Engagement involving all stakeholders is a key element of designing healthcare facilities that will support collaborative care.
One of the most important service delivery models — collaborative care — was highlighted in the Institute for Medicine's list of 20 national priorities for improving healthcare. Collaborative care, however, hasn't been widely practiced in the healthcare industry except at university-affiliated teaching hospitals and medical centers.
Long before most people had even heard of changing reimbursement and delivery models such as accountable care organizations, the academic medical center culture recognized a process to support the collaboration of medicine, research and education, with the ultimate goal to provide consistent, positive outcomes in patient care.
Likewise, the architecture, engineering and construction industry should use a collaborative approach in the facility design process to achieve an environment that supports positive patient outcomes, including more coordinated, cost-effective and measurable care.
A model example of such care is successfully realized at the Northwestern Comprehensive Center on Obesity, under the guidance of Lewis Landsberg, MD, of Northwestern University Feinberg School of Medicine in Chicago. In addition to conducting obesity research, the NCCO provides clinical care that involves physicians, dietitians, nurse practitioners, diabetes educators, psychologists and specialists, including hepatology, obstetrics/gynecology, cardiology, oncology and endocrinology. The NCCO's collaborative and interdisciplinary approach parallels the collaborative care process in facility design as it involves many facets of the healthcare environment and many individuals who have a stake in the patients' care.
In NCCO's "Healthy for You, Healthy for 2" program, for example, obstetrics/gynecology, preventive medicine and other specialties work together to improve the overall health of pregnant women and their unborn children by promoting optimal weight gain and lifestyle balance during pregnancy. Dr. Landsberg says the program has been beneficial for the patients as well as the collaborating specialists.
"Each department and discipline has its own expertise and ways of looking at problems. But by bringing these groups together at the interface, using a collaborative approach, evaluating our efforts and continuing to provide follow up, success is obvious and transfers throughout the organization," he says.
According to this proposed definition from a 2007 report, healthcare delivered through the collaborative care model will be very different from what most physicians and healthcare professionals are used to. Care will be more team oriented with shared responsibility by the patients and the providers, with patients involved in their care and not just a recipient of care. This will require new processes and a new way of thinking; in essence a cultural change.
Traditionally when architects design and plan new facilities, they hold separate user group meetings with administration, facilities, the clinical department, operations, food service, pharmacy, housekeeping and other departments. In contrast, to design a collaborative care environment, architects will require feedback from an expanded list of stakeholders who participate in group meetings where all voices are heard. These meetings are most successful when structured to empower physicians, staff, administration, operations and others to participate freely without judgment, with the sole purpose of having a valuable exchange of information. In addition, it's important that participants discuss not just one department's needs but how and when all stakeholders involved in patient care (the patient, their families, clinical operations, building operations and system operations) interact with each other.
Vanderbilt University Medical Center in Nashville is a good example of an organization that successfully uses the collaborative approach to design its facilities. When Vanderbilt began planning its new Critical Care Tower and Vanderbilt-Ingram Cancer Center, it developed a comprehensive list of all stakeholders and sought their input at every step of the process. This included key stakeholders who participated in meetings to evaluate the overall design and end users who assessed design mock-ups of specific spaces and rooms.
"The biggest difference between Vanderbilt and other organizations is that we don't just hand the design to stakeholders and ask them to fit into it," says Charlotte Chaney, associate hospital director of Vanderbilt University Hospital. "All of the core departments as well as the ancillary departments and the end users are involved in the design process."
In the collaborative design process, key stakeholders meet to formulate a collective vision that documents and clearly communicates goals and objectives and other factors. At Vanderbilt, the hospital leaders developed a charter that included strategic goals, a definition of the project, what they wanted to accomplish, a list of stakeholders, a description of how they would work together, the decision-making process, the approval process and an organizational chart showing whose approval is required at different stages.
Once the overall charter and design have been approved, Vanderbilt set up separate teams of stakeholders, each with its own charter, to deal with specific issues. This included operations planners who discuss how staff and physicians will work in the new environment, a move-in logistics team, occupancy planning group, education and orientation teams, and more. Vanderbilt even has "day in the life" and "night in the life" teams that test all systems before they're used in patient care.
