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UBC Theses and Dissertations

A Delphi application in the developing of a pattern language approach to health facilities design guidelines 1982

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A DELPHI APPLICATION IN THE DEVELOPING OF A PATTERN LANGUAGE APPROACH TO HEALTH F A C I L I T I E S DESIGN GUIDELINES by IAN FREDERICK WALDIE FORBES B.ARCH., U n i v e r s i t y o f M e l b o u r n e , 1968 Dip.Bus.Admin., U n i v e r s i t y o f New S o u t h W a l e s , 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES (Department o f H e a l t h C a r e and E p i d e m i o l o g y ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA J a n u a r y , 1982 ( c ) I a n F r e d e r i c k W a l d i e F o r b e s , 1982 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of i N ^ O T t A ^ A \ g ^ £ &?\&'&lA\Gl^>4.y The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date DE-6 (3/81) i i ABSTRACT The use o f S t a n d a r d s t o r e d u c e t h e c o m p l e x i t y o f H e a l t h F a c i l i t i e s D e s i g n has become an i n d i s p e n s a b l e and i n t e g r a l p a r t o f t h e p l a n n i n g p r o c e s s . U n f o r t u n a t e l y t h e s t r u c t u r e o f p r e s e n t S t a n d a r d s i s i n f l e x i b l e , and w h i l e t h i s s t r u c t u r e may h a v e been a c c e p t a b l e i n t h e p a s t , t h e s t a n d a r d s i t p r o d u c e s have become i n e f f e c t i v e . Such S t a n d a r d s have been u n a b l e t o a d a p t t o t h e c h a n g i n g a t t i t u d e s and needs o f t h e p l a n n i n g p a r t i c i p a n t s who r e s p o n d t o t h e s o c i e t a l c h a n g e s a r o u n d them. I t i s o u r o b j e c t i v e t o d e v e l o p a method w h i c h can b u i l d b e t t e r S t a n d a r d s . In t h e f i r s t c h a p t e r we examine t h e s t r u c t u r a l p r o b - lems o f S t a n d a r d s and f i n d t h a t t h e r e i s a f u n d a m e n t a l d i f f e r e n c e between t h e p o s i t i v e p u r p o s e o f S t a n d a r d s as u s e d by h o s p i t a l s and p l a n n e r s and t h e r e s t r i c t i v e p u r p o s e s o f S t a n d a r d s used by government. We have u s e d t h e t e r m s G u i d e l i n e s and S t a n d a r d s t o d e n o t e t h e s e d i f f e r e n t c o n t e x t s . H a v i n g e s t a b l i s h e d t h a t a good S t a n d a r d i s one w h i c h i s s i m i l a r t o a G u i d e l i n e , we t h e n e x p l o r e an a l t e r n a t i v e s t r u c t u r e d e v e l o p e d a t B e r k e l e y , C a l i f o r n i a , c a l l e d a " P a t t e r n " w h i c h we o b s e r v e w i l l s a t i s f y t h e r e q u i r e m e n t s f o r "good" S t a n d a r d s . S i n c e P a t t e r n f o r m a t s a r e a d m i r a b l y s u i t e d t o d e v e l o p i n g s o c i e t a l l y - r e s p o n s i v e G u i d e l i n e s and S t a n d a r d s we e v o l v e a method t o a s s e m b l e t h e s e ' n e w S t a n d a r d s . i i i T h i s method i s b a s e d upon t h e D e l p h i T e c h n i q u e . I t u s e s t h e t e c h n i q u e ' s i n h e r e n t a d v a n t a g e s t o e s t a b l i s h com- m u n i c a t i o n between two g r o u p s o f e x p e r t s ( P l a n n e r s and M e d i c a l ) who t h e n i n t e r a c t t o e x p l o r e p r o b l e m s and s o l u - t i o n s i n p l a n n i n g Newborn N u r s e r i e s and N e o n a t a l I n t e n s i v e C a r e U n i t s . The m e t h o d o l o g y w h i c h i s d e s c r i b e d i n C h a p t e r 2 u s e s t h e c l a s s i c a l components o f a P o l i c y D e l p h i w i t h t h r e e r o u n d s o f q u e s t i o n n a i r e s s e n t t o M e d i c a l E x p e r t s ( P h y s i c i a n s and N u r s e s ) i n v a r i o u s p a r t s o f B r i t i s h C o l u m b i a and A l b e r t a . I t adds s u c h v a r i a t i o n s as t h e i n c l u d i n g o f i n p u t f r o m t h e P l a n n e r E x p e r t s as one method f o r t h e f e e d b a c k o f i n f o r m a t i o n . T h i s s p e c i a l D e l p h i d e s i g n a n t i c i p a t e s e f f e c t s f r o m i n d e p e n d e n t v a r i a b l e s and b u i l d s i n c o m p e n s a t o r y s t e p s . One o f t h e s t e p s i n c l u d e d i s a M i n i - S u r v e y o f a l a r g e r g r o u p o f p o t e n t i a l p a r t i c i - p a n t s , t o e v a l u a t e t h e P a t t e r n s r e s u l t i n g f r o m t h e D e l p h i S t u d y . T h i s l a r g e r g r o u p was s i x t e e n h o s p i t a l s i n B r i t i s h C o l u m b i a and t e n h o s p i t a l s i n A l b e r t a . C h a p t e r 3 d e s c i b e s t h e d e t a i l s i n c a r r y i n g o u t t h e t h r e e q u e s t i o n i n g r o u n d s o f t h i s m o d i f i e d D e l p h i method, and i t s s u c c e s s i n a s s i s t i n g t h e p r o d u c t i o n o f a s e r i e s o f N u r s e r y P a t t e r n s w h i c h a r e u s a b l e as G u i d e l i n e s . In t h e m e t h o d o l o g y i s t h e i n h e r e n t c a p a b i l i t y f o r r e t a i n i n g f l e x i b i l i t y , and t h e r e a r e a s e r i e s o f p r o c e s s a d j u s t m e n t s t h a t o c c u r . E v a l u a t i o n o f t h e method i n C h a p t e r 4 shows t h a t d e s p i t e w e a k n e s s e s , b o t h a n t i c i p a t e d and u n a n t i c i - i v p a t e d , t h e r e s u l t s p r o v i d e an i m p o r t a n t s t a r t i n g p o i n t t h a t h e l p s c r e a t e b e t t e r , more u s a b l e S t a n d a r d s . P o s s i b l e f u t u r e d e v e l o p m e n t s a r e b r i e f l y m e n t i o n e d i n t h e hope t h a t e v a l u a t i o n and change w i l l o c c u r a s t h e p l a n n i n g e n v i r o n m e n t c h a nges a b o u t u s . John H. M i l sum, P r o f e s s o r Department o f Heal th Care and Epidemiology V TABLE OF CONTENTS L I S T OF TABLES v i L I S T OF ILLUSTRATIONS v i i i ACKNOWLEDGEMENTS . i x CHAPTER ONE: AN APPROACH TO THE PROBLEM OF STANDARDS 1 1 .0 I n t r o d u c t i o n 1 1.1 Who Uses t h e S t a n d a r d s ? 5 1 .2 How R e l i a b l e a r e t h e S t a n d a r d s ? 9 1.3 How a r e S t a n d a r d s B e i n g Used i n Canada? 15 1 .4 Toward a New S t a n d a r d 29 1.5 A Change i n t h e R o l e o f A r c h i t e c t u r e 32 1.6 The P a t t e r n s o f D e s i g n R e d i s c o v e r e d 35 1.7 The Format o f t h e P a t t e r n Language 48 1.8 Toward a New Method 52 CHAPTER TWO: A METHODOLOGY FOR CREATING DESIGN GUIDELINES AND STANDARDS 57 2.1 An A p p r o p r i a t e M e t h o d o l o g y 57 2.2 The G r o u p s and I n t e r g r o u p S t r u c t u r e 61 2.3 C o n t r o l l i n g t h e I n d e p e n d e n t V a r i a b l e s 71 2.4 Summary Remarks 83 v i CHAPTER THREE: CARRYING OUT THE DELPHI 84 3.1 Round 1: The Q u e s t i o n n a i r e P r e p a r a t i o n 84 3.2 Round 1: The Response 98 3.3 Round 2: The Q u e s t i o n n a i r e P r e p a r a t i o n '. 10 8 3.4 Round 2: The Response 114 3.5 Round 3: P r e p a r i n g t h e P a t t e r n s 121 3.6 Round 3: The Response 163 CHAPTER FOUR: CONCLUSIONS AND RECOMMENDATIONS 17 8 NOTES AND REFERENCES C h a p t e r One 192 C h a p t e r Two 196 C h a p t e r F o u r 198 BIBLIOGRAPHY 199 APPENDIXES ^ A p p e n d i x A: Round One Q u e s t i o n n a i r e 20 2 A p p e n d i x B: Round Two Q u e s t i o n n a i r e 235 A p p e n d i x C: Round T h r e e Q u e s t i o n n a i r e and The P a t t e r n s 333 v i i L I S T OF TABLES TABLE Page 3.0 Round One Q u e s t i o n n a i r e S t r u c t u r e 92 3.1 M e d i c a l E x p e r t s S e l f - R a t i n g S c o r e s 102 3.2 U s a b i l i t y R a t i n g C r i t e r i a 122 3.3 Summary o f R a t i n g s f o r O b j e c t i v e s : Newborn N u r s e r i e s 126 3.4 Summary o f R a t i n g s f o r O b j e c t i v e s : I.C.N. 128 3.5 Summary o f R a t i n g s f o r F u n c t i o n s : Newborn N u r s e r i e s 129 3.6 Summary o f R a t i n g s f o r F u n c t i o n s : I.C.N 137 3.7 Summary o f R a t i n g s f o r S p a c e s : Newborn N u r s e r i e s and I.C.N 145 3.8 P a r a g r a p h s Used i n F a m i l y Room 151 3.9 P e r c e n t a g e o f M e d i c a l E x p e r t s A n s w e r i n g i n S e c t i o n One . . 166 3.10 P e r c e n t a g e o f M i n i - S u r v e y R e s p o n d e n t s A n s w e r i n g i n S e c t i o n One 16 8 3.11 P e r c e n t a g e o f M e d i c a l E x p e r t s A n s w e r i n g i n S e c t i o n Two 170 3.12 P e r c e n t a g e o f M i n i - S u r v e y R e s p o n d e n t s A n s w e r i n g i n S e c t i o n Two 172 v i i i 3.13 P e r c e n t a g e o f M e d i c a l E x p e r t s A n s w e r i n g i n S e c t i o n s 3, 4, & 5 174 3.14 P e r c e n t a g e o f M i n i - S u r v e y R e s p o n d e n t s A n s w e r i n g i n S e c t i o n s 3, 4, & 5 175 i x A L I S T OF ILLUSTRATIONS D i a g r a m Page 1.1 An Example o f a P a t t e r n 47 1.2 A P a t t e r n Language f o r P u b l i c S p a c e s 50 2.1 The I n t e g r o u p Model 70 2.2 Mode A c t i v i t i e s 77 3.1 D e l p h i I n f o r m a t i o n and O r g a n i z a t i o n Model 85 3.2 F a m i l y Room 153 3.3 Newborn N u r s e r i e s 1 s t S t a g e G r o u p i n g s 158 3.4 Newborn N u r s e r i e s 2nd S t a g e G r o u p i n g s 159 X ACKNOWLEDGEMENTS T h i s p r o j e c t would n o t have been p o s s i b l e w i t h o u t t h e c o n s i d e r a b l e t i m e and d e v o t i o n o f t h e t w e n t y - t h r e e p e o p l e who became M e d i c a l and P l a n n i n g E x p e r t s and s p e n t many months o f t h e i r v a l u a b l e t i m e p a r t i c i p a t i n g . S i n c e t h e y d i d n o t a l l a g r e e t o t h e p u b l i c a t i o n o f t h e i r names, we have c h o s e n n o t t o m e n t i o n any o f them. The e x c e p t i o n s a r e Mrs. B e r n a d e t R a t s o y o f S t . P a u l ' s H o s p i t a l , V a n c o u v e r and Ms. B a r b a r a R a c i n e o f C h i l d r e n ' s H o s p i t a l , C a l g a r y , who a s s i s t e d p e r s o n a l l y i n t h e e a r l y s t a g e s , and a l s o P l a n n i n g E x p e r t s , M i c h a e l M o r r i s , o f Edmonton, and Ian C a r t e r , o f V a n c o u v e r . S p e c i a l t h a n k s go t o t h e c o m m i t t e e , Dr. C o r t l a n d M a c K e n z i e and Dr. L a r r y Moore, b u t e s p e c i a l l y t o Dr. J o h n M i l s u m t h e t h e s i s c h a i r m a n , f o r h i s p e r c e p t i v e comments and t i r e l e s s e d i t i n g ; t o Lou Carbone f o r h i s g r a p h i c s and l o g i s t i c s a d v i s e ; and t o A l i H i l d e b r a n d t and H o l l y McDonald who p e r s e v e r e d t o t h e l i m i t s o f s a n i t y w i t h t y p - i n g and c o r r e c t i o n s . F i n a l l y t o my p a r t n e r s a t Thompson B e r w i c k P r a t t and e s p e c i a l l y my w i f e Pamela w i t h o u t whose t o l e r a n c e and s u p p o r t t h i s w ould have been i m p o s s i b l e , a s p e c i a l t h a n k s f o r s e e i n g i t t h r o u g h . 1 CHAPTER 1: AN APPROACH TO THE PROBLEM OF STANDARDS 1.0 I n t r o d u c t i o n When d e a l i n g w i t h t h e c o m p l e x i t i e s w h i c h o c c u r i n H e a l t h F a c i l i t i e s D e s i g n , i t i s r e a s o n a b l e t o assume t h a t t h o s e p a r t i c i p a n t s i n v o l v e d i n t h e d e c i s i o n - m a k i n g w i l l where p o s s i b l e s e e k t o s i m p l i f y t h e p r o c e s s . An e a s y way t o do t h i s i s t o s t a n d a r d i z e t h e d e t a i l s o f as many i s s u e s as p o s s i b l e , s o t h a t r e c u r r e n t d e c i s i o n s a b o u t many complex p r o b l e m s a r e a v o i d e d . The d e c i s i o n - m a k i n g f o c u s - s e s on t h e d i s c u s s i o n o f v a r i a t i o n s and n o t d e t a i l s o f t h e i s s u e s . T h i s o c c u r s b e c a u s e t h e v a r i o u s p a r t i c i p a n t s i n v o l v e d i n H e a l t h P l a n n i n g have t y p i c a l l y s t e r e o t y p e d t h e r o l e r e f e r e n t s w h i c h t h e y use t o d e c i d e t h e o b j e c t i v e s t h a t have p r i o r i t y . T h e r e f o r e t h e r e s u l t s o f most d e c - i s i o n s a r e l i k e l y t o become p r e d i c t a b l e b e c a u s e t h e o b j e c - t i v e s c h o s e n and t h e r o l e s p e r f o r m e d a r e so s t a b l e t h a t t h e d e c i s i o n p r o c e s s becomes t y p i c a l o f a l l h o s p i t a l p l a n n i n g a p p l i c a t i o n s . P e o p l e s e l e c t t h e i r p r e f e r r e d s o l u t i o n s f r o m t h e p o i n t o f v i e w o f Government R e g u l a t o r s , P h y s i c i a n s , N u r s e s , A r c h i t e c t s , and H o s p i t a l P l a n n e r s , r e g a r d l e s s o f w h i c h p r o j e c t , w h i c h p r o v i n c e , o r w h i c h c o u n t r y t h e p r o c e s s i s o c c u r r i n g . S i m p l i f i c a t i o n t h r o u g h s t a n d a r d i z a t i o n o f b u i l d i n g i s s u e s i s u s u a l l y s u c c e s s f u l 2 where t h e r e i s a h i g h d e g r e e o f c o n s e n s u s among t h e p a r t i c i p a n t s a s t o t h e v a l u e o f c e r t a i n o b j e c t i v e s when p r e s e n t e d f o r d e c i s i o n - m a k i n g . W i t h o u t s u c h c o n s e n s u s , e a c h i s s u e must be r e p e a t e d l y a d d r e s s e d . U n d e r s t a n d a b l y , as t h e number o f i s s u e s w h i c h need t o be a d d r e s s e d by t h e s e p a r t i c i p a n t s become more numerous and more d i f f i c u l t t o r e s o l v e , t h e r e i s a d e s i r e t o e n s u r e t h a t more s t a n d a r d i z a t i o n o c c u r s . I t i s c l e a r t h a t h i s - t o r i c a l l y t h i s p r o c e s s o f s t a n d a r d i z a t i o n h as r e d u c e d t h e need t o c o n s t a n t l y a d d r e s s s i m i l a r i s s u e s t i m e and t i m e a g a i n . An a d d i t i o n a l b e n e f i t has been t h e i m p r o v e d com- m u n i c a t i o n w h i c h has r e s u l t e d between t h e p a r t i c i p a n t s , e n a b l i n g c o n c u r r e n t o b j e c t i v e s t o b r i n g p r o g r e s s and b e n e f i t t o a l l p a r t i e s . Now, t h i s i s now no l o n g e r t h e s i t u a t i o n . T h e r e i s e v i d e n c e t o i n d i c a t e t h a t t h e s t a n d a r d s b e i n g u s e d i n H e a l t h F a c i l i t i e s P l a n n i n g a r e n o t r e p r e s e n t a t i v e o f common o b j e c t i v e s , t h a t t h e y a r e c a u s i n g a n t a g o n i s m be- tween t h e p a r t i c i p a n t s , and t h a t t h e y a r e t h e r e b y r e d u c i n g c o m m u n i c a t i o n and t h e a c h i e v e m e n t o f good r e s u l t s . T h e r e i s e v i d e n c e t h a t a m a j o r f a c t o r h a v i n g an e f f e c t on t h e p r o c e s s i s t h e change i n p r i o r i t i e s o c c u r r i n g i n o u r s o c i e t y . T h i s i n e v i t a b l y s t a r t s c h a n g i n g t h e p r i o r i t i e s o f t h e r o l e - p a r t i c i p a n t s t h e m s e l v e s . E x i s t i n g S t a n d a r d s 3 have n o t changed t o meet new needs and a r e b e i n g u n i l a t e r - a l l y e n f o r c e d w i t h o u t c o n s e n s u s and i n some c a s e s t o t a l l y d i s r e g a r d e d . S p e c i f i c a l l y , S t a n d a r d s have n o t a d a p t e d t o c h a n g e s i n t h e m e d i c a l and s o c i a l e n v i r o n m e n t , and t o t h e v e r y s i g n i f i c a n t c h a n g e s f r o m a "Growth Economy" t o a "No- Growth", f i s c a l l y - c o n s t r a i n e d economy. These e n v i r o n m e n - t a l c h a n g e s i n f l u e n c e t h e r o l e s o f t h e p a r t i c i p a n t s i n t h e f o l l o w i n g ways: Governments now v i e w s t a n d a r d s as f i s c a l c o n t r o l d e v i c e s r a t h e r t h a n a means t o improve q u a l i t y o f c a r e o r s e r v i c e ; H o s p i t a l s have begun t o v i e w S t a n d a r d s a s m e r e l y s i m p l i f y i n g t o o l s , t o r e d u c e t h e i m p a c t r e s u l t i n g f r o m t h e f l o o d o f i n f o r m a t i o n demanded o f them i n d e a l i n g w i t h p l a n n i n g and n o t t o e n s u r e q u a l i t y o f s p a c e ; A r c h i t e c t s and P l a n n e r s use t h e S t a n d a r d s t o s p e e d up c o m m u n i c a t i o n between u s e r s o f t h e S t a n d a r d s , t o a s s i s t i n q u i c k l y r e s o l v i n g t h e i m p a c t o f c h a n g e s i n h o s p i t a l s y s t e m s , w h i l e s p e e d i n g up d e c i s i o n - m a k i n g . A r c h i t e c t s t e n d t o d i s r e g a r d t h e i r s o c i e t a l o b l i g a t i o n s t o e n s u r e S t a n d a r d s r e f l e c t d e s i r a b l e a s p e c t s o f t h e s p a c e t h e y c r e a t e , n o t j u s t t h e e x p e d i e n c y o f i t s c r e a t i o n . At one t i m e , S t a n d a r d s were c a p a b l e o f s i m p l i f y i n g d e c i s i o n - m a k i n g and, t h r o u g h c o n s i s t e n c y o f a p p l i c a t i o n , i m p r o v i n g t h e q u a l i t y o f t h e h e a l t h f a c i l i t i e s t h e y p r o - d u c e d . Today, t h e y c o m p l i c a t e d e c i s i o n - m a k i n g and a r e 4 a f f o r d e d l i t t l e o p p o r t u n i t y f o r c o n s i s t e n t a p p l i c a t i o n b e c a u s e t h e y can n o t r e s p o n d t o t h e d i v e r s e and complex n e e d s o f t h o s e who use them. In t h i s c h a p t e r we examine t h e p r e s e n t S t a n d a r d s t o d e t e r m i n e t h e i r p r o b l e m s , and t h e n p r o c e e d t o d e v e l o p new r e s p o n s i v e S t a n d a r d s . Once we have t h e s e e l e m e n t s i n p l a c e , we c a n c o n c e n t r a t e on o u r p r i m a r y o b j e c t i v e , t h e d e v e l o p m e n t o f a method t o b u i l d t h e s e new r e s p o n s i v e S t a n d a r d s . We e x p l o r e t h e p r i n c i p l e s o f s u c h a method i n t h e l a t t e r p a r t o f C h a p t e r 1 and d e v e l o p i t i n C h a p t e r 2. T h i s method i s a v a r i a t i o n o f t h e D e l p h i T e c h n i q u e , w h i c h i s an i t e r a t i v e i n q u i r i n g p r o c e s s u s i n g m u l t i p l e q u e s t i o n - n a i r e s w i t h g r o u p s o f e x p e r t s as t h e i n f o r m a t i o n r e s o u r c e . In C h a p t e r 3 we c a r r y o u t t h e s t u d y t o e n s u r e t h a t i t w i l l p r o d u c e u s a b l e S t a n d a r d s . B e f o r e we b e g i n t o examine t h e s u b j e c t i n d e p t h , an u n d e r l y i n g p r i n c i p l e must be s t a t e d . The use o f S t a n d a r d s i s i m p o r t a n t , and i f t h e y a r e a g a i n made u s e f u l i n f u t u r e y e a r s t h e y w i l l be p o w e r f u l t o o l s i n i m p r o v i n g t h e q u a l i t y o f h e a l t h f a c i l i t i e s . I t s h o u l d be c l e a r t h a t r e j e c t i o n o f S t a n d a r d s i s n o t an a c c e p t a b l e o p t i o n . The use o f S t a n d a r d s i n h e a l t h c a r e p l a n n i n g has become so i n t e g r a l a p a r t o f t h e p r o c e s s o f p l a n n i n g t h a t as Peckham s u g g e s t s , S t a n d a r d s a r e " t h e p r o c e s s o f t h e p l a n n i n g p r o c e s s " . ^ 5 S i n c e r e j e c t i n g them i s u n a c c e p t a b l e t h e y must be renewed and made p u r p o s e f u l . U n l e s s we c o l l e c t i v e l y a d d r e s s t h i s p r o b l e m , i t a p p e a r s t h e y w i l l c o n t i n u e t o be used as n e g a t i v e i n s t r u m e n t s o f d e s p e r a t e F u n d i n g A g e n c i e s w h i c h w i l l r e s u l t i n p o o r l y d e s i g n e d f a c i l i t i e s . We now p r o c e e d t o e x p l o r e some p r o b l e m s which become a p p a r e n t when one a s k s s u c h q u e s t i o n s a s : Who u s e s t h e S t a n d a r d s ? ; How r e l i a b l e a r e t h e y ? ; and How a r e t h e y b e i n g used i n Canada? T h e s e a s p e c t s a r e examined s e q u e n - t i a l l y . 1.1 Who Uses the Standards? B e g i n n i n g w i t h a r e p o r t i n O c t o b e r o f 1980, t h e A m e r i c a I n s t i t u t e o f A r c h i t e c t s ( A I A ) , Committee on A r c h - i t e c t u r e f o r H e a l t h , u n d e r t o o k t h r o u g h a s u b - c o m m i t t e e ^ t o do a c o m p r e h e n s i v e r e v i e w o f space S t a n d a r d s i n t h e U n i t e d S t a t e s . T h i s move was prompted by t h e f a c t t h a t t h e members, who a r e h e a l t h f a c i l i t y a r c h i t e c t s and p l a n n e r s f r o m a l l o v e r t h e U n i t e d S t a t e s o f A m e r i c a (USA), b e l i e v e d v e r y few S t a n d a r d s a r e b e i n g c o n s i s t e n t l y used i n t h e USA and t h o s e t h a t a r e i n use c o u l d be as much as t e n y e a r s o u t o f d a t e . 6 When t h i s s u b - c o m m i t t e e r e p o r t e d b a c k i n March o f 1981,3 some s i g n i f i c a n t f a c t s were p r o v i d e d . They 'were a b l e t o s a y t h a t t h e r e e x i s t s a body o f a c c u r a t e knowledge w h i c h encompasses some new S t a n d a r d s and m e t h o d o l o g i e s and t h e s e a r e b e i n g u s e d by p l a n n e r s t h e m s e l v e s , b u t few R e g u l a t o r y A g e n c i e s a r e i n f a c t u s i n g them. In a sample o f 29 s t a t e s , t h e com m i t t e e d i s c o v e r e d t h a t 61 p e r c e n t o f t h e H e a l t h S e r v i c e A g e n c i e s (HSAj w h i c h a r e t h e S t a t e R e g u l a t o r y A g e n c i e s , have no e s t a b l i s h e d S t a n d a r d s f o r p r o j e c t i n g g r o s s s p a c e r e q u i r e m e n t s . I t a p p e a r e d however t h a t most s t a t e s had some p u b l i s h e d n a t i o n a l r e f e r e n c e s , s u c h as t h o s e f r o m t h e Department o f H e a l t h , E d u c a t i o n and W e l f a r e (HEW), w h i c h d e s c r i b e room s i z e s i n s p e c i a l d e p a r t m e n t s . These a r e most o f t e n u s e d when making c h e c k s on l i c e n s e a p p l i c a t i o n s . I t was a l s o n o t e d t h a t 24 p e r - c e n t o f t h e HSA's had n o m i n a l S t a n d a r d s and t h a t 15 p e r - c e n t had d e t a i l e d S t a n d a r d s . T h e r e a p p e a r s t o be a v e r y r e a l c o n c e r n i n t h e USA a b o u t t h e l a c k o f c o n s i s t e n c y i n t h e a p p l i c a t i o n o f S t a n d a r d s . The AIA n o t e d i n i t s r e p o r t : "A g l a r i n g f a i l u r e o f t h e r e g u l a t i o n s w h i c h c a n n o t be d i s m i s s e d i s t h e seeming l a c k o f c o n c e r n , a t t h e . S t a t e l e v e l p a r t i c u l a r l y , o v e r e s t a b l i s h i n g s p e c i f i c g u i d e l i n e s o r m e t h o d o l o g i e s t o s e r v e as a benchmark f o r p r o j e c t i o n . " 4 C l e a r l y i n q u e s t i o n , where t h e r e a r e no c o n s i s t e n t 7 benchmarks, i s t h e c o n c e r n a s t o how h o s p i t a l s and p l a n - n e r s c a n know what w i l l be a c c e p t a b l e t o r e g u l a t o r s . W h i l e no s i m i l a r s t u d y has been u n d e r t a k e n i n Canada, we b e l i e v e p l a n n e r s and h o s p i t a l s , when d e a l i n g w i t h t h e P r o v i n c i a l Government r e v i e w a g e n c i e s , have ' s i m i l a r p r o b l e m s . The q u e s t i o n i s s i m p l y w h e t h e r a l l h o s p i t a l s a c r o s s Canada c a n e x p e c t t o be p l a n n e d f r o m a c o m p a r a b l e d a t a b a s e . In Canada, t h e h e a l t h s y s t e m has been a P r o v i n c i a l r e s p o n s i b i l i t y f r o m t h e s t a r t o f C o n f e d e r a t i o n , t h e r e f o r e no c e n t r a l ( F e d e r a l ) p l a n n i n g a u t h o r i t y e x i s t s . B e g i n n i n g w i t h i n c r e a s e d h o s p i t a l b u i l d i n g i n t h e l a t e 1950's, b u t e s p e c i a l l y s i n c e t h e mid-1960's ( w i t h t h e i n t r o d u c t i o n o f F e d e r a l l y s u p p o r t e d H e a l t h I n s u r a n c e ) , t h e e x i s t i n g r e v i e w a g e n c i e s have a t t e m p t e d t o make use o f S t a n d a r d s . In t h i s i n s t a n c e we d i f f e r f r o m t h e USA b e c a u s e S t a n d a r d s do e x i s t . However, e a c h p r o v i n c e has a l w a y s had s e p a r a t e r e s p o n s i b i l i t y f o r h e a l t h c a r e d e l i v e r y , t h e r e f o r e t h e s h a r i n g o f c u r r e n t p l a n n i n g methods have been i n f o r m a l and n o t v e r y e f f e c t i v e . The r e s u l t i s t h a t , as i n examples f r o m t h e USA, c o n s i s t e n c y i n P l a n n i n g S t a n d a r d s b e i n g u s e d a c r o s s Canada i s n o t e x t e n s i v e . O n t a r i o , a s t h e " S e n i o r P r o v i n c e " , ( c e r t a i n l y t h e one h a v i n g t h e l a r g e s t p o p u l a t i o n , ) a p p e a r s t o have m a i n t a i n e d a ' r e l a t i v e l y c u r r e n t s e t o f P l a n n i n g S t a n d a r d s . The F e d e r a l Government, t h r o u g h t h e H e a l t h 8 F a c i l i t i e s D e s i g n Group i n t h e H e a l t h S e r v i c e s and P r o m o t i o n B r a n c h o f H e a l t h and W e l f a r e Canada, has been i n s t r u m e n t a l i n d e v e l o p i n g v a r i o u s p l a n n i n g s t a n d a r d s f o r use by a l l P r o v i n c e s . These a r e n o t m a n d a t o r y and u s u a l l y have been m o d i f i e d o r a d a p t e d t o c o n d i t i o n s t h o u g h t t o be d i f f e r e n t by e a c h P r o v i n c e . The l a t e s t F e d e r a l Government g u i d e i s a F u n c t i o n a l P r o g r a m G u i d e l i n e method f o r use i n most m a j o r d e p a r t m e n t s i n h o s p i t a l s . T h i s was d e v e l o p e d w i t h t h e i n v o l v e m e n t o f C a n a d i a n H e a l t h P l a n n i n g A g e n c i e s by C h i S y s t e m s , a company f r o m Ann A r b o u r , M i c h i g a n . The method f o c u s s e s upon th e c r e a t i o n o f f o r m u l a e w h i c h t r a n s l a t e p r o j e c t e d w o r k l o a d s i n t o s p a c e needs and i s d e p e n d e n t upon agreement about c e r t a i n b r o a d a s s u m p t i o n s r e g a r d i n g h o s p i t a l o p e r a t i o n s . T h i s o p e r a t i o n s agreement i s n o t c o m p l e t e and once a g a i n t h e P r o v i n c e s a r e making m o d i f i c a t i o n s t o t h e g u i d e l i n e s . P r i o r t o t h i s e f f o r t , t h e r e have been M a t e r n a l G u i d e l i n e s , 5 and S p e c i a l C a r e U n i t G u i d e l i n e s , ^ b o t h p r o d u c e d t h r o u g h t h e e f f o r t s o f t h e F e d e r a l Government, and n o t u n i v e r s a l l y a p p l i e d by P r o v i n c e s . Our p r o b l e m , d e s p i t e t h e s e s p e c i a l e f f o r t s a t g u i d i n g t h e p l a n n i n g f o r newly i n t r o d u c e d p r o g r a m s , r e m a i n s t h e same as t h a t o f t h e USA. T h e r e has been no r e a l i m p r o v e - ment i n t h e d e v e l o p m e n t o f a common g r o u p o f S t a n d a r d s a c r o s s t h e c o u n t r y . Even t h e new F u n c t i o n a l Program 9 G u i d e s have been made P r o v i n c e - s p e c i f i c . In a n s w e r i n g t h e q u e s t i o n o f who u s e s S t a n d a r d s , i t i s c l e a r t h e r e a r e t h e H o s p i t a l s , t h e P l a n n e r s , and t h e R e g u l a t o r s . The f o r m e r two g r o u p s have a c c u m u l a t e d a body o f knowledge t o a s s i s t them i n d e v e l o p i n g t h e i r p l a n s , w h i l e t h e F u n d i n g o r P l a n n i n g R e g u l a t o r s use S t a n d a r d s t o c h e c k t h o s e p l a n s when p r e s e n t e d . One o f t h e c o n c e r n s w h i c h t h e AIA s u b - c o m m i t t e e has r e m a i n s unanswered; a r e t h e S t a n d a r d s w h i c h do e x i s t and a r e b e i n g u s e d by t h e s e g r o u p s , r e l i a b l e ? 1.2 How Reliable are the Standards? The b e s t way t o d i s c u s s t h e p r o b l e m o f r e l i a b i l i t y i s t o l o o k b r i e f l y a t t h e h i s t o r i c a l d e v e l o p m e n t o f t h e S t a n - d a r d s c u r r e n t l y i n u s e . T h i s i s f i r s t t o d i s c o v e r what i n f a c t t h e y a r e and, s e c o n d l y , how t h e y have changed t o a c c u r a t e l y r e f l e c t c u r r e n t p r a c t i c e . W i t h t h e t h r u s t o f b u i l d i n g f o r s o c i a l p r o g r a m s , p a r t i c u l a r l y i n N o r t h A m e r i c a a f t e r t h e Second W o r l d War, h o s p i t a l s were h i g h on t h e a g e n d a . W i t h t h e i n t r o d u c t i o n o f t h e C a n a d i a n N a t i o n a l H e a l t h G r a n t s Program i n 1948, f u n d s f l o w e d t o t h e p r o v i n c e s f r o m t h e F e d e r a l Government t o t h e e n c o u r a g e b u i l d i n g o f h o s p i t a l b e d s . In B r i t i s h C o l u m b i a , James A. H a m i l t o n ^ p r e p a r e d a r e p o r t on t h e 10 needs o f t h e h o s p i t a l s o f t h e P r o v i n c e , t h i s b e i n g a r e q u i r e m e n t o f t h e new a c t . T h i s h e l p e d s t a r t t h e f i r s t a s s e s s m e n t o f p r o g r a m s , s p a c e and f a c i l i t i e s , as w e l l as p r o v i d i n g a d e f i n i t i v e s t a t e m e n t o f o b j e c t i v e s . T y p i f i e d by t h e H a m i l t o n r e p o r t , t h e e a r l y p l a n n i n g S t a n d a r d s were p u b l i c a t i o n s d e s c r i b i n g h o s p i t a l r e q u i r e - ments, w r i t t e n by v a r i o u s e x p e r t s who had b u i l t t h e i r c o n s i d e r a b l e e x p e r t i s e t h r o u g h t h e b u i l d i n g o r p l a n n i n g o f h o s p i t a l s . In t h e USA s u c h S t a n d a r d s came f r o m i n d i v - i d u a l s who, l i k e R o s e n f i e l d , 8 p u b l i s h e d a h o s p i t a l p l a n - n i n g book i n 1947, o r f r o m government d e p a r t m e n t s w h i c h had c e n t r a l p l a n n i n g r o l e s , and t h u s p u b l i s h e d P l a n n i n g S t a n d a r d s . E a r l y e x a m p l e s i n t h e USA i n c l u d e t h e D e p a r t - ment o f H e a l t h , E d u c a t i o n arid W e l f a r e who p u b l i s h e d g u i d e s i n 1953 and i n Canada t h e M i n i s t r y o f H e a l t h i n O n t a r i o p r o d u c e d some i n 1954. Th e s e e a r l y S t a n d a r d s were v e r y p r e s c r i p t i v e i n a p p r o a c h , w i t h d i a g r a m s o f t y p i c a l p l a n n e d s o l u t i o n s f o r h o s p i t a l d e p a r t m e n t s and o f t e n d i a g r a m s o f whole h o s p i t a l s . The r e s u l t was t h a t s m a l l e r h o s p i t a l s , o r l e s s f i s c a l l y w e l l s u p p o r t e d a g e n c i e s i n N o r t h A m e r i c a (and e l s e w h e r e i n t h e w o r l d ) , r e a d i l y a d o p t e d t h e g u i d e - l i n e s as an e c o n o m i c a l p l a n n i n g a p p r o a c h b u t w i t h o u t c r i t i c a l e v a l u a t i o n . The h o s p i t a l s ' s i z e s and d e s i g n s r e f l e c t e d t h e l a t e s t N o r t h A m e r i c a n s y s t e m s and t e c h n o l - ogy. T h i s r e s u l t e d i n h o s p i t a l s h a v i n g d i f f i c u l t y o p e r a t - 11 i n g w i t h l e s s s o p h i s t i c a t e d much m o d i f i c a t i o n f r o m t h e c o n s e q u e n c e s r e s u l t i n g . methods o r t h e i r r e q u i r i n g g u i d e l i n e s w i t h u n f o r e s e e n By t h e e a r l y 1960*s, a more a p p r o p r i a t e m e t h o d o l o g y was d e v e l o p e d . Two b o o k s a p p e a r e d w h i c h became m i l e s t o n e s i n h o s p i t a l p l a n n i n g ; E s t i m a t i n g Space Needs and C o s t s i n G e n e r a l H o s p i t a l C o n s t r u c t i o n by James J . S o u d e r , ^ was p u b l i s h e d i n 1963; and H o s p i t a l D e s i g n and F u n c t i o n by E. Todd W h e e l e r , 1 ° was p u b l i s h e d i n 1964. These p u b l i c a t i o n s t a l k e d a b o u t s p a c e r e l a t e d a s p e c t s o f t h e f u n c t i o n s t a k i n g p l a c e i n h o s p i t a l s and p r o v i d e d , f r o m t h e a u t h o r s ' own r e s e a r c h i n t o numerous h o s p i t a l s , recommended s i z e s f o r h o s p i t a l d e p a r t m e n t s . The s i z i n g f o r m u l a t h e y p r o p o s e d c r e a t e d p r o j e c t i o n s o f s p a c e , b a s e d on a recommended amount o f a r e a ( s q u a r e f e e t ) p e r b e d . T h i s meant, v e r y s i m p l i s t i c a l l y , t h a t a h o s p i t a l o f a c e r t a i n s i z e ( i n t e r m s o f t h e bed complement) c o u l d d e t e r m i n e t h e s p a c e needs f o r e a c h d e p a r t m e n t , o r i n some c a s e s t h e rooms, by s i m p l y m u l t i p l y i n g a s u g g e s t e d a r e a by t h e number o f b e d s . T h i s m e t h o d o l o g y was a d o p t e d i n b o t h t h e U n i t e d S t a t e s and Canada. In b o t h c o u n t r i e s , t h e r o l e o f t h e R e g u l a t o r y A g e n c i e s i n v o l v e d , was t o r e v i e w and a p p r o v e o v e r a l l a r e a s f o r t h e p u r p o s e o f f u n d i n g e s t i m a t e s , s o t h e " S o u d e r - W h e e l e r " numbers were most u s e f u l . 