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INTANGIBLES: Design Quality Standards that Bring Hospitals to Life
Tye Farrow, Senior Partner
Sharon VanderKaay, Director Knowledge Development
Farrow Partnership Architects, Toronto, Canada
For over twenty-five years, the terms “patient-focused care” and “healing environment” have been in common use by hospital administrators and health care design professionals. Despite well-intentioned efforts to provide psychosocially supportive settings, we continue to see spaces that demonstrate little empathy for the vulnerable state of patients, family and staff.1
Canadian architecture critic Lisa Rochon has described the majority of hospital environments as “factories built to contain the ill.” She continues, “Sadly, for the most part, inspired hospital design is wishful thinking.” 2
While there are rigorous technical construction codes that dictate requirements for fire and life safety, no code protects the public from exposure to austere health care infrastructure. To avoid the risk of building hospitals that function merely to process sick people, decision makers must confront the inherent challenges of defining, monitoring and implementing intangibles.
For example, the intangible design qualities of a hospital influence its position on the Asset-Liability Pyramid (Figure 1). In contrast to technical standards, design standards cannot be validated by means of traditional scientific methodologies. However, if such barriers to working with intangibles are viewed as insurmountable, it will be difficult to make a convincing case in support of economically vibrant health care assets.
Generic and vague statements such as “patient-centered” or “re-thinking the 21st century hospital” may represent the sincere aspirations of decision makers; however, these phrases are inadequate when creating meaningful, location-specific design quality standards.
DESIRE v REALITY
The research presented in this paper set out to examine the nature of gaps that frequently occur between espoused desires to create a “healing environment” and the built reality of these spaces. This research began broadly by reflecting on over ten years of conscious experimentation in the field with client stakeholder groups. Six questions were raised at this early stage:
1. Why is there frequently a gap between espoused aspirations and physical reality?
2. Can one assume that improved design quality standards will inevitably result in truly therapeutic hospital environments?
3. Are decision makers capable of discerning the difference between facilities that are merely new in contrast to facilities that address complex psychosocial issues?
4. What motivates administrators and politicians to take a strong advocacy role in achieving optimal human-centric design?
5. What motivates apathetic or hostile decision makers to become strong advocates for improved design standards?
6. Can we assume that the causal connections between intangibles (e.g., design that conveys a meaningful identity and makes an emotional connection) and tangible outcomes (e.g., attract staff and major donors) are apparent to decision makers?
2. Can one assume that improved design quality standards will inevitably result in truly therapeutic hospital environments?
3. Are decision makers capable of discerning the difference between facilities that are merely new in contrast to facilities that address complex psychosocial issues?
4. What motivates administrators and politicians to take a strong advocacy role in achieving optimal human-centric design?
5. What motivates apathetic or hostile decision makers to become strong advocates for improved design standards?
6. Can we assume that the causal connections between intangibles (e.g., design that conveys a meaningful identity and makes an emotional connection) and tangible outcomes (e.g., attract staff and major donors) are apparent to decision makers?
