Herding Cats? Implementing Pre-Design Strategies to Align Multiple Stakeholders

As designers, our intensive training prepares us to creatively solve problems for our clients, which usually means we start to draw. At SmithGroup, we have a different approach to our design process: we help our clients first fully define the problem they need to solve, well before we begin exploring design solutions.

At this year’s Healthcare Facilities Symposium and Expo in Austin, Texas, Leigh Snow and Alison Faecher from our Boston office, along with Jackie Dockham from Exeter Hospital, shared their pre-design journey to “identifying the problem first.” Cleverly referring to the process to as ‘Herding Cats,’ they presented the strategies they implemented to align multiple stakeholders to a common understanding and investigation of existing conditions. This approach ultimately united the project team with a clear vision and goals to move forward “in the same direction” as they prepare for the design phase of the project.

Why was this pre-design study important to the project? To answer this question, Jackie shared a brief history of Exeter Hospital and why the pre-design phase was critical to a cost-effective design process. Exeter is 100-bed community hospital located in Exeter, New Hampshire, just an hour north of Boston. Its most recent hospital construction projects have been focused on outpatient services while inpatient renovations and improvements have not been a priority. However, with competitors advertising a “private room for every patient” and existing conditions that are ill-equipped for multi-discipline care teams, new equipment, or evolving technology, it was time for Exeter to evaluate and redesign their inpatient platform. Instead of executing a traditional process where stakeholder influence dwindles as the project develops and costs increase, Exeter wanted to focus on value for their patients and the organization. This new value proposition could only be established by creating a team of ambassadors that together would make thoughtful, informed decisions throughout the life of the project, aligned with the future state of the organization.

Exeter Hospital Workshop

SmithGroup utilized an A3 process in combination with Lean strategies to frame the study, breaking down the problem analysis into stepped, digestible segments for the team. As Alison Faecher stated, “It is not our job to tell Exeter what to do, but to enable learning”: to enable them to identify the problem and make decisions in a collaborative, informed environment. Over the course of 10 months, approximately 21 team members were engaged in seven all-day interactive workshops, in addition to three facility tours. The workshops and tours were structured around the Lean A3 problem-solving structure that follows seven basic steps:

  1. Background – Why are we talking about this?
  2. Current State – Where do things stand now?
  3. Future State – Where do we want to be?
  4. Problem Analysis – Why does the problem exist? Look for root causes.
  5. Countermeasures – Testing out proposed solutions
  6. Action Plan – Specify tasks and timeline
  7. Evaluate/Follow Up – Take measurements

The first workshop, Background, was the team’s first time being together in one big room. This session was arguably the most important to set up the study for success. Through team-building activities and hands-on exercises, the group worked together to define the boundaries of their exploration and their time. During an exercise called ‘Keys to Success,’ all team members wrote on index cards their definition for success. The index cards were then pinned on the wall for each member to vote (with stickers) for their top choices; this allowed for a visual, group dynamic that brought the team to a shared understanding of the project goals. By the end of the first workshop, there was a collective creation of the team’s mission statement that would be shared with the hospital and revisited throughout the process.

The next step was to identify the current state of Exeter’s inpatient units. This was done through a plus-delta exercise, which focused on the physical environment of the existing units, including how they were working well (plus) and how they could be improved (delta). Following that was a direct observation of the inpatient units. SmithGroup first educated the stakeholders in a common language of healthcare design. This preparation was essential to help the stakeholders learn to see the inpatient unit in a new way, ultimately unveiling existing issues they may not have seen before. Each team member then spent four hours within the existing unit observing or shadowing working staff. They recorded travel paths and made notes on the unit floor plans, identifying and understanding new challenges or verifying the issues recorded during the plus-delta exercise.

With our shared experiences, knowledge, and vocabulary, we became ambassadors for the project.

Jackie Dockham RN, CIC
Director of Infection Prevention, Exeter Hospital

Once all stakeholders were well versed in the existing conditions of the inpatient units, it was time to envision the future. Through a listen and record exercise, the workshop facilitators created post-it notes with everyone’s vision for revitalized units. The team’s top goals for the future state included:

  • Patient- and family-centered design
  • Units that are quiet and welcoming
  • A private room for every patient
  • Efficient delivery of supplies and equipment, accessible at point of care
  • Enhanced technology to improve patient experience and clinical outcomes
  • Standard workflow and processes across all patient care environments
  • Increase nurse time with the patient; reduce paperwork
  • Zero HAI’s and zero patient falls

The process then transitioned to envisioning the future and understanding what the rest of the industry was doing to address these issues in their facilities. The best and most effective way to engage in this knowledge-share among peers was at a national platform, the Healthcare Design Conference. The entire team attended 42 unique learning sessions and toured one facility at the conference.

