Modelling Facility and Operations in Design of and Transition to a New Healthcare Space

Marvina Williams,  Senior Healthcare Operations Planner, Perkins+Will, US

Amanda Hobbs,  Healthcare Operations Planner, Perkins+Will, US

Physical design and process design are inseparably connected in healthcare facilities. Modelling facility and operations aids in evaluating design alternatives and in familiarising an organisation and its staff to a new space during transition. This article explores simulations of various fidelity, their characteristics, and their uses in healthcare management.

All across the world, healthcare organisations face changes from their payers. Insurers and governments are changing reimbursement models while the healthcare consumer, the patient and their family, is increasingly informed and discerning. This pace of change is driving the need for improvement in healthcare management. While operational improvement projects can be nearly continuous, facility projects occur more intermittently.

Facilities projects represent an opportunity for great transformation in the management of a hospital or other healthcare organisation. The permanence of a built facility and the large investment required mean that incremental testing of various design options is both more important and more difficult. A full build of multiple facilities to “test” which results in the outcomes important in healthcare–improved health for the population, improved experience of care, and reduced costs–-is not reasonable financially. Instead, various models of facility and operations can allow for testing alternatives through other mediums.

What is Modelling and Simulation?

Modelling and simulation allow for building and testing operations and facilities in a different medium than the medium of the finished project. Merriam-Webster defines the verb model as “to produce a representation or simulation of” and the noun simulation as “the imitative representation of the functioning of one system or process by means of the functioning of another.” Thus, the terms modelling and simulation can, and will within this article, be used interchangeably.

However, there are many different types of models. This article discusses various simulations popular in operational and facility improvement projects along their focus and their fidelity. Simulations can focus on operations or facility or integrate both operations and facility process and constraints.

Simulations can be of various degrees of accuracy and exactness in terms of how well they represent the final product. In modelling, this degree is usually referred to as fidelity; a low-fidelity model is designed in a system less representative of the final product, while a high-fidelity model more closely represents the final product. Models that take a more integrated systems approach and focus on both operations and facility tend to be of a higher fidelity than more-singularly-focused models.

There is no single best way to model or sequence of models that works for every project. While high-fidelity models more closely represent the final product, they tend to require a greater investment of resources: more time and more money. The progression of simulation is iterative and at times disordered throughout the lifetime of a project, but the fidelity of simulations generally increases as time passes. Overall, it is best to match your method of modelling to the phase of the project and the resources and goals of your organisation. It is also important to understand your stakeholders and what simulations will best communicate new operations designs and/or facility designs so that the users themselves can evaluate and learn the new healthcare space. Engaging the right simulations of your operation and your facility at the right times can lead to many improved outcomes.

A Sample of Simulations

Listed below are some simulations that range from those most established and common to those on the cutting edge of the industry. However, there are limitations. Different people and/or different organisations may call the same model by different names. Often, the distinguishing characteristics that categorise or name simulations are not black-or-white, making their naming tricky. Additionally, this is by no means an exhaustive list.

Floor Plans

In the world of healthcare architecture, a floor plan is the most utilised and recognisable facility simulation.  A floor plan is a scale diagram of the arrangement of rooms in a story of a building. The fidelity of a floor plan can range from an initial hand-drawn sketch to fully detailed computer drawings that act as construction documents.

Process Flow Mapping

Process mapping is a very common simulation that focuses on operations. The fidelity of process flow mapping can range from rudimentary to quite complex, while being constrained to a 2D representation. At its bare minimum, mapping generally involves rectangles representing processes and arrows representing direction and order of processes; often, diamonds serve to represent decision points.

Lean, a quality management methodology that views value from the customer’s perspective, tracks the processes a patient experiences in a “value stream map.” Further developments of this methodology have suggested mapping processes for patients and families, staff, medications, supplies, equipment, information, and process engineering. There are many different ways that process flow mapping can simulate the operations for a healthcare organisation. Visio is a common tool for process flow mapping.

Spaghetti Diagraming

A spaghetti diagram is a beneficial simulation that incorporates the facility modelling of floor plans and the operational modelling of flow mapping into one 2D simulation. Often, multiple flows are diagrammed on top of a floor plan in a hybrid simulation that address both facility and operations.


