Research_Case Study

designing for health

ARTICLE PUBLISHED IN: Contract Magazine Online, January 14, 2010

http://www.contractmagazine.com/contract/content_display/design/features/healthcare-design/3i45e69997d0a6aeab8e1510d5e363cc70

“Designing for Health” is a monthly, web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today’s healing environments.

Designing For Health: Leading by Design – A Place to Flourish Tama Duffy Day, FASID, IIDA, LEED AP

me to be a better leader in a generative organization and hopefully to use those skills to inspire our design teams to truly create generative space.”

Another participating in Leading by Design, James Lesslie, president of BOLYÜ Contract Carpet, says, “This collaboration completely changed our product design thought process. The concept of ‘generative space’ challenges everyone to expand their ideas about healthcare.”

Arlington Free Clinic “bloom” partiagram Image Credit: Perkins+Will

In 2004 Dr. Wayne Ruga launched Leading by Design, an experiment to pioneer the next generation of improvements in health and healthcare delivery through the design of the environment. Leading by Design is an applied research project, currently working with 10 active case studies in five countries. Culminating in “generative space,” Leading by Design focuses on growing leadership attributes in one’s personal life, organizational and professional work, and community engagements. In the simplest of definitions, “generative space” is a place to flourish.

Bruce Raber, vice president and practice leader for healthcare at Stantec Architecture in Vancouver, B.C., a participant in Leading by Design for the past three years, states, “When Wayne first approached me about the project, I was excited about the opportunity to get involved with a group of people from around the world who all really wanted to make a difference. Through participating in Leading by Design, I have learned concepts about leadership that allow

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The Arlington Free Clinic (AFC) project is one example of a case study illustrating how Leading by Design helped to cultivate generative space and how it did, indeed, expand ideas about healthcare. As Nancy Sanger Pallesen, the executive director of AFC, explains, “I was intrigued with the concept of healing design. My initial meeting with the Perkins+Will team opened the door to learning how design really can influence healing. Through conversations with the design team, reading articles about healing design, and being introduced to generative space themes, my view of what could be accomplished in our new clinic space increased dramatically.”

AFC, a private, nonprofit, community-based organization, provides medical care at no charge to low-income, uninsured people through utilizing volunteers and partnering with other health providers. At its inception in 1994, AFC saw 12 patients in the Thomas Jefferson Middle School. In 2008, AFC provided 8,655 patient visits, including primary care, specialty care, mental health, physical therapy, and patient education. And on June 18, 2009, the Arlington Free Clinic held its grand opening, showcasing a new 8,000 sq. ft. facility built entirely on donor contributions. This is the first free clinic in Virginia to become LEED certified.

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Although the project started along the typical phases of programming and schematic design, participation in Leading by Design inspired a different structure for the project. The team focused on distinction of space, understanding the importance of creating a physical environment where the patient and medical professional engage in both the physical and the social space. We embraced concepts of sustainable design and evidencebased design all under the auspices of creating generative space.

AFC floor plan Image Credit: Perkins+Will

AFC “welcome” reception area Photo Credit: Ken Hayden Photography

More data on the AFC project can be read in the Leading by Design Case Studies, but through action research strategies including behavioral mapping, observation, questionnaires, programming and reflective study, one consistent element connects all the research: nature. Nature always had a core, a center—the AFC logo was a tree with a core of people, the director of the AFC was the core of the organization.

And with that connection, a simple flower became the diagram for the plan and our design parté. Bloom became our symbol, and this core engaged the four essential elements of the Arlington Free Clinic: welcome, support, community, and treat. As the physical design emerged, the multifunctional conference room became the literal core of the plan, as it was used by patients, volunteers, and staff alike. As the design components grew from the floor plan— the shapes and forms in the flooring materials to the ceiling elements to the wing-like moveable workstation dividers— all solutions built on the symbolic element of “bloom.”

Since opening, the success of the clinic has been recognized through a number of awards in design, sustainability and sustainable leadership. In addition, Arlington Free Clinic and Perkins+Will along with team members—Integral engineers, Bognet Construction, and Washington Workplace—won the Team Award, presented during the Healthcare Facilities Symposium. The Team Award focuses on a project team that has worked together to change the face of healthcare design through innovation, creativity, efficiency, and teamwork.

AFC “support” administration area Photo Credit: Ken Hayden Photography

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designing for health

In a post-occupancy survey of the 14 full-time clinic staff, 100 percent responded that the new clinic space is “light filled and uplifting,” and 75 percent indicated that the new space “inspires health.” Mardelle McCuskey Shepley, D. Arch. at Texas A&M University, is conducting additional independent post-occupancy research. Results of that study will be shared on June 4, 2010, when the Arlington Free Clinic will be the location of a tour and presentation during the Environmental Design Research Association (EDRA) conference in Washington, D.C. EDRA advances and disseminates behavior and design research toward improving understanding of the relationships between people and their environments.

AFC “community” conference room Photo Credit: Ken Hayden Photography

Upon completion of the clinic, the patients had a celebration in which they brought in homemade food, played music, and danced to celebrate the space, the care, and the community. “Healing design really did create a place where all who come through our doors immediately felt better. They tell us that they feel they are in a truly special place,” Pallesen says. Recently, a patient held the front door open for another patient and said, “Welcome to the Arlington Free Clinic. This isn’t a clinic, this is a space for healing….”

As the clinic continues to provide clinical services, we will continue to seek additional quantitative metrics to evaluate and track its ability to support generative space—lifeenhancing, systemic, and sustainable improvements. As a result of these evaluations, the physical and social spaces will continue to evolve as a reflection of the continued learning that will enable a progressively improved generative space to be cultivated.

AFC “treat” examination corridor Photo Credit: Ken Hayden Photography

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To see a video of the completed clinic and their journey, please view the YouTube video here.

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Tama Duffy Day, FASID, IIDA, LEED AP, has been an active participant in Leading

by Design since 2007. She is a principal at Perkins+Will and is the national interior design healthcare practice leader, formulating research and design initiatives throughout the firm. She can be reached at Tama.DuffyDay@perkinswill.com.

Additional Resources: Tama Duffy Day Perkins+Will / Washington, D.C.

Arlington Free Clinic web site: http://www.arlingtonfreeclinic.org Bognet Construction: http://bognetconstruction.com/ – BOLYÜ Carpet: http://www.bolyu.com/index.asp Environmental Design Research Association: http://www.edra.org/ Healthcare Facilities Symposium ‘Team Award’: http://hcarefacilities.com/awards.asp Integral Engineering: http://www.integralpe.com/ Leading by Design Case Studies: http://www.thecaritasproject.info/ leadingbydesign/index.html Stantec Architecture: www.stantec.com Texas A&M University: http://www.arch.tamu.edu/ The ‘Generative Space’ Health Improvement Award: www.thecaritasproject.info/ aplacetoflourish The CARITAS Project: http://www.thecaritasproject.info/index.html Washington Workplace: http://washingtonworkplace.com/

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designing for health

ARTICLE PUBLISHED IN: Contract Magazine Online, April 19, 2010

http://www.contractdesign.com/contract/design/Designing-for-Health-1573.shtml

“Designing for Health” is a monthly, web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today’s healing environments. This month’s article focuses on connecting a healthcare facility with its urban community.

Designing for Health: An Urban Clinic – Connecting with Community John Spohn and Megan Bell Strolling through Minneapolis’ Historic Mill District, one passes by the Mill City Museum, an array of specialty restaurants, and the new Guthrie Theatre. Across the street lies Minneapolis’ newest urban park, Gold Medal Park, which offers views of the Mississippi River, the historic Stone Arch Bridge, and Gold Meal Flour ruins that are nestled amongst the newly inspired riverfront condominiums, one of which houses the new University of Minnesota Physicians Mill City Clinic in its street-level retail location. A new urban neighborhood has been created, and the design goals of the Mill City Clinic were to integrate patient care into this environment.

Photo Credit: Lucie Marusin

This clinic was born to reflect the neighborhood culture and give back to the community. Conveniently located in the new Zenith Condominium Building, Mill City is easy to find, and parking is readily available between the nearby parking ramps and direct on-street parking spaces. Mill City Clinic incorporates art and healing to create an inspirational and inviting healthcare environment, designed to promote positive patient outcomes in a unique neighborhood.

Dr. Jon Hallberg, family physician and medical director at the clinic specializing in primary care, family medicine, performing arts medicine, and health communication, states, “My charge is to make [the clinic] one of the highest in patient satisfaction, if not the highest in the system.”

Working closely with Hallberg and other clinical leadership, the design team strove to create a healthcare setting that would accommodate staff on a functional level, while also developing a sleek hospitality aesthetic that would fit in well

Photo Credit: Christopher Barrett

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with the urban neighborhood. The clinic’s modern design, use of light, and art displays are not only intended to make the clinic visually appealing, but also, as Hallberg notes, “Good design makes our job easier.”

Photo Credit: Christopher Barrett

Photo Credit: Lucie Marusin

The design team aimed to bring the best design value to the project, exceed the expectations of the neighborhood for outpatient care, and incorporate this clinic as a part of the community. Designers struck a healthy balance between featuring tall storefront windows along the sidewalk that connect the clinic to its environs with the need for patient privacy. Shimmering full-length sheer drapes in the lobby adjust to the changes in the natural northern light, while the contemporary and relaxing lounge coexists with the harmony of art and medicine. Passersby are intrigued with the beautiful sculptures and artwork that they see as they gaze inside the clinic, and patients and visitors alike are treated to music from students of the University of Minnesota music department and the neighboring McPhail Center for Music, who are invited to use the space to practice. Professional actors from the Guthrie often use the space to study their lines and at times even rehearse. And the Nina Bliese Gallery has a portfolio of art on display in the clinic, which is rotated to keep the pieces fresh and maintain patient interest during each visit. Events such as Hippocrates Café—a production illuminating the essence of family medicine through song, poetry, and essay—have welcomed a number of visiting healthcare professionals to this clinic and this unique neighborhood. This production—designed to illuminate the human condition, particularly from a healthcare perspective, through creative, artistic means—is just one of Hallberg’s ways of giving back to the community.

This clinic also sets itself apart from the ordinary healthcare facility with the level of care provided by the hospitable staff—a fact that is proven itself with very high scores from the last patient satisfaction survey. After being welcomed by the concierge, patients are personally guided back to

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designing for health

Photo Credit: Lucie Marusin

Photo Credit: Christopher Barrett

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a private consultation room to discuss and review medical information and insurance. Patients then are escorted to a private medical exam room, where a combination of daylight streaming through clearstory windows above and soft indirect light brings a sense of calm to the room. To alleviate apprehension associated with medical procedures, designers hid medical instruments from view behind a sleek recessed wooden cabinet, and books and magazines are on display for patients to enjoy while a waiting for treatment to begin. Comfortable, flexible seating arrangements accommodate family members, attendants, and/or interpreters who might accompany the patient. The layout of the exam room has been optimized to encourage the exchange of medical information between doctor and patient in a more personal, one-on-one conversation. The exam room is similar to an office setting with the articulating, flat-screen monitor positioned convenient for both doctor, and patient use.

Considering Mill City Clinic’s urban setting within the art district and along with condo residents who are accustomed to contemporary color and finish palettes, the design team knew the standard medical finishes would not be acceptable for this neighborhood. Sleek flooring materials and deep wood tones in concert with a rich neutral background complement the artwork and soften the palette, while bold, yet calming textures work with the sophisticated lounge furniture in the lobby to help Mill City Clinic redefine its interpretation of a “healing environment.” Hallberg calls this project “the iPod of clinics— something that is beautiful, thoughtful, inviting, easy to use and navigate, and maybe even game-changing.”

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John Spohn, LEED AP ID+C, CID is a senior associate with the healthcare market sector for Perkins+Will in Minneapolis with more than 25 years of design /planning experience, creating innovative environments for healthcare clients. He can be reached at john.spohn@perkinswill.com.

John Spohn Perkins+Will / Minneapolis

Megan Bell, LEED AP BD+C, CID, IIDA is an interior project designer at Perkins+Will in Minneapolis. She works within the Corporate+Commercial+Civic market sector and has experience of working on a wide range of interior architectural projects. She can be reached at megan.bell@perkinswill.com.

Data and content for this article was developed from the following sources: “Dose of Independence,” Chen May Yee, Star Tribune, August 18, 2008 “Mill City Clinic Now Open,” Barb Heyer and Emie Buege, Family Medicine Connection, January 2009 “Creative Thinking for the Healing Arts,” Fellman Studio Blog, November 8, 2009 Megan Bell Perkins+Will / Minneapolis

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Ray and Joan Kroc Community Center

The Ray and Joan Kroc Center is sited on the north shore of Staten Island at the southeast corner of the current Bayley Seton Hospital site.