12 F o r a p p r o x i m a t e l y t e n y e a r s i n t o t h e e a r l y 1970's t h e s e g u i d e s p r o v e d t o be a p p r o p r i a t e f o r t h e l e v e l o f r e v i e w g i v e n by a g e n c i e s . In B r i t i s h C o l u m b i a , a number o f h o s p i t a l s b u i l t between 1964 and 1979 u s e d t h e s e G u i d e - l i n e s i n d e t e r m i n i n g d e p a r t m e n t a l s i z e s . However, as t h e AIA-CAH s u b - c o m m i t t e e d i s c o v e r e d , 1 1 h o s p i t a l s o f 200 t o 300 beds between 1972 and 1979 s h o u l d have had many d e p a r t m e n t a l s p a c e s i n c r e a s e d by as much as 50 p e r c e n t o v e r t h e s e G u i d e l i n e s , and t y p i c a l l y , f r o m a p p r o x i m a t e l y 700 s q . f t . o f g r o s s a r e a t o j u s t l e s s t h a n 1,000 s q . f t . g r o s s p e r bed, f o r t h e whole h o s p i t a l . The i n c r e a s e was n e c e s s a r y t o r e f l e c t c h a n g e s t h a t had o c c u r r e d i n p r o g r a m s and S u p p o r t Space a r e a s . U n f o r t u n a t e l y , t h e AIA d i s c o v e r - ed t h a t t h e R e g u l a t o r y A g e n c i e s i n t h e USA, w h i c h do have P l a n n i n g S t a n d a r d s i n most i n s t a n c e s , a r e s t i l l r e f l e c t i n g 1972 s i z e s w h i c h means t h e s e S t a n d a r d s a r e as much as t e n y e a r s o u t o f d a t e . The p r o b l e m i s o n l y m a r g i n a l l y b e t t e r i n B r i t i s h C o l u m b i a . I t i s o n l y now, s i n c e 1980 and 1981, t h a t t h e M i n i s t r y o f H e a l t h , H o s p i t a l P r o g r a m s , has f o r m a l l y r e c o g - n i z e d l a r g e r s p a c e n e e d s i n h o s p i t a l s , i . e . , above t h e 700 s q . f t . o v e r a l l a r e a s , f o r o t h e r t h a n t e a c h i n g h o s p i t a l s . F o r c e r t a i n i n d i v i d u a l h o s p i t a l s , s p e c i f i c d e p a r t m e n t s have been e n l a r g e d where new e q u i p m e n t has r e c e n t l y been d e v e l o p e d and where j u s t i f i c a t i o n f o r u n u s u a l s i z e s c o u l d 13 be made by t h e i n d i v i d u a l h o s p i t a l . I t i s t h e e x p e r i e n c e o f B.C. h o s p i t a l p l a n n e r s t h a t many new d e p a r t m e n t s have been p l a n n e d t o i n a d e q u a t e s i z e s . I t s h o u l d be remembered t h a t i t i s f r o m t h e H o s p i t a l Review A g e n c i e s i n e a c h P r o v i n c e o f Canada t h a t p l a n n e r s must s e e k a p p r o v a l f o r a l l o f t h e a r e a s t h a t t h e y w i s h t o b u i l d . T y p i c a l l y , i f a h o s p i t a l d e p a r t m e n t c a n be shown t o r e q u i r e a c e r t a i n number o f rooms and t h e i r combined a r e a s amount t o t h e o v e r a l l a c c e p t a b l e a r e a a s s i g n e d by t h e p a r t i c u l a r g overnment s t a n d a r d , ( u s i n g t h e a r e a p e r bed f o r m u l a ) , t h e r e i s no p r o b l e m w i t h a c c e p t a b i l i t y o f t h e s p a c e . I f , however, t h e h o s p i t a l l o o k s a t i t s method o f o p e r a t i o n and d e c i d e s t h a t c e r t a i n a d d i t i o n a l s p a c e s a r e needed t o r e f l e c t some new p h i l o s o p h y , t h e y w i l l have a p r o b l e m . I f t h e y a r e n o t p r e p a r e d t o r e l i n q u i s h o t h e r s p a c e s t o meet t h e o v e r a l l a r e a g i v e n by t h e S t a n d a r d s , t h e y a r e l i k e l y t o have t h e i r s p a c e r e q u e s t r e j e c t e d . I t s h o u l d be r e a l i z e d , however, t h a t r e j e c t i o n p e r se i s n o t a u t o m a t i c a l l y a bad t h i n g as i t i s w e l l r e c o g n i z e d t h a t h o s p i t a l s , when p l a n n i n g , r e c e i v e p r e s s u r e s f r o m s p e c i a l i n t e r e s t g r o u p s t o o v e r s i z e s p a c e s , and c l e a r l y t h e c u r t a i l m e n t o f t h i s o v e r s i z i n g i s t h e p r i m e p u r p o s e o f Government Review. The m a j o r c o n c e r n i s one o f p r i n c i p l e . I f S t a n d a r d s 14 a r e t o be u s e d t o d e t e r m i n e a c c e p t a n c e o f p l a n n e d a r e a s i n h o s p i t a l s , and c o n s e q u e n t l y t h e i r r e l a t e d methods o f o p e r a t i o n , t h e S t a n d a r d s must be c u r r e n t and r e l i a b l e . I t i s t r u e t h a t i n some i n s t a n c e s t h e a r e a s p e r bed have e v e n t u a l l y been u p g r a d e d t o i n c l u d e s p a c e f o r more modern s y s t e m s o r t o r e f l e c t d i f f e r e n c e s i n h o s p i t a l s i z e and r o l e , however, t h e r e i s s t i l l t h e p r o b l e m r e c o g n i z e d i n t h e AIA s t u d y , t h a t t h e p r o c e s s t a k e s t o o l o n g . I t i s e v i d e n t t h a t i n t h e C a n a d i a n H e a l t h F a c i l i t i e s P l a n n i n g p r o c e s s , a r e v i e w o f a S t a n d a r d o n l y o c c u r s a f t e r t h e r e has been numerous a t t e m p t s by h o s p i t a l s , h o s p i t a l p l a n n e r s and m e d i c a l u s e r s , t o have a change i n a p p r o a c h r e c o g n i z e d . Once t h i s r e v i e w o c c u r s i t s t i l l t a k e s y e a r s t o be a c c e p t e d . T h i s k i n d o f d e l a y may have been a c c e p t a b l e f i f t e e n y e a r s ago, o r e v e n t e n y e a r s ago, b u t n o t now. When i t t a k e s f r o m t h r e e t o e i g h t y e a r s t o d e s i g n and b u i l d f a c i l i t i e s f o r w h i c h p l a n n i n g must p r e d i c t t h e needs f i v e y e a r s p a s t t h e i r c o m p l e t i o n d a t e , i t i s n o t p o s s i b l e t o a c c e p t d e s i g n S t a n d a r d s w h i c h a r e up t o t e n y e a r s o u t o f d a t e a t t h e s t a r t i n g p o i n t . The i n i t i a l q u e s t i o n we p o s e d was r e l a t e d t o t h e r e l i a b i l i t y o f t h e P l a n n i n g S t a n d a r d s . The u n f o r t u n a t e answer i s t h e y a r e n o t r e l i a b l e b e c a u s e t h e y do n o t a l w a y s r e f l e c t c u r r e n t o p e r a t i o n a l c o n c e r n s and t h e r e f o r e s p a c e s a s s i g n e d by t h e S t a n d a r d s a r e f r e q u e n t l y t o o s m a l l o r 15 i n a p p r o p r i a t e . In h i g h l y t e c h n i c a l a r e a s s u c h as l a b o r a t o r i e s and r a d i o l o g i c a l d e p a r t m e n t s , t h e r e i s a n o t i c e a b l e and s i g n i f i c a n t e x c e p t i o n . The M i n i s t r y o f H e a l t h i n B.C. h a s A d v i s o r y G r o u p s t o d e a l w i t h R a d i o l o g y and L a b o r a t o r y p l a n n i n g , 1 2 w h i c h i n c l u d e r e p r e s e n t a t i v e s o f t h e u s e r p r o f e s s i o n s . T hese p a r t i c u l a r g r o u p s have k e p t t h e s p a c e S t a n d a r d s up t o d a t e . T h i s i s most i n t e r e s t i n g , i n t h a t w i t h o u t c u r r e n t " u s e r " i n p u t t h e M i n i s t r y r e c o g n i z e s t h e i r i n a b i l i t y t o d e a l a p p r o p r i a t e l y w i t h r a p i d l y c h a n g i n g and complex s p a c e needs o f t h e s e t e c h n o l o g i e s , y e t t h i s i s c e r t a i n l y n o t so i n o t h e r a r e a s . I t i s n o t i c e a b l e i n a r e a s where t h e B.C. M i n i s t r y o f H e a l t h P l a n n i n g C o n s u l - t a n t s f e e l c o n f i d e n t t h a t i t i s n o t c r i t i c a l t o p e r i o d i c - a l l y change t h e i r p o l i c i e s ( e . g . , g e n e r a l n u r s i n g p o l i c y , v a r i o u s s u p p l y s y s t e m s p o l i c i e s , e t c . ) , t h a t any s o u r c e o f c o n s t a n t i n p u t by t h e p e o p l e who use h o s p i t a l f a c i l i t i e s i s n o t h i g h l y r e g a r d e d . T h i s a t t i t u d e c a u s e s p l a n n i n g p o l i c y w i t h i n t h e Government t o r e m a i n f i x e d f o r l o n g p e r i o d s o f t i m e . 1.3 How are Standards Being Used i n Canada? We have o b s e r v e d t h a t S t a n d a r d s e x i s t i n g i n Canada 16 a r e n o t a p p l i e d c o n s i s t e n t l y a c r o s s t h e c o u n t r y and as i n tihe USA, t h e r e i s a r e a l c o n c e r n a b o u t t h e i r r e l i a b i l i t y . Why t h e n a r e p l a n n e r s demanding t h a t S t a n d a r d s be c o n s i s - t e n t l y a p p l i e d when t h e y a r e a l r e a d y c o n c e r n e d a b o u t t h e r e l i a b i l i t y o f t h e ones t h a t e x i s t ? The f a c t i n h e r e n t i n t h i s demand f o r c o n s i s t e n c y i s t h e b e l i e f t h a t a g e n c i e s u s i n g E x i s t i n g S t a n d a r d s w i l l b r i n g them i n t o l i n e w i t h New S t a n d a r d s a l r e a d y a v a i l a b l e , b u t n o t u s e d , and i t i s b e l i e v e d a g e n c i e s n o t u s i n g S t a n d a r d s w i l l a d o p t t h e New S t a n d a r d s . In t h e p a s t , we have s e e n t h a t b o t h P l a n n e r s and R e g u l a t o r s d i d use t h e same i n d e p e n d e n t l y d e v e l o p e d r e s o u r c e m a t e r i a l . However, i n t o d a y ' s p l a n n i n g e n v i r o n - ment, n o t o n l y do t h e needs o f t h e g r o u p s u s i n g S t a n d a r d s d i f f e r , b u t t h e S t a n d a r d s t h e m s e l v e s a r e n o t t h e same. I t i s c r i t i c a l t h a t we b e g i n making a d i s t i n c t i o n between two d i f f e r e n t t y p e s o f S t a n d a r d s . The S t a n d a r d s t h a t P l a n n e r s and h o s p i t a l s need a r e e s s e n t i a l f o r t h e i r u s e f u l n e s s i n t h e c o m p a r i s o n o f o p e r a t i o n a l methods and t h e r e s u l t a n t s p a c e n e e d s . These a r e c o m m u n i c a t i o n t o o l s u s e d t o e n s u r e t h a t s h a r e d e x p e r i e n c e w i l l i n c r e a s e t o t a l k n owledge and t h a t when a p p l i e d t o a p r o b l e m t h e b e s t s o l u t i o n w i l l r e s u l t . The o t h e r k i n d o f S t a n d a r d i s used by t h e F u n d i n g and P l a n n i n g A u t h o r i t i e s . These a r e u s e d t o c h e c k f o r c o m p l i a n c e w i t h a P l a n n i n g "Norm", e s t a b l i s h - ed by t h e s e a g e n c i e s , a s a measure o f t h e i r a c c e p t a b l e 17 minimum r e q u i r e m e n t s . The S t a n d a r d used by P l a n n e r s i s an O p t i m a l G u i d e l i n e , t h e one us e d by t h e A u t h o r i t i e s i s a M i n i m a l S t a n d a r d . I t i s c l e a r t h a t o v e r t h e l a s t t e n y e a r s , t h e G u i d e l i n e s w h i c h have been s h a r e d by P l a n n e r s a r e c o n s t a n t l y e v o l v i n g and have l e f t t h e more s t a t i c S t a n d a r d s b e h i n d . In o r d e r t o r e i n f o r c e t h e d i f f e r e n c e i n t h e n a t u r e o f t h e p u r p o s e s o f t h e s e two forms o f g u i d e , i t i s i m p o r t a n t t o d i f f e r e n t i a t e d i s t i n c t l y between t h e terms G u i d e l i n e and S t a n d a r d . The AIA t h r o u g h t h e i r s t u d y have begun t o r e c o g n i z e t h a t t h e R e g u l a t o r y A g e n c i e s have S t a n d a r d s w h i c h do n o t r e s e m b l e t h e p r e s e n t G u i d e l i n e s u s e d by P l a n n e r s . The r e a s o n i s t h a t i n most c a s e s up u n t i l t h e i n t r o d u c t i o n o f r e c e n t l e g i s l a t i o n i n t h e USA, 1^ t h e r e has been l i t t l e need f o r r e g u l a t o r y s t a n d a r d i z a t i o n . N o t a b l y , t h e S t a n d a r d s t h a t do e x i s t .have come f r o m s u c h a g e n c i e s as t h e Department o f V e t e r a n s A f f a i r s , who l i k e t h e C a n a d i a n P r o v i n c e s , a r e t h e m s e l v e s f u n d i n g t h e c o n s t r u c t i o n o f f a c i l i t i e s . - I t i s n o t s u r p r i s i n g t h a t when r e q u i r e d t o a p p r o v e r e q u e s t s f r o m P l a n n e r s f o r h o s p i t a l s p a c e , t h e H e a l t h S e r v i c e A g e n c i e s (HSA) have c h o s e n t o use t h e a v a i l a b l e documents, a l r e a d y p r o v e n t o be a c c e p t a b l e , s u c h a s t h e S o u d e r W h e e l e r f o r m u l a , p l u s some c u r r e n t HEW G u i d e s . S o p h i s t i c a t e d A g e n c i e s and P l a n n e r s have p i c k e d up t h e e x i s t e n c e o f any f l a w s i n t h e S t a n d a r d s t h e y a r e u s i n g , and a r e making c h a n g e s , w h i l e o t h e r s have n o t . 18 The C a n a d i a n A g e n c i e s were f o r c e d i n t o t h i s s i t u a t i o n e a r l i e r and i n t h e l a s t t e n y e a r s have s l o w l y s t a r t e d t o c l o s e t h e gap between S t a n d a r d s and G u i d e l i n e s . In f u r - t h e r s u p p o r t o f t h e i d e a t h a t a S t a n d a r d / G u i d e l i n e d i f f e r - e n t i a t i o n i s a v a l i d c o n c e p t , t h e new C a n a d i a n P r o g r a m G u i d e l i n e s ( C h i S y s t e m s M e t h o d o l o g y ) have been d e s i g n e d as a d e l i b e r a t e s t e p t o w a r d c l o s i n g t h i s m e t h o d o l o g y gap. The new S t a n d a r d i s s u p p o s e d t o be a G u i d e l i n e f o r b o t h P l a n n e r s and G o v e rnments and u s e s d e p a r t m e n t a l w o r k l o a d s as a b a s i s f o r d e t e r m i n i n g f u n c t i o n a l and s p a c e r e q u i r e - ments. T h i s i s a s i g n i f i c a n t improvement o v e r th e o l d S o u d e r - W h e e l e r f o r m u l a o f s p a c e p e r bed. The o b v i o u s a d v a n t a g e i s t h e method's r e c o g n i t i o n o f programs which r e l a t e t o o u t p a t i e n t s , who c r e a t e w o r k l o a d and s p a c e needs t h a t do n o t a f f e c t i n p a t i e n t demands (number o f b e d s ) . W i t h t h e move t o more o u t p a t i e n t s e r v i c e s , b e d - b a s e d c a l c u l a t i o n s a r e i n a p p r o p r i a t e and have o f t e n been r e s t r i c t i v e o f o p p o r t u n i t i e s f o r p r o g r a m i n n o v a t i o n s . L i k e Canada, as t h e r e a l i z a t i o n o f t h e need f o r c u r r e n t S t a n d a r d s o c c u r s i n t h e USA, t h e more s o p h i s t i c a t e d HSA's have s o u g h t b e t t e r r e s o u r c e s . The two most c u r r e n t r e s o u r c e s w h i c h a r e c l o s e s t t o G u i d e l i n e s , a r e t h e 1979 C h i c a g o H o s p i t a l C o u n c i l R e p o r t and t h e S t a n d a r d s o f t h e N o r t h e r n I n d i a n a H e a l t h S y s t e m s Agency. T h e s e r e s o u r c e s a r e now f i n d i n g a p p l i c a t i o n i n t h e USA H e a l t h P l a n n i n g S y s t e m . 19 When we l o o k a t t h e use o f S t a n d a r d s and G u i d e l i n e s one c o n c e r n r e m a i n s u n a d d r e s s e d . I s i t p o s s i b l e t h a t i f we do r e a c h a p o i n t where G u i d e l i n e s a r e b u i l t i n t o S t a n d a r d s , t h e r e b y e n a b l i n g R e g u l a t i n g A g e n c i e s and P l a n n e r s t o s h a r e t h e same body o f knowledge, t h e p l a n n i n g p r o c e s s w i l l p r o c e e d s m o o t h l y ? We have e v i d e n c e w h i c h i n d i c a t e s t h e r e i s d o u b t t h a t t h i s w i l l o c c u r . W h i l e i t i s c l e a r t h a t s u c h a body o f knowledge i s e s s e n t i a l , i t w i l l n o t s o l v e t h e p r o b l e m w i t h p r e s e n t S t a n d a r d s them- s e l v e s . J u s t b e c a u s e a p o i n t i s r e a c h e d where t h e new S t a n d a r d s a r e p u t i n p l a c e , t h e r e i s n o t h i n g t o e n s u r e t h a t when t h e s e a r e o u t d a t e d f u r t h e r change w i l l c o n t i n u e t o o c c u r . We a r e c o n s t a n t l y aware t h a t b e i n g o v e r l y r i g i d i s s t i l l a m a j o r c a u s e o f c o n c e r n w i t h t h e D e s i g n S t a n d a r d s . As Peckham p o i n t s o u t , ^ t h e c o n s t a n t impact o f new c o n - c e p t s , methods and e q u i p m e n t , w h i c h a p p e a r s t o be a c c e l e r - a t i n g i n r e c e n t y e a r s , has thrown t h e p l a n n i n g p r o c e s s i n - t o a T o f f l e r i a n " f u t u r e s h o c k " . S t a n d a r d s t h a t have been t r a d i t i o n a l l y used i n p l a n n i n g now s e r v e e i t h e r as a p o i n t o f d e p a r t u r e o r c o n s t a n t a d d i t i o n s and c h a n g e s t o them l e a d o n l y t o e v e n t u a l l y i g n o r i n g them a l t o g e t h e r . T h i s h i s t o r i c a l p r o b l e m w h i c h s u g g e s t s t h a t t h e gap between G u i d e l i n e s ( w h i c h do r e s p o n d t o c u r r e n t knowledge) and S t a n d a r d s (which do n o t ) , can n e v e r p e r m a n e n t l y be 20 c l o s e d . U n l e s s we can d e v e l o p f l e x i b l e S t a n d a r d s , • i t w ould a p p e a r t h a t a s s o o n a s t h e gap d o e s c l o s e i t w i l l soon open up a g a i n . To b e t t e r a p p r e c i a t e t h i s p r o b l e m we c a n l o o k a t how t h e a p p l i c a t i o n o f t h e B r i t i s h C o l u m b i a E x t e n d e d C a r e G u i d e l i n e has f a i l e d . I n 1974, a B r i t i s h C o l u m b i a G u i d e l i n e f o r p r o g r a m - ming, p l a n n i n g , and s i z i n g E x t e n d e d C a r e U n i t s (ECU) was p r o d u c e d . T h i s was d e v e l o p e d c o o p e r a t i v e l y between t h e M i n i s t r y o f H e a l t h ' s p l a n n e r s and t h e H e a l t h F a c i l i t i e s Committee o f t h e A r c h i t e c t u r a l I n s t i t u t e o f B.C. I t was presumed by t h e a r c h i t e c t s t o be a g e n u i n e a t t e m p t t o p r o d u c e a G u i d e l i n e t h a t would p r o v i d e o p t i m a l s p a c e s f o r r e s i d e n t s o f t h e s e f a c i l i t i e s . I t s s i z e s were b a s e d upon r e s e a r c h c a r r i e d o u t a t t h e t i m e . 15 I t was a l s o t o be a way o f a s s i s t i n g w i t h t h e s i m p l i f i c a t i o n o f t h e p r o c e s s o f c o m m u n i c a t i n g between the M i n i s t r y , t h e h o s p i t a l s , and t h e p l a n n e r s . T h i s example i s t h e n an ' i d e a l ' S t a n d a r d w h i c h i s b a s e d upon c o o p e r a t i v e G u i d e l i n e s and t h e gap was c l o s e d between t h e two. The c o v e r i n g p a g e s o f t h e g u i d e e v e n s t a t e s t h a t i t i s n o t t o be a r i g i d document and t h a t t h e p r a c t i c a l use o f i t w i l l l e a d t o r e v i s i o n s . T h i s h a s n o t been t h e c a s e . I f a n y t h i n g , t h e g u i d e g ave t h e M i n i s t r y o f H e a l t h t h e o p p o r t u n i t y t o s t o p d i s c u s s i n g ECU n e e d s . D e s p i t e c o n s t a n t c o m p l a i n t s by 21 u s e r s and p l a n n e r s , t h e r e was l i t t l e f o r m a l r e c o g n i t i o n by g overnment u n t i l a b o u t 1980, t h a t t h e g u i d e r e f l e c t e d a c u s t o d i a l model o f c a r e and d i d n o t i n c l u d e s p a c e s f o r some n e c e s s a r y a c t i v a t i o n p r o g r a m s . The o p p o r t u n i t y t o d e v e l o p new b u i l d i n g s w h i c h c o u l d i n c o r p o r a t e s u c h c h a n g e s o c c u r r e d i n 1975. These c h a n g e s were f i r s t p r o p o s e d f o r t h e D e l t a E x t e n d e d C a r e U n i t i n t h a t y e a r and a g a i n i n 1979 when t h e Shaughnessy H o s p i t a l r e q u e s t e d t h e o p p o r - t u n i t y t o d e v e l o p a new a p p r o a c h t o t h e i r u n i t . On b o t h o c c a s i o n s t h e M i n i s t r y o f H e a l t h r e f u s e d t o c o n s i d e r a n y t h i n g b u t an e x a c t t r a n s l a t i o n o f t h e ECU G u i d e l i n e . The a p p l i c a t i o n o f t h e r i g i d G u i d e l i n e was c o n s i d e r e d t o be a c o s t - s a v i n g a p p r o a c h a t D e l t a . The M i n i s t r y o f H e a l t h n o t o n l y e n f o r c e d t h e G u i d e l i n e , b u t a l s o i n s i s t e d t h a t t h e p l a n s and d r a w i n g s o f a u n i t p r e v i o u s l y b u i l t a t Kamloops must be b u i l t a t D e l t a . In t h e e n d , c h a n g e s r e q u i r e d by l o c a t i o n a l d i f f e r e n c e s r e d u c e d t h e d i r e c t c o s t - b e n e f i t , and t h e i n h e r e n t f u n c t i o n a l p r o b l e m s w h i c h were r e p e a t e d , were i g n o r e d . T h i s r e p e t i t i o n o f ECU u n i t s has o c c u r r e d on a number o f o c c a s i o n s s u p p o r t e d by t h e i d e a t h a t t h e G u i d e l i n e i s f i x e d and t h e r e f o r e t h e government may as w e l l s a v e a b o u t f o u r p e r c e n t o f p r o j e c t c o s t i n r e d u c e d c o n s u l t a n t s ' d e s i g n f e e s . We b e g i n t o see h e r e a use f o r S t a n d a r d s by g o v e r n m e n t w h i c h i s c o n t r a r y t o t h e o b j e c t i v e s o f b o t h t h e 2 2 H o s p i t a l s and the P l a n n e r s . U n l e s s t h e s e S t a n d a r d s can be u sed as a p o i n t o f r e c o n c i l i a t i o n , t h e y w i l l f a i l as d e v i c e s t o improve p l a n n i n g and w i l l r e m a i n t o o l s o f r e s t r i c t i o n , i n t h e hands o f government. R e s t r i c t i o n and c o n t r o l i s n o t w i t h o u t p u r p o s e . I t i s u s u a l l y a r g u e d by r e g u l a t o r s t h a t t h e r e s t r i c t i o n s c r e a t e d by m a n d a t o r y S t a n d a r d s w i l l h e l p t o r e d u c e t h e i m pact o f what a u t h o r i t i e s c o n s i d e r t o be "run-away" c h a n g e s and t h e r e f o r e c o s t s o c c u r r i n g t o H e a l t h C a r e b u i l d i n g s . I t i s c l e a r t h a t t h i s i s s u b s t a n t i a l l y t h e m o t i v a t i o n o f g overnment a g e n c i e s who a r e f o r m a l i z i n g t h e s e g u i d e s . Where a u t h o r i t i e s have a t l e a s t t h e power t o d e l a y p r o j e c t s and most o f t e n t h e c a p a b i l i t y t o r e f u s e t o c o s t - s h a r e i n a p r o j e c t , t h i s i s a p o w e r f u l c o n t r o l t o o l . The r e s t r a i n t w h i c h g o v e r n m e n t ' s d e s i r e i s n o t an u n r e a s o n a b l e o b j e c t i v e c o n s i d e r i n g t h e c o n t i n u e d growth o f t e c h n i c a l change w h i c h a p p e a r s t o be an i n d e p e n d e n t (and hence u n c o n t r o l l e d ) v a r i a b l e i n h e a l t h c o s t s . ^ I t would a l s o a p p e a r t h a t t h e p o i n t o f d i m i n i s h i n g r e t u r n s w i t h r e s p e c t t o m o r t a l i t y has a l r e a d y been r e a c h e d f o r m e d i c a l t e c h n o l o g y . However, i n t h e i r d e s i r e t o c o n t r o l t h e c a p i t a l c o s t v a r i a b l e and t h e r e f o r e h o p e f u l l y t o s t o p o p p o r t u n i t i e s f o r i n c r e a s e s i n o p e r a t i n g c o s t s , Government a r e b e i n g o v e r l y s i m p l i s t i c . I t has a l r e a d y been shown t h a t o t h e r u n c o n t r o l l e d s y s t e m v a r i a b l e s ( s u c h as 23 p h y s i c i a n c o n t r o l o v e r t e c h n o l o g y c h o i c e s ) a r e h a v i n g g r e a t e r c o s t i m p a c t on t h e System,17 a n < 3 t h e r e f o r e g o v e r n m e n t s must r e a l i z e t h a t o t h e r mechanisms must be put i n p l a c e t o r e d u c e c o s t s . I t w i l l need a m a j o r h e a l t h s y s t e m r e s t r u c t u r i n g t o r e d u c e c o s t s i n t h e way t h a t t h e a u t h o r i t i e s d e s i r e b u t have n o t as y e t a d d r e s s e d . R e s t r i c t i o n i s c o n s i s t e n t w i t h t h e c u r r e n t p e r c e p t i o n o f g overnment r o l e i n p l a n n i n g . T h a t d o e s n o t mean a f l e x i b l e S t a n d a r d c a n n o t e x i s t w h i c h accommodates a l l p a r t i c i p a n t s ' n e e d s . An u n f o r t u n a t e t r u t h has become c l e a r . Even i f t h e S t a n d a r d s a r e c r e a t e d t o be l i k e G u i d e l i n e s , t h e r e s u l t i n g p r o d u c t i s n o t c a p a b l e o f change so we a r e s t u c k w i t h a gap between S t a n d a r d s and G u i d e l i n e s ; b u t why i s t h i s ? We have o t h e r k i n d s o f S t a n d a r d s — E l e c t r i c a l S a f e t y S t a n d a r d s , Equipment H a z a r d S t a n d a r d s , R a d i a t i o n L e v e l S t a n d a r d s , e t c . , w h i c h a r e r e g u l a r l y u p d a t e d and o f t e n a r e r e g u l a t e d by law t o a f a r g r e a t e r e x t e n t t h a n D e s i g n S t a n - d a r d s . What i s i t a b o u t t h e D e s i g n G u i d e l i n e s o r S t a n - d a r d s t h a t makes them so i n f l e x i b l e ? The answer l i e s w i t h t h e d e v e l o p m e n t a l b a c k g r o u n d o f D e s i g n S t a n d a r d s w h i c h i s v e r y d i f f e r e n t f r o m T e c h n i c a l S a f e t y S t a n d a r d s . W i t h T e c h n i c a l S a f e t y S t a n d a r d s , t h e r e a d i l y q u a n t i f i a b l e b a s i s a l l o w s s p e c i f i c , r e a l l i m i t s t o 24 be r e c o g n i z e d i n e v e r y a p p l i c a t i o n . T h i s i s b e c a u s e the same v a r i a b l e s a r e a l w a y s p r e s e n t f r o m a p p l i c a t i o n t o a p p l i c a t i o n . F o r example, an ungrounded m o n i t o r l e a d w i l l a l w a y s c a u s e a r r y t h m i a and c a r d i a c a r r e s t i f a l a r g e enough amount o f c u r r e n t l e a k s from e l e c t r i c a l e q u i p m e n t . I t c a n be m e a sured, a s a f e l i m i t g i v e n and p r e c a u t i o n s s e t down f o r e v e r y a p p l i c a t i o n . I t does not m a t t e r i n w h i c h h o s p i t a l , i n w h i c h c o u n t r y o r o f t e n w h i c h p i e c e o f e q u i p - ment i s c a u s i n g t h e l e a k , a c u r r e n t o f a c e r t a i n l e v e l w i l l a l w a y s c a u s e d e a t h . D e s i g n S t a n d a r d s a r e t r y i n g t o d e f i n e t h e same s o r t s o f l i m i t s as T e c h n i c a l S t a n d a r d s t h r o u g h i d e n t i f y i n g d e l e - t e r i o u s r e s u l t s w h i c h o c c u r a s a r e s u l t o f t h e i n c o r r e c t a r r a n g e m e n t o f o b j e c t s o r e v e n t s w i t h i n a s p a c e . The D e s i g n S t a n d a r d i s r e q u i r e d t o d e s c r i b e what a r r a n g e m e n t s a r e i n c o r r e c t , o r s t a t e t h e amount o f s p a c e r e q u i r e d t o a v o i d t h e s e n e g a t i v e e f f e c t s . The r e a l p r o b l e m i s t h a t t h e outcomes a r e n o t a l w a y s q u a n t i f i a b l e . We can see i n e x a m i n i n g t h e r e s u l t s o f bad p l a n n i n g , t h a t t h e s e d e l e t e r - i o u s outcomes may o n l y have e m o t i o n a l and t h e r e f o r e u n m e a s u r a b l e e f f e c t s — e . g . , t o o l i t t l e s p a c e c a u s e s c r o w d i n g , f u n c t i o n s c o n t i n u e but a t enormous l e v e l s o f s t a f f s t r e s s . O f t e n what i s i d e n t i f i e d as a p r o b l e m i n one s i t u a t i o n , even where a l l t h e same v a r i a b l e s seem t o be p r e s e n t , may n o t be c a u s i n g t h e same c o n c e r n i n a n o t h e r 25 s i t u a t i o n . In e f f e c t , D e s i g n S t a n d a r d s a r e an a t t e m p t t o r e g u l a t e , i n some p r a g m a t i c way, e v e n t s w h i c h a r e amor- phous and s u b j e c t i v e . What becomes c l e a r i n D e s i g n S t a n d a r d s i s t h a t t h e y do n o t d e s c r i b e s p e c i f i c outcomes o f an e v e n t , b u t d e s i r e d outcomes o f an e v e n t . I f t h i s f a c t has not been r e a l i z e d by t h e p e o p l e who d e v e l o p D e s i g n S t a n d a r d s t h e n some o f t h e p r o b l e m s w i t h t h e i r i n f l e x i b i l i t y become c l e a r . S i n c e t h e p r e o c c u p a t i o n i n S t a n d a r d s i s w i t h s c i e n t i f i c a l l y m e a s u r a b l e outcomes, t h e y g e n e r a l l y l i m i t t h e m s e l v e s t o d e s c r i b i n g t h e o u tcomes. They g e n e r a l l y do n o t d e s c r i b e what r e l a t i o n s h i p e x i s t s between t h e e v e n t ' t h a t i s b e i n g c o n t r o l l e d and t h e outcome r e q u i r e d . T h i s may be a c c e p - t a b l e i n T e c h n i c a l S a f e t y S t a n d a r d s where the r e l a t i o n s h i p o f e v e n t t o outcome i s c o n s t a n t , however i t i s u n a c c e p - t a b l e i n D e s i g n where t h e r e l a t i o n s h i p i s not c o n s t a n t . I f D e s i g n S t a n d a r d s o n l y s t a t e what must be done t o s o l v e t h e p r o b l e m , t h e n t h e v e r y a s p e c t r e q u i r i n g d e s i g n f l e x i b i l i t y i s i g n o r e d s i n c e s o l v i n g p r o b l e m s i s t h e p u r p o s e o f b u i l d i n g d e s i g n . I t i s u n a c c e p t a b l e f o r a D e s i g n S t a n d a r d t o i g n o r e t h e p r o c e s s o f d e s i g n . Even i f we w i s h t o a c h i e v e more p r e c i s i o n by s e p a r a t i n g t h e P r o c e s s o f D e s i g n o f b u i l d i n g s i n t o a P r e - D e s i g n p h a s e , ^ i n w h i c h p r o b l e m s a r e s c i e n t i f - 26 i c a l l y a n a l y z e d , and t h e D e s i g n Phase i n w h i c h t h e y a r e s u b j e c t i v e l y s o l v e d , t h e two p a r t s f o r m an i n t e r d e p e n d e n t c o n t i n u u m . The b e s t d e s i g n s o l u t i o n comes from more t h a n j u s t p r o v i d i n g t h e c o r r e c t number and s i z e s o f s p a c e s i n t h e f u n c t i o n a l l y c o r r e c t r e l a t i o n s h i p s . T hese a r e c e r - t a i n l y t h e f u n d a m