Mock-ups refer to full-scale representation of a facility ranging from a mocked floor plan to an entire room fitted with the materials determined for use in the actual healthcare building. Mock-ups are facility-focused, but their life-size scale empowers more operational testing and understanding than a floor plan. Tape or paint representing boundaries and fixtures create a mock-up floor plan. At the highest end of fidelity, a 3D mock-up room outfitted as the designed room fully represents the final product. While this is costly, healthcare organisations find this useful to make final decisions before building when the facility may contain hundreds of these standardised rooms. Other materials can be used to move into 3D while containing modelling cost; for example, cardboard mock-ups have represented entire floor layouts.

Discrete Event Simulation

While process flow mapping represents a relatively basic form of event simulation, computerised models built with complex software packages provide even greater fidelity. Modelling software, such as SIMIO, is grounded with an operational focus, but can also incorporate facility models to constrain the operations. It is high-fidelity–taking healthcare process mapping to a new level by incorporating mathematical variation. Today’s software can visually represent stakeholders and resources as they move throughout the system, which communicates well to the

Virtual Reality

Virtual Reality (VR) is on the cutting edge of simulation. Traditional facility modelling software files, such as Revit and BIM files, transform into a Virtual Reality (VR) experience. While it is possible that a user could try to simulate certain operations while “inside” a VR of a healthcare facility, this model remains a high-fidelity and facility-focused simulation. VR is already giving stakeholders at healthcare organisations a look into the future of their facilities, and VR will be used more and more frequently in the coming years.

Case Studies

Perkins+Will engages in various facility and operational modelling depending on what is mostly suitable to the needs of the stakeholders and the project’s scope, cost, and schedule. During the course of a project, Perkins+Will will employ many different types of modelling.  The following case studies describe four simulations that the design-and-client teamemployed at a certain time for a specific client and project. These case studies serve to demonstrate how modelling aids in evaluating design alternatives and familiarising stakeholders to a new space in the healthcare sector.

Intermountain Healthcare Alta View Hospital: 3D Full-Scale Cardboard Room and Module Mock-up

Alta View Hospital located in Sandy View, Utah, USA engaged Perkins+Will in the strategic re-imagination and structural reconfiguration of their campus after its integration into the Intermountain Healthcare System. This was a highly interactive process guided by Lean methodologies. Through user-centred design events, the schematic design that emerged was representative of integrated operational and facility goals.

For this project, cardboard 3D full-scale mock-upswere used to demonstrate important rooms and spaces. The modelled spaces included a standard inpatient room, operating room, emergency department exam room, prep/post-surgery room, and a clinic module (which included patient rooms and staff space in the core). The integrated design-and-client team called this model a “cardboard city.” Cardboard was the chosen material  because of its cost and flexibility; as alternative ideas were developed, the cardboard walls were quickly dismantled or revised into a new model. A two-fold perspective is gained through the model: 1) the design team better understands the users’ needs, and 2) the users better understand their future space. Ultimately, this results in better health outcomes, increased time and cost efficiency, and better experience of care for users.

Intermountain Alta View’s users, clinical and staff stakeholders as well as patient focus groups, visited the cardboard city during “open houses” to explore and provide feedback. With a facility-focus, users visualised their rooms exploring alternatives like standardised rooms. Operationally, users could explore the Lean flows of healthcare (the movement of key resources such as patients, staff, medications, and supplies) in a full-scale model. The cardboard city successfully facilitated a feedback loop that led to improved design interventions including:

• Placing telehealth in all emergency department and critical care rooms as well as some acute care rooms
• Relocation of provider documentation areas to increase clinical team teamwork and patient and family interaction
• Standardisationof clinic module for the ambulatory clinic building
• Placing smart board technology in inpatient rooms to provide integrated, timely information

Rush University Medical Center: Full-Scale Floor Plan Mock-Up

Rush University Medical Center located in Chicago, Illinois, USA engaged Perkins+Will in an expansion project that resulted in a new bed tower. The site for the new tower that the system had acquired consisted of fenced-off tennis courts - a site ideal for a full-scale floor plan mock-up. With white tape on the court, entire floors with rooms and corridors were modelled to scale with Rush doctors, nurses, and administrators directly participating in the design process.

Modelling the inpatient unit layout allowed for users to explore efficiency and flexibility by understanding the size and adjacencies of different spaces. The modelling aided in finalising the decision to have all patient rooms same-handed, as opposed to mirrored, to provide Rush opportunities to engage in research on evidence-based design for safety. Developing the hospital design from the inside out was key to increasing value and decreasing waste in the new expansion for the healthcare system. Walking through the model with an eye for minimising the travel distances for patients and nurses and distributing staff strategically among patients resulted in floor layout matching the tower’s butterfly-like shape.

