Like it is not.

I agree.

We need a lot.

Network overnight shifts of up all hours a day.

And I think that athletes need to become that.

I just need to know what I'm saying.

I'm saying, like you.

Okay, well.

I can start.

All right.

How do you.

How are you all doing today?

Wonderful.

So we have Doctor Ben Bason joining us today.

Doctor medicine is a leader in emergency medicine and health care innovation, serving as a director of the Medici Family Foundation Emergency Critical Care Center AC three and associate professor of emergency medicine at the University of Michigan with deep expertise in critical care.

He has pioneered advancements in emergency department design and patient centric design as a vice president at London Design.

He integrates clinical expertise with innovative design strategies to enhance healthcare delivery and outcomes.

And also recently, he won the Innovator Award of the year at the University of Michigan.

So please help me welcome the best.

One.

Thank you so much.

More importantly, we can't take anything.

So thank you for having me.

It's great.

An awful lot of you.

So I've actually never been in politics.

Quite impressive campus for having me.

Thank you.

Matt.

One of my brand new colleagues.

Doctor Anderson, a few weeks ago, maybe eight months ago.

We've worked together on a lot of things to collaborate.

So I have a very unique role in practicing medicine for 20 plus years, mostly in Michigan.

I do emergency medicine critical care, but I, and I healthcare design great by the last man.

And I work for Canon design, so I'm doing appointment Universe and Industry and so I can design my innovation practice nationally.

So quick disclaimer I'm not an architect back there, so give me grace that an architect.

But I hang around with a bunch of them and I try to sound like them.

But I'm not an architect for sure.

So, couple of disclaimers.

I did found a healthcare design consulting company about eight years ago.

I'm the chief medical officer for a few startups.

I'm a suicide, a clinical care medicine.

I see design guidelines.

We just released, the FGA guideline paper last month with an Anderson.

And then again, I am not an architect, so keep that in mind as I'm talking, and feel free to call me out on things that don't make sense.

So what I want to talk about today is when we talk a lot about an ICU, and I think actually maybe your studio next semester may address some of these things.

So we started the first emergency department based intensive care unit in Michigan ten years ago.

Now it's a decade old.

I've been the director since it opened.

It was the first time in the country it had ever been done.

And so, although I know this semester mostly working on empath and behavioral health units, the goal is really just use an ICU as an example of how you think about changing health care delivery models, both from a design perspective and a care delivery perspective.

And so what's great about you all is you're not jaded like me yet, right?

I've been practicing medicine for 20 years.

And sometimes you forget how to be creative and innovative when you've been doing it a long time because you think about things that don't work and you don't start.

Think of the things that could work.

And so you're in a perfect position to start thinking about how do I get out of this rut of the way things have been done, and how do we do things differently?

So I once spent a long time on this.

When you start thinking about how do we change models of care?

There's a few premises that aren't intuitive to most physicians, for sure, because we're creatures of habit.

We train in a very structured way over many years, and you forget that you can be creative and you can be an inventor at some point.

So part of it is thinking about nontraditional answers to things that are very in a very traditional conservative environment.

Thinking that what I might create might actually become the new foundation, the baseline for tomorrow.

And I think one of those is that, like, I get especially Buchanan and other things, I get pulled in to be a subject matter expert on lots of different things.

And lots of times I tell them, don't think of me as subject matter expert.

Let's think of ourselves as inventors.

What do we need?

Not where we come from.

And some of it is just really being okay with the gray areas and being uncomfortable and knowing that the gray areas are okay and finding comfort in the gray.

In medicine, obviously things are very black and white.

That's how we train.

But it's very hard for us to live in gray areas of ambiguity.

And that's actually where the most creativity and the best solution is coming from.

So I'll just use this emergency care center, essentially, the world's where the country's first edict is just kind of a lean journey, kind of where we came from.

And you may be thinking, you know, you're an elementary school.

And this opened like, why is he talking about ten year old stuff?

I just want to take you on a bit of a journey of at the time.

Why?

This was a bit novel.

How we got to where we are.

And at the end give you kind of a version of a post occupancy analysis of did this actually work?

Did it actually do anything or did it do we intended it to do?

So just a quick roadmap and we don't have a ton of time.

When I get to all of it, that's fine.

Feel free to interrupt me.

Ask questions.

I think that's fine.

Let's.

I'm at the end as well, but I don't mind, being interactive.

I think that's the best way to do it.

So, quick, identify what problem we're trying to solve within this journey.

Now, ten plus years ago, how do we implement S3 into a very complex, big quaternary medical center like the University of Michigan?

And then did it work or not, or was there kind of post occupancy analysis?

So our problem to solve this is where I work half of my career, my career as a canon.

But it's just a really big academic medical center.

It's not very different than a lot of the other giant ones around the country, including here in College Station and certainly in Houston.

So the biggest thing is when you talk to a bunch of people who are really conservative in terms of doing the same thing their whole careers in medicine, you have a new idea and you try to push it into a really risk averse place, like a giant academic medical center.

You probably don't have a lot of face time with the people who make decisions.

And when you do, you got to be able to sell it pretty quick.

So why do you want to do this?

What are you trying to solve and what's it going to do?

What's it going to?

How is it going to help.

So really have to always have an idea of what am I trying to solve.

Why does it matter?

And why is now the right time to try to solve it?

So for us, our North Star was this.

You have to have a guiding principle in North Star or something you measure all your decisions against and say you can have lots of guiding principles, but usually you want one overarching one.

What's your North star that's going to guide you?

And for us, we knew even though a really big, really well resourced health system, probably the biggest hospital in the state of Michigan, we knew that we weren't taking care of our sickest patients in the way we should be taking care of them, because of the way the system was set up and set us up to fail.

So our North Star was, how do we enhance the quality of critical care delivered to our sickest patients in the emergency department in Michigan?

Medicine?

And so don't try to read this.

Is it just an A3?

If you all seen it there, use this as a way to communicate ideas that comes out of automobile manufacturing.

Toyota specifically.

It's just right away.

