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https://doi.org/10.1177/1937586719843877

1 INTERDISCIPLINARY USER GROUPS & THE DESIGN OF HEALTHCARE FACILITIES

The Australian healthcare system is a large and expensive part of the Australian

economy with approximately 3.6% of GDP spent on the hospital system per annum

(Australian Institute of Health and Welfare, 2014a). In 2013-2014 estimated capital

expenditure on hospitals was $9.1 billion in total, including $4.8 billion spent by state,

territory, and local governments (Australian Institute of Health and Welfare, 2014b). Hospital

buildings are significant public buildings, often large, complex, with increasingly high levels

of sophisticated and high-priced technology, and expensive to operate due to large numbers

of staff. They cost more to construct than other major public buildings including airports

(Turner & Townsend, 2013). Australian, New Zealand and healthcare clients in countries

such as the United Kingdom (UK) and Canada usually require, as part of the design process

for a health facility, consultation with "user groups" whose members include clinicians,

managers, and other hospital employees, and where possible, patients, their families and the

broader community.

Significance

Effective interdisciplinary collaboration entails understanding the differing

skills, decision-making and design-related priorities of all design team members, and

especially how the expectations of project clients and funding bodies affect achieving,

managing and applying "user" input to their projects.

Aims

Part of the requirements for a Doctorate in Creative Industries at the Queensland

University of Technology (QUT), Australia, this research explored the contributions of user

group participants from diverse professional discipline backgrounds to the design of

healthcare facilities, including how they understand, define, and perform their roles, and

assess the outcomes of the process. The research questions were: "What is the role of


interdisciplinary project 'user groups’ and how do they affect the design of a healthcare

facility?" To investigate this, an online survey with closed and open-ended questions probed

how user group participants viewed the user group process, including how well informed

they felt, whether it was successful in achieving specific outcomes for their healthcare design

project, and how they believed their project client or funding body assessed these same

issues.

Literature Review

Introduction

The changing nature of architectural design practice, including the rise of the

specialist "health architect", has influenced contemporary healthcare facility design. In

Australia and New Zealand, interaction of the design team with an interdisciplinary user

group is almost always required. Resulting considerations include participants' differing

attitudes towards health design research, and how this affects the decision-making process,

and negotiation of the different professional cultures and skill asymmetries of managerial,

clinical, and design team project members. In particular, the impact of professional culture on

user group participants’ attitudes must be acknowledged and addressed to ensure the effective

pursuit of common goals and objectives. Further, the channeling of users' diverse skills and

knowledge into the design process for a healthcare facility is required to ensure best-practice

and innovative healthcare delivery.

Rise of the Health Architect as a Specialist Designer

Verderber and Fine (2000) described the rise of the health architect as a specialist

designer during the 1960s, but it was well into the 1990s before the mainstream architectural

profession became convinced of the value of interdisciplinary education in health

architecture. Yet Australia and New Zealand still lag behind in this type of educational

initiative despite the optimism of Lyon (2013). It is also rare for clinicians to be formally


educated in the design or management of capital projects unless they enroll in a health

administration course or degree (Forbes, 2013). Yet as "users", they are increasingly expected

to participate in the design and briefing (programming) of health facilities, and so designers

including architects must initiate them into this process. Architects have traditionally worked

with users (Lawson, 2006), and Miller and Swensson (2002) emphasize for health projects,

the importance of "socially responsible design" noting that "[d]uring the design process itself,

the participation of the users of the facility needs to be sought. This will help to clarify the

design objectives and to ensure that the objectives of the primary project planners, the

architects, and the users mesh" (Miller & Swensson, 2002, p. 56). However, as there is often

an asymmetry of skills or knowledge, the relationship between the design team and the

clinical users working in a collaborative setting requires highly nuanced communication

(Kim & Shepley, 2008). As clinicians know much about their practice but significantly less

about design, they are often more interested in functionality, and less concerned about how a

building will look or feel whereas an experienced health architect, trained to appreciate

aesthetics, may know much about clinical practice from previous projects, but is rarely also a

clinician. Further, attitudes towards research and training differ between the world of science-

focused clinicians and designers such as architects.