e n t a l p l a t f o r m s f o r t h e d e s i g n , b u t a g r e a t d e a l more w a r r a n t s c o n s i d e r a t i o n . We must remember t h a t t h e s p a c e s w i l l be o c c u p i e d by human b e i n g s who o p e r a t e a t a s u b - c o n s c i o u s l e v e l as w e l l as a c o n s c i o u s l e v e l . P e o p l e w i l l be happy o r unhappy w i t h t h e r e s u l t o f the d e s i g n a c c o r d i n g t o how they " f e e l " a bout the s p a c e . They w i l l use s u b j e c t i v e c r i t e r i a t o a s s e s s the " T i g h t - n e s s " o f t h e p r o d u c t . They w i l l not even be a b l e t o t e l l i n some i n s t a n c e s what makes them f e e l happy o r s a d . I t i s the t a s k o f those who c r e a t e the s p a ce t o e n s u r e that o n l y good r e s u l t s o c c u r . The u n f o r t u n a t e r e a l i t y i s t h a t e f f o r t s p r e s e n t l y b e i n g made t o improve b o t h G u i d e l i n e s and S t a n d a r d s c o n c e n t r a t e o n l y upon t h e f a c t u a l and t h e s c i e n t i f i c a s p e c t s o f t h e g u i d e s . In a d d i t i o n t o t h i s e m p h a s i s , an e f f o r t i s b e i n g d i r e c t e d , toward d i s t i l l i n g m a t e r i a l r e q u i r e d f o r S t a n d a r d s t o i t s s i m p l e s t f o r m u l a t i o n so t h a t d a t a c o n t a i n e d i n S t a n d a r d s i s e a s y t o u s e . The S o u d e r - W h e e l e r f o r m u l a t i o n o f a r e a p e r bed was o f t h i s s i m p l i s t i c t y p e . New G u i d e l i n e s c a n no l o n g e r be t h i s way. 27 J In recent years the major participants in the design process have come under considerable pressure to be more accurate. This has occurred because, as a l l kinds of funding resources have become limited, demand i s created for better predictions of space, (therefore of costs) and for measures of the anticipated productivity of opera- tions, which usually depend upon good pre-planning of services. Increasingly, the architects and hospital planners are being asked to supply more and more informa- ti o n to c l i e n t s and regulators to make better decisions. It seems incongruous that the Guidelines should seek to be simple tools, supposedly used by the inexperienced or layman-user while the planning process gets more and more complex. In the AIA-CAH review of the Canadian Federal Programming Guidelines, they discovered that even though the format had been del i b e r a t e l y s i m p l i f i e d (using boxes for numbered entries alongside m u l t i p l i e r s which e a s i l y give summary t o t a l s ) , considerable experience with hospital s t a t i s t i c s and planning was s t i l l needed. It would seem that in answer to this problem we need to recognize there i s a complex " s c i e n t i f i c " aspect as well as a " s o c i a l " purpose to the Guidelines and Standards. The s c i e n t i f i c aspect relates to the methods used for measuring space and the analysis of systems implications of flow processes. This i s complex data 28 w h i c h r e q u i r e s t r a i n e d p e o p l e t o d e a l w i t h i t so t h e r e i s no harm i n r e d u c i n g t h e c o m p l e x i t y , by s h o r t h a n d methods, as l o n g as i t i s r e a l i z e d t h a t o n l y i n t h e hands o f e x p e r - i e n c e d u s e r s c a n t h e i m p l i c a t i o n s o f t h i s s i m p l i f i c a t i o n o f complex m a t e r i a l be s a f e l y u s e d . I t i s not w i t h t h e s c i e n t i f i c a s p e c t s o f G u i d e l i n e s t h a t s i m p l i f i c a t i o n c a n be s u c c e s s f u l l y a c h i e v e d . I t i s o n l y t h e h u m a n i s t a s p e c t o f t h e G u i d e l i n e d e a l i n g w i t h t h e c o n c e r n s and d e s i r e s o f p e o p l e i n s p a c e s t h a t c a n be s i m p l i f i e d . T h i s d a t a must be c a r e f u l l y c o m p i l e d by e x p e r t s b u t p r e s e n t e d i n a f o r m a t f o r l a y p e r s o n s t o u s e . To some d e g r e e , i t i s o b v i o u s t h a t t h e p r e c i s e "number," r e l a t e d a s p e c t s o f G u i d e l i n e s c a n be b u i l t i n t o t h e more s i m p l i s t i c f o r m a t t h a t d e a l s w i t h t h e " s o c i a l - s p a t i a l " r e q u i r e m e n t s o f t h e G u i d e l i n e s b u t i t i s n o t p o s s i b l e t h e o t h e r way a r o u n d . R e g a r d l e s s o f which f o r m a t i s u s e d , t h e e x i s t e n c e o f t h i s b i - l e v e l s e p a r a t i o n must be r e c o g n i z e d . Needed w i t h i n t h e G u i d e l i n e i s a f i r s t l e v e l o f S o c i a l S y s t e m s upon w h i c h i s b u i l t a s e c o n d l e v e l o f S c i e n t i f i c S y s t e m s . H e r e , we f i n d t h e answer t o t h e p r o b l e m o f r i g i d i t y i n p r e s e n t D e s i g n S t a n d a r d s . The S t a n d a r d s a r e n o t m u l t i - d i m e n s i o n a l , s i n c e t h e y a r e o n l y c o n c e r n e d w i t h t h e p r e c i s e outcomes o f e v e n t s and can n o t r e s p o n d t o c h a n g i n g s o c i a l c o n c e r n s as t h i s a s p e c t i s n o t r e p r e s e n t e d . A l t h o u g h t h e many G u i d e l i n e s used by P l a n n e r s may n o t a l w a y s d e s c r i b e an e v e n t - o u t c o m e r e l a t i o n s h i p , t h e y a r e f r e q u e n t l y c h a n g e d , b e c a u s e t h e u s e r s o f G u i d e l i n e s a r e f i r s t l y r e s p o n d i n g t o t h e s o c i a l and program c h a n g e s , t h e n s e c o n d l y , t o t h e s c i e n t i f i c i m p l i c a t i o n s . S t a n d a r d s must a l s o r e c o g n i z e t h e s o c i a l b a s i s , w hich has an e f f e c t upon s p a c e s , so t h a t when a change i n one a s p e c t i s a c c e p t e d t h e n t h e r e c an be a change i n t h e o t h e r a s p e c t s . The p r o c e s s o f c o m m u n i c a t i o n between P l a n n e r s and R e g u l a t o r s h o u l d i n c l u d e t h i s f u n d a m e n t a l p l a n n i n g a s p e c t ; p r e s e n t l y u n a t t a i n a b l e . 1.4 Toward a New Standard We have s e e n t h a t i n o r d e r f o r D e s i g n S t a n d a r d s t o be e f f e c t i v e t h e y must r e s e m b l e r e s p o n s i v e m u l t i - d i m e n s i o n a l D e s i g n G u i d e l i n e s w h i c h P l a n n e r s t y p i c a l l y u s e . T h i s w i l l e n s u r e t h a t t h e c o n t i n u i t y needed i n t h e p r o c e s s e s o f p l a n n i n g and r e g u l a t i n g h e a l t h f a c i l i t i e s c o n s t r u c t i o n w i l l o c c u r . I f S t a n d a r d s a r e t h e same as r e s p o n s i v e G u i d e l i n e s t h e y w i l l be f l e x i b l e b e c a u s e t h e y w i l l r e s p o n d r e a d i l y t o t h e new a p p r o a c h e s b e i n g i n t r o d u c e d by t h e 30 P l a n n e r s who a r e c o n s t a n t l y d e a l i n g w i t h demands from t h e f a c i l i t y u s e r s . I t i s v e r y e v i d e n t t h a t t h e p r e s e n t D e s i g n S t a n d a r d s do n o t do t h i s and t h e r e i s g r a v e d o u b t t h a t m e r e l y t o t a k e t h e e x i s t i n g D e s i g n G u i d e l i n e s and f o r m them i n t o S t a n d a r d s w i l l a s s i s t . What i s r e q u i r e d i s a new form o f D e s i g n G u i d e l i n e t h a t c a n be us e d as a S t a n d a r d . The new S t a n d a r d must be a b l e t o d e a l w i t h t h e s c i e n - t i f i c c o m p l e x i t i e s o f s o p h i s t i c a t e d d a t a i n e i t h e r " d i s t i l l e d " f o r m , f o r g e t t i n g q u i c k e r r e s u l t s , o r as d e t a i l e d p r e d i c t i v e a n a l y s e s . T h i s S t a n d a r d must be u s a b l e by R e g u l a t o r s t o c h e c k d a t a p r e s e n t e d by h o s p i t a l s and by t h e h o s p i t a l s ' c o n s u l t a n t s who w i l l t h e n be aware o f t h e b o u n d a r i e s t o t h e s u b j e c t s u n d e r d i s c u s s i o n . The S t a n d a r d must d e a l w i t h d e s i g n i t s e l f , b e c a u s e , a l t h o u g h n o t f u l l y r e c o g n i z e d i n D e s i g n S t a n d a r d s , t h i s i s t h e f u n d a m e n t a l b u i l d i n g b l o c k o f t h e p r o c e s s . F o r t h i s t o o c c u r , t h e D e s i g n G u i d e l i n e s must e x p r e s s t h e s i m p l e s t e l e m e n t s o f t h e s u b c o n s c i o u s f e e l i n g s o f p e o p l e who use b u i l t s p a c e s . In t h e same f u n d a m e n t a l way t h a t t h e S o c i a l S c i e n c e s a r e b u i l t upon t h e t h o u g h t o b j e c t s c o n s t r u c t e d by t h e "common s e n s e " t h i n k i n g o f p e o p l e , l i v i n g t h e i r d a i l y l i v e s w i t h i n t h e i r s o c i a l w o r l d , so must t h e f o u n d a t i o n s 31 of the Design be based upon these objects. The constructs of the Social Sciences are t y p i c a l l y of a second l e v e l , that i s , constructs of the constructs made by the actors on the s o c i a l scene, whose behaviour the s o c i a l s c i e n t i s t , has to observe and explain in accordance with the pro- cedural rules of his science. If we use such a method to build our Guidelines, then we may seek to discover the ways i n which people "operate" their world and to discover from them from which elements of the b u i l t environment people receive t h e i r f r u s t r a t i o n s or joy. In this way, we can start to produce a new Guideline that includes such attitudes to people and building. Before we begin to look for some better Guidelines, l e t us return for a moment to a requirement that the Standards should be responsive to the needs of a l l p a r t i c - ipants in the Planning process. As such, we have seen that Standards can provide boundaries required by Regula- tors, they can be made responsive to hospital needs through being multi-dimensional, but what can they do for architecture and the changes in the buildings that result? There has been a fundamental change in the attitudes of the public and the professionals involved which must be acknowledged. 32 1.5 A Change in the Role of Architecture I n t h e V a n c o u v e r Sun on T h u r s d a y , May 7, 1981, an a r t i c l e by E u n i c e R a i n e s a p p e a r e d on Page F i v e under t h e h e a d i n g "A T h i n g o f B e a u t y ... i s d i s m a y i n g l y r a r e i n modern a r c h i t e c t u r e . Why s h o u l d V a n c o u v e r s u f f e r from t h e g r e y s l i c k n e s s ? " B e g i n n i n g w i t h a q u o t e f r o m J o h n R u s k i n : " A r c h i t e c t u r e i s t h e a r t o f c r e a t i n g and a d o r n i n g a b u i l d i n g so t h a t t h e s i g h t o f i t may c o n t r i b u t e t o ou r m e n t a l h e a l t h , power and p l e a s u r e . " t h e a r t i c l e went on t o condemn a r c h i t e c t s and t o e x p r e s s a c o n c e r n s h a r e d by many p e o p l e i n o u r c i t i e s t o d a y . The a u t h o r makes a p o i n t t h a t i s i m p o r t a n t : " S a d l y , when I l o o k r o u n d V a n c o u v e r I c o n c l u d e t h a t a r c h i t e c t s t o d a y a r e f a i l i n g m i s e r a b l y i n one o f t h e i r p r i m e p u r p o s e s : t h e d e s i g n o f s o m e t h i n g b e a u t i f u l . " T h e r e i s n o t h i n g i n modern a r c h i t e c t u r e t h a t c o n t r i b u t e s t o my m e n t a l h e a l t h , power, o r p l e a s u r e . I f I see one more b u i l d i n g f i n i s h e d i n g r e y c o n c r e t e , I ' l l g a g . "I am u n s p e a k a b l y d e p r e s s e d by t h e s i g h t o f t h e b a r e b l e a k n e s s o f many new h o u s e s , a p a r t m e n t b u i l d i n g s , and h o u s i n g d e v e l o p m e n t s t h a t a r e r e m i n i s c e n t o f p r i s o n camps, o r P r a i r i e b u nkhouses, o r g r a n a r i e s , w i t h t h e i r s k i m p y l i t t l e m e t a l p i p e s j u t t i n g o u t o f t h e r o o f t o s e r v e as c h i m n e y s , t h e i r s k i n n y l i t t l e a luminum f r a m e s r o u n d windows and d o o r , t h e g a p i n g , o u t s i z e e x p a n s e s o f g l a s s u n r e l i e v e d by any l e a d e d o r wood-framed p a n e s , o r sometimes no windows a t a l l . "Where a r e t h e c h a r m i n g d e l i g h t s o f y e s t e r d a y ' s a r c h i t e c t u r e : t h e many-paned casement windows, t h e warmth o f r e d b r i c k c h i m n e y s , t h e f r e n c h d o o r s o p e n - i n g t o f l o w e r e d and l a t t i c e d t e r r a c e s , t h e d o r m e r s , t h e window s e a t s where, when l i f e was t o o much w i t h y o u , you' c o u l d c u r l up w i t h a book and be l o s t f o r h o u r s i n hopes and dreams?" We a r e becoming c o n s t a n t l y aware, p a r t i c u l a r l y s i n c e t h e e a r l y 1970's, t h a t f o r some t i m e we have been d e s i g n i n g e n v i r o n m e n t s which do n o t c r e a t e a s e n s e o f w e l l b e i n g f o r t h e p e o p l e , who u s e , v i e w , i n t e r a c t o r l i v e w i t h them. Thomas B l a i r i n The I n t e r n a t i o n a l Urban C r i s i s n o t e s t h a t : "Urban man i s t h e l i t m u s p a p e r o f t h i s g r e a t age o f t r a n s i t i o n . . . T h e c o n t i n u o u s a s s a u l t on h i s s e n s e s p l a y havoc w i t h t h e mind and e m o t i o n s . . . A s a r e s u l t , t h e p r i c e o f l i v i n g i n t h e c i t y i s a , c o n s t a n t s t a t e o f a n x i e t y b o r d e r i n g on p a n i c . T h e r e i s a c r i s i s o f human i d e n t i t y i n c i t i e s , and t h e i l l n e s s l i e s somewhere down i n t h e u r b a n i z e d s o c i e t y i t s e l f , i n s i d e i t s v a l u e c o n f l i c t s , i t s e x p l o i t a t i v e s o c i a l i n s t i t u t i o n s and i t s a l i e n a t e d i n d i v i d u a l s . " ^ B l a i r o b s e r v e s a d i r e c t l i n k between P h y s i c a l and S o c i a l d e c i s i o n s i n o u r s o c i e t y . T h e r e a p p e a r s t o be a breakdown o f t h a t l i n k , and a l t h o u g h t h e p e o p l e who l i v e i n o u r modern c i t i e s a r e aware o f t h e demise i n which t h e y f i n d t h e m s e l v e s , t h e y a r e t o o a l i e n a t e d b o t h f r o m t h i s e n v i r o n m e n t and e a c h o t h e r t o c o r r e c t , t h e s i t u a t i o n . The breakdown o f t h i s p h y s i c a l / s o c i a l l i n k i s n o t a new phenomenum, but i s t h e r e s u l t o f a 200 y e a r p r o c e s s . 34 P e r h a p s t h i s a l i e n a t i o n e x i s t s b e c a u s e c o l l e c t i v e l y we a r e s u b j e c t t o t h e p h i l o s o p h i e s o f an i n d u s t r i a l s o c i e t y i n which t h e b e l i e f i n t h e " p u r i t y " o f s c i e n t i f i c t h o u g h t makes i t n e c e s s a r y f o r us t o s e p a r a t e m a t e r i a l o r m a t t e r from e m o t i o n o r mind. T h i s p r o c e s s began w i t h t h e r e v i v a l i n t h e 17th C e n t u r y o f t h e P h i l o s o p h y o f t h e D o c t r i n e o f M a t e r i a l i s m and has d e v e l o p e d w i t h t h e e m p i r i - c a l s c i e n c e s t h r o u g h o u t t h i s p e r i o d u n t i l t o t o d a y . What s t a r t e d w i t h D e s c a r t e s , L o c k e and o t h e r s , we do n o t even r e c o g n i z e t o d a y as a p h i l o s o p h i c a l c o n c e p t , b u t s i m p l y t h e way we v i e w t h e w o r l d . We see m a t t e r as o b j e c t i v e t o o u r s e l v e s . I t i s v i e w a b l e , t e s t a b l e , m a n i p u l a b l e b u t a l w a y s f r e e f r o m any " p e r s o n a l " o r " e m o t i o n a l " i n f l u e n c e . We b e l i e v e t h a t o n l y knowledge c o l l e c t e d t h r o u g h s c i e n c e i s a c c e p t a b l e . The Modern Movement i n a r c h i t e c t u r e i s a p r o d u c t o f t h i s p h i l o s o p h y . 2 0 B o r n i n t o an age o f new m a t e r i a l s , w i t h c r e a t i v e a r c h i t e c t s and e n g i n e e r s who used them t o b u i l d s c u l p t u r a l f o r m s , t h e movement c r e a t e d monuments t o t e c h n o l o g y as symbols o f s c i e n t i f i c p r o g r e s s . I t was an a p p r o a c h t o t h e improvement o f t h e q u a l i t y o f human l i f e i o n l y as i t c o u l d be g a i n e d from w i t h i n t h e bounds o f t e c h - n i c a l a c h i e v e m e n t s . We have come t o see t h e f a l l a c y o f t h i s " t e c h n i c a l i m p e r a t i v e " and not o n l y t o d i s t r u s t t e c h - n o l o g y i t s e l f b u t t o s e e l i f e q u a l i t y a s s e p a r a t e f r o m 35 i t . D e s i g n c o n c e p t s o f t h e P o s t - M o d e r n Movement,^ 1 a r e b e g i n n i n g t o e x p r e s s t h e c o n c e r n s o f s l o w - g r o w t h econom- i c s , r e s p o n s i v e t e c h n o l o g y , c o n s e r v a t i o n and human n e e d s . U n f o r t u n a t e l y , t h e e x i s t i n g methods f o r g u i d i n g t h i s c o n c e p t u a l p r o c e s s r e s t s s t i l l w i t h t h e e a r l i e r p h i l o s o - phy. In t h e d e v e l o p m e n t o f G u i d e l i n e s w h i c h do r e s p o n d t o " P o s t - M o d e r n " c o n c e r n s we must r e d i s c o v e r t h e s o c i a l r e a l - i t y o f o u r b u i l d i n g s . The s t r u c t u r e o f t h e s e new G u i d e - l i n e s w i l l r e q u i r e t h a t we p r e s e n t d a t a d e s c r i b i n g what makes t h e b u i l t s p a c e "work" s o c i a l l y , and t h e s c i e n t i f i c r e a l i t y o f what must be done f o r i t s a c h i e v e m e n t . We s h a l l now t u r n o u r a t t e n t i o n t o a method w h i c h w i l l encompass a l l t h e a s p e c t s r e q u i r e d o f "good" D e s i g n G u i d e l i n e s . 1.6 The Patterns of Design Rediscovered The i d e a t h a t t h e r e e x i s t s a c e n t r a l s e t o f v a l u e s h e l d by p e o p l e a b o u t space and d e s i g n w i t h i n a s o c i e t y , o r a c u l t u r e , i s n o t o r d i n a r i l y a p a r t o f modern D e s i g n i d e o l o g i e s . The b e l i e f t h a t even s h o u l d t h e y e x i s t , i t i s a p p r o p r i a t e f o r t h e s e common r u l e s f o r o r d e r i n g s p a c e t o be a n a l y z e d and w r i t t e n down, i s even more u n u s u a l . The 36 o n l y d e v e l o p m e n t o f t h i s a p p r o a c h w i t h w h i c h we a r e f a m i l i a r i s by C h r i s t o p h e r A l e x a n d e r and h i s c o l l e a g u e s a t t h e C e n t r e f o r E n v i r o n m e n t a l S t r u c t u r e i n B e r k e l e y , C a l i f o r n i a , who began t h i s work i n t h e l a t e 1960's.22 In o b s e r v i n g and r e c o r d i n g t h i s i n t e r a c t i o n o f p e o p l e and s p a c e , A l e x a n d e r ' s work has a l l t h e e l e m e n t s r e q u i r e d t o p r o v i d e r e s p o n s i v e , s o c i a l l y aware D e s i g n G u i d e l i n e s . He u s e s an e m p i r i c a l m e t h o d o l o g y t h a t a p p r o a c h e s c l o s e l y t h e work o f s o c i a l s c i e n t i s t s u s i n g E t h n o g r a p h i c T e c h n i q u e s . The same t e c h n i q u e s a r e examined l a t e r i n t h i s c h a p t e r when we a d d r e s s t h e p r o b l e m o f f i n d i n g a method f o r d e v e l o p i n g o u r own G u i d e l i n e s . By e x a m i n i n g some key b e l i e f s o f A l e x a n d e r a b o u t b u i l d i n g s , d e s i g n and p e o p l e , we can see why i t i s a p p r o p r i a t e t o a d o p t A l e x a n - d e r ' s c o n c e p t s i n d e v e l o p i n g a new G u i d e l i n e w h i c h r e s p e c t s t h e d e s i g n a s p e c t s as w e l l as t h e o t h e r i m p o r t a n t f e a t u r e s we have i d e n t i f i e d . A l e x a n d e r ' s f u n d a m e n t a l b e l i e f i s t h a t h i s t o r i c a l l y g r e a t b u i l d i n g s , w h i c h f o r t h o u s a n d s o f y e a r s have d e l i g h t e d t h e " p o p u l a c e " were formed w i t h an a w a r e n e s s o f c e r t a i n r u l e s o f d e s i g n . He c a l l s them " P a t t e r n s " i n w h i c h c e r t a i n s p a t i a l e l e m e n t s a r e r e l a t e d t o e a c h o t h e r and r e p e a t i n a l l good b u i l d i n g d e s i g n s . He b e l i e v e s t h a t i t i s n o t t h e p h y s i c a l b u i l d i n g e l e m e n t s w h i c h a r e 37 r e p e a t e d i n , s a y , G o t h i c C a t h e d r a l s ( a l t h o u g h some t e c h - n i q u e s f o r s o l v i n g b u i l d i n g p r o b l e m s a r e common) r a t h e r i t i s f r o m s p e c i a l s p a t i a l a r r a n g e m e n t s , p r o p o r t i o n s and r e l a t i o n s h i p s between b u i l d i n g e l e m e n t s , t h a t p e o p l e r e c o g n i z e as s t i m u l a t i n g , p l e a s i n g and "good". I t i s t h i s t h a t f o r m s t h e " P a t t e r n s " o f t h e G o t h i c C a t h e d r a l . T h e s e P a t t e r n s a r e e s s e n t i a l a r r a n g e m e n t s which keep r e a p p e a r i n g i n d i f f e r e n t b u i l d i n g s and b e c a u s e t h e y a r e i n t e r l o c k e d w i t h b u i l d i n g e l e m e n t s , t h e y g i v e c h a r a c t e r t o t h e p l a c e i n w h i c h t h e y o c c u r . T h e s e e v e n t s c r e a t e t h e " q u a l i t y " o f a b u i l d i n g . T h i s " q u a l i t y " i s c e n t r a l t o e a c h i n d i v i - d u a l ' s p e r s o n a l v a l u e s y s t e m , a v a l u e s y s t e m w h i c h i s n o t d i f f e r e n t f o r e a c h i n d i v i d u a l , but s h a r e d by a l l p e o p l e w i t h i n a s o c i e t y . In t h e s e a r c h f o r good d e s i g n we seek t h o s e moments and s i t u a t i o n s i n b u i l d i n g s when we f e e l most " a l i v e " . We u n c o n s c i o u s l y g e n e r a t e b u i l d i n g s and towns from s u c h p a t t e r n s , and when we examine t h e p r o c e s s , we d i s c o v e r : " . . . e a c h b u i l d i n g and e a c h town, i s u l t i m a t e l y made o u t o f t h e s e p a t t e r n s i n t h e s p a c e , and o u t o f n o t h i n g e l s e : t h e y a r e t h e atoms and t h e m o l e c u l e s f r o m w h i c h a b u i l d i n g o r a town i s m a d e . " 2 3 A c c o r d i n g t o A l e x a n d e r t h e d e s i g n e r s and b u i l d e r s o f modern b u i l d i n g s have a l i e n a t e d t h e p e o p l e a t l a r g e f r o m 38 t h e b u i l d i n g p r o c e s s e s and have l o s t t h e l a n g u a g e s which were s h a r e d i n e a r l i e r t i m e s . He p o i n t s o u t t h a t due t o f i f t y y e a r s o f t h e modern movements n e o - p o s i t i v i s m , p e o p l e a r e so d i v e r g e n t and i n t e l l e c t u a l l y u n c o n n e c t e d t h a t d i s c o u r s e i s i m p o s s i b l e . We a r e a l l a l i e n a t e d from e a c h o t h e r ' s e m o t i v e c o r e . A l e x a n d e r i s c o n c e r n e d t h a t a l l p e o p l e s , p l a n n e r s and u s e r s o f b u i l d i n g s o r towns, r e d i s - c o v e r t h e l a n g u a g e s w h i c h he b e l i e v e s we s h a r e b u t no l o n g e r a r t i c u l a t e . He i s a l s o c o n c e r n e d t h a t we c o n t i n u e t o e v o l v e and use t h e s e l a n g u a g e s s o b u i l d i n g s c a n have q u a l i t i e s w h i c h : " c a n n o t be made, but a r e g e n e r a t e d , i n d i r e c t l y , by t h e o r d i n a r y a c t i o n s o f t h e p e o p l e , j u s t as a f l o w e r c a n n o t be made, b u t o n l y g e n e r a t e d f r o m t h e seed."24 The a c t o f b u i l d i n g i s n o t t h e e x c l u s i v e e g o c e n t r i c domain o f t h e b u i l d i n g s p e c i a l i s t b u t r a t h e r an a p p r o p r i a t e i n v o l v e m e n t f o r a l l who " l i v e " i n a s o c i e t i e s ' b o u n d a r i e s . I n t h e same way t h a t A l e x a n d e r has ch o s e n t o use h i s P a t t e r n s t o f o c u s upon~ e s s e n t i a l e l e m e n t s o f s p a c e , i n o r d e r t o make d e s i g n e r s aware o f t h e i r e x i s t a n c e , we can f o r m a l i z e t h e i r c o n t e n t f o r G u i d e l i n e s . I t i s b e c a u s e t h e P a t t e r n s a r e " c a p s u l e s " o f t h e e s s e n c e o f s o c i a l l y r e s p o n s i v e s p a c e t h a t t h e y c a n be used as G u i d e l i n e s . We 39 s h a l l e x p l o r e the s t r u c t u r e and p h i l o s o p h y o f these P a t t e r n s . In t h e i r b r o a d e s t sense, A l e x a n d e r ' s P a t t e r n s are a d e s c r i p t i o n o f r e l a t i o n s h i p s between the s p a t i a l elements which make up a b u i l d i n g and even though t h e y do not d e s c r i b e what the b u i l d i n g elements a r e , they do d e s c r i b e laws o r P a t t e r n s which connect both k i n d s o f e l e m e n t s . The P a t t e r n s can be removed from t h e i r s p e c i f i c b u i l d i n g c o n t e x t and we a r e l e f t w i t h a f a b r i c o f r e l a t i o n s h i p s between s p a c e s , s t r u c t u r e and e v e n t s . Through t h i s r e l a t i o n s h i p b u i l d i n g elements can be assembled t o produce an i n f i n i t e v a r i e t y o f b u i l d i n g s which w i l l s a t i s f y the e s s e n t i a l r e l a t i o n s h i p between the e v e n t s which w i l l t a k e p l a c e i n the b u i l d i n g . " T h i s i s not o n l y t r u e o f g e n e r a l p a t t e r n s ; i t i s t r u e o f the e n t i r e b u i l d i n g : a l l i t s d e t a i l s ; t h e shape of rooms, the c h a r a c t e r of ornaments, the k i n d o f window panes i t has... the c o n n e c t i o n of the b u i l d i n g t o the garden and the s t r e e t , and t o the spaces and the p a t h s and t o the d e t a i l e d s e a t s , and w a l l s w h ich are around i t . . . " 2 ^ In s e e k i n g t h e s e P a t t e r n s we r e a l i z e t h a t t h e r e a r e r e m a r k a b l y few P a t t e r n s from which a b u i l d i n g o r a town i s d e r i v e d . I t i s the power and depth o f t h e s e few P a t t e r n s which a l l o w s an i n f i n i t e v a r i e t y o f b u i l d i n g s t o be 40 assembled. Alexander l i k e n s t h i s to the atoms of our universe. Just as the world i n a l l i t s complexity i s made up of some 92 elements, so the small number of these patterns which are fundamental to our world repeat themselves over and over again. Our problem concerning design stems from the f a c t that j u s t as we can look at the m i l l i o n s of t a n g i b l e things i n our world and ignore the essence of t h e i r source, so we have become concerned w i t h the outward form of b u i l d i n g s i n our world and not the essence that gives them l i f e . When i t comes to using the Patterns i n design, they describe those aspects of the environment which must be put i n place to have a w e l l - f u n c t i o n i n g s e r i e s of spaces. L i k e the s o c i a l s c i e n t i s t who knows he w i l l not get a u s e f u l answer i f he asks about the r u l e s of s o c i e t y from a member of that s o c i e t y , since the i n d i v i d u a l ' s frame of reference i s undetermined and unquestioned, Alexander sees l i t t l e value i n assessing needs. Asking the c l i e n t does not ensure that the c l i e n t knows h i s needs from h i s wants and there i s no way to determine whether a statement of need i s true or f a l s e ; i f , f o r example, one says a person needs water we know i t i s a matter of l i f e or death. I f he says he needs a museum what does i t mean? To re s o l v e t h i s problem, so as to use an o b s e r v a t i o n a l methodology, Alexander changes need i n t o i t s o p e r a t i o n a l a l t e r n a t i v e , 41 / T e n d e n c y . S i n c e the P a t t e r n i s so fundamental to making spaces which s a t i s f y s o c i a l c o n c e r n s , how does A l e x a n d e r ensure tha t the needs of the people who use the space are r e s p e c t e d ? He r e p l a c e s need w i t h a d e s c r i p t i o n o f what i t i s people are t r y i n g to do . He p o i n t s out i f we say "People working i n o f f i c e s need a view", we have no way of i n t e r p r e t i n g the meaning o f t h i s need or whether i t i s even a f a c t . I f we make the statement o p e r a t i o n a l and say "People working i n o f f i c e s t r y to get a view from t h e i r o f f i c e s " , we have a statement o f f a c t which can be t e s t e d . T h i s statement of Tendency i s an h y p o t h e s i s which can be t e s t e d by e m p i r i c a l o b s e r v a t i o n to r u l e out a l t e r - n a t i v e h y p o t h e s i s , such as; are they t r y i n g to get more l i g h t ? ; more v e n t i l a t i o n o r more s u n s h i n e ? ; and not a view? T h i s h y p o t h e s i s , once s t a t e d , can be e v a l u a t e d over a p e r i o d o f t i m e . S i n c e peop le can u s u a l l y be l e f t to f u n c t i o n i n d i f f e r e n t environments wi thout having to modify tha t env ironment , t h e r e i s not always a need f o r i t s r e d e s i g n . Only when t e n d e n c i e s are l i k e l y to come i n c o n f l i c t must we a c t to r e s o l v e them. Alexander b e l i e v e s the concept o f good d e s i g n i s not one i n which needs are met but one i n which no two t e n d e n c i e s c o n f l i c t s i n c e t h i s i s o b s e r v a b l e 42 and r e a l . A P a t t e r n a p p l i c a t i o n s t a r t s by r e c o g n i z i n g t h e t e n d e n c i e s o f e v e n t s i n t h e e n v i r o n m e n t t o be i n c o n - f l i c t . In t h i s s e n s e we use t h e P a t t e r n s t o d e a l o n l y w i t h r e a l d e s i g n p r o b l e m s w h i c h need t o be r e s o l v e d . The r e a l v a l u e t o o u r e x p l o r a t i o n f o r a new D e s i g n G u i d e l i n e l i e s i n t h e f a c t t h a t t h e P a t t e r n d o e s n o t r e q u i r e an a c t u a l b u i l d i n g p r o c e s s i n o r d e r t o have a c o n t e x t . The P a t t e r n d e s c r i b e s a f u n d a m e n t a l r e l a t i o n s h i p between a p r o b l e m w h i c h a l w a y s o c c u r s i n a g i v e n c o n d i t i o n and p r o v i d e s a s o l u t i o n w h i c h w i l l a l w a y s s o l v e t h e p r o b l e m . T h i s i s what a G u i d e l i n e r e a l l y d o e s . T h e r e i s a s i m p l e f o r m u l a which h o l d s t h e s e a s p e c t s t o g e t h e r and d e s c r i b e s t h e s c o p e o f e a c h P a t t e r n . The P a t t e r n has two p a r t s t h e P a t t e r n s t a t e m e n t and t h e P r o b l e m s t a t e m e n t . 