A Conversation with Dr. Delaney Ruston, Filmmaker, Speaker and Stanford-Trained Physician Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis. NBBJ: Could you tell us a bit about your upcoming documentary, Screenagers NEXT CHAPTER, about children with anxiety? Dr. Delaney Ruston: We live in a screen-saturated world, and we’re examining how this affects teens’ emotions and communication preferences. In our film, we speak with teens about their personal stories, and talk with parents as well as schools — about what they are doing and how they can better support our teens. The film also explores my daughter’s experience with depression and my role as a parent. A key goal of our film is to help all teens develop and build skills to thrive with hard emotions, such as stress, clinical depression and anxiety. We’re also motivated to raise awareness, to increase the national discussion surrounding teens and mental health. There are lots of interactive interventions, but it can be complicated and painful for our teens (and parents, too). We’re so excited that this film uncovers lots of different solutions to a troubling situation. It also ramps up the science that shows why the teenage years are such an emotionally complex time. Teens are not just moody — their brains are undergoing rapid physiological changes. What are the most impactful changes that could be made to how behavioral health is handled in the United States? The first is that we could revolutionize the system to fully appreciate the magnitude of solutions available, particularly people power — our support teams, teen peer groups, school psychologists, etc. From my personal standpoint, my father with schizophrenia bonded with his case workers in such a profound way. I think we need to further contemplate and build this task force. The power of positive, supportive relationships is fundamental. The other is integrating medical and behavioral health into one. Behavioral health is complex, and for some conditions, like depression, we need lots of mental health and social services support. To strengthen the link between the two healthcare areas, while training professionals (and paying them a living wage) as well as community members and peers, would go a long way. What is an innovative approach/treatment you — or another institution, city, state, country, etc. — are working on when it comes to behavioral health treatments? As a Fulbright fellow, I made films in India. During my time there, I spoke with and filmed mental health workers across the country and examined their peer-training system. Globally, I think the peer movement needs more funding and resources, particularly targeting college-age groups and above as mentors. Traditional behavioral health facilities are seen as socially isolating or unpleasant to the senses. How should the design of behavioral health facilities transform to better serve patients (and their families and visitors) and staff? If the right presentation and program is offered through a medical setting, the community will come. Seattle has a “birds and the bees” program, where parents come with pre-teens to discuss the impacts of puberty. It is critical we create welcoming spaces for behavioral health discussions, programs, training interfaces and more. What makes you hopeful when it comes to combating the behavioral health crisis? People are so eager to talk about these issues — and adolescents are overall being raised in environments that are more open to talking about these topics. Thankfully, this cultural mindset of greater acceptance is pulling the cover off the silence around mental health issues. It only hurts the situation by not discussing it. By seeing positive stories and showing that talking more about behavioral health leads to better outcomes, we’ll continue to benefit, as a community, in our families, and as individuals.

A Conversation with Dr. Gregory Miller, Chief Medical Officer, Unity Center for Behavioral Health Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis. NBBJ: What is the most impactful change that could be made to how behavioral health is handled in the United States? Dr. Gregory Miller: The development of a truly integrated system of care — not between behavioral health and physical health, but within behavioral health itself — is one change. Care for episodes of illness has become spread out between disparate providers, such as inpatient, partial hospitalization programs, outpatient, case management, etc. Often one team knows nothing about the real handoff information necessary to change the level of care smoothly. Delivering care from truly integrated systems would make a huge difference. In addition, community services need to be built out and invested in. What is an innovative approach/treatment you — or another institution, city, state, country, etc. — are working on when it comes to behavioral health treatments? The concept of Psychiatric Emergency Services, i.e. specialty mental health care that is immediately accessible, is an innovation that mostly benefits the severely mentally ill (SMI), a poorly-resourced population. It helps to rebalance the needs of the SMI population when community services are inadequate or poorly accessible. It should be seen as a temporary approach, providing access during a period of transition to more richly-resourced community services. When the community is adequately resourced, the need for such higher-end services will decrease. Traditional behavioral health facilities are sometimes seen as socially isolating or unpleasant to the senses. How should the design of behavioral health facilities transform to better serve patients (and their families and visitors) and staff? I like the design of progressively expanding “spheres of community.” For example, in an inpatient unit or subacute unit, the most intimate sphere of community is where one sleeps and tends to personal hygiene. Units where patient rooms are clustered internally with progressively expanding bands — such as an area for dining and group treatment, with activities that emerge into a larger sphere for consultation with providers, school service and family and visitation — tend to mimic life in the communities that we live in. What makes you hopeful when it comes to combating the behavioral health crisis? I am hopeful regarding the progression of knowledge and treatments. However, I am disappointed that care has become, over the course of my career, progressively more disintegrated and confusing. Systems do not converge to provide cohesive treatment. Patients are confused by the systems they are involved in. Providers, likewise, are confused. Hopefully this will be the next wave of progress.

