Insights from a Healthcare Architect’s Journal

By Timothy J. Spence

 Perspective.  The best way to gain perspective is through experience.  Learning how a patient and their family member respond to a facility’s design requires taking the patient’s perspective.  As a healthcare designer, I tour healthcare facilities after hours to capture this view.

Such walk-throughs offer both an incomparably genuine as well as a uniquely rich angle on what patients and providers experience as they navigate the space.  These are extraordinarily effective ways to gain this insight.

Perspective often drives change. For example, when Michael Graves, world famous architect, became disabled and wheelchair bound, the later part of his career became focused on healing and handicapped issues. His perspective changed and so did the trajectory of his career.

On a recent trip to Ghana, I had the opportunity to see firsthand how medical personnel performed 75 surgeries in 3.5 days, revealing significant differences in the type of systemic support relative to what we have in the U.S. – staffing, MEP systems, facilities, administration, maintenance, and the list continues.

The perspective of being completely immersed as part of the medical team and see how the various medical roles were fulfilled was career-changing.

Context + Benefits.  Designers don’t know all the unique aspects which brought each project to market, but they do have the benefit of understanding the relationship between design decisions and the overall effectiveness of the facility in practice.

There has been a humanizing of healthcare spaces over the past 20 years. Where the focus prior was on strategic concepts such as flow, throughput, and adjacencies, today there is a much more human approach.

The other noticeable trend, more recently in the years following the recession, has been the scaling of non-revenue-generating spaces, such as elaborate atriums.  With more limited budgets, healthcare leaders are putting the focus on the spaces supporting their bottom line and less on the opulence of expensive, commanding spaces which are underutilized.

Future trends will involve integrating the latest technology while humanizing the space.  For example, in most outpatient settings, patients feel the doctor has his/her back to them while charting their information. Changing that perception indicates charting should be intuitive and easy, allowing the patient to see and discuss the information on screen with his/her physician. Technology can integrate seamlessly, complementing care, not distracting from it.

Providers, as well as patients, could benefit from better integration of technology as a means of humanizing their roles, as they report burnout related to the shortcomings of electronic medical records.

Observations + Interpretation of Change

 In the current economic climate, costs and consumerism are driving change.  Among the 2018 Annual CEO Survey of the Advisory Board, cost containment was the number one concern. This explains the focus of healthcare leaders on how to contain costs amidst revenue drops and cost escalation. Therefore, the root concern ultimately becomes the catalyst for the disruptive change evident in the marketplace as economics are the driver which makes things happen (follow the flow of funds).

Where does this change ultimately lead?  Consumerism comes to the forefront here in 2019 as hospitals are now required to post pricing, restoring control to the consumer to determine value.

 Change is manifesting in two questions: “Is space needed?” and “What kind of space is needed?”  Capital is shifting from buildings to healthcare, translating to both highly optimized facilities as well as healthcare professionals serving at top of license.

Through this process, services are also shifting to specialized facilities like ambulatory surgery centers (ASCs), long-term care facilities, urgent care and primary care.  Facilities are designed and used for specific specialized services – and will include greater outpatient space as well as virtual care.

Change manifests itself through space and the use of materials.  Space is consequential in the new paradigm, and impacts cost and use.  In one example, a healthcare facility constructed just before the downturn reflects the times in materials and use of space. There is a huge three-story atrium running the length of the building and a large fireplace elegantly detailed with stone and wood in the lobby.

As funding becomes a presiding concern, such imposing public spaces in healthcare facilities have begun to diminish in scale.

Spaces can have an element of grandeur without being opulent.  A careful balance has begun in which healthcare facilities translate how far branding extends while conveying quality care without excess opulence.

A project in the northeast US was just getting off the ground when the recession hit.  Leaders put the project on hold until a design builder approached them with a proposal to complete the project in a more economical way.  The project design became leaner, connecting spaces vertically with fewer unallocated square feet.