Users' Professional Discipline Backgrounds and Decision-making

Kim and Shepley (2008) observe that architectural design decisions can appear to lack

credibility in the eyes of healthcare clients and users, and so, to ensure effective

collaboration, user group participants must not only jointly agree on the project requirements,

but they must also accommodate differing perspectives regarding research and "evidence"

when making decisions in a user group setting in order to successfully practice evidence-

based design. This type of decision-making requires a collaborative learning environment

that explores the needs of end users and the available evidence base that will guide design


decisions - a "method...in sharp contrast to construction meetings that focus primarily on

room size and building location" (Elf, Frost, Lindahl, & Wijk, 2015, p. 3).

The differing professional discipline backgrounds of user group participants may also

result in different professional cultures affecting decision-making in collaborative work

settings. Interdisciplinary clinical teams work together differently than those comprised of

clinicians solely from one background such as only doctors, or only nurses (Bloor & Dawson,

1994; Hall, 2005; McNeil, Mitchell, & Parker, 2013; Mitchell, Parker, & Giles, 2011;

Sommerfeldt, 2013). Bloor and Dawson used a case study to demonstrate "medical

dominance" as the prevailing theme when team members drawn from different medical

subcultures work together, and Hall (2005) discusses the development of professional

identity, the different cultures of each health care profession, and how these result from

history, "social class and gender" factors. Education and socialization that occur during

training reinforce "common values, problem-solving approaches and language/jargon of each

profession" and "cognitive learning theory suggests that each profession may attract a

predominance of individuals with a particular set of cognitive learning skills and styles"

(Hall, 2005, p. 190). McNeil et al. (2013) further contend that "the differing processes of

professional socialisation within the healthcare occupations mean that there are divergent

values…[and] varying opinions as to the nature of the roles within the team is a potential

source of conflict" (p. 298).

Education of Designers, Pierre Bourdieu and "Habitus" Theory

In terms of the socialization and professionalization of designers, various authors

discuss how architects are educated, and how they view their role both within the

construction industry, and in relationship to their clients. Dana Cuff (1991) and Gerry

Stevens (1998) refer to the philosophy of Pierre Bourdieu (1990), in particular the theory of

"habitus" that explains how the worldview of different professionals determines what each


regard as important, and perhaps more significantly how "common sense", the "thinkable", or

the "unthinkable" are defined for each particular habitus. Socialized through education,

architecture graduates are then inducted by architectural practice into the ways of the

profession, including assisting novice architects to develop and identify with the social,

cultural, and economic capital of the architect persona that ensures the survival and

promotion of the profession when interfacing with other professionals and the wider

community.

Creation of Successful and Productive Working Relationships

However, architecture is also a practice that requires business and management skills,

and acknowledgement of its responsibilities in creating a built environment for the wider

community, as discussed by Cohen, Wilkinson, Arnold, and Finn (2005). Developing this

theme, Oak (2009) explores the roles or social categories of "architect" and "client" and how

these manifest, with Sang, Ison, Dainty, and Powell (2009) confirming that "the anticipatory

socialisation process of architects…appears to have fostered a belief that the core value of the

architectural profession is creativity, despite this accounting for little of a practicing

architect’s work load" (p. 318). Cuff (1991) and Stevens (1998) support this, and propose an

inevitably steep learning curve for any client working with an architect for the first time. Siva

and London (2012) also noted this in explaining the development of the relationship between

an architect and a client during a housing project as a form of learning that includes at least

partial adoption by the client of the architectural habitus, and believe this to be almost

inevitable if the project is to be regarded as successful, particularly by the client. Similarly,

although often relatively inexperienced in the design of a healthcare building, clinicians must

also learn quickly about the architectural habitus in order to add maximum value to the user

group process. Chandra and Loosemore (2010) describe how project participants, particularly

clinicians, learn during the interdisciplinary process of briefing a health facility and found


that the clinicians’ learning accelerated as the project progressed, and they were then able to

offer a much more nuanced appraisal of its outcomes than any of the clinicians who were not

involved. Thus, clinicians and other user group members possessing their own distinct

habitus and seeing the world from that position, must learn about the habitus of other group

members, and in doing so, adopt some of their skills, traits and points of view in order to

form the most successful and productive working relationships (Siva & London, 2009).