A Conversation with Dr. Curtis Wittmann, Associate Director, Acute Psychiatry, Massachusetts General Hospital Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis. NBBJ: What is the most impactful change that could be made to how behavioral health is handled in the United States? Dr. Curtis Wittmann: The biggest issue currently is a lack of resources. This crosses many domains, ranging from a lack of true parity, which makes recruitment of providers more difficult; a lack of places to refer patients; inadequate inpatient and state hospital beds; and a lack of social resources and programs, which impedes our patients’ ability to engage in treatment. An increased availability of resources, both within the mental health field and as social supports, would allow for meaningful and novel approaches to be implemented. Until then, even in relatively resource rich-environments, we don’t have enough to offer our patient populations. What is an innovative approach/treatment you — or another institution, city, state, country, etc. — are working on when it comes to behavioral health treatment? At Massachusetts General Hospital we have been redesigning our dedicated emergency psychiatry space and increasing both our capacity and attention to patient comfort. We are moving to minimize the use of inappropriate clinical space and attempting to allow for a more open design to allow more patient interactions and increased programming while patients are boarding in the emergency department. Concurrently, we are working to initiate treatment from the point at which patients arrive to the ED and are screened by emergency medicine. Both of these initiatives are designed to decrease the amount of boarding that takes place and the length of stay for patients who are boarding. Traditional behavioral health facilities are sometimes seen as socially isolating or unpleasant to the senses. How should the design of behavioral health facilities transform to better serve patients (and their families and visitors) and staff? There is always a balance between the need for safety on the one hand, and maximizing patient comfort, freedom and environments on the other. Increasing safe open spaces to allow for connection between patients, between patients and staff, and between patients and their families and visitors is critical. Ideally these settings would make better use of natural light or, if possible, outdoor spaces — though this is very challenging in city environments. It may be possible to create a more natural space indoors through the use of plants and more creative design. Finally, there is increasing attention to the role of physical activity and exercise in mental well-being, and even suggestions that exercise may be an effective treatment for several mental health conditions — a creative design would work to implement increased walking space and/or a semi-dedicated space for exercise with associated programming to implement positive habits or continue them while patients are hospitalized. What makes you hopeful when it comes to combating the behavioral health crisis? I’m made hopeful when I see the response to the opioid use disorder epidemic. Although it was delayed, across the country there has been a dramatic increase in the commitment of resources to treatment and to novel programs within hospitals and communities. These resources have been a blend of government resources along with hospital and private resources. The mental health epidemic does not have the same dramatic statistics regarding increasing death rates, but arguably it extracts an even larger price from a larger number of people. Should we be able to learn from some of the lessons of the opioid crisis — rapid access to treatment, de-stigmatization, increased recovery supports — we could have a similar impact on improving our country’s approach to behavioral health.

A Conversation with Dr. Susan Swick, Physician in Chief and Medical Director, Ohana Montage Health Editor’s Note: The number of people reporting behavioral health issues is on the rise, a crisis often compounded by lower-than-average funding, a lack of psychiatric beds and high occupancy rates of behavioral health facilities. This week we are posting interviews with experts in behavioral health, following an NBBJ-hosted panel discussion, to learn how different parts of the country are addressing the crisis. NBBJ: What is the most impactful change that could be made to how behavioral health is handled in the United States? Dr. Susan Swick: Psychiatric illnesses are common and treatable, often curable, but access to effective treatment remains maddeningly difficult in the United States. Yet even with effective treatments, being disease-free is not the same as being healthy. Building mental health can protect against disease and contribute to a life of meaning, with happier relationships, satisfying work and better physical health. Helping people to understand that good mental health is something each individual must develop will not only improve public health, but also diminish the stigma that remains around mental illnesses. Finally, by helping parents to understand that mental health is something we help our children develop, rather than simply protecting them from mental illness, we contribute greater resilience in children and well-being in families. I have seen the power of these ideas at work in my patients and in my own family and am passionate about contributing to a health care system that builds health. What is an innovative approach/treatment you — or another institution, city, state, country, etc. — are working on when it comes to behavioral health treatment? The physical environment in which care occurs contributes profoundly to the well-being of patients and caregivers, just as classrooms affect students. Environments create our sense of what is possible, while raising or lowering the volume of what we are hearing in the moment. Environments — including the materials, presence of natural light, fresh air and sounds — have the power to be soothing and quieting or highly stimulating and activating. In a windowless, crowded psychiatric emergency department in NYC, I experienced the power of music to quiet agitation and comfort the lonely: a cozy office filled with art, books and overstuffed furniture created the personal, warm and reliable setting that allowed effective psychotherapy to take place. In addition, an escalating child was able to go on a walk outside with a trusted adult and was able to naturally re-regulate themselves and not require medications or restraints to do so. The setting never does all the therapeutic work, but the right setting makes it possible for the clinician and patient to do the work together. Traditional behavioral health facilities are sometimes seen as socially isolating or unpleasant to the senses. How should the design of behavioral health facilities transform to better serve patients (and their families and visitors) and staff? Behavioral health facilities are still healthcare facilities, and they must ensure safety, including infection control, prevention of suicide and everyone’s safety around agitated or aggressive patients. But they must support quality care, also. I think design for highest-quality behavioral health care should create an environment which is soothing — with, for example, lower noise levels, natural materials, neutral colors, predictability and options for retreat or privacy. At the same time, they should be inspiriting or support a sense of possibility with higher ceilings, dynamic views, fresh air and ample, diffuse, natural light. It is critical that these spaces include the potential for agency or choice, more so when patients spend more time in them. We hope that the skills which our patients build in these spaces will remain when they return to their homes, offices and schools. Therapeutic spaces should echo the spaces our patients inhabit. But they can still be special — spaces in which to pass storms and glimpse a new horizon. What makes you hopeful when it comes to combating the behavioral health crisis? If design can serve both the passing of a storm and the promise of an open horizon, all while promoting agency, it will be an extraordinary space. When we provide care and offer education about mental fitness in spaces that everyone is delighted to be in, it destigmatizes mental illness in ways that words and statistics cannot. When we provide care in humane spaces that promote autonomy and individualism, alongside nurturing connections between patient and clinician, between family members, among colleagues, between friends, and across a community, we support mental fitness in our patients, ourselves, our colleagues and our guests.