It's just A3 is just the size of paper it's printed on, but it's really just a way of taking a problem identifying on the left side what the background of it is, what the current state is, what your desired future state is, and then how am I going to implement it, and how am I going to measure my success?

And so it's just a way to communicate an idea as a kind of a living document.

So these are user lots and lean process.

And if you've ever used them before.

So we start the left side.

The background is the why.

Why are we doing this.

Why do we need to change something.

What's our problem to solve.

So in medicine and I realize most probably and in medicine, but these things hopefully will ring true especially in emergency medicine.

We have these very tight time window to change life threatening illnesses that we know make a difference.

So if you're having a cardiac arrest of your heart stops, we have minutes right, to get your heart restarted or else things don't go well and you probably don't live.

So we have I mean, usually ten minutes or less to get your heart restarted or else things don't go well if you're a trauma.

There's something called the golden hour, a trauma.

You've been a bad accident.

The first 60 minutes, the most critical to your survival.

And you surviving your injuries.

If you had a heart attack, which is what a Stemi is, we have 90 minutes from the time your heart, your artery, is blocked in your heart to get that artery re-opened, to get perfusion or blood flow back to your heart.

If you've had a stroke, we have three hours for a clot busting drugs into your brain to open up those arteries and get blood flow back to your brain.

Those these time dependent interventions that we know change mortality and morbidity.

So we're on a really tight time clock to take care of some very discreet things to make people do better.

And then this is just showing that in the first six hours is when we can impact your physiology and your outcome the most.

So when you have one of these life threatening problems, the first six hours are the most critical to your survival.

And where are you in those first six hours?

You're either in that at home or over this accident or something else happened to your stroke happens, your heart attack happened, or your heart stops.

You're in the ambulance or you're in the emergency department.

So in that window is where we have the biggest chance to make an impact.

So how do we develop a system that allows the greatest intervention in that time?

Part of the problem this is all data.

Now this is like 15 years old, but this is the data we had when we started is critical illness in in the United States was doubling over the last previous ten years and was set to double again in the next ten years.

So people are getting sicker, people are living longer with more advanced illnesses and are generally getting sicker, and now they get sicker.

The appointed point, that's okay.

When they are sick and they come to the Ed, they were spending over six hours in the Ed, and that may not seem like a lot of time.

It's a really long time when you have a finite built environment capacity that you can't expand.

Right.

We can never close our front door 24 hours a day.

Patients keep coming and if you can't get people out, then you only have so much space to work with.

And there's lots of data that shows six hours is an inflection point in mortality.

If you're in the Ed and you're critically ill for over six hours, your chance of dying is one and a half times.

Anybody else who's not there for six hours.

So six hours again, it's time to impact your physiology and morbidity.

Mortality.

And there's definitely a risk of death.

So so being Ed if you're super sick for longer than six hours.

So Ed at that time 15 years ago critical care centric universities were growing 10% year over year.

That's a huge amount.

It was about 100 million Ed visits in the year in the US every year.

And at the time spent we are spending, taking care of those critically ill patients is going up almost 25% year over year, because if they can't get out to the ICUs or full, there's nowhere to go.

And we're spending more and more time taking care of those patients.

So that is somewhat unsustainable.

And so that's the concept of boarding.

You guys may have heard of Ed boarding or not.

Boarding is essentially when a patient comes the emergency department, they've been admitted to the hospital to kind of continue their care journey, whether it's the operating room, a floor, a regular room, telemetry reward, an ICU, but there's no bed to go to.

Then they sit in the Ed and they board, so they already have a plan and a place to go, but they can't physically go.

So now they're admitted patient who's sitting in the Ed sometimes for days.

So if you're a boarding that's the concept of boarding or boarding in the Ed.

You're physically to look at an ad for some very long period of time.

Your care drops off because we have to move on to the next patient's.

We already saw you stabilize you.

We talked to the ICU doctors.

They're not assuming care because you're not upstairs yet.

But now we have, like, five more trauma patients coming in.

We have to keep moving.

So your care falls off the slope all of a sudden, and you're super sick and you're not getting the care you need.

So we know when you're boarding and you do, bad things happen.

You're more likely to be on a ventilator for longer.

You're more likely to have organ failure for all your different organs.

You're more likely to have a longer ICU and hospital length of stay, and you're more likely to die in the ICU or in the hospital, right?

So the concept of boarding, it's all over the country.

It's here at College Station.

I promise you, it's in Houston.

I promise you, my friends at work in both places.

And it is a huge problem for Ed boarding.

It certainly is in Ann Arbor as well.

So where is our current state again?

This is 2012 when we first started to think about this.

The unit opened in 2015.

So again, if we start looking down at that current state, where where are we?

So back then we were this is fiscal year 2012.

So again, a long time ago we saw about 1900 patients in the Ed a year that went up going to the intensive care unit from the E.R.

that's about five a day.

And those patients were staying in the Ed at that six hour inflection mark.

The majority of them are staying there over six hours, which, you know, is associated with badness.

And we knew that was going to grow 10% year over year.

We already couldn't manage the patients we have, and we knew more were coming.

And so this is kind of in that first 24 hour period of care, part of that time, you're in the Ed and then if you're really sick, you need to go to the intensive care unit.

So this is where we are really good at taking care of you.

The first two, 3 or 4 hours stabilizing, you figure out what's wrong, restarting your heart, getting your arteries open, getting all kinds of CT scans and consultants and things that happen.

But at some point, somebody else, let's take care of your care.

You should be going to the ICU.

The ICU team should be taking care of you, but there's no beds in the ICU.

So now you're super sick.

The team has kind of moved on, and now you're in this no man's land where nobody's really taking care of you.

What?

You're part of the sickest patient in the hospital because the ICU team can't leave the ICU necessarily, because they're super busy upstairs.

We can't keep taking care of you because we have so many other patients to take care of.

So who's taking care of all your critical care needs when you have these time windows that have to be met or I think it's bad things are going to happen.

This is a long time back then, you know, we weren't built for this.

Like our idea was built in the 80s and it was built to take care of 35,000 patients.