Location Staten Island, New York Client The Salvation Army Area 110,000sf Schedule 2006/2010 In Association With Barker Rinker Seacat Architecture, Rampulla Associates Architects

A sloping site allows for a 3-story building, with the main entrance on the middle floor. The plan is organized around two circulation axes. Visitors enter on a “Sacred Way” that connects the Chapel, the Worship/Performing Arts Center, and the Sacred Space on the Upper floor., which intersected by a central corridor or “Main Street” on which all other program elements are distributed. Recreational areas requiring membership are located on the entire lower level.

All unpaid program elements are located on the Entry and Upper levels.

Because views of the Pool from the Lobby are an important design consideration for a community center of this type, the Natatorium is adjacent to the Lobby while the Gymnasium is located nearby. The Natatorium is a tall dramatic space with southern and eastern exposure. From the street, the three-story glass volume will act as beacon. In addition to the traditional lap pool, the natatorium will have a number of special pools geared more toward family water play, beginner swimmers, and the elderly. A leisure pool with zero-depth entry is a way to allow children

DattnerArchitects

learning to swim to enter the water at their own pace. A “lazy river” with a gentle current is good for children and the elderly. There is also a therapy pool and a whirlpool.

The gymnasium is located in a more peripheral position in relationship to the main circulation. It has bleachers that can accommodate 200 people viewing a game on a high-school sized basketball court. The gym can also be divided into two cross courts or volleyball courts for more informal play.

Fitness and Aerobics are located on the Lower level, near the Locker Rooms, and have views of the harbor.

Leading by Design

‘Leading by Design’ Case Study Tama Duffy Day – a work in progress

Table of Contents Who is Tama Duffy Day: My Position in the World Why ‘Leading by Design’

pages 2 – 7 page 8

‘Leading by Design’ projects Personal Work Community

pages 9 - 17 pages 18 - 29 pages 30 - 31

Next Steps

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Note: Specific words throughout my Case Study are underlined to signal the use and discussion of one of the applicable 22 ‘Leading by Design’ themes. This underlining convention identifies the presence of case study evidence that supports the action research methodology by demonstrating how and where specific learning and improvements have been made.

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My Position in the World My journey in the field of healthcare architecture and interior design has been filled with ups and downs, twists and turns, forks in the road. In 1985 when I was “selected” by my supervisor to join the team working on the Mayo Clinic’s new cancer treatment center in Rochester, MN, I nearly fainted. During the time I had been working at “inside” the corporate interior design practice within Ellerbe Becket, Inc. in Minneapolis, MN. As an entry level interior designer I enjoyed the challenge of test fits, square footage calculations, space planning, furniture selections and specifications and learning the art of corporate interior design. Being “selected” to work on the Mayo Clinic project felt as if I had been demoted. Healthcare design was, at the time, lacking in “innovation” and it also meant literally moving my workstation from downtown Minneapolis to the suburbs in Bloomington, MN. In my mind I didn’t really have a choice but to accept this project assignment. So, I packed up my things and began my journey into healthcare.

NORTH DAKOTA

MINNESOTA

From that moment forward my learning has grown exponentially. I knew nothing of the words nuclear medicine, linear accelerator, magnetic resonance imaging, but in time I learned much about the treatment of cancer and the methods in which the layout and design of a facility can make the experience for both the patient and the staff more friendly, more thoughtful. My mentors at Ellerbe Becket, Inc. - Rolf Oliver, John Waugh, J. Michael Florell, Susan Farr, Frank Nemeth - were generous in sharing their knowledge while I began to understand this complex science. And my mentors within the Mayo Clinic were equally as generous and gracious – Robert Fontaine, Richard W. Cleeremans and Cheryl Lavin-Meyer. In reality, I had no clue about healthcare design and that it was, in fact, very innovative and extremely challenging.

So, I often say, healthcare design picked me and I have been fortunate by that selection. It has influenced every step of this 20+ year journey in both my career and in my life providing me many paradigm shifts.

Around this same time two other eye-opening paradigm shifts occurred. I was one of a small group of healthcare leaders representing the United States of America invited by Tarkett, a worldwide leader in flooring, to visit their headquarters in Sweden. On that trip I met Jain Malkin, Barbara Huelat, Richard Babcock and Alan W. Mack. Being the youngster in the group, only later did I realize the significance of being included in this tremendous group of Leaders. We toured healthcare facilities, one of the Tarkett flooring factories and the Tarkett flooring design center. It was an amazing opportunity both personally, educationally and culturally. I truly became aware of Distinctions of Leadership.

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Images courtesy of Tarkett flooring

The second paradigm shift was attending the First National Symposium on Health Care Interior Design at the LaCosta Hotel & Spa in California in 1988 where I was re-acquainted with everyone from my trip to Sweden, but I also met Wayne Ruga. The setting was beautiful, the program was inspirational and I left LaCosta a true believer in the powerful impact a well designed healthcare environment can have on healing. Wayne was thought provoking and challenged everyone to go beyond the expected. I was so inspired by the event that I became a speaker at the Second Symposium co-presenting two topics: Psychiatric Care Units and Intensive Care Units. I have seldom looked back.

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My participation in the Mayo Clinic project, since named The Charlton building, ended up to be rewarding in every meaning of the word; the friendships built with the Mayo clientele, the additional knowledge in the treatment of cancer, a new level in the understanding of health, and the project being recognized as innovative in a national forum.

In 1989 the Mayo Clinic Charlton Building in Rochester, MN, at the time the largest radiation oncology center in the United States, won the First Annual Health Care Environment Award cosponsored by the Symposium on Health Care Interior Design and CONTRACT magazine. This award (currently named The Healthcare Environment Award) was given to design /architecture professionals in recognition of innovative, life-enhancing interior design projects that support healing and promote well-being in the health care environment. (Journal of Health Care Interior Design, Volume II) It was with great pleasure I accepted this award with my colleagues and with my client. I learned that cultural values within leading healthcare organizations can provide great opportunity for innovation - a requirement for amazing projects - and that these cultural values are indeed, rare.

Mayo Clinic Charlton Building Images courtesy of Ellerbe Becket

Fast forward and my personal learning has been extreme. In 1990 I accepted a 9 month project assignment to lead the interior design component of the 1,000,000 SF replacement facility for the Kings County Hospital, a joint venture project with Ellerbe Becket and HOK in Brooklyn, NY. Having lived the first 21 years of my life in North Dakota I originally thought moving to Minneapolis was a culture shock. Renting an apartment on a fourth floor walk-up on Madison Avenue in New York City was yet another opportunity that has shaped my life and created a tremendous paradigm shift.

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The Kings County Hospital project office was located in SoHo – downtown New York - which at the time was a dirty and grungy strip in lower Manhattan. At every corner, turn, and view I witnessed a life and a culture I had never before experienced. Although I loved the rural elements and clear skies of the MidWest, I fell in love with this urban melting pot where I met and developed friendships with people from around the globe. I developed a new understanding and appreciation of language, color, smells, noise, culture and fashion.

And professionally, my first trip in 1990 to the existing Kings County Hospital was shocking. The facility was crowded, dirty, and patients and their families lined every hallway. Patients in the emergency department had been on stretchers in the same room for days – as there were no available patient rooms. I had never seen such poor conditions and the images of that first journey into urban healthcare remains vivid.

For 5 years various components of this joint venture moved forward; we razed buildings, built temporary structures, created make-ready buildings and at the completion of the construction documents, the project was put on hold due to an over-building of beds in the New York area. I soon began to understand politics, the government and the power of lobbying.

As the project came to a screeching halt, I stayed in New York and made it my home for 11 more years. In 1992 I accepted employment with Perkins+Will and was promoted from Senior Associate to Associate Principal and, at a young age, Principal. Again, supported and mentored by national leaders; Nila Leiserowitz, Neil Frankel and Gary Wheeler to name a few, they positioned me in front of magazine editors, product designers and academic medical center clients, providing me numerous platforms for recognition and growth. I became aware of their Organizing Leadership attributes as they did recruit, train and inspire me to Lead.

New York University 60 Year Anniversary Featured Faculty

Juror – Cooper Hewitt Museum of Design

Featured on magazine cover - 1993

With their support, I became a project and product juror for architectural, interior design and lighting awards. I authored a chapter on Furniture in Sara Marberry’s book Healthcare Design. I wrote several articles that appeared in Health Facilities Management, Contract magazine, Interiors and UltraSTAT! and I was quoted in numerous journal articles.

The projects I led at Perkins+Will won numerous design and innovation awards through The Center for Health Design, Modern Healthcare, AIA chapter awards in the New York region, and through this recognition I became a national speaker on the topic of health care and Interior Design.

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My speaking engagements have included presentations at Texas A&M University at College Station, TX, Cornell University in upstate NY, George Washington University and Marymount University both in Washington, DC, and The Fashion Institute of Technology and New York University both in NY, NY. In 2001 my alma mater, North Dakota State University, awarded me the “Alumni Master Award� from the College of Human Development and Education.

Through the efforts of Wayne Ruga and Joan Rangelli, in 1995 I helped launch a Healthcare Design Certificate program for the New York University, Real Estate Division and I taught extensively for five years. This sparked my interest in teaching. I frequently lecture at Marymount University in Arlington, VA and am adjunct faculty at the Corcoran College of Art + Design in Washington, DC.

My life journey has now lead me to Washington, DC where I remain a Principal with Perkins+Will and have recently accepted additional Leadership responsibilities as the Washington, DC coleader of our Healthcare Market and the National Interior Design Healthcare Practice Leader.

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As a part of my daily work, I am actively engaged in every aspect of our practice; business development, marketing, new project presentations, design concept development, medical planning and everything through and including contract administration. A large part of my job is mentoring and Leading.

To highlight our national healthcare interior design practice I am learning more skills of organizing. I invented a monthly on-line series with contract magazine by sharing with the editor our firm-wide research initiatives.

“Designing for Health” is a monthly, web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today’s healing environments. www.contractmagazine.com Although initially established to last a year, the on-line articles have been one of the most read articles on their web site, so we’ve agreed to continue the series. Designing for Health has created a paradigm shift in our firm, has extended past 18 months, has highlighted topics ranging from acoustic design to the most recent post on healthcare sustainability, and has allowed us to highlight the voices of 18 healthcare interior designers from 10 of our 19 offices. The synergy of this series has grown tremendously and authors are already lined up for the next 12 months extending our Health Design Leadership.

My focus continues to look more globally. My speaking engagements extend to the Indus School of Architecture in Karachi, Pakistan; The Guilin Institute of Architectural Design and Research in Guilin, China; a Leading by Design ‘Learning Collaborative’ presentation in London, England; San Diego, CA; and an upcoming presentation in India. I continue to shape both my regional and national roles, seeking to utilize my new understanding of health and my new understanding of Leadership.

LONDON SAN DIEGO D.C.

GUILIN KARACHI

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Why Leading by Design With all the growth and abundant opportunity with my position, experience and responsibilities at Perkins+Will, one might question why I became a part of The CARITAS Project, and agreed to be a participant in ‘Leading by Design’.

I was invited to join ‘Leading by Design” in 2004 and at the time was immersed in my responsibilities at Perkins+Will, but also was preparing to become a student at Marymount University seeking my Master of Arts in Interior Design. So, I initially said no. For two years the focus with my studies had been on research, evidence based design and the study of design influencing health outcomes. Although I have known instinctively for years that design influences health, I was seeking to find research methods that supported these concepts. I also found that I was actively seeking how to BE a better leader, an element within Technical vs. Adaptive Work that is a theme of ‘Leading by Design’.

My thesis, ‘A Healing Spa; Investigating the Healing Use of Light, Shape and Color in a Spa Setting’ had small components of quantitative research but focused on seeking more qualitative research. Having touched on research in my studies, I was intrigued by the concept of Action Research – one of the 22 themes in ‘Leading by Design’, it s a research method that is qualitative and reflective.

So, in February, 2008, two months after finishing my masters, I embarked on another paradigm shift by presenting my Leadership Attributes in London, agreeing to be a case study within the ‘Leading by Design’ Research Project. For over 20 years my paths have crossed with Wayne Ruga and when they have crossed, doors have always opened. With my new responsibility within Perkins+Will as National Interior Design Healthcare Practice Leader, I desired to understand Distinctions of Leadership and to utilize Synergy to grow an even better Interior Design Healthcare practice within Perkins+Will.

Having lead teams that have completed millions of square foot of healthcare space, I still felt something was missing and I believed that the ‘Leading by Design” theme of Generative Space was intriguing.

“As a means to develop a shared understanding of ‘generative space’, the following is a working definition – ‘Generative space’ is a place – both physical and social - where the experience of the participants in that place is one that both fulfills the functional requirements of that place and it also materially improves the health, healthcare, and / or quality of life for those participating in that experience in a manner that they can each articulate in their own terms.” Source: Wayne Ruga.