I had the privilege of joining the 2019 UN Climate Action Summit in New York City earlier this fall. Amongst the many tracks at the event, my focus was on Infrastructure, Cities, and Local Action — how to bring climate solutions to bear in cities that are on the front lines of emissions, impact and action. As the creators of cities and the urban context, our profession plays an integral part of any climate crisis solution and must be actively involved in driving the world forward. My key take-away from the summit is the broader societal success that will result when our cities transform into zero-carbon economies. Zero-carbon cities will be healthier, cleaner, more connected, more resilient, and the drivers of innovation and green economic success. They will be the places where you want your children and grandchildren to live. It’s hard to argue against that. It is of utmost importance for the design industry to elevate the discussion around these greater societal benefits, especially in these times of disagreement over the urgency of the climate crisis. Focusing on the non-climatic benefits can drive greater change while we reap the environmental benefits. There are stories and threads for every audience — be it economic growth, resilience and security, human health, ecosystem restoration or social justice. What can we do, as city designers, in a context where, as Ms. Maimunah Mohd Sharif, executive director of the United Nations Human Settlements Programme, said at the summit, 75% of the 2050 infrastructure has yet to be built? Here are a few ideas: Bring long-term thinking to our projects. All our current buildings will be around in 2050 — are they able to make the transition and meet the 2050 goals for zero carbon? Utilize full-cost, life-cycle accounting in our decision-making, bringing in the cost of carbon and societal impacts and evaluating them from construction to decommissioning. Focus on the human experience — zero carbon means little if our projects aren’t wonderful places for people. Focus discussions around non-carbon benefits to build stakeholder support. Don’t look for a “new tech silver bullet” — the solutions we need, from heat pumps to solar and wind energy, are here, now. Lead from within.* While getting to zero carbon by 2050 is a daunting task, it is achievable. We see tremendous growth in action and commitment across the public and private sector — whether it’s Amazon’s recent Climate Pledge, New York City’s buildings’ carbon emissions law or the consortium success of the C40 Cities Initiative. I’m bullish about our capabilities and the passion and talent across the AEC industry and beyond. Together, we can drive this exponential curve to zero carbon and enjoy a beautiful and healthy future in our cities — cities that will house 5 billion of us by 2050. “Getting there [to zero carbon cities] will be the growth story of the 21st century.” —Lord Nicholas Stern, London School of Economics Source * Here are a few of the things NBBJ is doing: More than a decade of commitment to the Architecture 2030 Challenge Leaders who are active in their communities, from driving local code changes to serving on national and international boards and committees, including the Living Futures Institute, the AIA’s Energy Leadership Group and ASHRAE Founding sponsorship of and membership in Targeting 100! with the University of Washington Our Legacy Project in partnership with the Nature Conservancy

Editor’s Note: This post is adapted from an interview originally published in the Q4 2018 issue of DesignIntelligence Quarterly. What sustainability priorities should we focus on? High-performance, sustainable projects are the only future that is viable for our profession and our clients. Zero carbon is viable for many projects, and we’re able to steer clients toward an achievement that’s possible for them. Material selections for reduced environmental and health impact are easier every month. Planning and site development for resilience and for a healthier urban ecosystem are equally critical. You mentioned materials transparency. What are you doing about that? We’re tweaking our specifications in areas where we can knowledgeably improve our standard options. For example, if we want to include a product, and we have enough manufacturers that are willing to disclose what’s in their product, we can require that disclosure. We’re getting a bit more sophisticated about reducing the carbon footprint of our projects, as well. For example, what are all the concrete mixes? What’s the lowest-carbon concrete mix we can use for that particular structural purpose? How can we make sure that we are fine-tuning those mixes for the lowest carbon while maintaining performance? The largest carbon and environmental footprint tends to be in the structure and exterior materials. The health footprint, the complicated chemistry, and the disclosures tend to congregate around the finish materials and that end of the spectrum. Where do the ideas of being practical and being effective intersect best for sustainability? If we’re doing things in the right way, we shouldn’t need to add money. We should be able to reallocate resources in a smarter way to do almost everything we want to do. So, for instance, if we create a better conceptual design — with the right window/wall ratio, better orientation and massing for passive energy flows, and we put the effort into better architecture — we should be able to spend less money on mechanical heating and cooling. To me, that’s pragmatic and effective because we’re conserving first-cost resources and getting more from our client’s money. The goal is to do that while also creating a more comfortable, more livable place for everyone who experiences it. In the years that you’ve been practicing sustainable design, what changes have you observed in clients’ viewpoints? Many of our clients recognize the value of creating space that helps them and their people be more comfortable and perform better. This was an idea that probably didn’t resonate well a few years ago because there weren’t enough studies to show the connection between what we thought intuitively were good things for people and our quantitative goals. What makes you hopeful? What challenges you? What makes me hopeful is the human spirit and the desire to make things better. You see it a lot lately in various movements outside of the building industry as well as all of the groundswell around addressing climate change. At the core, I believe we all want to make the world a better place. The challenge is how hard it is sometimes to find a common understanding or a way to communicate that gets us all headed in the same direction.

