Balancing Act: 5 Lessons in Connecting Standardization and Innovation in Healthcare Design

It's one of the greatest challenges in healthcare design, as finding the right balance between standardization and innovation will earn efficiencies in time, effort and money and create an iterative approach to developing a system that's resilient against current and future challenges. However, how can we ensure the tension between the two is successfully managed? Standardization is critical as part of the solution to the challenge of building and delivering sustainable, resilient healthcare infrastructure at scale. It offers the potential to lower risk and costs while providing more speed in design and construction and, ultimately, better health outcomes, but on the flip side, an overly rigid approach can also hamper innovation.

Effective standardized solutions support the adaptation and flexible use of standard space, and technically, they also allow for (at a capital cost) rapid adaptation of layouts and the mechanical, electrical and plumbing needed for new equipment, for instance, within a platform of care typology.

However, standardization within healthcare, specifically the pre- and off-site manufacture of standard components, is less mature compared to other major infrastructure sectors, and there are many reasons for that, including its legacy of having bespoke-built institutions - particularly in the U.S. According to Stephen Farrington-Bell, a partner at PA Consulting and expert in healthcare strategy and planning, there is evidence showing the benefits of reducing risk and avoiding cost overruns using standardization in specific modular examples of healthcare design, such as rooms or theatre modules. However, he also explains while these select examples are relatively well-established and tested, the application to whole hospital builds isn't.

So, how do we ensure we earn the potentially significant time and cost savings through standardization at the national scale? And how do we guarantee space and flexibility to innovate and iterate?

1. Data is critical to unlocking a cycle of standardization and innovation

Tom Best, MBE, Clinical Director at King's College Hospital, offered one of the most salient insights. Healthcare design should apply principles and rigor from evidence-based medicine (EBM). "Standardization and innovation should be part of a cycle informed by data. By appropriately measuring the outcomes and gauging the success of standardization, it provides the room (and evidence) for innovation," explains Tom. One fact that illustrates the lack of health design research is comparing online peer-reviewed articles. For example, there are over 34m research publications on PubMed, while there are only 5,391 research publications in the Center for Health Design Knowledge Repository.

We need more data, more clinical engagement and good governance around data gathering and utilization in research. This will rely on industry-wide collaboration to share national and global data, best practices and supply chain insights. For the U.K. specifically, we also need to break the NHS's Health Trusts' silos of information. Once we start collecting the evidence nationally, we can employ this knowledge when undertaking clinical engagement for new projects. For example, this could be a database or log within the NHS that includes the learnings of previous projects.

One key point is to ensure all the correct data is collected across several feedback loops, not just clinical data. We need to choose the proper measures that link to the desired outcomes. This should include insights into assets, estates and commercial decisions. This may require upgrading the electronic systems used across the industry. If we don't do this research and data gathering, we risk reaching conclusions without understanding the entire system.

This also includes the critical role of pre-and Post-Occupation Reviews (also known as Post-Occupation Evaluations [POE]). This needs to be included in the budget to learn what has (and hasn't) worked. Functional performance assessment needs to be part of projects from the start, and a methodology needs to be developed and funded to provide data. This kind of performance review will need to be done by a third party to counter bias and will require national oversight.

1. Ask the right questions at the start to define the right goals

Agreeing with Tom Best, "We know a lot about designing health facilities and about standardization. We have been experimenting with standardization for at least 200 years, but we also keep repeating the same mistakes," explains Regina Kennedy, Director of Healthcare Strategy and Planning at Lexica, an architect by background. "And it's mostly due to not understanding our true goals. The critical question we must ask is what are we trying to achieve?"

Standardization and mass customization can offer major benefits, and they've been proven in the manufacturing sector with items like clothing and shoes. We can learn from other sectors' successes, but we need to understand and work toward the right goals. An example of this: the Nightingale ward, the basis for the pavilion system employed the world over for decades. The goal there was expandability - and they were very successful in that regard and others. However, now almost 200 years later, it's no longer fit for purpose.

To develop standardization for our future hospitals, we need to ask, "What are operational costs, productivity levels, health outcomes and benefits I want to achieve in that hospital?" says Regina. "Within those parameters, what standardized processes and mass production offer the potential to produce healthcare resources faster, cheaper, and better, with better quality control."

1. Apply standardization at a part level and include a review cycle

Rooms and departments aren't the only options for standardization; we can create a kit-of-parts successfully, as highlighted in the German systems of operating theatres built up from standardized modular components. These assemblies must be paired with a careful review system, such as the Kaiser Permanente example. "This is where regular reviews are vital, as they can help provide incremental improvements in design procurement, clinical safety and risk reduction, construction, maintenance, and life cycle. In the Kaiser system, reviews occur every two to three years with an expert panel of clinicians who review the outcomes to lead to incremental changes," explains Jane McElroy, Principal at NBBJ Architects.

This highlights the benefits of longitudinal measurement and assessment, where testing and reviews happen often, versus focusing on doing one big assessment at a point in time and then potentially struggling with the amount of change needed.

1. Standardization should be dynamic and adaptable

This isn't a contradiction, but rather about creating codes and standards that guide design and infrastructure builds instead of focusing on strict, static designs that can't be easily modified.

Focusing on standards and codes will help create flexibility and allow things to develop incrementally. We need a framework or grid of options that can be applied, for example, rooms of regular size to suit various needs. While this increases the range of materials and items as part of the standardization, it can still help reduce risks and costs whilst delivering long-term flexibility.

A critical focus here is not to reduce the designs so much that they aren't adaptable. Case in point: if outpatient rooms become too small and can't be modified to work for different patient and healthcare needs. This highlights the critical need to learn from data to inform better design decisions based on outcomes. This is also where mock-ups and 'test fits' can help to review things incrementally, as well as carrying out Post-Occupancy Evaluations of completed projects.

1. The clinical model must be a crucial influence on the design

With the rise in digital and remote care and data integration, the clinical model will help define how our new healthcare systems are designed and delivered. However, the physical build can also enable a new model of care, as there are questions about the hardware needed. It's a relationship between the two, and both will influence and inform each other. It also raises the role of engagement: clinical input and inclusive stakeholder participation with patients, clinical and non-clinical staff are paramount.

It was a pleasure to host Tom Best clinical director of critical care at King's College Hospital, Stephen Farrington-Bell of PA Consulting, Jane McElroy of NBBJ and Regina Kennedy of Lexica for the discussion of Design Standardization vs Innovation: Finding the Right Balance at the European Health Design conference.

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