practice elective: design business start-up culture

CONVERSATION

SUMMER 2021 | PRACTICE ELECTIVE | PROF. MICHAEL GAMBLE

A conversation about evidence-based design with Camilla Moretti, Principal Architect at HKS, and Michael Gamble, Director of the Master of Architecture Program at Georgia Institute of Technology.

camilla moretti anna rogers michael gamble

144 Anna Rogers Thank you so much for taking time out of your Friday afternoon to talk to us. I'd like to kick it of by allowing you to introduce yourself and then we'll jump into the questions.

Thank you for having me. My name is Camilla Moretti. I am an architect and healthcare planner for HKS. I am the health studio leader for the Detroit office and work with a lot of different offices nationally within our HKS world. I've been with HKS for 14 years now. I joined right after grad school and have been lucky enough to work with the best in the market. Our Detroit office is one of the research hubs for HKS and I am privileged to work with Dr. Upali Nanda, who you probably know from the health-design world. She's fantastic and I've had many, many opportunities to work with her on applied research projects. So, looking at some of your questions, I'm like this is fantastic. I'm very interested in combining operations and lean thinking into design and applying research – either evidence that exists or, when it doesn't exist, trying to find that you know and do the applied research as part of our project so. We talk a lot about, within our design continuum, trying to insert and integrate research at every step of the way.

A.R. Wonderful, thank you. Can you tell us a little bit about what evidence-based design means to you?

C.M. To me the thing that we look at is all of the data that's out there. You can't do all the research yourself, so we like to leverage the types of research and information that peers are doing and things that are available in peer reviewed journals. It's really looking at what is hearsay, what is anecdotal information, and what really has data to support it. A lot of times it’s not just evidence-based design, it’s evidence-influenced design. There are certain things that are solutions to each problem that our clients might have that are not exactly prescribed by the evidence, but you can connect back to evidence. Does that answer your question?

A.R. Absolutely, yes, and it leads me into the next one about working with clients. I was wondering if there is any resistance from clients to engage in applying the evidence?

C.M. Well, when you work with health systems, they are very empirical in their own way of working. A lot of times when we talk about different aesthetics and things that are a little more subjective – that is harder for them to grasp. Data is the language they speak. I found that using data to help support a design is a lot more successful than anything and they appreciate knowing that there are things that are supportive of a design strategy and things that are not supportive of the design strategy. You know, what are certain things that are proven by data and some of the things that are – maybe, you know, there's a lot of good anecdotal data, but not quite yet a study that they might be up for participating as part of a deeper dive study. We actually had that with ProMedica, the system up here in Ohio, and they were on board with doing an applied research project for pre-design to help guide the design of their new in-patient tower.

Camilla Moretti

And through that we were able to gather a lot of really good data, use that data to help define the design of the new units. And we're able to test through some parametric tools that HKS has developed in real time. We're finally going back on site to do our functional performance evaluation, our POE. So we are now closing the loop – the informational loop – on that project. And they were just such fantastic partners. Very interested in the evidence and, where there wasn't evidence, how can we get that information based on a deep dive study.

I had one follow up question- well, it was really more of an observation. Architects, I think, were complicit in magical thinking about evidence related to energy consumption. Architects, for the longest time, drew these magic arrows that suggested air flow that never really went anywhere. But now, if anything, it's given architects more purpose to say that applied research and evidence actually matters. And that we can learn through post occupancy evaluation and evidence-based research. So, my question would be related to those, what's next in the area of evidence-based design? I know Anna may have that question, but I couldn't help following up anecdotally related to magical thinking.

