Identification of Tools and Techniques to Enhance Interdisciplinary Collaboration During Design and Construction Projects

Abstract

The purpose of this study was to collect the perceptions of design professionals and clinicians regarding design process success strategies and elements of interprofessional engagement and communication during healthcare design and construction projects. Additional objectives were to gather best practices to maximize clinician engagement and provide tools and techniques to improve interdisciplinary collaboration for future projects. Strategies are needed to enhance the design and construction process and create interactions that benefit not only the project but the individuals working to see its completion. Meaningful interprofessional collaboration is essential to any healthcare design project and making sure the various players communicate is a critical element. This was a qualitative study conducted via an online survey. Respondents included architects, construction managers, interior designers, and healthcare personnel who had recently been involved in a building renovation or new construction project for a healthcare facility. Responses to open-ended questions were analyzed for themes, and descriptive statistics were used to provide insight into participant demographics. Information on the impressions, perceptions, and opportunities related to clinician involvement in design projects was collected from nurses, architects, interior designers, and construction managers. Qualitative analysis revealed themes of clinician input, organizational dynamics, and a variety of communication strategies to be the most frequently mentioned elements of successful interprofessional collaboration. This study validates the need to include clinician input in the design process, to consider the importance of organizational dynamics on design team functioning, and to incorporate effective communication strategies during design and construction projects.

Keywords

interdisciplinary design organizational culture nurses in design qualitative research academic research

The dynamics of the healthcare environment are impacted by technology, service line, financial, and regulatory changes, which often lead to expansion, renovation, or design of new facilities. These design and construction projects require the collaboration of representatives from significantly different backgrounds to produce optimal results (Suter et al., 2009). While interprofessional collaboration during the design process produces optimal results, nurses often leave design meetings frustrated from misunderstandings, architects and interior designers leave wondering why there are so many design changes, and the construction team must make adjustments during completion of the project. Interprofessional collaboration strategies are needed to mitigate frustrations, decrease potential delays due to change orders, keep project costs down, and create interactions that benefit not only the project but also individuals. Such strategies will support the meaningful interprofessional communication and collaboration essential to the success of any healthcare design project (Clark, 2014; Reno et al., 2014).

Significance/Aim/Purpose

Interprofessional teamwork can improve the quality of a healthcare design project when time and effort is dedicated to ensure all team members can easily understand and collaborate with one another (Quan et al., 2014). The purpose of this study was 2-fold. The first was to collect the perceptions of design and construction professionals and clinicians regarding successful elements of engagement and communication during design and construction projects in the healthcare environment. The second was to gather insight into strategies recent design project participants perceived as contributing to effective interprofessional collaboration and communication. Additional objectives were to gather best practices to maximize clinician engagement and provide tools and techniques to improve and promote interdisciplinary collaboration in future projects.

Review of the Literature

The physical space of a healthcare facility can have an impact on healthcare providers, patients, and their significant others. When the clinical perspective is not effectively integrated into a design project, clinicians may create work-arounds. A work-around is a method of accomplishing an activity when the usual system/process is not working well (Rouse, 2005). For example, supply rooms or cabinets may be designed in a size that is unsuitable for supply storage. As a result, clinicians will place the supplies in an alternate space or location but may increase the likelihood of ergonomic injury due to unnecessary bending or reaching or possibly increase walking distances. Including clinicians in healthcare design projects can significantly mitigate potentially dangerous work-arounds (Rodriguez, Ford, & Adams, 2011).

One of the main barriers to successfully engaging and drawing upon the expertise of clinicians in the design process is the lack of mutual language or shared context (Suter et al., 2009). While some authors have suggested interprofessional competencies to promote interdisciplinary collaboration, this may not be feasible when real-time decisions need to be made to keep a project on track (Lamb, Zimring, Chuzi, & Dutcher, 2010; Stichler, 2014). This study seeks to identify strategies to promote interdisciplinary collaboration and communication while still adhering to the design schedule.