When this happened in 2012, we were taking care of 80,000 patients in the same size, building the same size.

Ed.

And so we're just doing whatever we can.

We're using stools.

We're putting ventilated patients in regular curtained rooms, all kinds of places.

We're never intended for critical care, and we're kind of doing the best we can.

But it was never built for this kind of capacity, throughput or critical illness.

So just in summary, current state 2012, this is kind of where we were.

So ed volumes were going up by 30% around the country, including us.

The population is aging and living longer with sicker and sicker illnesses.

And more complexity and more acute admissions to the ICU.

We're going up 10% over year over year and doubling over a decade.

The hours of time we were spent taking care of really sick patients who are still in the Ed, even though they're admitted to the ICU, which going up by three times Ed and ICU capacity wasn't growing because there's also an intensive shortage.

There's a lack of ICU doctors in the country.

And so there weren't more ICUs that could just be opened up.

And staff, there's nobody to staff them.

And then we know that poor outcomes happen at six hours of Ed boarding.

And that was happening to us, and it was only going to start to grow more and more.

So that's where we were when we started this journey of maybe there's a better way.

Have I established a case to solve some of understand sort of where we come from questions?

Not yet.

Yes.

Yeah.

I guess is architecture as a way to solve some of these issues?

Yeah.

So the question is, what does architecture have to do with any of this?

Yeah.

Okay.

Yeah.

Good question.

Because if not, I came to the wrong place.

So so what's our future state?

How are we going to fix this?

I want it to look like.

So where do we want to go.

So one thing is most big academic medical centers around the country, certainly all the big ones in Houston and here at Scott and White as well, have an ICU for every different type of illness.

This is not true in smaller community hospitals.

They generally have one medical ICU and maybe one surgical ICU.

It takes care of everything.

But the big high specialty hospitals like we are and the hospitals in Houston are Methodist and Memorial Hermann, all the big ones.

We have an ICU for every disease process.

There's a neurological ICU, there's a surgical series, a cardiovascular ICU.

The trauma ICU is a medical ICU.

There's a different ICU for each specialty case.

The problem is patients always come in with a sticker on their head saying, I have a stroke or I have a heart attack, or I'm bleeding.

My organs.

That's our job to figure that out.

And there's not always a bed for the right patient condition in the right place.

And sometimes patients have more than one problem.

So what our goal was to take the silos of care away and break them down in these high level specialty medical centers and say, what if we brought all that care forward to the Ed and created a way that we can create or deliver that ongoing, longitudinal, critical care to whatever patient comes in?

Because we're in the Ed we're used to taking care of, no matter what you have, it's a head bleed, you have a septic shock, you have a GI bleed, your battery failure, you have a car accident, you have a stroke.

Whatever it is, we're used to taking care of that.

We're just not used to doing it for hours and days on end.

So what if we got the capability to do that to the emergency department?

So there is no gap in care.

You get the care you need until you can make it to one of these kind of silos of critical care or ICU.

And so our old state, and this is what most EDS around the country look like.

You come in, either you walk in and you're triaged by the front staff.

The nursing staff.

You might come in by ambulance, either by ground or by helicopter.

You might come in as a transfer.

If you're a big center like we are, like we take patients from around the state that are too sick for their local hospitals.

So however you come in, the only really assets we have or you have regular treatment rooms.

And in Michigan at the time, we had about 70, 75 of them and we had three resuscitation bays, right.

For the sickest patients, trauma bays.

But there's really nothing in between.

And then from the Ed, you go out into the hospital somewhere there you get discharged home, you get admitted to a floor, you go to intensive care unit.

I go to the operating room.

But in a proposed future state, could we create something else in the middle that gives us flexibility, that becomes a bit of a Swiss Army knife to deliver care to a wide range of critically ill patients, that they could get the care they needed without any lapse in their care, and they could still transition to the right place in the hospital, continue to care when the time was right.

So that was our problem to solve.

And kind of our future state strategy is what is this thing in the middle and how could we do that?

So how and how do we do it?

How do we get there?

So this I've learned more and more the more I live in the design world now.

Candidate stuff is people, especially physicians and other people who don't train in architecture and design.

Like you all do, don't recognize good design.

They only know when it doesn't work right.

They recognize bad design, don't frequently recognize good design.

I saw great design when I pulled in the parking garage here today.

I've never seen the lights over the stalls that tells you if it's occupied or not.

That's brilliant.

I've never seen that before and it's so simple and it's such an easy design thing.

I've never seen anywhere and it's so intuitive once you see it.

So I can recognize good design there.

But most people recognize bad design.

Like, how do I know if there's a parking spot?

I'm gonna drive around for an hour trying to find a spot.

So most of us don't recognize good design until it doesn't work.

That's what we recognize.

So I realize I'm talking to a bunch of architecture students about lean design.

I'm probably out of my lane here, but in 2012, this was a big deal at Michigan.

Lean based design only evidence based design had never really been done in our hospital campus before.

So lean LA design when you're trying to create something new that's never been done before and there's no benchmark, it's not like we could go to anywhere Harvard or Houston or Vanderbilt or anywhere.

I'll just say, well, what does your EDC look like?

Because there wasn't one anywhere in the country.

So we had to figure out what are we trying to create, and not in terms of space, but what are we trying to create from a care delivery model.

And so it really is what are the requirements for the customers, which are really the patients.

How do we translate that into a vision, into guiding principles that we're going to measure every decision against?

And then let's start selling thinking up two parallel processes.

One is facility design.

Let's figure out what the built space needs to look like to support that vision.

But it's also how do we figure out what the future state process looks like.

Because really you have to figure out the process, optimize the process, and then build the space around it.

Frequently we do the opposite, right?

We build the future state, and then we're trying to shoehorn our workflows, our patient care, everything else into a suboptimal design.

Future state.

So this idea of lean LED design, I figured out optimize your processes, began your future process, perfect that and then start your design journey.

And only once you figure out the first part and also bring in the nontraditional stakeholders.

So the decision making table.

So usually in hospitals, right.

