Commissioning a design and construction project is a bit like buying an expensive new suit. With a suit, you may know the color and style you like, the amount you want to spend, and the size you wear. With a building, you may know functions that must be accommodated, the image to be conveyed, the approximate number of square feet (square meters) desired, the time frame, and the budget. But chances are you would not walk out of the clothing store until the suit had been altered to fit your exact proportions—the waist might need to be taken in, the hips let out a bit, the sleeves lengthened. The same is true of the design of a building. A general set of design parameters, even informed guidelines like the ones presented in this book, must be tailored to each project's specific requirements.
Design guidelines supply information of a general nature: for example, how to arrange cubicles in an admitting area, how to position a window in relation to a patient's bed, and the types of electrical connections needed on a patient-room headwall. However, in order to ensure that these guidelines are relevant to a specific situation—such as an admitting area short on space, an older hospital that cannot afford to change its windows, or a bed design that can abrade electrical plugs—it is necessary to supplement general design guidelines with detailed design-related information gathered from the people—staff, patients, and visitors—who use (and will use) the facility.
Of course, many others will also participate in the process. Designers, including architects, landscape architects, interior designers, and others will make major contributions. Consultants in such areas as Emergency Department design, Food Services, Universal Design, Wayfinding, Materials Management, and others, will contribute to the project as a result of their experience and expertise. Those who manage the organization and maintain the facility will also have significant input into the design in order to make sure it reflects the mission of the organization, its corporate culture, preferences of corporate leaders, as well as the available budget, schedule, regulatory, and other requirements. Philanthropic donors may also weigh in (Sommer, 1983).
User participation refers to a process of systematically gathering information about the design-related needs, expectations, preferences, and experiences of the facility's eventual users and incorporating this information into the design decision-making process. User participation is desirable for any healthcare-facility design project, small scale or large scale, including site planning, architectural design, interior design, and landscape architecture (Brubaker, 1985 [unpub.]).
As far back as the 1970s, the importance of “Participatory Design,” as it was then known, was becoming clear (Sanders and Stappers, 2008). Information about consumer needs and preferences, as well as quantitative and qualitative feedback from consumers about products, was recognized as a key to business excellence in producing consumer goods. These criteria now are understood as crucial for service industries such as healthcare, with patients acknowledged as “the ultimate (although not the only) consumers—the end consumers—of healthcare services” (Stern et al., 2003).
Evidence-based design emerged as a way of improving functionality by basing design decisions on knowledge about the impact of these decisions on people, costs, and management (Codinhoto et al., 2014). Evidence can provide a solid basis for questioning old standards and promoting innovation. A practice of routinely collecting evidence on the effects of the decisions made and the results achieved can stimulate learning and improve performance (Codinhoto et al., 2014).
Although orchestrating a participatory design process is complex and time-consuming, it can be beneficial for a number of reasons.
With objectives stated and constraints in mind, designers are free to do what they do best: meet these challenges with creative design approaches (Kaplan and Kaplan, 1983). Participation can also help relieve users' anxieties about the otherwise unknown changes ahead (Brill et al., 1985). User participation can encourage realistic expectations, because users can gain a better understanding of the project's financial, regulatory, and physical constraints (Dewulf and van Meel, 2002).
Without detailed familiarity with what goes on within a given space, design decision-makers may inadvertently fail to accommodate users' needs (Brill et al., 1985; Dewulf and van Meel, 2002; Hall, 1991; Lindamood, 1982; Reizenstein, 1982; Sommer, 1983). Participation can bridge the gap between generally relevant approaches and specifically workable options.
When people have been involved in a participatory process, they tend to take better care of the resulting design (Kaplan and Kaplan, 1983). They also feel a vested interest in the project, leading perhaps to less staff absenteeism, turnover, theft, or vandalism (Becker, 1977; Brill et al., 1985; Sommer, 1983).
A participatory design process often brings people together to talk about common concerns—something rare in segmented or large organizations. This opportunity for staff—at different levels, in different roles, or in different departments—to work together on an important and challenging task can create at least a temporary sense of teamwork that might otherwise be absent (Sommer, 1983).
When participants review proposed designs, questions often arise about related policies. For example, the degree to which a clinic waiting area is overcrowded may be a function of scheduling practices, as well as design. Design and policy need to work in concert to achieve organizational objectives (Cleary, 2003).
Knowing which design features and amenities are most important to consumers can help healthcare facilities attract patients and visitors. As healthcare organizations become more competitive, references to such design features as parking, comfort, green design, Universal Design, and healing gardens are likely to appear with greater frequency in marketing materials (Falick, 1981). Furthermore, the fact that consumers participated in the design process is a marketable feature in itself (Carpman and Trester, 1986).
Input from users enhances the design process by incorporating a wide variety of knowledge and expertise, making the process not only intrinsically more democratic, but also more productive, resulting in practical solutions.