Method

Design

Data for this study were collected using Qualtrics©, a web-based survey platform. After receiving an invitation e-mail, participants read the online consent form and voluntarily chose whether or not to participate. The e-mail contained a brief introduction and a link to the online survey. This was a one-time survey, and no identifying information was required for participation. If a participant was willing to be contacted to provide additional information, they had the option of providing their e-mail address. Responses from open-ended survey questions were used to elicit an understanding of the perceptions of various professionals involved in healthcare design projects. Descriptive demographic information was also collected. The study protocol was approved by the institutional review board of the principle investigator’s (PI) academic institution.

Sample

E-mails were sent to colleagues of the PIs who work in the healthcare design industry. Potential participants included architects, construction managers, interior designers, and healthcare personnel who have recently been involved in a building renovation or new construction project for a healthcare facility. Snowball sampling was used in that initial study participants were asked to share the survey e-mail to colleagues within their professional network. Respondents included clinicians (8%), facility administrators (18%), architects (45%), construction managers (9%), and a mix of other industry professionals (20%). The largest group of respondents were architects, and the majority were between the ages of 45 and 65 and had significant experience with 20% having between 5 and 9 years of tenure in the industry and 75% having over 10 years. Eighty percent of participants reported an inpatient facility project as their most recent.

Data Analysis

Descriptive statistics were used to analyze the demographic information, but because of the high percentage of architects, limited information was obtained. The bulk of the data was culled from content analysis of the open-ended questions (Table 1). All participant descriptions were horizontalized, so no hierarchy whereby one reality may be more valued than another (Ihde, 1977). NVivo Qualitative software (Version 8) was used to first code the open-ended text responses and then to examine essential features, structures, relationships, or invariants among the accounts. Resultant themes from the coding process were vetted by two professionals in the healthcare industry. Finally, the results of the analysis were presented at a national conference for discussion of issues and refinement of tools and techniques to promote effective interdisciplinary collaboration (Table 2).

Table 1.

Open-Ended Questions.

Please share any new communication skills or tools learned during your most recent design project.

Please share any new things you learned about patient care and the connection to the built environment from your most recent project.

Did you learn anything from your most recent project that you will use in the future?

During what part of the design process do you wish you’d had more time?

What do you wish you had known before starting your most recent design project?

Please list 3 things you liked about your most recent design project.

Please list 3 things you learned from your most recent design project:

What do you think would have decreased the number of change orders or prevented change orders from occurring?

What tools used on this project did you think were helpful to the design process? (e.g., project management, communication, decision-making tools, etc.)

Table 2.

Common Roadblocks Experienced by Participants and Suggested Solutions From Industry Professionals.