The decisions are made by the C-suite level, like the high level administrators, the people who control the money and the big decisions.

That's who makes decisions.

But they're not the ones doing the work in most cases.

So if you really want to do Leland design, talk to the people who do the work, including the patients and the families, and have to go through the process, talk to the nurses, talk to their support therapists, talk to the doctors, talk the social workers.

Talk to the people who are involved in the patient care journey of what are the problems in their current workflows.

What should the future state look like to care for this patient population, and what is their ideal future state, and then start building the design around them?

I won't go through all this, but on the left right is traditional design process and on the right is lean facility design or lean driven design process.

Lean is all about I'm not a I'm a. I am a big fan and lean is a dirty word in some places.

But in general it's all about adding value, increasing efficiency, and removing waste.

And so your future state processes should reflect those things.

That's what you're trying to do.

It's about engineering value streams that take all the frontline stakeholders and people experience the process, taking their opinions and moving those forward.

So again, I won't spend much time on this.

This probably looks familiar to many of you.

This is a probably a typical kind of design process that happens.

This is a Michigan kind of what we find ourselves in, which is programing, which you all, I think have been doing with your behavioral health units.

Then you're going to conceptual design.

But a lot of it, this is the lean tools underneath that kind of support those processes to get you to the spots and make it work.

And we only really get into schematic design and design development.

Most of our time is actually spent here.

We spent two years here in this case probably it's never been done before.

So we really had to figure out this before we ever got to a schematic or design development.

So not uncommonly, in traditional design, this gets moved way forward in lean design, especially when designing for a health care model.

It's never been done before.

The green.

The pre design phase is by far the longest part of the phase.

So one thing it's critical to this my team so which was pulled from all walks of life is in the Ed is that people take care of is the clerks physicians nurses rest for therapists physician assistants taking all of them and bringing them to the table saying, when you're taking care of really sick patients, maybe for the next 6 to 8 hours, what are all the problems or the things you don't have?

Not only space, but resources, knowledge, throughput, process?

What are all the things we're missing and what should it look like?

So we sat for two years meeting with all these people at the table, along with the architects, the facility planning department, all the people who are normally part of the design process.

All those people were there, but we also all the frontline workers there helping articulate what their day looks like and where the challenges are.

We also said like, although different down here, right.

But up north we believe bleed maize and blue.

We think we're the greatest of everything.

But we in this case knew like we didn't have it all figured out.

So what could we go look at?

See what other people have done?

We have to reinvent the wheel for everything.

We couldn't go see an ICU because no one had done in the country.

We could see things that might affect our future state workflows.

So we went, I'm not.

I'll be careful.

I'm not supporting any vendors.

I'm not endorsing any vendors or anything else.

In Western Michigan, there's a lot of health care vendors who make supplies, so there's a lot.

Herman Miller is there, sky there?

Still cases.

There's a lot of big vendors in health care are in Western Michigan.

Their headquarters are there, so they weren't far.

So we went to some of these places and we said, show us what you have.

And so they show us a lot of their products.

Guidelines, transit boom, manufacturer.

And we said, show us what you have.

And so they showed us this and we said, this is great, but we have to think of a super sick patients in these resuscitation bays.

And one of our current problems is that when we're taking care of them, they have tons of stuff coming to them, right?

Whether it's machinery, cords and plugs and oxygen tubing and ventilators and defibrillators and all kinds of stuff.

And traditionally and boom systems are had walls.

All that's at the head of the bed, right?

It sits there.

So everything if you're taking care of a patient and you're a nurse on the side, you're physician, you're trying to do procedures, you're stepping over cords underneath hoses, all this stuff to draped over you while you're trying to take care of a patient.

And we said, we need power, data and gas 360 degrees around the patient.

You have to be available at the foot of the patient, the side of the patient, and whatever we need it to be for when we need to be there.

But they had this and we said, well, that's a good start.

Just a swinging our, you know, auxiliary boom.

This is 2012 right.

So little Grace this is 13 years ago technology.

And we said we need better.

So they built this for us.

And we said because we take care of all these patients and we need more.

And so we said this is our guiding principle, this is our workflow.

This is what we're trying to accomplish.

Help us get there.

So this again was form follows function.

Right.

What are we trying to accomplish.

Help us get there.

So they built, you know, a very robust auxiliary room with power data gas 36 degrees are on the patient.

Yeah.

And suction.

We went to another local health care furniture manufacturer, and we said, you know, one of our lean principles was transparency in terms of inventory.

So we could see everything.

You know, what?

People digging through door drawers when someone's really sick, trying to find something like what's behind each thing.

So we want a transparent clear so you can see what's in the cabinet.

You could see what's there even when the doors were closed.

So you're not digging through stuff.

And when people come in really sick, it's a lot of chaos in the room, a lot of tension.

I see what to do is like running around trying to look for stuff.

And you have a lot of people coming down to help take care of patients that are always used to your space.

You're trauma surgeons and ask these allergists about people who don't work in your department all the time, while a sudden want something.

They're like tearing through stuff, trying to find things, and we try to eliminate some of that.

So this cabinet existing, we said, this is great.

This is kind of meets our principle for transparency, for inventory, especially the resuscitation bays.

But the problem is we have limited space.

And these doors, when they open they fold open like this and they block everything next to them.

And there's a wall on that side.

And so there's nowhere for that door to open.

And there's this when this door open to the blocks, the cabinets over here, we can't get into them.

So now the vendor and we said, would you put another panel in there?

So now the doors can fold back along the side of the cabinet, something seemingly simple.

It's not easy to get manufacturers to do something for you specifically have a machine of some brand power.

So that helped.

We said, you know, this is the goal we're trying to meet.

The current form doesn't meet that.

Can you help us develop something?

That's our future form, our future function?

I should say so.

Simple change, but it actually works much better.

Instead of doing a workaround of this cabinet.

This cabinet door's always in my way.

It's always bumping into things and I can't get out of the way.

Why don't we design something that fits our function?

So schematic design.

This is, you know, to see this all.

This is already floor plan layout as it was in 2012.

