Design for Discovery: Improving Young Lives through Exploration and Evaluation

At its core, design is a process of discovery — a process that relies on evaluating outcomes and lessons learned.

“Design for Discovery” is the 10th and last measure within AIA’s Framework for Design Excellence. It encourages architects to conduct post-occupancy and performance evaluations and continually engage with clients and building occupants to learn how the built environment functionally impacts people and the earth. But while the measure is listed at the end of the AIA guidelines, HKS designers believe discovery is anything but final.

“Design for Discovery is both measure zero and measure 10,” said Anthony Montalto, HKS’ Global Director of Design. “We should be focused on discovery throughout the entire design process.”

An architect and leader who guides projects in many different sectors, Montalto believes that great design is a balance of art and science. The scientific aspects, he said, often revolve around measuring outcomes and determining how much a design really “works” for all stakeholders.

“Every project presents a unique opportunity to apply lessons learned from previous projects and gather information to refine the design process. It’s a mindset of consistent learning,” he said.

How a design impacts people and the environment can be studied and measured on any type of project, from commercial offices to hospitals and from schools to stadiums. Research and evaluation strategies can also be applied at all project phases — in early planning stages, during design and after a space is occupied. At HKS, designers and researchers seek to understand how spaces perform from a human well-being standpoint as well as an environmental standpoint, guided by the mission to improve overall sustainability.

“Our impact framework is the triple bottom line — looking at human, fiscal and environmental outcomes,” said HKS’ Global Director of Research Dr. Upali Nanda. “Discovery from every project should raise the baseline for the next one to enable more meaningful impact that aligns growth with purpose.”

Engaging in a scientific process to gauge success — and shortcomings — is an exciting and important responsibility for designers, according to Montalto and Nanda.

“In many ways, design is a hypothesis,” said Nanda, who oversees dozens of research projects every year. Nanda seeks to instill a sense of curiosity in all HKS designers and embed research into as many building projects and processes as possible. “We’re not just measuring outcomes, learning and evolving, but we’re also continuously applying what we’ve learned to develop an authentic purpose and set of principles. Discovery is about what difference we are making by design.”

Discovery is about what difference we are making by design.

Large-scale design projects can be arduous, taking years of planning and management from conception to occupation. So, it’s no easy task for architects and their clients to embrace research and evaluation on top of all the traditional responsibilities within the design process. Discovery requires trusted partnerships and mutual curiosity to learn and improve people’s experience.

“It all starts with asking the client what they’re really interested in learning from their built environment. They’ve made a tremendous investment and, oftentimes, they’re equally as interested as we are in learning if what we’ve designed functions as they originally intended,” said HKS’ Kate Renner, an architect, medical planner and researcher. Based in Washington, Renner designs and evaluates health care projects.

Like Nanda and Montalto, Renner believes that research is an inherent and integral part of the design process. Collaboration and intentionality, she says, are two of the key puzzle pieces to successful outcome-based design.

“Research and evidence enable us to solve problems in a rigorous and intentional way,” Renner said. “We work collaboratively from the very beginning to define goals and strategies intended to achieve the vision and targeted outcomes for the project.

Evaluation at all project stages feeds into what Renner calls a “continuous improvement cycle,” which benefits her design teams as well as health clinicians working in the spaces they create. As medicine advances and operational processes and technologies shift — designing for discovery can lead to more efficient hospitals and enhance quality of life for patients and caregivers.

Creating Discovery-based Relationships with an Educational Health System

Renner and many HKS team members have been partnering with Virginia Commonwealth University Health System (VCUH) and the Children’s Hospital of Richmond at VCU (CHoR) for more than a decade on health projects small and large. In 2016, the HKS-designed outpatient Children’s Pavilion opened, providing care to one out of every eight children in the Richmond Metro region.

With a design centered on family-friendliness and operational optimization, the Pavilion houses 20 departments and more than 40 pediatric outpatient clinics for treating injuries and illnesses. Throughout the entire design process, HKS prioritized discovery, evaluating existing facilities and engaging with CHoR practitioners and community members to develop solutions that would meet their long-term needs.

A “great case study” in standardization, per Renner, 91% of the Pavilion’s exam rooms are identical, giving providers flexibility to increase exam room assignments based on the daily number appointments or shift their practices to other clinic modules as service line volumes increase. The building’s many collaboration areas and adaptable workstations for interprofessional care teams also provide flexibility, while spacious biophilic waiting areas with city views create a welcoming atmosphere for patients and families.

The Pavilion’s inventive design transformed operations for the teaching hospital, triggering many adjustments to the ways care teams members, medical students, patients and families give and receive care day-to-day. To get a grasp on the magnitude and impact of changes, VCUH partnered with HKS and the University of Kansas to continue our work and conduct multifaceted performance evaluations leveraging tools such as surveys, space audits, behavior mapping, shadowing and environmental quality studies.

In a behavior mapping exercise, researchers tracked the CHoR Pavilion’s user activities to help the design team and client understand how they experienced the space day-to-day.

In addition to illuminating an increased patient volume of 38% in the first year, the evaluations revealed that patient and family satisfaction with the new building skyrocketed to 80% immediately. Renner says that number continues to increase with each passing year. The LEED Silver Pavilion went on to receive more than a dozen design awards and a Gold distinction in the Center for Health Design’s 2018 Evidence-Based Design Touchstone Awards, a special honor for projects that employ design for discovery techniques. CHoR has also rated among the top 50 children’s hospitals in cancer, nephrology, pulmonology and lung surgery, and urology in US News’ Best Hospitals ranking.