Patients and their families also should participate in the design process, which will foster an environment of listening and learning as well as provide a means of measuring patient outcomes. Vanderbilt obtains regular feedback from its Patient Family Advisory Council that is active year-round under the guidance of the Patient Center Care Department. The council is involved in determining amenities for everything that patients and their families interact with, including patient rooms, waiting areas, food service, interiors and educational TV systems.
Stakeholder engagement should begin early in the pre-design/programming phase but also should be implemented throughout all phases, including schematic design, operational planning, design development, construction, transition planning, move-in and post occupancy. This will require a major investment of time and effort but will result in significant benefits such as long-term stakeholder satisfaction.
Finally, it's essential that hospitals and their consultant partners build in a measurement system for all stages of the process from planning through post-occupancy. This will help them determine how well the engagement process is working, how the facility impacts stakeholders and whether adjustments are required. Vanderbilt, for example, gains valuable information via "lessons learned" sessions with stakeholders who have moved into the first completed floors before they implement the systems on other floors.
"Our hospital leaders were busy so we felt it was important that our team step in and make progress and even lead part of the project," says Ms. Facemire. "We also have so many projects at Vanderbilt that we knew it was important not to overburden technology and the ancillary departments. We had to recognize that we have timelines, but they also have their own timelines."
Another challenge may be stakeholders who are satisfied with the status quo or who don't understand the value of the collaborative process. "While some people see the advantages to this type of collaboration, a major challenge is that others don't," says Dr. Landsberg of NCCO. "We need to have patience and use persuasion to demonstrate the added value that our collaboration brings to overcoming the disease of obesity."
"Sometimes we deal with architects who don't understand the importance of involving all our stakeholders, but we have to make them understand," says Ms. Chaney of Vanderbilt. "The key is that we take the time to listen to our customers and make sure each person is heard."
Listening to its customers has, indeed, benefited Vanderbilt, resulting in high-quality healthcare facilities with more efficient use of space, improved patient and family amenities, and enhanced design aesthetics and environmental/safety standards. For example, based on feedback from stakeholders, Vanderbilt scaled back the amount of furniture in one facility to accommodate more medical equipment. The medical center received valuable input from their nurses regarding new break-away doors that improved the use of space and provided more efficient staff and patient flow. Vanderbilt also has patients and families test various amenities and furniture before installing it throughout a facility. This included one family member who slept on a sleeper chair for 17 days to see if it was comfortable over time.
Most importantly, Vanderbilt has experienced increased staff, physician and patient satisfaction, according to Ms. Facemire. "In our lessons learned sessions, we hear from staff that the collaborative design process has made their jobs much easier. In some of the sessions, there was dead silence when we asked if any changes were required. There wasn't much they wanted to change."
Despite all of the challenges of designing a collaborative care environment, the collaborative approach is a transparent process that enables hospitals, academic medical centers and healthcare real estate developers to speak a parallel language focusing on facility development and oversight in healthcare excellence. Developing any new healthcare facility, using an approach like collaborative care design, requires caution and careful planning. But by working together with all stakeholders, developing well-thought-out goals, objectives and metrics, freely sharing knowledge and real-life lessons and experiences, the result will be a beneficial healthcare environment where a collaborative culture between medicine, research and education delivers consistent, positive outcomes in patient care.
Footnotes:
1 The healthcare industry has been focusing on the concept of the "patient-centered medical home” (PCMH). Four major medical associations – the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association – recently agreed on joint principles of the PCMH.
2 The Stanford University-UCSF Evidence-based Practice Center proposed this definition of care coordination in a 2007 report for the Agency for Healthcare Research and Quality.
Sharon Lleva-Carter is an executive director of healthcare with Duke Realty and has spent her 25 year career exclusively in the provider sector of the healthcare industry. She was previously director of design and construction at Northwestern Memorial HealthCare and Northwestern Medical Faculty Foundation in Chicago.
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One of the most important service delivery models — collaborative care — was highlighted in the Institute for Medicine's list of 20 national priorities for improving healthcare. Collaborative care, however, hasn't been widely practiced in the healthcare industry except at university-affiliated teaching hospitals and medical centers.
Long before most people had even heard of changing reimbursement and delivery models such as accountable care organizations, the academic medical center culture recognized a process to support the collaboration of medicine, research and education, with the ultimate goal to provide consistent, positive outcomes in patient care.
