Woulda, Coulda, Shoulda: Part One, Communications

Poem by Shel Silverstein

 In spite of our best efforts, this poem by Shel Silverstein, the well-known children’s author, describes the buyer’s remorse too many of our clients feel when they move into their completed space. When I say too many, one would be too many in my opinion. But it does happen, and we all have experienced that, amid the joy and relief associated with the long construction project finally ending and the pleasure at all of the things that work well, there are some unexpected disappointments.

Our job is not just to design buildings but to help guide our clients through the myriad details that make up a successful project. In order to do this we have to communicate a lot of complex interrelated information, often to users who a little or no experience with facilities planning or designing new construction.

Recently our work with mission driven, inner city health clinics made me focus more on ways we can improve communication to create more clarity during the design process, and how we can follow up with the client to help them evaluate how their how their space works for them. Specifically, in this case how their space either enhances or complicates their efforts to deliver healthcare.

There are two major components to this that we would like to improve; Communication during design (so we are better at explaining the space we are creating) and better understanding the users’ Process (to verify that it dovetails with the space created). Ultimately it is the interaction between these two concepts that create an effective facility. This post is going to focus on Communication and offer some ideas about how to help our less visual and more analytical clients feel more comfortable with the choices they make.

One of the most interesting aspects of working with this client type is their position on the front lines on the change in healthcare delivery. Although they have been working for years providing care in the same underserved communities, suddenly mainstream healthcare organizations and systems were interested in them and money was available for new construction. Going from 8,000 square feet in leased space with no windows to 35,000 square feet in a brand new building that they would own and manage themselves has opened a huge range of opportunities, not just to occupy better space, but to refine their processes to provide better patient care.

The difficult part for us as designers is the challenge of translating a new untested process into a built solution with a client who has difficulty visualizing solutions and how the changes in their process would be impacted by the space provided.

Since we work in Revit, from the earliest concept layouts we had 3-dimesional plans to show them. But our 3-dimension drawings and sketches are not much help. The client repeatedly attempted to correlate the new space to their existing situation without any understanding of how their existing inadequate space had formed their process. In other words, they just could not think outside the box, literally. Also, they could not imagine how their interaction as a medical team serving a patient would be transformed by an environment that was designed specifically for their process, because the process and the support technology they were using was new; new to them, new to their industry and still changing.

To make matters worse they were seizing this opportunity to rethink their treatment model. Encouraged by a managed care environment and knowing the challenges of dealing with a population which they may have trouble tracking for follow-up care, their new treatment model strives to address all aspects patient care in an integrated manner, while the patient is in the clinic. Additional communication among the care staff is required throughout the patient visit.

At the other end of the care spectrum, the new space has radically increased the number of exam rooms covered by each doctor; from one to three or four. This reduces the number of patients sitting in the waiting area and places them in exam rooms expecting the visit from the doctor. The doctor moves more efficiently from patient to patient and sees more patients per day, but how does this impact the interaction with the rest of the team and the patient themselves?

So we tried to look at the space created as a framework for their process. What tools could we use or create that would help them better understand the physical boundaries of their process so they evaluate it critically before it is built.

Various companies have developed software that allows you to use an avatar on-screen to walk a user though the space so they can experience the environment created. A lower tech, but equally effective tool, is to use a floor plan and different colored post-it’s to track the path of each care provider in the space, much like a programming session but with the added dimension of movement. Remember that a clinic is more like a factory than an office space, where individuals with specific jobs repeat patterns throughout the day; a dance where each player has specific set of steps which is complimented by those of others; prep, examine, document, clean, supply, prep, examine, documents, confer, etc.

The post-it method allows each person on the team to participate, to describe the pattern their work requires they must follow and how it could be optimized. The final diagram shows most of the critical data the designer needs; where paths intersect, where there is communication, where there is conflict.

This diagram affords a much more concrete view of the way processes are being impacted by the space and answers some questions that can remain open long after the design documents are complete: Should we use a triage system? If so where will it take place? Where will the physician complete his or her paperwork? What is the most efficient location? The most desirable from a patient care perspective? Do the medical assistants have good visual access to the exam rooms? Do they have good proximity to supplies? To clean and dirty utility? What is the patient’s path? What do they experience? What do they see? How can we improve their comfort? How do we maintain their dignity? How to we give them a better overall experience?

But the ultimate test is how the space works in the daily treatment of patients. How successfully we have been able to translate the process into a built environment that supports the efforts of the clinic staff. Since we are currently designing a second facility for the same client we have a wonderful opportunity to find out what we did right and improve their future facility.

Our next step is to tour the completed facility with the client, but that will only give us so much information. A richer treasure trove can be unearthed by observing the behavior of patients and staff alike within the space and translating that back into a diagram of the space.

I hope the next installment of this blog will be full of information that we’ve gathered about the actual function of the space and about user satisfaction, about what we did right and what we can do better in the future or as the poem says:


All the Woulda-Coulda-Shouldas

Layin’ in the sun,

Talkin’ ’bout the things

They woulda coulda shoulda done…

But those Woulda-Coulda-Shouldas

All ran away and hid

From one little Did.


Because as architects we are all about the DID!


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