C.M. One thing that always comes back – and I think it's kind of the missing loop – is how can we attach any of the evidence to a bottom line? For example, we know that there's a lot of evidence that supports point-of-care supplies and different strategies that support point-of-care supplies but to make the case to a client that they need to do this because it's going to save X amount of money or X amount of hours…that's kind of the missing piece. It's showing the ROI [return of investment], and I feel like that's where we could really connect the whole spectrum of evidence and design and the operations. Putting that all together and understanding, what is the return on investment making this decision? We talk about, well, there's more nurse time at bedside. Well, how much more? What does that mean? How does that translate? Does that truly translate in higher HCAB [healthcare access barriers] scores? For example, do I have a lower incidence of falls because nurses are closer to patients? Those are some of the things that go from the overall database and having some of that more applied to projects where we can get you know actual percentages and that hard data to share with our clients would be very important.

A.R. Great, that’s wonderful. My next question is related to billing. Do evidence-based design services cost more? How does your firm bill for research versus design services?

C.M. Well, I think that good design is evidence-based design. Good design is based on best practices and what we know of. That is baseline services, so that doesn't cost anymore. Something that would be an additional service or a service that we provide to our clients is that additional deep dive research that's applied to that project. So, if there is a question or something that would require X amount of hours from our team to do a deep dive shadowing

Michael Gamble [Director, M.Arch Program]

...good design is evidence-based design. ”

146 or observation or surveys – those kinds of things that are more on the applied research side – that would be considered an additional service or a service that we can provide our clients. But just to be able to apply evidence-based design strategies to a project – that should be every project. Every project should start with that baseline.

promedica | toledo, ohio | hks

A.R. I'm really happy to hear that.

MG: Me too, I mean, we’re coming to you from Georgia Tech – you know we like evidence.

C.M. I mean the whole point is, there is data out there if you're, you know, not keeping up with it and understanding different systems… you can't work with everyone right? So, if there are lessons learned or good things to learn from other systems, other researchers, other studies… that would just not be smart not do it, you know? So, why make the mistake? If we know something doesn't work, why would we want to do that to our project?

A.R. So how do you keep up? Are literature reviews or journal clubs part of normal practice at your firm or do you keep up with it on your own?

C.M. All of the above. A lot of times when we start a project, we do have lit review. What do we know? What's out there? And then we do have a lot of internal knowledge sharing opportunities. I personally run a monthly session of planning – early on pre-design and planning information – that's a national call. Every month presents something different and we have a library of everything that you could think of. So, it goes from full on formatted to a little more prescriptive presentations to just conversations on, ‘what did you learn this week?’ Or you know anything that the teams want to share on – the good, bad and the ugly. The internal knowledge sharing that we have is pretty robust and our research team internal to HKS is really

good at sharing, even if it's small little bites of different articles, different things. They actually are very good at synthesizing a paper into – you know, for those of us that are not researchers – [something we] understand and kind of just get to the point. Like, the executive summary of that enormous paper, this is what we need to focus on. They're really good at doing that so we can keep up with that information that's available.

A.R. Excellent. That's really encouraging to hear. So, changing gears a little bit, I want to talk about post-occupancy analyses. I’m curious- what percentage of projects does your firm perform a post-occupancy evaluation on?

C.M. Sometimes, as part of the project on the get go we'll do a functional performance evaluation and at the end a year, usually a year after. I personally have done four or five big projects that we had identified early on or, there was things that we had applied during design that we, as a firm, wanted to verify how it worked, what worked, what didn't. It's always a great way to close that information loop.

A.R. And what do the post-occupancy evaluations usually look like?

C.M. We do a survey, we do interviews with key stakeholders, and we go and shadow. So there's observational data as well as different key performance indicators that we identify early in the design and want to measure after the fact. So we take those key data points and document those as well. So it’s a multi faceted approach to that POE. We want to make sure that we are walking the walk, that we are there with them and doing the shadowing. One thing that we learn earlier on is that, if you’re just doing interviews, the human brain has a way of smoothing through hiccups. We had this very interesting process where we were doing current state mapping with nursing. They were describing their process and it was so very linear and beautiful. At the same time along side of [the interviews] we were doing the observations and we were like, “Well we noticed that you had to go to the nourishment room four times for that one medication event, they’re like, oh, I never thought of that.” So it’s really going and seeing – the lean terminology, going to Gemba – where the work is being done and learning from that is key. I gotta tell you, clinicians are fantastic at making things work. You know we joke around, it’s like the good, the bad and the work around because they’re going to provide care, the architecture supporting it or not, so they will make it work, and they’re fantastic at it. So, our job as architects is to really look at their process and see how we can make that better, make it easier for them. And, ultimately, it improves patient experience.

