Bridging buildings with the businesses that buy them

Rethinking Design Philosophy for Lasting Impact in Healthcare Structures

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Healthcare Design Design Philosophy

When it comes to healthcare structures, our industry engineers want them to last.  We live by volumes of codes and standards and reams of best practices — a vast body of knowledge based upon decades of experience.  The emphasis is quality design and construction with a dash of flexibility.  Standard practice is to work closely with our clients to understand how they work and how they want to work, followed by an intense design and coordination process which incrementally works its way through regulatory review.  At some point bulldozers start to push dirt, millions of dollars of steel reaches up into the heavens and an army of contractors fills in the blanks.  Before you know it, hospital staff starts training in their new facility and eventually patients start to be treated in a newly completed facility.  The designers and builders move on to the next project or may even start to help the client figure out their first remodel (we’ll get back to remodels in a bit). 

Our industry knows the big picture and executes the details of this process like clockwork.  We have codes, standards, committees, and entire educational systems to keep this complex machine moving and the results are consistently impressive.  We practically wallpaper our show rooms and corporate offices with amazing photos of architectural elegance, beautifully finished bed units, and finely-tuned infrastructures.  This artistic form of photographic evidence proves our prowess, our know-how, and the excellence with which we engineer structures and systems to last a lifetime.  We are experts and our clients need us, but I wonder if there is a slight adjustment of perspective that would do us all some good.

Some time ago I pulled one of our senior technology designers aside and asked him a seemingly dumb question, “why is the warranty for communications infrastructure so long — sometimes 20 years?”  He politely communicated a detailed and technical response about warranty structures and the life cycle value to a client (the expression on his face, however, communicated something different and more in line with “how did this imbecile ever get into senior leadership of a consulting and engineering company!”).  His unspoken response was my cue to rephrase the question.

“Okay the hospitals we program and design are built to last 50+ years, right?  During that period of time, our clients will demolish and remodel the interiors of that building numerous times.  Depending upon the ongoing evolution of our client’s business models, some departments will change more frequently than others, but nearly every square foot of interior space will eventually change.  Knowing this, why do we plan and build interiors equipped with systems and infrastructures that have warranties in excess of 20 years when these same systems will likely be dropped down a recycle chute within 10 years?”

Since that first conversation, this idea has evolved into a philosophical approach to technology design that can be simply described as a “Core & Shell to last a lifetime; Tenant Improvements to last a lot less”.  This is not an exclusive approach for us, but it has become one of the many design options that we discuss with our clients.  I admit it, this sort of discussion is heresy in many conference rooms and hallways of the engineering world (not to mention client staff who have been thoroughly indoctrinated that more is better and even more is best). 

In some cases I’ve been confronted by animated engineers who with high-pitched astonishment question my judgment, reputation, and sanity.  In some cases, this approach will prove impractical and in certain industries will not be code compliant (for now).  And in the silo of design and construction it could sound like I’m preaching compromise and shoddy workmanship.  But what I’m really preaching is thinking beyond the building into our clients business.  I’m talking about reconnecting the design and construction business with the qualities of pragmatism, practicality, and long-term owner value.  This industry, after all, is and always was about our clients investing in a complex tool called a building.  It will be the most expensive, complicated, and longest lasting tool they’ll ever invest in.  And it needs to be a physical extension of their business, not just on Day One but throughout its existence.  This reality must drive everything in our project planning, design, and build philosophies.

To help one group of design engineers better understand my agenda, I painted a hypothetical scenario.  If you had a client who wanted to build a high-performance hospital but was planning to demolish it with a wrecking ball in ten years, would you do anything different in your budget planning, design, system configuration, and functional requirements?  The group thought about it and agreed they would do a number of things differently. 

By bridging this hypothetical scenario with the reality of relentless change that will occur within our clients business during the next 50 years, our thinking as a design culture began to shift which in turn began to alter our priorities and perspectives.  This growth is ongoing in my team and our clients are maturing too as we collectively reconsider our expectations of the building.  Our definitions of flexibility and scalability have evolved.  Our perspectives on best practice and industry standards have changed.  Our view of the life and role of buildings has shifted.  Our opinion of Day One requirements and life cycle management has morphed.  And because our design culture is the manifestation of each of these things, it too is radically shifting. 

Was this change due to a shift in engineering capability or a professional self-improvement program — no. Was it caused by a new code version or design conference theme — no.  Did we read a book, hire a consultant, get lean, or discover a new process – no.  Was it because some guy asked a seemingly dumb question?  Of course not.  The change began with a team of bright and motivated designers who took the time to start answering the ‘why are we doing this’ question rather than perpetuate standard operating procedure.  We saw the world changing and knew in our souls that the popular mantras of value-based design, target-value design, back-to-basics, let’s-get-lean, gotta-go-BIM and so many others were often empty platitudes or misplaced emphasis.  The optimism, good will, and marketing lingo sounded great.  But the philosophy behind it all was the same. 

We sought a renewed emphasis on purpose and intent in our planning and design.  The journey has led my team to a new mission that guides us in every project we touch regardless if the team member is in our consulting services group or our engineering services team: 

​Plan and implement solutions that make our clients’ business better; always adhere to purpose-driven design that   makes their business more effective,  more competitive, and less costly throughout its existence.  (If we can’t clearly explain how a particular design approach or technology will enhance or sustain the client’s business capabilities then we need to seriously evaluate its importance.  Empty references to best practice or industry standard are not good enough.)
​This single article is not the forum to give you an exhaustive review of how we are better guiding clients, reconsidering standards, recreating best practices, changing habits, evolving design guidelines, and delivering higher-value projects.  But it is an opportunity to invite you to join us in thoughtfully questioning the status quo, in constantly measuring the validity of own assumptions, in creating a new norm based on realism, and in revitalizing the value each us needs to bring to our clients.

About the Author : 
A breakthrough thinker, Nate revels in the quest to optimize the intersection of sociology and technology within the evolving context of patient care. By understanding where healthcare markets are moving, how people and cultures are perpetually impacted by technical tools, and what techno-social interconnections best support effective and efficient care delivery, he cultivates a culture of practical creativity that is focused on the patient experience and operational excellence.   
Known as a visionary and thought leader in global healthcare technology planning, Nate’s award-winning track record includes more than 50 million square feet of healthcare capital projects, numerous technology concept development and design engagements, hundreds of enterprise planning and design projects, data transport and storage architectures for government, healthcare providers, corporations, and educational institutions.  In addition to his passion for strategy and performance technology solutions, his extensive national and international experience has addressed a wide variety of human experience technologies, immersive technology solutions, business analysis, enterprise architectures, program development, design and implementation of fully converged healthcare-grade enterprise networks, multinational wide area networks, metro-grade campus transmission applications, and mobility planning for corporate and healthcare environments.
Nate lives with his family in San Diego, California and frequently speaks, writes, and consults on a variety of technically-oriented themes.

Nate Larmore
Principal / IT Architecture Practice Leader, Sparling | + posts