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MARCH / APRIL 2004

FEATURES

The language of space and design

Mitchell and Gillis are working closely with both city planners and the leadership of Hua Shan Hospital in China on a facilities project located in Pudong.

Much of the collaboration between Harvard Medical International (HMI) and our partners involves helping to foster sustainable progress among health care professionals, whether through enhanced medical knowledge or new approaches to health care delivery and education. Yet on a very concrete level, HMI is also challenged to transform physical space into clinical and educational facilities that most efficiently and affordably meet the needs of the people who use them.

Judy Mitchell, HMI’s director of planning, rarely sees the outcomes of her work. By the time a new facility is welcoming its first students or patients, she is already working on the next great beginning. To Mitchell, trained as an architect, vacant lots and empty buildings represent blueprints of opportunity for the HMI team to help “translate the vision of our partners into the language of space and design.”

The major objective of Mitchell and Albert Gillis, HMI’s director of health care facilities development, is to help HMI’s partners arrive at a design and development solution that meets their health care delivery goals without compromising on quality. To accomplish this, they have helped create an integrated program that uses the design process to foster dialogue about local practices, initiate operational changes, explore new approaches to staffing, and identify training needs.

An artist’s rendering of an in-patient tower being planned for Nanchung, China, by Hua Shan Hospital.

Designing for people
HMI works to make the design process a collaborative effort involving every member of the care team. Through a program which uses computer-generated, prototypical designs, HMI helps to instigate discussion among the various groups within the staff, from physicians and nurses to executive management and administrators. The prototypes are used to simulate workflows within the hospital, based on variables like staff availability, equipment utilization, and numbers of patients.

“It’s a powerful approach for many reasons,” said Mitchell. “First, it provokes a discussion that uncovers the needs of every member of the care team. Second, we get a clear picture of how they work, which helps us to tailor the process to their specific requirements. Third, the program encourages a team-oriented approach to planning and design—in an environment where people are often not accustomed to working together.”

This collaborative process mirrors an important shift in health care delivery to team-based patient care. HMI’s integrated approach to design places the care team in the position of having to think about how they will interact with the patients, with the facility, and with each other. “We are using the design process to precipitate a dialogue about hospital operations and clinical program planning,” said Mitchell. It’s more than a refinement of the design process—this approach, with its strong emphasis on communication and the inclusion of a diversity of voices, both extends design beyond the boundaries of blueprints and building codes, and sets the stage for the development of an effective care team.

Master plan for Hua Shan Hospital’s Nanchung facilities, designed by the Shanghai Xian Dai Architectural Design Group.

High-tech, yes, but don’t forget the details
Technology can be a double-edged sword in health care facilities development. “Many of HMI’s partners place a big emphasis on equipment because it is tangible evidence of progress,” said Mitchell. “So facilities become the wrappers around that equipment.” It is important to understand, however, that a good facility involves a lot more than just equipment. “Clinical programming must drive hospital design,” Mitchell stressed. “Similarly, if you are building an academic complex, then the curriculum must be the driver.”

“It’s not uncommon to look at an early design for a new facility and see many missing elements,” said Gillis. “In addition to clinical space, it is critical to provide space for support services, such as housekeeping, laundry, engineering, and supply rooms, which are often overlooked in the clinical areas. These are all necessary pieces of the overall design. Often, planners identify key treatment spaces but fail to consider the support areas that are essential to making a unit efficient and safe.”

Gillis also works with HMI’s partners to design and implement fully integrated hospital information systems suitable for their particular organization. “Most of what is available in the countries where we work are sophisticated billing and registration systems that are obviously very important. But the idea of having an information system that lends itself to direct patient care often takes a back seat,” he said. “The challenge is to get doctors, nurses, and other health care providers to use the system, and ultimately appreciate the convenience of having test results available immediately upon confirmation, along with easy access to a patient’s recorded history.”

The implementation of new systems and processes, such as scheduled appointments or digital records, can involve significant cultural changes for patients as well as staff. HMI has designed implementation plans that address these differences and help its partners phase in new operational models over time.

Designing for the future
The dynamic nature of medical technology requires that health care providers and medical educators live in both the present and the future. “The sheer effort of getting a facility built can cause people to focus on what is in front of them,” said Mitchell. “But HMI helps organizations to examine the future as well, because health care is always changing.”