Henri Tajfel and Group Behavior

Henri Tajfel (1974, 1981), in discussing how the behavior of groups may be biased,

outlines the concept of "in-groups" and "out-groups" as a fundamental organizing principle of

human society. This offers an individual a "continuing process of self-definition" (Tajfel,

1974, p. 67) and "social identity [as] that part of an individual's self-concept which derives

from his knowledge of his membership of a social group (or groups) together with the

emotional significance attached to that membership" (1974, p. 69). An in-group usually

displays favoritism to its members including preferring their attitudes and opinions, yet will

also see and allow for greater differences within that group than they would ascribe to any

out-group members. This favoritism determines those who can be trusted or assumed to

understand what is required from the design process, and therefore an out-group will not be

trusted, will be regarded with suspicion, and on occasion, treated with outright hostility

(Brown, 2000).

"Profession-centrism" and Communication Within User Groups

In these circumstances, an in-group may be "profession-centric", for example, with

membership restricted to say clinicians or designers, and this will affect communication

within the user group setting. Described by Pecukonis (2014) as "similar to ethnocentrism,

profession-centrism (professional centric thinking) is a constructed and preferred view of the

world held by a particular professional group developed and reinforced through their training,


educational, and work experiences" (p. 62), and results in "the creation of stereotypes that can

be limited, involve bias judgment and action, and must be managed" (p. 63). So, clinical and

other users must overcome "profession-centrism", in order to guide cohesively the work of

the design team that may otherwise be regarded as an out-group not to be trusted or respected

(Khalili, Orchard, Laschinger, & Farah, 2013). Sometimes, even the project client or funding

body, the patients and the wider community may be regarded (perhaps unconsciously) as out-

groups with negative consequences for project outcomes. Although there is little in the

literature regarding the manner in which architects and other designers form in-groups and

out-groups, it is reasonable to assume that this does occur. The formation of these groups is

again centered around a similarly "constructed and preferred view of the world" derived and

reinforced by professional training as described by Pecukonis (2014, p. 63), and so must be

managed in a user group setting. Strategies suggested by Pecukonis, Doyle, and Bliss (2008)

to improve the functioning of interprofessional teams include the creation of a

"superordinate" identity for all team members that will more closely identify with the

strategic goals of the healthcare project. The focus of the project should also be broadened to

include the needs of patients and the wider community rather than largely concentrating on

clinical workplace needs. Similarly, a skillful leader or user group facilitator should address

power imbalances (for example, doctors versus nurses), organizational political hierarchies

(clinicians versus managers versus funding bodies), and differing professional cultures and

roles (clinicians versus designers versus managers). Creating positive team interactions may

reduce the incidence of profession-centrism impacting negatively on user group outcomes.

Leadership of the User Group Process

However, the most suitable discipline to lead the user group process can be

contentious. Stichler, a nurse, contends that nurses are very capable of providing leadership

to the healthcare design process using their clinical knowledge to guide facility outcomes


(Stichler, 2007, 2009, 2014, 2016; Stichler & Gregory, 2012; Stichler & Okland, 2015).

Others also look at how nurses can add value to the process as leaders and advisors (Lamb,

2016; Lamb, Connor, & Ossmann, 2007), and how nurses can work with architectural

educators to develop core competencies in students of healthcare design (Lamb, Zimring,

Chuzi, & Dutcher, 2010). D. Kirk Hamilton (2010a, 2010b, 2011, 2014), an architect,

discusses the issue from a different perspective and calls for greater recognition of the skills

of all participants in the process, whether clinician, manager or designer. Various authors

note the need for effective "interprofessional" collaboration, yet, this is a term used far more

frequently in the literature by healthcare professionals, in particular nurses, than by designers.

Design Decision-making and Participatory Design

Becker and Carthey (2007) discuss how decisions are made in interprofessional health

design settings noting that the process is non-linear, iterative, reflective, involves many

players, with outcomes passing through a series of filters or frames to a final solution.

Lawson (2010) outlined a decision support tool called ASPECT – "A Staff and Patient

Environment Calibration Tool" believing that the "process of briefing [programming] is itself

interactive…and current thinking suggests that problem and solution emerge together in a

good design process rather than one totally preceding the other". (Lawson, 2010, p. 104).

Zerjav, Hartmann, and Achammer (2013) reviewing a complex railway station project

proposed that reflective practice assists in making decisions in an interdisciplinary design

team setting, especially where many complex issues require resolution, with issues "framed"

consecutively as manageable pieces of work that move a project forward. It seems likely that

the user group process supports similar framing of the major issues that drive a healthcare

project towards a design solution.

