What follows is my favorite song; viz: Kasey Musgraves singing “Follow your arrow.”
The following was my post on December 28th, two days earlier.
My fear of eviction stems from the fact that I have not been able to pay my December rent. My December 2015 rent is $900.
On the day of my spinal operation performed by Dr. Christopher J. Winfree, I logged onto to my Wells Fargo account. My deposit from Social Security had arrived. There were not substantial bites from the bank which in previous months had made substantial reductions before I received whatever was left from Social Security.
When I logged on and checked the deposit was there.
What follows is the gloomy previous posting . This demonstrates my current optimism which all resolves upon money.
In the previous posting I state that I owed my landlord $450 in rent and fear for the consequences if I cannot pay. Today, the staff member in charge of Addison Court told me I owe $380. I received a generous donation by check. The check clears at Midnight. At Midnight I write a check to Addison Court for $100. At 8:30 AM when Kimberly begins work, I will go to her office and hand her a the check and my official obligation is $280.
How am I going to obtain $280? Perhaps from a $25 donation from you. Will you please help me out?
Log onto PayPal https://www.paypal.com/home
Select send. Enter my email address [email protected]
Please send me $25.
On Friday, December 4th, Dr. Christopher J. Winfree inserted a test stimulator in my spine at the operating room at Columbia Medical Center in New York City.
This is a photograph of the controls to increase the intensity of vibrations to my spine. For the past 14 months I have experienced crippling pain. Here in State College PA where I live, Dr. Todd B. Cousins, widely regarded as the best pain specialist in this area, recommended that I go to New York for this surgery.
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A nurse took this photograph of my back immediately after surgery. So skillfully did Dr. Winfree insert the test stimulator that on December 22nd upon examining my back, Geisginger internist Sepana Menali could find no surgical scar.
A nurse took this photograph of my back immediately after surgery. So skillfully did Dr. Winfree insert the test stimulator that on December 22nd upon examining my back, Geisginger internist Sepana Menali could find no surgical scar.
Following Dr. Winfree’s successful test, I must return to NYC for final insertion of a spinal stimulator manufactured by Medtronic, the medical device company with $28 billion in annual revenue. The stimulator’s vibrations interrupts pain signals to my brain.
Given that in October I spent three weeks in the hospital in State College recovering from an infection that nearly killed me, I rushed to NYC while I was still eligible for surgery without obtaining the necessary funds to pay for the trip.
The considerable financial crisis I am currently experiencing is a result of the conviction that the quality of my life and the improved productivity that would make it possible to earn my living (rather than depend on government assistance) was worth the risk.
Regarding the bad news/good news construction which began this posting:
The good news is:
After a difficult trip to New York City to begin the process of controlling crippling pain
After weeks of hiding from family and friends (refusing to answer the phone, read emails, and post on Facebook)
I have emerged (still afraid of being evicted from my apartment and other economic catastrophes)
To report on my progress
Ask for help
Provide an optimistic view not only of my future but that of millions of Americans who have survived cancer
[Not only did medical achievement result in my not dying of Hodgkin’s disease–cancer of the lymphatic system–but I was able to father two daughters. Indeed, in April, God willing] I will be a grandfather.
One of the consequences of radiation treatment that saved my life from cancer is that radiation damage has caused my spine to degenerate to the point where my daily pain level averages 7.5.
Hospitals and physicians use wide variety of pain scales to understand and treat pain. Since October 2014, I have been asked to evaluate my pain level on a 1 to 10 scale such as this one. In October of this year, for example, when I was in the hospital for three weeks, I was asked at least four times a day I was asked to provide a number for my pain. Following each answer I was injected with morphine or provided with an opioid such as Oxycodene. To avoid dependency on these drugs, I turned to Dr. Winfree to help manage my intense pain without drugs.
Hospitals and physicians use wide variety of pain scales to understand and treat pain. Since October 2014, I have been asked to evaluate my pain level on a 1 to 10 scale such as this one. In October of this year, for example, when I was in the hospital for three weeks, I was asked at least four times a day to provide a number for my pain. Following each answer I was injected with morphine or provided with an opioid such as Oxycodene. To avoid dependency on these drugs, I turned to Dr. Winfree to help manage my intense pain without drugs.
Another common pain measurement chart includes faces allowing patients to relate feelings with numbers.
These are the faces for the pain I average on a daily basis.
These are the faces for the pain I average on a daily basis.
Karen Lee Richards, pain patient writing for healthcentral.com does an effective job of describing the different levels of pain. Since my average daily level is 7.5, there are moments of intensity when the pain level goes off the chart. In one instance, I made the foolish decision to go to the emergency room–not a good place to be when screaming in pain.
THE PAIN SCALE
0 – Pain free.
Mild Pain – Nagging, annoying, but doesn’t really interfere with daily living activities.
1 – Pain is very mild, barely noticeable. Most of the time you don’t think about it.
2 – Minor pain. Annoying and may have occasional stronger twinges.
3 – Pain is noticeable and distracting, however, you can get used to it and adapt.
Moderate Pain – Interferes significantly with daily living activities.
4 – Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting.
5 – Moderately strong pain. It can’t be ignored for more than a few minutes, but with effort you still can manage to work or participate in some social activities.
6 – Moderately strong pain that interferes with normal daily activities. Difficulty concentrating.
Severe Pain – Disabling; unable to perform daily living activities.
7 – Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep.
8 – Intense pain. Physical activity is severely limited. Conversing requires great effort.
9 – Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably.
10 – Unspeakable pain. Bedridden and possibly delirious. Very few people will ever experience this level of pain.
My objective is not to eliminate pain. My objective is to combine the spinal stimulator with vigorous daily activity making extensive use of physical and occupational therapists. The combination will allow me to lower my daily level to 4.5 which is manageable.
However, there are many obstacles to overcome to reach that objective. These obstacles include the American Cancer Society’s insensitivity to cancer survivors. It is time now to push the publication button before returning to this site for further clarification.
The ACS is certainly to be commended for this report it published on the number and special requirements of cancer survivors. What is now required is an understanding of the human and indeed economic productivity costs of failing to heed the significance of ACS’s own report.
“A first-ever report by the American Cancer Society – in collaboration with the National Cancer Institute – estimates there are 13.7 million cancer survivors alive in the US today, and that number will grow to almost 18 million by 2022…..
“The report was created to help draw attention to the growing number of cancer survivors in the US who have specific medical, psychological, and social needs. It also aims to raise awareness of resources that can assist patients, caregivers, and health care providers in navigating treatment and recovery from cancer.”
Specifically, my concern is the American Cancer Society’s refusal to open the doors of its Hope Lodge housing to cancer survivors. Three years ago, when I received surgery at Memorial Sloan Kettering Cancer Center, the ACS provided me with accommodations in short supply in NYC; namely, bedrooms with bathrooms where, as a paraplegic, I could get my scooter into and where it was possible for me to take a shower.
However, since I was not receiving chemotherapy, radiation therapy, and surgery I was denied entrance to the American Cancer Society facility. As a cancer survivor trying to improve the quality of my life from problems caused by cancer treatment, I was turned away.
Therefore, on visits to New York City’s Memorial Sloan Kettering Cancer Center with oncologists, the ACS turned me away. When ACS oncologists recommended that I receive treatment from Dr. Winfree for the cancer-caused pain, I was turned away again and found myself unable to get into the bathroom without crawling and facing the indignity of being unable to shower for weeks. The following raw footage reflects my sense that something must be done to stop punishing cancer patients for living.
Finally, at least for today, I will end with an email I received from an architecture friend in China who with her 12 year-old daugter celebrated Thanksgiving with me last year in State College:
I was delighted to hear from you.Yesterday did not seem like Thanksgiving with you and Kelly. Last year, Kelly and her friends played on the drum set. The neighborhood is still resounding at the sound.
Here is an explanation on my current situation. https://joelsolkoff.com/in-a-rush-to-eliminate-cancer-pain-my-surgeon-begins-the-operation-nov-30th/
I am in New York City now. I am in the apartment of a friend of my mother’s rabbi. My entire world here in the apartment is astonishingly primitive. My scooter–a poorly designed travel scooter–is too wide for the bathroom door. To go to the bathroom I must crawl.