Top Themes/Categories	Issues	Recommended Tools and Techniques
Organization dynamics/culture: “Client Management is the most important aspect of an architect’s job.”	Building trust Knowing the culture Internal communication within the team Lack of communication between owners Decision-making—who and how? Clients frequently change their mind which affects the schedule and budget Lack of shared decision-making delays processes Inconsistent clinician involvement Late clinician involvement	Use a Project Kick off to identify the decision-making structure Understand client’s culture and how it affects all aspects of the project and process Develop project organizational chart and facility organizational chart Implement team building events Develop a communication plan and integrate it into the steering committee and user-group processes Identify project leadership early Share information Engage and give authority to service line leaders Develop pros and cons list for changes Use methods that include a structured approach to working with teams Create a project charter Focus on “what” versus “who” when issues arise
Clinician Input: 96% of the 144 respondents noted that direct care clinicians provide value for their project and 98% said that they had direct care clinicians involved.	Clinicians are not consistent through the design process New clinicians coming into the meetings mid-process Not enough time for clinician input between design meetings Lack of design knowledge (terminology, phases, nsf vs. dgsf vs. bgsf, and reading drawings) Documentation of decisions made during the design meetings not carried forward to the next meeting Meaningful clinician participation Clinicians not oriented to design language or project elements	Design team needs to listen to clinician input Identify clinical workflow insight early in the process (adjacencies, function, patient perspective, etc.) Onboard clinicians with design and project knowledge Understand roles and responsibilities of the team Assign roles to the users—such as documentation/scribing key operational issues and design decisions Use multiple methods to demonstrate concepts (3-D, mock-ups, 3-D printing, and other visuals) Ensure the right people are in the meetings Include support and ancillary staff early Allocate time between meetings to allow input and meaningful feedback from the clinicians Understand early on hospital standards for policy, equipment, and materials Provide benchmarks to manage space requests Share FGI guidelines and best practices from other hospitals Put the architectural and construction terms into a medical context, e.g., describe a visual as a “CT slice” Create an onboarding tutorial “Design for smarties” Designate someone to assume a “translator” role Establish parameters Nonnegotiables Internal processes Make some decisions internally and present a united front to construction professionals Establish “rules of engagement” for communications Query clients using customized questionnaires to guide interactions Use mock-ups early (tape-outs, 3-D software) Use mock-ups specific to various construction phases Use visual references…“half a football field”
Project delivery: “If we over communicate we can succeed.”	Need to understand the current operational flow Getting people to communicate to the professionals and to each other People joining the project in the middle of the process Document sharing/meeting minute sharing Scope changes due to unfinished program and budget impacts IT budget underestimated and need for IT integration Infection prevention involved early	Project overall Utilize integrated project delivery Utilize A3 decision-making Co-locate design and construction team “Big Room” Utilize mock-ups early in the process Site visits virtual or actual Include simulation modeling when appropriate Spend more time in DD phase Scope validation early and often Predesign process Utilize experience mapping Value stream current and future operational flows Use lean processes and A3s
		Meetings Meet regularly/weekly preferred Develop goals for the meeting Develop and disseminate meeting minutes Leverage technology for meetings and communication End meetings with homework
		Patient/family Focus on the patient-centered perspective; specialty and disease-specific Incorporate patient focus group meetings
		Project communications Advocate for staff to be allowed to attend training, activation, transition planning, dress rehearsals Include patient-centered perspective Patient council involvement in all design phases Patient representative included on team Maintain weekly communication from project management related to previous week’s activities on Mondays with feedback requested by Thursday Provide wide distribution of meeting notes

Note. nsf = net square feet; dgsf = departmental gross square feet; bgsf = building gross square feet; FGI = facility guidelines institute; CT = computerized tomography; IT = information technology; DD = design development.

Findings

Qualitative analysis revealed themes of clinician input, organizational dynamics, and a variety of communication strategies to be the most frequently mentioned elements of successful interprofessional collaboration (Table 3).

Table 3.

Breakdown of Most Common Participant Comments.

Category Breakdown	# of Comments	# of Participants
Clinician input	39	22
Organizational dynamics	30	18
Communication strategies
Mock-ups	26	17
Team skills	30	16
Meeting strategies	27	14
Design orientation	18	12

Clinician Input

Clinician input was by far the most commented on element of successful design collaboration. Of all design industry professionals participating, 98% valued the input of direct care clinicians and had direct care clinicians involved in their projects.

The majority of architects responding emphasized the importance of clinician input and several noted they would have liked more time for this type of exchange. Several also noted they would have liked to have had clinician input earlier in the design process.

The hospital/nursing administrators responding to this survey were supportive of including the clinician’s perspective in healthcare design projects in order to maximize the benefits to the project and the clinicians. One hospital administrator noted clinicians need to be more assertive when they are asking for something and focus on the reason for the request regardless of the cost. Another noted the importance of clinical input by stating “architects do not understand what it takes to keep patients and staff safe.”

Throughout the design process, there are cost estimates done on the building project. If it is determined the design and project costs are over budget, it is necessary to determine which elements of the design need to be modified or deleted to decrease the cost. These changes are referred to as value engineering. One hospital/nursing administrator noted that while clinical input was incorporated at the beginning of their project, more engagement of clinicians should have occurred in value engineering decisions.

Finally, design and construction professionals indicated they wish they had understood the importance of the clinician experience, as it related to the end product and had learned to take the thoughts of stakeholders and use them in their respective design processes earlier in the project. One construction/project manager noted participation from stakeholders will always save money by reducing change orders.

