April 23, 2009

Architects: Listen and learn from your clients

  • Even a project completed on time and under budget is not a success if the staff and patients are unhappy with the results.
    Scherer Associates, Architecture and Planning


    In 1988, I was asked to sit in on a meeting between the nursing staff at a local hospital and the architects from another design team. The project involved the remodel of a patient floor. The work was complete and patients were using the floor, but the nurses that worked there were extremely unhappy with the results.

    The facility’s administration wanted to know what had gone wrong and they were determined to find a way to avoid the situation on future work. It was clear that the staff cared deeply about their patients, their department and what it was like to work there.

    The design team was a nationally recognized firm — they understood health care. They had done dozens of projects just like this one and, ultimately, that turned out to be the root of the problem: This project was no different from ones they had done before, and the staff at this facility wanted a design that responded specifically to their needs and their priorities. There was an almost complete lack of communication between the architects that did the work and the people they were working for.

    That meeting took place many years ago, and since then the industry’s design process has changed for the better. Architects recognize that effective communication with the people that will work in the hospital is critical to the success of any project. Administrators clearly understand that even if a project is on schedule and under budget, it cannot be a success if the staff and patients (our clients) are unhappy with the results. Our clients’ happiness is not always easy to predict and it is less easy to quantify, but if architects are going to succeed in this industry, they need to listen very carefully to what the client has to say.

    Communication tools

    Photos courtesy of Scherer Associates
    A nurse station mock-up (top) designed for Providence Centralia Hospital cost just over $12,000 to build, but is estimated to have saved at least $250,000 in change orders during construction. A structural column was relocated in the final design (bottom).

    There are techniques that help us communicate with our clients, methods that help us understand their needs, and tools that allow our clients to become participants in the design process and to take ownership for the decisions that are made. A brief list of these tools includes:

    • Conducting patient satisfaction surveys and using that information to benchmark design goals. There is a tendency in our industry to forget that we work ultimately for the patient.

    • Arranging to spend several days observing the department. Experiencing it from the patient’s point of view.

    • Establishing a core group of staff members that represent all of the departments involved in the work, not just nursing.

    • Conducting staff surveys to determine what works best for the people that work there and what does not.

    • Taking the core group on field trips to other hospitals with similar projects. Interviewing the staff at each facility to find out what they have to say about the place they work.

    • Assessing existing clinical protocols and operations to identify bottlenecks and inefficiencies within the department. As an example, count the number of times a task is repeated and the number of steps it takes to do so. Use that information as a basis for design recommendations.

    Design workshops

    Carry out design workshops with your core group. Include physicians and nursing staff, pharmacy, social services, materials management, information technology, and housekeeping and security.

    Get everyone in the same room at the same time and encourage participation from everyone there — document their priorities and concerns on a white board or a flip chart. At the end of the session, set time aside so that they can vote on the things that are most important to them. Limit each participant to just a few votes and let them argue and bargain with one another, but make certain that before they leave they commit to a series of priorities. If we give them a chance to take ownership, they will.


    It is difficult for most clients to visualize a design. Sight lines, the movement of materials and the flow of staff and patients are hard to communicate when the means to do so is limited to a floor plan or a rendering.

    Full-scale models, or mock-ups, are a much better way to explain your intentions. Build the mock-ups from modular wall elements, foam core and lots of Velcro. Add as much detail as you can. The more the staff sees, the more they will have to say.

    A mock-up of a nurse station designed for an emergency department at Providence Centralia Hospital was approximately 60 by 40 feet. A local contractor built the walls, located the systems and detailed the components.

    Next, the patient gurneys and medical equipment were rolled in so the staff could “work” in the space to assess its performance.

    We documented everyone’s comments and made photo inventories of what we saw. We counted the steps staff had to take and ended up revising the plan. We assessed sight lines and relocated a structural column. We analyzed patient flow and added a new path.

    An investment

    Admittedly, full-scale models are a relatively expensive design tool, but the return on investment is literally the difference in cost between foam core and steel. The Providence model cost a little over $12,000 to build, but we estimate that it saved between $250,000 and $300,000 during construction.

    Convincing CFOs that modeling a project is worth the expense is relatively simple once they see it as a good investment. A small amount is invested during design to gain a significant return during construction.

    The architects working on that patient floor all those years ago were both right and wrong. They were the design experts. In many ways, they understood the implications of their decisions far better than the nurses that would work there. Their failure was in not balancing their experience in health care design — their “best practice” point of view — with the priorities and expectations of the staff at that facility.

    Architecture is about more than creating spaces. A successful project, particularly a successful health care project, has to go beyond “form follows function.”

    As design professionals, we are responsible for coordinating the project’s schedule and budget, the materials and the details. Ultimately, we must listen carefully to our clients and understand their needs. Once we do, it is our job to create spaces that allow them to care for their patients better than they ever did before.

    John Scherer is the owner at Scherer Associates, Architecture and Planning. The firm works exclusively in the planning and design of health care facilities.


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