All right.

Howdy, howdy, howdy.

How are y'all doing?

Thank you.

So today we have Renee Rich from HCA joining us, Wendy, which is a design researcher and senior associate at VA.

And, she connects the both environment and human outcomes through data driven research.

Without a master of science in statistics and EDA certification.

She specializes in evidence based design, data analysis and strategic problem solving.

And and she tries to transform insights into impactful design solutions that.

Thank you so much for joining us.

So thank you.

So yes.

All right so today I'm talking about combining lean and presence based design approaches to inform and evaluate healthcare facilities.

And a little bit about how we do that.

In particular ADHD.

So doctor, before I gave a little bit of background about me, like she said, I have a master's in statistics.

My undergrad is actually in advertising, and, shortly after I finished my degree, I, worked at HDR as a research analyst.

And then about four years ago, I, became a design researcher at HDR.

So.

And I really appreciated their integration, research and being in practice.

And I'm excited to share about that with you today.

So as I was, digging into the kind of the history of how these two approaches became incorporated both in healthcare and in design, there were some really interesting studies that were done along the way.

So I'm going to give you a little quiz.

And I want to see what you think about when these studies or, building projects happen.

So the first one is a study found that post-operative patients with a view of nature received less pain medication and recovered faster.

And I think tonight with this one.

Any guesses on here.

This happened.

In 1997 okay.

We'll get to that in a minute.

I'm going to go through all of them.

First, focus on patient centered care and using operations research to improve efficiency.

A new hospital implemented single patient rooms, decentralized nursing and healing gardens.

What do you think happened?

About the same 1925 2005 okay, a new hospital was designed with innovative use of air filtration, airborne isolation and climate control to reduce infections.

11,000 11,000 in 2008.

And so we said 2020, 2000 and 2007 and a few of several nursery and maternity unit configurations found that greater proximity between mother and baby reduced infections, increased interactions, and encouraged breastfeeding.

By 17 2015, 1998, 1998 okay, so this first one is, doctor Earl Richards, seminal evidence based design study from 1984.

Second one is 1965 the Greater Baltimore Medical Center project.

This one about use of air filtration and climate control, was 1889 at Johns Hopkins Hospital.

And then lastly a study of maternity industry wards since 1945 at George Washington University Hospital.

So while evidence based design, I'll show you in a minute is relatively new, there are a lot of cases going back quite a ways that these, these methods and interest in incorporating research and lean process into their healthcare projects.

So as I was digging into the literature on these topics, these are the, points at time that people mentioned as being really important to the development, in this case, evidence based design.

So a lot of studies point to Florence Nightingale in the 1850s and 60s and for, interest in how the environment affects patients and then kind of skip over a lot of that that I just talked about, and into really, like the 1970s, 1980s when, the growing momentum around this, this topic and, the center for Health Design was founded in 1993, and the term evidence based design actually wasn't used.

The first time we think it was published was in 2000.

So, really kind of pretty recent zooming into the 1990s to 2000, more dates when either pay attention to the bottom row here where, in 1996, the center's first literature review of evidence based design publications, they found 48 studies, but that increased pretty rapidly.

The last comprehensive literature review was in 2008, and already by then there were more than 1270.

So, pretty, fast adoption and interest in, using research in design and then looking at the lean side again, some people attribute at least the idea of lean process to Henry Ford.

And his use of flow production in 1913.

But then, really the 1950s in Japan, the Toyota Production System was developed, and then, in 1986, six Sigma was introduced at Motorola.

And, those have both been combined many times.

You may have heard of Lean Six Sigma.

We'll talk about that a bit later.

And then kind of zooming in again, you see that lean started being incorporated into healthcare organizations, kind of before design in the early 2000s, it became common to look at the processing and, then started seeing, it incorporated into evidence based design.

What I found first mentioned in the evidence based design literature was 2008 was when read was mentioned, heard again, part of this whole issue focused on lean kind of highlighting it in 2013.

And then there was actually a third issue looking at combined evidence based design in lean in 2017.

But I thought it was really interesting that these two approaches developed kind of simultaneously.

It seems like there was, a need for both of them during the same time frame.