At the very top there, there's three bigger boxes or four bigger boxes where I resuscitation bays north.

To the north of the very top there's our old pediatric there.

All pediatric ed kind of sat around our resuscitation bays, and the rest was our adult ed.

So this north area in 2011, we built the new children's hospital in Michigan.

And so the pediatric Ed moved over to the children's Hospital.

So this space became available.

And the original thought was, let's just make it more ed treatment rooms.

We need the space.

And then we have this concept for an ICU.

And we said, well, this is kind of perfectly positioned.

These rooms are being vacated.

It's adjacent to the trauma resuscitation base where the most critically ill patients kind of roll in.

It's contiguous.

And we want to have one way flow, meaning you go from resuscitation, you get stabilized, and then you can move into the space where you get your ongoing critical care treatment over those 6 to 12 hours.

So this was kind of the initial schematic design phase.

We said, well, here's I think it's nine rooms, ten rooms.

Some of these be we have like 156ft².

That's pretty big and meets the technical minimum 120ft², some minimum for an EDI treatment room technically meets the minimum, but it's not nearly big enough for the stuff we need to take care of.

Really sick patients.

So this is our initial design from our architect.

They said, well, see what we can do with the space.

And we said, well, we've never done this before.

That might be fine.

And I think a lot of times people would say, all right, well, let's just go to construction documents and make it work.

But we decided at this time we're going to take a pause and we did for the first time ever at our health system, we did full scale mock ups, which had never been done before.

And I know it's very common now.

13 years ago that was not common for us.

So we built full scale mock ups of the space.

And again, these are low fidelity.

It is drywall and studs as opposed to cardboard, but it is low fidelity in terms of just printing things on the wall where things go, we started putting things in the room like ed stretchers and other things that might be in the room.

And we realized for the first time, actually, we're gonna have really sick patients.

They can't sit on an E.T gurney or stretcher for 24 hours.

They're going to be on ICU beds, which are much bigger than 80 stretchers.

So we just made cardboard cutouts which are the same footprint or size as an ICU bed.

We sort of figure out what's it like to work around a patient who's on this size bed.

And then we brought in simulation mannequins and other things to figure out what to like, take care of a patient space.

And we brought all our teams in, including all our end users, rather physicians as our medical director, our interior designers, our architect, our head of operations, that's the project manager, the back from facilities.

And we said, what's it like?

And then he had the drawings, and he's making changes in real time based on feedback.

And we did this for two weeks, bringing every job family through, including like social work, risk management, families, patients and just daily feedback.

Every time of these teams.

And there are simple things like, if we had built the sliding doors the way it was designed, we could not get this bed out of the door with any pumps or ventilator attached to the patient, which many of these patients have.

And that was just never consider that these actually would be ICU beds instead of Gurney.

So we would have built doors are way too small and from day one we would've had to rip them out.

We also realized we're going to intubate a patient, like put a patient on a ventilator.

It's a procedure.

You need to be ahead of the bed and do it.

The room was not deep enough.

We would have to put the patient's feet into the hallway, intubate them, and then pull them back from the hallway into the room.

And so if you're opening a brand new unit, it's not great optics for the first patients for taking care of it.

You're like pushing them in the hallway to take care of them because you didn't build a brand new unit right?

We had a movable barriers.

It is always in the basement of every hospital.

I don't know why, but it is.

So we are stuck with lots of columns which hold up the rest of the hospital.

These are immovable barriers.

So we thought about instead of these being obstructions, how could you use them to facilitate our design?

And so we want to putting monitors on these but med gas on them.

And we had an MRI vault below us which is lead lined.

So you can't really drop any plumbing chases or anything down into it.

But to think, how do you put sinks in here and how do you do those things?

And a lot of things we had to kind of work around.

We had a very simple idea.

Board was just everybody who came through, had to write a comment of what they would do different, what they liked, what they didn't like, what they would change.

And then we collated all those things.

And even if we had no changes, the one thing we learned again years ago was this was a really good idea.

And probably the biggest reason was a good idea.

It was empowering, was empowering the people who do the work, because the people who do the work are not the people, usually making the decisions of most of the health systems, people in the C-suite, they're sitting on top making the decisions are not at the bedside.

So this gay people ownership over the space they were in a work in that they had a part in designing the space they had a part.

And somebody listen to what they struggle with every day to give good patient care.

And actually design changed because of their feedback.

So built morale, a bit ownership and empowered our teams and loyalty to be honest.

And ultimately from the architecture side, for the first time in a long time, it led to no significant change orders after construction that came in under budget, ahead of schedule.

Not every project does.

Most projects don't.

I realize that, but had we not done this, we would have massive, expensive change orders like ripping out doors and walls.

It would have been way over budget and we're taking way longer.

So this is a concept of going slow to go fast.

But the hospital didn't like this whole process.

They'd never done it before.

We need to pull people out of work for two weeks to come to the space and get feedback that's not paying the hospital's bills.

Surgeons operating us as taking care of patients, nurses taking care of patients.

That's what pays the hospital bills.

Not walking through mock ups space so that hospital doesn't necessary always like this process because it's taking people away from their primary job.

However, two weeks of going slow allowed us to go way faster at the end by building a design that made sense and could drive and deliver care in a way that made sense.

So this is our initial design.

After all those changes.

This is our final design.

It may not look much different.

We actually took two rooms away to make bigger rooms.

The staff station moved down.

There's direct access from one to the other.

And the design actually changed quite a bit.

So this opened ten years ago, just over ten years ago.

Now it's the first in the country.

There's a bunch of lean design features that were incorporated, and I'm probably running out of time.

Roxana.

Right.

So, okay, I'll get to a couple more things.

This is our old resuscitation space, so just three curtained open bays.

If you're really sick.

It's cold in Michigan.

Unlike here.

Our ambulance bay is basically where you guys are sitting.

So the ambulance bay doors open six months out the year, it's really cold.

So if you're super sick, it's like Arctic air just blows into the station space where it is.

The Cat scanner is right here.