2 7 The P a t t e r n s t a t e m e n t b r e a k s i n t o two f u r t h e r p a r t s , an I F and a THEN. The f o r m u l a which c r e a t e s t h e p a t t e r n , r e a d s : IF t h e c o n d i t i o n s X o c c u r s , THEN we s h o u l d do Z (a s p a c i a l r e l a t i o n s h i p which needs t o be p r e s e n t u n d e r c o n d i t i o n X ) , i n o r d e r t o s o l v e t h e p r o b l e m Y (a p r o b l e m a l w a y s l i k e l y t o o c c u r u n d e r c o n d i t i o n X ) . To i l l u s t r a t e t h i s l e t us use t h e example o f l o c a t i n g 4 3 t h e R a d i o l o g y D e p a r t m e n t . One o f t h e common a s p e c t s o f l o c a t i o n i s t h e r e q u i r e m e n t s o f p u b l i c a c c e s s t o t h e f a c i l i t y . We know t h a t I n p a t i e n t s and O u t p a t i e n t s have c o n f l i c t i n g needs f o r a c c e s s t o t h e d e p a r t m e n t . O u t - p a t i e n t s a r e n o t f a m i l i a r w i t h the h o s p i t a l y e t must f i n d t h e d e p a r t m e n t ' s l o c a t i o n e a s i l y , so t h i s w o u l d r e q u i r e t h e l o c a t i o n n e a r an O u t p a t i e n t e n t r y . On t h e o t h e r hand, I n p a t i e n t s a r e p a r t i a l l y c l o t h e d on s t r e t c h e r s and do n o t want p u b l i c e x p o s u r e , so we would t e n d t o l o c a t e t h e d e p a r t m e n t c l o s e t o an I n p a t i e n t a c c e s s . We have a c o n f l i c t i n g t e n d e n c y r e q u i r i n g us t o l o c a t e t h e f a c i l i t y i n d i f f e r e n t p l a c e s . In a n a l y s i s o f t h e p r o b l e m we know t h a t i t i s p o s s i b l e t o have a l e s s d i r e c t r o u t e f o r I n p a t i e n t s b e c a u s e t h e y a r e e s c o r t e d and t h i s more complex r o u t e can be made n o n - p u b l i c . The P a t t e r n t h a t r e s u l t s i s a s f o l l o w s : ( I F ) Where b o t h i n p a t i e n t s and o u t p a t i e n t s use a h o s p i t a l d e p a r t m e n t , (THEN) p l a c e t h e f a c i l i t y where i t c a n be r e a c h e d f r o m two d i r e c t i o n s . D e s i g n th e a c c e s s f o r o u t - p a t i e n t s s o t h a t i t i s d i r e c t l y and s i m p l y a c h i e v e d . D e s i g n t h e a c c e s s f o r i n p a t i e n t s s o t h a t t h e r o u t e has l i t t l e o r no p u b l i c u s e . T h i s (THE PROBLEM) w i l l a l l o w u n f a m i l i a r o u t p a t i e n t s an u n c o n f u s i n g a c c e s s , 44 and i n p a t i e n t s , who are e s c o r t e d by someone f a m i l i a r with the route, a d i s c r e t e access. We have produced an i m p a r t i a l r e l a t i o n s h i p . There i s no need to decide on an a c t i o n based upon one's s u b j e c t i v e judgement, or one's p e r s o n a l v a l u e s . That the c o n f l i c t w i l l be r e s o l v e d by the a c t i o n d e s c r i b e d i s e i t h e r r i g h t or wrong. I t i s a statement of f a c t . I f i t i s wrong, there w i l l be e m p i r i c a l evidence that any other designer can b r i n g to t h i s t y p i c a l problem and the c o r r e c t s p a t i a l r e l a t i o n s h i p can be d e s c r i b e d . I f i t i s r i g h t , then the r e l a t i o n s h i p holds f o r a l l s i m i l a r c o n f l i c t s so t h a t design s o l u t i o n s that are r e f l e c t i v e of t h i s P a t t e r n w i l l always produce good d e s i g n s . By c o l l e c t i n g numerous fundamental "elements" i n t h i s way these "capsules" or P a t t e r n s ( v i z . , the l i n k between the c o n d i t i o n , the problem and the s o l u t i o n ) stand alone as guides f o r any r e q u i r e d d e s i g n a c t i v i t y . We now begin to see how the P a t t e r n s form a s e r i e s of u n i v e r s a l Design G u i d e l i n e s . When c o l l e c t e d together f o r a s p e c i f i c b u i l d i n g , or p l a n n i n g p r o j e c t , they w i l l i f the s o l u t i o n i s f o l l o w e d , a l l o w a design to evolve which w i l l be unique to the p r o j e c t yet have no " c o n f l i c t i n g t e n d e n c i e s " between people and spaces, t y p i c a l of that a p p l i c a t i o n . \ 45 We have i n e a c h P a t t e r n t h e e s s e n t i a l e l e m e n t o f t h e D e s i g n G u i d e l i n e s we a r e s e e k i n g . They a r e b a s e d upon o b s e r v a t i o n ( e m p i r i c a l m e t h o d o l o g y ) o f how p e o p l e o p e r a t e , r e l a t e t o and g e n e r a l l y d e r i v e t h e b e s t r e s p o n s e f r o m t h e i r b u i l t e n v i r o n m e n t . T h i s we c a n c o n s i d e r t o be t h e F i r s t L e v e l ; t h e s o c i a l l y r e s p o n s i v e d e s i g n a s p e c t s . The Second L e v e l , t h e s c i e n t i f i c r e q u i r e m e n t s , w h i c h i s t h e b a s i s f o r r e g u l a t a b l e S t a n d a r d s , comes f r o m f u r t h e r a s p e c t s o f t h e P a t t e r n . E ach P a t t e r n forms a s i n g l e s t a t e m e n t o f f a c t , a h y p o t h e s i s t h a t c a n be t e s t e d , c h e c k e d , d i s c u s s e d and a p p l i e d w i t h o u t a f f e c t i n g t h e v a l i d i t y o f any o t h e r P a t t e r n . T h i s means P a t t e r n s c a n be a p p l i e d s e l e c t i v e l y by R e g u l t o r s where t h e a g e n c i e s see f i t . They c a n a t t h e same t i m e be c o n s t a n t l y r e v i e w e d by t h e P l a n n e r s ( f u r t h e r t e s t e d ) f o r any f l a w s t h a t m i g h t be n o t i c e d i n t h e b a s i c r e l a t i o n s h i p s w i t h i n t h e P a t t e r n , t h e n by c l e a r l y and f a c t u a l l y p r e s e n t i n g t h e s e f l a w s t o R e g u l a t i n g A g e n c i e s , r e v i s i o n s c a n be made. Where R e g u l a t o r s have a c c e p t e d P a t t e r n G u i d e l i n e s i n t o t h e i r S t a n d a r d s t h e y w i l l have a c c e p t e d i t s f a c t u a l h y p o t h e s i s . Where e v i d e n c e i s b r o u g h t t o show R e g u l a t o r s t h a t t h i s h y p o t h e s i s i s wrong and a new h y p o t h e s i s s h o u l d be s u b s t i t u t e d , n e i t h e r p a r t y s h o u l d f e e l t h r e a t e n e d by s u b j e c t i v e i n t e r p r e t a t i o n s , s i n c e t h e i s s u e s c a n be k e p t a t a p u r e l y ' s c i e n t i f i c ' 46 l e v e l , t h e r e f o r e change w i l l be e a s i l y a c h i e v e d . B e l i e v i n g t h e P a t t e r n Language a p p r o a c h t o be . i d e a l f o r a p p l i c a t i o n i n D e s i g n G u i d e l i n e s , we use t h i s f i n a l s e c t i o n t o examine A l e x a n d e r ' s s p e c i f i c f o r m a t s b e f o r e we b e g i n t o d e v e l o p a method f o r c r e a t i n g o u r own P a t t e r n s . In h i s s e c o n d volume A P a t t e r n L a n g u a g e 2 8 f r o m a s e r i e s o f t h r e e books on t h i s new a t t i t u d e t o a r c h i t e c t u r e , A l e x a n d e r p r e s e n t s some 253 P a t t e r n s . Each i s p r e s e n t e d i n t h e same f o r m a t w h i l e r a n g i n g f r o m t h o s e r e l a t i n g t o a r e g i o n t h r o u g h t h o s e c o n c e r n e d w i t h c o n s t r u c t i o n d e t a i l s . U s u a l l y , e ach P a t t e r n has a p i c t u r e w h i c h shows an a r c h e t y p a l example t o c a p t u r e t h e i d e a o f t h e P a t t e r n (see t h e example D i a g r a m 1.1 o v e r ) . T h e r e f o l l o w s an i n t r o d u c - t o r y p a r a g r a p h w h i c h p r o v i d e s t h e c o n t e x t o f t h e P a t t e r n and w h i c h i n c e r t a i n c a s e s , e x p l a i n s how i t w i l l h e l p t o c o m p l e t e c e r t a i n o t h e r P a t t e r n s . N e x t, i s a s h o r t p r o b l e m s t a t e m e n t w h i c h g i v e s a summary o f t h e p r o b l e m b e i n g p r e s e n t e d . The l o n g e s t p a r t o f t h e P a t t e r n f o l l o w s and t h i s i s t h e d e t a i l e d d e s c r i p t i o n o f t h e p r o b l e m , the e m p e r i c a l d a t a and o t h e r e v i d e n c e f o r s u p p o r t i n g t h e v a l i d i t y o f t h e r e l a t i o n s h i p s w i t h i n t h e P a t t e r n . T h e r e f o l l o w s a s u c c i n c t s t a t e m e n t o f t h e s o l u t i o n t o t h e p r o b l e m , and t h i s i s t h e c o r e o f t h e P a t t e r n . The s o l u - t i o n i s , a l w a y s g i v e n as a p o s i t i v e i n s t r u c t i o n as t o what DIAGRAM 1.1 47 Short Passages "...LONG, STERILE CORRIDORS SET THE SCENE FOR EVERYTHING BAD ABOUT MODERN ARCHITECTURE. WOT TWS / ? U14HT N O T T O O U O M £ / THEREFORE: MAKE EACH STRETCH OF CORRIDOR LESS THAN 50 FEET; IN EFFECT, THIS MEANS NO MORE THAN 5 OR 6 UNITS OPENING OFF THE SIDE OF ANY SINGLE STRETCH OF CORRIDOR. BREAK LONGER CORRIDORS INTO LESS-THAN-50-FOOT UNITS BY JOGGING THEM, OPENING ONE SIDE TO A COURT, WIDENING THEM INTO LOBBIES, ETC. In f a c t , the ugly long r e p e t i t i v e c o r r i d o r s of the machine age have so far in f e c t e d the word " c o r r i d o r " that i t i s hard to imagine that a c o r r i d o r could ever be a place of beauty, a moment i n your passage from room to room, which means as much as a l l the moments you spend i n the rooms themselves. Where a number of rooms are to share a c i r c u l a t i o n path, i t i s common p r a c t i c e to s t r i n g them along a s t r a i g h t c o r r i d o r . However, the i n t u i t i o n p e r s i s t s t h a t , from a human point of view, long c o r r i d o r s with many rooms o f f them are d y s f u n c t i o n a l : People d i s l i k e them; they represent bureaucracy and monotony. Let us t r y to make t h i s i n t u i t i o n more s p e c i f i c . What evidence i s there that long c o r r i d o r s c o n t r i b u t e to human uneasiness? THIS ' 48 i s r e q u i r e d t o s o l v e t h e p r o b l e m . F i n a l l y , t h e r e i s a d i a g r a m w h i c h i s used t o c a p t u r e t h e g e n e r i c s p a t i a l f o r m o f t h e P a t t e r n . We f i n d , i n a n a l y s i s o f t h e P a t t e r n s , t h a t t h e y a r e v e r y c l e a r and t h a t a g r e a t d e a l o f e f f o r t has gone i n t o n o t o n l y t h e d e t a i l , b u t i n r e d u c i n g t h e w o r d i n g i n them t o an a b s o l u t e minimum. 1.7 The Format of the Pattern Language L e t us now l o o k a t t h e d e v e l o p m e n t p r o c e s s o f t h e l a n g u a g e w h i c h i s i n e s s e n c e a c o l l e c t i o n o f P a t t e r n s . I t i s c l e a r t h a t e a c h P a t t e r n d o e s n o t e x i s t as an i s o l a t e d e n t i t y . " Each P a t t e r n c an e x i s t i n t h e w o r l d , o n l y t o t h e e x t e n t t h a t i t i s s u p p o r t e d by o t h e r P a t t e r n s : t h e l a r g e r P a t t e r n s i n , w h i c h i t i s embedded, t h e P a t t e r n s o f t h e same s i z e t h a t s u r r o u n d i t , and t h e s m a l l e r P a t t e r n s which a r e embedded i n i t . " 2 9 A l e x a n d e r u s e s t h e t e r m " s i z e " as a measure i n a h i e r a r c h y o f w h i c h P a t t e r n s d e a l i n g w i t h Macro ( r e g i o n a l ) i s s u e s a r e l a r g e r t h a n P a t t e r n s d e a l i n g w i t h d e t a i l s ( o r nament, window p a n e s , e t c . ) o r s m a l l e r i s s u e s . The p r o c e s s s t a r t s w i t h a c o l l e c t i o n o f f u n d a m e n t a l P a t t e r n s and c o n n e c t s them w i t h o t h e r P a t t e r n s , c o n t i n u i n g u n t i l one f e e l s e a c h P a t t e r n i s " c o m p l e t e " i n t h e network o f 49 P a t t e r n s . I f t h e r e a r e " i n c o m p l e t e " P a t t e r n s ( P a t t e r n s t h a t need t o be l i n k e d t o o t h e r s t o f o r m a more m e a n i n g f u l s t a t e m e n t ) t h e n new P a t t e r n s may need t o be c r e a t e d t o make e x i s t i n g o nes "whole". The l i n k a g e o f P a t t e r n s c r e a t e s t h e framework o f t h e d e s i g n . In t h e f o l l o w i n g example (s e e D i a g r a m 1.2), we have some s y n o p t i c d e s c r i p t i o n s o f some P a t t e r n s t h a t a r e l i n k e d f o r t h e p u r p o s e s o f d e s c r i b i n g a s p e c t s which must be c o n s i d e r e d i n d e s i g n i n g any " P u b l i c S p a c e s " w i t h i n a h o s p i t a l d e p a r t m e n t . In t h i s D e s i g n Language, t h e r e a r e o b v i o u s l y no t e c h n i c a l d e t a i l s , s u c h as how many rooms a r e t o be p r o v i d e d , o r how t h e s e rooms must be i n t e r - r e l a t e d f o r p l a n n i n g a s p e c i f i c d e p a r t m e n t . T h i s i s n o t t h e p u r p o s e o f t h e D e s i g n G u i d e l i n e s i n c e t h e s p e c i a l needs f o r t h e p a r t i c u l a r p r o j e c t w i l l be d e s c r i b e d i n i t s F u n c t i o n a l Program. Such t h i n g s as t h e number o f rooms and how t h e y f u n c t i o n , i s p r o j e c t - s p e c i f i c and n o t u n i v e r s a l (as i n a G u i d e l i n e ) . I t s h o u l d be remembered t h a t where t e c h n i c a l d e t a i l s s u c h as c o r r i d o r w i d t h s , c e i l i n g h e i g h t s , window h e i g h t s , o r bench h e i g h t s a r e f u n d a m e n t a l a s p e c t s o f a s p a t i a l r e l a t i o n s h i p , t h e P a t t e r n w i l l s t a t e what i s r e q u i r e d . 50 DIAGRAM 1 . 2 A PATTERN LANGUAGE FOR PUBLIC SPACES Circulation Realms (The a b i l i t y t o move e a s i l y w i t h o u t b e i n g d i r e c t e d i n an i n s t i t u t i o n ) LARGER PATTERNS Two Entrances for Patients ( S e p a r a t i o n o f In and O u t p a t i e n t s ) Short Corridors (Making c o r r i d o r s e n j o y a b l e c o n n e c t i o n s between a r e a s ) No Dead (Making t h r o u g h p l a c e ) End Corridors space f l o w not d i e a t one Nl/ Entrance Transition i (The need t o pause and A—1 change r o l e s from one sp a c e t o a n o t h e r ) SMALLER PATTERNS Welcoming Place (Warm a s p e c t s o f a r r i v a l s p a c e s ) Waiting ( C r e a t i o f a c t i >Ĵ >1/ P e o p l e No Wall Unused ( U s i n g t h e w a l l f o r t h i c k n e s s o f t e x t u r e and s t o r a g e ) Landscape ng an a s p e c t v i t y f o r w a i t i n g ) Light Sides Room (The have more s i d e on of Two Every V - - - Pools of Light (Use o f l i g h t t o d e f i n e s o c i a l s p a c e ) SMALLEST PATTERNS need t o l i g h t on t h a n one o f a room t o improve q u a l i t y o f s p a c e Open Areas are a Series of Alcoves (Not h a v i n g l a r g e u n d i f f e r e n t i a t e d s p a c e s ) 51 i When l o o k i n g a t o u r example, we n o t e t h a t t h e P a t t e r n s a r e p r e s e n t e d i n " s i z e " s t a r t i n g w i t h L a r g e r P a t t e r n s r e l a t i n g t o c o n t e x t s o u t s i d e t h e d e p a r t m e n t i t s e l f ( i s s u e s t h a t l i n k t o t h e o u t s i d e ) e . g . , C i r c u l a t i o n Realms i s c o n c e r n e d w i t h l i n k a g e s between s p a c e s so t h i s r e l a t e s t o S h o r t C o r r i d o r s , w h i c h d e s c r i b e s t h e a c t u a l c o r r i d o r i t s e l f as does Two E n t r a n c e s f o r P a t i e n t s w h i c h d e s c r i b e s where c o r r i d o r s s h o u l d b e g i n and e n d . Two E n t r a n c e s f o r P a t i e n t s r e l a t e s t o Welcoming P l a c e , which i s a S m a l l e r P a t t e r n s i n c e i t s p r o b l e m a r e a i s w i t h i n t h e d e p a r t m e n t . Welcoming P l a c e d e s c r i b e s what must be p l a n n e d a t t h e r e c e p t i o n p o i n t t o welcome t h e p u b l i c and t h e r e f o r e i s i n a c o n t i n u u m w i t h the L a r g e r i s s u e s which l e a d s t o i t . We n o t e a n o t h e r S m a l l e r P a t t e r n , E n t r a n c e T r a n s i t i o n w h i c h d e s c r i b e s t h e need f o r a d i s t i n c t i v e e n t r y s p a c e where p e o p l e c a n change f r o m an o u t s i d e p e r s o n ' s r o l e t o an i n s i d e p e r s o n ' s r o l e ( o r i n t h i s c a s e t o a " P a t i e n t " ) and i s l i n k e d t h e r e b y f o r m i n g a l o g i c a l c o n c l u s i o n t o S h o r t C o r r i d o r s w h i l e Welcoming P l a c e forms o n l y one a s p e c t o f a r r i v a l . We c a n s e e f r o m t h e s e and o t h e r l i n k a g e s t h e way i n w h i c h t h e Language c o m p l e t e s th e c o n c e p t s w i t h i n i n d i v i d u a l P a t t e r n s . 52 1.8 Toward a New Method We have e x p l o r e d t h e p r o b l e m s o f and t h e d i s t i n c t i o n s between S t a n d a r d s and G u i d e l i n e s . We have e s t a b l i s h e d t h e i r h i s t o r i c a l u se and t h e i r f a i l u r e t o r e s p o n d t o t h e p r e v a i l i n g s o c i a l a t t i t u d e s o r t o meet t h e p r e s e n t needs f o r C o n s i s t e n c y and F l e x i b i l i t y o f u s e . As an a l t e r n a - t i v e , we have d e s c r i b e d a s o c i a l l y - r e s p o n s i v e a p p r o a c h , t h e P a t t e r n Language c o n c e p t , w h i c h s a t i s f i e s t h e e s s e n - t i a l e l e m e n t s o f a good D e s i g n G u i d e l i n e and t h e r e f o r e can become an a c c e p t a b l e D e s i g n S t a n d a r d . What r e m a i n s i s f o r us t o d e v e l o p a method f o r q u i c k l y and e a s i l y c r e a t i n g o r r e b u i l d i n g P a t t e r n s s o t h a t t h e y c a n be r e a d i l y a c c e p t e d i n t o t h e P l a n n i n g P r o c e s s . O n l y t h e n can we be s u r e change w i l l a c t u a l l y o c c u r r e s u l t i n g i n t h e a c c e p t a n c e o f D e s i g n S t a n d a r d s , as an i m p o r t a n t p a r t o f t h e H e a l t h F a c i l i t i e s P l a n n i n g P r o c e s s . To have a m e a n i n g f u l m e t h o d o l o g y f o r e s t a b l i s h i n g D e s i g n G u i d l i n e s o r S t a n d a r d s , t h i s method must d i s c o v e r t h o s e same f u n d a m e n t a l a s p e c t s o f s p a c e and e v e n t s w h i c h a r e b a s i c t o A l e x a n d e r ' s P a t t e r n s . I t must f i n d i t s b a s i s , n o t i n t e c h n i q u e s o f t h e n a t u r a l s c i e n c e s , b u t i n t h o s e o f t h e s o c i a l s c i e n c i e s , so t h a t t h o s e s o c i e t a l v a l u e s we a l l s h a r e c a n be r e c o g n i z e d and e s t a b l i s h e d w i t h i n t h e G u i d e l i n e s . S o c i a l S c i e n t i s t s have a l w a y s had t o d e a l w i t h t h e p r o b l e m s o f s c i e n t i f i c m e t h o d o l o g y . T h i s we r e c o g n i z e d e a r l i e r as a p r o b l e m i n o u r m e t h o d o l o g y f o r d e v e l o p i n g D e s i g n G u i d e l i n e s . The N a t u r a l S c i e n c e s a r e a b l e t o a b s t r a c t f r o m p e r s o n a l o r c u l t u r a l o b j e c t s , t h e o b j e c t s w h i c h t h e y w i s h t o o b s e r v e . S o c i a l S c i e n c e s , and i n f a c t a l l t h e o r e t i c a l s c i e n c e s o f human a f f a i r s ; e c o n o m i c s , s o c i o l o g y , c u l t u r a l a n t h r o p o l o g y , e t c . , have had t o d e v - e l o p p a r t i c u l a r d e v i c e s f o r e i g n t o t h e n a t u r a l s c i e n c e s i n o r d e r t o e x p l a i n s o c i a l r e a l i t i e s w h i c h a g r e e w i t h t h e common-sense e x p e r i e n c e s o f the s o c i a l w o r l d . W h i l e i t i s p o s s i b l e t o see t h i s need, i t i s t h e c o n c e r n o f some s o c i a l s c i e n t i s t s t h a t t h e d i s t i n c t i o n between t h e methods o f n a t u r a l and s o c i a l s c i e n c e s a r e not c l e a r l y enough a p p l i e d by many s o c i a l s c i e n t i s t s . 3 0 I t i s t h i s same c o n c e r n w h i c h we have about d e s i g n and D e s i g n G u i d e l i n e s . In an a t t e m p t t o a p p l y b e a u t i f u l l y s c i e n - t i f i c , a b s t r a c t e d , r a t i o n a l m e t h o d o l o g i e s t o e x p l a i n t h e p r o c e s s o f d e s i g n , we have a l l o w e d t h e human a s p e c t s o f d e s i g n t o become s u b o r d i n a t e d . B o r r o w i n g from t h e work o f H. G a r f i n k e l - ^ i n u s i n g h i s a p p r o a c h c a l l e d " E t h n o m e t h o d o l g y " we c a n d e v e l o p an a p p r o a c h t o u n d e r s t a n d i n g t h e "common-sense" o r " n a t u r a l f a c t s o f l i f e " a s t h e y r e l a t e t o t h e b u i l t e n v i r o n m e n t . .54 We r e c o g n i z e t h a t t h e s o c i e t y i n w h i c h members i n t e r a c t i s o r g a n i z e d w i t h i n a r a t i o n a l s t r u c t u r e , t h e r u l e s o f w h i c h a r e known a t a common-sense l e v e l . To u n d e r s t a n d t h e r u l e s r e q u i r e s t h a t we u n d e r s t a n d t h e n a t u r e o f t h i s r a t i o n a l s t r u c t u r e . S c h u t z , 3 2 p o i n t s o u t t h a t v e r y l i t t l e o f one's knowledge o f t h e w o r l d i s f r o m p e r s o n a l e x p e r i e n c e . The g r e a t e r p a r t i s s o c i a l l y d e r i v e d , t a u g h t by f a m i l y , f r i e n d s , t e a c h e r s and t e a c h e r s o f t e a c h e r s . In t h i s way one i s t a u g h t how t o d e f i n e the e n v i r o n m e n t ( t h e r e l a t i v e n a t u r a l a s p e c t s o f t h e w o r l d as t a k e n f o r g r a n t e d u n t i l f u r t h e r n o t i c e ) and a l s o how t y p i c a l c o n s t r u c t s have t o be for m e d i n a c c o r d a n c e w i t h a s y s t e m o f r e l e v a n c e s w h i c h one a c c e p t s as b e i n g p r o v i d e d from t h e anonymous u n i f i e d p o i n t o f v i e w o f t h e i n - g r o u p . S c h u t z n o t e s t h a t we come: " . . . t o t h e c o n c l u s i o n t h a t ' r a t i o n a l a c t i o n ' on t h e common-sense l e v e l i s a l w a y s a c t i o n w i t h i n an u n q u e s t i o n e d and u n d e t e c t e d frame o f c o n s t r u c t s o f t y p i - c a l i t i e s o f t h e s e t t i n g , t h e m o t i v e s , t h e means and e n d s , t h e c o u r s e s o f a c t i o n and p e r s o n a l i t i e s i n v o l v e d and t a k e n f o r g r a n t e d . They a r e , however, n o t m e r e l y t a k e n f o r g r a n t e d by t h e a c t o r b u t a l s o s u p p o s e d as b e i n g t a k e n f o r g r a n t e d by t h e f e l l o w m a n . 1 , 3 3 I n o r d e r t o d i s c o v e r what p e o p l e know o f t h e r u l e s o f t h e s o c i e t y , o r e v e n t h e p r i o r i t i e s t h a t t h e y p l a c e upon e v e n t s w i t h i n t h e i r s o c i e t y , we must l o s e t h e "knowledge" t h a t we have i n common w i t h them. We must remove o u r - s e l v e s f r o m t h e b a c k g r o u n d o f "seen but u n n o t i c e d " e x p e c - t a n c i e s w h i c h members o f s o c i e t y use f o r i n t e r p r e t a t i o n , b u t w h i c h i f a s k e d t h e y c o u l d not d e s c r i b e . G a r f i n k e l s a y s : "F o r t h e s e b a c k g r o u n d e x p e c t a n c i e s t o come i n t o v i e w one must e i t h e r be a s t r a n g e r t o t h e ' l i f e a s u s u a l ' c h a r a c - t e r o f e v e r y d a y s c e n e s , o r become e s t r a n g e d f r o m them . "34 In t r e a t i n g t h e " o b v i o u s " a c t i o n s o f p e o p l e as " s t r a n g e " , we a r e a b l e t o u n d e r s t a n d what i t i s t h a t p e o p l e a r e s a y i n g about t h e s o c i e t y and t h e r e f o r e what t h e y b e l i e v e i t i s . I f we f o c u s on t h o s e a s p e c t s o f o u r s o c i e t y w h i c h r e l a t e t o p e o p l e i n t h e b u i l t e n v i r o n m e n t i t i s p o s s i b l e f o r us t o o b s e r v e t h e a c t i o n s o f p e o p l e o p e r a t i n g t h e s o c i e t y w i t h i n an o r g a n i z e d a r r a n g e m e n t o f d e c i s i o n m aking, p l a n n i n g , c h o o s i n g , commenting, d i s c u s s i n g , c r i t i c i z i n g , e t c . I f we t r e a t t h e s e a c t i o n s a s " s t r a n g e " o r a t l e a s t " u n i q u e " we can d i s c o v e r what i t i s t h a t c a u s e s p e o p l e t o d i s p l a y t h e i r v a l u e s o f good o r bad i n r e s p e c t t o b u i l t s p a c e s , and i t w i l l be p o s s i b l e t o 56 id e n t i f y those consistent elements, or truths, which form the "rules" of good or bad design. When we have done t h i s analysis, we w i l l be able to describe confidently what must occur in the design of spaces to enable a l l members of the society to say that i t i s a good building. We can thus ensure that any Guideline containing such data w i l l improve the building we create and therefore the qua l i t y of people's l i v e s who use them. In the next chapter, we develop such a method i n d e t a i l . Then in Chapter 3 i t i s tested, to establish i t s v a l i d i t y for use in-creating Patterns as Guidelines, which are usable for Standards. We w i l l see that there i s a method available which simulates a conversation between two groups of people, thus enabling the d e t a i l s of the special features of t h e i r world to be recorded. In t h i s way, the tenets of the s o c i a l s c i e n t i s t s ' methods can be incorporated and the r e s u l t s of t h i s exchange w i l l provide the elements of a socially-founded, s c i e n t i f i c a l l y - v a l i - dated, Pattern, whose format i s that of our new Standard. We w i l l have achieved our purpose in finding a method which can create e f f e c t i v e Guidelines and Standards for Hospital Design. i 57 CHAPTER 2: A METHODOLOGY FOR CREATING DESIGN GUIDELINES 2.1 An Appropriate Methodology In o r d e r t o d e v e l o p P a t t e r n s f o r use as G u i d e l i n e s , w i t h i n t h e method used t h e r e a r e c e r t a i n key c h a r a c t e r i s - t i c s o f any P a t t e r n w h i c h must be accommodated. We need t o d e v e l o p an u n d e r s t a n d i n g o f how p e o p l e use s p a c e s and what t h e y s a y a b o u t t h o s e s p a c e s i n o r d e r t o r e c o g n i z e and comprehend t h e o r d e r w h i c h e x i s t s w i t h i n i t s e l e m e n t s . T h i s r e q u i r e s an i n t e r a c t i v e p r o c e s s between t h e g r o u p o f p e o p l e s o l i c i t i n g t h e d a t a and t h o s e "members" o f t h e l i v - i n g and o p e r a t i n g " s o c i e t y " . In t h i s i n s t a n c e we need a d i s c o u r s e between P l a n n i n g E x p e r t s who w i l l c o l l e c t , i n t e r p r e t and p r o d u c e t h e P a t t e r n s , and U s e r E x p e r t s who a r e t h e most i n f o r m e d "members" o f t h e v e r y s p e c i f i c " s o c i e t y " c h o s e n f o r o u r s u b j e c t a r e a . We have c h o s e n t o examine Newborn N u r s e r i e s and N e o n a t a l I n t e n s i v e C a r e U n i t s , b e c a u s e a b r o a d r a n g e o f b o t h M e d i c a l and Non- M e d i c a l i n t e r e s t g r o u p s a r e i n v o l v e d . T h i s s u b j e c t a l s o r e q u i r e s t h i s e x p e r t i n v o l v e m e n t from as d i v e r s e a g r o u p o f i n t e r e s t s ( e x p e r t i s e s ) as p o s s i b l e , p l u s , p a r t i c i p a t i o n f r o m a s wide a g e o g r a p h i c a r e a as p o s s i b l e . In t h i s way, we can e n s u r e t h e i n v o l v e m e n t o f a l a r g e c r o s s s e c t i o n o f t h e p o p u l a t i o n t h e r e b y r e d u c i n g p o s s i b l e b i a s e s from i n d i v i d u a l p e r s o n a l o r l o c a t i o n a l d i f f e r e n c e s . When an i n t e r a c t i v e p r o c e s s i s r e q u i r e d , i t s most u s u a l f o r m i s a c o m m i t t e e . U s i n g a committee i n q u i r y method would a l l o w us t o s e l e c t from a number o f committee f o r m a t s r a n g i n g f r o m "open" s t r u c t u r e d B r a i n - S t o r m i n g ^ t o t h e more " c l o s e d " s t r u c t u r e d N o m i n a l Group T e c h n i q u e 2 . The d i f f i c u l t y we would e n c o u n t e r w i t h any o f t h e s e methods i s t h e i r r e q u i r e m e n t f o r a s s e m b l i n g numbers o f p e o p l e i n one p l a c e . T h i s r e q u i r e m e n t would c a u s e t h i s p r o j e c t t o d e v e l o p i n t o a m a j o r "Task F o r c e " w i t h r e p r e - s e n t a t i v e s coming t o g e t h e r f r o m d i f f e r e n t g e o g r a p h i c l o c a t i o n s , t o r e p r e s e n t a v a r i e t y o f m e d i c a l s p e c i a l t i e s . T h i s c o u l d o n l y o c c u r w i t h a l a r g e , w e l l f u n d e d s t u d y o r a c o n s i d e r a b l e amount o f t i m e from v o l u n t e e r s p r e p a r e d t o a g r e e t o a s a t i s f a c t o r y s c h e d u l i n g o f t h e t i m e t h a t w o u l d be r e q u i r e d . S i n c e t y p i c a l l y n e i t h e r f u n d i n g n o r l a r g e amounts o f t i m e would be a v a i l a b l e , a p r o c e s s i s r e q u i r e d t h a t a l l o w s c o m m u n i c a t i o n w i t h p a r t i c i p a n t s l o c a t e d i n t h e i r own community. T h i s s u g g e s t s some f o r m o f " D e l p h i T e c h n i q u e " . A l s o , s i n c e more t h a n one c o m m u n i c a t i o n between t h e g r o u p s w o u l d be r e q u i r e d t o c o m p l e t e t h e s t u d y , t h e D e l p h i T e c h n i q u e , b e i n g an i n t e r a c t i v e p r o c e s s , would a p p e a r t o be a l o g i c a l c h o i c e . B e f o r e d e s c r i b i n g o u r p a r t i c u l a r a p p l i c a t i o n o f t h e t e c h n i q u e , we need an u n d e r s t a n d i n g o f t h e D e l p h i T e c h - n i q u e i t s e l f . The D e l p h i i s d i f f i c u l t t o d e f i n e b e c a u s e i n t h e p a s t 20 y e a r s s i n c e i t s o r i g i n a l use by O l a f Helmer and Norman D a l k e y a t t h e Rand C o r p o r a t i o n o f C a l i f o r n i a , 59 i t has e v o l v e d i n many d i r e c t i o n s . I t s p r e s e n t most c h a r - a c t e r i s t i c use i s s t i l l s i m i l a r t o t h a t used by t h e o r i g i n a l g r o u p ( i n t h e 1950's) who were l o o k i n g t o d e t e r - mine t h e most l i k e l y t a r g e t s f o r S o v i e t A-bomb m i s s i l e s . T h a t p a r t i c u l a r f o r m was t o " o b t a i n t h e most r e l i a b l e c o n s e n s u s o f o p i n i o n [ s i c ] o f a g r o u p o f e x p e r t s by a s e r i e s o f i n t e n s i v e q u e s t i o n n a i r e s i n t e r s p e r s e d w i t h c o n t r o l l e d o p i n i o n f e e d b a c k s " 3 . i n t h a t example a s e r i e s o f q u e s t i o n n a i r e s were s e n t o u t t o e x p e r t s t h r e e o r f o u r t i m e s by a m o n i t o r i n g g r o u p . These m o n i t o r s p r e p a r e d m a t e r i a l , e d i t e d , a s s e m b l e d and a c t e d t o f a c i l i t a t e com- m u n i c a t i o n between t h e members o f t h e g r o u p o f e x p e r t s , o f t e n c a l l e d a R e s p o n d e n t Group. The o b j e c t i v e was f o r e a c h e x p e r t t o g i v e answers anonymously and t o r e c e i v e f e e d b a c k f r o m t h e o t h e r members o f t h e g r o u p so t h a t m o d i f i c a t i o n t o answers o c c u r r e d , f r o m one q u e s t i o n i n g r o u n d t o a n o t h e r , u n t i l a g r o u p c o n s e n s u s was r e a c h e d . U s u a l l y c o n s e n s u s i s s o u g h t i n t h i s a p p l i c a t i o n . L i n s t o n e and T u r o f f , i n t h e i n t r o d u c t i o n t o t h e i r l a n d m a r k work on D e l p h i ^ , s u g g e s t t h a t o n l y t h e b r o a d e s t d e f i n i t i o n o f D e l p h i i s p o s s i b l e and Helmer h i m s e l f s t a t e s t h a t d e s p i t e t h e 20 y e a r s o f d e v e l o p m e n t , t h e r e i s n o t a c o m p l e t e l y sound t h e o r e t i c a l b a s i s f o r t h e t e c h n i q u e . B e c a u s e t h e t e c h n i q u e i s so d i v e r s e and has been w i d e l y u s e d , r a t h e r t h a n s e l e c t i n g one o f t h e D e l p h i s 1 t o use a s a m o d e l , we w i l l d e s i g n a s p e c i a l D e l p h i w h i c h w i l l p r o d u c e r e s u l t s c o n s i s t e n t w i t h o u r t y p e o f g u i d e l i n e s f o r 60 f a c i l i t i e s d e s i g n . We can b e g i n by u s i n g L i n s t o n e and T u r o f f ' s d e f i n i - t i o n t o e n s u r e t h e d e s i g n o f o u r D e l p h i i s r e p r e s e n t a t i v e o f t h e b r o a d e s t c o n c e p t s o f a D e l p h i . The d e f i n i t i o n i s : " D e l p h i may be c h a r a c t e r i z e d as a method f o r s t r u c t u r i n g a g r o u p c o m m u n i c a t i o n p r o c e s s s o t h a t t h e p r o c e s s i s e f f e c t i v e i n a l l o w i n g a g r o u p o f i n d i v i d u a l s as a whole t o d e a l w i t h a complex p r o b l e m . " 5 The D e l p h i as d e s c r i b e d c o u l d a p p l y t o any g r o u p a r r a n g e m e n t f o r i n t e r a c t i o n , s o we w i l l d e s c r i b e t h e p a r - t i c u l a r g r o u p s i n v o l v e d i n o u r s t u d y , t h e n s t r u c t u r e a method f o r c a r r y i n g o u t t h i s s t u d y . As a l r e a d y s t a t e d , t h e D e l p h i d o e s n o t have a p u r e l y t h e o r e t i c a l b a s i s , w h i c h would a l l o w us p r e c i s e r e s u l t s , so o u r s t u d y w i l l c o n c e n - t r a t e on t h e v a l u e o f t h e g r o u p i n t e r a c t i o n r a t h e r t h a n t h e m e a s u r a b l e v a l u e o f t h e r e s u l t s . T h i s D e l p h i must be s e e n as a "remote c o n v e r s a t i o n " between t h e g r o u p s i n v o l v e d . Our method w i l l use t h i s " c o n v e r s a t i o n " t o g e n e r a t e some c o n c e p t s o f what i s i m p o r t a n t i n p l a n n i n g Newborn N u r s e r i e s , use t h e s e c o n c e p t s t o p r o d u c e g u i d e - l i n e s , and t h e n c h e c k t h e r e s u l t s by a l a r g e r , s u r v e y g r o u p . ' In t h e s t r u c t u r i n g o f t h e s t u d y we c a n c o n c e n t r a t e upon two b a s i c e l e m e n t s . F i r s t , i t i s i m p o r t a n t t o c l e a r - l y d e f i n e t h e membership o f e a c h p a r t i c i p a t i n g g r o u p and t h e r o l e s e a c h w i l l p l a y i n t h e p r o c e s s . S e c o n d l y , we can 61 s t r u c t u r e t h e i n t e r a c t i o n between t h e g r o u p s so as t o c o n t r o l f o r t h e n e g a t i v e e f f e c t s o f any i n d e p e n d e n t v a r i - a b l e s w h i c h c o u l d r e a s o n a b l y be f o r e s e e n . In r e s o l v i n g t h e f o r m e r s i t u a t i o n , we c a n draw upon t h e knowledge o f t h e p r o c e s s e s o f g r o u p d y n a m i c s and i n t h e l a t t e r s i t u a - t i o n we c a n draw upon p u b l i s h e d l i t e r a t u r e , p a r t i c u l a r l y a b o u t D e l p h i p r o c e s s e s , t o g u i d e o u r a c t i o n s . 