Organizational Dynamics

The second major theme identified had to do with the organizational dynamics influencing collaboration during healthcare design projects. Architects mentioned it was important for them to understand the client organizational culture, hierarchy, and relationships between departments. One participant described the need to manage implications the design would have on staffing logistics when working with two related departments. Another architect described a situation where “the leadership appears to work in a group and closely with each other, but actually do not inform each other about decisions and often overrule other’s decisions.” In contrast to these examples, architects liked projects where there was good interdisciplinary participation and the team worked well together to achieve the goals and ideals of the hospital.

Clinicians felt it was important the administrators of the organization be supportive of clinician involvement and input. Without this support, clinicians may be included too late to have a meaningful impact. One specific comment by a clinician emphasized the importance of including a “communication link” early in the process. This would be a designated individual who would work with both the project professionals and the clinicians to translate the specific language used by the various disciplines. This role was described as critical to keep all parties oriented to project progress and to assist in making informed decisions.

Hospital/nurse administrators expressed frustrations when decisions were not communicated with transparency or when decisions that had been made at a corporate level were not up for negotiation or input from the team. Other administrators noted the importance of role clarification especially related to decision-making. Hospital/nurse administrators also noted meetings did not have the desired benefit if the right people were not at the table.

Interior design professionals mentioned the importance of organizational dynamics when they described the impact of team member changes during the project. They noted that when members of the client team changed during the project, the design might also need to be changed to reflect new opinions or agendas. Projects seemed to run more smoothly when administrators created an organizational dynamic in which clinicians were supported to (a) be part of the team, (b) be consistent throughout the project, and (c) be allowed scheduling flexibility to attend design meetings.

Communication Strategies

Communication strategies are related to organizational dynamics but specifically address the exchange between design professionals and clinicians. Four areas frequently mentioned include mock-ups, team skills, meeting strategies, and design orientation.

Mock-ups

Mock-ups are used by design professionals to create visuals for stakeholders to use in considering the impact of the proposed design. Architects considered mock-ups to be a critical communication tool. Some mentioned full-sized mock-ups that allowed users (clinicians) to better understand the space, while others used software that enabled scenario testing. Several architects noted better mock-ups, earlier in the process, would have been beneficial to their projects. One architect noted, “actually standing in the space offers much more value than looking at a drawing or a simulation.” An architect and clinician both noted the benefits of repeated refinement and testing of a full-sized mock-up. Another clinician who had worked on a pediatric project mentioned the benefits of including parents during mock-up walk-throughs.

Construction and project managers noted the benefits of creating even simple mock-ups, including columns or placing tape on the floor to help clinicians understand how equipment would fit into the space. Several found this process not only beneficial but enjoyable when clinicians were included and collaborated with the team.

Hospital and nurse administrators noted value was achieved from investment in full-sized mock-ups. One hospital administrator noted, “Mocking up one room and having staff actually see the real design before they did all of the rooms was critical as the vision of the designers and the vision of what staff asked for were not always the same.”

Team skills

One architect noted, “client management is the most important aspect of an architect’s job” and it was evident in the team skills that were emphasized by various participants. Collaboration was a key word in architect comments. When members of the design team worked well together and were committed to success of the projects, the projects ran more smoothly. One architect emphasized the need to get to know team members and understand underlying issues related to strong opinions that team members may express.

Construction and project management professionals’ comments were consistent with those of architects. They also described the benefits of building trust and collaboration among team members and one noted the need to “push people to communicate with one another.”

Hospital/nursing management also described working in a collaborative manner with team members to be one of the things they enjoyed most about their most recent healthcare design project. While they also emphasized the importance of communication and role definition within the team, they felt strong interdisciplinary collaboration enhanced the end product. One hospital/nursing administrator felt prepared for the collaborative approach because of previous experiences working with shared governance groups.

An interior designer also emphasized the importance of celebration to team cohesiveness. This participant wrote, “remember to celebrate the process and help the users realize the excitement of the outcome.”