Finally, Potter-Forbes and Barach (2012) recommended making the user group

process more transparent to participants especially in terms of purpose and required outcomes


following their review of several mental health building projects in NSW, Australia. This is

consistent with the findings of Sherry Arnstein (1969) who, in discussing urban planning in

the United States of America (USA), provocatively suggested that a participatory design

process requires those promoting it to explain and agree on the level of input required from

users, and the extent of their influence on the potential outcomes. Commenting that "[t]here is

a critical difference between going through the empty ritual of participation and having the

real power to affect the outcome of the process", Arnstein (1969, p. 216-217), proposed a

typology of eight levels of participation in a ladder pattern ranging from "manipulation" and

"therapy" as types of non-participation at the bottom of through to "citizen control" at the top,

intending to encourage debate about this type of activity.

Research Methodology

An online survey was used to examine how Australian and New Zealand user group

participants rate the user group design process including its outcomes, and this approach was

chosen in accordance with the observations of Groat and Wang (2002) that this is a suitable

method for gathering data quickly and broadly, and also to triangulate research data that will

be gathered using interviews in the next stage of the research. Questions were developed in

the software program Key Survey. Ethics approval was granted by Queensland Institute of

Technology (QUT) no.1700000155, and prior to distribution, the questions were trialed with

the input of several selected respondents from design, management and clinical backgrounds.

To ensure a spread of respondents from different professional disciplines, the survey was

distributed anonymously to a range of user group participants by: Australian and New

Zealand health authorities including Health Infrastructure NSW, the Victorian Department of

Health and Human Services, Queensland Health, Canterbury and Southern District Health

Boards; professional organizations such as the Australian Institute of Architects, Australasian

College of Health Service Management, and Australian and New Zealand Health Design


Councils; plus by several large architectural and project management consultancy firms.

Questions were both closed and open-ended, with further comments invited in

response to each section of the survey. Respondents provided informed consent by

proceeding past the information page and completing the first question. To ensure a suitable

spread of respondents, the first part of the survey gathered demographic information

regarding respondents' geographic location, professional background, project role, and

healthcare design experience. To continue to the next part of the survey, respondents were

required to have participated in a user group process for a healthcare facility within the last

five years.

Findings

The survey was open for a period of fourteen weeks, started by 107 people and fully

completed by 68. The completion rate was 64% although another 39 participants (36%)

answered at least one question. Ninety-five respondents (89%) confirmed that they had

participated in user group consultation within the last five years and were qualified to

proceed with the survey. However, 28 (30%) then dropped out progressively giving a

completion rate of 72% for all qualified respondents. These respondents may have found it

impossible to complete the survey at one sitting and may have intended to return to complete

it at a later date but never did so. Main workplaces were Australia (66, 64%), or New Zealand

(34, 33%), with the remainder Singapore (2, 2%), or another country. Australian respondents

came from Queensland (29, 44%), New South Wales (23, 35%), Victoria (9, 14%), and

Western Australia (5, 7%). The current professional disciplines / occupations of ninety-five

respondents were aggregated, ranked by major occupational group, and are shown in Table 1,

with the top three being (1) Designers (26, 27.4%), (2) Project Manager / Project Director

(20, 21.1%), and (3) Clinician (18, 18.9%).

[Insert Table 1 approximately here]


More than half (53, 52%) of the 102 respondents who answered this question had 11

years’ experience or more on healthcare design projects, (15, 15%) had six - ten years’

experience, and so (68, 67%) had more than six years’ experience overall, and (34, 33%) had

one to five years’ experience or less. Most experienced disciplines (11 years or more) on

healthcare design projects were Designers (25, 49%), then Project Managers/Project

Directors (9, 17%), followed by Managers and Service Planner/ Health Planners, both (4,

8%), and Clinicians (4, 8%). By contrast, Designers were (1, 2%) of those with less than 10

years’ experience compared to Clinicians as (14, 32%) of this group, followed by Project

Managers/Directors and Managers, both (11, 25%). Overall, Clinicians had the least

experience on healthcare design projects with (13, 73%) with five years or less experience,

compared to no Designers in this category.

Respondents were next asked how well informed they felt prior to commencing their

most recent project regarding the objectives of their Project Client or Funding Body for "user

group" consultation on projects within their jurisdiction. Ninety-two respondents answered

this question, with the majority (81, 88%) at least adequately informed - very well informed

(36, 39%), moderately well informed (29, 32%), and adequately informed (16, 17%) - while

(11, 12%) felt poorly or very poorly informed - see Figure 1.