So looking again, kind of zooming out, to a broader time frame and then looking at the 90s to today, you can see a lot of activity happening at the same time that kind of brought us to together in Past and symmetry.

So I'm going to focus on both of those two approaches.

Just introduce some basic concepts of processes, separately and then show how we have brought them together at each.

So you might be familiar with this definition of evidence based design from the center for Health Design.

How they like to talk about it is really focusing on three pieces that it's a process.

It's not a list of design strategies.

It uses credible research to inform decisions and design strategies based on the goals of the project.

And most importantly, the design is linked to achieving outcomes.

So that could be for patients or for family members or for staff.

Many different options.

There.

This is the current, diagram for the evidence based design process that aligns with the phases of design.

So starting from pre design and developing evidence based goals and objectives, and then really looking toward the literature and research sources for relevant evidence and incorporating those into the design process.

From there, developing hypotheses about what we think will happen, based on the design strategies that are chosen and then, monitoring and measuring those outcomes just to show and understand whether there was a difference or an impact.

So like I said, Evidence-Based design is not about rigid rules, but it's it's about the process and using the best evidence that's available.

So Doctor Kirk Hamilton in 2003 had developed these four levels of evidence based design that practitioners can adopt based on their knowledge and comfort levels.

So the first is just to evaluate the evidence and to incorporate it into projects.

The second level is to hypothesize the intended outcomes of design interventions and to measure the results.

Third would be to, report results publicly, and then fourth would be to publish those results in peer reviewed journals and perhaps collaborate with, academic social scientists.

So evidence based design really lends itself to being incorporated on health care projects particularly.

Well, because health care is already, used to looking at outcomes and measuring those results.

And so doctor, Kriegsmarine, created or published this paper on strategies for implementing evidence based design in health care.

And given these ten strategies.

So I just want to focus on a few of these, and I think you'll see a lot of overlap when we start talking about being in Six Sigma and the goals there.

So starting with the problems, identifying the problems that the project is trying to solve and for which the design of the facility plays an important role, gaining a system wide perspective.

So this is really about having an integrated and multidisciplinary approach, getting input from a lot of different people and perspectives and incorporati creating clear decision criteria, taking a broad and disciplined approach to participation and criteria management, and establishing measurable goals.

So having quantitative criteria that's linked to incentives to try to make, improvements in the built environment and, and in terms of outcomes.

Switching over to talk a little bit about Lean and Six Sigma.

Like I mentioned earlier, these are two different approaches.

But and they focus a little bit on different things.

Lean addresses process low and waste where Six Sigma focuses on variation in design.

But these have often come together to create, what's now known as Lean Six Sigma.

With the goals of eliminating non value added activity or what's known as waste reducing variation and optimizing process.

And consistent results.

So a strategic change process to ensure that you fix the right problems and optimize resources.

Lead has these five principles that should be of value.

And so all processes should be evaluated against these principles.

And anything that doesn't qualify as value added needs to be improved is the idea.

So, defining value means looking at what's valuable from the customer's perspective.

So in this case that would be the health care organization and its leaders and what they value.

And what's needed from that organization.

Mapping the value stream means examining all steps of the process because, all the steps influence each other and affect each other.

So they need to function together, to create value.

Creating flow is the process, meaning the process is designed to minimize waste.

Is about that a little bit more in a minute.

Establishing full means that, within a process, each step only produces something if the next step is ready for it.

So, kind of an on demand process is ideal.

And then pursuing perfection is seeking the ideal state, which would mean that all waste is eliminated at all steps of the process process, and, create value for the overall process.

So switching over to Six Sigma for a minute, there's a few different approaches, but one of them is this, it's designed for new processes and there's five steps of this.

The first is defining the project opportunity and goals.

Understanding customer requirements to define specifications.

So you might remember a that was also one of our, key strategies in implementing evidence based design, measure, which is about assessing the needs and specifications analyzed.

Just Six Sigma is really found it in statistics.

So statistically examining options to meet those specifications.

So we get to design, developing the process or product and verify checking that the design, checking the design to ensure the specifications are being met.

So I mentioned that, lean is all about eliminating waste.