So every patient needs a Cat scan, which is about 60% of our patients getting wheeled by these resuscitation bay bays to get into the Cat scanner.

There's no infection control.

There's no noise control.

There's no light control.

You're super sick.

You're under these bright fluorescent lights.

You can hear everything.

Some patients are dying.

You're trying to have end of life conversations with the patient or their family.

And you're in this curtain space with no privacy, no anything, and there's really no where it's not optimal to take care of patients.

This is also what the Bay looked like after 20 years of equipment just piling up and getting pushed to the back.

It has booms, actually, but they didn't move any more because they're so heavy and weighed down by garbage that we didn't use anymore.

That got pushed to the back or things you might need once a year.

It was like sitting in the back under a bunch of cobwebs and you had to, like, try to pull it out when you really needed it.

So this is all suboptimal design that naturally happens over time.

But then it turned into this, which is stored resuscitation bays.

This is our biggest ones, about 280ft².

And it has a few features intentionally, which is we told you like the North unit or the EC3, the ICU is now behind.

So now it's one way flow from resuscitation Bay in to the ICU, where you get your initial stabilization here, and then you go in to get your ongoing critical care delivery without having to go all over the place and all over the hospital.

We put cameras in because we knew we'd have to do kind of quality assurance and teaching continuous quality improvement.

We put video displays, so it's not uncommon with somebody really sick.

You're doing something like intubating and putting on a ventilator.

You might be doing an ultrasound or maybe an X at the bedside, but only one person can see it because I'm on little screen on the machine.

When you have a whole room of people who need to know that information to make decisions, that was a limitation for us.

So in the future design, we made it.

So screens around the room could broadcast those images.

So everybody that was a decision maker in their care was a trauma surgeon.

Me and geologist, whoever it was could see the same information and have the same data to work off of, as opposed to whoever could be by the screen.

Silly little things, like there's only room in our resuscitation base for one nurse to chart on the patient.

So if I wanted to look up medicines or as a patient on blood thinners or what's their history, I, as a physician had to leave the room, go across the hall, the computer, put orders in to look at stuff, figure out their history.

Our patients always come in with their whole record.

Sometimes they come in unresponsive.

We don't know anything about them.

So I had to leave the bedside to go do that.

So as simple things have, like for the future, why don't we just make it so the physicians can stay at the bedside to take care of the patient and get information?

This this was a renovation project, not a new build.

So we had to keep that eight foot corridor clearance.

But we had all these new carts because all these critical care supplies we needed.

So how are we going to do that?

So we decided to take transitional height counters, lift them up and put the carts underneath the counter.

That's a created a touch down space for the nurses coming out of room with their hands full of blood tubes and I.V.

supplies.

All kinds of things.

I touched on space to put things down and do work, but also keep our carts out of the corridor and maintain that eight foot clearance.

Simple things like, again, most rooms have all the stuff at the head of the bed.

And, you know, most of our big procedures are done at the head of the bed.

And you can't get in there because you're stepping over ventilator hoses, tubing options, suction, all these things.

The one thing is we want to clear the head of the bed from all these cords and plugs and keep it all to the sides.

And then this was the only place in the EU to have ambient light, which turns out when you're really sick and you're gonna stay for, you know, six hours, 12 hours a day or two.

Sometimes natural light is really good for delirium and for your, circadian rhythm.

So I want to take advantage of that.

Kept the head of the bed clear.

We put lifts in.

I didn't even think about that again, because I'm a physician, I do a lot of work, but I and I work closely with the nurses, but I don't do their job specifically, so I don't even think about it.

They're like, these patients are comatose.

Lots of times they're on a ventilator or unconscious.

They can't move themselves.

So I'm they're very large.

It breaks our backs every day trying to move these patients who can't move themselves.

We need to listen.

And the initial design had no accommodation for steel in the ceiling or reinforcements or or for lifts.

But after the mock ups and the feedback from nursing, it became clear this is an this is a necessity.

But I would have never thought of that because I don't do that work.

I'm sure the CFO of the hospital never thought about and put dialysis boxes in, which is usually only upstairs in inpatient units and dialysis units.

We put them in because these patients are going to dialysis, and nobody ever really thought of that before.

And then this is ten years before Covid, but we realized critically ill patients.

This is times of kind of Ebola.

SARS mirrors a lot of other kind of epidemics that came through H1n1.

Nothing like Covid ever was.

We built negative pressure and thinking, these are sick patients.

We don't know what the rest of our illness are going to be.

We should put negative pressure into this space.

We also we're teaching hospital, but in the Ed we don't always have time to like leave our shift and go teach.

We teach on shifts.

We can't.

I go to a conference room and do a whole presentation.

Sometimes.

So we put digital whiteboards, the patient monitors into the resuscitation bays.

So if there wasn't a patient resuscitation bay, we would just for five minutes pull in physicians, nurses, medical students, nursing students.

And we do a quick kind of presentation.

They're all sitting on the resuscitation stretcher because we just had to think of how do we teach and deliver care in the same space, because we don't have the luxury of leaving to go do some of that work.

And then those are those booms you thought about.

And then we also created between the five resuscitation bays.

We created glass doors between them.

So if we have a mass casualty incident and 50 patients show up, we can create one giant patient care space where we can take care of lots of people at once.

But we need to.

All right.

I'm going to skip ahead for sake of time.

So I know you guys are busy.

This is just that.

Cabinet in in place.

But this was our old pediatric dead space, so.

No offense, but heavy on the millwork, right?

Very heavy on fixed monuments and things were built in the 80s, for sure.

And then this same room was turned into this, which the only thing attached to the wall really is the sink, because we knew now.

And you get, you know, you get one chance to do this for 25, 30, 35 years.

This building, this renovation, that's how long it's gonna last for.

And so when you do, you want to do it right.

And I have no idea what medical care, critical care is gonna look like 15, 20 years from now.

So we wanted to build intentionally flexible space where the room can be completely reconfigured whenever it needs to be, for a type of patient that might come in that we're not prepared to care for in today's environment.

So we tried to futureproof it by limiting any sort of fixed monuments and casework, and everything is on.

