7.3 Participative Design, Charrettes & Advisory Councils

Participative Design, Charrettes & Advisory Councils

Core Principle: Healthcare facilities are among the most intricate socio-technical systems in human civilization. Participative design (also termed co-design or collaborative planning) asserts that patients, family caregivers, frontline clinicians, and operational support staff are not merely passive recipients of architecture, but essential co-creators who possess deep, unwritten tacit knowledge regarding clinical bottlenecks, human vulnerability, and physical friction points.

In traditional architectural programming, design teams routinely committed the error of consulting only department chairs, chief medical officers, and senior administrators. While executive leadership understands corporate strategy and capital constraints, they rarely experience the sensory, physical, and emotional reality of delivering or receiving care around the clock. When facility planning ignores the lived experience of bedside nurses, patient transport staff, environmental services cleaners, and vulnerable patients, the resulting building inevitably incorporates latent operational flaws that degrade clinical safety, increase staff turnover, and compromise human dignity.

Participative design establishes rigorous, structured frameworks to extract, synthesize, and translate stakeholder insights into evidence-informed physical spaces.

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Building the Interdisciplinary EBD Team (EDAC Study Guide 3)

EDAC study materials describe how the EBD project team should be formed:

• Assemble the team early and make it interdisciplinary—administrators, professionals and users, architects, consultants and planners, researchers, and others.
• Do not follow a linear timing of involvement. Team members should all be involved at the same early stage of the process, not added one after another.

Setting Expectations and Managing Perspectives

• Clearly identify each member's expectations: length of participation, decision-making authority, and responsibilities and deliverables.
• Team members should also state their expectations of the administrators, which supports open communication and collaboration.
• Managing diverse perspectives in a collaborative process requires an organizational structure and a decision-making protocol.
• By addressing multiple perspectives concurrently during all phases, the team can establish consistency among the project plan, vision, and implementation from the earliest points of the project.

Team Structure, Onboarding, and Responsibilities in the Exam Content Outline

CHD's current outline expands on the interdisciplinary team in several places. Candidates should be able to explain why achieving outcomes can be limited by a project delivery approach that does not use an interdisciplinary team—for example, when clinicians first see the plan after it is fixed, or when no researcher is involved until after occupancy.

Potential members, qualifications, and onboarding timing. The outline lists owners; patients, families, and other care advocates; other end users; consultants; researchers; contractors; vendors; community leaders; and community organizations. For each, the team should identify key qualifications and when to bring them on—researchers and clinical users at conception, contractors early enough to inform cost and constructability, vendors when product decisions are made.

Team structure should define:

Continuous education and engagement. The outline calls for ongoing education of the team and stakeholders about the EBD process, research findings, and their application to design decisions—through participation in user groups, establishing the vision and measurable goals, reviewing mock-ups and simulations, engaging in research planning, data collection, and review, and participating in post-occupancy evaluations and design research.

Responsibilities for integrating EBD into traditional project phases. The team's responsibilities, as listed in the outline, run from defining the project context, creating the business case for using EBD (if not already done in the business plan), developing the vision and measurable goals, and defining scope and budget; through initiating the research process, overseeing concepts linked to intended outcomes and hypotheses, and developing preliminary business cases for specific strategies; to documenting all of this in the functional program, creating a research plan for post-occupancy results, monitoring construction and activation, and measuring, evaluating, and disseminating results.

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The Spectrum of Stakeholder Engagement

Stakeholder engagement ranges from one-way information to genuine co-design. The spectrum below is adapted from public-participation frameworks; EBD projects aim for the deeper levels wherever practical:

┌────────────────────────────────────────────────────────────────────────┐
│                  SPECTRUM OF STAKEHOLDER ENGAGEMENT                    │
├─────────────┬──────────────────────────────────────────┬───────────────┤
│ LEVEL       │ DESCRIPTION & METHODOLOGY                │ EBD STATUS    │
├─────────────┼──────────────────────────────────────────┼───────────────┤
│ 1. INFORM   │ One-way broadcast (town halls, memos).    │ Inadequate    │
│             │ "Here is what we are building for you."  │               │
├─────────────┼──────────────────────────────────────────┼───────────────┤
│ 2. CONSULT  │ Reactive feedback (surveys, open forums).│ Minimal       │
│             │ Gathering opinions on predetermined plans│               │
├─────────────┼──────────────────────────────────────────┼───────────────┤
│ 3. INVOLVE  │ Interactive dialogue (focus groups).     │ Acceptable    │
│             │ Working directly to understand concerns. │               │
├─────────────┼──────────────────────────────────────────┼───────────────┤
│ 4. CO-DESIGN│ Active partnership (charrettes, mock-ups)│ Deepest       │
│             │ Stakeholders act as equal design partners│ participation │
└─────────────┴──────────────────────────────────────────┴───────────────┘

Identifying the Full Stakeholder Ecosystem

An evidence-based participative process maps four distinct concentric circles of stakeholders:

