Practicality vs. Probability in Building Planning and Design

by Nate Larmore, CCNP, ICNC, MCSE, LPI, Integrated Technology Practice Leader

This article is part of Wood Harbinger’s newsletter series.

In a recent panel discussion with an overseas software developer, we addressed the direct connection between culture and security technologies. The developer commented that foreign nations do not have the same emphasis on liability that we have in the US. As the conversation continued we kept encountering the phrase: “just in case.” When it comes to America’s approach to nearly everything in the security sphere, we follow a repetitive formula: identify the issues, debate the solutions, and then buy everything that allows us to litigiously mitigate the risk of “just in case” scenarios. When it comes to building facilities and their supporting infrastructure, we are obsessed with what-if scenarios and almost always pay too much to address them.

Not Seeing the Forest for the Trees

Last year, a California healthcare client asked me and one of my senior staff to help them map their patient workflows for a new clinical project. They had already spent weeks with their executive staff and the architectural team working on this exercise, but kept hitting a brick wall in the process. Our team sat with their team for a session to see if we could help. Within the first hour of the meeting, we observed that they were getting stuck on what-if scenarios: what if patients from a very specific demographic need something different? What if some patients don’t like to use kiosks? What about patients with a particular disability? What about this category of patients who speak a particular dialect? The list went on. Seeking to help this client make a break-through, we asked what percentage of their total visits they would classify into these specific what-if’s. No one knew for sure, but the chief medical officer estimated less than 5%. We suggested the exercise continue, but only by focusing on what would be normal for 85% of their patients.

It may seem obvious, but this group of leaders with amazing expertise needed gentle nudging throughout the rest of the session to keep the big picture in focus and avoid (for the time being) the minority report of what-if’s.

A Culture of Expertise

These experts are not alone. We are a nation of experts and specialists. Many of us are hired with structured compensation based upon specific expertise. RFPs for procuring project teams are often full of requirements intended to demonstrate expertise. The engineering industry has nearly evolved this quest for “experts” into a religion, exalting the “subject matter expert” and building cultural monuments to perpetuate the iconic stature of the technical specialist.

Most design and construction projects spend inordinate amounts of time and capital addressing a list of what-if scenarios that have an operational impact probability close to zero. As experts we feel compelled to do this because we are hired to be the smartest folks in the room with all the answers. What better way to perpetuate our expert status than designing and building structures that are the best in the world with all the answers shaped in steel, concrete, and cable. This approach makes most owners, project managers, and engineers feel safe, but in the grand scheme of things, the overbuilding is a waste.

American healthcare is grossly expensive and we are part of the problem. Our industry contributes to the bulging cost by overemphasizing what-if’s, over-programming requirements, over-specifying products, over-qualifying participants, over-building facilities, and failing to give clients our true opinions. Clients contribute to the problem by soaking the time and treasure of their consultants and engineers on manipulative design competitions, emphasizing the style of our presentation rather than its substance, and writing bloated RFPs intended to impress rather than procure. These are artifacts of an expert culture seeking to impress itself and perpetuate itself rather than reinvent itself. Our costly facilities are the legacy of a process once called “design,” that has devolved into nothing short of monument building.

Back to a Purpose-Driven Design Reality

All is not lost. This industry can be saved by redrawing its priorities and thereby recreating its culture. Whether you’re a president, partner, principal, designer, program manager, decision-maker, or developer, you can begin to steer your part of this ecosystem back towards purpose-driven design and restore a sense of focus that is desperately needed. Going beyond bullets in your staff handbook or placards hanging on the wall of your job trailer, it needs to deeply characterize our priorities, processes, practices, and partnerships.

We need purpose-driven design that:

  • No longer starts by drawing a box and then figures out what fits inside.
  • Perpetually questions, evaluates, and reinvents design guidelines and best practice standards.
  • Bases space program assumptions on what is actually needed to support clinical procedures paired with the technologies and processes to deliver them.
  • Views the building itself as a tailored result – a flexible shell held together by a universal grid that will support numerous TI configurations during its lifetime.
  • Seeks to always benefit the customer (which, by way of reminder, is and always was the patient).
  • Treats project/program management as a support mechanism not a strategic driver.
  • Is based upon realistic, informed, and explainable capital budget line items.
  • Is tuned to specific and measurable operational purposes and benefits.
  • Seeks to accomplish maximum benefit in the smallest possible footprint.
  • Is based on realistic and pragmatic assumptions that have been validated and widely distributed.
  • Seeks out new, more effective spatial configurations and adjacencies.
  • Incorporates ingenuity and innovative combinations of old and new technologies.
  • Always maintains alignment with the true purposes behind the capital program.
  • Embraces new ideas and concepts while providing adequate safety.
  • Is led by patient advocates, clinical service providers, and technology planners. Not bureaucracy.

Our purpose is to drive this revolution. Are you with us?

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