We'll all right.

I'm running out of time.

I'm going to go to one last slide and skip through.

I just don't get to the.

The did it work?

So this is ten years later.

This is data from probably last month in S3.

Now I've taken care of 20,000 plus patients over the last ten years, 58% of the patients no longer need an ICU bed.

When we're done with them.

It's a big win for the hospital, right?

We have.

I was already way over capacity.

Not enough doctors and staff and not enough nurses.

We have an unsustainable demand for those beds, and now we've taken 60% of those patients that come through the Ed and no longer need ICU beds, 30% still will.

But now we frontload that care.

There's no drop off at six hours.

They get continuous, high quality critical care from the minute they hit our door, and it never stops until they go upstairs to the ICU.

8% 1600 patients go home from the ICU and never require admission at all.

We make them better quickly and they can actually go home and they don't need a hospital bed at any time.

And 2% will actually it will expire, passed away.

And you see, three in most of those patients are patients that I was kind of predicted in terms of a very advanced illness, and they come in at the end of their life, but we're able to take care of them in that space.

So they and their family are not shuttled throughout the hospital the last 24 hours of their life, which actually has a win.

So I'll finish with this.

So in health care, the value equation is quality divided by cost, right.

If you have unlimited money, if you have billions and billions of dollars, you can engineer quality.

You can make quality if you have enough money and resources to do it.

The question is can you engineer quality at a cost that makes sense?

That's value.

So we publishers, a few years after we open, this was three years before EC3 open February 15th, and this is three years after.

Clearly there's a dip when it S3 opens and not only is there a dip, but it's maintained and that's mortality.

So 13% lower mortality at 30 days, 13% less people die at 30 days because S3 exists and ICU utilization is down about 16%.

So 16% less ICU beds are needed in the hospital.

Because S3 exists.

I don't go through all this stuff.

So those are the two big wins from a quality perspective.

That being said, we publish on all kinds of stuff.

Nobody ever published on this in the field that never been done before.

We publish tons of papers about what's the impact of an e-bike model on patient care across all different disease states.

We kept publishing and publishing, and now we're the single biggest publisher in the space of anywhere in the world.

And what did we learn?

So we learned 30 day mortality is lower.

Three lives are saved for every 1000 patients that come to the Ed.

That equates about 220 people over the course of a year are alive now because S3 exists or otherwise be dead.

So that's a lot of lives to save.

We have less 24 hour admissions to the hospital, meaning patients who go to the ICU for less than 24 hours and then don't need that space anymore.

There's nowhere to go from.

So it's not really a use of really coveted ICU space.

I'm going to skip through some of these because time, just trust me, there's a lot of quality information and outcomes will be published that show benefit from the S3 model.

Lots of things.

This is all of that.

My one slide, all the things that S3 has provided from a quality improvement.

This is quality is better, but that doesn't mean value's better.

You have to be able to do it at a cost that places can afford to do.

So that's why we publish this paper on quality is better from the icMl first paper ever published in the world, and then it was followed with a rebuttal from other physicians who said, yeah, you made great quality improvements, but at what cost?

So we had to figure out the cost piece.

And so we published this paper in 2022.

You have to look at all of it.

But it basically it said we can provide this care with no change in cost.

Cost is flat.

So.

If quality is improved cost is flat then value goes up.

So we kind of solve the value equation that this model actually does provide care.

And we kind of took two separate historical specialties emergency medicine critical care.

And we kind of created a new specialty emergency critical care.

And then created a place to deliver that care.

So in summary, this was our North Star, right?

I told you at the beginning this was what we were shooting for, what our goal was to accomplish.

I think we got there.

I think we're still getting there.

We're still tweaking.

Ten years later, we're still making changes and tweaking and haven't hit it out of the park.

But in reality, what it's done is it really changed the way health care is delivered for critically ill patients who show up to the Ed.

I think that's evidenced by these are all the places in the world we worked with to kind of either talk about the model, how great the model.

So I think it's really taken off in the last ten years as a feasible model, a way to change the way health care is delivered.

If you'll give me the grace, I'd love to include you all right there and add to the slide, because you've been here now.

And then in 2060, the year after we opened, this was, acknowledged as one of the, innovations of the year in emergency care in the country.

So I talk a lot, I talk fast, not a ton of time.

The goal was taken idea of how to solve a health care delivery problem and then implement it and then measure the outcomes.

We don't do enough post occupancy analyzes in architecture.

I don't think we do great design.

And we I'm not the architect, I realize, but I work for a big firm that does a lot of really cool work.

We do great design, we implement great stuff, and we don't always know if you meet the marks didn't meet the metric in do we accomplish what we set out to accomplish?

So I think post-acquisition analyzes are underutilized and probably very valuable.

We kind of have at now a ten year post occupancy analysis of the work we've done.

So I realize where at time I'll finish there.

I think I'm going to studio with you so we can ask more questions there too.

Sorry I talk so much, but it's a lot to cover.

Thank you so much.

What an impressive project.

And then other papers that you published based on this, topic and also, the outcomes, of course, on the outcomes is just absolutely fascinating.

So we have time for one or maybe two questions.

For questions.

It's perfect.

And, and some pieces of the project though, so, you know, my question is that you have done a lot of work for the lean B side, you know, a process.

So, since 2015, a lot of things happen as well, you know, in the past ten.

Yes, especially Covid.

I heard a lot of things, you know, Covid, during the Covid time.

And the lean design may not work as expected.

Have you experienced the same thing?

What what could be done better, you know, to handle emergency situations like that, like, you know, the pandemic, like a lot of other things?

Yeah, I think I think it's a good question.

I think one thing that is a hallmark of lean design, that has held true and even kind of advanced more, is the fact that people who do the work had to come up with the solutions.

Right.

And that was very evident during Covid, is that people who are traditionally innovators or decision makers had to innovate.

So you had I mean, probably seen this, right.

But, you know, putting holes in walls to to string I.V.

tubing from the ICU outside because a ventilator could be in the room and we didn't have PPE, we don't have a vaccine for the first year.