And so in health care there's eight types of waste.

And we that we're focusing on in health care, it might look like, these types of outcomes that we want to try to achieve or improve.

So, just generally the targeted outcomes in health care might be, improved patient outcomes, increased efficiency or reduced cost.

And Lean and Six Sigma are highly matched with the health care doctrine because, there's a zero tolerance for mistakes and potential for reducing medical errors and all processes, much less work together.

It requires examination of how people use, move through and located in space.

So that's part all part of the process.

And so the environment is important in understanding that and supporting the process.

So okay.

We take kind of a practice space research approach.

This, diagram and information comes from a paper that was published from two of my colleagues at HDR.

So rather than focusing on basic research, which is really driven by curiosity and, just an interest to expand knowledge for applied research, which focuses on a specific question or a specific project, practice phase three research combines those two.

So looking at both generating new knowledge and also applying that to practice.

This is a diagram that we often use at HCA and illustrates how these methods that I just talked about from both the and of the evidence based design can be used at various stages of the design process.

So what we found a natural affinity between them and also with the design process.

And we've been practicing both of them for, for quite a while when started at HCA, probably like early 2000, maybe even a little bit before that.

And then, we started practicing evidence based design formerly with, one of my former coworkers who kind of started that practice in 2010.

So and one thing I want you to notice on the evidence based design line is that, we we changed the process just a little bit.

We moved collecting baseline performance measures up to earlier in the process than it's mentioned in the, the kind of standard evidence based design know.

We found that doing the, collecting baseline measures in like pre-designed or very early in the process could help with, not only baseline for comparison with post occupancy, but also then that current state can inform a lot of the decisions that are made and help set those goals and objectives.

So you'll see that in the case setting cycle through.

While I was looking at the literature on both of these topics, I found these to, put pieces of articles that, you can see just align almost identically with each other.

The first, about evidence based design, this was written by Doctor Ulrich.

And then, on the right side about lean.

This is written by Doctor Dan Stickler.

And both of them say that these processes should be used, included early in the design process because they affect the decisions about design.

So they affect, like, for instance, the architectural form configurations and interior design.

And as, stickler says, that dramatically affects the amount of space that might be needed.

So, I thought that was really interesting to see that, kind of very similar perspective on both of those.

And integrating these with design, it can be challenging but also very valuable.

So some reasons that practitioners might struggle to integrate evidence based design or even lean into their processes.

Projects tend to move really fast and have deadlines that, there is an awful lot of time to incorporate other aspects.

So that needs to be considered.

There might be a lack of design research understanding, or people just maybe feel more comfortable using their personal experience rather than looking to the literature and research that's been done.

But then looking at the benefits that research can provide and it can improve communication with clients, can improve business prosperity, innovation outcomes, the design quality and also just help to better inform design decisions that are made.

This quote here, by Nick Watkins, who is actually going to be presenting here, I think, in a couple weeks, says that research that disregards design practitioners goals has low impact.

Also research that disregards design impacts, impact on an organization's policy and operations has a low impact.

So very important to kind of look at it holistically and, use research and lean process in a way that supports the project and what it's trying to achieve.

So I'm going to get into a couple, quick case studies just to show how we've done some of these things at HCA and, and get a little bit more specific about the tools.

There's many different tools that can be used throughout evidence based design and lean process.

So I'll just touch on a few of them here.

So the first is, an emergency department expansion.

This was just a pre design process.

It's actually still in design currently.

So this is very recent.

This EDA was experiencing long lengths of stay and 40 patients, they had a strain on their ed because of limited inpatient bed availability.

The team on this is tasked with understanding and solving for the current state EDI issues.

But also integrating with the previous master plan that had been done and accounting for future patient volumes.

This is a, list of everyone that was engaged in the redesign process from the client core team, from the architecture and engineering firm, which was HCA, and the construction firm.

Those are just the, job titles of these people to give you an idea of the diversity of knowledge, experience.

And then we also, on the right side, engaged with a wide variety of executive leaders through an interview process, about 200 staff through a couple engagements, and then also looked at about a year of patient feedback that the organization had collected.