It is widely recognized that usability is determined not only by the immediate interface between users and design features, but also by how design features fit into the complex organizational environment. Thus documents by themselves cannot be sufficient sources of information. Direct contact with users is also necessary for understanding the contexts of use (Kujala, 2003). Designers certainly bring a view of context to the design process, but this will be to some extent, “a guess, a personal view based on personal experiences” (Sleeswijk Visser et al., 2005). Designers may have little experience with healthcare settings. And as one experienced healthcare architect and project designer observes, “We always make a conscious effort to design from the perspectives of the patient, family, and caregivers, but we aren't always fortunate enough to see the space in use” (Zeit, 2013). Moreover, project developers may underestimate the diversity of users over the full spectrum of personal (demographic), task-related, geographic, and social characteristics (Kujala and Kauppinen, 2004).
Research with real users offers “a richer, more dependable view” as the description and selection of representative users evolves (Kujala and Kauppinen, 2004; Sleeswijk Visser et al., 2005). Involving patients, family members, and healthcare staff in the dialogue about healthcare facility environments allows designers and architects “to go beyond their own limited experience with the built environment of a particular healthcare facility” to optimally accommodate users' needs (Stern et al., 2003). After all, “no one can validate flows and prioritize goals like an end-user” (Glushko, 2013).
In addition, designers characteristically have an intensely visual way of knowing and working. This visual expertise is a source of strength, but has its limitations (Franck and Lepori, 2007; Heylighen, Devlieger, and Strickfaden, 2009). The way a space looks is important, as is the way it feels, sounds, smells, and the way one moves through it (Pallasmaa, 2007). Architect Robert Campbell explains that the architect's typical way of working can result in “architecture reduced to two dimensions and one sense, the visual,” and can become “increasingly remote from the way lay people describe and prioritize architecture” (Campbell, 2007).
In this context, the lived experience of users—including people with functional limitations—is a valuable resource to ensure multi-sensory values and usability in the built environment. People with functional limitations, for example, are able “through their daily interaction with space . . . to identify and appreciate qualities in buildings and spaces that other people—and designers in particular—are not even aware of” (Heylighen et al., 2009). Recognizing users as “experts of their experience” “strives for user-friendly and elegant solutions and attempts to improve the environment for as many people as possible” (Herssens and Heylighen, 2007; Sleeswijk Visser et al., 2005).
The concept of “users” itself is changing and broadening, giving way in many instances to the idea of “stakeholders”: that is, all the people who will be affected by a designed environment, also known as a “system” (Baek et al., 2014). For artifacts and systems to effectively address the needs of the people for whom they are designed, all stakeholders must be integrated into the design process (Schuler, 2014).
Participation in design can encompass a number of quite different activities, from relatively little or no direct user involvement to a great deal. “Traditionally”—at least since the 1970s and ‘80s—these have occurred along the following scale of increasing involvement:
In recent years, design and design research have been undergoing a transformation (Sanders, 2006). The user-centered approach of informed experts “designing for users” is being expanded and sometimes superseded by the idea of co-designing, “designing with people” (Glushko, 2013; Sanders and Stappers, 2008). Knowledge useful for a design process can come in many forms: for instance, “knowledge of an end-user about her practice, knowledge of a researcher about some end-users' practices, knowledge of a designer about technology, an end-user's ideas for product improvement, a researcher's hunch about a certain problem, a designer's ambition to create something,” and the like (Steen, Kuijt-Evers, and Klok, 2007). Similarly, creativity occurs on several levels, from doing and adapting to making and creating (Sanders and Stappers, 2008). Those with passion and expertise about a subject can, as “experts of their experience,” become co-creators in the design process, if they are given effective tools for expressing themselves (Sanders, Brandt, and Binder, 2010; Sanders and Stappers, 2008; Simonsen and Robertson, 2013).
The complexity and scale of design challenges are growing. The best research into past practices and current user preferences cannot provide all the answers to questions about patients and their needs; healthcare staff and their needs, technology and its requirements, managers and their concerns, and the like (Sanders and Stappers, 2008). It is no longer a matter of simply designing a product for users. A design movement has arisen that seeks to address “the future experiences of people, communities, and cultures who are now connected and informed in ways that were unimaginable” even a short while ago (Sanders and Stappers, 2008). The design process now must often move to a purpose perspective, seeking new techniques and tools (Jensen, 2011; Sleeswijk Visser et al., 2005).
A further challenge to involving users in design is that, in well-learned tasks, much of a user's knowledge becomes tacit: not conscious or easily expressed in words (Kujala, 2003). In addition, while innovation must always aim to solve real problems, some of these may be latent issues that people are not yet aware of, “things you never knew you needed” (Brown, 2014). Strategies are needed that unlock these sources of potential design expertise.
An array of techniques and tools meets these challenges, particularly ones that avoid the high levels of abstraction of traditional design approaches (Sanders et al., 2010; Schuler, 2014; Simonsen and Robertson, 2013). This expansion in thinking is reflected in the language of design: prominent buzzwords include human-centered design, co-designing, cultural probes, generative design thinking, applied ethnography, contextual inquiry, lead user/lead consumer approach, and empathetic design. Overall, the design process has acquired a new outlook: “People who are not educated in design are designing; the line between product and service is no longer clear; the boundaries between the design disciplines are blurring” (Sanders, 2006).