As I participated in the Learning Collaborative in London I begin to understand Generative Space, an integrated component which is culminated through the major themes of the Action Research Project, Health Design Leadership, Space / Environment, Health, and Culture. In my monthly conversations with Wayne Ruga I have developed a better understanding of these themes and how they and all of the 22 themes can be utilized for improving Leadership.

Ultimately, my goal in participation is to learn new attributes of Leadership, to grow my personal knowledge, and to grow Leadership attributes in myself and others that will attract clients and talent to Perkins+Will and to cultivate Generative Space.

Tama Duffy Day

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Leading by Design projects In the first two years that I have been involved in the ‘Leading by Design’ Research Project, I can share examples of several “projects” where my participation in Action Research has shaped new ways of thinking and in some cases, created different “built” outcomes. Action Research focuses on qualitative research; the process of looking at past actions, reflecting upon them and shaping the next action as an outcome of that reflection.

1. The first example is a personal study of creating “home” My husband, Michael Day, and I live in a 1,100 square foot house on Capitol Hill in Washington, DC. Our house was built circa 1860, is defined as a semi-detached single family dwelling and is located in one of the many historic districts in DC. The house is located a block from the Metro and since 2001 when I moved in, the neighborhood called “Eastern Market”, has blossomed and become an urban destination for boutique shops and unique neighborhood restaurants. The neighborhood is diverse, multi-generational and ever changing.

I first moved into the house as a single person, its size seemed enormous to me – double the size of my previous loft in the Chelsea area of New York City. And with the addition of a garden, larger in size than the footprint of the house, I felt as if I was living in an estate. New York friends that came to visit were envious of all the “room”.

Our home

In 2004 I married and when my husband, Michael Day, moved into this “estate”, the use and allocation of space within the house changed. What felt previously as enormous, now felt very different. As we sought places to store his size 11 shoes and clothing for a man 6’ in height, scale took on a new meaning. Even chairs that suited my 5’ 4” frame now appeared dwarfed in size. Still, we loved the house, its historical character and our neighborhood. So, we choose to continue to live here and down-size our belongings. My husband will tell you he sold everything he owned, with the exception of his books and clothing to move into this “estate”.

In 2006 the prices for homes in this neighborhood tripled and we decided to create a small addition to this home which would increase our living area, but also increase the property value of the home. With Michael an architect and me an interior designer – the dialogue and conversation began about how, what and where to add. Not wanting to be “mortgage poor” we set the budget for the addition conservatively and the “challenges” began immediately.

While Michael set about to increase his knowledge of the approvals process for building in a historic residential neighborhood in Washington, DC, I embarked on examining “what” program areas to increase. Michael soon established that even a small addition requires the approval of four jurisdictions; The Historic Preservation Restoration Board (HPRB), the District of Columbia zoning authorities (DCRA), the Capitol Hill Restoration Society (CHRS) and the approval of our neighbors through our local Advisory Neighborhood Committee (ANC). Our home would need to engage in and be approved by our community. Due to our existing house having nonconforming lot coverage and our request to build into our “set back” the review process was extended significantly requiring several zoning special exceptions – all for a very modest

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expansion. Meanwhile I had determined that the addition should expand our kitchen and create a large storage room, thus providing our “stuff” a place to be stored and clearing the house of clutter.

As you might imagine, we had differences of opinions on design and layout, long and emotional conversations on priorities for how we spend our dollars, and Michael’s initial meeting with the HPRB was less than encouraging. As can be seen in the previous photograph, living in a small and the shortest house on the block impacted greatly the height of our addition. Since a third story addition could be literally “seen” from the street, HPRB would not support the design. We literally felt defeated and the project went on hold for several months.

EXISTING FRONT

EXISTING BACK Top Row: Model options of our initial house front

Bottom Row: Model options of our initial house back.

About a year into this process I returned from my first ‘Leading by Design’ learning collaborative.

While reflecting on several components of our collaborative discussions I realized that our home greatly affected our health, our relationship and our engagement in our community.

I began to study the ‘Six Conditions of Space’ Diagram illustrated below. The diagram illustrates six levels of engagement, Level 1 thru 3 engaging in Social Space only, Levels 4 through 5 engaging in Physical Space only and Level 6 Integrated, Simultaneous, Generative Social Space and Physical Space. Level 6 seeks Generative Space; life enhancing, systemic and sustainable.”

Source: Wayne Ruga. We certainly sought to create generative space in our home. So I began to investigate “how”…

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Source: Wayne Ruga, The CARITAS Project

In looking at our home, how we interacted in our home, and how we were influenced by our home; we arrived at a New Understanding of Health.

1. We realized we had no space for private contemplation, other than the bathroom.

2. If a guest arrived - attempting to provide them a place to sleep - greatly interrupted my psyche. I needed to give them their own space that would not interrupt my own sleep patterns.

3. Our bicycles and other large items basically sat in our living room all year long, as there was no space to store them (inside or outside). We have no basement, no garage and no attic space for storage.

4. Due to the house being built before the invention of air conditioning and central heating, we lived differently in the house depending on the season. a. In the summer our house is hot and humid and we spend more time downstairs – specifically outside, using the grill to cook most of our food and eating outside until the mosquitoes become unbearable. b. In the winter the difference in temperature between upstairs and downstairs is significant and we “camp” upstairs in one room – a room filled with the computer, TV, desk, sofa, storage, cat toys, and piles of books and magazines. The first level is freezing and unless you are bundled in winter coat, hat and boots and have a roaring fire, it is very uncomfortable.

5. And, although we are both creative, we had no area in our home that could foster creativity.

For reasons beyond our comprehension, neither Michael nor I had taken the time to understand how the impact of our one-room existence affected our communication, our health and how we were not utilizing our spaces efficiently. We had not created a truly generative space; as our engagement in the physical setting was less than ideal.

In hindsight, the fact that I had suggested investing the majority of space in our addition to a storage room, a costly storage room at that, seemed ridiculous. So with thoughts of distinctions of space, a new understanding of health, and a discussion about our cultural values I set about to re-think the program.

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Rather than establishing a program based on kitchen, dining room, living room, bedroom (common in a typical space program), I gathered the 7 cultural values that mattered greatly to both of us: creativity, love / friendship, nourishment, rejuvenation, laughter, spirituality and life activities. Of those cultural elements we determined together the percentage of space we’d like in our home for each component. We choose to establish 75% of the space to the first four elements: Creativity, Love / Friendship, Nourishment and Rejuvenation.

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I then evaluated, using color to represent each of our 7 cultural values on how we were utilizing our existing Physical Space. Below is the sketch showing the review of our existing home.

First Floor

Second Floor

The two graphs below illustrate the ideal percentages of our values on the right, and the existing on the left. The research determined that areas for nourishment (beige) and spirituality (orange) needed to grow; where as areas for life activities; check paying, storage, washing clothes, etc. (dark blue) needed to be reduced in size to meet our cultural values goal.

With this information in hand, we set about re-shaping the program and re-evaluating how to shape the physical space to be more generative. Generally other than the rooms with plumbing, we have rethought how and where to place the various activities in our home. The diagrams below are illustrative of how we set about to modify the various activity zones.

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First Attempt

Second Attempt

While I was shaping and re-thinking how to program a home, I created the new diagram illustrated below. Preliminary reviews of the floor plans provided the Spiritual element at the outside of our home, but perhaps it might be placed at the center. So the following diagram transpired, imagining the spirituality component as the center element upon which all else surrounds.

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For the past 13 months, Michael and I have drawn, re-drawn and shaped nearly 12 different versions of this addition. Did I already say that he is a very patient man? Oh, and did I tell you we have a very inquisitive cat, Skipjack? Everyone seemed to have a difference of opinion on what mattered but we all agree on the healing attributes of sunlight.

The images I share with you now illustrate where we have ventured in the most recent dialogue and although you may or may not find the images intriguing, it is the Structure upon which these changes have transpired that have allowed this to happen and this Structure is the focus of these images.

Left: Recent Massing Study Models

Tama Duffy Day

Right: Current shape of the Back Addition

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To the left are the floor plans that have been approved by our ‘neighbors’. The approval process that took nearly a year.

Discussions with neighbors modified the expansion size, the location of windows and the size and shape of our addition.

Proposed Ground Floor

Proposed Second Floor

The modifications grounded by this new Structure and created with an understanding of our Cultural Values have resulted in the following: 1. We will indeed add to our home, but the first priority is in improving our heating and air conditioning, allowing us to use all areas in our home for all 12 months of the year, in effect eliminating our one-room winter hibernation. We are currently investigating the use of a geothermal heating and cooling system; which would greatly reduce energy use and consumption.

2. The kitchen will be expanded due it its locale on the first floor, but areas of the kitchen will be designed to inspire creativity in cooking and gardening – as the kitchen is directly accessible to the garden. In addition the size of the kitchen can foster friendships through entertaining and the sharing of meals.

3. A small table and chairs will be added to the kitchen area located directly in sunlight and facing the garden. This area is for rejuvenation (views of nature), creativity (reading / writing) as well as love / friendship (an area for eating and enjoying companionship).

4. The dining room will be refurnished with a small dining table (for every day use) but one that can be expanded for guests. Near the fireplace will be placed two comfortable and cozy chairs, with lights, for reading and relaxing.

5. The living room will be refurnished with a sofa / couch that can support overnight guests, giving them direct access to the existing first floor bathroom. No longer will they be sleeping upstairs. Additionally, the TV will be moved to the first floor living area and away from our sleeping area.

6. On the second floor, rather than building a large storage area, we are designing a creativity room in support of drawing, designing, nourishment, contemplation and rejuvenation. It will have access to daylight and views down to the garden. The room will be furnished as a writing / working / reading / sewing area. It will also have a small single mattress / sofa, to allow naps in the sun and numerous pillows for the surface to also be used as a chaise lounge.

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7. We are relocating our bedroom and creating a room between the master bedroom / bathroom to accommodate clothing storage, a place to fold clothing (next to the washer / dryer) and another area with comfortable chairs. This will provide us several spaces to read / writing / think rather than only one that we both share. We will also use this room to display our own personal sketches and drawings – our own private rotating art collection.

8. Our storage area will be expanded, but rather than designate a large room, we have tucked storage areas into all the existing rooms of the house. We are building an “attic” space on the second floor, which will provide a 12’ x 5’ x 3’ tall space for boxes and suitcases. We have expanded our kitchen storage considerably in the new plan, we are building two shallow storage closets in the dining room, we are building a full height bookcase in the second floor ‘creativity room’, and have closet space designated for the golf clubs. A part of this addition will add a small storage / garden tool shed and that will house the bicycles.

We embarked on the approvals process in late 2008, having scheduled meetings throughout 2009 with the ANC, the HPRB and filing self certification for our DCRA hearing. September 8, 2009 was the big “day” where we received final approvals for everything at our DC Board of Zoning and Appeals hearing.

Reflecting upon our decisions through the Leading by Design Action Research, Michael and I have embarked on creating a home that reflects us and our life style – not just a home with 2 bedrooms, 2 bathrooms, and other components deemed desirable by realtors.

Both of us are LEED Accredited Professionals and in reflecting on our actions, realized we wanted a home that draws nature, sunlight and the garden into all spaces. As mentioned previously, we are looking to heat and cool our home using a geothermal heat pump system, a process that utilizes the nearly constant temperature (between 50 and 60°F) below the earth’s surface and requires little to no fuel. Additionally, we are seeking to design using the sustainable recommendations provided by the U.S. Green Building Council for residential design. (A LEED Accredited Professional distinguishes building professionals with the knowledge and skills to successfully steward the LEED certification process. LEED stands for Leadership in Energy and Environmental Design. Source: www.usgbc.org) As a working unit, we have learned many things about synergy. When we are working at odds with each other, hours drag on without resolution and frustrations grow. When we respect each others’ ideas, are patient and communicate with a culture of respect, progress and new thinking occurs continuously and rapidly. We are seeking praxis, living each day with purpose.

As with any Mastery, the path has been circuitous, but as a result we have a stronger structure upon which to make decisions and due to that, our home will be much more than an addition of a storage room and expanding our kitchen. Our home will be an expression of our health, our culture and will be much more life-enhancing, truly moving toward generative space.

We hope to complete the addition in early summer of 2010 and will continue to test and experiment with our home and its impact on our lives.

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2. My second example of integrating concepts of generative space is the Arlington Free Clinic.

On April 1, 2009, I was informed by Nancy Sanger Pallesen, the Executive Director of the Arlington Free Clinic (AFC), that Perkins+Will had been chosen to design their new clinic. We had competitively interviewed for the project and Nancy later told me that she knew immediately she had wanted to hire us. She “knew” that the outcome of the clinic would be different based on my Leadership and Understanding of Health. Nancy was the first client I discussed the concepts of Generative Space and I shared with her this diagram.

