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ELECTRONICALLY REPRINTED FROM MARCH 2014
By using an aggressive Lean approach to
planning and designing an expansion, Seattle
Children’s Hospital found that less is more
By Jennifer Kovacs Silvis
O ftentimes when embarking on a new healthcare facility
project, square footage and adjacency requirements will drive programming and, subsequently, design. But things were a bit different
when the team from ZGF Architects LLP (Seattle) partnered with
Seattle Children’s Hospital for the project Building Hope: Cancer,
Critical and Emergency Care Expansion.
“Leadership, from the top down, had looked closely at all aspects
of operations, care practices, and ongoing facility strategies” in
advance, says Allyn Stellmacher, design partner at ZGF. “They’d set
the table for where they wanted to go.”
It took a lot of work to get there, but when all the pieces came
together, Seattle Children’s got just what it needed—and it was a
lot less than originally anticipated.
Add and subtract
BENJAMIN BENSCHNEIDER
Building Hope included $4 million
in transportation improvements
around the campus to enhance safety
and provide more opportunities for
walking and biking.
deliver care and save significantly. Through
practice and investigation, you can improve
how you think about the future,” Stellmacher
says.
And soon a new challenge was brought
to the table that would require an equally
thoughtful solution: Hospital leadership
wanted to cut the size of the proposed new
addition in half. “It was 2008-2009, the
market had crashed, and it was a turbulent
economic time. The first read on this was
that it would be a $650 million project—that’s
huge for this institution. It still seemed like
the right idea to move forward but at a much
smaller scale,” Johnson says.
Above: Each floor of Building Hope
offers families “quiet rooms” to relax
and unwind without the interruption of
the facility’s intercom system. Below:
The design of Building Hope includes an
emphasis on family-centered care, with
a number of dedicated family zones
provided where patients’ parents and
siblings can relax, work, or prepare
food together. Opposite: An artwork
package for the building was developed
that includes a nature-inspired graphic
film that’s applied on glass walls inside
corridors to serve as a distraction for
older and younger kids. It also allows
light to stream into internal spaces.
BENJAMIN BENSCHNEIDER
How it all started
In 2006, Seattle Children’s partnered with ZGF
on its 2030 Major Institution Master Plan, including a long-term goal to double in size by adding
more than 1 million square feet to the campus
sited within the residential community of Laurelhurst in Seattle. Due to the nature of its location,
there are pretty tight parameters around the
facility’s growth that require a lengthy entitlement
process through the city. So when it was determined that additional space was needed, the
organization spent 24 months working through
that process. In the meantime, a lot was happening behind the scenes.
“It gave us a great opportunity to look at
our strategic plans, understand our volumes
forecast, and understand what our focus needed
to be in terms of both operations and facilities,”
says Todd Johnson, vice president of facilities at
Seattle Children’s.
The hospital hired consultant Joan Wellman and Associates and embarked on a Lean
process, or continuous process improvement
(CPI), to identify approaches to reducing waste
and improving quality and safety. In fact, the
process was so successful that a planned and
designed emergency department expansion
that had already cleared the entitlement phase
was canceled because the hospital realized its
overcrowding problems weren’t about volume
but about inefficient space utilization. “That was
a testament to the solution—they realized how to
BENJAMIN BENSCHNEIDER
More with less
What was initially planned to be Phase 1 of
1 million square feet of new building space
was eliminated in favor of the Building Hope
expansion, a 330,000-square-foot, eight-story
building housing 80 inpatient beds (with the capacity to expand to 192), a ground-floor ED, an
intensive care floor, and two cancer care units.
The ability to reduce the scope of construction as well as cost was born from the idea
to connect a new building back to an existing
patient tower that had originally been slated
Top: The wayfinding program used in the Building Hope project was created
as a new brand identity for the Seattle Children’s main campus, using four
themed zones—forest, river, mountain, and ocean—that rely on a design that’s
sophisticated yet playful. Above: The ED lobby features a modern approach to
the building’s forest theme, which is tied to the regional geography of the Pacific
Northwest.
BENJAMIN BENSCHNEIDER
Meanwhile, a new piece of property came
onto the organization’s radar. Though it hadn’t
previously been addressed through master
planning, an option surfaced to purchase
land adjacent to the hospital. With an internal push to reevaluate scope and a piece of
property that allowed innovative thinking about
the placement of a new building so close to
the old, the solution became clear: Seattle
Children’s didn’t need to start from scratch.
“We had to ask ourselves what we needed to
achieve and how much square footage it would
take. The idea was to knit the new to the old,”
Stellmacher says.
BENJAMIN BENSCHNEIDER
for demolition. While the hospital had been
constructed over years, with some areas far
more outdated than others, outdated space
didn’t necessarily mean unusable space. “It
resolved itself by combining old and new. The
older space can easily hold office, research,
or less-intensive bed usage like psychiatry. It became apparent that there’s a lot of value there,
a lot of synergies by connecting intelligently,”
Stellmacher says.
