A portion of Benjie and Nebal‘s discussion about the design aspects was published in the May 21, 2020, edition of the paper.

Links

• Chronicle Herald article
• Blog post announcing replacement of Villa Acadienne (new design is based on the household model discussed in the interview)
• Blog post discussing impact of household design on Long Term Care facilities in Nova Scotia
• Blog post announcing engagement to present Nova Scotia’s household model at healthcare architecture forum
• Blog post announcing engagement to present Nova Scotia’s household model at conference on aging
• Annapolis Royal Nursing Home (Nycum household model project)
• Northwood at the Parks (Nycum household model project)

Links

• Hadrian’s Blog Post
• Nanuk Technologies

Healthcare challenges in the future do not have a roadmap of experiences on which to create policies and plans, but they will be real, massive and swift: Technology-driven change is coming to healthcare that will combine with real pressures to disrupt almost every current healthcare practice. We have seen this disruption happen to other industries (for example the music industry in the 00’s presently in education and the taxi business). Much of this change has been good for consumers, but for providers it has created a new landscape. Unlike for other industries and service providers, technology-driven change has been slow and incremental for healthcare because there is so much liability and risk. But once these factors are overcome, the current paradigm will be massively disrupted. Most of the change will not be predictable or created and managed by the people in the know. It will come through the backdoor in unexpected ways. The driver of this disruption will be the superconvergence of technologies combined with diminished financial and human resources. The current planning window for any healthcare facility must recognize that plans will be implemented during this disruption so it is very important to avoid applying current assumptions. Things to think about:
• What are the factors and technologies leading to this disruption?
• How will the roles of patients and healthcare providers change?
• What will be the role of facilities when technology enables healthcare to be delivered in environments created by algorithms and networks rather than bricks and mortar?
• What is the future of the hospital?
• How do we get ahead of this so we can seize it as an opportunity rather than be subordinated to it?

Would it be safer to have Multi Gender Change rooms in our schools and how can we design these so that BULLYING is decreased and PRIVACY is improved?

Guidelines have been released to to support transgender and gender-nonconforming students. These guidelines state “All students have a right to safe washroom and change facilities.” We are launching an open-source forum on the possible design of Multi-Gender Change rooms. To read these guidelines click here.

Based on this theme we have four variations exploring how we can improve these environments. Feel free to walk through the four variations by clicking on our 3D viewer link on the right and let us know what you think. We have also released the Sketch Up model so you can create your own version. Click on the link to the right to download the Sketch Up file and don’t hesitate to send us your model at: mail@nycum.com

What happens when you design a portfolio of projects using a design standard?

We examined the designs of 44 newly constructed Nursing Home facilities in Nova Scotia in order to study how they followed a newly introduced design standard. We wanted to learn how closely the facilities resembled one another, and where they differed. The projects were designed by different teams for different builder-operators, and were designed and constructed roughly simultaneously. We found it intriguing how design standards can both restrict and encourage innovation and best practices (which are always evolving). This is a summary of our findings along with some considerations for crafting a design standard.

1. Not everyone interprets design standards in the way in which they were intended, and their meaning may not be widely and consistently understood. What is a “design standard” and what does it actually mean? (Is it official? Is it a guideline? A law?)
View the standard as driven by outcomes, rather than prescribed methods of getting to those outcomes, and include explanations of intent within the standard. Be clear about the enforceability of the standard.

2. Procurement processes in a multi-project portfolio impact the interpretation of the standard. The values against which the winning designers/constructors/operators are selected (i.e. cost, sustainability, durability, quality etc.) can impact the way the standard is interpreted and either curtail or enhance opportunities for innovation
Consider how procurement mechanisms relate to the standard that will be enforced. Are the procurement values in synch with the standard’s values? Seek alignment. If the main objective of the standard is durability, do not procure for lowest cost – the result will be challenges to the standard where durability can be interpreted in multiple ways.

3. A standard that is radically different from existing practices means that the processes of the occupants will be forced to change. Culture change must occur quickly and within the premise of “what will be.” This can be challenging at the best of times, but difficulties in adapting can be amplified when the impacts of a standard are not well understood, as is often the case.
Implement a structured culture change process as part of the design standard roll-out.