By refocusing the planning effort, they were able to get the same function and character spatially with less cost.  The spaces still had an element of grandeur without being opulent. Space and material were tied to the level of the facility.  Materials selection is important: Healthcare stakeholders still want entry spaces welcome patients, but don’t want them as huge statements that are dead space, not generating any revenue.

Overall scale of the facility is also a factor. A huge $500 million hospital still has space for a large entry space to be in an appropriate scale, whereas a $100 million community hospital is more likely to target a more moderate size.

For example, in the Eastern US, a high level cancer facility required a lobby which stimulated movement to avoid congestion points and necessitated computer simulation studies for 5 to ten years into the future to ensure functionality for growth.

The size and scale of a facility dictate how much scaling down can occur.  An academic healthcare facility may be larger with many more programs than a smaller community medical center, which must be more conservative.  Because of the scale and presence of a major academic medical center, and the world-class care they provide, there is a level of prestige that can be reflected in the design without seeming excessive.

Some facilities balance simplicity with necessity and expand when their enhanced services justify it via revenue generating spaces.  One east-coast facility started with a utilitarian simple box design.  With a surgery expansion around the turn of the century, they added skylights in the clean core between the ORs, bringing natural light into the space to enhance the experience for surgical staff.

When a heart and vascular addition was integrated, it provided an opportunity for them to rebrand and the design of the new space included updated materials—stone from Texas, terrazzo floors, white metal panel reminiscent of stucco, and plenty of windows to let in light.

Let’s consider another example.  A facility started with an ambulatory medical office building a decade ago and quickly realized they were not generating the required revenue.  The company under which this facility operated had a brand identity of having strong emergency departments, and patients were asking for an ED, which was eventually added and became an immediate and immense success.

The original projections for this community were seven patients/day in the ED.  During the first month the ED was open, they saw well over 70 patients/day.  A few years later, the same institution added more beds to the initial building, transforming the campus from ambulatory to inpatient to suit the expressed needs of the patient population.  Leaders didn’t want a big atrium, they preferred a lean, scaled-down space, with a few features that spoke to the patient experience, such as well-oriented patient rooms.

Square feet per bed is a key metric.  A hospital is typically around 2000 to 2500 square feet. In one example, the design/builder challenged the owner to make the project leaner, and the square feet per bed dipped below the 2000 mark.  To allocate resources most effectively, healthcare leaders can isolate the non-revenue-generating spaces and evaluate whether they are having an impact or if they need to be reconsidered.

One example is outdoor spaces adjacent to waiting rooms that are accessible to patients and families when the weather is appealing. These do not generate revenue inherently, but they can provide value.

Ambulatory Surgery Centers are the wave of the future, making hospitals and larger facilities explore metrics of need per square foot.  As this happens, comparison modules are increasing the focus toward competitive advantage.

In ASCs, the percentage of total square footage allocated to each of the ORs is typically 2500-3000 square feet, while for hospitals the need is 3,000-5,000 square feet. For hospitals, working toward a leaner, value-based metric of gross square feet per OR is key. Size of the space and key planning units offer a starting point for effective design.

In hospitals, where there is more available square footage, they are willing to move that metric up based on how they perceive that they can provide care in a better way—larger, segmented prep and recovery spaces, e.g.—whereas in developer-run ASCs, everything is as minimal and tight as possible because the budget and space is less generous.

What is the minimum space needed versus how much flexibility is needed for the future? Many healthcare leaders want to build in flexibility, so they are willing to accept a higher gross square footage and incur the additional strategic investment.

Clean core versus non-clean core support spaces factor into the latest design metrics. Clean core offers off-stage delivery of supplies, streamlined workflow, and builds in flexibility for growing and changing workloads for healthcare space.

Capturing A Unique Angle

Ultimately, capturing a unique angle drives change.  Through personally touring facilities, making observations and interpreting change, patients and their family members benefit from better design: creating inspired solutions that improve lives.

Timothy J Spence, AIA, ACHA, LEED AP BD+C, is National Healing Market Leader with BSA LifeStructures.  He can be reached at 919.740.4649 or