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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 109765