Likewise, the architecture, engineering and construction industry should use a collaborative approach in the facility design process to achieve an environment that supports positive patient outcomes, including more coordinated, cost-effective and measurable care.
The NCCO model
On the research and education side, collaborative care is defined as care that involves a patient's primary care physician who often works in conjunction with specialists from other disciplines, directing the team that manages the patient's care; the care is coordinated and integrated; the focus is on the whole person and all stages of their life; and the hallmarks are safety and quality.1A model example of such care is successfully realized at the Northwestern Comprehensive Center on Obesity, under the guidance of Lewis Landsberg, MD, of Northwestern University Feinberg School of Medicine in Chicago. In addition to conducting obesity research, the NCCO provides clinical care that involves physicians, dietitians, nurse practitioners, diabetes educators, psychologists and specialists, including hepatology, obstetrics/gynecology, cardiology, oncology and endocrinology. The NCCO's collaborative and interdisciplinary approach parallels the collaborative care process in facility design as it involves many facets of the healthcare environment and many individuals who have a stake in the patients' care.
In NCCO's "Healthy for You, Healthy for 2" program, for example, obstetrics/gynecology, preventive medicine and other specialties work together to improve the overall health of pregnant women and their unborn children by promoting optimal weight gain and lifestyle balance during pregnancy. Dr. Landsberg says the program has been beneficial for the patients as well as the collaborating specialists.
"Each department and discipline has its own expertise and ways of looking at problems. But by bringing these groups together at the interface, using a collaborative approach, evaluating our efforts and continuing to provide follow up, success is obvious and transfers throughout the organization," he says.
Coordinated care: A definition
The Stanford University-UCSF Evidence-Based Practice Center defines care coordination as "the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care."2According to this proposed definition from a 2007 report, healthcare delivered through the collaborative care model will be very different from what most physicians and healthcare professionals are used to. Care will be more team oriented with shared responsibility by the patients and the providers, with patients involved in their care and not just a recipient of care. This will require new processes and a new way of thinking; in essence a cultural change.
Engaging stakeholders: Vanderbilt University Medical Center
The best way to accelerate cultural change is to engage all of the stakeholders and obtain their "buy-in" on the most appropriate facility design that will support collaborative care.Traditionally when architects design and plan new facilities, they hold separate user group meetings with administration, facilities, the clinical department, operations, food service, pharmacy, housekeeping and other departments. In contrast, to design a collaborative care environment, architects will require feedback from an expanded list of stakeholders who participate in group meetings where all voices are heard. These meetings are most successful when structured to empower physicians, staff, administration, operations and others to participate freely without judgment, with the sole purpose of having a valuable exchange of information. In addition, it's important that participants discuss not just one department's needs but how and when all stakeholders involved in patient care (the patient, their families, clinical operations, building operations and system operations) interact with each other.
Vanderbilt University Medical Center in Nashville is a good example of an organization that successfully uses the collaborative approach to design its facilities. When Vanderbilt began planning its new Critical Care Tower and Vanderbilt-Ingram Cancer Center, it developed a comprehensive list of all stakeholders and sought their input at every step of the process. This included key stakeholders who participated in meetings to evaluate the overall design and end users who assessed design mock-ups of specific spaces and rooms.
"The biggest difference between Vanderbilt and other organizations is that we don't just hand the design to stakeholders and ask them to fit into it," says Charlotte Chaney, associate hospital director of Vanderbilt University Hospital. "All of the core departments as well as the ancillary departments and the end users are involved in the design process."
In the collaborative design process, key stakeholders meet to formulate a collective vision that documents and clearly communicates goals and objectives and other factors. At Vanderbilt, the hospital leaders developed a charter that included strategic goals, a definition of the project, what they wanted to accomplish, a list of stakeholders, a description of how they would work together, the decision-making process, the approval process and an organizational chart showing whose approval is required at different stages.
Once the overall charter and design have been approved, Vanderbilt set up separate teams of stakeholders, each with its own charter, to deal with specific issues. This included operations planners who discuss how staff and physicians will work in the new environment, a move-in logistics team, occupancy planning group, education and orientation teams, and more. Vanderbilt even has "day in the life" and "night in the life" teams that test all systems before they're used in patient care.