Meeting strategies

Design meetings are a part of every project and participants described several strategies that contributed to productive exchanges with team members. Architects and design professionals noted the importance of keeping accurate meeting notes to not only remind participants of decisions that had been made but also share progress with other stakeholders not intimately involved with the project. Another strategy shared by respondents was to have clear goals and an agenda for the meeting to promote focused discussion. Interior designers shared two strategies they found helpful to promote productive meetings: (1) recognize when clinicians should work out an operational issue during a design meeting or whether it should be tabled for the hospital to solve off-line. It is hard to accomplish everything required during design meetings because important but time-consuming policy conversations tend to arise. (2) Give meeting participants a deliverable/homework to accomplish for the next meeting. Several architects as well as hospital administrators noted while not novel, weekly work sessions and disseminating resulting updates were important to keep stakeholders engaged and informed.

Design orientation

The fourth communication element was design orientation and the importance for all stakeholders to have a shared understanding. There were many clinicians and hospital/nursing administrator comments related to the learning curve they experienced when working on their most recent design project. Several emphasized the importance of understanding the language used and the impact of their decisions. One clinician in particular would have liked to have had a better understanding of what they agreed to and the complexity of the change request process. Hospital/nursing administrators noted they had limited or no experience with the phases of design, design principles, or how to read a floor plan. From the design industry professional’s perspective, the benefits of investing the time to provide stakeholders with a good design orientation are reliant on consistent design team membership and regular participation.

Discussion

This study reinforced the notion of interprofessional collaboration and emphasized the importance of not only a competent collaborator but one who has worked in the clinical environment and has a keen understanding of how work is accomplished in the healthcare space (Clark, 2014; Rodriguez, Ford, & Adams, 2011). The importance of choosing the right members for a design project cannot be overemphasized (Stichler, 2011, 2014).

Our study noted the importance of organizational dynamics to interprofessional collaboration. Teamwork is jeopardized when there is frequent turnover on the design team or when the organizational culture does not foster clinician participation. The best laid design plans can go awry if organizational structures are not in place to support those plans. To mitigate negative outcomes, when issues arise, it is important for members of the design team to take good meeting notes and put decisions in writing in case a new set of players require orientation to the project (Reno et al., 2014).

Communication strategies recommended from participants were consistent with others in that using mocked up spaces can be beneficial to get clinicians and industry professionals to have a shared understanding (Clark, 2014; Reno et al., 2014; Stichler & Okland, 2015). Because clinicians are accustomed to working with other disciplines on behalf of their patients, they have the potential to work well on design teams; however, they may be unfamiliar with meeting strategies, the design process, terminology, reading, and understanding drawings and techniques that are second nature to industry professionals. Creating a nurse champion to orient new clinicians to the design team is just one of the several strategies that can be used to bring clinicians up to speed and provide them with a shared, design orientation (Clark, 2014; Reno et al., 2014; Stichler & Okland, 2015).

Creating a nurse champion to orient new clinicians to the design team is just one of the several strategies that can be used to bring clinicians up to speed and provide them with a shared, design orientation

Limitations

When considering the number of people who may be involved in healthcare design projects within the United States, garnering 144 responses is not a large number, but it is enough to provide some interesting insights. While the snowball sampling method is not likely to provide a representative sample, the method was used, as there are innumerable disciplines and specialties who contribute to healthcare design projects and there is not a master repository for such contributors (Trochim, 2001). Given that two of the PIs worked in architecture firms, it is not surprising that architects were the most represented specialty. This is also supported by the assumption that the architects invited to participate might have forwarded the survey link to other architect colleagues. Information from this study should be used with consideration of the sampling method since colleagues from similar projects or like design firms could be sharing similar experiences. Because data on the number and diversity of firms were not collected, it is impossible to mitigate the possibility of homogenous responses.

Conclusions

Information from this online survey will be useful to individuals involved in healthcare design projects. This study validates the need to have clinicians educated in the design process at the design table and the importance of interprofessional collaboration between design and construction professionals and healthcare personnel. It is hoped those who use the resulting information will enjoy more productive relationships when working on healthcare design projects.