Three things comfort me. 1. I will redesign travel scooters, 2. I will redesign communities so the entrance to each bathroom will be wheel chair accessible. 3. I meet the surgeon who will begin the process of drastically reducing my pain.
I have started giving seminars. Chimay suggested I lecture on proper English usage and Zotero. I will continue the seminar series after I return from New York.
It has been nearly 32 years since I last was in China. I miss China. Also, of course, I miss you and Kelly.
Note: I profiled Jane, the English name Ming Zhao prefers to use, in my column for e-architect, U.K. http://www.e-architect.co.uk/columns/belt-and-suspenders-routine
Jane and her daughter Kelly at my apartment in State College PA Thanksgiving 2014 where we followed an earlier holiday tradition of having a three-drum and cymbals set whose noise reverberated through the neighborhood. The drums, bathroom, and indeed the entire apartment is wheel chair accessible. May universal design prevail even in The Bronx, my birthplace.
Jane and her daughter Kelly at my apartment in State College PA Thanksgiving 2014 where we followed an earlier holiday tradition of having a three-drum and cymbals set whose noise reverberated through the neighborhood. The drums, bathroom, and indeed the entire apartment is wheel chair accessible. May universal design prevail even in The Bronx, my birthplace.
This chapter introduces the healthcare case study used for data collection, development and evaluation of the procedure for rapidly developing an Experience-based virtual prototype. The first part of the chapter introduces the case study, lays out the program requirements for the healthcare facility, the project description, status and context of the facility. The next section discusses the research approach and presents the timeline of the case study. The research approach includes the strategy for data collection and briefly describes the procedure for development, validation as well as evaluation of the EVPS along with a time line that shows when and how the process occurs.
The case study primarily uses focus groups as means of data collection for “Requirements analysis” of the EVPS. The focus group section describes in detail the method of data collection followed by analysis of these data to inform the development process and strategy for EVPS. Validation and strategy for development describes the rationale for design of the EVPS through identification of prioritized scenarios, spaces, end-users and overall purpose.
Development strategy for EVPS further discusses the model content, user interface and interactive features included in the virtual prototypes as well as challenges encountered during the development process. The evaluation section discusses the first part of evaluation of the EVPS used in the design review meetings with the pharmacy staff. This section describes in detail the pharmacy program, the pharmacy’s transition planning initiative and finally the integration of the EVPS in their move planning process. Finally, lessons learned and summary provide an overview of the findings and conclusions of the case study.
5.1 CASE STUDY DESCRIPTION
The new Penn State Milton S. Hershey Medical Center Children’s Hospital is a 263,000- square-foot, five-story facility that is expected to open by end of December 2012. The state of the art facility is currently under construction and the hospital personnel are gearing up for transition planning. The new hospital is an independent facility adjoining the main hospital and the Hershey Cancer Institute. At present, the Children’s Hospital is located on the seventh floor of the main hospital.
Figure 5-1. Rendering of the new Hershey Children’s Hospital (Source: Payette Architects).
The hospital design program includes a lobby and atrium with a family resource center, performance area, a café for family meals, a safety store, meditation space and an outdoor courtyard especially designed for children. The new facility will house outpatient clinics for children with cancer, and a new pediatric radiology unit.
The new Children’s Hospital will have a total of 131 pediatric beds that include pediatric medical/ surgical beds, pediatric intensive care unit (PICU) beds, pediatric intermediate care unit (PIMCU) beds and neonatal intensive care unit (NICU) beds. The integrated surgical and hematology/oncology suites have advanced equipment for infants and children.
The general medical and surgery beds will be in private pediatric and adolescent patient rooms with designated “zones” for families. The hospital has expanded space for PICU, PIMCU, five pediatric-only operating suites and a cardiac catheterization lab. The main pharmacy and state-of-the art blood bank will also be located in the ground floor of the facility.
Figure 5-2. Children’s Hospital under construction.
The owner, Penn State, and the design team decided to implement building information modeling (BIM) during the schematic design phase.
Throughout the project duration, the architect’s team updated and exchanged the Autodesk Revit models with contractors using an ftp server.
Table 5-1. Hershey Children’s Hospital facts.
L. F. Driscoll
CM @ Risk
263,000 square feet
5.2 CASE STUDY APPROACH
The Hershey Children’s Hospital case study started in October 2011, almost two years after project construction start on December 2009. The initial phase of research for requirements analysis included preliminary interviews with the nurse project manager of the Children’s Hospital. Meetings with the nurse manager, who was representing end-user needs throughout the building lifecycle, helped establish goals and scope of using the EVPS for Children’s Hospital and setting up dates for focus group meetings.
Figure 5-3 shows the timeline of the case study.
The EVPS was developed from highly detailed BIM models supplied by the architect’s team. Interviews with the architect helped in understanding the design intent and program with floor-by-floor space layouts within the facility and the current state of BIM use on the project. Discussions included permission to use BIM for developing EVPS, information exchange protocols and details on how the facility was modeled. The majority of requirements capture was done during two focus group meetings that are discussed in detail in the next section.
A draft EVPS of a part of the Children’s Hospital was developed during December 2011 and January 2012 to give the participants an idea of what to expect. After requirements analysis, the next phase was EVPS design and development. Meetings during this phase helped clarify and validate the scenarios of use identified during requirements analysis. Development took place from March through August 2012 with the final models delivered to the nurse project manager on September 7, 2012. EVPS evaluation was done in two parts.
The first analysis was done with the pharmacy leadership team and staff members where they used the EVPS for move planning during the design review meeting between February and March 2012. The next part of evaluation was user studies in July 2012 to understand the effect of embedding scenarios in virtual prototypes, which is discussed in detail in Chapter 6.
Figure 5-3. Timeline for Hershey Children’s Hospital case study.
5.3 FOCUS GROUPS
For initial requirements analysis for developing interactive virtual prototypes, focus groups were selected as a means for data collection.
Compared to one-to-one interviews, focus groups are more appropriate for the generation of new ideas formed within a social context (Breen 2006). Two focus group meeting were conducted over a span of two months.
The first meeting took place on December 09, 2011 and the second meeting took place on January 30, 2012.
5.3.1 First Focus Group – December 9, 2011
At the start of the first meeting, the researcher and facilitators welcomed participants, discussed the agenda and went through a round of introductions. The researcher presented a few slides outlining the background of the research project and outlined some goals for the meeting. Participants were shown two concept videos of the experience-based virtual prototypes; the first video showed scenarios of activities that can be performed in virtual prototypes and the second video showed the level of realism that can be achieved through use of lighting and textures. Focus groups were used to obtain data for identifying scenarios of tasks and spaces that need to be developed in the virtual prototype. Participants were split into groups of 4 to 5 so that they could discuss amongst themselves and provide feedback. Each mini group was required to discuss and work hands-on to help answer research questions.
5.3.2 Data Collection
Large 42” X 30” printouts of floor plans from levels 1-5 were used as artifacts during the focus group discussion along with the use of post-it notes to enable the participants to give feedback and answer the focus group questions. Questions asked during the meeting explored three broad themes (shown in Table 5-2) that focused on identifying and prioritizing the spaces, identifying and documenting scenarios and finally identifying modeling requirements for the development of the virtual prototypes. Table 5-2. List of questions asked during focus group 1.
Theme I. Identifying and Prioritizing Spaces
1. What do you see as the primary purpose of using the Experience-based Virtual prototyping System (EVPS) for your facility and why?