[Insert Figure 1 approximately here] Broken down by discipline / occupational group, those who felt poorly or very poorly

informed were Clinicians (4, 24%), Service Planner/Health Planners (1, 20%), Project

Managers/Project Directors (3, 16%), Designers (2, 8%), and no Managers or Facility

Managers. Designers, plus the small numbers of Facility Managers and Building Contractors,

felt the best informed while Clinicians did not feel as well informed as other disciplines with

(13, 76%) responding that they felt at least adequately informed (or better), compared with

(24, 92%) of Designers. When asked to indicate how well-informed respondents felt

regarding the purpose, process and outcomes required from the user group process for their


specific project, results were similar, with (83, 90%) responding that they felt adequately

informed (or better) - see Figure 2.

[Insert Figure 2 approximately here] The breakdown by discipline / occupation and comparison of answers to these

questions are shown in Figure 3.

[Insert Figure 3 approximately here]

Respondents were asked the extent to which they believe that the "user group"

consultation process achieves the results required by project clients or funding bodies for

projects in their jurisdiction. A majority of respondents (76, 85%) believed that it does so at

least adequately - adequately (34, 38%), well (36, 40%) or very well (6, 7%) - see Figure 4.


However, in terms of the respondents who believed that it did so poorly (13, 15%),

Clinicians were over-represented, although only (17, 19%) of all who answered this question,

(7, 42%) gave this response. In particular, half the nurses (5, 50%) felt the process achieved

poor outcomes for clients or funding bodies compared with no Managers, and few Designers

(3, 12%) or Project Managers/Project Directors (2, 10.5%). Respondents were then asked

how well the user group consultation process achieved the outcomes required for their

specific project. The majority of respondents (80, 90%) felt that it did so at least adequately,

scoring it adequately (40, 45%), well (32, 36%) and very well (8, 9%), with several believing

that it did so poorly (7, 8%) or very poorly (1, 1%), or didn’t know (1, 1%) as illustrated by

Figure 5.


Several Clinicians (7, 42%), and one Designer (1, 5%) assessed the outcomes as poor

or very poor, with Clinicians again over-represented as they were (17, 19%) of all who

answered this question. The breakdown by discipline or occupation, and comparison of

answers to these two questions are shown in Figure 6.



Although the quantitative results suggest that the user group process achieves an adequate

outcome for most participants, the qualitative results from the open-ended commentary

suggest more nuanced conclusions. As shown in Table 2, open-ended commentary was

analyzed - using NVivo in terms of emergent themes and key words, with additional coding

in Excel. The main themes identified were (1) how the user group process is run including

defining and managing the objectives and expectations of users (Governance);

(2) the demonstration of integrity by project clients (Governance); (3) how the success of the

process varies, depending on the knowledge of users and whether they had "buy-in" to the

project (Knowledge asymmetries); (4) the outcomes of the process including missed

opportunities for innovation (Process); (5) the ideal composition of user groups, and

recognition of their workload (Process); and (6) the quality of resources available to user

groups e.g. the Australasian Health Facility Guidelines (AHFG) (Resources).

[Insert Table 2 approximately here]

Conclusions

User group consultation is required for the design of healthcare facilities in Australia

and New Zealand (and some other countries), yet given the time and money spent on user

group consultation, less than 50% of all respondents assessed as "well" or "very well" the

extent to which the user group process achieved the goals either for their specific project, or

for their project client. Users from different professional backgrounds had very different

levels of healthcare design experience, especially managers (project, facility and general) and

clinicians who perhaps not surprisingly, generally had much less experience with healthcare

design projects than any other discipline group. Quantitative data analysis shows that the

majority of respondents considered the user group consultation process and its outcomes to

be at least adequate. Yet when analyzed in terms of respondents' professional discipline


backgrounds there was much greater variability, with clinicians in particular feeling less

informed, and less confident that the process achieves the required outcomes for either their

project clients or their specific projects. This suggests that with less healthcare design-related

experience, clinicians may have initially higher expectations of the process and its outcomes,

and consequently, find the process and its outcomes to be less successful than those with

more experience, especially the designers.