1. Primary Users (Patients & Families): Acute inpatients, chronic outpatients, pediatric patients, geriatric individuals, family care partners, visitors.
2. Secondary Users (Direct Care Clinicians): Staff registered nurses (day, evening, and night shifts), hospitalists, attending physicians, resident physicians, nurse practitioners, physician assistants, respiratory therapists, physical and occupational therapists.
3. Tertiary Users (Support & Operational Staff): Environmental Services (EVS), central sterile processing technicians, pharmacy staff, biomedical engineering, materials management and supply chain logistics, patient transporters, food and nutrition services, security personnel, facility plant operations.
4. Quaternary / Governance Users: Hospital board members, C-suite executives, legal and risk management counsel, regulatory and infection prevention officers, local community advocacy leaders, municipal emergency response coordinators.

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Patient and Family Advisory Councils (PFACs)

A Patient and Family Advisory Council (PFAC) is a structured, permanent institutional body composed of former patients, family caregivers, and clinical liaisons dedicated to infusing the patient voice into organizational operations. In evidence-based predesign, the PFAC serves as the primary conscience and human-centered lens of the capital project.

Critical Insights Uncovered by PFACs

While clinical staff focus naturally on diagnostic efficacy, throughput speed, and sterile protocols, PFAC members illuminate the hidden psychological, sensory, and dignity-related dimensions of healthcare architecture:

• Dignity During Transport: Patients express profound mortification when transported on gurneys in thin patient gowns through public elevator lobbies or crowded visitor concourses while connected to IV lines and catheter bags. PFAC advocacy directly drives the implementation of dedicated, off-stage patient transfer corridors.
• Sensory Overstimulation and Cognitive Stress: Family members highlight the terror induced by relentless auditory alarms, glaring overhead fluorescent lighting in waiting areas, and industrial intercom broadcasts. These insights reinforce EBD acoustic research on sound-masking, private consultation rooms, and circadian-attuned indirect lighting.
• The Reality of the Family Care Partner: PFAC members identify that families are not "visitors"—they are vital, unpaid members of the healthcare team. In traditional hospital rooms, family seating consists of a single stiff vinyl chair. PFAC engagement mandates dedicated family support zones equipped with convertible sleep sofas, built-in task lighting that does not disturb the resting patient, accessible charging stations, secure storage for personal belongings, and private showers.
• Wayfinding and Anxiety Points: Patients experiencing acute physiological stress suffer cognitive impairment. PFAC members evaluate signage typography, color coding, intuitive sightlines, and natural landmarks, ensuring that anxious families navigating the facility can find destinations without confusion.

Best Practices for PFAC Engagement

• Involve Early at Predesign: Engage PFAC representatives during Step 1 visioning, rather than presenting finished blueprints during construction documents for perfunctory approval.
• Provide Design Literacy Orientation: Demystify architectural conventions by teaching advisors how to read two-dimensional floor plans, understand spatial scales, and navigate three-dimensional virtual reality (VR) models.
• Compensate Advisors for Lived Expertise: Honor patient and family time through formal stipends, transportation subsidies, or childcare support, ensuring socioeconomic diversity among advisors.

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Engaging Frontline Clinical Staff & Support Services

A pervasive failure mode in hospital design is designing exclusively for the "idealized" clinical workflow envisioned by department heads rather than the messy operational realities navigated by frontline personnel.

Frontline Nurses: The 24/7 Clinical Reality

Staff nurses work across patient rooms, corridors, and support spaces around the clock. Their participation reveals ergonomic and workflow hazards that architects cannot discover in code books:

• Medication Preparation Distractions: Bedside nurses describe how locating medication dispensing cabinets in high-traffic, noisy corridors leads to frequent interruptions, which research has associated with more medication administration errors (Westbrook et al., 2010). This input supports dedicated, low-distraction medication preparation areas.
• Sightlines vs. Patient Privacy: Nurses demonstrate the critical need for direct visual sightlines from charting stations to high-fall-risk patient heads, balanced against patient auditory and visual privacy.
• Equipment Clutter: Nurses identify that a lack of dedicated alcoves for mobile telemetry carts, bladder scanners, and patient lifts pushes equipment into corridors, where it can obstruct required egress width and create trip hazards.

Environmental Services (EVS): The Linchpin of Infection Control

Perhaps no group is more frequently ignored during predesign—or more vital to hospital survival—than Environmental Services (EVS). Contaminated hands and environmental surfaces are important pathways for hospital-acquired infections (HAIs). EVS personnel possess profound practical knowledge regarding surface maintainability:

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Interdisciplinary Design Charrettes

An interdisciplinary design charrette is an intensive, multi-day collaborative workshop (typically lasting 1 to 3 days) where diverse stakeholders, architects, interior designers, clinical researchers, and healthcare executives assemble to rapidly brainstorm, visualize, and resolve complex facility challenges.