Several preliminary hypotheses for further study were identified as possible responses to questions 1-6 above. All of the themes that emerged from this early stage of inquiry were related to an inconsistency between espoused values and built reality. Explanations for this discrepancy that appeared worthy of further investigation included:
- Lack of rigor in defining what constitutes a therapeutic health care environment
- Believing that intangibles are too abstract to meaningfully define and monitor
- Failure to assist decision makers in connecting intangibles to tangible outcomes
- Expecting stakeholders to appreciate and support imposed standards
- Underestimating the hidden potential of even the most vocal naysayers to become enthusiastic advocates for quality design standards
The model was evaluated by Angus Reid Strategies in their research report, “Evaluating the Farrow Model of the Design Standards Creation Process,” dated May 27, 2009. For this study, Angus Reid collected qualitative survey data from six community hospital client representatives using a combination of closed and open-ended questions.3
BACKGROUND
The specific design quality standards procedures and tools evaluated by this qualitative research project were developed over a ten year period through a process of discovery, inquiry and reflection. In addition to field observation and experimentation, the procedure and tools were informed by literature research regarding 1) the nature of intangibles,4 and 2) adult learning principles.5
Listed below are qualities and characteristics that have been identified by experts 4, 5 as inherent to intangibles, and on which the design quality standards process and tools in this study are based:
1. Intangibles are a pre-condition for tangible benefits
2. The connection between intangibles and tangibles is not always obvious
3. Intangibles are typically valued at zero by accountants who avoid assigning rough numbers
4. Intangibles are susceptible to being dismissed by decision makers who believe only what can be counted counts
5. A first-hand hospital stay can suddenly change the mind of decision makers who believe that only what can be counted counts
2. The connection between intangibles and tangibles is not always obvious
3. Intangibles are typically valued at zero by accountants who avoid assigning rough numbers
4. Intangibles are susceptible to being dismissed by decision makers who believe only what can be counted counts
5. A first-hand hospital stay can suddenly change the mind of decision makers who believe that only what can be counted counts
The design quality standards model as defined in this study draws on adult learning theory. In the ten year development of this methodology it was hypothesized that stakeholders require a learning process to effectively implement effective standards, rather than a selling (commonly referred to as a “buy in”) process. Listed below are the adult learning principles6 that were applied to the quality standards creation and implementation process that is the subject of this study:
1. Adults learn best when they perceive a gap between what they know and what they need to know (i.e., imposed, highly ambitious standards may be rejected out of hand) or gaps between what is and what can be (i.e., “let’s examine a range of so-called “healing environments” to learn what is possible and the extent of any gaps”).
2. Adults learn best when they engage in a dialogue and inquiry process rather than through a lecture or one-way presentation (i.e., a process based on shared inquiry and discovery rather than the traditional buy-in model).
3. Adults learn best when the subject makes an emotional connection (i.e., pre-determined quality standards, however rigorous, may be regarded by stakeholders with indifference unless these standards gain personal significance).
4. Adults learn best when they are provided the context to make their own cause and effect connections (some links between intangibles and value creation are not always obvious; these links can be identified through dialogue between stakeholders and designers).
5. Adults learn best when they have opportunities for personal revelations, also known as the “a-ha moment” or a personal epiphany.
METHOD 2. Adults learn best when they engage in a dialogue and inquiry process rather than through a lecture or one-way presentation (i.e., a process based on shared inquiry and discovery rather than the traditional buy-in model).
3. Adults learn best when the subject makes an emotional connection (i.e., pre-determined quality standards, however rigorous, may be regarded by stakeholders with indifference unless these standards gain personal significance).
4. Adults learn best when they are provided the context to make their own cause and effect connections (some links between intangibles and value creation are not always obvious; these links can be identified through dialogue between stakeholders and designers).
5. Adults learn best when they have opportunities for personal revelations, also known as the “a-ha moment” or a personal epiphany.
For this research project, Angus Reid Strategies conducted semi-structured interviews consisting of approximately 30 standard questions with six key client representatives who had participated in a variation of the standards creation model described below. Participants were asked to assess the effectiveness of this process in designing a human-centric health care environment using a four-level Likert scale. Respondents were encouraged to make comments above and beyond the survey questions while being assured that all of their responses would remain anonymous. The survey aimed to test the process against four objectives:
1. To help you check your assumptions regarding what people expect
2. To help you identify potential roadblocks and how they might be circumvented
3. To translate your vision and values statements in to actual physical space
4. To give you a sense that this is something we are all in together.
The standards process and tools creation model that was the subject of this qualitative assessment consisted of these steps: 2. To help you identify potential roadblocks and how they might be circumvented
3. To translate your vision and values statements in to actual physical space
4. To give you a sense that this is something we are all in together.
Prepare stakeholders
Prepare stakeholders to participate in a facilitated dialogue session (which came to be known approximately four years ago as Common Ground) that has defined boundaries and outcomes, rather than a traditional meeting governed by an agenda, or a presentation and questions format. In contrast to being issued a rigid agenda prior to the session, invitees received a “Purpose, Principles and Expectations” document that briefly described the dialogue process, listed sample questions they could think about ahead of time, and defined anticipated outcomes for the session.