2. Referencing the floor plans of the new Children’s Hospital, identify the spaces of highest priority that should be developed as interactive virtual prototypes using the EVPS. E.g., Pharmacy, Nurse’s station to patient rooms, route between Blood bank to OR
Theme II. Investigating and documenting scenarios
3. What are the typical scenarios of activities that will take place within each space/ zone identified?
4. Identify typical routes that will be taken by the staff in the hospital with the brief description of their purpose.
Theme III. Identifying design requirements for the EVPS
5. What would be ideal level of detail that you would like in the virtual prototypes? Especially with regard to the following:
– Textures and colors (highly realistic to abstract)
-Lighting (Highly realistic to absent)
– Interactive objects (E.g., doors that open, crash carts that move)
6. Which of the following features would you like to see in the EVPS for a particular space:
7. What additional features would you like to see in the EVPS?
8. Is there any additional content that you would like modeled in the facility?
Based on the questions asked, participants were instructed to note down their ideas and answers on post-it notes. The post-it notes were color-coded based on: end-users (blue), scenarios (green), tasks (yellow), spaces (pink) and objects or elements (purple) required for modeling the hospital. Participants reviewed different floor plans of the hospital where they marked spaces they considered important enough to be included in the EVPS and wrote them on post it notes (Figure 5-4). Similarly different colored post-it notes were used to get brief descriptions of scenarios, tasks and level of detail required.
Figure 5-4. Data Collection during Focus Group 1.
After collecting the post-it notes from participants (Figure 5-5), they were organized on a white board. Questions and clarifications helped reorganize and match different spaces of the hospital with certain scenarios of tasks. Figure 5-5. Color-code post-it notes with end-user scenarios.
Detailed follow up discussion helped prioritize and further organize and group the scenarios. (Figure 5-6).
The goal of the first focus group meeting was to establish key areas to develop in the draft virtual prototype before final EVPS for the Children’s Hospital could be developed.
Figure 5-6. Scenarios generated from 1st focus group meeting.
An area of the fourth floor was identified to be developed as a draft EVPS. Within this space (Figure 5-7), participants identified and prioritized the following areas to be highlighted:
ClinicalCare Documentation Center – This area is centrally positioned to be in proximity with the maximum number of patient rooms and is used by nurses for documentation.
Patient Isolation Room with Dialysis – this room is chosen because it is used for patients with more complex conditions and because it has surgical boom equipment and an anteroom. The rationale to choose this room over others was to get nurses more familiar with one of the most complex rooms in the hospital.
Treatment Room – Although the entire second floor is dedicated to having operating rooms, it was decided to have one treatment room per department for patients that could be easily accessible and also appear to be a pain-free area for children being treated. The treatment room has an examination table and head wall for medical air, vacuum and gases.
Clean Supply Room – This room generally has storage of medical supplies and medication stored in shelves or automated dispensing cabinets like the “Pyxis” medication machines.
Medication Preparation Room – This room is used for distribution of medicine to the patients and is close to the nurse’s station. It contains a work counter for preparation of medication, refrigerator, sink for hand washing and locked storage cabinets for biological medication and drugs.
Soiled Utility Lab- This room is unique as it has the eye wash station and a laundry chute. It was deemed important to include this room in the EVPS so that nurses could familiarize themselves with the work process and know how to locate the room.
Figure 5-7. Spaces identified on the fourth floor for draft EVPS development.
Apart from a part of fourth floor with the above areas, the main pharmacy of the hospital located in the ground floor of the hospital was also identified as a space for possible inclusion in the draft EVPS.
There were 17 participants in the first focus group meeting and 20 participants in the second focus group out of which 12 participants attended both meetings.
Table 5-3 lists the participants of the focus group. Although all participants are connected to the Children’s Hospital, they come from diverse departments such as Safety, Infection control, Patient Transportation and Administration.
There were three physicians, six nurse managers from various departments, three clinical head nurses, and two safety officers.
Other staff included clinical nurse educators, nursing administration, anesthetics, patient transport, infection control, pharmacy staff, child life manager and family centered care specialist.
Table 5-3. Participants of focus groups in December 2011 and January 2012.
Nursing Project Manager
Children’s Hospital Support
Residency AssistantProgram Director
PICU (Pediatric Intensive Care Unit)Senior resident
Director of Nursing
Children’s Hospital Administration
Pediatric Acute Care and Hematology/ Oncology
Clinical Nurse Educator
NEPD (Nursing Education and Professional Development)
OR (Operating Room)
NICU (Neonatal Intensive Care Unit)
PICU/ PIMCU (Pediatric Intensive/ Intermediate Care Unit)
Perianethesia (nursing for patients undergoing anesthesia)
Float Pool /Per Diem/ NVAT (Nursing Vascular Access Team)
Clinical Head Nurse
Environment Health MgrFire protection Engineer
During the second focus group meeting, draft EVPS of the Children’s Hospital with interactive virtual prototypes of the fourth floor with varying levels of detail and the pharmacy were distributed to the participants. The goal of this meeting was to enable the participants to experience first-hand and interact with the EVPS model and then brainstorm ideas and goals for the next iteration of development of the EVPS.
Besides going through the same exercise of using post-it notes from the first focus group meeting, the participants were also asked to fill out a questionnaire.
The questionnaire asked the participants to fill in five questions on identifying a set of users, scenarios that they would perform, spaces that would be involved in the scenarios, detailed steps of tasks and finally level of detail of specific elements or features that would be required for the scenario.
The participants were also asked to state what they felt the overall purpose of the EVPS would be. The focus group questionnaire with detailed list of questions can be found in Appendix B. At the time, the Children’s Hospital project was in the third year of construction, had crossed the substantial completion milestone and was slated to open by January 2013.
The hospital staff was gearing up for transition planning to move from their current facilities into the new facility. At this stage of the project, most of the design decisions had already been taken as the project team had also used physical mockups patient rooms.
5.3.5 Potential Use of EVPS at Hershey Children’s Hospital
During focus groups discussions, participants envisioned using the EVPS for purposes of educating and providing a level of comfort for way finding to the entire hospital staff and possibly to patients and their families in the future. Apart from reviewing the design of the new facility, the hospital staff and project team envisioned using the EVPS in the transition process.
Participants felt that the EVPS could provide a snap shot of the new work environment and orientation of the pathways from the current facility to the new hospital thereby reducing the staff’s anxiety of moving and adapting their work processes into a new space.
They envisioned using the EVPS as a tool for training staff members or new hires to get acquainted with the building layout and use for locating life safety items and emergency evacuation drills. Another way the participants wanted to use the EVPS was to help develop new work processes and understand patient flow in the new facility layout.
Many example scenarios were discussed on how the workflow will be affected with larger distances and new locations for equipment. The participants also suggested using the EVPS as a “virtual tour” resource for patient’s families, caregivers and visitors to understand how to find specific services in the hospital. The goal was to develop interactive virtual prototypes of the chosen areas and use them for training during staff orientation at least 4-6 months before the move-in date.
5.4 SCENARIO ANALYSIS
Twenty-three total detailed scenarios were collected from the focus group studies. Using the scenario framework proposed in Chapter 4, first the scenarios were categorized based on the end-users, and then the scenarios were categorized based on the level of detail from the lowest of movement-based to detailed task-based.
The scenarios were mapped on a “type of scenario versus user” matrix. Finally, the scenarios were categorized based on the spaces they take place in to help prioritize the model content required for development of the Children’s Hospital EVPS.
5.4.1 Scenarios based on End-Users
As a first step of requirements analysis, participants were asked to identify who they envisioned to be the ultimate end-users of the EVPS. End-users identified to use the Children’s Hospital EVPS application can be broadly classified into three categories of patients, families and staff. Table 5-4 shows a list of potential end-users identified for using the EVPS application.
Table 5-4. List of potential healthcare facility end-users who could use the EVPS. Healthcare Facility Users Patients Families.
Within staff of the hospital, various categories were identified that included physicians, residents, surgical technologists and OR aides. Apart from majority of the staff, which is nursing, other staff included transport, anesthesia techs, and respiratory therapists. The nursing category was further divided into different type of nurses based on the specific duties they performed. While patients and their families were considered the most important potential users for the application, it was decided that based on the time requirements and knowing that this would be an internal pilot study, it was considered more appropriate to test the application with nurses. Content analysis using frequency of word count on the end-users of the twenty-three scenarios revealed the highest count for nurses (Figure 5-8). The next highest word frequency is for family followed by all staff. Other frequently occurring end-users are patients, transporters, physicians and pharmacy staff. Figure 5-8. Users identified for scenarios during second focus group meeting.
