February 22, 2017
HMC Architects: Improving Delivery to Improve Healthcare
HMC Architects reflect on how contractor-integrated design is reviving the healthcare industry.
Martin Luther King, Jr. Outpatient Center.
Photo by David Wakely.
For the past two years Metropolis’s publisher and editor in chief Susan S. Szenasy has been leading a series of discussions with industry leaders on key issues surrounding human-centered design. On April 13, 2016 she talked to HMC Architects in Los Angeles about how contractor-integrated design is reviving the healthcare industry by enabling owners to reduce construction costs and spend the savings where it counts most: on better care for patients, streamlined work environments, and beautiful hospitals that communities can be proud of. What follows is an edited transcript of the conversation.
Susan S. Szenasy, publisher/editor in chief, Metropolis magazine (SSS):
There are a couple of things in California that are unique, such as the Office of Statewide Health Planning and Development (OSHPD). It’s a government organization that keeps a watchful eye on all buildings, and especially hospitals, to be seismically safe. Kirk, you’ve worked with this agency, can you elaborate on their mission?
Kirk Rose, AIA, DBIA, principal/healthcare practice leader, HMC Architects (KR):
Their mandate is that in case of a natural disaster like an earthquake, the buildings remain structurally sound, but also functioning, so that people can go there after an emergency and have power for a certain number of days, on-site water, on-site food supply, emergency generator fuel. Those buildings will be up and running for three or four days, even if all the public utilities are out. As designers and builders, we have to design buildings to meet a lot of requirements. They’re very carefully inspected, and we actually call them the safest buildings on earth. They’re very intense.
SSS: With that intensity also comes a huge bureaucracy that you have to work with. Stacey, from the owner’s perspective, how does the OSHPD affect you?
Stacey Pray AIA, ACHA, CASp, owner and founder, SHP Project Development (SP):
They expect a 100% perfect building and we do not live in a perfect world. That is difficult. For instance, there might be a little air gap that you just can’t fill, and the project is stopped as the design team and the construction team scramble to make the fire marshal happy. That is a cost to the owner: months or years to fix the issue, and no other work can get done. It takes 24 months to build a new hospital somewhere else and 30-36 months in California.
Henry Mayo Newhall Hospital New Patient Tower.
Image by HMC Architects.
George Vangelatos, AIA, LEED AP BD+C, EDAC, principal/healthcare practice leader, HMC Architects (GV):
As designers who are involved early on in the project, we can design strategically to avoid or minimize delays by making decisions that are less prone to conflict with existing conditions.
KR: For instance, on a current project with Clark Construction, where we’re designing a $200 million addition to a hospital in central California, we’ve opted to submit what’s called a preliminary review. OSHPD is reviewing our drawings and we’re expecting them back any day now, so that by the time we do construction documents, we’ve solved all those issues.
SSS: And so, with a client like Kaiser Permanente—an integrated healthcare facility developer with a preventative care approach—how does this affect design?
GV: In order to create an environment where patients feel taken care of, we focus on cleanliness, sound levels, and daylight, which are measured and recorded. Kaiser Permanente is competing with other models. Clients are concerned about developing a facility where patients will want to come and bring their loved ones, and feel like they have the highest level of care. No patient or staff member is going to feel that the building is seismically sound, but if you have a large bay window with a great use of space, everyone’s going to appreciate that. There’s also a movement to have healing gardens. Kaiser Permanente has the concept of a “thrive path” around the building. While waiting for your appointment, you can be on your feet, walk a mile.
Martin Luther King, Jr. Community Hospital.
Photo by David Wakely.
SSS: And how is germ-control integrated in the design?
GV: Every early user meeting now includes an infection control director to address such issues.
SP: In many ways, maintenance is the bigger issue rather than the systems themselves. It helps to have the maintenance person meet with the contractor and the designer to ask, “How do I change the filters? How do I get on the roof?” We’ll angle the building so that the maintenance crew can change those filters without a problem.
SSS: From a developer’s point of view, how does design-build work for you?
Martin Luther King, Jr. Community Hospital, lobby.
Photo by David Wakely.
Barbara Wagner, DBIA, LEED AP, senior vice president, Clark Construction (BW):
A lot of clients feel that healthcare is too complicated for design-build: too many stakeholders and systems. But at the end of the day, there is a more buildable solution in terms of less cost, faster schedule, and higher quality.
SP: In such situations, it’s important for the owner to be involved in every single decision. For those who understand OSHPD, we have a total of six change orders in the field. That’s it!
SSS: Versus how many before?
SP: It would probably be up to fifteen or twenty. It’s been a huge time-saver to have our architect and contractor working side by side. When OSHPD comes out and sees something that’s not code compliant, the whole team knows who’s responsible. With a different arrangement, there might be finger pointing, “Did you follow the drawings correctly? Did you build that detail five steps back?” With design-build, there’s no question. The whole team is responsible.
BW: We also look at modularity and pre-fab opportunities, especially with the skins so that we can speed-up construction.