Engage in dailogue sessions
Engage stakeholders in learning process-based facilitated dialogue sessions. These sessions were eventually branded as Common Ground, Critical Eye, and Scenarios for the Future in order to set them apart as a reliable, repeatable set of workshops with defined tangible and intangible outcomes. The gap assessment tool that emerged from these sessions was known as the Facilities Balanced Scorecard.
Reflect on roles
Ask stakeholders to reflect on their role representing countless other citizens in the community for potentially generations into the future. This step helps participants think beyond their official title to their role as a communicator who assists others in learning about project priorities and challenges on an everyday basis. As well, this step highlights participants’ legacy and their shared responsibility for a successful project, rather than soliciting buy-in to pre-packaged quality standards.
Analyze local aspirational phrases
Jointly analyze locally-used phrases such as “patient-focused care,” including selected terms from the organization’s vision and values statements, for example, “healthy communities.”
During the dialogue sessions, examine what these terms mean to the specific stakeholders in the workshop. For example, must “patient-focused care” overshadow “staff-focused care”? Can a health and human-focused environment fulfill the needs of all?
This step recognizes that stakeholders typically have limited experience in evaluating intangibles such as “instilling confidence” and “conveying a strong identity.” The dialogue process gives participants an opportunity to become more constructively critical of vague design objectives. (See Figure 5: A new model for working with intangibles.)
While some design quality standards can be applied universally, such as “Our hospital conveys the message ‘you are in good hands,’” there are individual historically and culturally meaningful priorities that contribute to creating positive emotional connections. A generic “anywhere” hospital may be sufficient for functioning at the bottom of The Hospital Asset-Liability Pyramid shown in Figure 1; however, a sense of individual identity is a key component of the value creation model.
Examine tangibles and intangibles
Jointly examine the connection between tangibles and intangibles. Through the dialogue process, make the hidden (or less obvious) links between design and design outcomes more recognizable. This step helps apathetic decision makers or naysayers see that design standards (based on intangibles) are a necessary pre-condition for tangible benefits such as attracting donors, or reducing length of stay for patients.
Ask in-depth questions Ask in-depth philosophical questions that highlight the value of intangibles and design quality standards, as well as the cost of accepting vague standards. An intangible to be considered when developing design standards is the explicit recognition that a hospital is a highly emotional place. It has proven beneficial to review with decision makers how they should respond, as the Danish architect Erik Asmussen7 says, to “what happens here.” Life changing events and extremes of human drama call for non-technical qualities beyond competent infrastructure or corporate office quality standards. For example, depending on the specific client group, these questions have been posed:
- What kinds of connections do we perceive human beings seek with nature?
- Do hospitals share distinguishing qualities with other meaningful spaces, such as religious or academic buildings?
- How can these connections be made most effectively in a health care setting?
- What is the value of protecting these connections with standards?
- What is the cost of not making these connections?
- How and why should these qualities be expressed as design quality standards?
Create criteria for gap analysis
Jointly create criteria for a gap analysis diagnostic tool. The Balanced Scorecard aims to elevate design standards above the traditional intangible status of optional and arbitrary to the status of necessary and verifiable. Rather than accept vague aspirations such as “design excellence” and “healing environment,” the scorecard provokes decision makers to measure the gap between meaningful criteria for their specific project and what is being proposed at each stage as the design progresses.
Apply scorecard tool
Use the scorecard tool to jointly monitor any Say—Do Gaps that may be identified by anyone at any point as the design progresses. The purpose of this step is to share responsibility among all project participants for ensuring that the built reality will be as inspiring as the words. The scorecard encourages candid conversations about how planning participants are doing, rather than potentially accept lower standards or ignore collective self-delusion.
RESULTS
Overall, each of the respondents who participated in the Angus Reid research “reflected favorably on their experience with Farrow Partnerships Architects’ step-by-step method for developing design quality standards.”3
All respondents characterized the design standards creation experience as “a learning process, rather than a buy-in process.” The research also found that “What seemed particularly important to respondents was the ability of the process to accommodate a broader number of stakeholders in the planning and decision-making processes, as well as the ability of the process to organically generate consensus among a large group of stakeholders, even when a wide disparity of opinion existed to start.”
