4th Way Evidence

Healthcare systems and facilities are continually challenged with changing practices and variations in volumes. The new economy has supported a perfect storm of changes: consolidation of services and facilities, various health systems mergers, new acquisitions, new measurements of performance and reimbursement with CMS meaningful use and value based purchasing, the continuing emergence of evidenced based design and it’s impact of the environment, the aging of the Baby Boomers, increased demand in experience-based healthcare, excess building capacity, and an ever changing environment. To weather these changes, knowing how to create performance is crucial. Understanding how to identify the measures, and validate that those measures perform, will be essential to an organization’s ongoing success.

Healthcare business planning is always a part of the process of identifying a need for healthcare design within a specific department. Typically, this is a precursor to the identification of the need to expand a department to allow for growth or secure more revenue. Metrics are established for target volume, market share, and overall growth during the business planning process. These items need to be translated and reflected upon to determine if they will really provide overall improvement to the organization.

The architectural design process historically includes identifying space based on volume, defining peaks, and building space to support that need. In the last decade, architectural work has begun to shift away from the more traditional planning models of Chi and Dickerman (Dickerman et al, 2008) to a model which focuses on operational and evidence based planning. Traditional models also factor in operations but always use space to resolve any issues. Recent studies have been looking not just at space but how that space may impact a specific desired outcome, for example medical errors or worker injuries. There has been a shift in the industry, especially in the new economy, which warns we will not be able to build our way into improvement. To really make an improvement, businesses must look at overall operations. Operational assessments through LEAN and Six Sigma are just a few tools that have taken hold in the healthcare planning process. However, this process rarely ties itself to the business performance plan, nor does it identify ways to demonstrate that overall operations have been improved.

Once a space has been newly built or renovated, a frequently missing component is the ability to evaluate the environment and retrain the staff to work in the new environment in the most effective manner. The staff and patients will hold onto their habits from the old environment and modify them to fit the new, creating workarounds that do not align with intended operations. Taking the time to evaluate the space post-occupancy is imperative in confirming that the space is performing as designed— in a sense, the built environment must be commissioned. Without continued evaluation and training, the space will not perform optimally. Evaluation, along with a clear understanding of the intended internal operations and business performance, is therefore a cornerstone to success (Sadler & Zimring, 2008).

Financial first-cost thinking, or the cost-effective approach, can affect the anticipated outcomes. Executives push to have outcomes anticipated within six months of occupancy. Often, the impacts of a new space will not be demonstrated in improvements until the second or third year of occupancy. The impacts can vary from unanticipated benefits, to reduction in work related injuries or reduced medical errors.  The Post-Occupancy Evaluation may initially identify that there could have been a failure based on the environment.  However, the purpose of the POE is not to identify failure but to identify possibilities for continual improvement. The work of the Center for Health Design is aimed at demonstrating the importance of the environment and how its impact on an occupant can be monumental. For example, the Sound Sleep study illustrates the importance of noise control in healing environments in order to reduce stress and improve outcomes (Anjali & Ulrich, 2007).

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