4. Designing and constructing several facilities simultaneously reduces opportunities to learn from project to project. This is not a factor of standards, but of the timing of implementation of projects that follow the standard.
Implement projects in sequence and include a mechanism for studying impacts on a project-by-project basis. Include mechanisms in the standard to allow for adaptations from lessons learned.

5. Unexpected interdepartmental conflicts may emerge within government agencies responsible for various aspects of review and approval. For example, in a healthcare project in Nova Scotia, the Department of Agriculture may have concerns with food delivery, floor finishes, and tasks of the front line workers as outlined in the standard. Work-arounds during implementation to satisfy conflicts between agencies can cause cost and timeline chain reactions.
Cast a wide stakeholder engagement net in the early stages of writing the standard.

6. In a building’s lifecycle, operating costs are much greater than upfront capital construction costs. If operations costs are not contemplated in the standard, they will be sacrificed in order to meet the capital construction project requirements.
Consider life cycle performance of the building when developing standards, not just cost on opening day.

7. Standards are uniform, but projects are impacted by unpredictable variables. Geography, labour and materials, topography, site availability, risk management, and politics are factors that can put unexpected pressure on a standard.

8. Seeing is believing. When people can touch and feel what is in their future, they imagine fewer obstacles.
Run pilot projects within existing facilities.

An effective PM is someone who can lead and manage a project from start to finish while achieving targets in cost, quality, and schedule. Fundamental to success is the management of risks, resources, procurement, integration and relationships.

At Nycum + Associates we manage projects as well as work with PMs in the design and construction industry. This is our list of special qualities that identify a highly effective PM.

1. A strong PM has an intimate understanding of the tasks. Certification (i.e. PMP) is one part of the puzzle. Great PMs also have years of hands-on experience doing all, or most, of the tasks involved in a project. A PM understands how things can go wrong and can influence them going right. Your PM should come from within the industry of the project.

2. Effective PMs know what drives the people working on the project. The best PMs have been in the shoes of the people they are managing. They know what is delightful about a task and what is a bore. They can tell the difference between a legitimate technical difficulty and a lame excuse. A PM needs to be able to motivate people and needs an arsenal of experience paired with respect and understanding.

3. Great PMs respect standard industry contracts. PMs know that standard contracts have been developed over time by industry representatives from all facets of the interests to the contract. They know standard contracts have been shaped by legal precedent. A PM who offers clever amendments that favor one side should be avoided. A valid contract amendment is one that is an unavoidable customization to suit specific project conditions. Superfluous amendments frustrate the contractor, who typically does not foresee how they will be enforced at the time of signing the contract. They also present grey areas which may become legal quagmires. Seek a PM that understands why standard contracts are written in a particular way and balances that with educated and experienced insight into how to suit the project’s particular needs.

4. Truly talented PMs represent the success of the project – not just the client. Representing the client is a big part of the PM role. However, a weak PM uses this as leverage. A competent PM capable of seeing the project through to its successful end knows he/she must earn the respect of everyone involved on the project, not by imposing position. Look for a PM who is focused on successful project results on your behalf, not on being your mouthpiece.

5. A PM confronts problems openly. A strong PM brings all players to the table immediately to confront problems and create solutions. If a PM requests advance private meetings to “strategize,” be wary. This can be a sign that the PM has prioritized controlling the message over achieving a great solution.

6. A PM never undertakes or changes the task work themselves. Say a contractor has been hired to write a specification. Subsequently, the PM makes some changes to that specification, for what may seem to like good reasons – perhaps their change is intended to achieve better pricing. The PM has now taken liability for that specification. This liability is probably now no longer insurable. A good PM understands where responsibilities are assigned, and works respectfully to allow the contractor to consider changes to their own work.

7. A strong PM embraces existing work processes and nurtures innovation. Workers and contractors have well established work processes to maximize efficiency and avoid error. Some processes are more sensitive to change than others. On a rural construction project, a PM introduced and subsequently enforced a “.pdf digital documents only” policy where faxes would not be tolerated. This was met with confusion and resistance from the general contractor who communicated primarily by fax due to their construction trades who were not tech savvy (but nonetheless great carpenters), but the PM held to his policy. No one disagreed with the environmental principle, but forcing a change to an established process left the trades feeling disrespected and misunderstood. Not an ideal project start.