2.2 The Groups and Intergroup Structure , In a c c o r d a n c e w i t h t h e s o c i a l s c i e n c e a p p r o a c h d e s c r i b e d i n t h e p r e v i o u s c h a p t e r , o u r method f o r c o l l e c t - i n g d a t a on t h e b e s t e l e m e n t s o f N u r s e r y D e s i g n , i s t o 'know* what a p e r s o n o p e r a t i n g i n t h a t ' s o c i e t y ' knows. We a r e s e e k i n g t o know what a r e t h e r e c u r r i n g i s s u e s c a u s i n g c o n f l i c t i n t h e e n v i r o n m e n t and what ways p e o p l e use t o d e a l w i t h t h i s i n p l a n n i n g . We need i n v o l v e m e n t o f p e o p l e who a r e e x p o s e d t o b o t h t h e t h e o r y and as many o f t h e p r a c t i c a l p r o b l e m s as p o s s i b l e , so t h a t we may know what t h e y know. Even when f o c u s s i n g on a s i n g l e a r e a o f h o s p i t a l p l a n n i n g , s u c h a s Newborn N u r s e r i e s , t h e e x t e n t o f p u b l i s h e d m a t e r i a l a v a i l a b l e on t h e s u b j e c t i s e n o r - mous. To i l l u s t r a t e , t h e r e s u l t s o f a s k i n g f o r a B i b l i o - g r a p h i c a l Computer S e a r c h a t t h e U n i v e r s i t y o f B.C. B i o - m e d i c a l L i b r a r y , p r o d u c e d 35 a r t i c l e s , w i t h o n l y a c r o s s r e f e r e n c e between Newborn N u r s e r i e s and P l a n n i n g . In t h e 62 Ross L a b o r a t o r i e s book on Newborn P l a n n i n g * 5 , i n e x c e s s o f 60 r e f e r e n c e s a r e c i t e d . W h i l e i t i s c l e a r t h a t t h e r e i s , t h r o u g h p u b l i s h e d m a t e r i a l on t h e s u b j e c t , a v a s t amount o f e x p e r t i s e a v a i l a b l e , i t i s n o t so c l e a r t h a t t h e numbers o f p e o p l e i n v o l v e d i n t h e a r e a o f N u r s e r i e s i s as l a r g e . S i n c e t h e p o p u l a t i o n e x p o s e d t o t h e p r o b l e m s o f N u r s e r y D e s i g n a r e s u b j e c t s o f t h i s r e s e a r c h , and t h i s p o p u l a t i o n w i l l be c o n f i n e d t o M e d i c a l S t a f f , N u r s i n g S t a f f and t h e r e l a t i v e l y s m a l l number o f t h e p u b l i c who use h o s p i t a l n u r s e r y f a c i l i t i e s ; t h e p r o b a b i l i t y o f f i n d - i n g a r e p r e s e n t a t i v e sample i s e x c e l l e n t . We can a l s o r e c o g n i z e t h a t d a t a c o l l e c t e d f r o m a sample o f e x p e r t s i n - v o l v e d i n N u r s e r i e s f r o m t h e M e d i c a l and N u r s i n g f i e l d s a r e f r o m t h e p e o p l e n o t o n l y f u l l y aware o f t h e r e l e v a n t f a c t o r s ( as e x p e r t s ) b u t a l s o t h o s e l i k e l y t o be p a r t o f t h e l i m i t e d p o p u l a t i o n b e i n g o b s e r v e d . The c h o i c e o f t h e s e p e o p l e as a sample p o p u l a t i o n w i l l as a c o n s e q u e n c e i n c r e a s e c o n f i d e n c e i n t h e r e s u l t s o f t h e r e s e a r c h . F u r t h e r , i t i s r e a s o n a b l e t o assume t h a t t h e e x p e r t s w i l l be i n f o r m e d as t o t h e o p e r a t i o n a l i s s u e s and i f n o t c o n t r i b u t o r s t o t h e l i t e r a t u r e , t h e y w i l l c e r t a i n l y be f u l l y aware o f t h e m a t e r i a l a v a i l a b l e . I t i s a l s o r e a s o n a b l e t o assume t h a t a g r e a t d e a l o f t i m e and c o s t c a n be s a v e d by a v o i d i n g e x t e n s i v e l i t e r a t u r e r e v i e w s and 63 r e l y i n g i n s t e a d upon t h e e x p e r t s t o draw upon t h e i r b a c k - g r o u n d knowledge o f c u r r e n t l i t e r a t u r e . The p r o b a b i l i t y i s h i g h t h a t any c o n c e r n s d e s c r i b e d by t h e e x p e r t s a r e l i k e l y t o be b o t h r e l e v a n t and c o r r e c t . However, we must s t i l l assume t h e r e i s a need t o c r o s s r e f e r e n c e t h e s e e x p e r t o p i n i o n s . A s i m i l a r s e t o f c r o s s r e f e r e n c i n g c i r c u m s t a n c e s i s examined by K u r t F i n s t e r b u s c h ? i n a p a p e r w h i c h makes a s t r o n g c a s e f o r t h e use o f M i n i - S u r v e y s ( d e f i n e d a s s m a l l s a m p l e s s i z e d f r o m 15 t o 20 p e o p l e ) i n s o c i a l r e s e a r c h . In t h e p a p e r he p o i n t s o u t t h a t t h e M i n i - S u r v e y i s most u s e f u l i n m o d i f y i n g t h e e s t i m a t e s o f e x p e r t s by t h e s y n t h e s i s o f b o t h e x p e r t and M i n i - S u r v e y o p i n i o n . The t h e o r e t i c a l b a s i s o f t h i s p a r t i c u l a r p r o c e s s i s t h e use o f a B a y e s i a n a n a l y s i s t o d e t e r m i n e t h e p r o b a b i l i t y o f an e v e n t ( t h e outcome o f t h e M i n i - S u r v e y ) g i v e n t h e f a c t t h a t a s p e c i f i e d s e t o f p r i o r p r o b a b i l i t i e s e x i s t s w h i c h a r e p r o v i d e d by t h e e x p e r t s . The f i n a l p r o b a b i l i t y o f t h e outcome i s d e r i v e d f r o m t h e p r o b a b i l i t y f o r t h e j o i n t o c c u r e n c e o f t h e e v e n t and t h e s e t o f p r o b a b i l i t i e s . T h i s a p p r o a c h i s u s e f u l f o r o u r p r o b l e m , b u t c a n n o t be f o l l o w e d e x a c t l y . We know we have a g r e a t many i s s u e s r e l a t e d t o t h e f u n c t i o n i n g o f a u n i t w h i c h c o u l d be a d d r e s s e d . The p r o b - i a b i l i t y i s h i g h t h a t t h e key i s s u e s w h i c h a r e f u n d a m e n t a l t o t h e p l a n n i n g w i l l be a d d r e s s e d by e x p e r t u s e r s . I t i s 6 4 v e r y l i k e l y t h a t what i s p r o d u c e d by t h e s e e x p e r t s w i l l be e x a c t l y t h o s e i s s u e s w h i c h any p o p u l a t i o n o f u s e r s o f a l l f a c i l i t e s would have r a i s e d . I t r e m a i n s t h e n t o e n s u r e t h a t a c h e c k o f t h e e x p e r t o p i n i o n s o c c u r s t h r o u g h some fo r m o f M i n i - S u r v e y o f a l a r g e r p o p u l a t i o n . In t h e c a s e d e s c r i b e d by F i n s t e r b u s c h , i f t h e outcome o f t h e M i n i - S u r v e y shows a d i v e r g e n c e from t h e e x p e r t s , t h e n t h e B a y e s i a n Theorem w i l l a c c o u n t f o r t h e m o d i f i e d j o i n t p r o b a b i l i t y t h r o u g h a m a t h e m a t i c a l c o m b i n a t i o n . T h i s m a t h e m a t i c a l b a s i s i s v a l u a b l e where t h e n u m e r i c p r o b a b i l - i t y o f e v e n t s i s used i n f o r e c a s t i n g , but not o f much use i n a d i r e c t s e n s e h e r e . We need t o use t h i s i d e a d i f f e r - e n t l y . R e q u i r e d f r o m o u r e x p e r t s i s t h e i r i d e n t i f i c a t i o n o f s p a t i a l c o n f l i c t , t h e r e c o g n i t i o n o f i t s c a u s e and t h e c l a r i f i c a t i o n o f t h e s o l u t i o n most l i k e l y f o r i t s r e s o l u - t i o n . The n u l l h y p o t h e s i s i s t h a t an i s s u e i d e n t i f i e d i s n o t c a u s i n g c o n f l i c t , o r i f i t i s , t h a t t h e wrong ca u s e o r s o l u t i o n h as been i d e n t i f i e d and t h i s c a n be c h e c k e d by a l a r g e r ( M i n i - S u r v e y ) p o p u l a t i o n . However, we would be a b l e t o m o d i f y e x p e r t f i n d i n g s , s h o u l d t h e r e be a d i v e r - g e n c e , o n l y by h a v i n g f u r t h e r i s s u e s d e v e l o p e d by t h e e x p e r t s t h e m s e l v e s i n r e s p o n s e t o i n p u t f r o m t h e M i n i - S u r v e y . The f u l l e f f e c t o f t h e B a y e s i a n M a t h e m a t i c s i s n o t o f v a l u e ; o n l y i t s p r i n c i p l e . We w i l l c h e c k t h e e x p e r t s ' r e s u l t s by a M i n i - S u r v e y a t t h e end o f t h e s t u d y and b u i l d i n a c o r r e c t i v e r o u n d i f r e q u i r e d . Now we s h o u l d d e v e l o p t h e g r o u p i n t e r a c t i o n . 6 5 The f i r s t g r o u p we have i n v o l v e d a r e t h e P h y s i c i a n s and N u r s e s whom we have c a l l e d M e d i c a l U s e r E x p e r t s . We must r e c o g n i z e t h a t s o l u t i o n s d e v e l o p e d by i n v o l v i n g j u s t m e d i c a l u s e r s , r e g a r d l e s s o f t h e c r o s s c h e c k , would n o t make p r o v i s i o n f o r t h e b a l a n c i n g o f b i a s e s w h i c h n o r m a l l y o c c u r due t o p o s s i b l e s t e r e o t y p i c a l a t t i t u d e s h e l d w i t h i n t h e s e p r o f e s s i o n s . L i k e any d e c i s i o n making p r o c e s s , a l l p a r t i c i p a n t s c a n be presumed t o b r i n g w i t h them t h e i r own p o i n t s o f v i e w . T h i s i s not a l w a y s a n e g a t i v e a s p e c t b e c a u s e i t may j u s t r e f l e c t t h e d e g r e e o f one's p r a c t i c a l e x p o s u r e t o p l a n n i n g o r d i f f e r e n c e s i n t h e p r i o r i t i e s one a s s o c i a t e s w i t h a s p e c i f i c a r e a o f o n e ' s r e s p o n s i b i l i t y . T h i s can c l e a r l y be s e e n i n t h e d i f f e r e n c e i n a t t i t u d e between P h y s i c i a n s , N u r s e s and A d m i n i s t r a t o r s i n a h o s p i t a l . P e o p l e w i l l n o r m a l l y come t o t h i s p l a n n i n g p r o c e s s as a d v o c a t e s o f t h e i r p a r t i s a n p o i n t s o f v i e w , and s o , we must a c c e p t t h i s as a v a r i a b l e w h i c h w i l l a f f e c t t h e r e s u l t s . The d e s i g n o f t h e g r o u p s t r u c t u r e must a r r a n g e f o r b a l a n c e and t h i s comes from two o t h e r g r o u p s o f e x p e r t s ; t h e Consumers and D e s i g n e r s . M e d i c a l , N u r s i n g and Admin- i s t r a t i v e e x p e r t s a r e t h e ones who have the b e s t t e c h n i c a l k nowledge o f o p e r a t i o n a l f u n c t i o n and t e c h n i q u e . T h e r e w i l l be d i f f e r e n c e s between t h e i r p e r c e p t i o n s o f a p r o b l e m and t h i s w i l l be a d d r e s s e d t h r o u g h e a c h g r o u p e x p r e s s i n g c o n c e r n s w h i c h t h e o t h e r s can comment upon, d u r i n g t h e n o r m a l c o u r s e o f t h e D e l p h i e v e n t s . However, we r e c o g n i z e 6 6 t h a t t h i s c o m m u n i c a t i o n i s o n l y m e a n i n g f u l b e c a u s e each m e d i c a l g r o u p s h a r e s a s i m i l a r t e c h n i c a l c o m p r e h e n s i o n w h i c h t h e y do n o t have i n common w i t h c o nsumers. Consum- e r s have c o n c e r n s w h i c h t e n d t o r e f l e c t a more common- s e n s e , o f t e n e m o t i o n a l r e s p o n s e t o a s i t u a t i o n . Many p r o b l e m s o f t h e consumers may be c r e a t e d by p o l i c i e s , a t t i t u d e s o r p r i o r i t i e s o f t h e T e c h n i c a l u s e r s . These c o n c e r n s may be s h a r e d , o r a t l e a s t known, by M e d i c a l u s e r s but t h e two g r o u p s do n o t n e c e s s a r i l y have a common b a s i s f o r d i s c u s s i o n s u f f i c i e n t t o make a p r o d u c t i v e j o i n t e f f o r t . I t i s n e c e s s a r y , t h e r e f o r e , t h a t t h e b a s i c " t e c h n i - c a l " d e t a i l be d e v e l o p e d s e p a r a t e l y f r o m t h e " e m o t i v e " m a t e r i a l . T h i s r e q u i r e s a D e l p h i D e s i g n i n w h i c h t h e T e c h n i c a l e x p e r t s p r o d u c e b a s i c m a t e r i a l and Consumer ( o r n o n - t e c h n i c a l ) U s e r s s u p p l e m e n t t h e m a t e r i a l w i t h a d d i - t i o n s o r r e a c t i o n s . To a l l o w f o r t h i s , t h e t e c h n i c a l d e t a i l w i l l be c r e a t e d i n t h e D e l p h i - S u r v e y s and t h e Consumers must be g i v e n i n p u t a s a p a r t o f t h e c h e c k i n g M i n i - S u r v e y a f t e r t h e D e l p h i - S u r v e y s . A n o t h e r e x p e r t g r o u p w h i c h i s e s s e n t i a l t o G u i d e - l i n e Development c o m p r i s e s t h e P l a n n i n g E x p e r t s whose r e a l e x p e r t i s e l i e s i n two a r e a s . F i r s t i s t h e i r s k i l l i n a n a l y s i s o f p l a n n i n g p r o b l e m s i n c l u d i n g a v o c a b u l a r y o f ways t o s o l v e them; s e c o n d i s t h e i r s k i l l as s y n t h e s i s e r s , as e n a b l e r s i n t h e p r o c e s s by w h i c h p r o b l e m s a r e r e c o g - 67 I n i z e d , t h e common e l e m e n t s i d e n t i f i e d and a c c e p t a b l e s o l u - t i o n s p r o d u c e d . L i k e t h e Consumers, t h e y must be a l l o w e d t o r e a c t t o t e c h n i c a l e x p e r t i s e and t h e r e f o r e must n o t be a n s w e r i n g M e d i c a l E x p e r t s * q u e s t i o n n a i r e s a s a p a r t o f t h e t e c h n i c a l q u e s t i o n n a i r e r o u n d s . However, D e s i g n e r E x p e r t s a r e a c r i t i c a l p a r t o f b e i n g a b l e t o t a k e t h i s p a r t i c u l a r D e l p h i p r o c e s s p a s t j u s t i d e n t i f i c a t i o n o f p r o b l e m s i n t o t h e a r e a o f t h e r e s o l u t i o n o f p r o b l e m s . They have t e c h n i - c a l e x p e r t i s e w h i c h i s c e n t r a l t o t h e p r o c e s s , r a t h e r t h a n p e r i p h e r a l as w i t h Consumers. B o t h Consumers and D e s i g - n e r s a r e a d d i t i o n a l l y c r i t i c a l t o o b t a i n i n g a b a l a n c e o f a t t i t u d e s . In t h e t r a d i t i o n a l D e l p h i T e c h n i q u e , t h e M o n i t o r i n g G roup a c t s as i n d e p e n d e n t , o b j e c t i v e managers o f t h e p r o c e s s . T h e i r r o l e i s t o c o l l e c t t h e m a t e r i a l and r e d i s - t r i b u t e q u e s t i o n s between t h e i n t e r a c t i v e r o u n d s . They e n a b l e t h e e x p e r t s t o p r o d u c e t h e r e s u l t s b u t do n o t t a k e p a r t i n t h e p r o c e s s . In t h i s s t u d y , i t i s e s s e n t i a l t h a t t h e D e l p h i be d e s i g n e d as a c o m m u n i c a t i o n p r o c e s s between t h e D e s i g n e r s and t h e M e d i c a l E x p e r t s . R a t h e r t h a n t h e M o n i t o r i n g Group a c t i n g as o b j e c t i v e f a c i l i t a t o r s , t h e y would a c t as a n o t h e r g r o u p o f e x p e r t s ( P l a n n i n g E x p e r t s ) u s i n g t h e i n p u t f r o m t h e M e d i c a l ( t e c h n i c a l ) E x p e r t s t o d e v e l o p m a t e r i a l , t h e n r e t u r n t h i s m a t e r i a l t o t h e M e d i c a l E x p e r t s f o r r e a c t i o n and f u r t h e r d e v e l o p m e n t . 68 In b r o a d o u t l i n e t h e n , we have two g r o u p s o f e x p e r t s i n t e r a c t i n g v i a a remote i n t e r a c t i v e p r o c e s s . E a c h g r o u p u s e s t h e e x p e r t i s e o f t h e o t h e r t o d e v e l o p and m o d i f y t h e i r own p o i n t o f v i e w w h i l e b r i n g i n g t h e i s s u e s n e e d i n g t o be a d d r e s s e d i n t o f o c u s . T h i s a p p r o a c h i s s u p p o r t e d by L i n s t o n e who s a y s i n a d i s c u s s i o n o f t h e needs i n o u r p r e s e n t w o r l d f o r h e t e r o g e n i s t i c l o g i c when d e a l i n g w i t h complex s o c i e t i a l p r o b l e m s : " I f t h e t e c h n i q u e ( D e l p h i ) i s v i e w e d as a two-way c o m m u n i c a t i o n s y s t e m r a t h e r t h a n a d e v i c e t o p r o d u c e c o n s e n s u s i t f i t s t h i s e v o l v i n g c u l t u r e a d m i r a b l y . " 8 A l t h o u g h t h e r o l e s o f t h e M o n i t o r i n g Group and t h e P l a n n i n g E x p e r t s have now become t h e r e s p o n s i b i l i t y o f one g r o u p o f p e o p l e , t h e a c t u a l f u n c t i o n s o f e a c h g r o u p a r e s e p a r a t e l y m a i n t a i n e d . T h i s combined g r o u p must s t i l l p e r f o r m v e r y d i f f e r e n t r o l e s a t d i f f e r e n t t i m e s . To f a c - i l i t a t e t h i s , an i n t e r n a l s t r u c t u r e o f t h e g r o u p w o u l d be t h a t o f a s i m p l e s m a l l c o m m i t t e e . The committee a p p r o a c h i s a c c e p t a b l e i n t h i s i n s t a n c e b e c a u s e f i r s t l y , a s M o n i t o r s , u n s t r u c t u r e d d i s c u s s i o n i s r e q u i r e d i n o r d e r t o a c t a s o b j e c t i v e f a c i l i t a t o r s ( n e i t h e r r e p r e s e n t i n g M e d i c a l ( T e c h n i c a l ) e x p e r t i s e n o r r e p r e s e n t i n g any s p e c - i f i c g e o g r a p h i c l o c a t i o n ) and s e c o n d l y , as P l a n n i n g E x p e r t s , t h e y a r e s e l e c t e d f o r t h e i r c o n v e r g e n t i d e a s r a t h e r t h a n t h e i r d i v e r g e n c e s . They a r e t o r e p r e s e n t a s i n g l e p l a n n e r ' s p o i n t o f v i e w as o p p o s e d t o a d i v e r s e 69 group of planners. They w i l l i n t e r p r e t m a t e r i a l from, and prepare m a t e r i a l f o r , the Medical Experts and when doing t h i s they w i l l draw upon t h e i r knowledge of the 'world of planners' to summarize issues and a r t i c u l a t e planning con- s t r a i n t s or planning contexts. They can f i l l i n d e t a i l s , or add d e t a i l s and opinions of t h e i r own. They w i l l need to work as a cohesive group i n both of these r o l e s . The f i n a l aspect to be examined i n the design of the groups and group s t r u c t u r e s i s the matter of p r o v i d i n g f o r the Mini-Survey, (or l a r g e r group i n c l u d i n g consumers) to produce r e a c t i o n s to the work developed by the i n t e r - a c t i n g experts. This survey would occur a f t e r a s e r i e s of Planning Patterns had been developed. At the same time as the Technical Users would be commenting on what had been produced, the l a r g e r group would a l s o be r e a c t i n g to what had been produced. When the responses of both groups are c o l l e c t e d , the Planning Experts can make any necessary c o r r e c t i o n s i n response to the Mi n i Survey's i d e n t i f i c a - t i o n of any biases or overlooked areas. An e v a l u a t i o n of the d i f f e r e n c e s between the a c c e p t a b i l i t y of the work of the e x p e r t s , as rep r e s e n t i v e of the population and the r e s u l t s of the wider group survey of the pop u l a t i o n , w i l l i n d i c a t e how r e p r e s e n t a t i v e the experts r e a l l y are. This w i l l enable us to assess the a b i l i t y to g e n e r a l i z e the method f o r other a p p l i c a t i o n s and w i l l be a p a r t of the concluding e v a l u t i o n i n Chapter 4. 70 From t h e f o l l o w i n g D i a g r a m 2.1 t h e s t r u c t u r e f o r t h e f l o w o f m a t e r i a l between t h e D e l p h i g r o u p s becomes c l e a r . I t s h o u l d be n o t e d t h a t t h e M o n i t o r i n g G roup i s a l w a y s t h e c e n t r a l p o i n t f o r r e c e i v i n g and d i s t r i b u t i n g , o f m a t e r i a l as w e l l as i t s e d i t i n g . T h i s i s t o e n s u r e c o n t i n u i t y o f g r a p h i c s , l e t t e r i n g and s t y l e . DIAGRAM 2.1 THE INTERGROUP MODEL M ON nas. qz.cu?a> P L A N N I N G , 71 2.3 Controlling the Independent Variables H a v i n g d e s c r i b e d t h e r o l e s o f t h e f o u r g r o u p s i n v o l v e d and t h e r e l a t i o n s h i p w hich a l l o w s t h e D e l p h i t o p r o c e e d , a number o f I n d e p e n d e n t V a r i a b l e s must now be c o n s i d e r e d , b e c a u s e t h e s e c o u l d a f f e c t t h e r e s u l t s o f t h e s t u d y . T h e r e i s a l r e a d y p r o v i s i o n f o r d e a l i n g w i t h some v a r i a b l e s w i t h i n t h e s t r u c t u r e as d e s c r i b e d and t h e s e a r e as f o l l o w s : i . P o p u l a t i o n B i a s e s - t h e s e a r e e l i m i n a t e d by s e l e c t - i n g r e p r e s e n t a t i v e s f r o m t h e r e l e v a n t p o p u l a t i o n who c a n d e s c r i b e t h e M e d i c a l , N u r s i n g and A d m i n i s - t r a t i v e c o n c e r n s . These e x p e r t p a r t i c i p a n t s a r e s e l e c t e d f r o m e a c h d i s c i p l i n e and f r o m as many l o c a t i o n s as p o s s i b l e i n B r i t i s h C o l u m b i a and A l b e r t a . The M i n i - S u r v e y a l l o w s f o r f u r t h e r r e p - r e s e n t a t i o n by i n c l u d i n g Consumers and T e c h n i c a l u s e r s who have an even g r e a t e r g e o g r a p h i c a l d i s t r i - b u t i o n . i i . M i s u n d e r s t a n d i n g s o r O m i s s i o n s i n C o m m u n i c a t i o n - t h e s e a r e r e d u c e d t h r o u g h t h e E x p e r t s i n t e r a c t i v e p r o c e s s , a l l o w i n g a l l r e s p o n s e s t o be f e d back t o e a c h i n d i v i d u a l t h e r e b y s o l i c i t i n g f u r t h e r comments. I f t h e P a t t e r n s p r o d u c e d by the P l a n n i n g E x p e r t s do n o t r e f l e c t t h e i d e a s as u n d e r s t o o d by t h e M e d i c a l E x p e r t s , t h e f i n a l r o u n d o f t h e q u e s - 72 t i o n n a i r e s w i l l p r o v i d e an o p p o r t u n i t y f o r t h e e x p e r t s t o c o r r e c t t h i s m i s u n d e r s t a n d i n g . i i i . N e g a t i v e I n f l u e n c e s , o f Group Dynamics Upon t h e Commu n i c a t i o n - t h e s e i n f l u e n c e s g e n e r a l l y a r e de- s c r i b e d i n t h e l i t e r a t u r e 9 a s : d o m i n a t i o n by one p e r s o n a l i t y i n t h e g r o u p w h i l e i n a f a c e t o f a c e s i t u a t i o n ; u n w i l l i n g n e s s t o t a k e a p o s i t i o n u n t i l t h e d i r e c t i o n o f t h e m a j o r i t y i s known ( o r a l l f a c t s a r e i n ) ; t h e d i f f i c u l t y o f c o n t r a d i c t i n g o r p r e s e n t i n g i d e a s t o p e r s o n s p e r c e i v e d t o be i n a h i g h e r p o s i t i o n ; t h e u n w i l l i n g n e s s t o abandon a ( s t a t u s ) p o s i t i o n once t a k e n p u b l i c l y ; and t h e f e a r o f b r i n g i n g up an i d e a w h i c h may t u r n o u t t o be i d i o t i c and t h e r e b y c a u s i n g l o s s o f f a c e . These w i l l be e l i m i n a t e d i n u s i n g t h e D e l p h i , w h i c h f a c i l i t a t e s c o m m u n i c a t i o n w i t h o u t f a c e t o f a c e c o n t a c t , p a r t i c u l a r l y s i n c e r e s p o n s e s a r e d e a l t w i t h anonymously. The P l a n n i n g E x p e r t s a r e w o r k i n g ' i n a s m a l l - g r o u p committee s t r u c t u r e w h i c h i s n o t m u l t i - d i s c i p l i n e d , and does not a t t r a c t t h e s e n e g a t i v e i n f l u e n c e s . T h e r e a r e o t h e r i n d e p e n d e n t v a r i a b l e s w h i c h can be i d e n t i f i e d . Some w i l l a f f e c t t h e q u e s t i o n n a i r e s i n t h e i n t e r a c t i v e e x c h a n g e s and some w i l l a f f e c t t h e i n t e r - g r o u p s t r u c t u r e . The f i r s t o f t h e s e v a r i a b l e s r e l a t e s t o t h e 73 c a p a b i l i t y f o r m a i n t a i n i n g a d e g r e e o f f l e x i b i l i t y o r o p e n n e s s o f s t r u c t u r e . I f t h e m a t e r i a l e x c h a n g e d by t h e two e x p e r t g r o u p s c a n p e r i o d i c a l l y be r e p r i o r i z e d , t h e i n t e r - c h a n g e h as t h e a b i l i t y t o "mature" as i t c o n t i n u e s . T h i s would n o r m a l l y be a p a r t o f a f a c e - t o - f a c e c o m m i t t e e s t r u c t u r e where t h e p a r t i c i p a n t s may f e e l t h e need t o r e o r d e r t h e agenda so as t o o b t a i n t h e m e e t i n g ' s o r i g i n a l o b j e c t i v e s . The D e l p h i s h o u l d p r o v i d e t h e same o p p o r t u n - i t y . The l i t e r a t u r e c o n t a i n s many r e f e r e n c e s t o t h e p r o b l e m i n s u r v e y r e s e a r c h ( o f w h i c h t h e D e l p h i method i s c l e a r l y o n e ) , o f r i g i d i t y o r l a c k o f a b i l i t y t o change d i r e c t i o n o nce a c o u r s e o f a c t i o n has been t a k e n . F i n s t e r b u s c h l u n o t e s t h a t i n t e r v i e w e r s may r e p o r t d i f f i - c u l t i e s , o r new r e s e a r c h c o n c e r n s m i g h t a r i s e , o r a p a r t i c u l a r l i n e o f q u e s t i o n i n g may n o t be l e a d i n g a n y - where, b u t n o r m a l l y t h e q u e s t i o n n a i r e s c a n n o t be c h a n g e d . F i n s t e r b u s c h ' s example i s a s e r i e s o f M i n i - S u r v e y s w h i c h b r e a k down a l a r g e p o p u l a t i o n i n t o f o u r g r o u p s and between e a c h s u r v e y t h e n e x t q u e s t i o n s c a n be r e s p o n s i v e t o t h e p r e v i o u s s u r v e y ' s r e s u l t s . The s u r v e y i s t h e n c a r r i e d o u t i n s e r i a l f o r m w h i c h s u i t s t h e d y n a m i c s o f t h e e n q u i r y . I t i s e a s y t o see t h e s i m i l a r i t y between t h i s Dynamic M i n i - S u r v e y a p p r o a c h and t h e s t e p s i n a D e l p h i e n q u i r y . I t i s p o s s i b l e t o u t i l i z e t h e v a r i o u s r o u n d s o f 74 t h e D e l p h i t o make t h e p r o c e s s d y n a mic and a v o i d d i s c o v e r - i n g t o o l a t e t h a t t h e r e a r e some compromises w h i c h c o u l d r u i n t h e e f f e c t i v e n e s s o f t h e p r o c e s s . To make c e r t a i n t h a t t h i s f l e x i b i l i t y o c c u r s , t h e M o n i t o r i n g / P l a n n i n g G r oup w i l l e n s u r e , a t t h e end o f e a c h r o u n d o f q u e s t i o n s , t h a t m a t e r i a l b e i n g r e c e i v e d i s c o n s i s t e n t w i t h t h e i n t e n - t i o n o f t h e q u e s t i o n s a s k e d , and t h a t t h e i s s u e s b e i n g i d e n t i f i e d have a p l a n n i n g c o n t e x t . I f t h e y f i n d u n s a t i s - f a c t o r y p r o b l e m r e s o l u t i o n s , t h e P l a n n i n g Group c a n i n t e r v e n e , as p a r t i c i p a n t s i n t h e D e l p h i . They c a n make c o r r e c t i o n s when p r e p a r i n g t h e i r m a t e r i a l f o r t h e n e x t q u e s t i o n s , o r i n p r e p a r i n g t h e f e e d b a c k t o t h e answers a l r e a d y r e c e i v e d . T y p i c a l o f t h e k i n d o f t h i n g t h a t m i g h t o c c u r i s when a l l t h e P a t t e r n s a r e f i n a l l y p r e p a r e d i t w i l l be d i s c o v e r e d f u r t h e r d e v e l o p m e n t i s needed by t h e e x p e r t s p r i o r t o t h e P a t t e r n s b e i n g f i n a l i z e d , o r a new a s p e c t a r i s e s a f t e r t h e T e c h n i c a l E x p e r t s have s e e n t h e P a t t e r n s . In e i t h e r c a s e , i t i s p o s s i b l e t o add more r o u n d s . These p o s s i b i l i t i e s T u r o f f ^ warns c o u l d o c c u r when: "a r e s p o n d e n t f e e l s t h e s h o c k r e s u l t i n g f r o m a r e a l i z a t i o n t h a t t h e o t h e r s i d e a l s o f e e l s i t h a s some v a l i d p o i n t s t o be made. T h e r e - f o r e , i t i s o n l y a t t h e t h i r d r o u n d t h a t t h i s t y p e o f r e s p o n d e n t b e g i n s t o p u t a g r e a t d e a l o f c a r e f u l e f f o r t i n t o t h e p o i n t s he i s mak- i n g . . .". so t h a t more q u e s t i o n i n g r o u n d s w i l l be needed t o have a r e s o l u t i o n . 