After word frequency count of end-users, the scenarios were further analyzed to prioritize and organize them based on the context in which the end-users are mentioned.
Here again, it was noted that the maximum number of scenarios had sole or first mention of nurses followed by staff as end-users. Analysis revealed that there are specific detailed scenarios dealing with transport, pharmacy and OR staff along with some that included physicians, respiratory and radiology staff in second or third mention.
Although there was only one solely focused and one first mention scenario on patients and families, analysis revealed that most participants have patients and families as second mention end-users in their scenarios. This indicates that most of the scenarios that are developed for use of nurses and staff could also be tailored to and used by patients and families in the future.
Table 5-5 lists the end-users and indicates whether they were the sole, first, second or third mention as end-users in the twenty-three scenarios collected during the second focus group.
Table 5-5. End-users mentioned in scenarios collected during 2nd focus group meeting.
Patients and families
Next the scenarios were categorized based on themes starting from types of scenarios, scale of scenarios and level of detail required to implement the scenarios.
5.4.2 Scenario Categories
The first theme of identifying and categorizing scenarios was based on the matrix developed in Chapter 4. The scenarios are mapped on the spectrum of varying levels of detail on x-axis against the end-users of scenarios identified on y-axis (Figure 5-9). Scenarios identified are classified based on way finding or movement-based, process-based (combination of way finding and set of less detailed tasks), spatial organization and finally detailed task-based scenarios. Figure 5-9. Mapping scenarios based on category and users.
A lot of examples were categorized under way finding such that people needed to get from one place to the other in the new hospital and want to know the optimum routes to take to get from one place to another.
Some of the examples of getting from one place to another include going from the pharmacy, blood bank and radiology labs in the ground floor to the operating rooms in the second floor. Overall way finding related scenarios were concerned with locations of rooms and getting from rooms to the public services in the building like the cafeteria, courtyard and meditation room. As expected most of the scenarios that fell under the movement-based or way finding scenario category required less detailed models.
An important scenario proposed by participants from hospital safety was regarding “Fire emergency training” that envisions use of EVPS by all staff for location of emergency items fire extinguishers, exit signs and location of fire escape routes and staircases. Other healthcare emergency training related scenarios include location of gas shut off valves; crash carts and nurse alarm locations that are deemed important during patient emergencies.
On the task-based scenario spectrum, some important detailed scenarios identified include the “Code Blue”, an emergency scenario in hospitals. This scenario requires extremely high level of modeling and detail to show if multiple avatars of different specialties can fit in a patient room during heart failures and simulate activities that need to be performed in that situation such as alerting. The researchers identified that the scenario was out of scope for development as it would be very time and labor resource-intensive.
5.4.3 Scenarios based on Spaces
The next analysis of scenarios was done based on word frequency of spaces mentioned by participants in the scenarios (Figure 5-10). As most scenarios are concerned with way finding, pathways, hallways and elevators were in large numbers.
Medication room/ supplies
Cleaned utility/ med pyxis room
Figure 5-10. Spaces identified for EVPS development.
However, as shown in Figure 5-10, the most important and recurring spaces according to the participants were the operating rooms located on the second floor of the hospital. Most routes for way finding identified include going from the existing or main hospital as well as other parts of hospital especially ground floor to the second floor. Other routes of importance identified were within the second floor itself that houses the operating and treatment rooms. Participants were interested in knowing routes of getting from the pre-operating areas (pre-op) to the operating rooms and finally to the post anesthesia care units (PACU).
Another floor recognized for its importance based on discussions and the word frequency count was the ground floor as it houses the blood bank, radiology labs and treatment spaces as well as the main pharmacy of the hospital. Even though all these spaces also had specific scenarios with specialty end-users, all staff especially nursing was required to know their location and the way to get to the ground floor from all patient floors and treatment areas.
Certain scenarios assigned both the third floor and fourth floor that have patient rooms within different departments of hematology, oncology, PICU and PIMCU to be modeled. However, an overwhelmingly large number of scenarios recognize nursing stations, charting areas, medication supplies, utilities, storage and other staff areas as an essential part of the EVPS, thereby including the patient floors themselves to be modeled.
Apart from the spaces listed above, all patient rooms or isolation patient rooms with anterooms along with specialty treatment rooms within the third and fourth patient floors are also mentioned in the scenarios.
Other spaces mentioned in certain scenarios focused on family and staff as end-users included family waiting areas, children’s play rooms, child life areas, staff lounges and break rooms etc. The first floor, which houses the main lobby, some cancer treatment and infusion labs as well as the cafeteria was not specifically mentioned in any scenario. The fifth floor that has mechanical equipment and services was also not mentioned; therefore it was decided not to model the first and fifth floor of the hospital at all.
5.4.4 Validation of Scenarios
arms, booms and operating tables are required and curtains in PACU as they are not in the Revit model. Similarly, computer stations for nurses provided outside the patient rooms to enable nurses to chart and monitor the patients in the room are required. Lastly Pyxis machines in medication and supply rooms were also identified. Figure 5-11. Spaces identified for development in Second Floor and Ground Floor.
5.4 EVPS DEVELOPMENT STRATEGY
Based on the requirements analysis done on the data collected through focus groups and interviews, a list of features was developed and storyboarding was used to develop concepts for the EVPS. Although many more interactivity features could be added the scope was restricted based on the envisioned end goal of the prototype as well as the time and resources available to develop it.
Since the project was in construction phase, the Revit model used for the development of the virtual prototype was highly detailed. Based on the requirements, it was ensured that only the required architectural elements are included in the model. Some furniture and equipment model content not included in the model was added. Missing model content comprised of patient beds in all patient rooms, examination and operating tables in the treatment rooms and ORs. Other model content added included pyxis machines, booms, chairs for nursing and charting stations and other equipment identified during requirements analysis.
5.4.2 Level of realism
Due to the size of the models and the focus on way finding scenarios, the level of realism in textures required was relatively low in the virtual prototypes. However care was taken to incorporate the color schemes of the flooring, which was one of the main design features of the Hershey Children’s Hospital and used as an aid to way finding by the architects. Some of the important equipment identified in requirements analysis were colored red for easy identification in the virtual prototype. These included fire extinguishers, elevators, and pneumatic tube stations for blood or medication transport near the nurse’s station.
5.4.3 User Interface
End-users were provided with options to go to the main menu, select another floor to navigate in, get instructions on how to navigate the model, turn the mini-map on or off, and select a space / department within the floor to navigate in, or quit the application. On quitting the application, the Hershey Children’s Hospital web page opened in the user’s browser.
The storyboards helped design the menu of the Children’s Hospital EVPS. The opening screen of the EVPS was designed to show a rendering of the hospital and give options to the user to select the floor that they wished to navigate. The hospital was broken down into the four floors for EVPS development- Ground Floor, Second Floor, Third Floor and Fourth Floor. On selecting any of the floors, the user was shown another screen with a schematic plan of the floor depicting locations of major areas or departments on that floor. Figure 5-12 shows a snapshot of the menu developed for the Second Floor EVPS. The user could then select any space and start navigating the interactive 3D virtual prototype of that floor.
Figure 5-12. Second Floor schematic plan used in the menu for EVPS.
The mini-map was considered an essential element in the prototypes, as the main goal was to use the model for way finding purposes (Figure 5-13). A red arrow head was added in the controller object hierarchy that was visible in the mini-map indicating and updating in real-time, the location of the user and direction of where they are heading within the facility.
5.4.4 Interactive Objects
The developed EVPS enabled users to retrieve information such as names of different equipment throughout the hospital floors by clicking on the objects. Also similar to hospital hallways with motion sensor activated doors, the prototype simulated doors to swing open using triggers and animated door objects. Figure 5-13 shows the Unity game engine interface during EVPS development. Figure 5-13. Space trigger objects and mini-map camera in the second floor EVPS.