“This leveled the playing field for the stakeholders and allowed us to get curious together, creating a bonding opportunity where we continued to learn together,” said Leigh Snow. Additionally, the team confirmed that although there are universal challenges in healthcare institutions, each hospital is unique, and that they must engage with multiple stakeholders to form a collective solution.

After the team returned from the conference, the next step in the A3 process was Problem Analysis. Referring to the Keys for Success from the first workshop, the team prioritized its future state goals and then correlated the existing issues that were impeding these goals in a ‘Problems to Solve’ matrix. This identified the top four problems for the team to study through a Root Cause (5-Why) Analysis. The 5-Why is an iterative investigation technique that explores the cause and effect relationship of a problem; utilizing this within the Problem Analysis phase enabled the team to filter through symptoms that revealed root cause problems:

  • Not enough private rooms
  • Specific and inflexible units
  • Nurses too busy, pulled from patient care by other tasks
  • No tools for communication between caregivers
  • Patient journey is haphazard; not coordinated
  • Supplies and equipment too far from care
  • Nurses transporting items off unit

From this, they developed a list of potential design options or countermeasures that could help solve those problems, which were used to guide further research and the tours:

  • Flexible units; universal rooms; acuity adaptability
  • Observation units
  • Nurse station configuration (centralized/decentralized)
  • Caregiver communication technology
  • Patient journey tracking and coordination
  • Point of care storage
  • Transport systems

The most anticipated step of the process, facility tours, were next on the agenda. The team could now witness first-hand the solutions their competitors and peers implemented at their facilities. Building upon the design language they had learned, the team prepared by reviewing the floor plans of the facilities they would tour. Additionally, SmithGroup prepared a simulation exercise with patient scenarios that helped the stakeholders read the floor plans and envision the patient’s journey through the facility while also analyzing staff and supply circulation. This helped the team to formulate a list of critical questions they wanted to ask on the tours. The tours were a game-changer for the Exeter team. They were able to engage with peers who had also been involved in a design process and shared experiences and lessons learned, such as how they have had to adapt as new technologies are introduced to the industry.

The last workshop in the pre-design study developed the guiding principles that would transition the team to the project’s strategic planning process:

  • Develop a patient- and family-centered experience
  • Deliver a highly reliable (safe) environment
  • Eliminate all barriers to collaboration
  • Cultivate a culture that promotes staff engagement and retention
  • Make decisions based on qualified data and evidence
  • Use Lean principles to focus on process and flow
  • Create value

The final step of the study was to develop an action plan for non-building solutions that could be addressed immediately, including process improvement, technology solutions for better communication, and supporting a culture of collaboration.

“With our shared experiences, knowledge, and vocabulary, we became ambassadors for the project,” said Jackie Dockham, “The key for us was to develop shared conditions for satisfaction. We learned that there are things hospitals can and should do ahead of design.”

Following the presentation of the experience and process of the Exeter Hospital’s pre-design study, Alison and Leigh shared their recipe of essential ingredients that anyone could utilize to help align their project team.

  • Make sure you have the right people, including a champion on the client’s side, the correct specialty advisors and any facilitators that might be needed to advance the discussion.
  • Set the stage with a multi-disciplinary team that represents a variety of perspectives, and keep the dialogue open by leveling the playing field with common vocabulary.
  • Implement a Lean problem-solving process and define the problems before offering solutions.
  • And, lastly, create a work plan at the beginning of the process that allows for flexibility and permits appropriate time between events for facilitators to prepare between each workshop.

This team’s process is a great example of how we as designers, through an integrated investigation and analysis, can help clients take a step back and identify their problems before we begin proposing solutions. The panel ended with a metaphoric slide of Olympic athletes lined up for a race, and Leigh Snow concluded with, “Much like these runners, our project team members each have specific roles, but through this process, we are ready to go and all are headed in the same direction.”