Eighteen months ago my mother-in-law’s (Dixie) husband (Don) passed away very unexpectedly. They lived in a three story home in Laguna Beach, CA for fifteen years and were able to walk around town and go to the beach and their favorite restaurants, and see movies among all the other activities they loved to do. And Dixie volunteered some Saturdays at the Women’s League Thrift Store. They were truly living their golden life. The Phone Call It was a Thursday in May when I got an early morning phone call from Dixie. I immediately asked if everything was alright and she said no, Don had died and that she was at the hospital. My husband and I jumped in the car and were at Dixie’s side in two hours. Upon our arrival, it became clear that she was mistaken. Don had not passed away; he was comatose due to a brain blockage. That day became one of the longest days of my life because of the horrible circumstances surrounding Don’s death and because Dixie’s diminishing mental capacity became very apparent. She could not remember what happened or fully comprehend what was happening in the ICU. Every hour she would ask me if there was a change, if he was better, when they could go home. And every hour I would tell her no, he was not better, and that he would not be going home. This went on until Don’s sisters finally arrived at 11 PM and he was taken off life support and passed away just after midnight. There were signs and symptoms leading up to this event and even a confirmed report from the doctors that Dixie had dementia. There were instances where she was unable to remember how to get home from a routine walk to the downtown area and Don had revoked her driving privileges because she was struggling to remember how to get to and from places. Routine activities at the house, like laundry, dishes, and general cleaning, were starting to slip. Dixie and Don didn’t remember buying things and common goods like olive oil and saran wrap were piling up. Their eating habits had changed, mostly to ice cream and wine, and nothing was being cooked or thought about when we were visiting on weekends. My husband and I were talking to them about downsizing because of their age, Don’s general health, and Dixie’s seemingly worsening dementia. After many months of convincing them and, I believe, Don’s growing inability to anticipate Dixie’s increasing symptoms, they finally agreed to look at senior living facilities where they could live out their golden years together with additional care as needed. The plan to go and see some of these places had been set up months in advance and were scheduled for the week after Don’s passing. The Challenge Of Finding The Right Place Immediately following Don’s death, we stayed with Dixie in their home to comfort her and because it became very obvious how much we didn’t know about her inability care for herself. Reality set in so fast that we quickly understood Dixie would not be able to remain at home by herself and that we were now faced with the sudden challenge of finding the right care environment for her. None of Dixie’s children or their spouses were able to provide the kind of care that a person with Alzheimer’s or dementia needs. At one point Dixie decided to make cauliflower and left the pot on the stove, burner on, no water or cauliflower inside, potentially burning down the house had someone not walked into the kitchen to find her disoriented in her own home, the “cauliflower” forgotten. Anyone who considers it insensitive to put an elderly family member into any kind of long-term care or assisted living facility should rethink this. For us, our lack of understanding of how to care for someone with dementia could have easily caused Dixie more harm. When you are not trained to care for or anticipate the needs of a loved one, long-term care and assisted living facilities provide a safe, secure place that offers twenty-four hour care, food service, monitored outings and events, and activities that keep the body and the mind active. Our search for long-term assisted living began that summer. There are many things to consider when searching for the right place for a loved one who has Alzheimer’s or dementia. Consider the following: Some places have all the right in-room amenities but the facility cannot secure the perimeter. In our situation this was not suitable since Dixie has a history of getting lost. The step-up care from independent living to assisted living to memory care is not clearly defined. We had to consider that Dixie is coming from what she thought of as completely independent living, not realizing how much assistance she was getting from Don and then her children. The range of options is incredible. You really need to do your homework and ask a lot of questions: What type of meal services are provided? What about medication management to make sure everything is taken at the right time and in the correct dosage? How often will they clean the unit? Is there medical staff on site 24-hours? The Cost Of Care Increases With Each Additional Service If you wait until your loved one has been officially diagnosed with Alzheimer’s or dementia, the price almost triples compared to what it costs for those without. According to an article in seniorliving.com the average cost of long-term care/assisted living in a one-bed unit is $3,800 a month depending on the level of care and medication management. This does not include all the additional fees for medical management and memory care classes that can be an additional cost of up to $12,000 per month. Comparatively, the cost to stay in a hospital at an average of $30,000 per stay, the hospital stands to charge $10,000 per day on each stay (healthline.com). And here-in lies the problem with designing long-term care facilities. There is such a great disparity in the return on investment between designing and building acute care vs. long-term care ($10,000/day vs. $10,000/month, respectively), that I believe we will have to start making our own plans to change the future of long-term care. You cannot compare the two when it comes to “doing what is right” vs. just doing. And if we do it right, we should be able to make them affordable and avoid costly hospital stays. Redesigning Our Golden Years I deeply felt Dixie’s transition from her home to her new home. Would she have been less resistant if the environment was designed more like the Four Season’s with well-appointed high-end furnishings and crystal chandeliers? Or if the scents and air from the Midwest, where she grew up, and more familiar to her once younger senses were infused in her room? At NBBJ, our own Neuroscientist, Dr. John Medina, says that our strongest memories are from the ages of 18-22. For me, that means that when I am eighty, I will best remember the music from AC/DC’s Ball-breaker Tour, Morrissey, and Depeche Mode, and the aromas of freshly baked pepperoni pizza from my first restaurant job. I’ll want to watch Pretty Woman, Pretty in Pink, and Sixteen Candles…shouldn’t we start planning for that today? All of the research I did for Dixie made me think about my future. My husband and I have no children to help us make these decisions. We may have our own physical or mental ailments that make it difficult to choose what is best when the time comes for outside help and care. I half joke that the day I am eligible I will buy into one of these new long-term care communities so that I get the best deal and can enjoy my own golden years! We both enjoy the arts, not necessarily art museums and theatre but more along the lines of rock and roll bands, edgy documentaries, sports, even! We can’t be the only ones who would consider a long-term care or assisted living facility designed around our own personal life experience. In my case it would have well-lit music halls that allow cover bands to come and play the music of my era, the music that I will remember when I’m eighty, and some sort of theatre for plays and movies! As planners and designers, we need to design residences that integrate all our human physical needs with what we want to personally experience as we get older at a cost we can afford. We see the changes in hospitals turning more toward hospitality where a patient can customize the environment in their room. Let’s bring personalized hospitality to our golden years through flexible planning and new designs How about rock and roll camp for the ageing! Let’s make it someplace Mick Jagger would want to go. I wouldn’t mind my view from the penthouse looking down into an amphitheater with a rock and roll band playing my favorite AC/DC songs! Build that and I will come.