Trigger objects were placed in various departments or areas of interest throughout the hospital floors such that while navigating, when the user entered specific spaces, text was displayed on the screen to indicate the name and other information on the space entered. Another interactive feature included buttons on the user interface that allows the user to click on the names of certain spaces. Once selected the controller object instantiates in that space allowing the user to begin navigation from there.
5.4.5 Challenges in Development
Polytrans was used to further optimize the model content before transferring it to Unity game engine. It was decided to split the different floors and develop them as separate Unity projects to ensure smoother visualization. However, some of the interactive objects such as clicking on6. Type and number of doors in the second floor of the hospital.
DoorDouble Wrap Double Opposing Type G 84″ x 84″
DoorDouble Wrap Double Opposing Type V 84″ x 84″
DoorDouble Wrap Type F
48″ x 84″
56″ x 84″
60″ x 84″
84″ x 84″
DoorDouble Wrap Type G 84″ x 84″
DoorDouble Wrap Type V
72″ x 84″
84″ x 84″
DoorSingleWrap Double Acting Type F 36″ x 84″
DoorSingleWrap Double Acting Type G 36″ x 84″
Door SingleWrap Side Light Type FG 36″ x 84″
DoorSingleWrap Type F
36″ x 84″
42″ x 84″
48″ x 84″
DoorSingleWrap Type FV
36″ x 84″
42″ x 84″
DoorSingleWrap Type G
36″ x 84″
48″ x 84″
DoorSingleWrap Type V
36″ x 84″
42″ x 84″
48″ x 84″
DoorUnevenWrap Rev Type F 48″ (12 x 36) x 84″
DoorUnevenWrap Type S 66″ (18 x 48) x 84″
CasedOpening Wrap 36″ x 84″
Overhead rolling 11′ x 21′
The door object appears as a single object including the frame in the Unity game engine. Using either 3ds max or Revit, each door was split into separate frame and door panel objects; animation was applied to the door panel based on if the swing was clockwise or anticlockwise and a door trigger object was applied. Finally the door was taken to the desired location. There were many approaches to do this and prefabs in Unity enabled efficient and repeatable use of multiple doors once they were animated. Other interactive objects that were not implemented included arrows depicting the route to get from point A to B within a hospital floor. The draft virtual prototype fourth floor showed a scenario where the user could click on a specific space they would like to go to and the user interface displayed arrows depicting the route to take. However, in the full hospital floor virtual prototype implementation, there were far too many route options that could not be covered using this approach. An alternate method of clicking the name of the space and instantiating the controller object in that location was adopted instead.
5.5 PHARMACY DESIGN REVIEW
As per the plans of the Children’s Hospital, the main pharmacy serving the entire Hershey Medical Center was being relocated in the ground floor where all the pharmacy staff would be consolidated. The footprint of the pharmacy would increase substantially to 7200 square feet area, which was almost double the size of present pharmacy. With the increase in size, offices of the pharmacy staff would be in closer proximity as well. For transition planning, it was important for the staff to understand how they would adapt to a newer and larger space by configuring their workspaces and developing their work processes to be in alignment with the new facility design. Figure 5-14 shows images of the existing and new pharmacy. Figure 5-15 shows the location of the new pharmacy. Figure 5-14. Existing pharmacy (left) moving into the new pharmacy (right).
Compared to the entire staff of the Children’s Hospital, the pharmacy had a relatively small leadership team and staff comprising of up to 130 members.
After the first focus group meeting, the participants distributed the interactive virtual prototypes of the pharmacy for other staff members to view (Figure 5-16).
The pharmacy staff was able to familiarize themselves with the new layout using the EVPS pharmacy model for transition planning. Figure 5-15. Pharmacy floor plan and snapshot of pharmacy EVPS.
The new pharmacy, located in the ground floor level of the Children’s Hospital wing, is accessible from the cancer institute and the main hospital building through interconnected pathways.
On entering the pharmacy, the main door and dispensing window open into the central pharmacy area with a compounding station tucked in the right. The narcotics and secure storage room is located across the compounding area and has a door with restricted access. The central pharmacy has the major equipment and computers on workstations for staff (Figure 5-16).
On the far left of the pharmacy, there is space for break room that leads to three rooms – the inventory personnel room with work stations against the walls, a billing room and a room for trash. Both the inventory personnel and trash room can also be accessed from outside corridors.
On the opposite end of the central pharmacy area is the entrance to the intravenous (IV) prep room that is used for storing intravenous medicine. The IV room leads to an anteroom, which is connected to two highly sensitive medicine positive pressure rooms – the chemo/ hazard prep area and the clean room. There are two additional rooms that are only accessed from the outside corridors – the first is an investigational drug service (IDS) room that has adjoining refrigeration room along with file storage room and the second is a Pyxis office/ workroom.
Figure 5-16. Snapshot of pharmacy EVPS.
5.5.1 Design Review Meetings
Two separate meetings were held with the pharmacy leadership team to discuss the scope of using the pharmacy EVPS for their transitional planning efforts. The researcher also attended and observed a design review meeting where 10 pharmacy leadership team members explored the EVPS model of the pharmacy (figure 5-17). The model was used to design the inner layout focusing on configuration and orientation of working spaces as well as detailed design decisions on storage shelves to plan and decide on future storage organization of the pharmacy inventory.
Figure 5-17. Design Review meeting using the Pharmacy model.
During the meeting, the IV room was discussed in detail and one of the pharmacy staff members who had attended the focus group meeting led the discussions and also navigated the model.
The discussion in the IV room began with accessing the number of refrigerators and freezers that would be required in the room. The team decided to have a total of 5 refrigerators and 4 freezers making it a total of 9 pieces of equipment. It was noted that the plan did not clearly show the doors of the refrigerators.
The team also discussed having double doors on certain refrigerators. In conjunction with the using pharmacy’s EVPS, the team numbered each section of shelving or workspace on the plan. Navigating through the IV prep room, the team had a general discussion on the type of shelving- open, closed or with slanted shelves that will be required in each area. After numbering the sections, each area was discussed in detail (Figure 5-18).
The team discussed the intended purpose of each workstation and which technician would be allotted a particular space to work in. The team also discussed addition of cabinets where they thought they needed printers.
Figure 5-18. Transition Planning and design review meeting using EVPS and floor plans.
On entering the clean room, the team identified different equipment in the room and clarified issues if it was hard to identify what equipment was as in the case of a laundry basket. With so much equipment in the room, some team members raised concerns on the size of both the anteroom and clean room.
However some team members who had visited the actual pharmacy that was then under construction and going through fit-outs reassured that the anteroom was sufficiently sized– measuring the distance between tables and hoods to ensure that there was adequate carts depicted in the prototype were also taken into consideration for storage planning of syringes and needles.
Another concern raised in the clean room was a row of tall shelves for storage. Several team members expressed concern on accessibility of the upper shelves and requirement of step stools that could be a potential safety hazard (Figure 5-19).
Figure 5-19. Snapshot of IV Preparation and Clean Room with high shelves.
In conclusion, the staff was really relieved to be able to use an interactive virtual prototype of the pharmacy to identify workspaces and begin developing new work procedures. They felt that the EVPS was easy to navigate and had been using the prototype in internal meetings regularly. Although they had access to the actual pharmacy space under construction and staff was shown plenty of photographs and videos of the space, they still preferred the pharmacy prototype.
“It is easier to control where you are going and stop when you have to lookat something. You cannot even do that in a video where you just follow along where the camera goes” In previous staff meetings, it was found that the pharmacy virtual prototype actually helped the staff identify that they would require a mini refrigerator in the compounding area.
This requirement was overlooked in plans and previous design review meetings and had not come to light till the staff had started using the EVPS for reviewing the design. Some of the drawbacks of the pharmacy prototype were inaccuracies in the modeling of shelves and other storage cabinets. It was found that some cabinets were missing entirely or had the wrong type of shelving depicted; e.g., closed shelving instead of open or slanted shelves instead of straight. The reason for this was that the changes had been made after the update of the model that was used to develop the prototype.