So, really having an integrated and multidisciplinary team to solve this problem and a lot of equals, the very first thing we did in our kickoff meeting actually was, to ask the group that was in there what the vision for this expansion project.

And we asked them, what are the three things that you would defend at all costs?

What are the most important, to you?

And from there, you know, put this project in and values, project vision and values really focusing, like I mentioned on the customer and their, needs and what they think is important to achieve.

We looked at, understanding the current state through several different exercises, and we interviewed those executives to look at any gaps in the current state information that we have and capture, their diverse values and needs.

I'll talk about the demo ops and staff here on the next two slides.

And then I mentioned that we collected, looked at patient feedback.

So those were from, surveys and online reviews and things that the client had curated and looked for things and then, use those to make design recommendations.

So if you're not familiar with the term.

Yeah, but this comes from, in practice and DMA, it was interpreted as, the actual place.

So sometimes we say, go into Gamba or go to what we say, the work.

And that's really going and seeing how things are done, in real time, experiencing the constraints that, happened in the space where it occurs.

So visit and talk to the, the teams there looked at all their spaces with them and had them describe to us what they experienced, where their pain points are.

What aspects of the environment hinder their workflow.

And then we took all of these and analysis, analyzed them, through an eye like I which I wonder format to really understand that for each state.

The staff questionnaire was open to anyone who worked in it, and, we the intention was to gather feedback again about their current state and current environment and understand that from a wide range of occupants.

So the questions focused on experience with workflow and operations, design and layout and safety and well-being.

We also collected existing EDI data to understand and identify their current state issues.

Especially what was constraining their department.

From this, we projected future demands and presented several scenarios for determining spacesuit needs.

Based on those projections.

And then from that, our team had to design a strategy that focused on ideal states and developing those both at the unit and room level.

And, so these prioritized the criteria for decision making.

Like I mentioned earlier, the first one, sure.

At one was had we utilized a priority ranking, approach to looking at program needs and, paper doll exercises to identify different mentally adjacencies and then to further refine the unit planning and the adjacencies.

Through value stream mapping.

We looked at, they had determined a universal route model would fit their needs in terms of flexibility.

So looked at, ID ideation through virtual reality, and then defined their space needs while reviewing testing positive examples.

So from those exercise exercises, we developed plans for both the initial and future phases.

So different options for both.

These here are the ones that ultimately got selected.

And then lastly on this we use A3 documentation.

So this is also a leading decision making tool.

That weighs options against clients priorities and makes in order to make and document decisions for reference throughout the project.

So these often include the background problem, statement analysis, proposed actions and expected results.

So on the left hand side you can see those plans there.

That's kind of an overview of the, space decisions that were made.

And then on the right this is an A3 from our engineering team.

So they also use that to look at infrastructure options.

So another project that we often referred to is Upgrader Hospital, their med surge unit renovation.

This was his first platinum Touchstone Award winner.

If you're familiar with that.

That award process.

What happened here was, they had a unit they were going to renovate, and, the original plan was just to copy and paste the layout of another unit, and the staff actually spoke up and said, you know, we don't think that unit really functions as well as we would like, and we'd like to have some input and look at options to improve that if we're going to renovate this other existing space.

So, this was used as a baseline unit, but it's a 32 bed plan.

And that'll come into play later.

So similar to the other project started, documenting the current state and collecting those baseline measures used a few different approaches.

They did a lot of staff shadowing, so looked at time and motion of nurses where they spent their time, how much time they spent traveling, those kind of things.

Did interviews with patients and staff and also a staff survey and collected acoustic rate readings throughout the unit.

At the same time, again, they were, doing cameras to identify gaps in the current state information and, capturing diverse values and moves from, various staff.

They did this dating exercise, which you can see here.

They talked to a lot of different, departments and looked at their needs on the units, not just those who would be working on the unit on a regular basis.

From this current state, data was analyzed and significant findings were listed as needs.

And the needs were categorized into themes and then formulated into comprehensive data design criteria.

We refer to them, using the long term critical to quality metrics.

Cuz.

And then those from those, higher level needs, those were translated into specific design interventions, design metrics and clinical metrics.

And the project team used this table here as an aid in making decisions and operational changes throughout the project.