Source: Wayne Ruga, The CARITAS Project

The conceptual diagram above forms the basis for the ‘Leading by Design’ Action Research Project. The diagram illustrates the 22 themes ranging from Action Research Project to Generative Space. Throughout this case study, all words underlined are one of the 22 themes.

The uneven lines around the circles are intentionally squiggly for two reasons; that this is a work in progress and in recognition that as people, we are all unique and value diversity. To truly step into generative space takes a life time of personal praxis.

Although I shared this diagram just two months after my first Learning Collaborative, Nancy understood this diagram conceptually and was willing to embark on a journey with us to understand this more fully in the context of her organization and her new facility. With her

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willingness to venture into unknown territory, this amazing process began. A process based mostly on trust.

The Arlington Free Clinic is a nonprofit, community based, volunteer driven organization committed to providing access to quality health care services to low-income, uninsured county residents. Founded in 1992 it is supported through the services of 520 volunteers, of those volunteers, 270 are medical professionals and 170 are physicians. In 2008, volunteers provided over 14,150 hours of volunteer service worth over $797,775.00.

Source: www.arlingtonfreeclinic.org We embarked on this 8,000 SF project; me and a team of two others (Jamie Huffcut, LEED AP and Jonathan Hoffschneider, AIA, LEED AP) initially in a structure like all other Perkins+Will projects. We created a spread sheet of rooms needed, quantified those rooms, and established a program. At the same time we created an adjacency diagram attempting to understand the flow of staff, volunteers and patients. We understood there were three main components: the reception and greeting area, the clinic, which included a pharmacy dispensing area, and the office area, which includes a conference room that is also used for patient education.

Initial adjacency diagram

In an initial visioning session with Nancy and members of the AFC staff and AFC Board members, words that described their goals were: Respect, Dignity, Safety, Community, Quality, Light, Style and “WOW”. Nancy wanted their space to be “WOW”. And the “WOW” was to be built within a budget of $100.00 a square foot. For the Washington, DC region, in 2008, this was a tight budget for clinic space, especially with sinks in every exam room and the space being a cold dark shell (no lighting, no heating, and no cooling). We also sought to be more efficient, provide a calming environment and attract more volunteers and financial donors.

At the beginning of the project, our team diverged on different paths. Jon and Jamie reviewed the initial test fit provided to us by AFC, visited the shell space and set about to create our first plan, illustrated below. I returned to the Generative Space diagrams and looked for a new Structure for the project.

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Initial planning diagrams

I focused on Space / Environment and Distinctions of Space, understanding the importance, once again, of creating a physical environment where the patient and the medical professional engage in both the physical and the social space. I sought to embrace concepts of Sustainable Design and Evidence Based Design all under the auspices of creating Generative Space. It seemed we needed more feedback from the patients, another check on the Cultural Values of the patients and their community to provide validity to the initial visioning session with the AFC. So our team developed a brief “ballot” written in both English and Spanish and distributed it to patients and volunteers / staff for a week. The ballot consisted of six series of photographs and asked the survey respondents to select from each “pair” their favorite image. Image A or B and why? Image C or D and why? There were large poster boards with each “pair” of images displayed and the images were also duplicated on each ‘ballot”. The ballots were distributed in two colors – one color for patients and one color for volunteers / staff and were collected in a sealed box located in their existing waiting room.

A sample of the Ballot and the Large Poster Board images are below:

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When Jamie compiled the results of the survey, the responses were amazingly similar to the words that Nancy and her team had provided in the visioning session. In addition, many of the images preferred by patients were the images preferred by the volunteers / staff.

With larger text representing words used more often, this is a visual of the survey results:

Without question, images with views, sunlight and memorable spaces were selected over images that were corporate, neutral and uninspired. It appeared that the patients desired to be treated in a generative space, space that was both engaging in social and physical and what the physical and social space represents. And given the global nature of the patients, the representation of the physical space provided a unique challenge.

Again, I looked for the connections between their words, the images selected, evidence-based design, sustainable design and the over arching goal of generative space and one obvious element seemed to touch them all: nature. Nature always had a core / a center – the AFC logo was a tree with a ‘core’ of people, the director of the AFC was the ‘core’ of the organization. And with that connection, I doodled on a blue post-it (shown below) what has become the diagram for the plan and our design parté. New Distinctions of Space and a New Understanding of Health were being created. “Bloom” became our symbol.

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We investigated flowers, their color, shape, form and Jamie created the graphic interpretation of the sketch into a plan with three components; welcome, treatment, and support. The Synergy within our team was growing.

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As the physical design emerged, the multi-functional conference room became the core of the plan – as it was used by patients, volunteers and staff alike. Also included in the ‘core’ was the office of the Executive Director. The clinic treatment area (illustrated in blue) was efficiently planned at the back of the plan- the area least disrupted by columns.

Through a day-lighting study, natural light extended into the space only along the front face of the building – so the reception / welcome area and the staff / support areas were located (illustrated in orange and green in the plan on page 21) in this area. The floor and ceiling planes – illustrated below - continue to express a joyful pattern organic in nature and growing from the core.

This reflective study, analogous with Action Research, was utilized as the Structure for each element of the project. While determining how to bring pattern and yet calmness into the exam areas, the idea of a bee pollinating a flower created the concept behind the pattern and color transition. While reflecting on the first versions of the ceiling and lighting plan, we sought to find a solution that was cost effective and yet unique. The final solution incorporates different sized ceiling tiles and inexpensive 1’ x 4’ light fixtures in the petals - as both saving costs and fulfilling the project design objectives.

In reviewing the shape and form for the workstations within the ‘support’ area our intern, Lori Geftic, drew areas of the clinic in Revit, software able to easily illustrate the potential built environment. Through her series of renderings seen below, the client understood the work environment more clearly and made important furniture purchases based on these images.

Image Courtesy of Lori Geftic

Tama Duffy Day

Image Courtesy of Lori Geftic

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As the project was progressing and I reflected on the first 9 months of work, I saw several themes of ‘Leading by Design’ become evident;  The health of our team was inspirational. Client and design team alike were fully engaged working toward generative design.  I was engaged in Adaptive work as a Leader; determining ‘why’ we were moving in certain directions and engaging other team members in leadership - our values were aligned.  This project had become a paradigm shift in our office; innovation is seen as possible, even in small project with limited access to finances.  The spaces being created could support new Distinctions of Space; the rooms were of good size, the organization of the clinic flowed correctly, there was delight and access to daylight, the design met the requirements of good “sustainable” design, and the culture of the organization supported larger areas for social gatherings.  Evidence was being generated illustrating that our process was correct.

Presentations to user groups and the AFC Board of Directors were received in positive light. Design critiques within Perkins+Will were also positive.  The Structure of the project was supporting the end product, generative space.

The process of decision making, the sharing of ideas openly with the client, the investigation of affordable materials, and even the selection of a contractor to build the space was carrying forward the vision of the initial project.  In all levels, actions speak louder than words. All team members delivered what they said they would deliver, on time and with high quality. We have invested tirelessly in accomplishing the vision of this project and the vision of our design goals.

The synergy of the team and our services expanded as the project progressed. We were hired to develop graphics for the exterior windows, establish a process for displaying photographs of the volunteers within their space, design a new logo, and to develop a donor recognition graphic program - all elements that are continuing to expand this life enhancing space.

Polaroid photo wall in the existing Arlington Free Clinic pantry, highlighting their volunteers.

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Reception area and waiting space in the new clinic – highlighting the floral element in the ceiling plane and their new logo / graphic.

Views into the central conference / education / multi-use space adjacent to the reception – with their sliding curved doors.

All photographs on this page by Ken Hayden photography

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Top image: View of the clinic corridor. Bottom image: View of a typical exam room, with floor pattern and accent color.

All photographs on this page by Ken Hayden photography

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Images clockwise from upper left: new “magnetic” volunteer recognition wall created through donations by Bognet Construction and Perkins+Will, sustainable “educational” signage plaques in English and Spanish located throughout all areas of the clinic, administrative office area highlighting the floral ceiling element, the “butterfly” privacy screens, the unusual existing columns, and the access to natural daylight.

All photographs on this page by Ken Hayden photography

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At the grand opening in June, 2009, Nancy Sanger Pallesen, the Executive Director, acknowledged that she did indeed get her “wow” in the design of the new clinic, and that it also supports their clinic in terms of efficiency and allows them to continue to deliver high quality care.

The success of AFC has already been realized in a number of ways: awards, post occupancy results, and in upcoming academic research.

Awards Since opening, the success of the clinic has been recognized through a number of award recognitions: September 25, 2009 The Washington Metro Chapter of the American Society of Interior Designers announced their chapter design award winners at the Ronald Regan Building recognizing outstanding project design. Perkins+Will won for First Place in the healthcare category for the Arlington Free Clinic.

September 30, 2009 Healthcare Facilities Symposium - Distinction Awards Arlington Free Clinic and Perkins+Will along with team members Integral engineers, Bognet Construction and Washington Workplace won the TEAM Award, presented in Chicago, IL at Navy Pier during the Healthcare Facilities Symposium. The Team Award focuses on a project team that has worked together to change the face of healthcare design through innovation, creativity, efficiency and teamwork.

October 14, 2009 The Arlington Free Clinic won the Washington Business Journal 2nd Annual green business award in the category of design, recognizing their green business practices. The awards are intended to inspire organizations to make sustainability a central part of their business and are sponsored by the Washington Business Journal, the Greater Washington Board of Trade, and Washington Gas. October 23, 2009 The Washington Chapter of the American Institute of Architects at their annual award ceremony provided a 2009 Presidential Citation for Sustainable Design to Perkins+Will for their design of the Arlington Free Clinic.

On June 4, 2010, the Arlington Free Clinic will be the location of a tour and presentation by Nancy Pallesen, Wayne Ruga and I during the Environmental Design Research Association conference in Washington, DC. EDRA advances and disseminates behavior and design research toward improving understanding of the relationships between people and their environments. http://www.edra.org/

Post Occupancy Results Several components of evidence-based design were integrated into the design of AFC. Design attributes reduce infection transmission through the use of high quality HVAC systems, sinks in every exam room and the use of cleanable interior finishes.

In a post-occupancy survey of the 14 full time clinic staff • 100% responded that the new clinic space is “light filled and uplifting” • 75% indicated that the new space “inspires health” Upon completion of the clinic, the patients themselves had a celebration. Patients brought in homemade food, music and dance to celebrate the space, the care and the community. The new clinic design gave them space to celebrate.

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Since January of 2008 there has been a 164% increase in demand for their services. Due to the new physical space, the clinic can accommodate their patient lottery system more efficiently – resulting in serving more people.

The AFC clinical director is determining metrics to measure volunteerism before the new space and after the new space. She is also gathering data on efficiency and through put and will track these metrics in the upcoming year.

The Arlington Free Clinic is the first medical facility in Arlington County to achieve LEED certification status AND the first free clinic in Virginia to achieve LEED certification.

Upcoming Academic Research Through a friendship with Mardelle McCuskey Shepley, D. Arch. at Texas A&M University and my presentation of this project in Texas during their Architecture for Health Lecture Series, she has engaged her students at Texas A&M in creating, gathering and evaluating the current space and the new space of its healing attributes. Our first conversation with the students, held via video conference was just recently on February 27th, one year from the date of my first Learning Collaborative. Results from Texas A&M are expected early 2010.

In addition to the relationship with Texas A&M, we have engaged two other schools in Virginia in research efforts. George Mason University anthropologist students are researching the emotional components attached to the clinic design and a Marymount University interior design master’s student is studying the impact of 3-D renderings in informing occupants of the final design results during the design process. Results anticipated early 2010.

Closing comments As the clinic continues to provide clinical services we will continue to seek additional quantitative metrics to determine and track its ability to support generative space; life-enhancing, systemic and sustainable improvements.

During a recent meeting of The CARITAS Project Advisory Board we asked Wayne Ruga to share with us in a few words the meaning of Generative Space and he said “a place to flourish.” The Arlington Free Clinic is most definitely “a place to flourish.”

To see a video of the completed clinic and their journey please view the YouTube video at: http://www.youtube.com/watch?v=EWEZ-BPVYBw NEW LOGO graphic design by Rachel Conrad

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3. My third example is in my leadership in the American Society of Interior Designers.

In 2004 I was nominated to a two-year term to serve as a Director-at-Large at the Society level Board of Directors for the American Society of Interior Designers (ASID). Serving on a Board at a national level was a new experience and I was swept into the process of creating a strategic plan for ASID at a time when it was also re-branding. It was a time when I began to truly understand the concept of Technical vs Adaptive work.