As the next step for using the EVPS for transition planning, the pharmacy staff wanted to have labels on different workspaces and shelves to depict what they were going to be used for. Another thing that would have been nice to see was whether drawers and storage was open-able or closed to be able to better plan for the move.
As a future consideration, the staff expressed that it would be nice to be able to simulate certain processes that take place in the pharmacy as that could be used to train new personnel on work procedures as well as help the leadership team design more efficient processes that would work in a new facility design.
5.6 LESSONS LEARNED
scale healthcare facilities within limited resources.
Dealing with Large-scale Models: Some of the challenges that arose with the use of large-scale models in the Unity game engine (ranging from 814 MB to 1.55 GB) for real- time visualization was to maintain minimal lag time and smooth performance during visualization. It is important to ascertain the level of detail of the model content available for developing the interactive virtual prototypes and determine if more detail and content is required or if unnecessary detail and model content needs to be eliminated to make the geometric content lighter and leaner. Finally it is of utmost importance to align the resources available to develop the EVPS with the proposed virtual prototyping scope. –
Defining Scope: Focus groups proved to be an effective means to elicit requirements for the development of EVPS. Brainstorming during the focus groups helped in generating innovative ideas on the future use of the EVPS. However, it is very important to define the scope for development and continuously review this scope throughout the design and development process while identifying the resources that can be invested. Feedback from the end-users during development ensures that the process is on track and that the EVPS will meet the ultimate goals of their design review. –
Identifying Stakeholders: It is also essential to ensure that the participants for the focus group represent a mix of department so that they can represent their unique needs. It was observed that the scenarios generated during focus groups strongly reflected the departments, roles and responsibilities of the participants involved. –
EVPS Application in Training: Although this research envisioned use of EVPS for design review with the end-users of facilities during the design development phase prior to construction, this case study demonstrates that real-time visualization using interactive virtual prototypes of healthcare facilities can be used at any stage of the facility lifecycle for design review.
Moreover, this case study also shows that apart from design review, EVPS can be very effectively used as an education tool for training, way finding and reducing the anxiety of end-users before moving into a new facility. Additionally, the EVPS can be used to design activities and working procedure around the new facility design as in the case of the pharmacy where the staff used the EVPS to determine their future workflows.
In conclusion, this case study demonstrates that the EVPS can be used effectively for collaborative design reviews and decision-making as exhibited during the pharmacy transition and move planning design review meetings. Interactive virtual prototypes of the pharmacy became an instrumental tool for pharmacy staff to seek clarifications in design and led to a better understanding of the new space.
Moreover, the pharmacy leadership team was able to leverage the EVPS as a tool to develop new work procedures that would be more befitting in the new facility environment. This unique application of the EVPS revealed added potential benefits of developing interactive virtual prototypes for healthcare facilities.
This chapter begins with the description of the case of the Hershey Children’s Hospital and discusses the approach for research, data collection, analysis and development procedure for EVPS application. The pharmacy transition-planning meeting is discussed as part of the evaluation of using the interactive virtual prototypes for design review. Findings of this chapter suggest that even with large-scale healthcare facility models, EVPS can be developed and applied effectively. The next chapter discusses the evaluation of embedding scenarios in interactive virtual prototypes in more detail. ++++ Copyright 2013 by Sonali Kumar. All rights reserved. Thesis published on this site by the express permission of Sonali Kumar.Note: Under construction link to Chapter 6. ++++ Copyright 2014 by Sonali Kumar. All rights reserved. Thesis published on this site by the express permission of Sonali Kumar.
The dissertation of Sonali Kumar was reviewed and approved* by the following:
John I. Messner
Professor of Architectural Engineering Dissertation Advisor and Co-Chair of Committee
Chimay J. Anumba
Professor and Department Head of Architectural Engineering Co-Chair of Committee
Madhu C. Reddy
Associate Professor of Information Sciences and Technology
S. Shyam Sundar
Distinguished Professor of Communications
Richard A. Behr
Charles and Elinor Matts Professor Emeritus of Architectural Engineering
*Signatures are on file in the Graduate School
With rapid technological advances taking place in the architectural, engineering and construction fields, virtual prototyping is increasingly being used during the design review process of specialized building types such as healthcare facilities. Current research in healthcare facility design strongly indicates that the physical environment greatly impacts end-users in issues of safety and overall health quality. This has led to emerging trends and design approaches such as experience-based design and evidence-based design that encourage participation and collaboration with the end-users of healthcare facilities. Interactive virtual prototyping provides opportunities for embedding experience-based design concepts that enable end-users to truly experience design alternatives and concepts during design reviews. However, studies have also highlighted that developing interactive virtual prototypes is a time-consuming and labor intensive process.
This study proposes an experience-based virtual prototyping system (EVPS) that was developed, implemented and evaluated at the Hershey Children’s Hospital. The goal of the study was to simulate experience-based design concepts in virtual prototypes within the context of healthcare facilities. This goal was achieved through four objectives. First, requirements for experience-based design review were analyzed by documenting end-user activities in healthcare facilities. Second, a framework was developed to categorize end-user tasks into scenarios that could be simulated in interactive virtual prototypes of a healthcare facility. The third objective focused on developing a computer application called the Experience-Based Virtual Prototyping System (EVPS) to simulate scenarios that take place in healthcare facilities. Lastly, the developed EVPS application was implemented at the Hershey Children’s Hospital to evaluate the effectiveness of task-based scenarios for extracting end user feedback during design reviews.
A virtual prototyping procedure was developed to rapidly convert digital model content into interactive experience-based virtual prototypes for design review. Strategies for development included creation of a system architecture to identify interaction media, modeling content as well as features and functionality requirements. Design information workflows were investigated to efficiently transfer model content from building information modeling tools to an interactive real- time rendering platform. Procedures to incorporate interactivity were explored to enable simulation of task-based scenarios in virtual prototypes. Finally, a database of reusable interactive model content was developed and utilized for rapid production of experience-based virtual prototypes.
The experience-based virtual prototyping system was implemented and tested with nurse participants at the Hershey Children’s Hospital. Focus groups enabled the identification of end- user needs and functionality requirements for developing the EVPS. The EVPS application was developed and tailored to the needs of the end-users at the Children’s Hospital – these included transition planning, way finding and staff training before they moved into the new facility. End- users preferred the EVPS to traditional methods of design review, as they were better able to visualize the design and understand the layout of spaces. A user study was designed to compare the design feedback obtained from participants in two conditions comprising a simple walk through and a task-based scenario within the virtual prototype stimulus. The study revealed that adding task-based scenarios in interactive virtual prototypes increases the level of engagement in end users and enables them to provide detailed design feedback related to their daily healthcare activities.
TABLE OF CONTENTS
LIST OF FIGURES…….………………………………………………………………..…viii LIST OF TABLES…….…………………………………………….…………………..……xi ACKNOWLEDGEMENTS…….………………………………………………………..….xii
My journey thus far could not have been possible without the help of countless people who inspired and supported me. First, my deepest and most heartfelt thanks to my advisor and mentor, Dr. John Messner, for instilling in me a passion for innovation and the desire to always strive for the best through the utmost discipline and work ethic. I could never imagine that the quest we embarked on together would be as exciting, fun and rewarding as the virtual prototypes and gaming engines that were part of this research. I’m extremely grateful to have had such an understanding, compassionate and driven advisor.
I would like to thank Dr. Chimay Anumba, who always believed in me and supported me even when I was unsure of where the path would lead. More importantly, I learned from him the importance of always being humble yet confident in life. I thank Prof. Richard Behr for paying attention to the details and always encouraging me to do the best I could. I feel fortunate that he chose to support this research endeavor through the Smart Spaces Center.
I am grateful to Dr. Madhu Reddy, who enabled me to see my research through a healthcare perspective and helped me ask the right questions about my research. He taught me to take my work less seriously and yet be able to challenge the ideas and beliefs I held so close.
