a problem. A good example is when you have a dispute between critical care physicians and surgeons. Both parties may be unwilling to compromise. Usually a visit will be a good way to defuse this conflict.

James W. Evans, Facilities Director, Heartland Health System, St. Louis, MO

Responding to the question, what kinds of team-building activities were conducted before the actual visit took place? The functional space program stage is where you start building a team. Functional space programming is a narrative of what you want to do. If the programming includes a laboratory or some other specialty area, you would also want to have the consultant (if you are using one) involved in this process. Between blocks and schematics is when you want to go on any visits. By working together and staying together through big and small projects, you develop a lot of rapport and credibility.

Les Saunders, Nix Mann And Associates, Architects, Atlanta, GA

In the case of marketing visits, we try and present our unique abilities to our clients and to get to know each other better, Our visits are generally tailored to what the client group is trying to accomplish. Our functional experts will go on the visit so they can get to know the client and try to enhance “bonding.”

Facility visits allow healthcare organizations and design professionals to address several important trends in healthcare.

• As competition for patients increases, healthcare organizations are becoming more customer-oriented.

   

• A visit allows a team to understand the experience of stakeholders who they do not currently serve, and to examine the design and operations of facilities that are more customer-oriented.

• Social changes are resulting in some stakeholder groups gaining importance, such as outpatients involved in more complex procedures, higher acuity inpatients, older people, or non-English speakers.

• A visit may allow a team to learn about the experience and needs of some groups who may be unfamiliar to some healthcare organizations or design professionals.

   

• A greater emphasis on efficiency and Total Quality Management is placing more importance on benchmarking and data collection.

   

• A visit can provide quantitative and qualitative data that support future decision making.

• Tighter budgets, shorter design and construction schedules and more complex projects are requiring design teams to form more quickly and work more effectively.

• A visit can be an effective tool for building a design team early in a design project.

FALLING SHORT OF THEIR POTENTIAL

In a design project, the client healthcare organization generally pays for a visit, either directly or as a part of design fees. Do healthcare organizations usually get good value for their investment? Do visits generally achieve their ambitious goals of learning about competition and change, moving the design project along, and building teams? We found very different answers. Despite the usual rigor of healthcare planning and programming, many current visits are very casual. Whereas some planners of visits do careful searches of available facilities to fit specific criteria, most choose sites to visit in other ways— sites participants happen to already know because they have been written about in magazines, or sites where there is a contact that someone on the team knows. Though these ways of choosing sites may be appropriate, they raise a question as to whether most participants are visiting the best sites for their purposes.

In many cases visit teams simply do not spend much time structuring the visit. Most teams do not even meet in advance to decide the major foci of the visit. We did not find many groups who use checklists or sets of questions or criteria when they go into the field. Whereas some teams compile the participants’ notes, and one team actually created a videotape in a large project, most teams do not create any kind of written or visual record of their visit. Many teams hold no meeting at the end to discuss the implications of the visit, although many participants felt that they emerged in subsequent programming or design meetings.

Despite the apparent casualness of these visits, designers and clients alike almost without exception felt they were a valuable resource.

Simply visiting a well-run facility can be vivid and exciting. It is fascinating to see how excellent competitors operate, to talk to them and learn of their experience. (It is also an excellent opportunity for administrators and designers to get away from their daily routine and talk to professional counterparts.)

But there are large opportunity costs in the way most current visits are run, and they represent considerable lost value for the healthcare organization, designer, and design project.

COMMON PITFALLS

Opportunity costs of current visits come from several common pitfalls.

LOW EXPECTATIONS LEAD TO LIMITED BENEFITS

Often, participants see field visits as a way to get to know other team members and simply to see other sites, but have no clear idea about what information can be helpful to the project at hand. They don’t think through how the visit can help the goals of their project or organization.

TOO BUSY TO PLAN

The planner of a visit faces multiple problems. Often the visit is seen as a minor part of the job of most participants and doesn’t get much attention in advance; schedules and participants may change at the last minute. In many cases, no one is assigned to develop the overall plan of the visit, and to ask if the major components-choice of sites, choice of issues to investigate, methods for visits, ways of creating and disseminating a report-match the overall goals of the organization and project. This is especially ironic because participants are often advocates of careful planning in other areas.