┌────────────────────────────────────────────────────────────────────────┐
│                  FOUR-PHASE EBD CHARRETTE PROTOCOL                     │
├────────────────────────────────────────────────────────────────────────┤
│ 1. PRIMING & DISCOVERY ──> Evidence summaries, baseline clinical data, │
│                            patient journey videos, project vision.     │
│           │                                                            │
│           ▼                                                            │
│ 2. DIVERGENT IDEATION  ──> Heterogeneous small groups sketch layouts,   │
│                            unconstrained creative spatial mapping.     │
│           │                                                            │
│           ▼                                                            │
│ 3. CONVERGENT SYNTHESIS──> Multi-group presentations, identifying      │
│                            common patterns, cross-critique.            │
│           │                                                            │
│           ▼                                                            │
│ 4. EVIDENCE FILTERING  ──> Scoring concepts against EBD criteria and   │
│                            clinical feasibility; charter alignment.   │
└────────────────────────────────────────────────────────────────────────┘

Navigating Healthcare Hierarchy and Power Dynamics

The single greatest threat to the validity of a healthcare design charrette is the steep organizational hierarchy inherent to medical culture. In an open, unstructured conference room, medical power dynamics manifest immediately:

• Chief surgeons and department chairs dominate conversations, advancing personal spatial preferences (e.g., oversized private offices or dedicated departmental equipment).
• Frontline nurses, medical assistants, and EVS technicians remain silent, fearing professional embarrassment or administrative retaliation if they contradict a senior physician or vice president.

[!CAUTION]

EXAM TRAP: Flattening Hierarchy in Charrette Facilitation

To extract true operational evidence, charrette facilitators must enforce deliberate structural safeguards to neutralize hierarchy:

1. Suspension of Rank: Explicitly establish ground rules declaring that institutional rank and professional titles are suspended for the duration of the workshop.
2. Silent / Anonymous Brainstorming (Nominal Group Technique): Require participants to write ideas silently on sticky notes or submit them via digital polling software before open verbal discussions begin. This ensures an EVS cleaner's insight into dirty utility layout appears on the board with the exact same visual weight as a chief surgeon's request.
3. Heterogeneous Small Breakout Pods: Assemble mixed tables (e.g., one surgeon, one staff nurse, one EVS worker, one patient advisor, one architect) led by an impartial professional facilitator trained to actively solicit input from quiet participants.
4. Role-Reversal Exercises: Instruct senior surgeons to physically map the 12-hour workflow of an overnight CNA or an EVS cleaner, building visceral empathy for operational friction.

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Methodologies for Extracting Tacit Knowledge

Tacit knowledge cannot be accessed by handing someone a survey. EBD teams deploy specialized ethnographic and lean tools to uncover unarticulated spatial behaviors:

1. Patient Journey Mapping

A visual timeline mapping every micro-step, emotional state, physical touchpoint, and friction point a patient experiences from pre-admission arrival to post-discharge recovery. Journey maps illuminate "moments of truth"—such as the anxiety spike experienced when a patient is separated from their family at the pre-op surgical holding threshold.

2. Clinician Shadow Studies & Value Stream Mapping

Design researchers silently trail nurses, hospitalists, or supply chain techs across complete shifts with digital tablets and architectural floor plans, logging:

• Movement trajectories: Measuring total walking distance and identifying backtracking.
• Informal Workarounds: Uncovering unofficial physical modifications that reveal architectural failures (e.g., propping fire doors open with biohazard bins to maintain visual connection with high-fall-risk patients, or hoarding IV pumps in linen closets due to supply shortages).

3. Empathy Interviews & Card-Sorting Exercises

• Empathy Interviews: One-on-one, semi-structured interviews designed to explore the deep emotional narratives of patients, family members, and burned-out clinicians.
• Card-Sorting Exercises: Stakeholders receive physical cards representing potential spatial features (e.g., private bathrooms, decentralized charting alcoves, family sleep sofas, outdoor healing gardens, robotic supply delivery). Participants are forced to sort cards into tiers ("Non-Negotiable Essential," "High Value," "Nice to Have," "Low Priority") under budget constraints, revealing true consensus priorities.

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Synthesizing Disparate Desires into Evidence-Aligned Priorities

Inevitably, participative processes generate conflicting stakeholder desires:

• Attending surgeons demand a centralized lounge adjacent to the OR suites.
• Infection preventionists demand strict isolation of dirty utility pathways.
• CFOs demand maximizing billable procedural square footage.
• Patients demand private, hotel-like recovery rooms with expansive family lounges.

When desires collide, the project team should not resolve disputes through political horse-trading or bowing to the most aggressive voice in the room. Instead, the team screens requests with the same EBD Prioritization Matrix used later for budget decisions (Section 8.4), which compares expected impact on evidence-based goals with cost and complexity:

Filtering every stakeholder request through expected impact on evidence-based goals and cost and complexity gives the team a transparent, defensible basis for decisions that upholds the project vision.