Lastly, I cannot thank Dr. Shyam Sundar enough for teaching me about the rigor of research methodology and inspiring me to pursue my goals through dedication and a sense of joy. I feel truly privileged to have professors who are highly esteemed in their respective fields on my committee.
I am very thankful to all my friends at Penn State who have been a constant support to me at all times– Dragana, Tabitha, Rob, Craig, Steve, Ralph, Bimal, Bryan, Atefeh, Andrea, Yifan and Ying. I feel blessed to have such wonderful friends and would have been completely lost without you. Thanks to all the students of the Virtual Prototyping class who helped with my research, especially Chris Wiacek and Matt Hedrick for coming up with the idea of using interactive virtual prototypes in healthcare. I also extend my thanks to Michele Smith, the Nurse Manager at the Hershey Children’s Hospital for her enthusiasm towards this project and being a great help in recruiting nurse participants for the user studies.
Through the course of my research, I made an invaluable and lifelong friend in Joel Solkoff, who helped me in more ways than he will ever know. I have thoroughly enjoyed our deep and wholehearted conversations about the future of healthcare, potential of virtual prototypes and life in general. [Bold face supplied by the publisher.]
Lastly, I would like to thank my parents and family – without their support, encouragement, prayers and all the positive thoughts they sent my way, I could not have accomplished any of my goals. Thanks a lot for always understanding me, believing in me and assuring me that there is light at the end of the tunnel. No words can express my gratitude to Vijay for constantly motivating me and enabling me to be persistent through the best and worst times. I’m glad you made all those trips to visit me during the first two years of our marriage and offered your support, insight and advice whenever I sought it. Thanks for always being there for me, I could not have done this without you.
I dedicate this dissertation to my grandparents whose presence I will always miss. Thanks for giving me the most precious memories – I will cherish them all my life!
Chapter 1 INTRODUCTION
The Architectural, Engineering, and Construction (AEC) Industry is currently undergoing a rapid transformation from a primarily 2D design and review process to the implementation of more robust 3D Building Information Modeling (BIM) applications. One element of this transformation which is critical to delivering high quality, innovative design solutions is the ability for designers and other project stakeholders to truly experience design alternatives and concepts throughout the design process. Virtual facility prototyping is one of the approaches that provide opportunities for teams to develop innovative solution concepts throughout the design review process as well as propose changes relatively early in the building delivery process. This ability to design creatively in interdisciplinary teams and visualize the complex and specific tasks performed in increasingly specialized facilities such as healthcare can prove to be critical skills required for future design professionals.
Healthcare facilities are some of the most difficult building types to design due to the increasing complexity of their building systems as well as the need to address requirements of the many stakeholders. A seminal report on healthcare environments (Ulrich et al. 2004) suggests strong links between the physical environment to the patients and staff in areas of reducing staff stress and fatigue as well as increasing effectiveness in delivering care, improving patient safety, reducing stress, improving health outcomes, and finally improving overall healthcare quality.
This has led to the emerging phenomenon of including the end-users, such as patients and staff, in the design process to deliver better healthcare facilities. Therefore, this thesis explores experience-based design; a term used in the healthcare facility design context to involve end- users and examines the benefit of using virtual facility prototyping by the healthcare industry for interactive experience-based design review.
1.1.1 Experience-based Design
Experience-based design is a user-focused design process with the goal of making user experience accessible to the designers, to allow them to conceive of designing experiences rather than designing services (Bate and Robert 2007). There is widely published research that addresses the subject of end-user influence upon design from different perspectives. Some refer to that perspective as experience-based design (Bate and Robert 2006), evidence-based design (Hamilton and Watkins 2009, Stankos 2007), participatory design (Nutter 1995, Luck 2003), user-centered design (Norman 1988) and other frequently appearing terms with similar intent. Since users evaluate the built environment differently from designers (Zimmerman and Martin 2001), participatory design approaches attempt to bridge a gap in understanding between users and designers.
The Institute for Innovation and Improvement at UK’s National Health Services (NHS) is leveraging Experience-based design to focus on re-designing and improving healthcare services and facilities, based on patient and staff feedback (NHS Institute for Innovation and Improvement 2010). Similarly, the Center for Health Design is using the Evidence-based Design (EBD) approach to help healthcare and design professionals improve the quality of healthcare through the built environment (Center for Health Design 2010). Although there is a substantial amount of literature that cites “evidence-based design in healthcare facilities”, there is a lack of guidance for designers on quality criteria to improve the design of healthcare facilities (Dunston et al. 2007).
1.1.2 Virtual Prototypes for Healthcare Facilities
A virtual prototype is defined as a digital model (mock-up) of a structure or product used for testing and evaluating form, design fit, performance and manufacturability as well as for study and training (Wang 2002). Virtual prototypes can be extremely useful in understanding the tasks performed by healthcare practitioners by incorporating their knowledge of how things work in their settings into the virtual environment. For large complex projects such as hospitals and healthcare facilities, virtual prototypes can be used to tailor environments to user needs (J. Whyte 2002). In the AEC context, digitally rendered three-dimensional models have been used to review design aspects of physical spaces such as courtrooms (Maldovan et al. 2006), mechanical rooms, patient rooms (Dunston et al. 2007), nuclear power plants, industrial plants and stadiums. Virtual prototypes can provide a degree of functionality as they can allow further degrees of interactivity including multiple viewpoints, the ability to zoom in and out, and the ability to selectively view components. It has also been noted that virtual prototyping and 3D modeling is a means of rapidly developing designs (Gopinath 2004, Schaaf and Thompson 1997). There is immense opportunity in developing tools that not only create virtual prototypes of healthcare facilities but also allow interaction with the end-users. Healthcare facilities can benefit significantly through the application of virtual prototyping in the design process as it enables evaluation of a range of essential criteria.
1.1.3 Interaction with Virtual Prototypes
Virtual prototypes are distinguished by their “capacity to portray 3-D spatial information in a variety of modalities, and their potential to immerse the user in the virtual world” (Nelson and Bolia 2002). Previous research has shown that immersive virtual environments are increasingly being used to review virtual mock-ups, which are a cost effective alternative to physical mock-ups (Leicht and Messner 2009). Markham (1998) identified three factors contributing to visualization in a virtual environment as immersion, interaction, and engagement. Interactive virtual prototypes facilitate an immersive understanding of a virtual model, especially for ergonomic and aesthetic design, as well as customer participation in design and evaluation (Wang 2002). Virtual prototypes also enable participants to navigate through the model space and evaluate the design based on various criteria through numerous vantage points within the model. User involvement can take a variety of forms, from appraisal of an expert modeled and animated 3-D virtual model with ensuing discussion to active design using a virtual prototyping design tool. Moreover, designs can be worked on over a long period of time and discussed among a larger group than is possible in traditional design situations (Davies 2004).
1.2 RESEARCH GAP
Communication of design information is of vital importance in the facility design process as each building project involves the collaboration of several disciplines and project stakeholders. Traditionally, communication of design information took the form of 2D drawings. According to Anumba et al. (1997), this often led to inadequate capture, analysis and prioritization of client requirements, lack of communication of design intent and rationale as well as poor integration, co-ordination and collaboration between the functional disciplines involved in the project.
Virtual prototypes are being increasingly used during design review since they can be especially useful for communicating design intent of specialized building types such as healthcare facilities. Virtual prototyping provides opportunities for a team of project stakeholders to truly experience design alternatives and concepts in the early stages of the design process. While helping in design review, virtual prototyping also allows multiple participants to navigate through the model space and evaluate the design based on various criteria through numerous vantage points within the model. Virtual prototypes offer an opportunity for various stakeholders representing the client healthcare organization to have an interactive experience with hospital units ranging from a patient’s room to an operating room to an entire hospital at a fraction of the cost of physical mock-ups (Dunston et al. 2007). Prior studies that used virtual prototypes in design reviews of courtrooms (Majumdar et al. 2006, Maldovan and Messner 2006), operating rooms, and patient rooms (Dunston et al. 2007), indicated the benefits of using them over physical mock-ups. Virtual prototypes supported exploration and decision-making in the design process and offered an effective means of communication between diverse stakeholders of the project (Leicht and Messner 2009). Moreover, these studies also highlighted the opportunity to enhance end-user engagement in instances where team members leverage and communicate their tacit knowledge, enabling collaborative interdisciplinary participation over the early stages of the design development process.