Before starting each design research project, I fall into the habit of trying to talk myself out of it mostly out of cynicism. Why are we collecting similar data again? Will we learn anything new from this client versus the vast quantities of secondary research that already exists? However, the team always comes out of these research activities learning something new - whether unique to the client’s culture, finding a new frame to an existing problem that cuts across the industry, or how we can improve our own process to be more successful in the future. It is always worth having conversations with users no matter how brief the effort. Recently, NBBJ had the good fortune to facilitate similar discussion topics with two major academic medical centers back-to-back. This process gave us the opportunity to compare and contrast the two different efforts. While we can’t share the design opportunities we uncovered yet, we can share a three learnings about how we conducted these research efforts. Learning #1: Frame the desired level of conversation. While the objective of both of the studies were similar, one organization’s result leaned more heavily towards rudimentary opportunities than higher level improvements that an organization may tackle after getting the basics right. While hearing from users that they need the basic necessities is an important data point, precious time can be better spent with users if facilitators just spend a little bit more care up front outlining what type of discussion we desire to have. And if conversations meander back to undesired subjects, facilitators should not hesitate to remind participants of the scope of the discussion and steer the conversation back on topic. Learning #2: Frame the desired scope of conversation. Correctly scoping a research effort is a no-brainer. However, as a design firm known for a particular output (i.e. physical space), we need to be extra vigilant with framing the scope of the conversation. Very often we would find ourselves spending majority of the time discussing opportunities around space. This could be the desired outcome, especially under time constraints. However, I’ve seen discussions veer back into physical space even when the team has the time to tackle people, process, and technological opportunities. Whichever path the team wants to go in, make sure it is a conscious decision and utilize visual aids to ensure a balanced coverage of discussion. Another way the two different medical centers differed is how often the staff experience conversation became a patient experience conversation. While both work sessions were prefaced with IHI’s Quadruple Aim framework, one of the organizations veered away from the fourth aim, Improving Provider Work Life, which is the focus of the work. As a result, the facilitators had to make an extra effort to steer the discussion back to staff wellness. Facilitators should always be conscious about the scope of discussion and not by shy about getting the conversation back on track. Learning #3: Define who should not be in the room. Who you have in the room can affect the discussion outcome. In one set of staff focus groups, representatives from facilities planning and construction were present but not part of the discussion group. While their presence was not an issue for the majority of the conversation, it created an environment where the participants may not have felt safe to discuss freely their concerns about the space or, conversely, they would spend too much time focused on space. In hindsight, when planning the focus group, we should have talked about who should not be in the room as much as who should be in the room. These three learnings are by no means new to any experienced facilitator. But often a disproportionate amount of time is spent designing the content of the discussion and not on how the discussion should be facilitated. Spending just a bit more time carefully designing how a discussion could unfold will be time well spent. #transitionservices #operationalprocessimprovement #masterplanning

We have all heard the phrase transforming health care. Some of us have even personally experienced transformation in care as patients through improved work flow generated by Lean and other methods of process improvement. But how does this concept apply to your built environment and what is the value that this brings to your organization? In the last decade we have all become acutely aware of the forces driving change in health care delivery as embodied in the Institute for Health Improvement’s Triple Aim: Better care for individuals, better health for populations, and lower per capita cost. Innovative health care organizations have responded by streamlining and improving patient care and by changing the way they develop and manage their built environment. Facility design must support health care operational improvements. While Lean process improvement methods frequently result in excellent design solutions, these methods often fail to incorporate the creativity and benefits of a time-honored standard: Design Thinking. Many of the health care organizations we work with responded to this challenge by embracing a design process built around Integrated Facility Design (IFD) that integrates Lean and other process improvement methods with Design Thinking to align organizational initiatives with facility design. The success of this effort is highly dependent upon fulfillment of three objectives: Behavior and practice change, operational improvement, and facility design. Integrated Facility Design combines these three objectives. Lean Thinking In 2002 Lean was the new kid on the block in health care. Several organizations adopted Lean methods and thinking and used Lean improvement tools while other organizations embraced alternative process improvement methods and tools to sustain their transformation. Case In Point Several years prior to Virginia Mason adopting lean as their operating model, I managed the design team for Virginia Mason’s Ambulatory Surgery Center in Federal Way, Washington. How did the design team create and communicate a successful layout to their client? We employed the flow map below to show how patients, providers, instruments, and supplies would move through the space with minimal waste. As planners, we are trained to understand flow. And we employed design thinking to generate the best solution possible. The Lean process improvement method, originally developed around industrial production, has been successfully adapted to many service industries including health care. Many Lean tools are variants of time-tested quality improvement techniques and are widely used in other quality improvement methods. Design Thinking Design thinking requires careful consideration of how things could be and ways to transform existing situations into more desired ones. Process improvement and design thinking share the same goals and often the same tools. However, a major attribute of the design mindset is to be solution-focused and action-oriented and not problem-focused. Design thinking can best be described as a discipline that uses the designer’s sensibility and methods to match people’s needs with what is technologically feasible and what a viable business strategy can convert into customer value and market opportunity. Tim Brown, CEO of IDEO Some people think design means how it looks. But of course, if you dig deeper, it’s really how it works. Steve Jobs Positive change requires innovation and that requires a thorough understanding of your unmet and often tacit needs. With this understanding the design team embarks on a journey of discovery leading to the best solution. This is not a linear