75 W i t h t h i s p a r t i c u l a r D e l p h i , a n o t h e r a s p e c t needed i s a f l e x i b l e s t r u c t u r e , t o e n s u r e t h a t t h e r e i s c a p a b i l - i t y f o r d e a l i n g w i t h P o l i c y i s s u e s s i n c e i t i s q u i t e c l e a r we a r e d e a l i n g w i t h P o l i c y when we make D e s i g n S t a n d a r d s . A g r o u p d e v e l o p i n g D e s i g n G u i d e l i n e s f o r C a r d i a c C a r e U n i t s had t h e f o l l o w i n g comments: " U n i t p l a n n e r s a r e f a c e d w i t h t h e r e s p o n s i - b i l i t y o f d e f i n i n g h i e r a r c h y o f g o a l s , s u p - p o r t i v e o f , and c o n s i s t e n t w i t h l o n g - r a n g e h o s p i t a l g o a l s and o v e r a l l community h e a l t h c a r e n e e d s . T h e i r p o l i c i e s f o r u n i t o p e r a - t i o n must i n t u r n be c o n s i s t e n t w i t h t h e o b j e c t i v e s o f t h e u n i t . P o l i c i e s become t a n g i b l e o n l y t h r o u g h s p e c i f i c o p e r a t i o n s o f t h e u n i t , i n v o l v i n g a c o o r d i n a t e d s e t o f a c t - i v i t i e s and s u b - a c t i v i t i e s . The d e s i g n e r ' s r e s p o n s i b i l i t y i s t o d e v e l o p a c l e a r u n d e r - s t a n d i n g o f e a c h l e v e l i n t h i s h i e r a r c h y i n o r d e r t o p e r c e i v e c l e a r l y t h e o p e r a t i o n a l o r d e r w h i c h u l t i m a t e l y w i l l f i n d e x p r e s s i o n i n t h e p h y s i c a l d e s i g n . " ^ 2 S i n c e we a r e d e a l i n g w i t h p o l i c y l e t us l o o k b r i e f - l y a t what a P o l i c y D e l p h i e n t a i l s so t h a t we can e n s u r e o u r d e s i g n has t h e n e c e s s a r y a t t r i b u t e s . W h i l e t h e t r a d i - t i o n a l D e l p h i t e n d s t o d e a l w i t h t e c h n i c a l t o p i c s and s e e k s a c o n s e n s u s among homogeneous g r o u p s o f e x p e r t s , t h e P o l i c y D e l p h i s e e k s t o g e n e r a t e w i t h a h e t e r o g e n e o u s g r o u p t h e s t r o n g e s t o p p o s i n g v i e w s on a t o p i c w i t h a v i e w t o r e s o l v i n g them. T u r o f f 1 3 s u p p o r t s t h e c a s e t h a t i n p o l i c y i s s u e s t h e r e a r e no e x p e r t s , i n s t e a d a l l v i e w s a r e t h o s e o f i n f o r m e d a d v o c a t e s . An e x p e r t can c o n t r i b u t e an o p i n i o n a s t o t h e outcome o f a p o l i c y , b u t a p o l i c y maker i s n o t i n t e r e s t e d i n h a v i n g an e x p e r t g r o u p make h i s d e c - 7 6 i s i o n f o r him. He r e q u i r e s them t o d e v e l o p a l l t h e o p t i o n s and s u p p o r t i n g e v i d e n c e t o a l l o w him t o make h i s own d e c i s i o n . I t c a n be s e e n t h e r e f o r e , t h a t o u r a p p r o a c h t o d a t e " w i t h a b r o a d g r o u p o f d i v e r s e e x p e r t s , i s c o n s i s t e n t w i t h a P o l i c y D e l p h i . We a r e s e e k i n g P l a n n i n g G u i d e s w h i c h w i l l h e l p t o m i n i m i z e n e g a t i v e p l a n n i n g d e c i s i o n s and o p t i m i z e good p o l i c i e s i n p l a n n i n g . The o b j e c t i v e i n t h e P o l i c y D e l p h i i s n o t t o a r r i v e a t c o n s e n s u s among t h e g r o u p s i n v o l v e d , b u t t o e x p l o r e t h e i s s u e s . In o u r c a s e , we a r e l o o k i n g t o e n s u r e a l l p o s s i b l e o p t i o n s have been p r e s e n t e d ; t h i s d o e s n o t r e q u i r e c o n s e n s u s . However, i n o r d e r t o p r o d u c e more t h a n a s i m p l e i d e n t i f i c a t i o n o f p r o b l e m s , t h e P a t t e r n s p r o d u c e d must d e s c r i b e t h e r e s u l t i n g i m p a c t ( o r d y s f u n c t i o n ) f r o m u n r e s o l v e d p r o b l e m s . The P a t t e r n s must go on t o s u g g e s t t h e most l i k e l y way t o r e s o l v e t h i s c o n f l i c t w h i c h d o e s r e q u i r e c o n s e n s u s . What we have i s a p r o c e s s w h i c h r e q u i r e s e l e m e n t s o f t h e s t u d y t o o p e r a t e i n b o t h c o n s e n s u s and n o - c o n s e n s u s modes. We do n o t have a p u r e P o l i c y D e l p h i and must d e v e l o p a new a p p r o a c h . The d i a g r a m below shows t h e modes i n w h i c h we must o p e r a t e . 77 DIAGRAM 2.2 MODE ACTIVITIES R e c o g n i z e t h e r e e x i s t s a number o f a r e a s o f c o n f l i c t between f u n c t i o n and s p a c e . I d e n t i f y what t h o s e c o n f l i c t s a r e . \ I d e n t i f y t h e b e s t way t o s o l v e t h e c o n f 1 i c t s . / C o n s e n s u s R e q u i r e d No-Consensus R e q u i r e d C o n s e n s u s R e q u i r e d A c h i e v i n g f l e x i b i l i t y r e q u i r e s a D e l p h i D e s i g n c a p a b l e o f moving f r o m one mode t o a n o t h e r and p o t e n t i a l l y f r o m one whole d i r e c t i o n t o a n o t h e r i f t h e r e a r e i n d i c a - t i o n s t h a t t h e d e g r e e o f c o n s e n s u s r e q u i r e d i s not b e i n g a c h i e v e d . T h i s c a n be done i n two ways. F i r s t , t h e g e n e r a l f o r m a t o f t h e q u e s t i o n n a i r e ( t h e c o n t e n t o f t h e q u e s t i o n s t h e m s e l v e s ) c a n be d e s i g n e d t o a l l o w answers t o be e i t h e r i n c o n s e n s u s o r n o - c o n s e n s u s . S e c o n d l y , t h e P l a n n i n g E x p e r t s a t t h e end o f e a c h r o u n d o f q u e s t i o n i n g , can a n a l y z e t h e r e s u l t s and make c o r r e c t i o n s by e i t h e r p r o v i d i n g a d d i t i o n a l q u e s t i o n s ( i n d i c a t i n g i n t h e f e e d b a c k where c o n s e n s u s has o c c u r r e d ) o r by any o t h e r method t h e y c h o o s e , t o e n s u r e t h a t t h e a p p r o p r i a t e mode has o c c u r r e d . T h i s q u e s t i o n i n g and " s c a n n i n g " between r o u n d s w i l l e n s u r e f l e x i b i l i t y . A n o t h e r i n d e p e n d e n t v a r i a b l e w h i c h must be a d d r e s s - ed i s t h e impact o f any i n t e r v e n t i o n by t h e M o n i t o r i n g / P l a n n i n g Group. In a t r a d i t i o n a l D e l p h i , s h o u l d t h e r e be any b i a s e s by one o r o t h e r o f t h e g r o u p s who a r e a c t u a l l y 78 s h a p i n g t h e q u e s t i o n n a i r e s ( M e d i c a l U s e r s / P l a n n i n g U s e r s ) , i t would be d e t e c t e d by t h e M o n i t o r i n g G roup and t h e a c t i o n r e q u i r e d would be t o p o i n t t h i s o u t and p a s s on t h e b i a s e d m a t e r i a l t o s o l i c i t f u r t h e r comment. In t h i s d e s i g n we have c h o s e n t o a l l o w one o f t h e g r o u p s t o a f f e c t and i f n e c e s s a r y , m o d i f y t h e m a t e r i a l . They a r e no l o n g e r i n d e p e n d e n t o r d i s i n t e r e s t e d and t h e r e f o r e a p o t e n t i a l b i a s e x i s t s . B i a s e s c o u l d be e x p e c t e d i n two a r e a s ; b o t h a r e an a s p e c t o f t h e P l a n n e r s ' " p e r s p e c t i v e " . The f i r s t b i a s i s one where t h e P l a n n e r s may i n - a d v e r t e n t l y d i r e c t t h e p r o c e s s i n t o t o o n a r r o w a s e t o f i s s u e s , b e c a u s e t h e y m i s t a k e n l y b e l i e v e t h e s e t o be more r e l e v a n t t o p l a n n i n g t h a n o t h e r s . In t h i s i n s t a n c e , a whole s e r i e s o f P a t t e r n s m i g h t n o t be p r o d u c e d t h a t s h o u l d have been, o r v i c e v e r s a , y e t s i n c e t h i s o c c u r s p r i o r t o t h e l a s t e v a l u a t i v e r o u n d i n w h i c h b o t h M i n i - S u r v e y and E x p e r t G r o u p s a r e g i v e n t h e o p p o r t u n i t y t o s u g g e s t P a t t e r n s t h a t c o u l d be added o r d e d u c t e d , t h e i m p a c t f r o m t h i s b i a s w i l l be m i n i m i z e d . In f a c t , i f a g r e a t many a r e a s were i d e n t i f i e d as m i s s e d , t h e M o n i t o r i n g Group c o u l d i n s i s t t h a t a n o t h e r e v a l u a t i v e r o u n d be p r e p a r e d . The s e c o n d b i a s i s t h e p o s s i b i l i t y t h a t t h e P a t t e r n s p r o d u c e d may be a c c e p t e d by t h e M e d i c a l E x p e r t s and y e t be i n c o r r e c t b e c a u s e t h e M e d i c a l E x p e r t s c o u l d n o t e v a l u a t e t h e p l a n n i n g i m p l i c a t i o n s . In t h i s c a s e , t h e n e g a t i v e e f f e c t would be u l t i m a t e l y t a k e n c a r e o f t h r o u g h 79 t h e s t r u c t u r e o f t h e P a t t e r n i t s e l f . A l t h o u g h no o t h e r P l a n n e r s a r e i n v o l v e d i n t h i s e v a l u a t i o n p r o c e s s , s i n c e e a c h P a t t e r n i s a l w a y s p r e s e n t e d as an h y p o t h e s i s , i n t e n d - ed t o be t e s t e d and c o n t i n u o u s l y e v a l u a t e d , i t w i l l c e r t a i n l y be e v a l u a t e d by o t h e r P l a n n e r s i n f u t u r e p r a c - t i c a l a p p l i c a t i o n . A f i n a l i n d e p e n d e n t v a r i a b l e comes f r o m t h e p o s s i - b i l i t y t h a t i n t h e g e n e r a l p r o g r e s s o f t h e p r o j e c t , t o o much a t t e n t i o n m i g h t be p a i d t o l o n g - r a n g e f u t u r i s t i c i s s u e s o r c o n v e r s e l y t h a t t o o much c o n c e r n m i g h t o c c u r w i t h i n c r e m e n t a l c h a n g e s , i n s t e a d o f p u t t i n g t h e i s s u e s i n t o a b r o a d e r p e r s p e c t i v e . In o r d e r t o d e v e l o p a v a r i e t y o f p e r s p e c t i v e s w i t h i n t h e D e l p h i D e s i g n , i t i s n e c e s s a r y t o s t r u c t u r e t h e q u e s t i o n s so t h a t t h e y a d d r e s s i s s u e s a t v a r i o u s l e v e l s o f a " h i e r a r c h y " . Some w i l l be "Macro" o r l a r g e s c a l e i s s u e s , some w i l l be " M i c r o " o r d e t a i l e d i s s u e s . In s e l e c t i n g an a p p r o p r i a t e model f o r q u e s t i o n b u i l d i n g we chose t o f o l l o w n e i t h e r t h e " R a t i o n a l i s t i c " p l a n n i n g a p p r o a c h ( i n w h i c h ends and means t o a c h i e v e them a r e c l e a r l y d e f i n e d so t h a t t h e b e s t p o l i c y i s t h e one w h i c h h a s t h e most v a l u e t o t h e outcome) n o r t h e " I n c r e - m e n t a l . i s t " 1 ̂  p l a n n i n g a p p r o a c h (which a l l o w s t h e making o f s u c c e s s i v e c h o i c e s between p o l i c i e s b a s e d upon t h e r e l a - t i v e v a l u e o f t h e p o l i c y i t s e l f r a t h e r t h a n t h e o b j e c t i v e s t o be a c h i e v e d ) . We b e l i e v e t h a t a more a p p r o p r i a t e 80 model i s one w h i c h a l l o w s t h e o p p o r t u n i t y t o i d e n t i f y t h e m a j o r i s s u e s , and w i t h i n t h i s c o n t e x t t h e d e t a i l e d r e l e - v a n t f a c t o r s . T h i s must be done w i t h o u t t h e r i s k o f e i t h e r m i s s i n g i s s u e s o r d e a l i n g a t l e n g t h w i t h some w h i c h t u r n o u t t o be u n i m p o r t a n t . The " M i x e d - S c a n n i n g " a p p r o a c h i s an a p p r o p r i a t e m o d e l . T h i s model h a s b een d e v e l o p e d a s t h e " t h i r d " a p p r o a c h t o d e c i s i o n - m a k i n g by A m i t a i E t z i o n i . 1 5 I t has e l e m e n t s o f R a t i o n a l P l a n n i n g by u s i n g an o v e r v i e w w h i c h a t t e m p t s t o " s c a n " f o r a l l t h e m a j o r i s s u e s l i k e l y t o o c c u r b u t i g n o r e s t h e d e t a i l e d e v a l u a t i o n o f e a c h one. Once t h i s " s c a n " i d e n t i f i e s i s s u e s , t h e I n c r e m e n t a l i s t p o l i c y d e c - i s i o n - m a k i n g o c c u r s , b u t t h e p o l i c i e s a r e l i m i t e d t o t h e c o n t e x t o f t h e o v e r v i e w . T h i s E t z i o n i b e l i e v e s h e l p s t o r e d u c e t h e s h o r t c o m i n g s o f b o t h a l t e r n a t i v e s y s t e m s . He s t a t e s : "... i n c r e m e n t a l ism r e d u c e s t h e u n r e a l i s t i c a s p e c t s o f r a t i o n a l i s m by l i m i t i n g t h e d e t a i l s r e q u i r e d i n f u n d a m e n t a l d e c i s i o n s , and c o n t e x t u a t i n g [ s i c ] r a t i o n a l i s m h e l p s t o overcome the c o n s e r v a t i v e s l a n t o f i n c r e m e n - t a l i s m by e x p l o r i n g l o n g e r - r u n a l t e r n a - t i v e s ." 16 The a c t u a l q u e s t i o n n a i r e d e s i g n w i l l f o l l o w t h i s m i x e d - s c a n n i n g a p p r o a c h by u s i n g t h e f o l l o w i n g f o r m u l a - t i o n : P r i o r t o f o r m u l a t i n g t h e f i r s t s e t o f q u e s t i o n s t h e P l a n n i n g E x p e r t s w i l l r e v i e w t h e c u r r e n t p l a n - 8 1 n i n g l i t e r a t u r e f o r i s s u e s o r c o n t e x t and draw upon t h e i s s u e s w h i c h have been r a i s e d by c l i e n t s i n p l a n n i n g p r e v i o u s f a c i l i t i e s . From t h i s R a t i o n a l - i s t i c a p p r o a c h , a s e t o f s u b j e c t t o p i c s w i l l be i d e n t i f i e d and t h e q u e s t i o n n a i r e s d e v e l o p e d a r o u n d them. i i . The q u e s t i o n s a s k e d o f t h e T e c h n i c a l E x p e r t Group w i l l r e q u i r e them t o d e v e l o p two k i n d s o f a n s w e r s ; t h e f i r s t a r e open, l o n g - r u n , o r f u t u r i s t i c i n n a t u r e s i n c e t h e o b j e c t i v e i s t o c o n s i d e r , w i t h i n t h e g e n e r a l c o n t e x t s e t by t h e P l a n n e r s , i m p o r t a n t d i r e c t i o n s w h i c h w i l l have b r o a d impact o r w i l l a f f e c t c h a n g e s i n c u r r e n t t r e n d s . T h i s i s a " s c a n " by t h e T e c h n i c a l E x p e r t s o f major i s s u e s i n t h e R a t i o n a l i s t i c p l a n n i n g s t y l e . i i i . The s e c o n d k i n d o f q u e s t i o n w i l l p r o v i d e p o l i c y o p t i o n s and t h e n ask t h e M e d i c a l E x p e r t s t o make comments and c h o i c e s w h i c h w i l l a l l o w e x p l o r a t i o n o f t h e v a r i o u s e x p e r t s ' r e l a t i v e v a l u e s i n s e t t i n g p o l i c y . T h i s i s t h e I n c r e m e n t a l i s t a p p r o a c h t o d e v e l o p i n g p o l i c y o p t i o n s . An u n f o r t u n a t e outcome c o u l d be t h a t v e r y l i t t l e d e m o n s t r a t i o n i s g i v e n o f t h e i r v a l u e s so t h e r e f o r e , i n t h i s i n s t a n c e , t h e c h o s e n p o l i c y .can s i m p l y be a c c e p t e d w i t h o u t a knowledge o f why i t was c h o s e n . 82 In t h e s e c o n d r o u n d o f q u e s t i o n s , t h e P l a n n i n g E x p e r t s would t a k e a " R a t i o n a l i s t - S c a n " o f t h e r e s u l t s f r o m t h e f i r s t r o u n d , t o l o o k f o r any new d i r e c t i o n s , any i s s u e s t h a t m i g h t be w o r t h e x p l o r - i n g i n d e p t h , o r t o f i n d t r o u b l e s p o t s w h i c h need f u r t h e r p o l i c y c h o i c e s . I t i s a l s o i n t h i s r o u n d t h a t t h e r e s u l t s o f t h e p o l i c y c h o i c e s f r o m t h e f i r s t r o u n d a r e f e d back t o a l l p a r t i c i p a n t s and e v e r y o n e i s g i v e n a c h a n c e t o a s s e s s ( " r a t e " ) t h e v a l u e o f t h e c h o i c e s made by o t h e r s . In o t h e r words, t h e s e c o n d - r o u n d e v a l u a t i o n i s a p o l i c y - c h o i c e p r o c e s s , i n t h e I n c r e m e n t a l i s t v e i n , by w h i c h a l l p a r t i c i p a n t s e x p r e s s t h e i r p e r s o n a l v a l u e s i n c h o o s i n g between e a c h o t h e r ' s p o l i c y c h o i c e s . In t h e t h i r d and f i n a l r o u n d , t h e p l a n n i n g e x p e r t s must d e v e l o p t h e P l a n n i n g P a t t e r n s w h i c h s e r v e as t h e D e s i g n G u i d e l i n e s . These a r e i n t h e m s e l v e s p o l i c y documents w h i c h when c i r c u l a t e d f o r comment, w i l l a l l o w f u r t h e r d e c i s i o n s t o be made as t o t h e i r a c c e p t a b i l i t y . The c h o i c e h e r e c o n s t i t u t e s a d e c i s i o n t o a c c e p t , r e j e c t o r m o d i f y t h e p o l i c y o f f e r e d ( w i t h i n t h e D e s i g n P a t t e r n s ) , and as i n t h e e a r l i e r s t a g e , i s I n c r e m e n t a l i s t i n s t y l e . A t the same t i m e , a f i n a l " s c a n " i s b e i n g c o n d u c t e d by t h e use o f t h e M i n i - S u r v e y e v a l u a t i o n i n g o i n g t o t h e b r o a d e r p o p u l a t i o n . I f t h i s " s c a n " r e v e a l s any 83 f u r t h e r t r o u b l e s p o t s , t h e p l a n n i n g e x p e r t s can c h o o s e t o c o n t i n u e , t h r o u g h a d d i t i o n a l r o u n d s , t o e x p l o r e f u r t h e r p o l i c i e s and u l t i m a t e l y a c h i e v e r e s u l u t i o n . 2.4 Summary Remarks Our D e l p h i D e s i g n i s e s s e n t i a l l y an "open" c o n v e r s a - t i o n between two g r o u p s o f e x p e r t s . One g r o u p ( t h e P l a n - n i n g E x p e r t s ) l e a r n i n g and i n t e r p r e t i n g what t h e o t h e r g r o u p ( M e d i c a l E x p e r t s ) d e s c r i b e s as s i g n i f i c a n t f o r use i n p l a n n i n g a b o u t t h e w o r l d i n w h i c h t h e y o p e r a t e . The d e t a i l e d e l e m e n t s o f t h e D e l p h i D e s i g n , i n c l u d i n g t h e s t r u c t u r i n g o f t h e e x c h a n g e , t h e f o r m a t o f t h e q u e s t i o n s , and t h e s p e c i f i c r e p r e s e n t a t i o n w i t h i n t h e g r o u p s , have a l l been c a r e f u l l y c o n s i d e r e d t o e n s u r e maximum f l e x i b i l - i t y ( s t r u c t u r e o p e n n e s s ) w i t h o u t c a u s i n g n e g a t i v e i n f l u e n c e s on t h e p r o d u c t . T h i s open exchange can h a ppen- i n g w i t h o u t r e q u i r i n g p e o p l e t o t r a v e l from t h e i r v a r i o u s l o c a t i o n s so as t o p r o c e e d w i t h m i n i m a l c o s t and t i m e . I f t h i s D e l p h i p r o c e s s can be c a r r i e d o u t a c c o r d i n g t o t h e o b j e c t i v e s o u t l i n e d h e r e , i t w i l l p r o v e t o be an e x c e l l e n t t o o l f o r d e v e l o p i n g new and more r e s p o n s i v e D e s i g n G u i d e - l i n e s i n h o s p i t a l s . In t h e n e x t c h a p t e r we d e s c r i b e i n d e t a i l t h e p r o c e s s and r e s u l t s o f c a r r y i n g o u t t h i s D e l p h i . 84 CHAPTER 3: CARRYING OUT THE DELPHI 3.1 Round 1; The Questionnaire Preparation B e f o r e d e v e l o p i n g t h e f i r s t r o u n d o f t h e D e l p h i S t u d y i t was r e q u i r e d t h a t t h e P l a n n e r s p r e p a r e m a t e r i a l t o g u i d e t h e g e n e r a l d i r e c t i o n o f t h e whole s t u d y . T h i s g u i d e was a c h i e v e d i n two ways; f i r s t , by d e v e l o p i n g a d i a g r a m o f t h e i c o n c e p t u a l framework f o r t h e whole s t u d y ; s e c o n d l y , by e x a m i n i n g r e l e v a n t l i t e r a t u r e t o d e v e l o p a l i s t o f t o p i c s w h i c h c o u l d be u s e d a s a s u b j e c t r e f e r e n c e . The p u r p o s e o f t h e s t u d y d i a g r a m was t o d e s c r i b e v i s u a l l y t h e f i r s t r o u n d i n c o n t e x t o f t h e o t h e r r o u n d s . The p u r p o s e o f t h e l i t e r - a t u r e s u r v e y was t o i n f o r m t h e P l a n n e r s s o as t o e n s u r e t h a t by d e v e l o p i n g i s s u e s f a m i l i a r t o them t h e M e d i c a l E x p e r t s would be a b l e t o f o c u s t h e i r e f f o r t s upon s u b j e c t s r e l a t e d t o p l a n n i n g and n o t a d m i n i s t r a t i v e o r o t h e r i s s u e s w h i c h t h e y m i g h t f e e l were i m p o r t a n t t o them. The d i a g r a m was a l s o r e q u i r e d t o d e s c r i b e t h e e s s e n - t i a l f l o w o f i n f o r m a t i o n t h a t was needed t h r o u g h t o c o m p l e - t i o n o f t h e p r o j e c t . A l t h o u g h i t i s a v e r y s i m p l i s t i c d i a g r a m (see i l l u s t r a t i o n 3.1), i t i l l u s t r a t e s t h e c o n - s t r a i n t s w h i c h would be imposed upon t h e a c t i o n s o f t h e p a r t i c i p a n t s ; t h u s t h i s d i a g r a m r e p r e s e n t s t h e l i m i t s t o t h e p r o j e c t , as w e l l as i t s i m p o r t a n t b u i l d i n g s t e p s . 85 D I A G R A M 3.1 D E L P H I I N F O R M A T I O N A N D O R G A N I Z A T I O N M O D E L 86 The f i r s t a s p e c t w h i c h c a n be r e c o g n i z e d on t h e d i a g r a m i s t h e M a t r i x showing L e v e l s o f C o n c e r n ( i s s u e s ) and t h e A c t i v i t i e s t o be c a r r i e d o u t i n e a c h r o u n d . B e g i n - n i n g w i t h l e v e l s o f c o n c e r n , t h e d i a g r a m makes i t c l e a r t h a t we i n t e n d e d t h r e e d i f f e r e n t s t r a t a o f c o n c e r n s t o be e x p l o r e d . The f i r s t o f t h e s e s t r a t a i s Long Term I s s u e s , o r , t h o s e m a t t e r s w h i c h may have i m p l i c a t i o n s e x t e n d i n g o v e r a p e r i o d o f t i m e . These a r e r e f e r r e d t o as O b j e c t i v e s and a r e t h e t o p i t e m i n t h e d i a g r a m . Next s t r a t a i s t h e S h o r t Term I s s u e s w h i c h r e l a t e t o p r o b l e m s a s s o c i a t e d w i t h c u r r e n t p r a c t i c e s ; t h e s e a r e c a l l e d F u n c t i o n s . F i n a l l y t h e t h i r d s t r a t a a r e S p a c e P l a n n i n g I s s u e s w h i c h d e a l w i t h i t e m s o f t h e b u i l t e n v i r o n m e n t ; t h e s e a r e c a l l e d Space P l a n n i n g . These t h r e e l e v e l s a r e 'rows' i n t h e d i a g r a m and i t c a n be r e c o g n i z e d t h a t t h e i d e a s d e v e l o p e d d u r i n g e a c h r o u n d ( t h e c olumns w h i c h a r e shown numbered a t t h e b o t t o m ) , a r e a l w a y s k e p t w i t h i n t h e c o n t e x t o f t h e s p e c i f i c l e v e l o f c o n c e r n . These s t r a t a ( e . g . , Long Term I s s u e s ) , become d i s c o n t i n u o u s d u r i n g Round 3 when a l l t h e i d e a s a r e s y n t h e - s i z e d i n t o P a t t e r n s . In a d d i t i o n , we need t o r e c o g n i z e t h a t e a c h row i s n o t i s o l a t e d and t h a t t h e r e i s a downward f l o w o f i n f o r m a t i o n (shown a s a r r o w s w i t h i n e a c h r o u n d ) . T h i s h e l p s t o b u i l d d e t a i l , s t a r t i n g w i t h t h e "Macro" l e v e l o f O b j e c t i v e s and f i n i s h i n g w i t h t h e " M i c r o " l e v e l o f P l a n - n i n g C o n c e r n s . In t h i s way, e a c h " q u e s t i o n i n g r o u n d " w i l l d e v e l o p a b u i l d i n g b l o c k f o r t h e n e x t r o u n d . 87 The n e x t a s p e c t i s t o examine th e q u e s t i o n i n g r o u n d s , o r t h e A c t i v i t i e s w h i c h f o r m t h e columns on t h e d i a g r a m . T h e r e a r e t h r e e o f t h e s e , e a c h c o r r e s p o n d i n g t o a q u e s t i o n - n a i r e and' e a c h c o n c e r n e d w i t h d e v e l o p i n g a c e r t a i n s t a g e i n t h e p r o g r e s s i n g o f i n f o r m a t i o n . The f i r s t i s shown as D i s c o v e r ; t h e theme i s What? What a r e t h e i s s u e s t h a t must be d i s c u s s e d ? The s e c o n d i s E x p l o r e , t h e theme i s Why; Why a r e t h e s e i s s u e s i m p o r t a n t ? The f i n a l t o p i c i s shown a s E v a l u a t e ; t h e theme i s I f ; I f t h e s e a r e r e a l p r o b l e m s and t h e i r c a u s e s , a r e t h e s e t h e s o l u t i o n s ? The f i n a l r o u n d , a s i n d i c a t e d by t h e d i a g r a m , b r i n g s a l l h o r i z o n t a l "rows" and v e r t i c a l " c o l umns" t o g e t h e r i n t o t h e f i n a l r o u n d , i n f a c t i n t o t h e P a t t e r n s t h e m s e l v e s . To be more s p e c i f i c , t h e f i r s t r o u n d was t o s o l i c i t a g e n e r a l u n d e r s t a n d i n g o f what were t h e O b j e c t i v e s , t h e p r e s e n t f u n c t i o n s and s p a c e p l a n n i n g i s s u e s . The s e c o n d r o u n d w o u l d e x p l o r e t h e i s s u e s p r e s e n t e d by t h e r e s p o n d e n t s d u r i n g t h e f i r s t r o u n d . T h i s would be done t h r o u g h com- m e n t i n g on e a c h o t h e r s ' i d e a s and t h e n h a v i n g r e s p o n d e n t s d e v e l o p i n more d e p t h , some s e l e c t e d s p e c i f i c i s s u e s . The f i n a l r o u n d would summarize t h e most i m p o r t a n t i s s u e s f r o m Round 2, t h e n f r o m t h i s t h e d r a f t P a t t e r n s ( G u i d e l i n e s ) w i l l be c r e a t e d and d i s t r i b u t e d f o r e v a l u a t i o n . The com- ments r e c e i v e d f r o m Round 3 would be u s e d t o a m p l i f y , m o d i f y o r e x e m p l i f y t h e P a t t e r n s t h e m s e l v e s . 88 A l t h o u g h t h e r e was now a v i s u a l s i m p l i f i c a t i o n o f t h e o v e r a l l m e t h o d o l o g y , t o h e l p t h e e x p e r t s d e v e l o p a f e e l f o r t h e i m p o r t a n c e o f c o n t e x t , i t would s t i l l be n e c e s s a r y t o s e t some l i m i t s on t h e s c o p e o f t h e q u e s t i o n s t h e m s e l v e s . T h i s q u e s t i o n s t r u c t u r e was d e v e l o p e d i n an open forum d i s c u s s i o n by t h e P l a n n i n g E x p e r t s . The g r o u p a n a l y z e d a s p e c t r u m o f p o s s i b l e t o p i c a r e a s . These c o n c e r n s drawn f r o m t h e P l a n n e r ' s p e r s o n a l e x p e r i e n c e , f r o m t h e i r know- l e d g e o f r e c e n t l i t e r a t u r e , e s p e c i a l l y where t h e r e were known p l a n n i n g c o n f l i c t s . T h i s d i s c u s s i o n p r o d u c e d a s h o r t l i s t o f k e y C a t e g o r i e s : From t h i s s h o r t C a t e g o r y l i s t , M a j o r I s s u e s were d e v e l o p e d : ( i ) P a r e n t s and B a b i e s ( i i ) S t a f f and B a b i e s ( i i i ) E q uipment and S u p p l i e s ( i ) C a t e g o r y ; P a r e n t s and B a b i e s I s s u e s : A c c e s s by p a r e n t s E d u c a t i o n o f p a r e n t s C a r e by p a r e n t s The whole f a m i l y c o n c e p t 89 ( i i ) Category: Staff and Babies Issues: Infection Patient Mix Care of Babies Patterns of Staffing Staff Education Stress Administrative routines ( i i i ) Category: Equipment and Supplies Issues: Supply methods Access to other f a c i l i t i e s Space needs for access to equipment Environmental issues Mechanical service supplies Washing and cleaning A great many other issues were discussed, for example, concern with which types of incubators might be used, but th i s issue was then rejected as being beyond the s p e c i f i c task of rela t i n g to space or planning needs. The c r i t e r i o n used in deciding to reject was: Does the type of incubator affect the planning of nursery spaces? In this case the answer was no, because provision must be made for a l l types 90 o f i n c u b a t o r s . I t c o u l d be assumed t h a t i n c u b a t o r v a r i - a t i o n s would a l r e a d y be d e s c r i b e d as a s u b - i s s u e o f p e r - h a p s , h e i g h t o f s e r v i c e o u t l e t s o r as an a s p e c t o f a i r - c o n d i t i o n e d s p a c e s . In t h i s way o n l y "whole" i s s u e s w h i c h m i g h t be presumed t o i n c l u d e s u b - i s s u e s , would be a d - d r e s s e d . Once t h e c o n t e x t o f Round 1 q u e s t i o n s was i d e n t i f i e d and t h e i s s u e s t o be c o v e r e d i n t h i s round were e s t a b - l i s h e d , t h e s t y l e and c o n t e n t o f t h e q u e s t i o n s t h e m s e l v e s were f o r m u l a t e d . In d e c i d i n g how much " s t r u c t u r i n g " would be i n v o l v e d , two f a c t o r s were c o n s i d e r e d : 1. How much t i m e was needed t o answer t h e q u e s - t i o n ; b e a r i n g i n mind t h a t a l a r g e r a n g e o f i s s u e s had t o be t o u c h e d upon? 2 . How c l e a r would be t h e r e s p o n d e n t s ' u n d e r - s t a n d i n g o f t h e way i n wh i c h t h e q u e s t i o n s s h o u l d be answered when some g u i d a n c e was n o t g i v e n i n t h e q u e s t i o n ? To r e s o l v e t h e p r o b l e m t h e M o n i t o r Group d e c i d e d t h a t when i t came t o most Space P l a n n i n g q u e s t i o n s , a good answer would be t o o d e p e n d e n t upon t h e r e s p o n d e n t s ' 91 p l a n n i n g e x p e r i e n c e t o r i s k open q u e s t i o n s . The Space P l a n n i n g w ould t h e r e f o r e r e q u i r e t h e most s t r u c t u r e d q u e s t i o n s . The s u b j e c t s t h a t d e a l t w i t h O b j e c t i v e s and F u n c t i o n s would r e l a t e d i r e c t l y t o t h e m e d i c a l w o r l d and c o u l d t h e r e f o r e be o f a more open s t y l e . The q u e s t i o n s were t h e n s o r t e d so t h a t C a t e g o r y and I s s u e s w ould r e l a t e t o t h e a p p r o p r i a t e d e g r e e o f s t r u c t u r e r e q u i r e d i n t h e q u e s t i o n s and would match t h e a p p r o p r i a t e L e v e l o f C o n c e r n f r o m t h e o r i g i n a l m a t r i x . The q u e s t i o n f o r m a t i s shown i n T a b l e 3.0 as f o l l o w s : 92 TABLE 3.0 ROUND ONE QUESTIONNAIRE STRUCTURE L e v e l o f C o n c e r n C a t e g o r y I s s u e Q u e s t i o n Type OBJECTIVES any i d e a s s u g g e s t e d by r e s p o n d e n t any i d e a s s u g g e s t e d by r e s p o n d e n t C o m p l e t e l y open FUNCTIONAL P a r e n t s . A c c e s s . E d u c a t i o n . F a m i l y S t a f f . I n f e c t i o n . P a t i e n t Mix . C a r e I s s u e s . P a t t e r n s o f C a r e . E d u c a t i o n . S t r e s s . A d m i n i s t r a t i o n Semi-open (Answer t o a s p e c i f i c i s s u e t o p i c , any i d e a s . ) E quipment . S u p p l y Methods . C l e a n i n g PLANNING S t a f f E q u i pment . I n f e c t i o n . P a t t e r n s o f C a r e . A d m i n i s t r a t i v e R o u t i n e s . A c c e s s t o . Space f o r . E n v i r o n m e n t . M e c h a n i c a l S e r v i c e s C l o s e d (Most q u e s t i o n s t o i n v o l v e s e l e c t i o n f r o m g i v e n o p t i o n s . ) 93 W i t h i n e a c h l e v e l o f c o n c e r n ( t h e rows) the q u e s t i o n s were d e s i g n e d t o s o l i c i t d i f f e r e n t k i n d s o f i n f o r m a t i o n . In t h e f i r s t row, O b j e c t i v e s , t h e q u e s t i o n s were d e s i g n e d t o examine f r o m a l o n g e r - r a n g e p e r s p e c t i v e , any i d e a t h a t m i g h t l a t e r a f f e c t c u r r e n t p a t t e r n s o f c a r e . T h i s c o n c e r n was r e l a t e d t o w h e t h e r i s s u e s c o n s i d e r e d i m p o r t a n t t o d a y would s t i l l be i m p o r t a n t i n t h e f u t u r e . I t i s i m p o r t a n t t h a t t h e d e s i g n p r o c e s s a n t i c i p a t e t h o s e f u t u r e c h a n g e s w h i c h can be p r e d i c t e d , as w e l l as t h o s e w h i c h c a n n o t , s i n c e t h e r e must be a l l o w a n c e f o r b o t h w i t h i n t h e s p a c e s p l a n n e d . To a l l o w some c o n t e x t t o be m a i n t a i n e d and y e t s t i l l l e a v e a n s w e r s open t o r e c e i v e any i d e a s t h a t m i g h t be u s e - f u l , t h e f i r s t s e c t i o n o f t h e q u e s t i o n n a i r e was b r o k e n i n t o two p a r t s . F i r s t , we a s k e d f o r a d e f i n i t i o n o f N u r s e r i e s . T h i s q u e s t i o n would c a u s e t h e r e s p o n d e n t t o t h i n k o f bound- a r i e s t h a t would n a t u r a l l y f a l l a r o u n d t h e s u b j e c t . I t would t h e n a l l o w r e s p o n d e n t s t o f o c u s t h e i r c o n c e p t o f a n u r s e r y o n t o t h e s e c o n d . p a r t . The s e c o n d p a r t a s k e d what would happen, w i t h i n t h i s d e f i n i t i o n a r e a , o v e r the n e x t 10 y e a r s . Ten y e a r s was c h o s e n as b e i n g a t i m e , p e r i o d i n w h i c h r e a l e v e n t s c o u l d be a n t i c i p a t e d r a t h e r t h a n s p e c u l a - t i v e f i c t i t i o u s e v e n t s . Ten y e a r s , a f t e r a l l , i s o n l y two f i v e y e a r f i s c a l b u dget p e r i o d s f o r most P r o v i n c i a l c a s h f l o w s , t o w h i c h most h o s p i t a l s d o i n g p l a n n i n g must r e l a t e t h e i r a c t i v i t i e s and demands. 