As the Board engaged in the process of determining strategic direction for the Society I soon found myself much more able to do Technical Work, not Adaptive Work. I volunteered to be on the ASID Brand Team, and, as such, helped to review, shape and continue the work of the previous Board in expanding the Brand of ASID and the ASID Foundation. For these efforts I was awarded a Presidential Citation by the Society President. However, as the two years progressed, I was able to see that my role on the Board was really more about Adaptive Work; about addressing conflicts and seeking ways to minimize gaps in values and beliefs. Through out those two years I was able to watch the Board Members more skilled in this attribute and learn from those exchanges ways to move the Society forward through leveraging shared values.

As one of the only members on the ASID Society Board of Directors that had not served in a position of Chapter President prior to national service, in 2006 I eagerly accepted the nomination of the ASID Washington Metro Chapter, President-Elect. As I took office in October of 2007, I sought to utilize the skills of Adaptive Work as well as other components of Leadership.

Today I have completed my role as President-Elect as well as my year Presidency of the ASID Washington Metro Chapter in Washington, DC. Throughout these years I have engaged in the Community of this Chapter in new ways. Still learning leadership skills, I spent my time reflecting and embracing the following ‘Leading by Design’ themes: 





By utilizing elements of Action Research I have thought about and analyzed my methods of communicating and noticed areas for improvement. I have asked the Board members to also reflect on my leadership and suggest areas for improvement.

One of the areas improved is in requesting Board Members to deliver high-level brief and succinct reports; allowing our Board meetings to last 90 minutes rather than the initial 3 hours.

As mentioned in my reflective learning in the Society Board level positions, I have focused on Adaptive vs Technical Work. Rather than “doing” the work and controlling the energies of the Board, I have sought to do Adaptive Work; building consensus and engaging the shared values of the Board.

One of the new tactics I suggested and our Board delivered is the creation of Shadow Board Members. Seven emerging professional were selected to literally ‘shadow’ a board member. In this new tactic, I have engaged in Organizing / Leadership. We identified the emerging professionals, recruited them to take on this ‘shadow’ position, the Board Members are training them for leadership and have enjoyed watching them grown. One Shadow Member was nominated to serve on the next Board of Directors for our Chapter and the Shadow Member tactic has been extended into its second year.

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The organizational chart for our Board was re-shaped. As noted in the graphic below, rather than a hierarchical chart with the President at the top, I worked with a young interior designer, Matthew DeGeeter, to create a different image to reflect this shift; one that represents Synergy, a new Structure and a new understanding of our Culture. The “ring” is meant to illustrate this circle of leadership - and the importance of our teams in delivering all the programs throughout the year. Rather than a “buck stops here” culture, our Chapter relies on each other to shape and deliver all aspects of our strategic plan and allow leadership to flourish in everyone. Now in its second year, the new graphic for our Chapter board structure is still a circle, and the graphic is even better.

All in all, my responsibilities as Chapter President and Action Research have been instrumental in opening my eyes to Distinctions of Leadership. I am far from mastery, but each small step in learning has helped to shape my knowledge and open my eyes to new possibilities. At moments I am able to stay in an organizational role and guide, but when tasks need to be completed and there are few volunteers, I do step back into the “doing” role, understanding that in a community of volunteers, it is sometimes required to “do”.

I will continue to watch the Chapter over the next few years and see if any additional attributes of Leadership from my role as President are Systemic and Sustainable. I have also been able to utilize many of these attributes in becoming a better Leader within my own role as the National Interior Design Healthcare Practice Leader at Perkins+Will.

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Next steps As I reflect on my own personal growth this past year my learning has been significant – still miles to go, but a much larger awareness on my part of Leadership and, little by little, I have more fully grasped the 22 themes in ‘Leading by Design’. As I write my own understanding of the themes, they become clearer. As the themes become more evident, I am more able to put them into practice.

A part of my learning has been in delivering the ‘Leading by Design’ initiative at NeoCon in June in Chicago and at the Healthcare Facilities Symposium in a five-hour workshop in September also in Chicago. In both of these presentations I was a co-presenter with Annette Ridenour and Wayne Ruga.

I spoke to my Perkins+Will colleagues in Healthcare Interior Design during our annual summit just weeks ago and shared with them my Arlington Free Clinic case study. As a component of this ‘Leading by Design’ presentation we have agreed, as a group, to develop a national research project to deliver together.

I will continue to focus on Actions speak louder than Words, giving Action to my Action Research.

As I progress into 2010 I will seek to:  Further develop my own self mastery and praxis.  Develop Action Research methods while focusing on my role as the National Interior Design Healthcare Practice Leader at Perkins+Will  Follow the Arlington Free Clinic progress and report the findings of the academic research.  Continue to implement Generative Space attributes in the completion of our home  Find new clients willing to cultivate Generative Space – a place to flourish.

If you wish to discuss my learning further, please do not hesitate to contact me: tama.duffyday@perkinswill.com or on facebook.

Tama Duffy Day

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New York Presbyterian Hospital Medical/Surgical Oncology Center Columbia Presbyterian Campus The Herbert Irving Cancer Center New York, New York

1

The Medical/Surgical Oncology Center is a 30,000-square-foot treatment facility that occupies two floors of the five-floor Herbert Irving Comprehensive Cancer Center. It includes radiology, gynecology, and surgical departments, a day-hospital, examination rooms, consultation and procedure rooms, a pharmacy, laboratory, and patient counseling areas as well as group, semi-private, and private treatment areas and administrative space.

An arc shape in the ceiling, mirrored in the floor pattern and desk design, directs toward smaller waiting areas to the north and south, where the same material palette and banquette seating reoccur. These sub-waiting areas are centrally located between groups of exam rooms and consultation rooms, arranged for convenient way-finding. Translucent glass in doors and sidelights transmit light and minimize the apparent length of interior hallways.

The clearly organized plan, natural materials and colors provide a supportive environment for patients, visitors and staff. Patients enter through a light-filled elevator lobby, finished with glass wall panels, stone flooring and a vaulted wood ceiling, and are received in an open waiting area with oriented views to the outdoors. Warm beech wood used for the vault continues in the reception desk, paneled walls, accessible slat ceiling, banquette seating trim and throughout the facility. All are complemented by a soft green limestone floor.

The open group and semi-private chemotherapy areas take advantage of views, including one of the Hudson River, and are organized to minimize visual clutter and maximize staff efficiency.

Supply, waste and staff prep areas are nearby but out of patients' sight. Curved ceiling tracks define patient areas, each lighted by a translucent glass fixture mounted in a domed recess, creating a comfortable, diffuse light.

Task lighting is provided by the adjustable lamp attached to mobile storage taboret next to each patient.

The pharmacy and laboratory are centrally located to serve the entire five-floor center via dumbwaiter access.

1 Main reception and waiting area

Gwathmey Siegel & Associates Architects llc

Typical hallway with Nurse Station, Exam and Consultation rooms

Reception and waiting area

Typical Physicians Consultation room

New York Presbyterian Hospital Medical/Surgical Oncology Center Columbia Presbyterian Campus The Herbert Irving Cancer Center

Nurse desk and Chemotherapy area

Gwathmey Siegel & Associates Architects llc

Typical Chemotherapy room

Semi-private Chemotherapy treatment area

New York Presbyterian Hospital Medical/Surgical Oncology Center Columbia Presbyterian Campus The Herbert Irving Cancer Center

Typical private Chemotherapy room

New York Presbyterian Hospital Medical/Surgical Oncology Center Columbia Presbyterian Campus The Herbert Irving Cancer Center

Key Project Information • • • • • • • • •

• • • • •

• •

medical areas surgical department gynecology department radiology department day-hospital examination rooms consultation rooms and procedure rooms patient counseling areas group treatment, semi-private treatment, private treatment areas pharmacy laboratory administrative space planned for easy orientation generous wood detailing to add warmth completed gsf

1998 30,000

Typical sub-waiting area

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Pre- and Post Occupancy Evaluation of the Arlington Free Clinic

By Mardelle M. Shepley, Texas A&M University, Tama Duffy Day, Perkins+Will, Jamie Huffcut, Perkins+Will and Samira Pasha, Texas A&M University Abstract | Article Introduction In 2008, an architecture firm was hired to design a new facility for the Arlington Free Clinic. The clinic, established in 1994, is “a nonprofit, community-based, volunteer-driven organization committed to providing access to quality healthcare services to low-income, uninsured county residents.� As part of the design process, the designers and staff were interested in determining whether the physical environment of the new clinic adequately addressed the objectives of the client.

In order to examine this question, a research team involving a facility administrator, designers, a university researcher, and graduate students was created. The research project described here is the result of the occupancy evaluation conducted by this team.

Occupancy evaluation (OE) can be portrayed as a multistep procedure that consists of establishing a purpose, collecting and analyzing quantitative and qualitative data, making an assessment, and stating the lessons learned (Kennon et al. 1988). The focus of a building evaluation is to study and improve designed environments (Zimring 1980). Evaluations assess the effectiveness of design decisions for human users (Zimring 1980) or with regard to building system operations. Here, effectiveness is defined as the positive impact physical and organizational factors can have on perusing intended goals. Evaluations often focus on new buildings, but they are most effective when information is collected from both the predecessor building (preoccupancy evaluation) and the new building (postoccupancy evaluation). This approach allows for effectiveness comparisons. A number of potential benefits for conducting an occupancy evaluation include applying design skills more effectively, improving the commissioning process, improving user requirements, improving management procedures, providing knowledge for design guides and regulatory processes, and targeting refurbishment (Whyte and Gann 2001).

The building evaluator usually focuses on one type of environment (Zimring 1980). Healthcare facilities are a common target, because the design of healthcare environments has critical demands that are specific to these facilities. In this regard, OEs are feasible approaches to evaluate effectiveness of design (Kennon et al. 1988). OEs of healthcare facilities usually focus on a feature of interest (that is, privacy, stress reduction, accessibility) and test these relative to different groups of users (that is, patients, visitors, staff, administrators) (Harvey 1984).

Kennon and coauthors (1988) distinguish six major purposes of evaluations in healthcare facilities: functional adequacy, space adequacy, construction quality, technical adequacy, energy performance, and user satisfaction. Most evaluations focus on two to three of these concepts at a given time,

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separating functional adequacy, space adequacy, and user satisfaction into one category (human performance), and construction quality, technical adequacy, and energy performance into the other (technical performance). User health outcomes are another important purpose. Since the technique typically involves obtaining data from or about human users, in the case of new buildings it usually takes place after they have been occupied for a time. Suggestions for the length of this period vary from 12 to 18 months (Harvey 1984) or 6 to 14 months (Kennon et al. 1988) after occupancy.

During an evaluation, different viewpoints should be obtained by forming a diverse evaluation team consisting of the facility’s administrator, facility manager, user representative, programmer, designer, and project manager (Kennon et al. 1988). In forming data collection measures, it should be noted that different groups of users have different preferences for use of terminologies. Kotaka (1999) showed that the education level of respondents is highly relevant to how they perceive questions and answer them.

Sources of information include archives and records, standards and guidelines, facility program and plans, and users (Harvey 1984). Researchers usually employ behavioral mapping, surveys, and interviews as methods of data collection. Since using a single method or source for data collection may result in misleading data, a multiple-method approach (triangulation) is preferable.

The following is an abbreviated summary of other healthcare building evaluations, listed chronologically: • Harvey (1984) found various design deficiencies in a hospital, which resulted in wayfinding problems, energy waste, and security and maintenance problems.

• Cooper Marcus and Barnes (1995) made a comparative evaluation of gardens in several hospitals.

• Shepley, Bryant, and Frohman (1995) used questionnaire and interview techniques to evaluate design decisions in a labor, delivery, recovery, and postpartum (LDRP) unit and neonatal intensive care unit (NICU). Behavior mapping focused on decentralized nursing stations and patient-centered care provided in the NICU. • Shepley (1995) conducted a pre- and postoccupancy evaluation of a children’s psychiatric facility using a survey and comparing the number of negative behavioral incidents.

• Brown, Wright, and Brown (1997), in an evaluation of wayfinding in a pediatric hospital, collected data via staff-maintained logs and cognitive maps, interviews, photographs, and behavioral observation.

• Shepley and Wilson (1999) conducted an evaluation of a facility for persons with AIDS, using the intentions of the designers to formulate the hypotheses of their study. Information gathering techniques included interviews, surveys, and behavior mapping.

• Shepley (2002) conducted pre- and postoccupancy analyses of staff behavior in a neonatal intensive care unit using surveys and behavioral mapping techniques.

• Sherman et al. (2005) evaluated children’s hospital gardens and gathered information about major groups of users and types of garden use.

• Harris et al. (2006) studied patients and caregivers in single-family versus open-bay NICUs using survey and behavioral observation techniques.