And so, you know, you don't want to go in and out of the rooms of patients with Covid, so you're treating them from outside the room.

We had to figure out how do you communicate with people who are dying when you can't have their family members visit them?

We didn't have enough negative pressure, right?

Negative pressure is a fixed commodity or fixed capacity.

It's very expensive.

So we learned how do we convert ICU rooms into negative pressure rooms?

By blowing up the wall and putting Hvac filters in the wall to do it at scale.

And so we had to learn how to.

How do you share a ventilator?

A ventilator was never designed for more than one person.

And in New York City and other places, we had to figure out how do two people use one ventilator who's not enough?

And so we had a lot of innovation that was done by people doing the work who weren't traditional decision makers.

And so I think that was a win from a lean design perspective, is the people doing the work.

We're able to engineer solutions that provided better patient care.

That being said, we didn't have the runway.

We didn't have the length of time to do some traditional innovation work.

We want to do, in order to get things to the bedside.

I think, you know, lean design, certainly not perfect, but I think Covid as like contrary response to your question is Covid did teach us that innovation can be done by people who do the work and probably should be done by the people who do the work.

It's just you have to move the barriers out of the way.

The FDA, you know, during Covid, it all kind of folded intentionally and became emergency use authorization.

So innovation that was take in ten years to get the bedside got to the bedside in a few months because all the regulatory steps were somewhat bypassed.

So degree.

And so it just shows what's possible when you can kind of navigator, you see a problem.

And that's why I think mock ups are so great, because mock ups allow you to really see the space and how people work through the space that are going to do the work, and it might be something as simple as, like, I take this and I move it here, but there's nowhere for me to put it, or when I move here, there's a something in the way.

And it's so simple things that when you design them and you build them, and then the day it opens and people do their work like this doesn't work, and I have to create a workaround.

I do create an inefficient way to do my job.

But the design, the built environment is prohibiting me from doing so.

The built environment should always enhance the work in the care delivery.

It should never inhibit or hinder it.

That's why I think mock ups are such a big win and should be done.

And we're.

Roxann, I were talking earlier at lunch.

A lot of our can now obviously be done by AI and other things, which is advancing the time it takes to actually analyze the feedback and those things and bring it forward is really exciting time.

As opposed to manually charting everything and video reviews and those things.

But that mock up work and this kind of work at bringing people to bedside to actually give feedback is invaluable.

If I had the choice, I would never do another project without it.

The problem is you have to convince the stakeholders, which again, a lot of people don't want to, who are paying the bills, don't want to pause things for weeks or months to do this work, that they may not see the value out on the front end, the value adds on, not on the back end.

You're going to end up saving millions of dollars.

Time efficiency, and potentially lives by doing that work upfront.

But people do want to start projects that do that, and there's deadlines and there's budget to get it through.

So it is a it is a cost analysis decision, but it's one that every time I've seen it made for the right reasons, it leads to better outcomes on the back end.

Of so okay, okay.

Next question.

I'm just curious not specifically in this project alone, but sitting down at the round table with the design team.

And you know, round table full of practitioners and architects.

Is there any kind of disconnect that we've seen between the two different groups of people and going into the pre-planning of planning phases that you recognized in your experience in the field moving forward?

How do you feel the disconnects can be moved beyond create more efficient work in the design field?

Yeah, I mean, the biggest thing is that they speak two totally different languages, right?

The world of design and architecture does not speak the same language as medicine and vice versa.

And so like the physicians who want to and this is what I've been doing for ten years of my career, I've been a translator.

Again, I'm not an architect, but I have a field, you know, one foot in industry and one foot in academia.

I practice medicine.

And so part of the value proposition for not, let's say, me, but somebody like me is that we help translate not that brilliant architects who are sitting here in the room don't have amazing ideas, and they know what should happen.

But sometimes they can't get the clinicians to understand how to make that happen.

And sometimes the clinicians can't articulate their vision, from a design standpoint, what they think should happen or they they know where they want to get to.

They have no idea how to get there.

And it's the architecture designers jobs that help them get there.

So I think the biggest thing is that we train in such a, you know, medicine's a completely different language, right?

And if you don't speak that language, sometimes it's hard to interpret and vice versa.

You know, I don't know how many clinicians I know that can't look at a 2D drawing and understand what that means.

Like so many people I work with who are making the decisions right about what's going to be built ultimately, and they may be the ultimate decision maker, the clinical stakeholder.

And they're looking at it and they cannot conceptualize what they're looking at.

They have no idea what that looks like in real space, what that's going to mean for their daily work, what their operating room is going to look like.

I feel like when they're in it.

This is also why mock ups are important, obviously with digital tools and things, that's changing a lot.

Now.

But the biggest thing is that there's such a disconnect and you need translators that can they it might be the same people, but you need somebody who can speak both languages and translate the visions of both disciplines.

And so the ultimate outcome, which is sometimes challenging.

One.

Well that helps.

I think that's it.

But I also think it's, you know, there's a difference when you see, like, you have a senior architect who is in health care for 30 years and they're in the room as opposed to somebody who hasn't really done many health care projects, they can get the clinical stakeholders to get to where they want them to get to, because they can speak the language, they have enough experience, know what doesn't work and what does work.

And they know what the barriers are going to be.

But sometimes we don't know what the barriers are going to be down the road.

Like we can come up with all kinds of crazy ideas, you know, like, this will never happen in budget.

You can't do that because of X, Y or Z.

It doesn't meet FDI or code requirements.

You can't do these things.

And like, you know, as a clinician, we don't know that.

And so some of it is just trying to kind of be ahead of the game and saying, this is again, that's why you have to have vision and guiding principles.

If you get to like where are we trying to get to?

And then us as designers will figure out how to get you there or as close as we can, because I think that's part of the problem is, you know, so I get at a space and be like, oh, you can put eight, eight rooms in this space based on square footage, like, well, is that the right answer?

I don't know, but what are you trying to accomplish?

And let's figure out what the best way to get there is.

And I think that's the piece.

Sometimes we're missing.