94 The use of the two part question format also allowed the Monitor Group to cross reference the ideas given i n part 2 of the question to the s p e c i f i c aspects of part 1 so that any anomalies o c c u r r i n g i n l a t e r rounds could be r e - examined. In a l l stages of the p r o j e c t the questions for Newborn Nurseries and f o r Intensive Care Nurseries were separated i n order to allow respondents the opportunity to answer concering only one sub j e c t , i f they had no exposure to the other s u b j e c t , without i n v a l i d a t i n g the question- n a i r e . The second l e v e l of concern; F u n c t i o n a l Aspects, e s s e n t i a l l y required open answers, i n which respondents wrote down what they f e l t a p p r o p r i a t e , but i n t h i s instance they were given some l i m i t s to the subject area upon which they could r e p l y . Important was the f a c t that answers pro- vide p o l i c y c r i t e r i a , rather than o p e r a t i o n a l c r i t e r i a . The answer required would be a statement of an o b j e c t i v e and the purpose of the a c t i o n required to deal achieve i t . We d i d not need an answer which s a i d e.g. "Given that i n f e c t i o n c o n t r o l i s needed here s t a f f must wash." Our concern was with the e a r l i e r i s s u e ; what areas r e q u i r e i n f e c t i o n c o n t r o l and why. I t i s a d i f f i c u l t task to com- municate what a p o l i c y i s to l a y people, e s p e c i a l l y when an exact d e f i n i t i o n i s not always c l e a r even to p o l i c y p l a n - ners. We decided to re s o l v e t h i s by g i v i n g examples of what p o l i c y meant i n each context, u s u a l l y in the preamble 95 t o t h e q u e s t i o n . In a d d i t i o n t o r e s t r i c t i n g t h e a n s w e r s , i n o r d e r t o r e c e i v e p o l i c y c r i t e r i a , we s e t a l i m i t o f f i v e a s p e c t s t o be a d d r e s s e d and l e f t a s p a c e o f one t h i r d o f a page i n w h i c h t o answer. Even t h o u g h i t was s t a t e d t h a t we e n c o u r - aged f u r t h e r p a g e s , i t was f e l t t h a t s u b c o n s c i o u s l y r e s p o n - d e n t s would t r y t o be b r i e f and a l s o would n o t f e e l o v e r - whelmed by t h e amount o f work w h i c h t h e y must do i n a n s w e r - i n g . T h e r e were t e n t o p i c s i n e a c h n u r s e r y s e c t i o n and t h i s was f e l t t o be s u f f i c i e n t t o s o l i c i t most i d e a s w i t h - o u t c a u s i n g e x c e s s i v e work. The f i n a l s e c t i o n ; A r c h i t e c t u r a l P l a n n i n g A s p e c t s , ( r e f e r r e d t o as Space P l a n n i n g i n t h e d i a g r a m ) was d e v e l - oped a r o u n d a s e r i e s o f s e l e c t e d s i t u a t i o n s t h a t t h e P l a n - n i n g E x p e r t s f e l t would encompass t h e m a j o r p r o b l e m s e n c o u n t e r e d i n n u r s e r y p l a n n i n g . The q u e s t i o n f o r m a t was d e s i g n e d t o s o l i c i t o p i n i o n s and comments i n r e s p o n s e t o s t a t e m e n t s made i n t h e q u e s t i o n . In some i n s t a n c e s , t h e q u e s t i o n r e q u i r e d t h e s e l e c t i o n o f a p r e f e r r e d o p t i o n f r o m a g i v e n r a n g e . In t h i s l a s t s e c t i o n , o t h e r t h a n p r o v i d i n g t h e o p p o r t u n i t y t o comment, t h e q u e s t i o n s were o f a c l o s e d s t y l e . In some i n s t a n c e s where a q u e s t i o n a s k e d , a g r e e ? o r d i s a g r e e ? , t h e q u e s t i o n would a s k f o r an e x p l a n a t i o n i f 96 "disagree" was ticked; however, none was absolutely neces- sary. The questions on C r i t e r i a for Illumination and Tele- phone Systems (see questions 3 . 4.3 and 3 . 4 . 4 of Round I Questionnaire in Appendix A.) were l e f t open, because the context was so s p e c i f i c that the Monitor Group f e l t no mis- understanding would r e s u l t . Some unstructured ideas were needed in this section and this was f e l t to be a way of encouraging comments. The development of t h i s f i n a l section of the question- naire required most input by the Planning Experts. The questions had to present re a l situations and give appro- p r i a t e l y informed comment, p a r t i c u l a r l y with respect to the situations and examples presented, so that respondents could quickly grasp what was required of them. The sim- plest method was to present diagrams of plans, and within the question make comments about the plans (both pos i t i v e and negative) which would allow respondents to check a choice and say they agreed or disagreed. A specified range of "Degrees of Agreement" was given each choice. Where needed, the respondents could give additional comments. The basis for t h i s set of questions was developed by using some current, published guidelines, which would probably be used in a nursery planning process. Sizes and numbers were given (as in most guidelines) without reason 97 or e x p l a n a t i o n . Ranges of room temperatures, and numbers and types of e l e c t r i c a l and plumbing f i x t u r e s were o f f e r e d f o r s e l e c t i o n , u s u a l l y taken from commonly used F e d e r a l and P r o v i n c i a l standards. In a d d i t i o n to the three main s e c t i o n s of the ques- t i o n n a i r e , two s e c t i o n s of i n f o r m a t i o n were r e q u i r e d of the e x p e r t s , f o r background a n a l y s i s . The f i r s t s e c t i o n r e q u i r e d the respondents to i d e n t i f y t h e i r normal p o i n t of view by s e l e c t i n g from a l i s t o f c a t e g o r i e s o f i n t e r e s t , as i t a p p l i e d to t h e i r p e r c e p t i o n of t h e i r own e x p e r t i s e . The second s e c t i o n was designed to get an i n d i c a t i o n of t h e i r o p i n i o n as to how c o n f i d e n t they f e l t about t h e i r exper- t i s e , by s e l e c t i n g from a l i s t o f p o l i c y areas and r a t i n g themselves according to the p r o b a b i l i t y of p r o v i d i n g an a c c u r a t e answer on t h i s t o p i c . The use of t h i s s e c t i o n was to check how a p p r o p r i a t e the person was f o r the e x p e r t i s e category to which we had nominated them. This simply r e q u i r e d the matching of the e x p e r t i s e he/she was purported to have, with the e x p e r t i s e they f e l t themselves to have. In a d d i t i o n , i t would be used to check f o r any c o n s i s t e n t p a t t e r n of disagreements. Should t h i s o c cur, i t would suggest b i a s e s i n f l u e n c e d e i t h e r by the respondents' d i s c i p l i n e or area of e x p e r t i s e . 98 3.2 Round 1; The Response The q u e s t i o n n a i r e was p r e - t e s t e d by three nursing graduates at the U n i v e r s i t y of B.C. and one p r a c t i s i n g nurse. The p r e - t e s t was to confirm that the q u e s t i o n n a i r e could be done i n about three hours and that there were no misunderstandings e i t h e r i n the questions asked or i n the scope (of what was r e q u i r e d ) . The r e s u l t s of the p r e - t e s t showed that two approaches might be taken by respondents to the q u e s t i o n n a i r e . F i r s t , a respondent could go through the questions f a i r l y q u i c k l y making minimum comments i n the open questions and e s s e n t i a l l y checking the s e l e c t i o n most c l o s e l y representing t h e i r ideas i n the more d e t a i l e d f i n a l s e c t i o n . Secondly, a respondent could go through g i v i n g indepth answers and take a great deal of time. The p r e - t e s t a l s o showed th a t the f i n a l s e c t i o n had a major flaw. Some of the U n i v e r s i t y nurses supposed that the request-for-comment spaces i n the A r c h i t e c t u r a l Section required of them an e v a l u a t i o n of the diagrams provided. This was over and above the question already asked. This would cause an enormous and unnecessary time i n c r e a s e , so a note at the beginning of the s e c t i o n was added to make i t c l e a r that no e v a l u a t i o n was r e q u i r e d . In a d d i t i o n , because of t h e i r more academic o r i e n t a t i o n , the p r e - t e s t e r s experienced a problem with some d e f i n i t i o n s being used. 99 To avoid t h i s , minor rewording and more preamble were added i n t h i s area. Much more emphasis seemed to be needed on issues of family or parent involvement hence these were inc l u d e d . A f t e r the p r e - t e s t c o r r e c t i o n s were made the r e s u l t s were sent to the 20 experts s e l e c t e d f o r Round 1. When the r e s u l t s came i n from the respondents the f o l l o w i n g back- ground data was obtained: ( i ) The Mode f o r completion time was three hours, and the Mean f i v e hours. The D i s t r i b u t i o n was from two hours to ten hours. This was c o n s i s t e n t w i t h the r e s u l t s expected from the p r e - t e s t r e s u l t . ( i i ) Most of the experts c l a s s i f i e d themselves according to our a n t i c i p a t e d c a t e g o r i e s . An exception occurred with two p h y s i c i a n experts (who were l i s t e d as academics) , who chose t h e i r medical s p e c i a l t y (Neonatology) over t h e i r academic s p e c i a l t y . One other p h y s i c i a n who was i n the P e d i a t r i c category l i s t e d himself as a Neonatology s p e c i a l i s t . Two nurses who were l i s t e d as representing an a d m i n i s t r a t i v e p o i n t of view, chose 100 o b s t e t r i c s and two o t h e r s who were l i s t e d as o b s t e t r i c s c h o s e a d m i n i s t r a t i o n , so t h e i r names were exchanged on t h e l i s t s . R a t h e r t h a n make a d d i t i o n s t o t h e team on t h e b a s i s o f t h e s e m i n o r m i s c a l c u l a t i o n s , the M o n i t o r - i n g Group f e l t t h a t t h e s u b - c a t e g o r i e s under P h y s i c i a n s and N u r s e s were not s u f f i c i e n t l y i m p o r t a n t t o w a r r a n t t h e d e l a y c a u s e d by h a v i n g a d d i t i o n a l p e o p l e i n c l u d e d . The a d j u s t e d l i s t o f r e s p o n d i n g E x p e r t s was: P h y s i c i a n s A cademic 2 ( l e a v i n g s p e c i a l t y unchanged) P e d i a t r i c s 3 N e o n a t o l o g i s t s 5 N u r s e s A d m i n i s t r a t i o n 4 O b s t e t r i c s 6 T o t a l 20 Of t h e s e , 17 r e s p o n s e s were r e t u r n e d . ( i i i ) Two n u r s e s changed employment p o s i t i o n s , w i t h d r e w and d i d n o t r e s p o n d . One n u r s e answered b u t , due t o t i m e commitments, w i t h d r e w f r o m t h e s t u d y . One p h y s i c i a n w i t h - drew due t o o t h e r commitments, w i t h o u t a n s w e r i n g . 101 S i n c e we had a most u n u s u a l l y h i g h r e s p o n s e a t 85% and s t i l l had 80% o f t h e o r i g i n a l p a r - t i c i p a n t s , i t was d e c i d e d t o p r o c e e d t o t h e n e x t r o u n d . One e x c e p t i o n t o t h e d e c i s i o n n o t t o add p a r t i c i p a n t s was t h e i n c l u s i o n o f one o b s t e t r i c a l n u r s e who had a l r e a d y p a r - t i c i p a t e d i n t h e p r e - t e s t and t h e r e f o r e was f a m i l i a r w i t h t h e s t u d y . W i t h r e s p e c t t o t h e i r c o n f i d e n c e i n d e a l i n g w i t h d i f f e r e n t i s s u e s t h e r e s p o n d e n t s r a t e d t h e m s e l v e s as f o l l o w s : (See T a b l e 3 . 1 ) 102 TABLE 3.1 MEDICAL EXPERTS SELF-RATING SCORES ISSUE CATEGORY A. N a t i o n a l o r P r o v - i n c i a l P o l i c i e s B. L e g a l and E t h i c a l Outcomes C. I n t r a - d e p a r t m e n t a l f u n c t i o n s w i t h i n a h o s p i t a l D. I n t e r - d e p a r t m e n t a l . f u n c t i o n s w i t h i n a h o s p i t a l E. S t a f f O r g a n i z a t i o n I s s u e s F. S t a f f T r a i n i n g I s s u e s G. P a t i e n t F a m i l y I s s u e s H. E n v i r o n m e n t a l S a f e t y J . Equipment K. U n i t A d m i n i s t r a - t i o n P e r c e n t a g e o f P h y s i c i a n s R a t i n g t h e i r Answers by t h e p e r c e n t a g e P r o b a b i l i t y o f an A c c u r a t e Answer >80% 80% 50% 90% 80% 70% 90% 70% 90% 80% 80% >50% 10% 30% 10% 20% 10% 30% 20% <50% 10% 20% 20% 10% 10% 20% P e r c e n t a g e o f N u r s e s R a t i n g t h e i r Answers by t h e p e r c e n t a g e P r o b a b i l i t y o f A c c u r a t e Answer >80% >50% <50% 30% 30% 40% 40% 50% 10% 90% 10% - 80% 20% - 80% 20% - 90% 10% - 70% 10% 20% 70% 30% - 70% 30% - 80% 20% - Some c o n c l u s i o n s c a n be drawn f r o m t h e r e s u l t s : (a) N u r s e s do n o t f e e l c o n f i d e n t w i t h "Macro" i s s u e s s u c h as N a t i o n a l P o l i c y and do not f e e l i n f o r m e d about l e g a l and e t h i c a l i s s u e s . 103 (b) P h y s i c i a n s f e e l c o n f i d e n t d e a l i n g w i t h N a t i o n a l i s s u e s b u t f e e l i n a d e q u a t e w i t h l e g a l i s s u e s . ( c ) B o t h p h y s i c i a n s and n u r s e s f e e l c o n f i d e n t i n d e a l i n g w i t h most o t h e r i s s u e s a l t h o u g h c e r t a i n i n d i v i d u a l s were l e s s c o n f i d e n t i n c e r t a i n a s p e c t s t h a n o t h e r s . N o t a b l y , n u r s e s who a r e n o t i n v o l v e d on t h e u n i t b e c a u s e o f a d m i n i s t r a t i v e d u t i e s a r e n o t f a m i l i a r w i t h f a m i l y i s s u e s . P h y s i c i a n s p e c i a l i s t s i n l a r g e r h o s p i t a l s who a r e n o t i n v o l v e d i n u n i t a d m i n i s t r a t i o n f e e l v e r y u n s u r e i n t h i s a r e a . T h e s e same p h y s i c i a n s were n o t c o n f i d e n t about s t a f f o r g a n i z a t i o n a l i s s u e s p r o b a b l y f o r t h e same r e a s o n s o f n o n - i n v o l v e m e n t . (v) I t was n o t i c e a b l e when c o m p a r i n g t h e answers g i v e n i n t h e O b j e c t i v e s s e c t i o n w i t h t h e L e v e l s o f C o n f i d e n c e g i v e n i n t h i s s e c t i o n t h a t b o t h n u r s e s and p h y s i c i a n s t e n d e d t o f o c u s on " M i c r o " i s s u e s r a t h e r t h a n "Macro" i s s u e s . In most c a s e s t h e y p r o v i d e d i n t h e O b j e c t i v e s s e c t i o n a d d i t i o n a l comments on F u n c t i o n s and n o t on l o n g - r a n g e i s s u e s as had been e x p e c t e d . I t was c l e a r f r o m t h e M o n i t o r s " s c a n " o f t h e r e s u l t s o f Round 1, t h a t c e r t a i n o b j e c t i v e s o f t h e m e t h o d o l o g y had not been a c h i e v e d w i t h r e s p e c t t o t h e p u r i t y o f t h e L e v e l s o f 104 C o n c e r n . I t had n o t been p o s s i b l e t o m a i n t a i n t h e s e and i n some i n s t a n c e s t h e same d a t a was g i v e n i n two s e c t i o n s ; p a r t i c u l a r l y , t h e F u n c t i o n a l I s s u e s w h i c h a p p e a r e d a g a i n i n A r c h i t e c t u r a l A s p e c t s , where t h e e x p e r t s e n l a r g e d on t h e i r s h o r t - f o r m answers o f t h e e a r l i e r s e c t i o n . W i t h c o n s i s t e n c y , a l l t h e e x p e r t s f a i l e d t o d e a l w i t h t h e t e n y e a r t i m e span and i n f a c t t h e y d i d n o t d e v e l o p m e a n i n g f u l Long Range I s s u e s i n t h e O b j e c t i v e s l e v e l . I t c o u l d be a r g u e d t h a t t h i s i n d i c a t e d e x p e r t s f e l t t h e r e would n o t be ch a n g e s i n t e n y e a r s , b u t no s t a t e m e n t s t o t h i s e f f e c t were made. In f a c t t o t h e c o n t r a r y , i n s u p p o r t o f t h e v i e w t h a t t h e y d i d n o t d e a l w i t h t h e l o n g e r t i m e s p a n , t h e y documented d e t a i l s o f s h o r t - t e r m i s s u e s w h i c h a r e a l r e a d y a f f e c t i n g t h e s y s t e m . Some e x c e p t i o n s were t h o s e who c i t e d c h a n g e s w h i c h t h e y f e l t o u g h t t o o c c u r — e . g . , n o i s e r e d u c t i o n , b e t t e r e n v i r o n m e n t a l c o n t r o l , e t c . — w h i c h a r e u s e f u l p l a n n i n g o b j e c t i v e s and c o u l d be i n t e r p r e t e d as d e s c r i b i n g a t r e n d t h a t c o u l d o c c u r w i t h i n t e n y e a r s . I n t e r v e n t i o n was r e q u i r e d by t h e P l a n n i n g E x p e r t s ( a s p r o v i d e d w i t h i n t h e D e l p h i d e s i g n ) t h r o u g h t h e r e g r o u p i n g o f t h i s m a t e r i a l i n t o more a p p r o p r i a t e s e c t i o n s , and i t s e x t r a c t i o n f o r e x p a n s i o n as f e e d b a c k m a t e r i a l under t h e O b j e c t i v e s S e c t i o n ( s e e A p p e n d i x B, S e c t i o n s 1.3 and 1.4) f o r t h e n e x t r o u n d . I t was f e l t t h a t t h e s e r e s u l t s s u p p o r t t h e o l d adage t h a t p e r s o n n e l i n t h e c l i n i c a l h e a l t h s e c t o r a r e s h o r t t e r m 105 t h i n k e r s and n o t l o n g t e r m t h i n k e r s v i z . t h e y a r e i n c r e m e n t - a l i s t s , who d e a l w i t h e a c h p r o b l e m as i t p r e s e n t s i t s e l f . T h i s i n d i c a t e s p l a n n e r s c an e x p e c t l i t t l e f r o m m e d i c a l u s e r s i n t e r m s o f " a n t i c i p a t o r y " t h i n k i n g . An o p t i o n would have been p o s s i b l e a t t h i s s t a g e t o f u r t h e r e x p l o r e l o n g e r i t e m o b j e c t i v e s by " p r o b i n g " f o r d e t a i l . I t was d e c i d e d t h a t t o do so would f o r c e a n o t h e r r o u n d f o r m a r g i n a l b e n e f i t and i n s t e a d " p a r t i c i p a t o r y " a s p e c t s were s u b s t i t u t e d by t h e p l a n n e r s f o r use a t t h e end o f Round 2 i n p r e p a r i n g P a t - t e r n s . Drawing some g e n e r a l c o n c l u s i o n s a b o u t t h i s g r o u p may be o f i n t e r e s t b u t i t i s unwise t o g e n e r a l i z e t h i s t o o t h e r p o p u l a t i o n s o f p h y s i c i a n s and n u r s e s . Answers g i v e n t o t h e "open" q u e s t i o n s i n S e c t i o n s 1 and 2, were a b o u t s u b j e c t s m e n t i o n e d w i t h e q u a l f r e q u e n c y by p h y s i c i a n s and n u r s e s . B o t h g r o u p s i d e n t i f i e d n e e d s f o r i n f e c t i o n c o n t r o l , f a m i l y i n v o l v e m e n t , b e t t e r s t a f f t o p a t i e n t r a t i o s and a d d i t i o n a l s p a c e . A l t h o u g h t h e t y p e s o f i s s u e s i d e n t i f i e d were i n ab o u t t h e same p r o p o r t i o n s f o r p h y s i c i a n s and n u r s e s , more p h y s i c i a n s , e s p e c i a l l y t h o s e w o r k i n g as n e o n a t o l o g i s t s , i d e n t i f i e d g r e a t e r need f o r s p a c e i n t h e n u r s e r y a r e a s . I t was n o t i c e a b l e t h a t where p e o p l e may n o t have had r e c e n t e x p e r i e n c e i n an a r e a , b e c a u s e o f i n v o l v e m e n t i n a d m i n i s t r a t i o n and were n o t c l i n i c a l l y i n v o l v e d , o r where p e o p l e i n community h o s p i t a l s were t a l k i n g a b o u t I.C.N.s, t h e t e n d e n c y was t o a v o i d a n s w e r i n g some open q u e s t i o n s and 106 t o c h e c k t h e " a c c e p t a b l e minimum" o p t i o n i n some s e c t i o n s , b u t w i t h no comment. T h i s meant t h a t some b i a s e s were n o t i c e a b l e i n c o m p i l i n g s t a t i s t i c a l r e s u l t s ; p a r t i c u l a r l y , w i t h r e s p e c t t o t h e A r c h i t e c t u r a l S e c t i o n . T h i s b i a s c r e a t e d a s e r i o u s p r o b l e m w i t h o u r a b i l i t y t o p r e s e n t s t a - t i s t i c a l p e r c e n t a g e s . When p r o v i d i n g f e e d - b a c k s t a t i s t i c a l d a t a about t h o s e who a g r e e d o r d i a g r e e d w i t h an i s s u e , a q u a l i f y i n g mechanism was r e q u i r e d . I t was a l s o n e c e s s a r y t o i n t r o d u c e a " w e i g h t i n g " t o a c c o u n t f o r t h e comments g i v e n by r e s p o n d e n t s who d i s a g r e e d ; p a r t i c u l a r l y where t h e s e s t a t e - ments were made by o n l y one but where t h i s one i s a r e c o g - n i z e d e x p e r t i n a v e r y p e r t i n e n t a r e a . T h i s q u a l i f y i n g o r w e i g h t i n g o f i n f o r m a t i o n was done t h r o u g h t h e a d d i n g o f e x p l a n a t o r y comments w i t h t h e s t a t i s t i c s when p r e s e n t e d i n t h e n e x t r o u n d (See A p p e n d i x B, S e c t i o n 3, A r c h i t e c t u r a l A s p e c t s . ) . Good examples o f t h i s need f o r w e i g h t i n g o f comments can be seen w i t h r e s p e c t t o I s o l a t i o n Rooms i n N u r s e r i e s and i n t h e r e j e c t i o n o f c u r r e n t s p a c e g u i d e l i n e s f o r b a s s i n e t - t e s . In t h e l a t t e r c a s e , m e d i c a l s t a f f who had r e c e n t l y been i n v o l v e d i n p l a n n i n g t h e i r own u n i t s , and a l l t h o s e w o r k i n g i n N e o n a t a l I n t e n s i v e C a r e U n i t s , i n s i s t e d on as much as d o u b l e t h e s p a c e o f f e r e d i n o u r q u e s t i o n s (See A p p e n d i x B, S e c t i o n s 3.1.5, 3.1.6 and 3.1.7, Comments.). S i n c e t h i s l a r g e r s i z e p r o p o s a l was c o n s i s t e n t w i t h r e s e a r c h done by t h e A m e r i c a n I n s t i t u t e o f A r c h i t e c t s , i n 1980, as 107 d e s c r i b e d i n C h a p t e r 1 o f t h i s document, we f e l t i t was v a l i d . In t h e n e x t r o u n d we made t h i s s i t u a t i o n o b v i o u s t o r e s p o n d e n t s , t o a l l o w f o r f u r t h e r comments on s p a c e n e e d s . We n o t e d from t h e comments r e c e i v e d i n Round 1 t h a t c o n s i d e r a b l e p o l a r i z a t i o n o c c u r r e d w i t h i n b o t h p h y s i c i a n s ' and n u r s e s ' g r o u p s , w i t h r e s p e c t t o s e p a r a t e i s o l a t i o n rooms. T h i s c a n be s e e n i n Round 2 f e e d b a c k i n A p p e n d i x B, p a r t i c u l a r l y S e c t i o n 3.1.3, Comments. To r e s o l v e t h i s p r o b l e m , f u r t h e r o p p o r t u n i t y was g i v e n t o change p o s i t i o n d u r i n g t h e n e x t r o u n d , and t h e two s e t s o f arguments g i v e n by t h e g r o u p s , were p r e s e n t e d f o r t h e i r f u r t h e r comments. I t i s a l s o w o r t h n o t i n g t h a t p e o p l e w i t h s i m i l a r s p e c i a l i s t b a c k g r o u n d s , b o t h p h y s i c i a n s and n u r s e s , were d i a m e t r i c a l l y o p p o s e d on t h i s i s s u e and i t c o u l d o n l y be hoped t h a t once e a c h g r o u p saw t h e o p p o s i n g arguments t h a t a compromise would o c c u r . When a l l t h e q u e s t i o n n a i r e s had been a n a l y z e d , Round 2 was p r e p a r e d . The r e s u l t s o f Round 1 were g e n e r a l l y v e r y s a t i s - f a c t o r y . W i t h t h e e x c e p t i o n o f t h e l i m i t e d amount o f l o n g t e r m i d e a s p r o v i d e d , most s e c t i o n s were w e l l u n d e r s t o o d by a l l r e s p o n d e n t s and a g r e a t d e a l o f u s e f u l p l a n n i n g d a t a was s u p p l i e d . A h i g h d e g r e e o f c o n s e n s u s was e x p e c t e d f r o m t h i s f i r s t r o u n d and t h i s o c c u r r e d . The M e d i c a l E x p e r t g r o u p s e x p r e s s e d c o n c e r n a b o u t s i m i l a r t y p e s o f i s s u e s and t h e v a r i a n c e s i n p r i o r i t y c l e a r l y c o r r e s p o n d e d t o t h e 108 i n d i v i d u a l s ' p r o f e s s i o n a l c a t e g o r y . T h e r e a p p e a r e d t o be no e f f e c t o f g e o g r a p h i c d i f f e r e n c e s between p e o p l e i n s i m i l a r l e v e l s o f c a r e , a l t h o u g h t h o s e i n u r b a n and r u r a l s e t t i n g s d i f f e r e d on i s s u e s w h i c h t h e y f e l t i m p o r t a n t . I d e a s more o f t e n d i f f e r e d between p e o p l e i n t h e same c i t y , t h a n i n c o m p a r a b l e s i t u a t i o n s i n t e r - p r o v i n c i a l l y . 3 . 3 Round 2; The Questionnaire Preparation The p r i m a r y o b j e c t i v e s o f Round 2 were t o : ( i ) Feedback t h e r e s p o n s e s g i v e n i n Round 1 f o r f u r t h e r comment, and h i g h l i g h t p a r t i c u l a r l y any d i s a g r e e m e n t s t h e r e s p o n d e n t s m i g h t have had w i t h d a t a g i v e n i n Round 1. ( i i ) Ask f o r a d d i t i o n a l d a t a t o r e s o l v e p o l a r i z e d i s s u e s . ( i i i ) Rate t h e d a t a g i v e n i n Round 1 r e s p o n s e s , t o e s t a b l i s h what i n f o r m a t i o n must be i n c l u d e d i n t h e P a t t e r n s and what c o u l d be o m i t t e d . T h i s l a s t o b j e c t i v e was c r i t i c a l t o b e i n g a b l e t o d e c i d e w h i c h i s s u e s a c t u a l l y made whole i d e n t i f i a b l e p a t t e r n s , and w h i c h i s s u e s would j u s t c o n t r i b u t e t o a p a t t e r n . 109 The Preparation of the material for further questioning and for feedback, was done section by section, then reviewed as a whole. This review was to determine whether there were overlaps and whether adjustments were required to make Round 2 viable. This was consistent with the need to "scan" the work to check whether a corrective intervention was needed by the Planning Experts. It became obvious that an enormous amount of data had been collected and that i f everything was fed back to respondents, then each section would take hours to answer during the next round. The f i r s t task was to go through a l l answers looking for similar statements which could be taken exactly as stated, or reworded to combine a number of i n d i - vidual's responses. The Monitoring group was required to consider c a r e f u l l y where two statements were actually saying the same thing. It was often necessary to l e t statements remain as they were in case a misinterpretation had occurred or an intent had not been understood by the Planners that would be understood by Medical Experts. The Monitors' role was to analyze the material to reduce the volume. Then i t was required that the Planners intervene to reword and reduce material. In practice t h i s proved d i f f i c u l t because there was a tendency to reduce less than might have been desirable. 110 The M o n i t o r s g a i n e d f u r t h e r r e d u c t i o n by e x t r a c t i n g what was u s e f u l as F u n c t i o n a l I s s u e s f r o m t h e O b j e c t i v e s S e c t i o n and a l s o where any d u p l i c a t i o n o c c u r r e d as a r e s u l t o f t h i s move. S e c t i o n 1, f r o m Round 1, was now s p l i t i n t o two p a r t s . The d a t a on D e f i n i t i o n s w h i c h had r e c e i v e d c o n s i d e r a b l e c o n s e n s u s was c o l l e c t e d i n t o a s i n g l e s t a t e m e n t so t h a t one D e f i n i t i o n c o u l d be made f o r Newborn N u r s e r i e s and one f o r I n t e n s i v e C a r e N u r s e r i e s . R e s p o n d e n t s were s i m p l y a s k e d i n t h i s round t o a c c e p t o r r e j e c t t h e s e d e f i n i t i o n s but w i t h comments. The O b j e c t i v e s p a r t o f S e c t i o n 1 ( t h e s e c o n d p a r t ) was i n c l u d e d w i t h r e s p o n s e s f r om S e c t i o n 2, t h e F u n c t i o n a l I s s u e s , so t h a t t h e s t a t e m e n t s r e a s s e m b l e d by t h e P l a n n e r s t o d e a l w i t h O b j e c t i v e s , c o u l d be r a t e d l i k e t h o s e on F u n c t i o n s . T h r e e r a t i n g a s p e c t s were a s k e d o f t h e r e s p o n d e n t s . These were: I m p o r t a n c e ; how i m p o r t a n t was what had been s a i d ? D e s i r a b i l i t y ; how d e s i r a b l e would be t h e r e s u l t s o f d o i n g what was s u g g e s t e d ? , and F e a s i b i l i t y ; how p r a c t i c a l would i t t o be t o implement t h i s i d e a ? I l l I t was o b v i o u s t h a t t h e s e t h r e e a s p e c t s c o u l d be i n d i s a g r e e m e n t , i n t h a t s o m e t h i n g c o u l d be an I m p o r t a n t I s s u e b u t have u n d e s i r a b l e outcomes e v e n t h o u g h i t would s t i l l be p r a c t i c a l t o im p l e m e n t . Those s o l u t i o n s w h i c h s c o r e d h i g h l y on a l l t h r e e s c a l e s would be o u r f i r s t c h o i c e . C h o i c e s o f o t h e r i s s u e s f o r c o n s i d e r a t i o n among t h o s e r a t i n g h i g h on I m p o r t a n c e , would depend upon w h i c h a s p e c t and f o r w h i c h r e a s o n t h e y r a t e d l o w . In e a c h r a t i n g a S c a l e was o f f e r e d f r o m 1, (a p o s i t i v e a s p e c t ) t h r o u g h 5, (a n e g a t i v e a s p e c t ) . A t t h e b e g i n n i n g o f t h e r a t i n g S e c t i o n i n t h e Q u e s t i o n n a i r e , a s e t o f D e f i n i - t i o n s was g i v e n f o r e a c h r a t i n g p o i n t on e a c h s c a l e . T h i s was t o e n a b l e t h e r e s p o n d e n t s t o comprehend t h e meaning o f t h e v a l u e o f t h e p o i n t g i v e n and t h e r e b y t o e n s u r e c o n s i s - t e n t r e s u l t s . The q u e s t i o n s were f o r m a t t e d by p u t t i n g e a c h s t a t e m e n t g i v e n i n Round 1 ( o r a c o m p o s i t e d f a c s i m i l e ) on a l i n e by i t s e l f , w i t h s p a c e a l o n g s i d e i t , t o a l l o w a r a t i n g and a comment. T h i s was done t o e n a b l e r e s p o n d e n t s t o p e r c e i v e t h a t t h e y must d e a l w i t h e a c h i t e m s e p a r a t e l y , e v e n t h o u g h i n some c a s e s s t a t e m e n t s were s a y i n g a l m o s t s i m i l a r t h i n g s . Any v a r i a n c e s t h o u g h t t o e x i s t by t h e M o n i t o r s w h i c h r e s u l t e d i n the i n c l u s i o n o f two s i m i l a r i t e m s i n t h e q u e s t i o n n a i r e , would be v a l i d a t e d o r r e j e c t e d by t h e e x p e r t s , a c c o r d i n g t o t h e way t h e y s c o r e d t h e s e p a r a t e i t e m s . 