Core services provided from the existing
building include pharmacy, clinical laboratory, central stores, central sterile, outpatient
services, radiology, and surgery. By taking advantage of what Seattle Children’s already had,
the expansion avoided duplication and reduced
initial costs by 60 percent.
And thanks to all of the CPI work that had
been done, Seattle Children’s knew exactly
what it wanted out of its new space, even if the
scope was far from what was originally anticipated. Guiding principles included a keen focus
on safety in every aspect of design, ensuring
that caregivers were able to spend as much
time as possible at the bedside, and enough
flexibility to account for the unknowns surrounding the future of healthcare delivery.
To achieve those goals in the new space, a
group of stakeholders including staff, the
Lean consultants, and the design team set
out to first assess the hospital’s current
state through a 3P event (production, preparation, process). “They went to patient care
units, followed registered nurses, hunted for
supplies, went to medication rooms, looked
for equipment, and recorded all of that. We
had a sense of time spent at the bedside
and in wasteful activity,” Johnson says.
One approach used to eliminate waste,
reduce travel distances, and place key
departments together was to use horizontal
stacking for the new building as opposed
to a more traditional vertical model. Core
services are located on the same floor as
inpatient beds to allow caregivers to go
between inpatient and outpatient environments for a single service line (e.g., inpatient
cancer treatment beds are on the same
floor as outpatient cancer services).
Getting it right
While ideas for how the space could best
be used surfaced, the team relied upon
Lean to ensure it was right. And a big piece
of that process was gaining a realistic view
of what was being designed. “In Lean, you’ll
Patient rooms were designed to
be universal to allow the hospital
more flexibility in response to the
unknowns surrounding the future
of healthcare delivery. To support
that flexibility, as well as the need
for family space, the rooms are
larger at 292 square feet plus a
42-square-foot toilet room. “They
chose an investment in size to
ensure longevity in the inpatient
room, which required us to Lean
the supply delivery process to
remove waste. It sounds simple,
but it took a big investment of
people and time to get it right,”
says ZGF’s Allyn Stellmacher.
out of the simulation to help us get the full
spectrum of information,” he says.
For ZGF, taking the information provided and keeping it on track with project
goals was a critical piece. “We were
charged with helping the facility document direction, evaluate, and figure out
best models to facilitate that,” Stellmacher
says. Johnson adds that having an integrated team, including ZGF and general
Top: As part of the Lean design process,
the team constructed a full-scale unit
mock-up on the roof of a parking garage
to get a feel for space configurations.
Middle and above: Next, a warehouse
was rented where an entire floor was
constructed in much more detail, with the
design’s universal patient rooms, support
areas, and care team porches built to
scale to see if the concepts worked
during real-life simulation exercises.
COURTESY OF ZGF ARCHITECTS LLP
hear people say that it’s about ‘learning to
see.’ When you build, you’re able to see much
more clearly; it’s easier than working in BIM.
So we used mock-ups and simulation liberally
throughout the process,” Johnson says.
Starting with tabletop exercises using pieces
cut to scale, users were asked to move those
pieces around to decide on things like adjacencies, proximities, and shapes, with a focus on
seven flows of medicine: patients, families, providers, medications, supplies, equipment, and
process engineering. The next step was to take
the results and create mock-ups on the roof
of the hospital’s parking garage. With details
kept to a minimum, the mock-ups consisted
only of exterior walls to get a feel for the space
configuration. And it worked—the team realized
the right angle in the middle of its L-shaped
wings caused a pinch point. The solution was
to tweak the design to bring more of a curve to
the wing.
Next came the big event. The team rented
a 70,000-square-foot warehouse in Seattle,
where a cardboard mock-up of an entire
32,000-square-foot floor was built. Influenced
by previous design events, the mock-up
included established ideas for universal patient
rooms, support areas, and a concept for “care
team porches” outside patient rooms, to get
a feel for them at scale. Patients and families
were among those taken through the space,
with about 50 to 60 people overall involved in
the process. But there was a large focus on
staff, from nurses to housekeeping supervisors,
who simulated their activities on the mock-up
floor in as real-life a fashion as possible. Daily
rounds were conducted, travel distances were
measured, and all the data collected was compared against a baseline to ensure changes
were making things better. “The whole goal was
to improve operations while also building a new
space,” says Mark Gesinger, principal at ZGF.
“It was our task to synthesize all of that architectural information, knowing their aspirational
goals.”