Here we're looking at evaluating and applying evidence, which is a key part of evidence based design.

So understanding the outcomes that they were trying to achieve and then understanding what evidence there already has been, for incorporating those, in this case, they were looking at decentralized nursing stations and supply servers and also centralized medication.

Initiate some strategies that were adopted.

It's very important in the process needed to test scenarios and understand how they function and which will achieve the outcomes that, we want to.

So, full patient room mockups for each.

They had three unit prototypes that were identified.

They had mockups for each of those.

And users walked through those and tested based on common patient scenarios and which then they assessed against the acceptable and unacceptable qualities of each room based on the city human metrics.

And then so the final decision was, you might remember I mentioned that original unit was a 32 bed, and they actually changed to a 24 bed unit, that would best meet their programing needs, better operational efficiencies and patient and staff safety.

So and this was ultimately guided, based on performing a bed transfer scenario and evaluating, the city.

Cuz like I mentioned.

By this time we've collected some, benchmark studies and decentralized nursing units and had a good understanding of, that staff, time and motion data and, how that kind of design affected, travel time and distances and things like that.

So, we were able to hypothesize, what we thought the change would be based on the decisions that were made.

So, we thought that there would be less time spent in nurse stations and traveling and more time in the patient rooms.

And then finally, once the unit was room renovated and, the data was collected again, you can see, here in the red on the table.

The ultimate results really did line up very closely to the benchmark studies that were referenced and showed, significant increase in time spent in patient rooms and, decrease in travel time.

There were also, significant improvements in visitor patient satisfaction and staff satisfaction based on surveys that were done.

One unique thing that was some on this project, because of the reporting structure that the had, nurse, leader needed to do, they ended up doing this new shadowing, at various stages after the occupancy of the new unit.

So started very early at three months, which is typically a lot earlier than we would do, like a poll.

But, it identified some challenges with the operations very early on that were they were able to address and give recommendations and adopt into their process.

So, ended up doing a phased data collection at three months, eight months and ten months.

And here with, you can see some diagrams of travel paths, and the distances that the nurses traveled, they were able to reduce that, that time spent traveling throughout, that evaluation period, which was a great success for that project.

This is just another look at that from, frequency of trips to different types of rooms.

Again, you can see at three months those, number of trips that they were making to different areas was a lot higher and was reduced through those cost improvements and learning how to work in this space, more efficiently.

And then lastly, it was very important to show that the design change would lead to financial success for the organization.

Especially going from 32 beds to 24.

That's a big reduction for that unit in the number of patients they could have at one time.

So they needed to make up that or show that they can make that up in some other ways.

So the Pew findings were used to estimate return on investment for the project, which was found to be, estimated at about seven years.

So, for example, they predicted a 6% increase in efficiency, which, would equal about two full time equivalent employees, which translates to about $880,000 annually in, productivity costs.

And then that was, similar across all these different aspects.

And this ultimately became one of their highest performing units in the organization.

And they did really, see a justify the value add of the increased room size that came along with, a reduction in the number of rooms.

So that's what we have for the presentation part of this.

And I'd love to hear your questions and I'll try to get those for you.

Thank you.

Oh, thank you so much.

It was an amazing presentation.

Thank you.

So, yeah, thank you.

So, let's see if students have any questions asked them.

Great.

How are you?

Good.

I just I'm curious if you have any advice for Young Soon on the architecture going into the field and working.

What advice would you give them throughout their careers?

And so, yeah, that's a great question.

I would say just be really curious.

Look at what others have done and learn from that.

And, try to apply in the work that you do.

I'd say also like in, in an architecture firm like ours, we have a lot of diversity and experience and resources and knowledge that people have.

So you engage with others that you work with and, hearing different perspectives and learning from that.

It's really important to go a long way to helping new projects.

Thank you.

Well, I have a question for you.

One of the highlights of this presentation.

Of course, there were many highlights, but one of them was just combining, building framework and evidence based design framework approach and propose your own framework to, basically tackle different issues related to healthcare design.

We talked about evidence based design a lot in healthcare design studios.