While virtual prototypes are useful for design visualization, allowing the review participants to walk through the design of a facility to examine the space, textures and lighting, they are typically implemented in a static manner. Most virtual prototypes do not allow the user to interact directly with the elements and objects within the virtual model. Moreover, visualization in virtual prototypes is a challenge due to the lack of human characters (or avatars) and animations that depict how the facility is used or the tasks performed within the facility. At present, the prototyping process typically lacks a systematic structure or method to allow for task- based scenarios to take place for the review participant. Although a Building Information Model (BIM) of the facility contains geometric and attribute data that is transferred in the virtual prototype, there is no information on the behavior of the components within the facility. For instance, doors modeled in a facility do not swing open in a virtual prototype, despite containing intelligent attribute information such as location of its hinges. As a result, while reviewing, participants either walk through doors or they are simply not displayed in the prototype. This is because animation is still cumbersome to incorporate while developing the prototypes, which can lead to an unrealistic representation of the facilities. Due to these challenges, most current virtual prototypes do not enable people to truly experience the design.
The gaps in the current research on virtual prototyping for design review indicate a need to make the virtual prototyping process more efficient for developers, while also engaging healthcare end users in the design review process. Therefore, an opportunity exists to conceptualize and develop interactive virtual prototypes for the design review process that can enable participants to interactively perform certain task-based scenarios within the virtual prototype. Figure 1-1 shows a concept proposed in this study that combines theories of experience-based design with interactive virtual prototyping to form the Experience-based Virtual Prototyping System (EVPS).
Figure 1-1. Concept of the Experience-based Virtual Prototyping System (EVPS).
1.3 RESEARCH GOALS
In previous studies that were performed with static virtual 3D stereoscopic virtual prototypes in an immersive display (Maldovan et al. 2006, Leicht et al. 2010), it was observed that the reviewers, and in particular the end-user reviewers, of the models would frequently be found discussing the tasks that they would perform in a space. Yet, they were only able to navigate around the model and envision the task performance in their mind. Through their own visualization of the task, they could provide valuable feedback to the design team. Moreover, according to Dunston et al. (2010), owners, architects and construction managers generally have a need for rapid resolution of design alternatives, which places a significant time pressure in producing virtual mockups. Therefore, the aim of this research is to investigate methods to rapidly develop interactive virtual prototyping systems for design review, which allows the user to explicitly perform typical daily tasks just as they would in a physical setting. This would allow the user to improve their design review feedback and expose ineffective architectural layouts as well as allow the design professionals to review design through the role of end-users by engaging in scenarios of tasks performed in healthcare facilities.
1.3.1 Research Questions
How can virtual prototypes which are used for design review of healthcare facilities incorporate end-user experience?
What procedures can enable rapid development of experience-based virtual prototypes of healthcare facilities for design review?
How can the use of experience-based virtual prototypes impact the design review process of healthcare facilities?
1.3.2 Goals and Objectives
The primary goal of this research is to define, develop and assess the impact of a virtual prototyping framework for the rapid creation of scenario-based design reviews of healthcare facilities. The main purpose of the framework is to develop an efficient approach to creating virtual prototypes that allows interactive design review within the healthcare facility design context for end-users. The following objectives are being pursued to achieve the primary goal:
Develop a virtual prototyping procedure to represent end-user experience of healthcare activities in interactive virtual prototypes;
Design a framework for structuring end-user activities into scenarios that can be simulated in an interactive virtual prototyping system;
Develop an interactive computing platform entitled the Experience-based Virtual Prototyping System (EVPS) for implementation in healthcare facility design reviews; and
Assess the developed EVPS to evaluate the effectiveness of interactive virtual prototyping for enhancing the experience-based design review process of healthcare facilities.
1.4 RESEARCH SCOPE
The research focuses on the design, development and implementation of the experience- based virtual prototyping system concept in a healthcare setting to study its impact on extracting design feedback from end-users. The design and development of the EVPS concept employed in this study was guided by literature review of prior studies, theories of virtual prototyping, real- time rendering and game engine development. The developed prototyping process was tested using various healthcare related projects that are outside the scope of this dissertation. However, implementation of the finalized experience-based virtual prototyping procedure was carried out through a case study in the healthcare facility setting- “Hershey Children’s Hospital”, which is discussed in more detail in Chapter 5.
To evaluate the developed virtual prototyping system, both qualitative and quantitative approaches were adopted to assess the impact of the EVPS on the design review process.
Although, the design review process involves many stakeholders including the project team and clients, the assessment of EVPS was geared towards end-users of healthcare facilities, specifically providers of healthcare such as nurses.
1.5 RESEARCH METHODOLOGY
The research methodology adopted for this study is discussed in detail in Chapter 3.
Briefly, the following steps were undertaken to meet the objectives of this research:
1.5.1 Experience-based Virtual Prototyping System Concept
The first step was to review literature on virtual prototyping, design review and theories related to experience-based design in the healthcare context to conceptualize the EVPS concept. A pilot study was conducted to illustrate the potential of applying the EVPS concept during design review of healthcare facilities.
1.5.2 System Design
This phase began with the design and development of a framework for structuring healthcare activities into scenarios that can be effectively simulated in interactive virtual prototypes. A data structure of task-based scenarios was developed to characterize the attributes and behaviors of elements required for simulation of scenarios. Next, an overall system architecture was created to define the components, databases and libraries required for developing the EVPS. Finally, interactive interface were designed to integrate features and functionality requirements that allow end-users to interact with the EVPS.
1.5.3 System Development
System development started with identification of an appropriate real-time rendering engine for EVPS development and investigating various design information workflows to transfer facility model content from BIM authoring tools to the EVPS. Next, strategies and methods to incorporate interactivity were investigated so that the EVPS would enable the end-users to perform specific task-based scenarios through use of interactive objects and scenario scripting. Consequently, a database of reusable interactive model content was generated to enable rapid development of the EVPS. The proposed virtual prototyping procedure was continuously reviewed by assessing capabilities and limitations of the developed EVPS through healthcare related projects and case studies.
1.5.4 System Implementation
This phase included identification of suitable facility within the healthcare context that would benefit from employing the EVPS during design reviews. Next purpose of using the EVPS in design reviews was determined and several specific scenarios of activities to ascertain features and functionality requirements for inclusion in the EVPS were documented. Finally the EVPS was developed for end-users to review the facility design interactively while engaging in task- based scenarios within the virtual facility prototype.
1.5.5 System Assessment
The final phase of system assessment was carried out through an observational study to assess the EVPS implementation during design review sessions with end-users of the healthcare facility. A user study was conducted using the EVPS with healthcare end-users, to evaluate the effect of task-based scenarios in obtaining design feedback.
1.6 THESIS STRUCTURE
The current chapter introduced the research gap, research questions and objectives as well as the scope of research and methodology. Chapter 2 reviews literature to determine the role of virtual prototyping in the design review process and explores possibilities of combining experience-based theories in interactive virtual prototyping to develop more effective design review tool for end-users. Chapter 3 introduces the systems development methodology used for conducting this research and gives an overview of research steps and methods employed. Chapter 4 describes the framework for experience-based virtual prototyping. Chapter 4 explains in detail the EVPS system design process, strategies for rapid development and incorporation of interactivity in virtual prototypes. Chapter 5 introduces the Hershey Children’s Hospital case study that is used for implementation of the EVPS. This chapter describes focus group discussions used for requirements analysis and an observational field study with the pharmacy staff that uses the EVPS during design review. Chapter 6 describes a user study to evaluate the effect of task-based scenarios embedded in the EVPS on end-user feedback during design reviews. The study protocol, analysis and findings are discussed. Finally, Chapter 7 presents the conclusions, contributions of the study, as well as limitations and directions for future research.