process: It’s iterative, relying on experimentation and incremental improvement. If this process sounds familiar, recall Deming’s Plan-Do-Check-Act (PDCA) improvement method. Design thinking employs scientific methods and creativity to explore the possibilities of what could be, and deliver results that fulfill your requirements. To illustrate this concept here are reviews of three similar approaches to Design Thinking. Design Squiggles One of the most graphic illustrations of the design process is the Squiggle Diagram created by Daniel Newman of the Central Office of Design, Sausalito, CA. The diagram represents a transformation from uncertainty to clarity using design thinking. (Diagram courtesy Central Office of Design/Daniel Newman) To many, the design process is a mystery, with creative types practicing their craft single-handedly in a design studio. However, even without the captions, the above diagram tells a different story. The process can be described as: Define the challenge Do the research Develop concepts Test prototypes Create the design And by iterating through this process you create continuous imporevement. These are team-based actions involving everyone associated with the project. Continuous improvement is the key phrase that describes how design works. Design is an iterative process that embraces continuous refinement of creative solutions. The squiggles eventually resolve to a wavy line and finally to a straight line. Designing for Growth In their publication “Designing for Growth”, Jeanne Liedtka and Tim Oglivie present the design thinking process in an ostensibly linear fashion, as a series of four questions. Their goal is to decode the design process: From abstract to practical, from thinking to doing, and from analysis to experimentation. The central theme of this model is divergent and convergent thinking. It recalls the Lean 3P workshop wherein teams are encouraged to use convergent thinking to describe current-state and divergent thinking to guide innovation and to create a construct of how things could be in a future state. The first question: What is? Assess current-state in order to frame the design challenge Understand and visualize the client’s needs Second question: What if? Establish design criteria and draw upon nature for potential solutions Envision choices for a new future: How things could be Third: What wow’s? Choose the most effective solutions Exhibits a wow factor that is appealing to users And fourth: What works? Test the design solution Take the design to the marketplace Strategic Design The diagram below from the Design Council (UK) also illustrates the divergent/convergent thought process used in design thinking: The Design Council’s approach to design is straightforward, based on a logical progression of four action-oriented steps: Discover, define, develop, and deliver. Each one these approaches defines a process based on design thinking and employs critical thinking and Lean process improvement methods at strategic intervals. Design thinking and process improvement are interdependent, each providing a structured framework for problem-solving and customer-focused solutions. Integrated Facility Design: Bringing It All Together How do Integrated Facility Design and process improvement methods complement each other? The greatest advantage of IFD is that the process integrates the expertise of all stakeholders to achieve breakthrough improvements. The stakeholders may include patients and their families, hospital administrators, physicians and surgeons, nurses, staff, the design team, the general contractor, and operational excellence experts. By leveraging the collective intellect of all the participants, the IFD team is better equipped to solve a complex design problem and is enabled to visualize their future built environment. Even more important, the iterative nature of this design process produces lasting results. Our IFD strategy integrates operational improvements and facility planning by focusing on: Change management: We facilitate your people working together in a collaborative, transformed practice Operational Improvement: We lead a process of discovery whereby you redefine and improve flow by eliminating operational waste and focusing on more efficient delivery of patient care Facility planning: We facilitate the creation of standard, adaptable spaces that enable the operational improvements defined by you Our design approach was created in response to an unpredictable marketplace working with organizations who were choosing to align with design teams who really understood their business and market position. These organizations wanted partners who really understood the needs of patients and care teams. They wanted planners and facilitators who could help implement organizational change. Moving The Curve The chart below shows how Integrated Facility Design can move the curve and reduce waste and project cost by tying down the design earlier in the process leading not only to significant savings early on but through the life of a completed project. Experience shows that the time invested in IFD workshops (green dotted line) yields a pre-schematic layout that jump-starts the entire design process, trimming significant production time from the project schedule and minimizing design changes along the project timeline. The Integrated Facility Design Workshop What happens in an IFD workshop? By blending design thinking and process improvement tools a customized plan for your project/process improvement is created. Key workshop elements in a three-day event include: A full three-day IFD workshop employs the following process improvement methods and tools: Visioning: Guiding principles; community involvement Observation: What we heard; what we observed Analytics: What we know; patient volumes; market opportunities Quality Improvement: Optimizing flow; visual control; communication; case studies Waste Reduction: Identify current-state process waste; 8-Wastes Current-State Flow: Flow maps to show how it’s done now; identify wasteful steps; 7-Flows Innovation: 7-ways innovative thinking; future-state ideation Future-State Flow: Design and map new flow; eliminate waste; develop patient-centric designs Key Adjacencies: Organize spaces; test adjacencies; test flow prior to test-fit layouts Test-Fit Layouts: Use standard, scaled templates; refine adjacencies based on flow; test flow Rapid Prototyping: Construct full-scale mock-ups; cellular and modular design; locate key elements Simulation: Scenario planning; script standard work; create flow map; run multiple scenarios Implementation: Create momentum map; draft implementation plan; draft communication plan Additional tools are employed when required and may include: Set-Based Design, Standard Ops, PDCA, Value Stream Maps, Quality Function Deployment templates, and A3 storyboards. The underlying goal for the use of these tools is that design should be based on optimal flow that reflects the best of your organization. Bottom Line Re-engineering processes alone will not resolve the challenges facing the health care industry. Health care organizations need to integrate facility redesign into process improvement to gain full value. The design profession is prepared to employ design thinking and the design tools required to face these challenges. With over twenty certified Lean leaders in our organization we have integrated Lean processes and tools into our design practice and have worked with, and learned from, the most forward thinking health care organizations. We are built upon design thinking principles and fully committed to continuous quality improvement. #leanthinking #operationalprocessimprovement