A.R. What types of buildings or settings present the biggest challenges in applying evidence to?

C.M. I think every project has its own set of challenges. I mean you have those very complex renovations that a lot of times is having to deal with existing structure, existing MEP things that you just can’t go around. But there’s nothing that prevents you from applying the concept of evidence-based design. It’s all about framing and getting that rapport with the client that you know they understand. It’s always an education process, right? They don’t do [design] every day. They live in it; they live the space. They’re the experts on how that space functions. But we design spaces every day. So, we work together with our clients to establish what’s relevant of the evidence that we have available. How can we apply it to improve the processes

148 that happen within the space? And how is that going to improve their operations? How is that going to make their lives easier? Really, that’s the whole point. Why would somebody who spend millions of dollars to do a renovation or an addition or a brand-new greenfield hospital if we’re not trying to make their lives and their patients’ lives and their staffs lives easier and make them more efficient? So, I think every project has its challenges is just identifying [the problems]. I think that’s really the beauty of our job – is understanding the challenge and rising to that challenge; to deliver a beautiful project that works really well.

M.G. Have you participated in interviews with patients who believe that their experience in one of your newer evidence-based hospital or healthcare environments contributed to faster healing, better state of mind, etc.

C.M. So, the interesting thing with a lot of the research that we do is that anytime that you are dealing with clients, you have the IRB (institutional review board). So, a lot of times what we do is focus on the PI, the performance improvement area. We get the relationship of where the HCAB scores were before and where the HCAB scores were after. When we do have access to patient-family advisory, absolutely, that is such a wonderful connection to have. We don’t get that in every project, unfortunately.

M.G. You know, I’m the kid who didn’t like blood growing up. I just wasn’t interested in medicine. We have a number of doctors in the family and they’re big believers in [biophilia]. They’re also, increasingly, bigger believers in homoeopathic treatment and just exercise, you know, just commonsense stuff that people feel like they need a prescription, or they need to see a doctor for, and it really just has to do with the simple things. And I can imagine the same applying to hospitals. You go through all of the filters of reason, as healthcare was emerging as a major discipline in the industrial period, but then common sense falls out of the equation. And then it finds its way back in. Part of my feeling about evidence-based design – or evidenceinfluenced design, which I really like, very clever – I like the fact that common sense finds its way back into the room.

C.M. You know, and it’s so funny because, to me, the best designs are simple. There’s something just so beautiful that you can walk into a space and intuitively know where you’re going. That’s one of the biggest issues with healthcare. It’s usually a very large building and you’re catching people at their worst. Can we make it so that it’s simple? That common sense, as you’re saying, can be the guide. Providing our patients and our staff what they need

...just to be able to apply evidence based design strategies to a project

–that should be every project. ”

when they need it. It’s just so simple, right? Providing them with what they need, when they need it. It’s a simple concept, but something that is so very important, and I think that is one of the big things you know when I look at a plan and I’m working with the with the team, the thing I want is for them to think is, “Wow this is very simple.” Because simple is hard to do. That’s the point is, you know, trying to bring simplicity in and something that’s intuitive, too. Provide that connection back to the outside so they can reorient themselves. We have museum syndrome in a lot of our hospitals where you don’t know what’s North, South, East, West, anymore because you don’t see a window and you can’t tell.

A.R. This has been great and was incredibly informative. We are about at time, so I don’t want to hold you any longer. Thank you so much for taking time out of your day to chat with us.

C.M. My pleasure.

A.R. I hope you have a wonderful rest of your Friday afternoon and a great weekend.

C.M. Thanks, you too. See you guys!