Form-Based Codes Could Streamline HC Design

Posted on April 20, 2011


At times I have marveled at how much power one person can have on a healthcare project, specifically, one administrator. Even in the most democratic hospitals and systems, an executive such as the Chief Nursing Officer can trigger a project re-design. Sometimes it is ego, sometimes it is the belief additional input will benefit the project, but an administrator change anytime during a project can mean a complete undo and redo of a lot of work. It has happened to my team more than once.

On one level, it makes sense that the CEO can step in and make some tweaks. After all, he pays the bills. Then again, it could be argued no one, not even the CEO, should have the power to derail an otherwise progressing project—especially for the sake of ego. Which leads to my very important question:  in your hospital or system, is a person or process the final word on healthcare design?

Administrators are in flux at hospitals, and it is nigh on impossible to think that, for example, during your next heart center project, there will not be any change in cardiology physicians, nursing, surgery or corporate director-level staff during the 20-month project. If so, how does your organization handle that change? Would they allow a new cardiologist to come in after ground is broken for construction and scrap the PACU design that is already signed-off, modeled, and detailed?

In my experience, 100% of hospitals allow people to dominate healthcare design decisions. In my opinion, this is to the detriment of the specific project, and the overall hospital or system itself.

Allowing one or more people the authority to re-design or put their fingerprints on a project on the client-end is counterproductive for several reasons.  First, it destroys team morale. Everyone’s input is devalued when someone new comes on board, regardless of title, and makes impactful decisions without ‘paying their dues’. Second, decisions made out of context (i.e. without being part of the team from the beginning) are dangerous. Third, it calls into question the sacredness of a final decision.  If something can be revised late in the game, is any decision really final? Fourth, late decisions cost a lot of money. Design and construction professionals rely on a series of decisions and work under the assumption some basics are set, in order to progress to a finer level of detail and decision-making.

Form-based codes (FBC) are tools used in urban planning to help attain desired planning objectives and provide greater consistency and certainty of outcomes. Building codes work in conjunction with master plans, zoning and other regulatory measures to provide the desired results for development and growth without being overly prescriptive as to how to do something. They are design standards; they provide an idea of how something will function without saying exactly what the solution will look like or how to arrive at it. Form-based codees allow for interpretation and creativity.

Healthcare design could benefit greatly from an adaptation of the form-based code idea. Such a document would be a handbook, a cookbook of sorts that would allow an internal hospital team to execute a project in conjunction with their design-builder regardless of the personnel or project expertise. It would allow people to swap out, internally or externally, on the project team without destroying team chemistry, decision making or hierarchy.

For instance, if a hospital decided that inboard toilets are preferable to outboard, then that would be part of the form-based code or design standard, and no one—not facilities, not nursing, not risk management, not the CFO—could change that because it was written into the hospital’s FBC. Likewise, similar decisions on nurse stations or ED design for example, could be outlined. After all, these decisions are not merely preference, but have great impacts on staffing, scheduling, patient satisfaction, and ultimately profit.

In an earlier post, I discussed how evidence-based design could be integrated into healthcare design on the owner’s side through a “design liaison”. Too many decisions are not made based on the clinical or even business case. It is one thing to have a facility standard for a certain type of toilet partition or hardware finish, but something else entirely to know and stand by the decision to always double-load a corridor and never use a racetrack on all projects.

Better healthcare design solutions would be achieved at less cost if hospitals wrote and utilized a healthcare ‘form-based code’ of their own.