When I started working at NBBJ I was surprised to hear grumblings from talented medical planners and designers who felt the user group process was tedious and did not always provide the big results to them individually. This was partly because many organizations had similar needs, similar constraints, and wanted to try similar designs based on similar healthcare flows for in-patient and ambulatory settings. Another reason was that many of the healthcare leaders who contribute to the concept design are not always the leaders who lead the staff into the new space leading to conflict and frustration in the design. As I listened, I realized that the user group process isn’t only about the next innovative design concept but is about managing people through an extended, large-scale change that could be as long as ten years. If this is true what can you do to get yourself ready for the challenge to lead your staff and organization through the process? Here are seven steps you can take now: Get clear about the design process: Sadly, it's not as linear a process as it might seem. Ask questions of the designers and medical planners; get clear on what is fluid and when decisions are final. Learn the design terms, which can seem like a foreign language. Prepare to think outside of today’s challenges: Use today’s challenges to inform your future state not define it. It can seem impossible that you will have enough staff for the process when you can’t hire now or a new care procedure you tried a in the past didn’t work. This is the time to have a do over, taking advantage of the opportunity to start over completely. Understand your own resistance to the change: It sounds great when you hear you will get to design your own new workspace until the practical reality of budget limits hit you. Will there be downsizing as a result of this change? Will I still be able to get that one piece of equipment that’s critical to my department? Spending the time to work through your own feelings will put you in a better, more positive emotional state to lead your staff through their possible disappointment. Give yourself permission to take care of yourself: During the design process leaders do not usually get to off-load the day-to-day work, which makes it even harder to take time for yourself. This can lead to burnout, health issues, and the inability to be as present as you might want to be. Taking care of yourself is something to be scheduled just like the design meetings. Understand your staffs strengths and interests: As a leader you won't be able to do everything and you won't want to. Talk to your staff and understand how they might want to be involved in the process. They will become your change agents and advocate for the process when things get hard. Involving front line staff provides perspectives, opinions, and subject matter expertise that others in the room might not have. You are helping them grow as the leaders of the future who will continue to promote the project as time goes on Communicate, communicate, and communicate: Create a communication plan for the design process now and keep it going throughout the project. Communicate in multiple ways: Huddles, 1:1s, rounding, a design newsletter; even use wall space but remember to keep it current. I like to think if it seems like too much it is probably not enough. One way to assess this is simply ask the staff; if they don’t know the process is underway it gives you a great place to start. Change is about the people and the more you involve them the better the outcome will be. Find alternative ways to elicit feedback and listen to your staff: Working in healthcare means people work a variety of shifts and it is hard to involve many people in design events at one time. Think about your team and ways to involve them in the process even if they are not in a design event. It is okay to just listen and not have a response. In fact, I like to start setting that expectation at the beginning and then follow-up with a communication that addresses their questions when I have had time to think about them. It prevents me from getting defensive and puts me in a space to try to understand and ask questions instead of responding. Here are a few resources on change management to get you started: · IHI's Psychology of Change Framework · Leading Change - John Kotter · Switch by Chip and Dan Heath · Prosci

Cancer prevalence is estimated to increase to 26.1 million in the United States by 2040 (Figure 1) along with increases in survivorship. Fueled by advances in the field of immunotherapy and new ways to manage and reduce dangerous side effects, cancer is becoming more like a chronic disease with fewer patients needing ED admission, intensive care, or new treatments. And new CMS regulations are creating incentives to retool how cancer care is delivered. Investing in new facilities like dedicated cancer centers and cancer urgent care clinics becomes a much more prudent endeavor. Growth of Immunotherapy Programs Immunotherapy is one of the newest ways doctors and researchers fight cancer. Normally, the immune system has many ways to deal with foreign invaders to the body, such as bacteria and viruses. With cancer, however, the immune system has difficulty targeting cancerous cells as they resemble the body’s normal cells. Immunotherapy is a form of treatment where the immune system is enhanced or re-engineered to function at a higher level. One newer form of cancer immunotherapy treatment involves removing patients’ own T cells, a white blood cell capable of killing foreign invaders, and through a laboratory process, inserting hybrid receptors that can selectively target and destroy cancerous blood cells back into the patients’ T cells. These hybrid receptors are known as Chimeric Antigen Receptors, thus calling the treatment CAR T cell therapy (Figure 2). One operational challenge to healthcare providers happens before the CAR T cell therapy is administered. In order for patients to receive the treatment, they undergo a version of chemotherapy to prime their immune system. From an operational side, hospitals must align the infusion schedule with the CAR T cell process, which can be difficult to coordinate. After treatment, CAR T cell therapy can affect the utilization of the hospital’s critical care units. One major side-effect to the therapy is called cytokine storm response, and is actually a sign that the treatment is working well. This is because when the modified T-cells target and destroy the cancerous cells, they create such massive amounts of debris and dead cancer cells that the body’s natural inflammatory response to debris goes into overdrive. This inflammatory response is characterized by a release of signaling proteins, cytokines, and causes difficult to manage side effects, such as fevers, low blood pressure, rapid heartbeat, and hallucinations. Following treatment, either out of necessity or out of precaution, hospitals have been admitting their treated patients to critical care units. Even if patients do not exhibit dangerous side effects, the FDA, aware of the uncontrolled nature of the treatment, has mandated that hospitals become certified to give this treatment. As part of this certification, patients must remain within 2 hours of hospital where they received treatment for at least 4 weeks following infusion. This mandate alone is spurring the development of new cancer urgent care centers. New CMS Incentive to Keep Cancer Patients out of the Emergency Department The Centers for Medicare & Medicaid Services (CMS) is adding a new claims-based outcome oncology measure, OP-35, to their Hospital Outpatient Quality Reporting (OQR) program. (QualityNet) This measure aims to