112 The h e a d i n g s used t o c a t e g o r i z e t h e i s s u e s i n Round 1 were used as s u b - s e c t i o n h e a d i n g s i n Round 2 and a l l t h e m a t e r i a l c o l l e c t e d i n Round 1, was g r o u p e d under t h e s e h e a d - i n g s . In t h i s way, S e c t i o n s 2.1 t o 2.10 c o v e r e d Newborn N u r s e r i e s , 2.11 t o 2.20 c o v e r e d I n t e n s i v e C a r e N u r s e r i e s . S e c t i o n 2 had r e c e i v e d some a d d i t i o n a l comments f r o m r e s p o n - d e n t s i n Round 1, so t h e s e were p u t i n a s e c t i o n numbered 2.0 (See A p p e n d i x B . ) . A f u r t h e r p a r t was p r e p a r e d t o go w i t h i n S e c t i o n 2 i n Round 2. T h i s e x t r a s e t o f q u e s t i o n s was c o n s i d e r e d n e c e s - s a r y t o o b t a i n a more d e t a i l e d d e s c r i p t i o n o f t h e a c t i v i t i e s t h a t t a k e p l a c e i n e a c h a r e a o f t h e n u r s e r i e s . I t was f e l t by t h e P l a n n i n g E x p e r t s t h a t i f a d e t a i l e d u n d e r s t a n d i n g o f t h e a c t i v i t i e s w h i c h s t a f f f e l t were i m p o r t a n t c o u l d be compared w i t h t h e p o l i c i e s t h e y f e l t n eeded t o be a c h i e v e d , c o n f l i c t s i n t h e e n v i r o n m e n t would be i d e n t i f i e d . T h i s new i n p u t would r e q u i r e r e s p o n d e n t s t o d e s c r i b e u n d e r two g e n e r a l h e a d i n g s ( P a t i e n t C e n t r e d A c t i v i t i e s and o f S t a f f S u p p o r t A c t i v i t i e s ) f o r b o t h Newborn and I n t e n s i v e Care N u r s e r i e s , t h o s e a c t i v i t i e s w h i c h t h e i n d i v i d u a l r e s p o n d e n t s f e l t most i m p o r t a n t . Each r e s p o n d e n t was a s k e d t o c o n c e n - t r a t e on d e s c r i b i n g a r e a s w i t h w h i c h t h e y were most f a m i l i a r and i n a d d i t i o n were g i v e n a l i s t o f a c t i v i t y t o p i c s t h e y s h o u l d c o n s i d e r . T h i s p a r t o f S e c t i o n 2 was t o be t h e new i n p u t a s p e c t s o f Round 2. 1 1 3 In S e c t i o n 3 , A r c h i t e c t u r a l A s p e c t s , w i t h i t s c l o s e d s t y l e o f q u e s t i o n i n g , c o d i n g and s t a t i s t i c a l a n a l y s i s o f r e s u l t c o u l d be e a s i l y done. As feedback, the p r o p o r t i o n a l p e r c e n t a g e s o f r e s p o n s e s t o the q u e s t i o n s were i t e m i z e d and comments g i v e n from the M o n i t o r Group about the s t a t i s t i c s . As has been o u t l i n e d e a r l i e r t h e s e comments were used t o d e v e l o p " w e i g h t s " t o q u a l i f y answers where the s t a t i s t i c s were c l e a r l y not c o n v e y i n g the sense o f c o n v i c t i o n c e r t a i n i n d i v i d u a l s had i n g i v i n g an answer. The s t a t i s t i c a l d a t a and comments by the M o n i t o r s was f o l l o w e d by a s e c t i o n which i n c l u d e d a l l the comments about th e a r c h i t e c t u r a l a s p e c t s s u p p l i e d by the respondents i n Round 1. In t h i s i n s t a n c e comments were i n c l u d e d v i r t u a l l y i u n a l t e r e d and the respond e n t s were r e q u i r e d t o i n d i c a t e whether a l l o r some o f the comments were v a l i d . The oppor- t u n i t y t o add f u r t h e r comments or d e v e l o p a d i s c u s s i o n about any i s s u e r a i s e d d u r i n g the p r e v i o u s round was g i v e n i n o r d e r t o e x p l o r e more d e e p l y some i s s u e s . Throughout the comment segment o f S e c t i o n 3 , where a d d i - t i o n a l q u e s t i o n s were needed t o h i g h l i g h t o r d e v e l o p an i d e a , the P l a n n i n g E x p e r t s s i m p l y i n s e r t e d q u e s t i o n s as they f e l t n e c e s s a r y . The i d e a was f o r the respond e n t s t o move th r o u g h t h i s s e c t i o n as a continuum, r e a c t i n g and d e v e l o p i n g t h e i r i d e a s and expanding on those o f o t h e r p a r t i c i p a n t s i n e a r l i e r rounds. 114 3 .4 Round 2: The Response T h i s q u e s t i o n n a i r e r e p r e s e n t e d a s u c c i n c t i n t e g r a t i o n o f t h e p r e v i o u s r o u n d , and as s u c h i t was f e l t a p r e - t e s t w ould n o t be u s e f u l . When c o n s i d e r i n g t h e l i k e l y r e s p o n s e t o t h e Round 2 q u e s t i o n n a i r e , the major c o n c e r n t h e M o n i t o r - i n g Group had was p o s s i b l e r e a c t i o n t o t h e s i z e o f t h e q u e s t i o n n a i r e i t s e l f . T h e r e was c o n c e r n t h a t , t o a g r o u p o f v o l u n t e e r s , t h e immediate r e a c t i o n would be t o f e e l o v e r - whelmed by t h e t a s k o f r e s p o n d i n g . To o f f s e t t h i s , i n b o t h t h e l e t t e r a c c o m p a n y i n g t h e document and t h e f i r s t page o f t h e document i t s e l f , e m p h a s i s was put on how t o h a n d l e t h e volume o f work (See I n t r o d u c t i o n A p p e n d i x B . ) . A s u g g e s t i o n was i n c l u d e d as t o how t h e r e s p o n d e n t s m i g h t do t h e q u e s t i o n n a i r e i n p a r t s and c o n c e n t r a t e on t h o s e s e c t i o n s w i t h w h i c h t h e y had g r e a t e s t f a m i l i a r i t y . W h i l e i t was r e c o g n i z e d t h a t we m i g h t g e t i n c o m p l e t e q u e s t i o n n a i r e s t h e f a i l u r e t o g e t r e s p o n d e n t s t o r e t u r n what t h e y had done, o r t o be u n w i l l i n g t o do t h e q u e s t i o n n a i r e a t a l l , would be f a r w o r s e . In r e v i e w i n g t h i s p r o b l e m p r i o r t o s e n d i n g o u t t h e document, r e d u c t i o n was c o n s i d e r e d u n n e c e s s a r y . I t was a g r e e d t h a t a d j u s t m e n t s c o u l d be made d u r i n g t h e r o u n d . T h i s s o o n p r o v e d t o be r e q u i r e d . The f i r s t , f e a r t h a t t h e r e was a p r o b l e m w i t h t h e amount o f t i m e r e q u i r e d t o c o m p l e t e the q u e s t i o n n a i r e , began t o be r e a l i z e d a s t h e r e q u e s t e d d e a d l i n e p a s s e d and o n l y 115 f i v e r e s p o n s e s were r e c e i v e d . Those r e s p o n d i n g i n d i c a t e d t h a t some d a y s were needed t o a d d r e s s a l l t h e i s s u e s i n d e p t h . The M o n i t o r Group n o t i c e d t h a t t h e new i n p u t segment o f S e c t i o n 2 was n o t b e i n g answered s a t i s f a c t o r i l y . The r e s p o n d e n t s had n o t u n d e r s t o o d t h a t d e s c r i p t i o n s o f a c t i v i - t i e s r a t h e r t h a n l i s t s o f a c t i v i t i e s , were needed. On c h e c k i n g by t e l e p h o n e w i t h some o f t h e n o n - r e s p o n d i n g p a r t i c i p a n t s i t was c l e a r t h e r e were p r o b l e m s i n t h e f o l l o w - i n g a r e a s : ( i ) In S e c t i o n s 1 and 2 r a t i n g e a c h i t e m w i t h t h r e e d i f f e r e n t f a c t o r s p r o d u c e d t h o u s a n d s o f p o s s i b l e c o m b i n a t i o n s and was v e r y t i m e c o n s u m i n g . ( i i ) The "new i n p u t " segment i n S e c t i o n 2, r e q u i r e d r e s p o n d e n t s t o t h i n k t h r o u g h and p r o v i d e o r i g i - n a l m a t e r i a l , i n a d d i t i o n t o e v a l u a t i n g p r e v i o u s m a t e r i a l , w h i c h seemed t o be an o v e r w h e l m i n g t a s k f o r most p e o p l e . ' ( i i i ) R e g a r d l e s s o f t h e I n t r o d u c t i o n and l e t t e r , R e s p o n d e n t s had been overwhelmed by t h e i r p e r c e p t i o n o f t h e t a s k and had p u t o f f d o i n g t h e q u e s t i o n n a i r e . As t i m e went by, t h e y l o s t a l l m o t i v a t i o n t o c o n t i n u e . 116 S i n c e t h e m e t h o d o l o g y o f t h e s t u d y had made a l l o w a n c e f o r t h i s e v e n t u a l i t y t h e M o n i t o r i n g Group was r e q u i r e d t o r e a s s e s s p r i o r i t i e s and c o r r e c t t h e a t t r i t i o n p r o b l e m . The f i r s t t a s k was t o r e d u c e r a d i c a l l y t h e t i m e r e q u i r e d t o answer w i t h o u t i n v a l i d a t i n g t h e s t u d y . The new i n p u t f o r S e c t i o n 2, p a r t 2, c o u l d be d r o p p e d a l t o g e t h e r , making Round 2 an e x p l o r a t i o n o f p r e v i o u s l y p r e s e n t e d i d e a s and n o t one o f d e v e l o p i n g new i d e a s . T h i s was s t i l l c o n s i s t e n t w i t h t h e o r i g i n a l i n t e n t and t h e p u r p o s e o f Round 2. R e s p o n d e n t s c o u l d be g i v e n t h e c h o i c e o f v a r y i n g w h i c h o f t h e r a t i n g s t h e y would do i n o r d e r t o r e d u c e the amount o f time r e q u i r - e d . T h e s e o p t i o n s were: ( i ) To c o n t i n u e t o do a l l t h e r a t i n g s on a l l q u e s - t i o n s . ( i i ) To' do o n l y t h e Im p o r t a n c e r a t i n g s and h a v i n g made a s e l e c t i o n , l e a v e t h e s o r t i n g o f i s s u e s t o t h e P l a n n i n g E x p e r t s , t h e s o r t i n g o f i s s u e s b a s e d upon t h e i r own a s s e s s m e n t o f D e s i r a - b i l i t y and F e a s i b i l i t y . ( i i i ) To do a l l r a t i n g s on t h o s e i t e m s which were h i g h on I m p o r t a n c e r a t i n g and n o t on o t h e r s . By a l l o w i n g r e s p o n d e n t s t h e c h o i c e o f s e l e c t i n g f r o m e a c h o f t h e s e o p t i o n s t h e answers r e c e i v e d would s t i l l make 117 p o s s i b l e what was e s s e n t i a l ; i d e n t i f y i n g t h e most i m p o r t a n t whole i s s u e s and s u b - i s s u e s r e q u i r e d t o d e v e l o p t h e p a t t e r n s . A f i n a l c o n c e r n was how t o d e a l w i t h t h e a t t r i t i o n o f e x p e r t s , p a r t i c u l a r l y s h o u l d some members o f t h e o r i g i n a l r e s p o n d e n t g r o u p s now not w i s h t o c o n t i n u e . To g e t some i d e a o f t h e p r o b l e m s o r a c c e p t a b i l i t y o f c h a n g i n g e x p e r t s d u r i n g D e l p h i s t u d i e s , i n f o r m a t i o n was s o u g h t from Mr. M i c h a e l Y e s l e y i n Los A n g e l e s , C a l i f o r n i a . Mr. Y e s l e y was a t t h a t t i m e w i t h t h e Rand C o r p o r a t i o n and had p r e v i o u s l y been a s t a f f member o f a C o n g r e s s i o n a l Commission t h e y e a r b e f o r e , who c a r r i e d o u t a l a r g e D e l p h i S t u d y from W a s h i n g t o n , D.C. In t h e s e d i s c u s s i o n s i t was c l e a r t h a t i t would be a c c e p t a b l e t o add new members d u r i n g a round as l o n g as t h e s u b s t i t u t e s were few and were o f a s i m i l a r e x p e r t i s e . T h i s was done d u r i n g t h e W a s h i n g t o n D.C. s t u d y and no d e t r i m e n t a l e f f e c t s were n o t e d . The p a r t i c i p a n t s who had n o t r e s p o n d e d were t e l e p h o n e d , t o i n f o r m them o f t h e c h a n g e s , t h e r e d u c t i o n i n t h e t i m e n e e d s o f t h e s t u d y , and t o a s k them t o c o n t i n u e . I t was f e l t t h a t i f 14 answers c o u l d be r e c e i v e d , p r o v i d e d t h e y were r e p r e s e n t a t i v e o f b o t h p h y s i c i a n s and n u r s e s , an a c c e p t a b l e sample would have been, a c h i e v e d . T h i s would be a more t h a n 80% r e s p o n s e f r o m t h e 17 who answered Round 1 and 70% o f t h e o r i g i n a l 20 p a r t i c i p a n t s . 118 The t e l e p h o n e s u r v e y i n d i c a t e d t h a t i n a d d i t i o n t o t h e f i r s t f i v e r e s p o n d e n t s , s e v e n o f t h e o r i g i n a l g r o u p would c o n t i n u e and t h a t one p h y s i c i a n had l e f t h i s A l b e r t a d i r e c t - o r s h i p and gone t o t h e U.S.A. On r e q u e s t , h i s r e p l a c e m e n t s a i d he would c o n t i n u e and t h i s o f c o u r s e meant a c o m p a t i b l e e x c h a n g e b r i n g i n g t h e numbers t o 13. One a d d i t i o n a l n u r s e was r e q u i r e d t o make up t h e 14 and once a g a i n a head n u r s e i n t h e same h o s p i t a l n u r s e r y a s one o f t h e r e t i r e e s a g r e e d t o c o n t i n u e . A l e t t e r was s e n t e x p l a i n i n g t h e "new" method and i n some c a s e s a d d i t i o n a l q u e s t i o n n a i r e s , were d i s t r i b u - t e d . An u n f o r t u n a t e p r o b l e m was t h a t one o f t h e Academic P h y s i c i a n s and one o f t h e o t h e r p h y s i c i a n s , c o n s i d e r e d by t h e P l a n n i n g E x p e r t s t o be t h e most e x p e r i e n c e d i n p l a n n i n g I n t e n s i v e Care U n i t s , were n o t p r e p a r e d t o c o n t i n u e due t o w o r k l o a d . W h i l e t h i s weakened c e r t a i n p a r t s o f t h e team i t was e x p e c t e d t h a t by t h e t i m e t h e a c t u a l P a t t e r n s had been p r e p a r e d t h e y would be a b l e t o e v a l u a t e t h e r e s u l t s i n Round 3 and s t r e n g t h e n t h e p l a n n i n g a s p e c t s a g a i n . Once t h e s e f i n a l c h a n g e s had been made t h e a d d i t i o n a l n i n e r e s p o n s e s came b a c k f a i r l y q u i c k l y . 119 The f i n a l l i s t o f E x p e r t R e s p o n d e n t s was: P h y s i c i a n s A c a d e m i c P e d i a t a r i c N e o n a t o l o g i s t s 1 1 4 N u r s e s A d m i n i s t r a t i o n O b s t e t r i c s 3 5 T o t a l 14 Once a l l t h e r e s p o n s e s were a v a i l a b l e t h e M o n i t o r s " s c a n n e d " t h e answers and a s s e s s e d t h e i m p a c t o f t h e s e r e s u l t s . I t was c l e a r t h a t by e n s u r i n g t h e h i g h e s t l e v e l o f r e s p o n s e , t h e d a t a was i n c o m p l e t e . A g r e a t many r e s p o n d e n t s ( s i x ) c h o s e t o use t h e I m p o r t a n c e p l u s o t h e r r a t i n g s on h i g h I m p o r t a n c e s c o r e s o n l y ( O p t i o n 3 as o f f e r e d them) w i t h t h e f i r s t f i v e r e s p o n d e n t s d o i n g a l l s e c t i o n s and t h r e e r e s p o n d e n t s d o i n g o n l y I m p o r t a n c e r a t i n g s . T h i s meant t h e P l a n n i n g E x p e r t s would be r e q u i r e d t o p r o v i d e a g r e a t d e a l more d a t a t h a n had been a n t i c i p a t e d i n s a t i s f a c t o r i l y c o m p l e t i n g t h e P a t t e r n s . The c o n c e r n h e r e i s w i t h t h e p o s s i b i l i t y o f b i a s e s due t o t e c h n i c a l i n e x p e r i e n c e b u t t h i s has b e en c o u n t e r e d i n t h e D e l p h i d e s i g n , t h r o u g h t h e e v a l u a t i o n i n Round 3 by E x p e r t s and M i n i S u r v e y r e s p o n d e n t s . The r e s u l t o f t h i s e v a l u a t i o n m i g h t i n d i c a t e t h e need f o r a f u r t h e r r o u n d o f q u e s t i o n s , b u t n o t more s e r i o u s e f f e c t s . In e x a m i n i n g t h e r a t i n g s r e t u r n e d , i t was n o t i c e a b l e 1 2 0 t h a t p o s i t i o n s had n o t changed s u b s t a n t i a l l y f r o m Round 1 . In c o m p a r i n g t h e i s s u e s upon w h i c h t h e r e was a h i g h d e g r e e o f c o n s e n s u s ( t h r o u g h h i g h I m p o r t a n c e s c o r e s ) w i t h t h e com- ments and s t a t i s t i c s f r o m Round 1 , i t c o u l d be s e e n t h a t p r i m a r y i s s u e s were s t i l l f i r m l y a g r e e d upon, s u c h a s : more s p a c e ; b e t t e r f a m i l y a c c e s s ; b e t t e r i n f e c t i o n c o n t r o l , e t c . S i m i l a r l y , w i t h i s s u e s upon w h i c h t h e e x p e r t s were i n i t i a l l y . d i v i d e d , eg t h e need, f o r I s o l a t i o n Rooms, i t a p p e a r e d as t h o u g h most e x p e r t s r e m a i n e d d i v i d e d even a f t e r s e e i n g t h e a r guments made by o t h e r s . A l t h o u g h a s h i f t o f p o s i t i o n s had been e x p e c t e d , t h i s i n d i c a t e d t h a t a P o l i c y D e l p h i was s u c - c e s s f u l l y o p e r a t i n g and t h e P l a n n i n g E x p e r t s were now p r o - v i d e d w i t h t h e " p o l a r i z e d " p o l i c y o p t i o n s . The P l a n n e r s c o u l d now p e r f o r m t h e i r r o l e by u s i n g t h i s i n f o r m a t i o n t o p r e p a r e s o l u t i o n s t o t h e p r o b l e m s and t h e n e x p l o r e t h e s e s o l u t i o n s w i t h t h e M e d i c a l E x p e r t s i n t h e f i n a l r o u n d . The s e c o n d r o u n d had b een v e r y u s e f u l i n p r o v i d i n g good comments f r o m t h e M e d i c a l E x p e r t s , a l l o w i n g them t o i l l u - s t r a t e f r o m t h e i r e x p e r i e n c e , t h e p o s i t i v e and n e g a t i v e e f f e c t s o f o t h e r p e o p l e s ' s u g g e s t i o n s . T h i s i n f o r m a t i o n was c o n s i s t e n t w i t h o t h e r comments g i v e n a c r o s s t h e d i f f e r e n t p r o f e s s i o n a l c a t e g o r i e s , i t was a l s o c o n s i s t e n t w i t h p u b l i s h e d m a t e r i a l and g e n e r a l l y p r o v i d e d t h e p l a n n e r s w i t h a knowledge o f t h e " w o r k i n g s " o f t h e " w o r l d " o f n u r s e r i e s . 121 3 « 5 Round 3 ; Preparing the Patterns As soon as more t h a n h a l f o f t h e r e s p o n s e s t o Round 2 were r e c e i v e d , t h e t a s k o f p r e p a r i n g t h e P a t t e r n s began. I t was d e t e r m i n e d t h a t a l l t h e m a t e r i a l p r e s e n t e d i n Round 2 w o u l d have t o be a n a l y z e d and a s s e m b l e d i n t o a s e r i e s o f i n d i v i d u a l P a t t e r n s . The P a t t e r n s would be c o l l e c t e d i n a book f o r m and c i r c u l a t e d w i t h q u e s t i o n n a i r e s t o t h e E x p e r t and M i n i - S u r v e y g r o u p s . T h i s p r e p a r a t i o n t a s k p r o v e d t o be t h e most t i m e consuming e v e n t f o r t h e P l a n n i n g E x p e r t s . However t h i s was e x p e c t e d , s i n c e i t was t h e i r m a j o r r o l e i n t h e s t u d y . The method used t o p r e p a r e d a t a was q u i t e s t r a i g h t f o r w a r d , and a s f o l l o w s : ( i ) F i r s t , " S c a n " S e c t i o n s 1 and 2 t o i d e n t i f y a l l i t e m s w i t h r a t i n g s o f 1 f o r a l l s c a l e s , o r i f o n l y t h e I m p o r t a n c e R a t i n g had been f i l l e d i n , t h o s e w i t h s c o r e s o f No. 1; ( i i ) Then, a s s i g n t o e a c h answers f r o m t h e q u e s t i o n - n a i r e , a U s a b i l i t y R a t i n g o f f r o m 1 t o 4 a c c o r d - i n g t o t h e c r i t e r i a o f T a b l e 3.2. 122 TABLE 3.2 USABILITY RATING CRITERIA R a t i n g D e s c r i p t i o n 1 . More t h a n 20% o f r e s p o n d e n t s (Most I m p o r t a n t ) gave a No. 1 s c o r e on a l l t h r e e s c a l e s . . Where >75% o f r e s p o n d e n t s gave No. 1 on t h e I m p o r t a n c e S c a l e o r No. 1 p l u s No. 2 t o t a l e d >75% on I m p o r t a n c e . . Where a M e d i c a l E x p e r t , r e c - o g n i z e d i n t h i s a r e a , has a d d i t i o n a l s u p p o r t i n g comments. . Where t h e P l a n n i n g E x p e r t s f e l t t h a t t h e i t e m was i m p o r - t a n t f o r a P a t t e r n e v e n i f t h e m e d i c a l u s e r s d i d n o t . 2 . Where >50% o f No. 1 r a t i n g s (2nd O r d e r o f o r c o m b i n a t i o n s o f No. 1 and Imp o r t a n c e ) No. 2 r a t i n g s were g i v e n on t h e I m p o r t a n c e S c a l e . . Where a s p e c i a l i s t ' s comments l e a d t h e P l a n n i n g E x p e r t s t o c o n s i d e r t h e i t e m ' s i n c l u s i o n i n a P a t t e r n f o r s u p p o r t i n g an i s s u e . . Where t h e P l a n n i n g E x p e r t s f e l t i t s h o u l d f o r m a s u b - i s s u e o f a P a t t e r n . 3 . Where a h i g h l y r a t e d i t e m was ( U n i m p o r t a n t ; n o t f o r c o n s i d e r e d by P l a n n i n g use i n P a t t e r n ) E x p e r t s t o p e r t a i n more t o management t h a n t o s p a c e o r p l a n n i n g i s s u e s . . Where an i t e m s c o r e d low on Im p o r t a n c e and a l l s c a l e s . 4 . Where M e d i c a l E x p e r t s r a t e ( R e j e c t e d ) * the i s s u e v e r y low e s p e c i a l l y on t h e D e s i r a b i l i t y o r F e a s i b i l i t y S c a l e s . 123 ( i i i ) Where comments g i v e n were a s s o c i a t e d w i t h No. 1 r a t e d a n s w e r s , t h e s e would be examined f o r v a l i d i t y and f o r any i s s u e s w h i c h would c a u s e t h e r a t i n g s g i v e n by r e s p o n d e n t s t o be " w e i g h t e d " . The U s a b i l i t y R a t i n g m i g h t be a d j u s t e d a s a r e s u l t o f t h i s r e v i e w . ( i v ) The a n s wers U s a b i l i t y Rated No. 1 would be a s s e m b l e d by s u b j e c t g r o u p i n g s so t h a t t h e y c o u l d f o r m r e l a t e d s u b - i s s u e s . Good judgment would be r e q u i r e d by t h e P l a n n e r s t o d e t e r m i n e w h i c h was an a s p e c t o f a whole i s s u e and w h i c h was r e a l l y a new t o p i c . (v) Where whole t o p i c s c o u l d be i d e n t i f i e d b u t t h e r e was i n s u f f i c i e n t d a t a t o c o m p l e t e t h e P a t t e r n , t h e P l a n n e r s would s u p p l e m e n t f r o m o t h e r s o u r c e s o r draw upon l e s s e r r a t e d i s s u e s b u t use " e x p l a i n i n g " q u a l i f i e r s w i t h i n t h e P a t t e r n p r o d u c e d . The f o l l o w i n g c h a r t s summarize t h e r e s u l t s w h i c h were u s e d i n Round 3 f r o m Round 2. F o r i l l u s t r a t i o n we have s e l e c t e d t h o s e i s s u e s w h i c h f i n i s h e d w i t h a No. 1 U s a b i l i t y R a t i n g and t h e r e f o r e t y p i c a l l y had more t h a n 30 p e r c e n t o f r e s p o n d e n t answers w i t h a l l t h r e e s c a l e s r a t e d No. 1. In 124 many c a s e s t h e P l a n n e r s examined t h e p r o s and c o n s p r e s e n t e d i n U s e r comments so t h a t d a t a w h i c h was u s e f u l i n t h e r e s o - l u t i o n o f a p r o b l e m c o u l d be i n c l u d e d i n a P a t t e r n . S e c o n - d a r y i s s u e s a r e n o t shown i n t h e s e summary c h a r t s , a l t h o u g h t h e s e s e c o n d a r y i s s u e s were used i n v a r i o u s ways. They were o f t e n u s e d t o d e c i d e i f an i s s u e r e a l l y r e p r e s e n t e d a p l a n - n i n g p r o b l e m o r j u s t a m a n a g e r i a l p o l i c y p r o b l e m . Then b e c a u s e i n many c a s e s i m p r o v e d p l a n n i n g c o u l d n o t s o l v e t h e p r o b l e m as p r e s e n t e d , t h e i s s u e was n o t d e v e l o p e d f u r t h e r i n t h e s e g u i d e l i n e s . In s u c h an i n s t a n c e , a No. 2 r a t e d i s s u e w ould be downgraded t o a No. 3. S e c o n d a r y i s s u e s o f t e n p r o v i d e d a d d i t i o n a l s t a t e m e n t s t h a t s u p p o r t e d p r i m a r y i s s u e s and t h e s e s t a t e m e n t s were i n c o r p o r a t e d w i t h i n t h e P a t t e r n . F i n a l l y , n o t shown i n t h e s e summaries a r e t h e i s s u e s r a t e d H i g h l y I m p o r t a n t b u t r e j e c t e d as i n f e a s i b l e by t h e U s e r s . On s e v e r a l o c c a s i o n s t h e comments and v o t i n g i n d i c a t e d t h a t i t was most i m p o r t a n t t h a t a c e r t a i n a c t i o n d i d n o t happen. As an example we p r e s e n t t h e f o l l o w i n g s t a t e m e n t , made by a r e s p o n d e n t i n Round 1 and p r e s e n t e d unchanged i n Round 2: 1.3.11. Where l e n g t h o f s t a y i s r e d u c e d , s m a l - l e r n u r s e r i e s a d j a c e n t t o t h e M o t h e r s ' Room ( o r s h a r e d between two rooms) c a n be p r o v i d e d f o r t h o s e m o t h e r s / b a b i e s where t h e s t a y i s l o n g e r . In t h i s c a s e , 75 p e r c e n t o f r e s p o n d e n t s r a t e d t h e i s s u e 3, 4 o r 5 on a l l t h r e e s c a l e s and t h e comments s a i d t h a t t o i mplement s u c h an i d e a would be d a n g e r o u s . One p h y s i c i a n c i t e d an example i n Denver where a s i m i l a r i n s t a l l a t i o n was b u i l t and due t o t h e i n a b i l i t y t o c o n t r o l a c c e s s o r s u p e r - v i s e p r o p e r l y , b a b i e s were s t o l e n f r o m t h e u n i t . S i n c e i t was an i m p o r t a n t i s s u e f o r p l a n n i n g , c a r e f u l c o n s i d e r a t i o n had t o be g i v e n b e f o r e r e j e c t i n g t h e i d e a . The summary c h a r t s , T a b l e s 3.3 t o 3.7, a r e e x h i b i t e d i n t h e f o l l o w i n g manner. F i r s t , e a c h i t e m i s numbered a c c o r d - i n g t o t h e s e c t i o n used i n Round 2, and a summary i s g i v e n o f what was s t a t e d . (The r e a d e r s h o u l d r e f e r t o A p p e n d i x B, f o r t h e f u l l d e s c r i p t i o n s . ) The i n i t i a l U s a b i l i t y R a t i n g a s s i g n e d t o t h i s i t e m i n a c c o r d a n c e w i t h t h e b a s i c c r i t e r i a i s l i s t e d n e x t , f o l l o w e d by t h e f i n a l U s a b i l i t y R a t i n g r e s u l t i n g f r o m t h e e v a l u a t i o n . The I m p o r t a n c e R a t i n g s a r e l i s t e d by p e r c e n t a g e s o f t h o s e who r e s p o n d e d by r a t i n g 1, 2 o r 3 r e s p e c t i v e l y . Where t h e y do n o t t o t a l 100% i t i s due t o l o w e r s c o r e s (4 o r 5) n o t b e i n g shown on t h i s c h a r t . The n e x t column b r i e f l y l i s t s r e a s o n s why t h e U s a b i l i t y R a t i n g e i t h e r r e m a i n e d unchanged o r was c h a n g e d . I n c l u d e d i n t h i s c olumn a r e r e f e r e n c e s t o comments f r o m t h e A r c h i t e c t u r a l S e c t i o n f r o m t h e Round 2 q u e s t i o n n a i r e . These comments had a m a j o r i n f l u e n c e on t h e P l a n n e r s ' d e c i s i o n a s t o w h e t h e r an i t e m was used i n a P a t t e r n , b e c a u s e r e s p o n d e n t s o f t e n made t h e i r b e s t s p a c e - r e l a t e d comments i n t h i s s e c t i o n . I t s h o u l d be n o t e d t h a t comments f r o m a l l s e c t i o n s formed a u s e f u l b a s i s f o r e v a l u a t i n g t h e r e a s o n s why r e s p o n d e n t s c h o s e t h e i r r a t i n g s . T h i s was most i m p o r t a n t i n t h a t a f u n d a m e n t a l r e q u i r e m e n t o f t h e m e t h o d o l o g y was i t s a b i l i t y TABLE 3.3 SUMMARY OF RATINGS FOR OBJECTIVES: NEWBORN NURSERIES BRIEF DESCRIPTION AND ITEM NO. IN I T I A L USABIL- ITY RATING FINAL USABIL- ITY RATING % RESPONDING BY IMPORTANCE RATING REASON FOR USABILITY RATING USED IN PATTERN % NO. 1 SCORES ON ALL SCALES 1 2 3 1.3.1 F a m i l y O r i e n t a - t i o n 1 1 80% 10% 10% . I m p o r t a n c e R a t i n g s . B i r t h Home 30% 1.3.3 D e s i g n e r s must p r o v i d e f l e x i - b i l i t y 2 1 25% 50% 25% . I m p o r t a n c e R a t i n g s . P l a n n e r s Comments . S i z e o f W e l l B a b i e s ' Room <20% 1.3.4 D e s i g n i s t o a l l o w m o t h e r s ' c h o i c e s 1 1 60% 20% 20% . I m p o r t a n c e R a t i n g s . P l a n n e r s and U s e r s comments . S i z e o f W e l l B a b i e s ' Room 30% 1.3.5 B a b i e s t o spend t i m e w i t h p a r e n t s 1 1 50% 50% . A l l t h r e e s c a l e s h i g h . H i g h I m p o r t a n c e . S i z e o f W e l l B a b i e s ' Room . F a m i l y Room 40% 1.3.7 P a r e n t s a t t i t u d e t o l e a r n i n g e x p e r i e n c e 1 1 50% 25% 25% . I m p o r t a n c e R a t i n g s . P l a n n e r s and U s e r s comments s u p p o r t . F a m i l y Room . 30% TABLE 3.3 - Continued SUMMARY OF RATINGS FOR OBJECTIVES: NEWBORN NURSERIES BRIEF DESCRIPTION AND ITEM NO. IN I T I A L USABIL- ITY RATING FINAL USABIL- ITY RATING % RESPONDING BY IMPORTANCE RATING REASON FOR USABILITY RATING USED IN PATTERN % NO. 1 SCORES ON ALL SCALES 1 2 3 1.3.8 S i z e r e l a t e d t o I n f e c t i o n C o n t r o l 1 1 100% . I m p o r t a n c e R a t i n g s . U s e r s Comments . S i z e o f W e l l & S i c k B a b i e s ' Room 50% 1.3.9 A p p l i c a t i o n o f s y s t e m s a p p r o a c h t o D e s i g n 1 3 60% 20% 20% . I m p o r t a n t i s s u e b u t P l a n n e r s c o u l d n o t r e l a t e t o b u i l d i n g i s s u e s .Not used 30% TABLE 3 .4 SUMMARY OF RATINGS FOR OBJECTIVES: I.C.N. BRIEF DESCRIPTION AND ITEM NO. I N I T I A L USABIL- ITY RATING FINAL USABIL- ITY RATING % RESPONDING BY IMPORTANCE RATING REASON FOR USABILITY RATING USED IN PATTERN % NO. 1 SCORES ON ALL SCALES 1 2 3 1.4.1 The s i z e o f the U n i t i n r e l a t i o n t o S t a f f s t r e s s 1 1 80% 20% . I m p o r t a n c e R a t i n g s .The S i c k e s t B a b i e s ' Room 30% 1.4.3 R e c o g n i t i o n o f t h e number o f s t a f f needed • 2 '1 75% 25% . I m p ortance R a t i n g s . P l a n n e r s Comments . A d u l t s i n t h e N u r s e r y Room <30% 1.4.4 A t t e n t i o n t o r e s e a r c h i n the a r e a o f I.C.N. 1 1 80% 10% 10% .High a l l t h r e e S c a l e s .Major P l a n n i n g I s s u e s .The S i c k e s t B a b i e s 1 Room 40% 1.4.7 Need f o r im- (a) p r o v e d F a m i l y o n l y Educ. f a c i l i t i e s 1 1 25% 75% . H i g h Impor- t a n c e s h i g h . U s e r s comments m o s t l y s u p - p o r t e d . P l a n n e r s f e l t t o be good . F a m i l y Room <30% 1.4.8 P o s i t i v e need t o d e f u s e p h y s i c a l e n v i r o n m e n t 2 1 30% 40% 30% . P l a n n e r s f e l t i m p o r t a n t a s p e c t f o r s p a c e . F a m i l y Room <30% 1.4.10. Need s p a c e f o r p a r e n t s t o g r i e v e 1 1 25% 50% 25% .High s c o r e s on I m p o r t a n c e . A d u l t s i n t h e N u r s e r y <30% TABLE 3.5 SUMMARY OF RATINGS FOR FUNCTIONS: NEWBORN NURSERIES BRIEF DESCRIPTION AND ITEM NO. INI T I A L USABIL- ITY RATING FINAL USABIL- ITY RATING % RESPONDING BY IMPORTANCE RATING REASON FOR USABILITY RATING USED IN PATTERN % NO. 1 SCORES ON ALL SCALES 1 2 3 2.1 UNIT S I Z E AND MIX 2.1.1 S i z e a s a f u n c - t i o n o f n u r s e r a t i o 1 2 30% 50% 20% .Used by P l a n - n e r s a s a s u b - i s s u e . S i z e o f W e l l B a b i e s ' Room <30% 2.1.3 N u r s e r y s t a f f must be c o v e r e d d u r i n g m e a l s 1 1 50% 50% .High R a t i n g on Im p o r t a n c e . U s e r s comments v e r y s u p p o r t i v e . S i z e o f W e l l B a b i e s ' Room <30% 2.1.8 16 I n f a n t s a r e Maximum i n Group 2 2 40% 20% 20% .Used as a d i s - c u s s i o n p o i n t . S i z e o f W e l l B a b i e s ' Room <30% 2.2 PATTERNS OF CARE 2.2.1 M o t h e r s need c h o i c e o f l o c a t i o n 1 1 50% 30% 20% .High r a t i n g . U s e r s and P l a n n e r s f e l t c r i t i c a l i s s u e . S i z e o f W e l l B a b i e s ' Room . A d u l t s i n t h e N u r s e r y 30% TABLE 3 . 5 - Continued SUMMARY OF RATINGS FOR FUNCTIONS: NEWBORN NURSERIES BRIEF DESCRIPTION AND ITEM NO. IN I T I A L USABIL- ITY RATING FINAL USABIL- ITY RATING % RESPONDING BY IMPORTANCE RATING REASON FOR USABILITY RATING USED IN PATTERN % NO. 1 SCORES ON ALL SCALES 1 2 3 2.2.3 W i t h r o o m i n g - i n n u r s e r y becomes t e m p o r a r y h o l d 1 1 60% 30% 10% . H i g h I m p o r t a n c e R a t i n g . U s e r s comments p o s i t i v e . S i z e o f W e l l B a b i e s ' Room <30% 2.2.4 P a r e n t s e n c o u r - aged by i n v o l v e - ment i n u n i t f u n c t i o n 1 1 70% 20% 10% . H i g h R a t i n g .User comments p o s i t i v e . P l a n n e r s used . F a m i l y Room 30% 2.2.5 F l e x i b i l i t y o f a t t i t u d e s t o h e l p p a r e n t s r e l a x 1 1 80% 20% .High R a t i n g s on Im p o r t a n c e .Some bad U s e r comments but P l a n n e r s used . F a m i l y Room <30% 2.3 INFECTION ISSUES 2.3.1 Need f o r s i n k s i n w a l k i n g d i s t a n c e 1 1 90% 10% - .High R a t i n g s .User and P l a n - n e r s f e l t m a j o r i s s u e . S i z e P a t t e r n s . I n f e c t i o n B a r r i e r s 40% 2.3.2 A d e q u a t e gown & wash a t a c c e s s 1 1 80% 10% 10% .Major i s s u e f o r p l a n n i n g s p ace . A d u l t s i n N u r s e r y . I n f e c t i o n B a r r i e r s 50% TABLE 3 . 5 - Continued SUMMARY OP RATINGS FOR FUNCTIONS: NEWBORN NURSERIES BRIEF DESCRIPTION AND ITEM NO. INITIAL USABIL- ITY RATING