KR: That’s the classic benefit of design build. We get the elevator, the building skin, the metal framing, the mechanical systems designed ahead of time. Those people are designing alongside us, but they’re not just engineers. They’re the builders of those systems. Every detail gets solved literally 2-3 years earlier than it used to. It makes less work for us as architects because we don’t have to review all of that direct construction. The contractor has more cost certainty and more schedule certainty during the design phase. Then to make it all even better, we can submit packages early. The drawings used to sit on their desk for two years, and that saves the owner usually tens of millions of dollars in escalation, getting services to the community earlier.
SSS: Also, Building Information Modeling (BIM) helps with this. I think that has changed everything you do in a smart way.
GV: Exactly. We just finished a hospital a couple years ago where they only had one set of drawings on the site, and the only reason was because of OSHPD. Everybody else used the “BIM box.” In the field people were looking at the actual model, which was used for quality control. You can do laser scans and compare it to a 3D model. Anything that was off was instantly picked up. If it wasn’t for OSHPD’s requirement, we could have done it without any drawings. I think the absolute best way to have a collaborative team is co-location, but that’s not always possible. Co-location is where the entire team is working together in the same room. You’re asking questions in real-time. Even in the most sophisticated teams I’ve worked on, where we’ve had really state of the art technology, cloud-based connections and everything was at our disposal, face-to-face time was still the most valuable.
KR: In user meetings, where we meet with doctors and surgeons whose time is very valuable, we usually have two or three screens up; one might be a 3D axonometric. If they say, “Can you move the door?” we show a sketch of the door moving. This is a very fast and effective way to arrive at consensus.
SSS: Clearly, integrated project delivery [IPD] seems to be the right path because otherwise the process can be very fragmented.
GV: When you start to show people what they’re doing and how it impacts others, everybody is learning. By putting a unit there, you create a view issue from this patient room. In fact, the users are probably learning the most from our team. Being left out of the equation so often tends to lead to a lot of disgruntled employees. But if they’re part of the team, they understand why they didn’t get the gold plated doorknobs, because we chose to allocate funds elsewhere. They’re inside the decision process, so they become stakeholders in the design.
SSS: Speaking of users, who does the observational research?
Photo by Lawrence Anderson.
Rebecca Hathaway R.N., M.S.N., EDAC, PVDN, founder and president, Bridgestar Consulting (RH):
The information comes from an integrated group, not just the nurses or surgeons. We look at the process flow, everybody who touches something along the way. The housekeeper knows for sure that the patient’s laundry cabinet in the room needs to be dusted on top. The workers, not the managers say, “We don’t do it that way. We do it this way.” It’s more of a discovery process than a design process. The discovery leads to imagination and innovation. From there, we consider design and construction possibilities.
GV: In our user meetings we typically start with what we call the seat sweep, the directors and the people connected to the board. Then ultimately we get to the frontline staff, the people working the floors, turning over the rooms, dealing with patients day-to-day. A lot of facilities now have patient advocates. We also submit surveys for patients. They’re required and done on a regular basis that facilities use to gauge their quality.
SSS: Let’s talk about technology, because that’s ever shifting in terms of recordkeeping and communication.
KR: We have good consultants whose job is to keep up with technology and then we have to somehow plan for the future. The structure of the building is the same as it was 25 years ago, but the electronics within that building are very different. It’s really tough. There’s no way to plan for it, except to try to understand the trends. We’re dealing with very sensitive communication like code blue signs, and with privacy of patient records.
GV: It’s not so much whether technology has changed in the physical building. It’s how technology has changed your client. Technology is impacting the human being, not just the physical building.
SSS: Well put. Would anybody in the audience like to ask a question?
Audience member: What are some of the design elements that you provide to give patients a sense of rescue and the feeling that everything will be okay?
GV: One of the things that attracted me to healthcare was the scale of the projects and their position as landmarks in communities. When you go to almost any small town, you’ll know where the hospital is, and you’ll find out where the university or the college or high school is. Those are key infrastructure buildings for that community. The hospital is a landmark for the community and is usually iconic or identifiable. That starts with having very logical solutions to the site plan with probably six different circulation paths that approach the campus. The more you can make it clear and easy to find that door with no obstructions, the better. Let’s design barriers out of the path, and give a sense of safety. The more clarity you can embed in a design the better it will perform. That’s not usually easy. You have to work hard to make something look easy, and that’s certainly the case in healthcare.
I think a goal of mine is to be at a hospital, but not realize you’re at a hospital. It’s part of your daily life. You’re integrating with this environment that’s going to take care of you, but it’s not the hospital.
Susan S. Szenasy poses a question to the panel at HMC Architects’ space in Los Angeles.
Image Courtesy HMC Architects.
Rebecca Hathaway, R.N., M.S.N., EDAC, PVDN, founder and president, Bridgestar Consulting;
Stacey Pray, AIA, ACHA, CASp, owner and founder, SHP Project Development;
Kirk Rose, AIA, DBIA, principal/healthcare practice leader, HMC Architects;
George Vangelatos, AIA, LEED AP BD+C, EDAC, principal/healthcare practice leader, HMC Architects
Barbara Wagner, DBIA, LEED AP, senior vice president, Clark Construction.
Susan S. Szenasy, Publisher/Editor in Chief Metropolis magazine.
The Metropolis Think Tank series is presented in partnership with DuPont Surfaces, Sunbrella, KI, and USGBC.