reduce preventable emergency department (ED) visits and hospital admissions of cancer patients. In 2020, hospitals may be penalized for avoidable visits. This new measure will: Include Medicare fee for service (FFS) patients who are 18 or older and enrolled in Medicare FFS in the year before their first outpatient chemotherapy treatment. Record the number of patients with an ED visit or hospital admission within 30 days of receiving outpatient chemotherapy by a hospital outpatient department (HOPD) Count patients only if the ED visit or hospital admission is due to one of ten conditions: Anemia, Nausea, Dehydration, Neutropenia, Diarrhea, Pain, Emesis, Pneumonia, Fever, or Sepsis Exclude patients who receive oral chemotherapy treatment and those with a diagnosis of leukemia As patients may receive chemotherapy from more than one facility, treatment will be counted in each facility’s cohort, and the facility(s) that provides outpatient chemotherapy treatment will be accountable for that patient experiencing a qualifying outcome event within the 30-day window. How One Health System Is Responding Froedtert Health and the Medical College of Wisconsin network created a very successful 24-Hour Cancer Clinic (Figure 3). The system recognized that their cancer patients needed more specific care for complications of their disease. A busy ED was not the best option so they launched an after-hours clinic in November 2016 to prevent unnecessary ED visits and hospital admissions. The clinic is staffed by an oncology team to help manage side effects and provide additional treatment or monitoring. Unlike a typical urgent care clinic, the patients cannot arrive without an appointment and must contact their oncologist for instructions. What You Should Do Now If you do not have a dedicated cancer center now is the time to plan one. As the projections make clear prevalence is growing and regulations are creating incentives to create one. A local, dedicated cancer center will be a necessity. Make your dedicated cancer center as convenient as possible. Ensure that your patients do not have to negotiate the labyrinth of your hospital; they are very sick and making access simple and accessible is a priority. Establish a cancer urgent care clinic as part of the dedicated center Consider creating your own cell manufacturing lab. Systems that treat a large number of patients and are using immunotherapy know that this treatment will grow. While only a few have their own manufacturing lab, several more are planning them to control the quality of the cell stock and access. Cover Photo: “bispecific-antibodies-myeloma-immunotherapy” Celgene. October 13, 2016. https://www.celgene.com/redirecting-immune-cells-fight-myeloma/ Figure 1: Bluethmann, PhD, MPH, Shelley & B Mariotto, Angela & Rowland, Julia. (2016). Anticipating the "Silver Tsunami": Prevalence Trajectories and Comorbidity Burden among Older Cancer Survivors in the United States, Figure 1. Cancer Epidemiology Biomarkers & Prevention. 25. 1029-1036. 10.1158/1055-9965.EPI-16-0133. Figure 2: “CAR T-cell manufacturing process”. June, 2018. https://www.lls.org/sites/default/files/National/USA/Pdf/Publications/FSHP1_CART_Factsheet_June2018_FINAL.pdf. Figure 3: “Froedtert and MCW vistspmonth” AJMC, Walradt, Jessica. September 29, 2017. https://www.ajmc.com/contributor/jessica-walradt/2017/09/expanding-access-and-value-24-7-cancer-clinics. #masterplanning

What exactly is a hospital? We rarely ask ourselves that basic question because most people think it’s that big building over there with the emergency room. But consider all the species that have evolved since the first ambulatory surgery center opened in 1970. Now we have places like the outpatient hospital, the micro-hospital, the digital or virtual hospital, mobile integrated health and the freestanding emergency room, among many other forms. This latter speciation occurred over the last ten to fifteen years. Medical care inexorably advances, allowing us to do more outside of the classic hospital setting. Driven by technological advances, we now have, for example, outpatient robotically assisted cardiac catheterization, day surgery hip replacements, personalized genetic nano treatments, autonomous service robots, and predictive analytics. And these advances are accelerating at a rate faster than many organizations can implement them. Three Keystone Hospital Species Are Emerging From a taxonomic viewpoint, the hospital family or genus has created many new species because of these advances. Three that are emerging can be considered keystone species: The Intense Acute Care Facility: Characterized by expertise, autonomous efficiency, and information via robotics and artificial intelligence, it will have very short lengths of stay, the minimum number of beds to do the job and a 24/7 working environment. The Intense Ambulatory Care Facility: This species will have many of the same features as the Intense Acute Care Facility and provide many of the same services, but length of stay will be in measured in hours. The Virtual Care Facility: Doctors and data scientists will work here coordinating care and doing research. This facility is the receiver and integrator of all wearable, implantable, and mobile data streams of patients. It will manage the mixed-reality environment that will connect the patient’s experience to all aspects of care no matter where it is provided. And it will be the Network Operations Center for the entire system. These facilities and their functions don’t necessarily have strict borders between them. They will come together in various combinations depending on the market and the system. For purposes of differentiation, though, we can divide them according to whether care is delivered inside the Intense Acute Care Facility or outside of it: What Will Happen Inside an Intense Acute Care Facility? Major emergency and disaster response, maternity and neonatology, infectious disease requiring intensive care and/or containment Care for cancer and other chronic diseases with complex morbidity to stabilize and return a patient home Advanced procedures that need a high degree of infection control and post-procedural monitoring Invasive entry and use of intensive technology involving active robotics, ultra-precise placement of devices/implants and/or intensive care due to procedural failure, and the 3D printing of biologics, implants, and custom instruments Therapeutic treatment that needs containment to ensure nano waste does not go into the general waste stream, and administration of otherwise toxic or high-dose pharmaceuticals What Will Happen Outside an Intense Acute Care Facility? Everything else. Here are the major functions that will be managed in the Intense Ambulatory Care Facility, the Virtual Care Center or other purpose-specific places (sub-species): Urgent, super-urgent, and emergency care The care of cancer and other chronic diseases that are digitally managed including IV meds and hydration Incisionless and minimally incisionless procedures Therapeutics, whether pharmaceutical or nano-tech based, that do not require waste stream containment The Challenge for Architecture The challenge for architecture is to merge the mixed reality of the physical and virtual care provided in these keystone species so it is indiscernible to the patient. Digitalization is taking over every aspect of healthcare and the power to heal and stay healthy will be in us and on us. Perhaps, in the long-term, the most intriguing species to emerge will be you, as your own personal hospital. The lessons learned now will go a long way to inform how architecture responds to this greater challenge. #hospitals #healthcare #future #architecture