8. A worthy PM avoids promising the impossible. If a PM argues they should be hired because they possess the tools to control the workers to meet targets, be cautious. The reality is no PM can control quality, schedule and budget. They can only influence aspects of these. On the flip side of overpromising, be wary of a PM who is over managing your expectations. While managing expectations is important, an obsession with this is a sign that the PM is setting the project up to align with his/her abilities and not the optimum project potential.

9. A strong PM takes responsibility. Even a verbal acknowledgment of responsibility for outcomes is a good sign. If a PM has reduced their role to ‘just the messenger’ it’s a sign they have lost control. A weak PM reports on failure and takes credit for success. A strong PM takes responsibility to overcome failure and openly gives credit for success.

10. A PM should make outward demonstrations of respect and desire for everyone’s success. The best way to achieve project success is for everyone to feel like they are contributing to this success and they themselves are successful. A Project Manager we worked with on a construction project that achieved all of its targets was known to drive hundreds of miles through the snow to deliver progress payments to the trades working on the project. It was a little thing, but the intended message was received by the trades. They knew the project manager was invested in their own success as part of the larger project success picture.

The article is a reference to the NXT Patient Room 2020 Prototype, a full scale prototype that involved 30 industry partners in its construction. Among these are Amuneal, Armstrong Commerical Ceiling Systems, Barrisol, Bendheim, Christian Rae Studio, Cleankeys, DuPont, Duravit, Evans and Paul, Evergreen Medical, Grohe, Hafele, Handicare, Holosonics, Infinity Drain, Intense Lighting, Jay R Smith MFG, Co., Linet Americas, Lutron, Medline, Milliken, Osram Sylvania, PK30, Duracel Powermat, Price, Savant, Skanska, Smith, Seckman, Reid, Inc., Standard Textile, Synapse, Traxon, Trufig, and Tyco.

The prototype is the kind of thing over which techies salivate. So it’s no surprise that Wired Magazine also chimed in with a piece about it entitled “What Would the Ideal Hospital Look Like in 2020?”. In their story, Wired called it “the nicest hospital you will never visit” with design touches that “make it feel like an iPhone” and references “the sterile palette of hospitals from the 1950s and 60s.” which “also brings gamification to the hospital.” The comments left by readers in response to these claims are well worth the read.

The NXT Prototype pushes the thinking on managing the spread of hospital acquired infections and endeavors to incorporate a wide range of emerging technology into patient care – all good things. It emphasizes overcoming challenges faced by patients and caregivers, such as “patient and staff safety, engagement and empowerment in care process, quality of care, and efficiencies in work processes.” These are all valid issues that need to be considered and improved in the patient room.

Unfortunately the prototype appears to be heavily influenced by its industry partners in what should be a more rigorous academic study. Instead of casting itself in the role of a patient-centered futurist, it could more appropriately call itself “what 30 highly interested members of the supply chain would do if they could bypass the architects (and patients) when hospitals are built.”

Another issue is not with the NXT Prototype itself, but the journalistic slant that sustains the simplistic concept that high-tech and high-sterility equate to better care. In the USA, hospitals compete with one another to attract patients. By extension, promote-ability is also an important factor in room design. If Hospital A can brag about offering something Hospital B does not, then hopefully Hospital A will have more patients clamoring to occupy their beds. The problem is that the important metrics of actual patient care and outcomes are replaced with the potency of trends in technology and futuristic aesthetics. This, of course, is nothing new. Seductive images of the future are keys to promoting consumer spending, but it comes at the cost of being patient-centered. Furthermore, this is an expensive room, so it also comes at the cost of patient access, especially in the USA.

When a patient room design is authentically focused on the patient experience it is known as patient-centered design. The NXT prototype promotes things that may end up contributing to an improved patient care outcome, but in themselves have failed to put the experience of a truly ill or dying patient at the center.

There has been a lot of progress in the design of the patient-centered room of the future [1, 2, 3, 4, 5, 6] and it is often reflected in both the popular media and in media created and consumed by the relatively small international circuit of Healthcare architects.