• Shepley, M. (2006) conducted an ICU/ER postoccupancy evaluation at Grossmont Hospital.

• Ornstein (2007) employed focus groups, surveys, and semistructured interviews in an evaluation of accessibility and fire safety in a hospital.

• Shepley, Harris, and White et al. (2008) studied family behavior in single-family versus openbay NICUs using computerized behavior-mapping technology.

• Whitehouse et al. (2000) evaluated a garden in a pediatric hospital relative to use and user satisfaction.

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For a detailed summary of these studies and a guide on how to conduct facilities evaluations see Healthcare Facility Evaluation: A Comprehensive Guide (Shepley 2010, in press).

Methods In the context described above, this research addresses the evaluation of human performance (space adequacy and satisfaction). The study was carried out in two phases: the evaluation of the existing facility (Figure 1) and the evaluation of the new facility, which was located at another site (Figures 2 through 8). In order to determine the focus of the study the research team was provided the original programming documents and a presentation on the design process was given by professional staff from the firm responsible for the design. As this was, in part, an academic exercise, students in a graduate architectural programming class generated a twenty-question, two1-page survey based on the objectives of the design identified in the program and the presentation.

Figure 1: Old Clinic Floor Plan (courtesy of Perkins+Will)

Figure 2: Clinic Conceptual Diagram (courtesy of Perkins+Will)

Figure 3: New Clinic Floor Plan Prior to Remodeling (courtesy of Perkins+Will)

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Figure 4: New Clinic Floor Plan (courtesy of Perkins+Will)

Figure 5: Exam Room Corridor

Figure 6: Column Detail (courtesy of Perkins+Will)

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Figure 7: Reception Area (courtesy of Perkins+Will)

Figure 8: Entrance to Conference Room (courtesy of Perkins+Will) • Phase I. After receiving IRB approval, 100 staff/volunteer questionnaires (English) and 100 patient questionnaires (Spanish and English) were provided to the existing clinic in April 2009.

AFC volunteers helped to explain and distribute the questionnaire to the patients. Staff questionnaires were advertised at meetings and by word-of-mouth. Participants were given approximately two weeks to respond. • Phase II. The clinic moved into its new facility in May 2009. Based on the number of responses from Phase I, 50 staff/volunteer questionnaires (English) and 100 patient questionnaires (Spanish and English) were provided to the new clinic approximately six months after the relocation. Researchers recommend that the evaluation of a building be delayed for at least six months after occupation to ensure an appraisal of the building that is not negatively affected by adjustments associated with the move or positively affected by the honeymoon period associated with a new environment (Center for Health Design 2009). Participants were given approximately two weeks to respond.

Results and discussion Phase I The 46 staff and volunteers at the clinic who participated in the survey ranged in age from 17 to 81, with an average age of 46. The majority of the group consisted of females (83 percent) whose native

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language was English (83 percent). Roles of the participants included medical staff (48 percent), administrative staff (20 percent), and other positions within the clinic (32 percent), some of which were volunteer positions (67 percent). The average duration of employment of the respondents was 4½ years, but a few employees had worked there for as long 15 years.

When asked about the design of the original facility, 89 percent of the staff and volunteers felt it was appropriate for the local community and 91 percent felt it supported the needs of patients and families. However, less of a consensus was found (73 percent) when asked if the design supported staff. Only 14 percent felt that the design made them say “wow.” The survey asked participants to rate spaces based on target design factors on a five-point scale. The staff and volunteer participants were neutral when answering questions about the organization of spaces (3.05) and whether the current facility supported organizational efficiency (2.85). Hand washing before and after patient visits was perceived as low by all staff and volunteers (2.61), regardless of whether they actively participated in exam room procedures. However, they did think the patient waiting area was comfortable (3.80) and that the exam rooms’ location and design provided privacy and confidentiality (4.17). The materials and colors of the clinic were not perceived as helpful in wayfinding (2.45), although patients are always accompanied by staff when moving through the clinic spaces. As for the impact of spaciousness, quality of light and noise level evaluations varied from room to room (see Figure 9).

Offices were rated low for spaciousness (2.52), but the reception area was rated highly (3.91). The quality of light was rated low in the offices (2.83) and high in the waiting area (4.07). The evaluation of noise control in each space ranged from a low of 2.62 (workstations) to a high of 3.76 (exam rooms).

The 91 patients and families who contributed to the survey ranged in age from 24 to 86, with the average age being 51. The majority of patients and their families were Spanish-speaking (62 percent) and female (71 percent). Most participants were patients (95 percent), as opposed to family members, and the average number of visits was 10.8.

When asked about the design of the original facility, patients and families agreed with the staff that the design was appropriate for the local community (87 percent) and supported the needs of the patients (86 percent). When ranking design qualities on the five-point scale, patients and families had a more positive impression regarding the organization of spaces (3.61) than had staff, perceiving the waiting area to be very comfortable (4.87), the exam rooms to be private (4.2), and the clinic to be relatively spacious (3.57). Patients found the materials and colors helpful when trying to find their way around the clinic (3.78) and 53 percent felt that they would describe the facility as “wow.”

Patients and families had moderately positive responses when asked about the artwork providing a pleasant distraction (4.05) and whether the clinic environment was relaxing (3.81) or felt bright inside (4.11).

As shown in Figure 10, the patient and family ratings for spaciousness and quality of light were about the same for all the spaces listed. According to the figures, the entrance (3.86) and reception area (3.81) were rated as having lower qualities of light in comparison to the exam rooms (4.07) and eligibility workstations (4.0). Patients and family members also felt the waiting room size was least effective in supporting their needs (3.76), although essentially adequate. Regarding noise control, the reception area was thought to be the least effective (3.57) (see Figure 10).

Overall, the preoccupancy evaluation showed some discrepancies between the views of the staff/volunteers and patient/family members in terms of the use of color and materials to support orientation (2.45 versus 3.78) and the “wow” factor of the design (14 percent versus 53 percent).

Overall, patients and their families rated the old clinic more highly than staff and volunteers. This may have been a reflection, in part, of their gratitude for having access to good healthcare services.

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Figure 9: Staff and Volunteer Responses - Phase 1

Figure 10: Patient and Family Responses – Phase 1 The design of the new facility was intended to focus primarily on achieving better quality of light in the spaces in which users spend most of their time; that is, workstations and waiting rooms.

Respondents recommended that more attention be given to space provided for staff and the patient waiting room to help boost productivity and support the needs of the users in the respective spaces.

Phase II Eighteen staff and volunteers at the new Arlington Free Clinic who participated in the survey ranged in age from 22 to 66, with an average age of 50. The majority of the subjects were females (89 percent), whose native language was English (89 percent). The roles of the participants included medical staff (41 percent), administrative staff (35 percent), and other positions within the clinic (24 percent). A slightly smaller majority of the respondents (53 percent), compared to Phase I (67 percent), were volunteers. The majority of the participants had worked at the clinic for less than four years, but one staff member had worked there for 15 years.

When asked about the design of the current facility, 94 percent of the staff and volunteers felt it was appropriate for the local community and 94 percent felt it supported the needs of patients and families. Eighty-nine percent felt that the design supported staff. In contrast to Phase I, 78 percent felt that the design made them say “wow.” The staff and volunteer participants were somewhat positive when answering five-point-scale questions about the organization of spaces (3.71), the impact of the design on hand washing (3.44), and whether the new facility supported organizational efficiency (3.82). The patient waiting area was perceived as comfortable (4.22), and the exam rooms’ location

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and design provided privacy and confidentiality (3.59). The materials and colors of the clinic were perceived as helpful in wayfinding (3.56). The staff rated the overall environment at 4.0 relative to helping users know where they are. As for the spaciousness and quality of light in each of the spaces, Figure 11 indicates that the staff and volunteers believed the facility to be effective. The entrance, waiting, and reception areas received high marks, while the eligibility work areas and offices were evaluated slightly lower. Regarding staff/volunteer perception of the impact of facility spaciousness on staff productivity and satisfaction, spaces were rated from 3.53 (workstations) to 4.50 (reception).

Figure 11 indicates the perception of a high level of acoustical control, with spaces ranging from 3.50 (eligibility workstations) to 4.61 (entrance/reception/waiting).

The 79 patients and families who contributed to the survey ranged in age from 26 to 71, with the average age being 48. The majority of patients and their families were Spanish-speaking (51 percent) and female (68 percent). Most participants were patients (95 percent), as opposed to family members, and the average number of visits was five.

When asked about the design of the current facility, patients and families agreed with the staff that the design was appropriate for the local community (97 percent) and supported the needs of the patients (97 percent). Patients and families also had strong feelings in favor of the organization of spaces (4.46), the comfort of the patient waiting area (4.56), the privacy of the exam rooms (4.59), and the spaciousness of the clinic (4.44). Patients (4.29) found the materials and colors helpful when trying to find their way around the clinic, and 83 percent felt that they would describe the facility as “wow.�

Patients and families had positive responses when asked about the artwork providing a pleasant distraction (4.45) and whether the clinic’s interior environment was relaxing (4.32) or felt bright (4.52). Regarding the adequacy of space, rooms were rated from 3.87 (entrance) to 4.52 (reception) (see Figure 12). Light levels were highly regarded, ranging from 4.3 (entrance) to 4.48 (workstations).

Noise control was also perceived as effective. The entrance was rated 3.93 and the exam rooms 4.42 (Figure 12).

Figure11: Staff and Volunteer Responses - Phase 2

Figure 12: Patient and Family Responses - Phase 2 Conclusion

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This study compared the evaluations of an old and new free clinic, in the context of the design objectives that were developed during the programming phase of the design (see Figures 13 and 14).

The methodology represents a model for the responsible evaluation of built projects. The results of this research, however, are limited to the case under review and cannot be applied to all clinics. The data have been described analytically, rather than inferentially.

Figures 15 and 16 clearly demonstrate improvements in the majority of the primary design objectives.

The most dramatic increase was in regard to the “wow” factor for both staff and patients. This term encapsulated one of the primary design objectives expressed by staff during programming meetings.

Of the eighty-four comparators, however, there were two reductions. First, staff perceived the exam rooms to be slightly less private in the new facility (4.17 in the old building versus 3.59 in the new), although patients had the opposite impression (4.2 in the old building versus 4.59 in the new). Second, patients found the overall environment to be slightly less comfortable (4.87 in the old building versus 4.56 in the new), although both were thought to be very comfortable spaces. In the latter case, patients and their families might have felt slightly less comfortable in a newly refurbished environment; for example, for fear of damaging the furniture and materials. If a future study were to be conducted at this facility, it might focus on these two issues—exam room privacy and sense of comfort—using an in-depth survey, behavioral observation, or interview techniques.

Figure 13: Staff Environmental Evaluation

Figure 14: Patient/Family Member Environmental Evaluation

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Figure 15: Staff Quality Evaluation

Figure 16: Patient/Family Member Quality Evaluation References Brown, B., Wright, H., and Brown, C. 1997. A post occupancy evaluation of wayfinding in a pediatric hospital: Research findings and implications for instruction. Journal of Architectural and Planning Research, 14(1), 35-51.

Cooper Marcus, C. and Barnes, M. 1995. Gardens in Healthcare Facilities: Uses,Therapeutic Benefits, and Design Recommendations. Concord, CA: Center for Health Design.

Harris, D., M. Shepley, R. White, J. Kolberg, J., and K. Harroll. 2006. The impact of single family room design on patients and caregivers: Executive summary. Journal of Perinatology, Supl. 3, S38– S48.

Harvey, J. 1984. Post occupancy evaluation: do you meet users' needs? Dimensions, June, 12-13.

Kennon, P. A., J.S. Bauer, and S.A. Parshall. 1988. Evaluating healthcare facilities. The Journal of Health Administration Education, 6 (4-part1), 819-831.

Kotaka. 1999. The importance of worker, staff and patient participation in hospital evaluation. World Hospitals and Health Services, 35(3), 20-23.

Ornstein, S. W., R. Ono, M.E. Lopes, and R.Z. Monterio. 2007. Health care architecture in Sao Paulo, Brazil: evaluating accessibility and fire safety in large hospitals. International Journal of Architectural Research, 1(1), 13-25.

Shepley, M. 1995. The location of behavioral incidents in a children’s psychiatric facility. Children’s Environments, 12 (3), 352–361.

Shepley, M. 2002. Predesign and postoccupancy analysis of staff behavior in a neonatal intensive care unit. Children’s Health Care, 31 (3), 237–253.

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Shepley, M. 2006. Grossmont Hospital ICU/ER postoccupancy evaluation. Proceedings of ASHE, San Diego, CA. Shepley, M. 2010. (in press). Healthcare facility evaluation: A comprehensive guide. Myersville, MD: Asclepion Publishing.

