Putting the Cart before the Horse

Abstract

Visualize the scene of a horse harnessed to a cart and pushing it forward. This mental picture certainly seems awkward, but it is not entirely impossible. One wonders why anyone would attempt such a feat when it is clearly more efficient to have a harnessed horse leading the cart in an intended direction rather than pushing the cart in front of it. What does this visual exercise have to do with the design and construction of healthcare environments? The focus of this column is the importance of leading change through the collective input of point-of-care providers and decision makers who consider process and culture to be critical determinants of design in contrast to driving change through a completed structure without regard to existing processes or outcome data from similar structures.Recently I had the opportunity to visit four new hospitals or inpatient towers in two states; all were newly completed or in the final stages of completion. Expecting that the nursing and medical staff would be excited about their new facilities, I was struck by the feedback from the clinical and managerial nurses who escorted me on tours. In one instance where the building was nearly finished, the nurse and medical directors shared their concerns about the impending move to the new facility. Excitement about and pride in the new facility were trumped by disappointment and despair. Undoubtedly, these were not the emotions intended by the executives of these hospitals-nor by the four different architectural teams who facilitated the design process. Clearly, it was the intent of the executive teams to create an improved work and healing environment and to foster organizational change in the philosophy of care and care delivery models. So what happened?In speaking with the tour guides, I noticed that several common themes emerged from the nurses' discussions, including: (1) We didn't have adequate input into the design of the new facility; (2) Our leadership team implemented 'trendy' design concepts without evaluating feedback from a site that had implemented the designs; (3) Our system facility leaders' opinions trumped the opinions and desires at the local hospital level; and (4) Due diligence about the effect of the new design on culture, care delivery models, and efficiency paled in comparison to the desire to be a high-profile hospital of the future. The nurses shared concerns about how they were going to practice safe, efficient care in the new facilities; in two instances, modifications had already been initiated in patient units that were less than a year old.In its exuberance to facilitate organizational change, did the executive group put the cart before the horse to drive change rather than letting the horse lead the cart in the desired direction? Without a doubt, a new facility creates an opportunity to make necessary changes in care delivery and even in the culture of an organization, but careful attention must be paid to how care providers will be transitioned from one model or care philosophy to another. In fact, this organizational transition plan must be planned as strategically as the facility design itself, and the providers must be included in the design of the organization as well as the design of the facility. Without such involvement, the providers will not have a feeling of authorship or ownership in the facility when it is completed, and they may consider the new building an impediment to their care delivery processes instead of a complement to their care.Inadequate Input from Point-of-Care ProvidersOne of the major themes of those leading the tours of the new facilities was a concern that point-ofcare providers had inadequate input into the new design, which may be one of the biggest mistakes that can be made in healthcare design. Excluding point-of-care providers in deference to the decision makers (healthcare executives and architects) who believe that they know best what is needed to improve safety at the point of care can lead to some unexpected and costly outcomes. …