So I wanted to ask you to see what were some directly impacts of compliance frameworks when, and the new framework was, actually applied to practice and for healthcare design?

Yeah.

And this was a little bit of a new approach for me to I came more from the evidence based design side of things.

So I'm much more familiar with that.

But, seeing how these, these approaches really come together and complement each other very well.

It has been really interesting looking, more holistically at an organization's needs, both from a design standpoint and spatial standpoint, but also the process each they all work together and they have to, they have to aligned in order to, achieve the outcomes that we want for our clients.

So it's been it's been really interesting to learn more about that design and how that helps with design and also the design process incorporating a lot of those, approaches and theories in practice.

Was there any feedback from the clinicians side on this day, for example, during the sessions, that you had, just the workshops, did they make it and do they make any comments, apply this approach?

Yeah.

So I'm trying to think on this most recent project.

They, they were very, I think they liked the idea that, diverse voices are, are listened to and, taken into account, this process of kind of integrating the two with evidence based design and lead that, that that's even, one inch to some projects.

It was presented at a conference and from there led to some other design projects from organizations who are really interested in incorporating those ideas in maybe are already familiar or integrating lean.

Since that is, practice pretty widely on the healthcare side.

And so, the clients really appreciate, that diverse knowledge as well.

You can hear questions.

I have one more question.

So, you presented the project with, I'm not going to touch the work.

So, as a general, basically a question for especially our group is on students who will soon join the industry.

What is the process of applying for, these awards, basically, how do you put together like where do you start?

Yeah.

So I think for a Touchstone Award, in particular, it's quite the undertaking.

It's, posted through the center for Help Design, and now it's, presented at the DC conference.

And the application is, I want to say probably about 30 questions across three different areas.

They want you to talk about, the education and incorporation of a diverse team in one section.

Another one is evaluate.

So it's, based about on the hypotheses that are developed and the research that's done and the findings from that.

And then the last is, sharing and that's all about taking the knowledge that was seen through that project and sharing it both internally with the team and the organizations and also externally, presenting it at conferences and publishing papers and articles and things like that.

So it is, quite the process to create, these, this application and it's, it's very helpful if you start kind of gathering all this information early in the design process like this.

Emergency department project will probably start, filling out the application this year, even when the design is not complete, because there's so much detail, you you have to list all the different stakeholders that you, incorporated and, the team that was involved and provide a lot of detail that it's hard to go back and curate, many years down the road after the project is completed.

So the client and stakeholders are involved in the process even before the project starts.

It starts to start with, oh yeah.

Absolutely.

Yep.

And some of the questions are about how do you educate your team on evidence based design.

So it's it's important to, think about how you're going to do that and who you're going to include in the process, whether it's from the client organization or the construction team or, consultants that have brought in or the the staff and patients themselves for using this space.

It's very easy for everyone.

Thank you so much.

And yes, I'm sorry.

This is kind of an off topic question that I had, kind of also request that, like my experience in some.

Projects that I've worked on, I have never, yeah.

I have never seen a project in the healthcare industry.

At least I wouldn't say.

Yeah.

Have you seen that in your career and come up.

With leads that you said, oh, with me?

Yeah.

We do have some, projects that are I think a lot of it depends on, the interests and the goals of the client and if that, those sustainability goals are important to them and, and aligned with their values.

There's I'm not I'm only familiar with kind of the evaluation, portion of the.

So I don't know all the technical details, but it's quite a process to undertake and comes with some sort of a cost to.

So it has to be something that the clients will need, what they value.

So I'm important.

Healthcare industry.

Aspect of it's more.

Consultation resources.

Yeah.

I think it just depends on the situation.

I, did some research at, Parkland Hospital in Dallas, and I think they have a gold rating.

I want to say, so that was something that was, undertaken for that project.

And it's a huge hospital, like 900,000 hospital.

Yeah.

So.

Thank you so much.

And it's really interesting because energy consumption is also a big issue.

Yeah, yeah.

Okay.

Any other questions?

Final questions for you.

If not, well, let's, thank, many rich again.

Thank you so.

The references from the presentation.

I think you might have a copy of this.

So, put all those in there.

So you basically find all the sources that you're interested.