The open-ended commentary of clinicians, project managers, and designers also

suggests that the user group process is not as effective as it could be, with governance of the

process being the most commonly expressed reason for dissatisfaction. Drawing on

Arnstein's (1969) findings and referring to the conclusions of Potter-Forbes and Barach

(2012), the objectives and expectations of users should be better defined and managed,

making it clear whether users are the decision makers, or if their role is that of expert

advisors and as such, one part only of the input to the decision-making process by clients and

funding bodies. Sources of expertise are available from other fields such as urban planning

including methodologies promoted by the IAP2 Spectrum of Public Participation (Federation

of International Association of Public Participation, 2014) that discuss differing types of

design participation (inform, consult, involve, collaborate or empower), goals for each, and

promises that can be made to participants regarding process and outcomes.

Many clinician users do not understand the overall user group process and exactly

what it is expected to achieve, although designers offer clinicians and others who participate

in user groups interactive presentations explaining the stages in the process and what to

expect from designers, and employ technologies such as virtual reality modelling to explain

the design as it proceeds. Instead, several clinicians made negative comments regarding the

motives of project clients and designers, and although designers understand the process

better, rating it and the results more highly, they feel it could be improved, especially in terms


of promoting more innovative healthcare delivery. One designer stated that the success of the

process "varies according to the knowledge base of the users", and another felt that it "seems

to produce the lowest common denominator". Consistent membership, composition and user

group workloads should also be addressed, and as suggested by several designers and

health/service planners, the design process could be improved if the Australasian Health

Facility Guidelines (Australian Health Infrastructure Alliance, 2016) were more widely

recognized by users, made more robust as a design reference, and applied more consistently

across projects.

No patients answered the survey and their needs were not explicitly considered by

respondents who were primarily concerned with the design of a clinical workplace. As noted

previously, strategies to address profession-centrism include the creation of a super-ordinate

identity for the project user group, expanding it to include patients and the wider community

to ensure their issues receive as much attention as other project priorities. This is an

implication for practice as an improved user group process may improve the design quality of

healthcare facilities for all those who pay for, work in, visit or are treated there.

Limitations and Future Research

Limitations of this study include (1) the lack of specific input from project clients,

owners or funding bodies; and (2) no input from patients, families or members of the wider

community affected by the design of a healthcare facility.

Future research will look at how the user group process may be improved,

commencing by inviting input from project clients, owners and funding bodies. Drawing on

participatory design principles in fields such as urban planning and planning methodologies

for other types of major public projects, it may also be possible to offer new or refined

techniques to user group design forums in sectors in addition to healthcare. In the healthcare

sector, these techniques may also be useful for health service planning, development of


healthcare delivery models, and for more effectively including patients, their families and the

wider community in the healthcare facility design process in Australia, New Zealand, and

other countries.

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Figure 1: How well informed were respondents regarding the objectives of their project client or funding

body?


Figure 2: How well informed were respondents regarding the outcomes required for their specific

project?


Figure 3: How well informed did respondents feel regarding: B2 - the objectives of their client / funding body for projects in their jurisdiction; B3 - the purpose, process and outcomes required for their specific project

Figure 4: How well does the process achieve the outcomes required by project clients and funding bodies?


Figure 5: How well does the process achieve project-specific outcomes?


Figure 6: How well did respondents feel the process achieved its outcomes in terms of: B4 - the objectives of their client / funding body for projects in their jurisdiction; B5 - the purpose, process and outcomes required for their specific project

Table 1: Responses by Current Discipline aggregated and ranked in terms of Occupational Group

Rank Current Discipline / Occupational Group Number % Respondents

1 Designer - any type 26 27.4

2 Project Manager / Project Director 20 21.1

3 Clinician – any type 18 18.9

4 Management 15 15.8

5 Service Planner / Health Planner 5 5.3

6 Facility Manager 4 4.2

7 Building Contractor 1 1.1

8 Other – including Equipment (FF&E) Specialist, ICT Program Manager, Wayfinding Consultant, Design and Fabricate artwork, Consultant – User Group Facilitation, Clinician-Nurse/Design-Interiors/Health Planner

6 6.2

Total who answered this question 95 100


Table 2: Qualitative Commentary - emergent themes and examples

Emergent Theme / Sub-theme

Examples of commentary

Governance

Sub-theme:

How the user group process is run including defining and managing the objectives and expectations of users

Designer: "Clients believe very strongly they need user group input but do not have a clear idea of exactly what they want user group input to achieve and how that might be distinct from expert advice."

Clinician: existence of "conflicting agendas/function vs form"

Service Planner /Health Planner: "Roles of participants and their expectations could be more clearly articulated."