HKS’ research didn’t just prove how the Pavilion’s design exceeded VCUH’s goals, it also uncovered some critical pieces of information that would go on to impact an even larger project – their new Children’s.

Currently under construction, the Children’s Hospital of Richmond at VCU Children’s is a full-service children’s hospital for youth in need of surgery and treatment for illnesses and injuries including cancer and rare diseases. At over 560,000 square feet, the building will house acute and intensive care units, a Level 01 trauma center for emergency care, surgical and imaging services, cancer care, and specialty services. Designed with the goal of creating a cohesive oasis-like environment, the building will be fully integrated with the Pavilion and benefit from the outcomes HKS observed and recorded there.

Embracing Outcomes and Improving Design for Better Health Care

Outcome-driven design processes that engage a variety of stakeholders are important to the work occurring at Children’s Hospital of Richmond, according to VCU Health’s Tracy Lowerre, a nurse clinician and clinical liaison for the Children’s project.

“We want to be able to work smarter, not harder, in the future with increasing demands of health care and improved technologies,” she said. “By involving the entire team including architects, our patients and families, we captured ways to provide excellent patient care and support the education of learners and children.”

The Children’s Hospital of Richmond at VCU Children’s Tower is a 564,540 square foot full-service inpatient hospital.

The HKS team worked hand in hand with CHoR and VCU Health to develop the Children Tower’s design. Renner served as a senior medical planner, the client lead and the project’s research champion alongside fellow senior medical planner, HKS’ Lindsay Stevenson.

Stevenson believes that collaborating with CHoR in a deliberate and deep way led to a fruitful dynamic based on respect. “Everyone becomes an active contributor, taking on responsibility for the final design outcome. There are no inactive or passive participants in the room,” she said, noting that on top of engagement, robust research also informed health planning strategies.

“We are relying on sound data and concrete precedents to teach us something about the best solution based off the prioritized parameters from the client,” she said.

When the project kicked off in 2018, Stevenson, Renner and the rest of the HKS team referred back to behavior maps and survey data from the Pavilion and conducted design diagnostics in current inpatient environments. They identified things that could be improved such as common area flow and wayfinding, flexible workspace arrangements and supply storage constraints. For the Children’s Tower, they implemented design solutions that enhanced these areas for care team members and visitors alike.

The team also identified a feature that worked really well at the Pavilion — standardization. Standardized inpatient units with similarly sized and equipped patient rooms became a cornerstone of the Children’s Tower, which Lowerre says “will improve efficiencies for all” and allow rapid response team members to easily find the right room and deliver emergency treatment more rapidly.

Standardized units could be lifesaving as the nature of inpatient illness and recovery tend to be highly complicated. Renner says the flexible, yet identical, rooms can accommodate even the most critical cases. “Every room is designed to grow to ICU-level care if they need to up their intensive care capacity. Standardization will enable them to place patients in any room within the acute care units,” she said.

Design for Discovery in Action

How exactly the Children’s Tower’s units design came together, was a major discovery-based process in itself.

“You find that clinicians and health care providers aren’t trained to read floor plans just like I’m not trained to provide clinical care,” Renner said.

To solve this problem, the design team constructed full-scale cardboard mock-ups of key areas of the inpatient units. In Renner’s experience, mock-ups offer a much better idea of scale than a floor plan and a good sense how a space will function once it’s built.

VCUH’s Tracy Lowerre (second from right) worked with the design team closely to facilitate evaluation of full-scale mock-ups of clinical modules for the Children’s Tower, helping inform final design decisions.

With Lowerre’s help, the team invited more than 300 health care professionals and community members to walk through them. They modified mock-ups as the months progressed, adjusting dimensions and layouts. They also posted research articles and data points directly onto the cardboard walls that offered scientific evidence about their design considerations.

“This was a tangible way to illustrate the rigor behind the design,” Stevenson said, noting that the approach helped to build buy-in and greater confidence that the outcomes would be more successful.

The design team itemized and prioritized every single piece of feedback they collected to make the most relevant changes in accordance with VCUH’s goals for the project and best practices for health planning.

Lowerre believes that the mock-ups served many purposes, but perhaps most importantly, they helped create a true community-based design for the Children’s Tower. The building has already received a 2019 Gold honor in the Evidence-Based Design Touchstone Awards and will be submitted for Platinum upon completion and evaluation.

“All users were able to get into the space and make suggestions on design. This building has been built by our professional teams, patients and families, as well as our community members,” Lowerre said.

Renner, who conducted research with VCU Health in her first year at HKS in 2011, will continue to lead research efforts for the Children’s Tower over the next several years.

“The opportunity to have a continuous loop of understanding of whether the design intent was met once the Children’s Tower is occupied and operational greatly improves our understanding of what we create,” Renner said.

The power of creation and the ability to design for discovery is about far more than making advancements for the future. In the case of the Children’s Hospital of Richmond at VCU Children’s Tower, it’s about offering the best possible environment for children to be healed and be themselves.

“We’re making sure we can provide for developmental needs and address them in a holistic way in addition to providing state-of-the-art health care,” Renner said. “We’re providing spaces where kids can be kids.”