Shepley, M., and P. Wilson. 1999. Designing for persons with AIDS: A post-occupancy study at the Bailey-Boushay House. The Journal of Architectural & Planning Research, 16(1), 17-32.

Shepley, M., C. Bryant, and B. Frohman. 1995. Using a post-occupancy study to validate a building prototype: An evaluation of a new women’s medical center. Journal of Interior Design, 21 (2), 19–40.

Shepley, M., D. Harris, and R. White. 2008. Open-bay and single family room neonatal intensive care units: Caregiver satisfaction and stress. Environment & Behavior, 40 (2), 249-268.

Shepley, M., D. Harris, R. White, and F. Steinberg. 2008. Impact of single family NICU rooms on family behavior. In The AIA Report on University Research, 3. Washington, DC: The American Institute of Architects.

Sherman, S., J.W. Varni, R.S. Ulrich, and V.L. Malcarne. 2005. Post occupancy evaluation of healing gardens in a pediatric cancer center. Landscape and Urban Planning, 73, 167-183.

Sherman, S.A., M. Shepley, and J.W. Varni. 2005. Children’s environments and health-related quality of life: Evidence informing pediatric healthcare environmental design. Children, Youth and Environments, 15 (1), 186–223.

Whitehouse, S., J.W. Varni, M. Seid, C. Cooper-Marcus, M.J. Ensberg, J.R. Jacobs, and R.S. Mehlenbeck. 2001. Evaluating a children's hospital garden environment: Utilization and consumer satisfaction. Journal of Environmental Psychology, 21, 301-314.

Whyte, J. and D.M. Gann. 2001. Closing the loop. between design and use: post-occupancy evaluation. Building Research & Information, 29(6), 456-459.

Zimring, C.M., and J. Reizenstein. 1980. Post occupancy evaluation, an overview. Environment and Behavior, 12(4), 429-450.

Acknowledgments The authors would like to acknowledge the contributions of the following individuals from the Arlington Free Clinic: Paula Potts, Marietha Mayen, Nancy Pallesen, and Jorge Ramallo, Jonathan Hoffschneider from Perkins+Will, and the following students from Texas A&M University: Xin Bai, Brian Briscoe, Andrew Brown, Yuxiang Chen, Moon HWI Cho, Justin Dreyer, Jose Fernandez-Solis, Chaojun Gu, Nupur Gupta, Shruti Gupti, Purvashri Hatkar, Nicole Hoffman, Dyutima Jha, Yin Jiang, Shireen Kanakri, Min Hee Lee, Yuan Ma, Glen Marsh, Chrystal McLemore, Haifeng Pan, Pallavi Pramod, Stephanie Schwindel, Yilin Song, Zhouzhou Su, Nicholas Thorn, Jacob Russell, Claire Wren, Siaodong Xuan, Haijuan Yan, Rana Zadeh, Jin Zhao, and Tan Zheng.

Keywords: post-occupancy, evaluation, clinic, survey, healthcare

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The St. Vincent’s Comprehensive Cancer Center a part of the saint vincents catholic medical centers New York, New York

1

The renovation of St. Vincent’s Comprehensive Cancer Center involved the consolidation, expansion and enhancement of all of St. Vincent’s Hospital's existing outpatient cancer diagnostic and treatment services into approximately 65,000 square feet of renovated space. The center is located on the ground floor of 111 Eighth Avenue, a 17-story, reinforced concrete commercial loft building from the 1930's with two levels of below grade parking.

The Center includes a breast center, diagnostic radiology, radiation oncology, chemotherapy, medical oncology, and outpatient surgery with related clinical and public support spaces. It is designed as a state-of-the-art out patient facility.

The St. Vincent’s Center is a major alteration and is designed as a stand-alone, autonomous facility that allows 24-hour operation of specific departments: chemotherapy and related support spaces. Basic utilities—such as electrical power, sprinkler system, riser standpipes, domestic cold water, high and low pressure steam, etc.—are provided by the building.

All mechanical systems, including a self-supporting cooling system and exhaust, electrical, plumbing, fire protection and communications systems, are new.

Patient access is on West 15th Street under a covered vehicle drop-off. Patients who drive to the Center are provided with valet-type parking services. Ambulet and ambulance access for patients arriving by gurneys is provided at two locations on West 16th Street.

1 Entry rotunda looking toward lobby

Gwathmey Siegel & Associates Architects llc

Detail of rotunda looking toward main public waiting area

View of treatment area alcoves in Chemotherapy

Typical departmental sub-waiting area

The St. Vincent’s Comprehensive Cancer Center a part of the saint vincents catholic medical centers

Main public waiting area

View of linear accelerator control area

Typical exam room

Typical operating room

Gwathmey Siegel & Associates Architects llc

The St. Vincent’s Comprehensive Cancer Center a part of the saint vincents catholic medical centers

Typical linear accelerator vault

The St. Vincent’s Comprehensive Cancer Center a part of the saint vincents catholic medical centers

Key Project Information  Consolidation,

expansion, and enhancement of all existing outpatient services  state-of-the-art outpatient cancer facility  designed as a stand-alone autonomous center  24-hour operation of some departments  date  date

of design of completion

 gsf

1996 1999 65,000

Main entrance and patient drop-off

Radiation Oncology Department

Women's Breast Health Center & Diagnostic Radiology Department

Chemotherapy & Stem Cell Pheresis Department

Medical Oncology Department

Outpatient Surgery Department Primary Circulation Secondary Circulation Waiting Areas, Reception, Scheduling and Patient Resource Staff Support Spaces

St. Vincent's Comprehensive Cancer Center Ground level plan

Examination Rooms and Medical Support Consultation Rooms and Medical Offices Group and Private Treatment Rooms, Procedure Rooms, Operating Rooms, Support Spaces, Pharmacy and Lab Service

Vassar Brothers Hospital Comprehensive Cancer Center Poughkeepsie, New York

Vassar Brothers Hospital retained Perkins Eastman to design a new 32,000 sf pavilion for chemotherapy and oncology practice suites. The new building attaches to an existing radiation therapy department, increasing the size by fourfold of this important ambulatory and inpatient service.

The Cancer Center was advantageously located in a single-story wing on the ground floor attached to the inpatient facility, providing a discrete ambulatory entrance on grade and a connection to the inpatient circulation corridors. After reviewing options for growth, a new three-story pavilion was added adjacent to the department, permitting a tight integration of modalities between the existing linear accelerators and all the new ancillary spaces. The new facility includes a chemotherapy suite, pharmacy, conference center, and medical practice suites for various oncology specialists.

The design of the addition is modulated by the adjacent brick structures, which range from Georgian to mid-60s modern. The building also provides a new dedicated entrance for oncology outpatients, facilitating their arrival and presenting an identity that had been previously lacking. The Cancer Center's entrance element relates to the hospital's nearby new glass-enclosed main entrance atrium.

Vassar Brothers Hospital Comprehensive Cancer Center Poughkeepsie, New York

Leading by Design Case Study Account: Wayne Ruga

1. Introduction This case study account presents my own learning in designing, developing, and participating in the Leading by Design research project. Because of my role as the founder of the Leading by Design project, and the introductory material that my case study contains, it serves as the foundation for all of the following participant case studies.

2. Summary of Purpose I designed the Leading by Design project as a learning process to enable its participants to understand how to actively exercise ‘health design leadership’, as a means for them to develop increasing mastery in cultivating ‘generative space’.

When participants cultivate ‘generative space’, they are demonstrating their mastery in creating environments where it begins to become possible to systemically and sustainably improve health and healthcare delivery.

3. Leading by Design Overview Research and the Learning Process The Leading by Design learning process is, itself, a model of how to cultivate ‘generative space’ in practice.

The Leading by Design research project enables this learning process and its related outcomes to be operationalized, refined, expanded, documented, and disseminated. The research project supports the promotion of new understandings of how to systemically and sustainably improve health and healthcare with the design of the environment to a wide range of diverse, health-related stakeholder groups.

As the researcher, I have had a continuous personal debate as to the legitimacy of my own life and work qualifying as a Leading by Design case study. I have decided in favor of my being a Leading by Design case study, with the primary focus of my own case study research being: to research and develop the Leading by Design learning process as a vehicle for actively exercising ‘health design leadership’ for the purpose of cultivating ‘generative space’.

My case study, like the others in the Leading by Design project, follows the action research methodology – with its iterative and increasingly expansive pattern of utilizing a continuous personal reflexive assessment to: (1) reflect on my practice; (2) generate new learnings from these reflections; and (3) inform my practice with these new learnings.

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This iterative learning process provides the analytical framework that is applied to each Leading by Design participants’ life and work to provide the evidence of how improving the environment has systemically and sustainably improved health and/or healthcare. It should be noted that, because of the inherently creative nature of this learning process, participants have the freedom to apply it flexibly.

Further, it should be noted that the learning process that the Leading by Design project utilizes is not a conventional, ‘academic-type’ of classroom or book learning. Rather, the Leading by Design learning process relies on an approach to experiential learning requiring each participant to draw upon specific challenges that their own unique day-to-day experiences provide the situational context for.

Personal Context: My Own Learning Journey My journey to become both the originator of the Leading by Design project, and a case study participant in it, actually can be traced back to 1973. At that time, as an undergraduate student of architecture, I became passionately interested in better understanding how the environment can be used to improve health and healthcare.

As the years progressed, my interest in developing this better understanding deepened. I committed myself to a career in healthcare architecture, and subsequently enrolled in a Master of Architecture program that offered a specialized ‘health facility planning and design’ graduate degree.

I developed a successful career as a practicing architect – yet, my interest and curiosity continued to deepen as I yearned to discover how to make healthcare facilities that tangibly improved health. As my quest for this discovery spanned the globe for practical answers – and I found very few – my focus began to evolve away from a desire to be a practitioner toward becoming more of an influencer. Although my interest and passion did not waiver, I began to see my self in the role of influencing the overall industry to better understand how to build more life-enhancing healthcare facilities – rather than my actually designing them myself, anymore.

During the period of 1978 – 1985, while still engaging in professional practice as an architect – because of my shifting focus on learning and influencing, rather than practicing – I began to spend increasingly more of my time teaching in universities and design schools, lecturing at conferences, and writing articles.

In 1985, I made the landmark decision to start a new symposium that would engage a diverse crosssection of healthcare and design-related stakeholders in an inquiry into both the desirability and the practicality of creating ‘healing environments’. The first symposium was held in 1987. The twentieth annual symposium was held in Chicago in 2007. During this twenty year period, the entire healthcare industry has dramatically – and visibly – advanced.

In my dual role, both as a practicing architect and as the leader of this rapidly expanding symposium, it had become increasingly apparent to me that quality research was now required to lend support to claims that the environment could be more effective in its support of healthcare.

In 1993, I founded The Center for Health Design to serve as the umbrella organization for an expanding portfolio of initiatives – of which, by now, the symposium was just one of the many. One of the core purposes for my founding The Center for Health Design, was for it to function as a non-profit organization and – therefore – be well positioned to fund, produce, and disseminate quality research. Today, The Center for Health Design continues to function in this useful capacity.

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1998 was an extremely eventful year for me, as I continued to follow my interest in developing a better understanding of how the environment can be used to improve health. I was awarded a Loeb Fellowship for Advanced Environmental Studies in the Graduate School of Design at Harvard University. This provided me with a one-year residency at Harvard, and access to its vast resources, for the purpose of improving my effectiveness as an industry leader. I spent the year immersed in leadership studies within the Kennedy School of Government, having realized that learning more about effective leadership was the single-most useful resource that Harvard could provide to me.

Also in 1998, in my ongoing role as the President and CEO of The Center for Health Design, I succeeded in selling the production rights for the annual symposium to a for-profit, event-producing partner. This transaction provided The Center for Health Design with a much-needed infusion of capital, and allowed the important transition to be made from an event producing organization to becoming a resource producing organization, with a partner providing the platform for The Center’s content to continue to be presented upon.

During this period of twenty-five years, that I have just outlined – and, particularly, during the last 3 to 4 years in this period – it had become apparent to me that something, quite significant, was still missing in our ability to develop a better understanding of how the environment can be used to improve health.

Indeed, our inquiry into ‘healing environments’ resulted in a noticeable overhaul of our healthcare building stock – both in the US and around the developed world, and the idea that the design of the healthcare environment could be – and should be – evidence-based had become well established. And yet, it seemed to me, that a large gap remained in our ability to develop this better understanding and to implement it in such a manner that health became materially improved.

This gap, it seemed to me, had something to do with the ability of the environment to support, encourage, and reinforce both systemic and sustainable improvements in health. In many of the projects that I designed during my years as a practicing architect, as well as in the Planetree projects, and in an occasional rare discovery – the environment did enable systemic and sustainable improvements in health - - however, in most other projects, this did not appear to be the case.

