The typical hospital design process is often more participatory by nature than the design process used to develop many other types of large facilities. The traditional hospital design process involves a large number of staff members who participate in user groups that work with the architects to design their particular units or departments. These groups may or may not be aware of innovations in design that will improve their operations, and they seldom recommend design strategies that affect the entire facility.

Palomar Pomerado Health (PPH)—a Center for Health Design Pebble Partner in San Diego—chose to take participatory design a step further by focusing on the development of internal expertise and knowledge to inform the design process. The design process that evolved resulted in the creation of a PPH think tank composed of staff members that cut across departmental silos, created significant staff buy-in for the proposed changes, and created thought leaders who can take a lead role in promoting new ideas and culture change.

As a Pebble Partner, PPH collaborated with researchers from The Center for Health Design and Georgia Institute of Technology (commonly referred to as Georgia Tech) in documenting this innovative participatory design process. This included:

  • Documenting the steps involved in this process;
  • Understanding how the process really worked from the perspective of the different participants; and
  • Identifying lessons learned and how the process could be improved.

The researchers conducted 13 telephone interviews from late April to late June 2006. Six focus group sessions were held with champion team participants in early May 2006. In this article, we briefly describe this process and some of the key lessons learned that could be used to inform other design processes. For more detailed findings from this study, please contact the authors for the complete report.

The Process

PPH initiated an innovative participatory design process early in 2005 to plan for the expansion of the existing Pomerado Hospital in Poway, California, and construction of a replacement facility for Palomar Medical Center in Escondido, California. PPH leadership chose to use a participatory evidence-based design process where individuals from all departments in the hospital were invited to participate in researching new and emerging ideas in healthcare design.

One of the first steps in implementing the participatory design process was the formation of Champion Teams. These interdisciplinary teams served as a think tank to identify, evaluate, and challenge innovative design concepts such as acuity-adaptable patient rooms, decentralized patient care stations, integrated interventional platforms, healing environments, and sustainability. The primary purpose of the Champion Teams was to serve as a resource to the User Groups and to the Steering Committee. These teams were tasked with evaluating design innovations using criteria based on the PPH Balanced Scorecard. Thus the four Champion Teams mirrored those domains: Financial Strength, Customer Service, Quality, and Workforce/Workplace Development (figure 1).

PPH Design Project Organizational Structure showing the relationship of the Champion Teams to the User Groups and design teams.

Hospital staff from different departments either volunteered or were recommended by their department heads to participate in the Champion Teams. A toolkit was provided to Champion Team members outlining the goals and steps of the process. Participants and their supervisors signed a contract acknowledging that the Champion Team members would be expected to participate in meetings and activities outside of their regular duties to support the hospital design process.

As the Champion Teams began researching the various design innovations in terms of their domain areas, they realized that they were often duplicating efforts. The subgroups within different Champion Teams were spending time exploring the same themes, but from different perspectives. For example, a subgroup within the Quality team might evaluate how acuity-adaptable patient rooms could improve patient safety and quality outcomes, while a subgroup in the Financial Strength team looked at acuity-adaptable rooms in terms of cost, including savings from avoided adverse events. To address this concern, the subgroups working on the same topic within the different domain-based Champion Teams came together to form topic-specific teams. These included:

  • Acuity adaptability
  • Interventional platform
  • Sustainability
  • Healing environments
  • Technology
  • Diverse, nontraditional alternatives

During this year-long process, Champion Team members were exposed to many learning opportunities at internal conferences and presentations from outside experts. Events called Innovation Weeks were organized twice during this period. The purpose of the Innovation Weeks was for all involved to see the big picture, to integrate knowledge between groups, to understand the impact of others, and to assure innovation and best practice. Champion Team members and other outside experts were asked to use this opportunity to view plans with the User Groups to offer ideas for innovation based on their research. The Champion Teams made presentations based on their research to the User Groups at the Innovation Weeks, and also to the Expansion Steering Committee and the Board of Directors. figure 2 indicates the sequence of events that took place during the design process.

Chronology of participatory design activities.