The rapid pace of change in technology and health care delivery means that the priorities of a facility can change—sometimes even before it is built. No organization developing a health care facility can predict the future with any great accuracy, but they can collect data to assess what is occurring in their defined market area, and how technology changes will impact health care delivery. Information related to patient volumes and disease profiles, for instance, is critical to defining clinical programs and understanding the requirements of a given facility or space. “In many parts of the world, health care providers have not been in the mode of studying what they do, and so they lack this data,” said Mitchell. Added Gillis, “It is very important for an organization to plan as well as they can for what it is they want to provide in Year 1, in Year 5, in Year 10, and we can provide the tools to do that.”

Gillis and the chief of laboratory services at Mulund Hospital, Dr. S. Narayani, discuss the hospital information system.

Building a foundation for local improvement
Mitchell finds the process of facilities design exciting because every project is unique. “We try to tailor the design process to each partner organization’s specific needs,” she said.

The process can develop in a number of ways. In some circumstances, an HMI partner health care provider might engage an international firm to handle design, architecture, and engineering. HMI then works with the partner to develop clinical program plans and operational models that reflect the needs of their community. The HMI team conveys this information to the design team in a timely way that enables them to work most effectively. “We understand the many different project delivery models being used around the world because we’ve worked with them,” said Mitchell. “We can help international firms understand the local practice for design, construction, and permitting. It makes the design team more effective and that translates into reduced costs and a better facility for our partner.”

Some HMI partners have access to very skilled local design firms that, while well versed in planning and design, lack experience with health care facilities. In these instances, Mitchell and Gillis have developed educational programs that enable these firms to get up to speed on the unique challenges associated with developing hospitals and other clinical facilities.

“It is gratifying to work with the local firms,” said Mitchell, “because you can influence how they will approach this process in the future.” One such example is a project for Hua Shan Hospital (HSH) in Shanghai. HMI helped train local talent from the Shanghai Institute of Architecture and Design, who will perform the architectural planning for HSH’s current project and hopefully future projects as well. “Our goal is to work ourselves out of a job,” said Mitchell.

Gillis said that HMI routinely encourages its partners to come to Boston to tour local facilities during the early phases of facilities planning. “It’s valuable for them to see in reality what we have talked about in concept.” The obvious advantage is that partners can gain a clear sense of what they are embarking upon, and compare what they see to their own objectives. Gillis noted that these interactions have often resulted in extended communication between Harvard Medical School faculty and HMI’s partners abroad. “It’s an informal opportunity for training,” said Gillis, “and we are happy to serve as the matchmaker. ”

Master plan for a University Town to be developed in the Phillipines by AMA Education Systems Holdings, Inc., designed by Palafox Associates (Manila).

Empowering partners to raise the bar
One of the most exciting facets of HMI’s facilities development work has been the opportunity to help partners work with local regulators to raise the standards of hospital design and development. The regulations governing the building process are often out of step with advances in health care, but until recently, many of HMI’s partners have not felt empowered to challenge these regulations. HMI is now helping them to see that they can influence public policy—for the betterment of health care delivery—through their own projects.

“It can be difficult to raise issues or concerns with regulatory agencies,” said Mitchell. “We have experience bringing the two parties—the regulators and the hospital developers—together, and facilitating an exchange that reexamines the regulations in light of changes in the health care industry.” Backed by HMI’s experience, partners now feel credible engaging the regulatory groups in discussion, with the potential outcome of higher standards. “It’s a win-win situation for all involved, and can produce a ripple effect throughout the health care community,” said Mitchell, who cites China as an example of a country where the organizations designing and building health care facilities are playing an active role in updating the standard of facilities development.

Brick by brick, partners become better builders
Much of this work is about integrating different practices—taking an approach to planning and design that has proven successful in other places and meshing it with local practices, customs, and working styles. It is important to remember that working to create new facilities means working with people. “You have to appreciate the culture of your partner,” said Gillis. “What we try to do is use what we know to help them create the best facility possible for their culture and their community, and try to integrate practices that have been shown to be successful.”

Asked what energizes him for the long trips to places like China, India, Zimbabwe, and Turkey, Gillis gave an answer that rose above the nuts and bolts of planning and design. “We have an opportunity to have an impact on how health care is delivered—to hopefully help our partners do it better, more efficiently, and more affordably, and that is extremely rewarding.”