In early 1999, having completed my residency at Harvard, I met with my Executive Committee at The Center for Health Design to discuss how my recent experience – as a Loeb Fellow – could inform the work of The Center for Health Design.

In my discussion with my Executive Committee, that afternoon in early 1999, we talked about this gap.

I proposed that, since there were so many more questions than we had answers for, I wanted to contribute toward closing this gap by engaging in original research to explore these questions – and, in the course of doing so, work toward earning a PhD. The conclusion of our discussion was my departure from The Center for Health Design as its founder, president and CEO. Professional Context: Founding The CARITAS Project In March of 1999, I founded The CARITAS Project to serve as the organization that would pioneer the next generation of resources for improving health and healthcare with the environment. In August, 2000, I was awarded a three-year grant from the UK government to conduct original research to pioneer these new resources, that would lead to my receiving a PhD.

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In July, 2005, The Manchester Metropolitan University awarded me a PhD for the completion of a dissertation entitled: ‘An “Action-Oriented” Research Investigation To Develop A Better Understanding Of How Space Can Be Used To Improve Health And Healthcare Delivery’. In conducting this investigation, I spent 3 years doing fieldwork with 18 individuals to learn about improving health from their unique experiences with the local healthcare environment. I, then, spent an additional year analyzing my fieldwork, reflecting on its implications, and ‘writing-up’ my findings.

Research Context: Designing the Leading by Design Research Project It was during this time that I began the Leading by Design project. There were three distinct reasons for my deciding to do this. First, since my fieldwork was complete, I already had a clear indication of what my research findings were. I was excited to test these findings out with participants representing larger stakeholder interests and across a wider geographical field.

Secondly, within the University framework for writing a dissertation, there is a section that must be written on ‘further work’. This section is intended to describe how the original research will be further developed for its practical application, beyond the completion of the dissertation. I used the opportunity that this section provided to formulate and describe the initial research design for the ‘Leading by Design’ project – and, also, I wanted to take advantage of the scientific scrutiny that the rigorous academic review process would provide.

My third reason for beginning the Leading by Design project was to actively take the work of The CARITAS Project forward, and – as such, for it to serve as the practical means to enable The CARITAS Project to succeed in pioneering the next generation of resources to improve health and healthcare with the environment. The CARITAS Project had already conducted two projects, since its founding in 1999 – a Leadership Summit, in 2001, for 22 invited participants; and an international conference, in 2003, for 100 invited professionals and 2500 local participants.

I used this initial description as an ‘invitation’ to invite diverse, non-competing healthcare stakeholders to join the project. Now, four years later, there have been a total of 14 participants and there are currently 11 active case studies that are engaged in operationalizing the findings of my research in their respective contextual situations.

4. Key Learnings and Outcomes Year One: Defining a New Practice of Leading My PhD research provided me with the dramatic evidence and first-hand experience that it is possible to create the environment in a new and different way, so that health and healthcare can be systemically and sustainably improved.

Reflections on my practice – I found that the overall concept of ‘generative space’ is relatively simple for most people to understand – however, as I reflected on my many attempts to explain how to cultivate ‘generative space’ I realized that the actual practicalities of explaining it are both elusive and difficult to visualize. Consequently, I decided to make a diagram to make it simpler for me to discuss the cultivation of ‘generative space’ with the participants in the Leading by Design project, and with prospective participants.

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Generate new learnings from these reflections – In my initial sketches, of this diagram, I used the findings from my dissertation to illustrate the relevant and overlapping knowledge domains, their relationship to one another, and the respective thematic findings in each of these domains. In the research for my dissertation, I had concluded that there were three relevant knowledge domains – health, culture, and environment. Each one of these domains included various thematic findings related to the exercising of leadership.

This activity of developing a diagram provided me with the opportunity to reflect on the practical application of my dissertation findings to the more broad field of practice. In these reflections, I realized that, in fact, I had not given adequate recognition to the overall importance that the subject of leadership plays in cultivating life-enhancing environments for health and healthcare.

This reflection, of the overall importance of leadership, significantly informed my practice by enabling me to reconfigure the findings from my dissertation into four knowledge domains – with the newly defined domain of leadership becoming the all-encompassing domain, within which the other three became situated (see Appendix, Figure 1).

And more precisely, this series of reflections generated a new learning for me by clearly establishing the primacy of the practice of ‘leading’ as the critical understanding that is required in all attempts to cultivate ‘generative spaces’ that make both systemic and sustainble improvements.

Inform my practice with these new learnings – This new learning allowed me to appropriately define the overall practice of working toward cultivating ‘generative space’ as the practice of ‘health design leadership’.

Specifically, this practice of ‘health design leadership’ will not, in-and-of-itself, create spaces that are generative- rather, developing mastery at the practice of ‘health design leadership’ is just one of the competencies necessary in a process of learning that supports the ability to cultivate ‘generative space’ predictably, reliably, and consistently.

And finally, at the end of my first year in Leading by Design, my most significant new learning – as I engaged with my own practice to define a new practice of leading – was the understanding that Leading

by Design is a learning process about personal leadership. Now, having arrived at this essential clarity, I focused my efforts in the second year at developing a coherent learning process that would provide increasingly advancing mastery in the practice of cultivating ‘generative space’.

Year Two: Defining the Leading by Design Project Reflections on my practice – In the beginning of my second year of Leading by Design I realized that this second phase of my research really had the potential to have a significant influence upon mainstream practice – yet, as I reflected on my practice of engaging with Leading by Design participants in the research, it was not perfectly clear to me exactly what the critical essence of this learning process of Leading by Design was – or, how to most effectively share it with others.

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This reflection enabled me to focus my attention on demonstrating the tangible benefits of cultivating ‘generative space’ to make systemic and sustainable improvements to health and healthcare. As I reflected on my new practice, I realized that the benefits of these improvements are precisely what prospective participants are seeking, and that my ability to design and deliver a learning process that enables participants to produce these benefits was the unique contribution of the Leading by Design project.

Generate new learnings from these reflections – My reflections helped me to become highly focused on engaging in conversations – both with the Leading

by Design participants, as well as prospective participants – that identified their own practical leadership challenges as the subject of our conversations. This new and sustained focus, which was a learning generated by my reflections, enabled me to identify those contextual challenges – that were unique to each of the participants – as the material to apply the Leading by Design learning process to.

Inform my practice with these new learnings – Up until this time, it was my practice to discuss ‘generative space’ conceptually – without ever having written a working definition that could be shared with all of the participants. My new focus on the contextual leadership challenges of the participants – as a new learning – informed my practice by enabling me to understand the need to draft a working definition of ‘generative space’ (see Appendix, Figure 2). This working definition augmented the Leading by Design diagram (Figure 1) and helped to further define the overall Leading by Design project.

Year Three: Validating the Leading by Design Project Reflections on my practice – The first two years of the Leading by Design project were challenging, to say the least: I was defining the research and the project as I was doing it; I was continuously learning how to cultivate ‘generative space’, myself, and to actively demonstrate it; and three of the participants did not renew their participation after their first year.

At the very end of the second year, I convened the first Learning Collaborative. Five of us met for 3 days in May 2005. At the conclusion of the meeting, the group was delighted with its outcome and were enthusiastic about planning our next Learning Collaborative. This enthusiasm indicated to me that these other four participants would continue their annual participation because they were receiving definite value for their investment – I took this as an important, and needed, signal of personal encouragement.

Additionally, two new participants had just joined – but it was too soon for them to make the arrangements to attend the Learning Collaborative. As I reflected on my practice during the past two years of developing the Leading by Design project, I found that I had a life-affirming sense of personal and professional validation for this work.

Generate new learnings from these reflections – As I reflected, further, on my new sense of validation – a new learning emerged: both the Leading by Design project and I were now ready to engage in a larger scale validation project.

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This new learning formed the agenda for the next eighteen months – an international speaking tour to present the Leading by Design project to professional and academic audiences. My new learning about the importance of peer review validation of this research initiated the third phase of the Leading by Design research project – that of a peer review process through presentations made to an international group of diverse healthcare stakeholders.

Inform my practice with these new learnings – By the middle of the fourth year, I had made 12 peer review presentations about the Leading by Design project. My own personal practice of actively exercising ‘health design leadership’ to increase my own mastery in cultivating ‘generative space’ reached a new level of confidence as a direct result of both this peer review process, as well as the through the validation that this process afforded the Leading by Design project. I now knew for certain that the Leading by Design learning process would leave its indelible mark upon the mainstream practice of health and healthcare delivery.

Year Four: Broadening the Influence of the Leading by Design Project Reflections on my practice – A new awareness has come to me – within the expanding ‘portfolio’ of the Leading by Design project outcomes, there is now a sufficient body of evidence to support a focused discussion about the ability of the Leading by Design learning process to close this sustainablity gap that I have identified – the subject of my discussion with my Executive Committee in early 1999.

This new awareness has enabled me to shift my thinking: re-focusing the emphasis of the Leading by Design project from only being based upon the case study accounts of the participants, to a new and equally meaningful focus that is based upon specific topics – in this case, that of ‘sustainability’.

Specifically, within the context of Leading by Design, the term ‘sustainability’ means that the improvements that have been made by the active exercising of ‘health design leadership’ to cultivate ‘generative space’ are improvements that continue to improve over time.

Generate new learnings from these reflections – The second Learning Collaborative is scheduled to be held in London, in February 2008.

As I reflect upon my recent experiences, and the new learnings that I have gained from these – particularly in anticipation of my organizing the Learning Collaborative to serve as a most useful learning experience for all of the participants – my own practice has been informed, in my role as the project organizer, by my new awareness that I should plan our discussions to provide the space for both dimensions of the Leading

by Design work to be discussed: (1) the case studies as well as; (2) a focused discussion about the evidence of ‘sustainability’ that we, as a group, are now producing.

Inform my practice with these new learnings – This new learning, about highlighting our focus on documenting evidence of sustainable improvements to health and healthcare that we have achieved through our active cultivation of ‘generative space’, will – most likely – become the theme of year five of Leading by Design. This new learning will inform my own practice by providing a theme for the coming year’s work, that seems to be emerging as – ‘Sustaining and Documenting the Improvements that have been Achieved through the Leading by Design Project’.

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5. The Future As the Leading by Design project progresses through its fourth year, it is well positioned to expand the pattern that it has already established. Specifically, in its quest to expand this pattern, it will be addressing its ongoing viability as an applied research project; and its ability to successfully assert an impact upon the mainstream practice.

From my position of learning today, and prior to the new learning and understandings that emerge at the upcoming Learning Collaborative, the future Leading by Design activities will include the following, as they seem to offer a prudent path forward: 2008 Establish the fourth phase of the Leading by Design project – a ‘prototype’ project.

Establish the fifth phase of the Leading by Design project – a formalized learning program.

Continue to expand the influence of the Leading by Design project.

2009 – Begin writing the ‘generative space’ book.

2010 – Finish writing the ‘generative space’ book.

Present all completed Leading by Design case studies at an international conference and publish the proceedings as a special issue of a distinguished academic journal.

Establish the sixth phase of the Leading by Design project – the operationalization of the ‘care-centred model’ within a major provider system.

6. Concluding Reflections and Summary The reflexive process of writing my own Leading by Design case study account has helped me to demonstrate the actual reflexive steps that this personal learning practice entails. Additionally, it has helped me to clarify a series of my own key learnings, and in doing so, it has enabled me to have a more strategic perspective on planning an intelligent network of future activities.

In my reflecting back, and in my imagining forward, I am – both - inspired by the progress that Leading

by Design has made toward its goal and extremely enthusiastic about the future potential for the continued expansion of this work.

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7. Appendix Figure 1. The Leading by Design Diagram

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Figure 2. Working Definition of ‘Generative Space’ As a means to develop a shared understanding of ‘generative space’, please consider the following as a working definition – ‘Generative space’ is a place – both physical and social - where the experience of the participants in that place is one that both fulfils the functional requirements of that place and it also materially improves the health, healthcare, and / or quality of life for those participating in that experience in a manner that they can each articulate in their own terms.

Additionally, and by its very nature, a ‘generative space’ is a place that progressively and tangibly improves over time.

The purpose of cultivating ‘generative space’ is to improve performance effectiveness. Depending upon the interests of the particular individual, the organization, or the community – the measurements of effectiveness will vary. However, in all cases, whatever these measures are – they will be used to encourage, support, and reinforce increasing performance effectiveness in health, healthcare, and /or quality of life.

The goal of understanding how to cultivate ‘generative space’ is to be able to produce it consistently, reliably, and predictably across the full range of life’s contextual situations – including – 1. our personal lives; 2. our professional and organizational work; and 3. throughout the vast spectrum of our community engagements.

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