Research Findings

PPH chose to modify their design process to facilitate greater involvement and participation from staff with the intent that the staff would play an active role in creating and disseminating knowledge about the design process throughout the organization. The research findings suggest that while the process was challenging to implement, PPH was successful in achieving these goals.

Benefits. During the interviews and focus groups, the researchers identified the benefits of this process to PPH.

Design impacts. The researchers found that the PPH staff who participated in the design process felt as though their voices were heard and that they positively affected the design of the new facilities. According to the architects and Steering Committee members, the degree of adoption of and commitment to the innovative design concepts in the schematic plans was greater than it would have been without these teams. Some of the design innovations and ideas that might have been cut from the design to reduce costs are now likely to stay because of a deeper facility-wide understanding of the benefits of these innovations.

Effects on staff behavior, attitude, and culture. This process was particularly successful in affecting staff behavior and attitude and in fostering cultural change. Some of the benefits described by staff during interviews and focus groups included:

  • Breaking down departmental silos and getting to know colleagues from other departments
  • Acceptance of innovative design concepts
  • Understanding of anticipated changes in the new environment and ways of providing care, thus increasing openness to process changes and facilitating the move to the new facility
  • Creation of new leaders and proponents of change within the organization
  • Increased perception that staff opinions are valued within the organization
  • Staff feeling as though they made a valuable contribution to the new design
  • Generation of employee buy-in for facility designs

Broader communication and dissemination of ideas. The participatory design process at PPH enabled the leadership to communicate the ideas about the design of the new facilities to a much broader audience than might have been possible with a traditional design process.

A model for future participatory processes. The organization recognizes that this process was very helpful in engaging a larger number of staff members and could be a useful model for future design processes where high staff input and participation is desirable (e.g., information technology).

Challenges. During the interviews and focus groups, the researchers also identified some challenges faced by the organization in implementing this process.

Changes in Champion Team structure and charge. The Champion Teams that were originally created around the PPH Balanced Scorecard domains eventually morphed into topic teams focused on specific design innovations. Most interview and focus group participants felt that the topic-based groups worked better, as the charge was clearer. The leadership played a critical role in facilitating this change in team structure which eventually led to better outcomes in the process.

Communication of information. The Innovation Weeks represented two formal events where User Groups and Champion Teams had the opportunity to learn from and critique each others’ work. However, outside of the Innovation Weeks, there was little opportunity for regular interaction between Champion Teams and User Groups unless a Champion Team member also served on a User Group. The study participants felt that more communication would have improved the process and that good communication as the process moves forward is critical.

Resource use. The process was challenging because it involved a large number of staff members, many of whom had taken on Champion Team responsibilities in addition to their regular work load. Suggestions made by participants for making the process more efficient included reducing the primary work load of several staff members to allow them to spend focused time on the design project, and provide research articles and resources up front so that Champion Team members do not have to spend their time searching for articles. Almost unanimously, those who participated in the design process believe that the time required of them to participate was definitely worth the effort.

Lessons Learned

An organization that chooses to involve a large number of staff members in planning and designing a hospital will reap many rewards—particularly in terms of improving employee morale (if many of their recommendations are incorporated into the design) and in improving the design. However, because of the time and monetary demands of such a process and the challenges associated with making the best use of staff time, the leadership (including the CEO) must be committed to the process for it to succeed. Other elements for the success of the project include an innovative architecture firm and a highly motivated project coordinator. Providing administrative support for staff involvement is critical, as is providing the organizational framework to facilitate a high level of communication about the design process throughout the organization. HD

Anjali Joseph, PhD, is Director of Research for The Center for Health Design.

Sheila Bosch, PhD, LEED AP, is a research scientist with the Georgia Institute of Technology, College of Architecture, where she is involved with applied research related to improving patient and staff well-being in healthcare environments through the application of evidence-based design.

Carrie Frederick is Director of Performance Excellence and Marcia Jackson is Chief Planning Officer for Palomar Pomerado Health in San Diego.


The Pebble Report focuses on the research efforts and interests of The Center for Health Design’s Pebble