Recommendations for Future Study

The study of clinician impact on healthcare design projects is in its early stages. There are many opportunities for future study including the difference in perceptions of various disciplines involved on a design project, different methods of preparing design team members to work together, and exploring to what degree financial metrics are impacted when clinicians are consistently included on design teams and when design teams work together well. Another important area relates to patient and staff safety. It would be interesting to determine whether patient and staff safety metrics are improved when (a) clinicians are included on design teams and (b) design teams work together well. Finally, a future inquiry into the impact of patient and visitor feedback during the design process is also recommended. The combinations are innumerable, and it is important to continue to build the science of healthcare design to promote best practices for future initiatives.

Implications for Practice

Provides validation to the Chief Nursing Officer (CNO) and healthcare administrators the importance of including clinicians on design projects.

Encourages designers to enhance their meeting strategy to ensure clear communication and understanding in design meetings.

Defines the importance and value of mock-ups during the design process.

Identifies organizational project structures to enhance the design process and the design end result.

Supplemental Material

Supplemental Material, Identification_of_Tools_and_Techniques_to_Enhance_Interdisciplinary_Collaboration_During_Design_and_Construction_Projects - Identification of Tools and Techniques to Enhance Interdisciplinary Collaboration During Design and Construction Projects

Supplemental Material, Identification_of_Tools_and_Techniques_to_Enhance_Interdisciplinary_Collaboration_During_Design_and_Construction_Projects for Identification of Tools and Techniques to Enhance Interdisciplinary Collaboration During Design and Construction Projects by Yolanda Keys, Susan R. Silverman, Jennie Evans in HERD: Health Environments Research & Design Journal

Footnotes

Acknowledgments

Special thanks to the Texas A&M University-Corpus Christi CONHS Graduate Research Fund.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Texas A&M University-Corpus Christi CONHS Graduate Research Fund.

References

Clark

(2014). Bedside to blueprints: The role of nurses in hospital design. Health Environments Research & Design Journal, 7, 100–107.

Ihde

(1977). Experimental Phenomenology. New York: G. P. Putman & Sons.

Lamb

Zimring

Chuzi

Dutcher

(2010). Designing better healthcare environments: Interprofessional competencies in healthcare design. Interprofessional Care, 24, 422–435. doi:10.3109/13561820903520344

Quan

Geboy

Ginsberg

Bosch

Joseph

Keller

(2014). Building the evidence base: Understanding research in healthcare design (3rd ed., Vol. 2). Concord, CA: The Center for Health Design.

Reno

Okland

Finis

LaMantia

Call

Cardon

… Zeigler

(2014). Lessons learned: Clinicians’ post-occupancy perspective of facility design involvement. Health Environments Research & Design Journal, 7, 127–139.

Rodriguez

Ford

Adams

(2011). Does proper design of an intensive care unit affect compliance with isolation practices? Critical Care Nurse Quarterly, 34, 36–45.

Rouse

(2005). Workaround. Internet acronyms and lingo glossary. Retrieved from http://whatis.techtarget.com/definition/workaround

Stichler

J. F.

(2011). Selecting the best design team partners. Journal of Nursing Administration, 41, 337–339.

Stichler

J. F.

(2014). Interprofessional practice: Magic at the intersections. Health Environments Research & Design Journal, 7, 9–14.

10.

Stichler

J. F.

Okland

(Eds.). (2015). Nurses as leaders in healthcare design: A resource for nurses and interprofessional partners. Zeeland, MI: Herman Miller, Inc.

11.

Suter

Arndt

Arthur

Parboosingh

Taylor

Deutschlander

(2009). Role understanding and effective communication as core competencies for collaborative practice. Journal of Interprofessional Care, 23, 41–51.

12.

Trochim

W. M. K.

(2001). The research methods knowledge base (2nd ed.). Cincinnati, OH: Atomic Dog Publishing.

Supplementary Material

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