Patients and their families also should participate in the design process, which will foster an environment of listening and learning as well as provide a means of measuring patient outcomes. Vanderbilt obtains regular feedback from its Patient Family Advisory Council that is active year-round under the guidance of the Patient Center Care Department. The council is involved in determining amenities for everything that patients and their families interact with, including patient rooms, waiting areas, food service, interiors and educational TV systems.
Stakeholder engagement should begin early in the pre-design/programming phase but also should be implemented throughout all phases, including schematic design, operational planning, design development, construction, transition planning, move-in and post occupancy. This will require a major investment of time and effort but will result in significant benefits such as long-term stakeholder satisfaction.
Finally, it's essential that hospitals and their consultant partners build in a measurement system for all stages of the process from planning through post-occupancy. This will help them determine how well the engagement process is working, how the facility impacts stakeholders and whether adjustments are required. Vanderbilt, for example, gains valuable information via "lessons learned" sessions with stakeholders who have moved into the first completed floors before they implement the systems on other floors.
Challenges and solutions
Health systems that implement the collaborative process to design their new facilities will face challenges. Some stakeholders might not have adequate time to invest in the process. When developing the Critical Care Tower at Vanderbilt, hospital leaders were too busy and had many competing interests, according to Cynthia Facemire, director of expansion and transition at Vanderbilt."Our hospital leaders were busy so we felt it was important that our team step in and make progress and even lead part of the project," says Ms. Facemire. "We also have so many projects at Vanderbilt that we knew it was important not to overburden technology and the ancillary departments. We had to recognize that we have timelines, but they also have their own timelines."
Another challenge may be stakeholders who are satisfied with the status quo or who don't understand the value of the collaborative process. "While some people see the advantages to this type of collaboration, a major challenge is that others don't," says Dr. Landsberg of NCCO. "We need to have patience and use persuasion to demonstrate the added value that our collaboration brings to overcoming the disease of obesity."
"Sometimes we deal with architects who don't understand the importance of involving all our stakeholders, but we have to make them understand," says Ms. Chaney of Vanderbilt. "The key is that we take the time to listen to our customers and make sure each person is heard."
Listening to its customers has, indeed, benefited Vanderbilt, resulting in high-quality healthcare facilities with more efficient use of space, improved patient and family amenities, and enhanced design aesthetics and environmental/safety standards. For example, based on feedback from stakeholders, Vanderbilt scaled back the amount of furniture in one facility to accommodate more medical equipment. The medical center received valuable input from their nurses regarding new break-away doors that improved the use of space and provided more efficient staff and patient flow. Vanderbilt also has patients and families test various amenities and furniture before installing it throughout a facility. This included one family member who slept on a sleeper chair for 17 days to see if it was comfortable over time.
Most importantly, Vanderbilt has experienced increased staff, physician and patient satisfaction, according to Ms. Facemire. "In our lessons learned sessions, we hear from staff that the collaborative design process has made their jobs much easier. In some of the sessions, there was dead silence when we asked if any changes were required. There wasn't much they wanted to change."
Despite all of the challenges of designing a collaborative care environment, the collaborative approach is a transparent process that enables hospitals, academic medical centers and healthcare real estate developers to speak a parallel language focusing on facility development and oversight in healthcare excellence. Developing any new healthcare facility, using an approach like collaborative care design, requires caution and careful planning. But by working together with all stakeholders, developing well-thought-out goals, objectives and metrics, freely sharing knowledge and real-life lessons and experiences, the result will be a beneficial healthcare environment where a collaborative culture between medicine, research and education delivers consistent, positive outcomes in patient care.
Footnotes:
1 The healthcare industry has been focusing on the concept of the "patient-centered medical home” (PCMH). Four major medical associations – the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association – recently agreed on joint principles of the PCMH.
2 The Stanford University-UCSF Evidence-based Practice Center proposed this definition of care coordination in a 2007 report for the Agency for Healthcare Research and Quality.
Sharon Lleva-Carter is an executive director of healthcare with Duke Realty and has spent her 25 year career exclusively in the provider sector of the healthcare industry. She was previously director of design and construction at Northwestern Memorial HealthCare and Northwestern Medical Faculty Foundation in Chicago.
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