Once out of the warehouse, a final phase of
Lean design homed in on refining the patient
rooms, with more mock-ups built—this time
with real materials and equipment, where care
delivery could be simulated and the design
tested. Overall, Johnson says, he saw the
Lean effort as a consensus-driven process
that refined divergent views to create a single
approach. “We would use data and anecdotes
contractor Sellen Construction (Seattle) involved
throughout provided much-needed counsel
to ownership on what ideas would also fit the
budget. “The process doesn’t focus users on how
much things cost. There has to be a safety net so
you don’t decide on something you can’t afford to
build,” he says.
Left: A view of the ED captures open
and closed collaboration spaces for
staff, all easily visible to other staff
members, patients, and families while
also just steps away from patient
rooms. Above: A curved flooring
and ceiling pattern provides a clear
directional cue in inpatient units,
while color is used to denote entry
into the patient rooms. Opposite,
top: The care team porches offer
workspace for staff as well as storage
for medications and other supplies.
The Building Hope project utilizes
just-in-time delivery of supplies to the
porches as one of the efforts made
to Lean the building’s processes.
Opposite, bottom: Inpatient floors
feature a narrow core, where private
and open collaboration spaces are
available to staff, while care team
porches are located adjacent to
patient rooms.
BENJAMIN BENSCHNEIDER
Core concepts
When all was said and done, the Lean process
identified a number of design approaches to support Seattle Children’s goals for a safe, efficient
environment of care, starting with eight-bed
patient room neighborhoods in 16-bed units designed around an extremely narrow building core.
“In a traditional outpatient unit, you would have a
core taken up with storage of items, and here the
core is taken up by people functioning in different
ways, interacting,” says Anita Rossen, senior
interior designer at ZGF. The narrow core not only
offers open and closed collaboration spaces but
provides short travel distances to patient rooms
and allows daylighting to cross the unit while offering easy visibility, too.
When nurses aren’t at the bedside, their next
point of contact is the care team porches, small
workstations adjacent to patient rooms. The
spaces are also used to store supplies, charts,
equipment, and medication, and to support justin-time supply delivery. “It really becomes this
multifunctional space, but it’s visually right in your
path of travel, which is impactful for families and
staff,” Rossen says.
BENJAMIN BENSCHNEIDER
Though largely scaled back
from the hospital’s original
intentions, the Building Hope
project is a first step toward
a greater plan.
To support both safety and future flexibility,
patient rooms are universal and capable of being
flexed between acute care and ICU, or to other
modalities as necessary over time.
Jennifer Kovacs Silvis is managing editor of
Healthcare Design. She can be reached at jsilvis@
vendomegrp.com.
Completion date: April 2013
Owner: Seattle Children’s
Architecture: ZGF Architects LLP
Total building area: 330,000 sq. ft.
Total construction cost: $136 million
Interior design: ZGF Architects LLP
Construction manager: Seneca
Group
General contractor: Sellen
Construction
Lean design: Joan Wellman &
Associates Inc.
Engineering: Coughlin Porter Lundeen
(structural, civil); Sparling (electrical,
technology, security, acoustic and
vibration); Affiliated Engineers
(mechanical)
Artwork: Amy Ruppel, Lab Partners
Medical equipment: Design Works
Inc.
Lighting: Pivotal Lighting
Signage and wayfinding: Studio SC
Landscape: Site Workshop
Furniture: Garrison Design
Sustainability efforts include the use of
high-performance glazing on the façade to
reduce solar gain, while the overall building
envelope was enhanced by adding insulation
to the roof and exterior walls.
Posted with permission from the March 2014 issue of Healthcare Design. ©2014 Vendome Group LLC. All rights reserved.
For more information on the use of this content, contact Wright’s Media at 877-652-5295
BENJAMIN BENSCHNEIDER
Results
After its April 2013 opening, the organization
talked to users at the 90-day mark to see how the
space was working, Johnson says. And outside
of requests to add a few hooks and move some
clocks, the feedback was largely positive. “They
said nurses had been spending 40 percent of
their time at the bedside before and now are
spending 60 percent,” he says. Improvements
have also been noted in family experience surveys, with satisfaction trending upward alongside
staff satisfaction. While goals weren’t met in every
instance, improvements were seen against the
baselines.
Building Hope, though largely scaled back from
what was originally thought to be the next move
for Seattle Children’s, is also a first step toward a
greater plan. Over the next two decades, it and
other additions will replace the current hospital.
And, currently, two floors of shelled space in the
Building Hope expansion are being built out for an
additional acute care floor and critical care floor.
ZGF is currently doing a master plan of Seattle
Children’s east campus, which was previously
occupied by the primary service lines that have
moved into Building Hope, to be completed in
2014. Overall, the Building Hope experience provided a new perspective for the firm on creating
an appropriate facility without overbuilding—essentially, providing a client more value by designing less. “It’s been a sea change in discovering
how much more effective we can be. It puts a
large responsibility on Seattle Children’s to seek
change, to organize, and find value that may
be beyond what they anticipate,” Stellmacher
says. HCD
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