After the mock-up aided in envisioning, testing, and adjusting the inpatient floor plan, the design team focused on creating an arrival experience for patients and their families. Users participated in developing designs for a large entrance to the new hospital tower and gardens provided respite for patient and families. Through modelling, an unused tennis court transformed into an arena for design that embraced interaction and feedback from the administration, clinical staff, patient and families, and the community.

University Health System: High-Fidelity Room Mock-Ups

University Health System in San Antonio, Texas, USA engaged Perkins+Will for design of a new trauma tower at University Hospital to include additional beds, an expanded emergency department, and an interventional platform. When the integrated design-and-client team discussed modelling, the client desired to utilise full-scale room models that would evolve throughout the design process into fully-outfitted rooms. To maximise the value of the high-fidelity and higher-cost model, the University Health System (UHS) partnered with the University of Texas Health Science Center at San Antonio (UTHealth) School of Nursing to jointly fund and jointly benefit from the models. First, the mock-ups aided UHS users and the design team in the design process for the tower; after the design was completed, the fully-outfitted space served, and continues to serve, as a simulation lab at UTHealth where hundreds of students each year receive hands-on clinical training.

The rooms modelled included a trauma room, an emergency department exam room, an inpatient room, and two operating rooms. From schematic design through design development, users including physicians and staff from different departments met inside the space to experience it and provide input.

Operationally, the UHS project focused on leveraging technology and research to provide cutting-edge, evidence-based healthcare to their patients. To incorporate the latest technology into each room type, users met with medical equipment vendors for demonstrations in the modelled space. As a result, rooms are equipped with a patient engagement system and tele-conferencing capabilities that allow for consultation and learning with colleagues and students at the facility and around the world. The mock-ups were vital to the users understanding and participating in designing the ideal rooms for their units. As a bonus, the finished mock-ups, fully sheet-rocked and equipped with technology, now continue to serve as a simulation lab for UTHealth nursing students.

Jackson Health System: Discrete Event Simulation

Jackson Health System in Miami, Florida, USA engaged Perkins+Will in a greenfield project to design a new emergency department with diagnostic capabilities. The innovative vision for the project focuses on leveraging a hospitality model, operational efficiency, and technology to deliver the highest level of patient-centred care.

During programming and schematic design, computerised discrete event simulation was a modelling method chosen for its ability to consider facility design simultaneously with operational design at a higher fidelity. Because the vision of this greenfield project unprecedented operational efficiency, the client wanted the chosen method of modelling to not only model the designed space, but to also model what would occur in the space.  This simulation allowed the design-and-client team to define and redefine operations, including processes and staffing, while investigating facility alternatives.

This modelling focused on utilising operational processes to determine the correct numbers of different types of rooms in the emergency department including, but not limited to, rapid medical evaluation rooms, emergent rooms, behavioural health rooms, resuscitation rooms, and paediatric rooms. The model is data-driven, utilising statistical distributions and probabilities that model real-world variation and able to incorporate multiple options for room assignment. This ability to model chance and change in operational processes is especially valuable in a dynamic system like an emergency room. For example, the simulation utilises a room preference order for different types of patients by their acuity and resource needs. Ultimately, the modelling process provided data to allocate rooms to each room type and aided in defining the operations that would bring the client’s vision to life.


The case studies demonstrate various simulations engaged at different phases of the design project. Intermountain Healthcare Alta View Hospital, Rush University Medical Center, University Health System, and Jackson Health System are unique clients, and Perkins+Will  customising our modelling approach to each client’s needs is crucial to success. The case studies represent the many ways simulation can aid in the design of and transition to a new healthcare space.

Hospitals and other healthcare entities should embrace facility projects as an opportunity to redefine operations and improve quality in their organisation. Integrated facility and operational design can improve health for the population served by the organisation and improve the experience of care all while reducing costs. Modelling and simulation allow for iterative testing of and familiarisation to new facility and operational designs to meet an organisation’s goals.

-- Issue 36 --

Author Bio

Marvina Williams

Marvina Williams is a registered nurse and Senior Healthcare Operations Planner on Perkins+Will’s Healthcare Planning + Strategies team. She previously directed a large emergency department and enjoys connecting the architectural team and clinical users. She is an expert in workflow, workload and staffing, clinical procedures and support services.

Amanda Hobbs

Amanda Hobbs is an industrial engineer and Healthcare Operations Planner on Perkins+Will’s Healthcare Planning + Strategies team. Amanda is experienced in human factors engineering, systems engineering, and quality improvement methodology. Amanda is passionate about concurrently designing operations and facilities to improve health and the care experience while increasing value.