Getting the design “right” on a patient room is important because it is a room typology that is repeated many times in a single hospital project. We admit that in our patient room designs, we don’t achieve all of our objectives. Many factors – including cost, constructability, consensus building, conflicts between staff and patient ideals and others – often conspire to water down an “ideal” patient room design. It should be noted we work primarily in Canada where we are blessed to not be burdened by the corporate objectives of hospital competition. The NXT prototype will be enjoyed here as a frame of reference, but it will be understood as a fantasy. Only the aspects that offer true value will be cautiously embraced. The staff control centre and the accessible bathroom are two examples that would be of value. The size at 400 sq ft and the halo are probably no-gos.

A compounding factor in any healthcare visioning exercise is the lag between the design of the room and actual occupancy (often 3 to 5 years). To design a patient room is, by rights, to design obsolescence. In other words we can dream of integrating all kinds of technology today but in 2020, technology and medicine will be very different. In his book “The Creative Destruction of Medicine” Dr. Eric Topol demonstrates how this will be a monumental issue in the not-so-distant future because we are upon a super-convergence where today’s practice of medicine will soon be dramatically transformed to “new, individualized medicine that is enabled by digitizing humans.” The patient room has as much chance of being eliminated altogether as having a likeness to the NXT prototype.

The NXT Patient Room 2020 Prototype’s aesthetic suggests (and the Wired article infers) that healing is best done in an environment akin to being trapped inside an iPhone. But human comfort comes from what we know: the familiar. The sterile look of the 50’s hospital fused with the latest spoon feeding from Apple is probably a pretty exciting experience better suited to a futuristic theme park ride or possibly the cabin of the latest long-haul commercial airliner (sidenote: A recent project by priestmangoode offers up some exciting potential by fusing aircraft cabin design with hospital recovery spaces). The NXT room is an environment alien to anything a patient would experience in their day-to-day life. Thus, not only is the patient forced to confront the complicated and deeply unsettling realities of their own illness or procedure, they must also overcome the overwhelming sensation that nothing around them is normal. It is hard to imagine a less healing environment.

The aesthetic of the NXT Patient Room 2020 Prototype is not just designed to be futuristic, but like hospitals of the 50’s, it is inspired by sterility itself. Designing healthcare environments to minimize or prevent the spread of infection is a given and a reflection of the function of the facility. In and of itself, however, this is not patient-centered design. What a sterility aesthetic really suggests is that the patient is an infection waiting to happen. Designing a sterile environment is not difficult. Designing a patient environment that supports and promotes the individual’s physical, emotional and psychological healing, while being efficient, cost-effective and minimizing the incidence of hospital-acquired infections should be the framework for patient-centered design.

The presence of family is another sadly lacking contributor to patient comfort, care and recovery, and safety. A patient-centered room makes family welcome and comfortable. Designers must work hard to provide this in spite of the limited square footage available. The NXT Patient Room 2020 prototype, the WSJ and Wired have missed this important feature.

Being patient-centered also means enabling the efficiency of the front-line staff that care for patients. Hiding “medical” services behind indistinguishable/blank/sound & light reflective solid-surface panels means extra steps for staff who would rather be providing care than converting a room. If we are to dream – after all that’s what prototypes are about – then we need to embrace a holistic approach that conceals the intimidating gear while also improving efficiency and productivity,

With the increasing body of evidence [1, 2] pointing to the health benefits of biophilic design, the absence of natural products, daylight, views, nature, or any kind of softness in this prototype seems like a huge oversight. The only thing missing from the NXT room is an automatically triggered laser beam to kill fresh flowers brought by unwelcome visitors.

It is crucial that research continues to push current thinking about what it means for spaces to be truly patient-centered. There is plenty to learn from the NXT prototype and much of it is very good. Hopefully the next NXT prototype room (for 2030) will incorporate a human side and not just let the industrialists and techies be the ones to imagine the future. Maybe they will let patients participate, as in the example of the Saskatoon Regional Health Board in this video, where an authentic community engagement was undertaken in the design of a pediatrics hospital. Perhaps it will embrace all the good things technology has to offer while also embracing the human stuff like interaction, our place in the natural world and more elements of psychological comfort.

As it stands right now, we might choose the hospital of future 1950 over the Hospital of the Future 2020 – at least it had a pool!