Clinician: "depends on the facilitator of the user group. Outcomes are dependent on what management and CAPEX can provide. Often there is a lack of feedback to the user group once a decision has been made that the user group schedule of accommodation has been reduced".

Clinician: “you are constrained by $$ and building footprint & key principles”

Clinician: “requested changes not always implemented”.

Clinicians - several: [user] input was often disregarded and not translated to the final design outcomes.

Designers, Managers and Project Managers / Project Directors: called for strong leadership of the user group process and the need for skilled facilitation to reconcile the needs of users with the demands of the project especially where meeting budget and other non-negotiable requirements.

Governance

Sub-theme:

Demonstration of integrity by project clients

Clinician: concerned with “lack of integrity within [the] process displayed by project clients and funding bodies”.

Clinician: felt “powerless as decisions made were over-ridden by groups higher up the chain”.

Clinician: “issues with the concept design were raised multiple times and resulted in papers being written informing the Executive Team that compromises in design are at high risk of affecting patient safety and experience. Whether there is an outcome from this remains to be seen”.

Clinician: “the buck often stops due to financial constraints and acts as a major roadblock to the user group needs”.

Clinician: “[I] felt that the opinions and ideas of the user group were well regarded within the group and in immediate managers above, but once it went higher into management other requirements (budget, management agendas) began to take priority”.

Clinician: “I feel that the user group process was used by both the project and health department to tick a box stating they had 'consulted' users during the process”.

Knowledge asymmetries

Success of the process varies depending on the knowledge of users and whether they had ‘buy-in’ to the project

Designer: the success of the process “varies according to the knowledge base of the users”.

Designer: “changes in stakeholders leading to changes in requirements, despite signoff”.

Manager: achieving the outcomes of clients “depends on the project and user buy in to process”.

Manager: “I feel end users can lack understanding of plans/FF&E and the ramifications of their decision making".


Clinician: “some ideas from other hospitals may have helped rather than being given a totally empty sheet”.

Project Manager/ Project Director: users' lack of ability to read plans “we still had changes when built”.

Project Manager/ Project Director: the process could increase “ownership” of the outcomes by the users.

Clinician: “architects took note and ideas but clearly had their own agenda and imposed designs that were not best practice. A lot of useless space with inefficient design which looked impressive was the outcome”.

Architect: knowledge of users varied widely, and that the input of “strong” characters could sway the process to produce poorer outcomes for all those involved.

Architect: need better education of the users regarding how designers work, how project decisions are made, and also how things are done differently in other locations and countries.

Project Managers / Project Director: is the time and cost of the user group process worthwhile in terms of the design outcomes it achieves (“time and costs vs benefits unproven”)?

Project Manager/ Project Director: “typically its more about bringing people on the journey and initiating the change process than providing any major benefit to the designed outcome”.

Process

Sub-theme:

Outcomes of the process including missed opportunities for innovation

Designer: “it seems to produce the lowest common denominator”.

Designer: it introduces inconsistencies in outcomes by “sometimes contradict[ing] agreed policies and minimum standards”.

Designer: ongoing user group involvement can delay project progress.

Project Manager/ Project Director: need for change management to improve outcomes.

Project Manager / Project Director: “the input is valuable in terms of sharing experience and understanding” but “there is also the risk that 'users' struggle to transition their thoughts from the now resulting in missed opportunities”.

Process

Sub-theme:

Composition of user groups, and recognition of their workload

Manager: “the full extent of consultation is not achieved” due to lack of consultation with Engineering and Maintenance staff, and administrators, compared to the greater representation of clinical people in the process.

Designer: size of groups is important (with smaller groups preferable).

Designer: membership should be consistent as commonly the changing of members “caused backtracking and re-assessing of things previously agreed”.

Clinicians - several: time pressures are an added burden to their everyday work.

Designer: time pressures due to inadequate time allowed, and inexperienced users.

Resources

Quality of resources available to user groups e.g. the Australasian Health Facility Guidelines (AHFG or AusHFG)

Designers and Service Planners / Health Planners - several: need greater recognition of standardization and the need to ensure consistency and minimum standards across projects as embodied in the Australasian Health Facility Guidelines (AHFG).

Designer: draft status of the AHFG renders them less robust as a design reference and hence more easily disregarded by clinician users.

Service Planner / Health Planner: “user groups are often not even aware of the existence of the AusHFG's and this should be part of the introduction to their role as a 'user'".

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