TOO FOCUSED ON MARKETING

Many visits, and especially designer-client visits, are billed as data gathering but are in fact aimed at marketing. A design firm may literally be marketing services or may be trying to get a client to accept a solution that they have already developed: marketing an idea. This may lead to an attempt to create a perfect situation in the facility being visited, one without rush, bustle, or everyday users and the information they can provide. For designer-client teams, we heard many designers complain that they couldn’t control their clients, that they couldn’t keep them focused on prearranged ideas or keep them limited to prearranged routes. (This is often the result of not enough advance work aimed at understanding what interests the participants have and not enough time spent building common goals.)

CLOSING THE RANGE OF DESIGN OPTIONS TOO EARLY

Many visits occur early in the design process or when an organization is considering significant change, a perfect time to consider new possibilities or address issues and solutions not previously considered. This timing, and the chance to see and discuss new options in a visit, presents an opportunity for a design team to open its range of choices and consider novel or creative alternatives. However, many visit participants feel strong pressures to “already know the answer” when they start the visit. Many designers and consultants feel that their clients do not want them to genuinely explore a range of options, that they were hired because they know the solution. Similarly, some medical professionals establish positions early to avoid seeming foolish or uninformed. As a result, the team may choose sites that bring only confirmation, not surprise, and people will be interviewed who bring a viewpoint that is already well established. This is not simply a matter of the individual personalities of people who set up visits, but rather a problem of the design of teams and the context within which they operate. It is often important for a design firm to show a client the approach it is advocating and for them to jointly explore its suitability for the client’s project. However, if the client expects a designer to know the answer before the process starts, rather than developing it jointly with the client, the designer is forced to use the visit to exhort rather than to investigate.

TOO LITTLE STRUCTURE FOR THE VISIT

Whereas no one likes to be burdened with unnecessary paperwork before or during a visit, it is easy to miss key issues if there is not an effort to establish issues in advance, with a reminder during the visit. Seeing a new place, with lots of activity and complexity, makes it easy to miss some key features. Many team members come back from visits with a clear idea of some irrelevant unique feature such as the sculpture in the hallway, rather than the aspect of the site that was being investigated.

INTERVIEWING THE WRONG PEOPLE

Often, out of organizational procedure or courtesy, a site being visited will assign an administrator or person from public relations to be the primary guide. It is almost always preferable to interview people familiar with the daily operations of the department or site.

MISSING CRITICAL STAKEHOLDERS

Almost every healthcare facility is attempting to become more responsive to customers, both patients and “internal” customers such as staff. Patients often now have a choice of healthcare providers, and staff are costly to replace. Despite these trends, many visits miss some key customer groups such as inpatients, outpatients, visitors, line staff, and maintenance staff. It is very important that these groups or people who have close contact with them be represented in visits.

A DESIGNER PROVIDING TOO MUCH DIRECTION DURING A DESIGNERCLIENT VISIT

In an effort to control the outcome, a designer may attempt to ask most of the questions during interviews. In addition to the problem of focusing exclusively on “selling” ideas described above, clients do not like to feel that their role is usurped.

MISSING OPPORTUNITIES FOR TEAM BUILDING

Teams are most effective when everyone understands the values, goals, expertise and specific roles of others on the team. Teams are also most effective when the team understands the process and resources of the team, the nature of the final product, how the final product will be used: who will evaluate it, and by what criteria the success of the product will be evaluated. Although management consultants routinely recommend making such issues explicit at the beginning of team building, we found few visit teams that deal with these issues directly. Many teams do not even get together before a visit to discuss these issues.

NOT ATTENDING TO CREATING A COMMON LANGUAGE

Multidisciplinary design teams often speak different professional languages and have different interests and values. Designers are used to reading plans and thinking in terms of space and materials; healthcare administrators are used to thinking in terms of words and operational plans. Unless a field visit team is conscious about making links between space and operations, there can be little opportunity to establish agreement.

LACK OF AN ACCESSIBLE VISIT REPORT

Most current visits produce no report at all; some produce at least a compilation of handwritten notes. We heard a repeated problem: no one could remember where they saw a given feature.