The following are a range of comments that were representative of those received. On “values”, one participant commented that it was “a collaborative approach involving our organization learning as much about ourselves as we did about the principles of design.”
Some of the intangible outcomes were identified as:
“...creating a great quality of life for staff”
“...creating a buzz in the community”
“....people are happy to come here...it’s an uplifting place; it’s not just a hospital”
“...provide hope and inspiration”
“...a source of pride for our community.”
“...a better frame of mind while administering care.”
With regard to the process, participants commented:
“...creating a buzz in the community”
“....people are happy to come here...it’s an uplifting place; it’s not just a hospital”
“...provide hope and inspiration”
“...a source of pride for our community.”
“...a better frame of mind while administering care.”
“The architect has a lot of ideas, but so does the owner. The design process involved a lot of back and forth, a sharing of ideas.”
“...this isn’t just getting a hospital built; this is a chance to step back and look at the ways in which we deliver health care.”
“...that iterative process was really important.”
And on value for money:
“...this isn’t just getting a hospital built; this is a chance to step back and look at the ways in which we deliver health care.”
“...that iterative process was really important.”
“I did not believe in the beginning that we could accomplish what wanted to for patients while being within a budget that could be tolerated by the public purse. But guess what? We did it. And, for cheaper than many other generic big-box hospital projects.”
CONCLUSIONS Although there is evidence of global interest in raising health care design standards, advocacy alone is unlikely to result in significant change. This paper has presented the results of a standards development process, based on adult learning principles, that builds on a fundamental understanding of the nature of intangibles.
As the research by Angus Reid Strategies indicates, when participants become engaged in a step-by-step learning process, they develop a sense of shared responsibility for creating site-specific, meaningful standards. This learning process, based on dialogue and discovery, can be more effective than efforts to gain buy-in for pre-conceived standards.
Decision-makers who are neutral, apathetic, or actively opposed to raising design quality can become sensitized to the impact of human-centric design though the process of articulating standards. When these intangible qualities are captured in precise terms, such standards can be rigorously monitored using a balanced scorecard.
When ratings are reviewed with client groups at major milestones during the project, there is remarkable consensus regarding the appropriate number to be assigned to these intangibles on a scale of 1-5. Although there is no way to prove such numbers objectively, the exercise indicates that intangibles can be monitored effectively.
Based on research in the field, the process of creating and applying effective design quality standards requires a willingness to challenge what constitutes a true healing environment. Meaningful terms of reference, developed and refined through facilitated dialogue with each unique client group, are the foundation for meaningful standards. Each project has unique design priorities and sensitivities that make their standards, and therefore their hospital, come alive.
Authors
Tye Farrow, BArch, MArch UD, OAA,MAIBC, NSAA, NAA, FRAIC, senior partner, Farrow Partnership Architects, Toronto, Canada.
Sharon VanderKaay, BSc Design, Associate AIA, director, knowledge development, Farrow Partnership Architects, Toronto, Canada.
REFERENCES
1. “Experts call for action on design quality,” World Health Design, October 2008.
2. Rochon, Lisa. “Why is hospital design so unhealthy?” The Globe and Mail, December 15, 2007.
3. Angus Reid Strategies, “In-Depth Interviewing Qualitative Research Project: Evaluating the Farrow Model of the Design Standards Creation Process”, May 27, 2009
4. Lev, Baruch. Intangibles: Management, Measurement and Reporting, Washington, D.C.: Brookings Institution Press, 2001
5. Blair, Margaret M. and Wallman, Steven M.H., Unseen Wealth: Report of the Brookings Task Force on Intangibles, Brookings Institute Press, Washington D.C., 2001.
6. Knowles, Malcolm S., Holton, Elwood F. III and Swanson, Richard A. “The Adult Learner: The definitive classic ” Elsevier Inc.
7. Coates, Gary J., Erik Asmussen, Architect, Stockholm, Byggforlagte, 1997.