Our aim here is not to single out any one approach for detailed analysis, but rather to lay out general challenges and opportunities at the leading edge of design thinking. Certain themes emerge, however, from an exploration of the literature. Focus is increasingly on “the fuzzy front end” of the design process, formerly called “pre-design”: the open-ended exploration of what is to be designed—and sometimes, what should not be designed and manufactured (Sanders and Stappers, 2008). Emphasis is more on experiential concerns than on physical or material ones. A multi-disciplinary approach and communication among all the stakeholders are critical (Baek et al., 2014; Jensen, 2011; Steen, Kuijt-Evers, and Klok, 2007). Such conversations need to be more about exploring and exchanging knowledge than about making decisions and reaching closure (Baek et al., 2014). And throughout the design process, there needs to be enough time to allow for multiple iterations of research, design, and analysis.
Some examples may help clarify some participation alternatives. They show that participation can occur throughout the design process and can use a variety of techniques. Some of the following examples occurred in the 1980s as part of the design process for the University of Michigan Medical Center in Ann Arbor, one of the first extensive health-facility user participation projects in the United States. Since then, similar efforts in other hospitals have been made to involve patients and family members in designing new facilities and patient rooms (Johnson, 1999; Spohn, 2007).
Before decisions were made at the University of Michigan Medical Center about the layout of the acute-care inpatient room, including the location of the bathroom and the relationship of beds to the doorway in a semi-private room, randomly sampled patients were interviewed, using small, three-dimensional models that the patients could hold and manipulate to show the arrangements they preferred. Their preferences, in addition to staff preferences and other considerations, played an important role in decisions about the eventual layout (Reizenstein and Grant, 1981).
At the University of Michigan Medical Center, as part of pre-design programming, staff members in each clinical, hospital, and administrative department were interviewed about their requirements for space, equipment, lighting, finishes, and furnishings. This information was recorded and used to guide design.
During preparatory workshops for the new patient tower of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, nurses co-created a concept for ideal workflow on a patient floor. All the toolkit components were round, to help the nurses think in terms of activities, rather than rooms, at this early stage of the design process. When the team proceeded to co-design the ideal future patient room, a three-dimensional toolkit was used for generative prototyping (Sanders and Stappers, 2008).
A number of conditions are needed in order to achieve maximum benefits from user participation in design:
User participation in design can occur in a variety of ways. Three frequently used mechanisms are working groups, systematic research, and consultation by outside experts.
User' working groups may meet frequently or infrequently. They might represent a particular occupational group, they might represent users from one department, they might comprise users from several different departments, or they might share some other commonality. A particularly successful strategy is to develop internal expertise through early creation of “think tank” groups that cut across departments, thereby creating thought leaders to promote new ideas and encouraging staff buy-in for proposed changes (Joseph, Bosch, and Frede, 2007).
On a small design project, such as the renovation of an obstetrics and gynecology clinic, one or two working groups may suffice. On a large-scale project, such as the design of a teaching hospital, there may be a need for many working groups: perhaps one for each department, plus some additional groups organized by functional issues such as safety, security, Universal Design, and wayfinding.
These working groups may review relevant studies and reports, visit other facilities, use design tools to generate ideas and develop concepts as co-creators, review the details of proposed design schemes, select from several completed design schemes, and/or try out proposed designs or design features through simulation. Regardless of the ways each group functions, users can collaborate on and respond to different design alternatives and predict what will work for them (Kaplan and Kaplan, 1983; Sanders and Stappers, 2008). By creating understanding of the benefits of innovations, such user participation can result in fostering change, retaining design features that might otherwise have been lost to cost-reduction decisions (Joseph et al., 2007).
The working-group format requires that users and design decision-makers negotiate as they work toward a final design. It is important that all working-group members have an opportunity to contribute and that the process not be dominated by one or two individuals. Otherwise, the design will reflect a unique mode of functioning and could become ineffective if a particular individual leaves the organization. In addition, other working-group members may feel that their own efforts are not valued.
Working groups function most smoothly when they are run by skilled, neutral leaders. Leaders can be responsible for scheduling, setting agendas, procuring necessary documents, and guiding discussions, as well as recording and distributing meeting notes. Because working-group discussions can become heated, the leader's neutrality and group-facilitation skills can maximize the group's productivity.
Systematic research is another approach to user participation. A large group of users, such as obstetrics and gynecology clinic patients, can be sampled to obtain a reasonably accurate representation of user characteristics and viewpoints. Research techniques might include face-to-face and telephone interviews, online surveys, and simulations such as the evaluation of rough scale models or conceptual drawings (Becker, 1982).
Participation through research may be useful on both small-scale and large-scale projects. It would be a cost-effective and time-effective way for obstetrics and gynecology patients and companions to voice their needs and preferences about a clinic renovation, for example. It would also be a practical way to involve house officers, staff nurses, housekeeping and maintenance staff, clerical staff, and patients and visitors in the design of a new teaching hospital.
User needs and preferences might be tapped in a single study, such as a study of responses to 3D models or drawings showing different layouts for obstetrics and gynecology examination rooms and waiting areas. Or a number of different studies might be needed to optimize user participation in the design of a teaching hospital, such as studies of patients' comfort, nurses' ease of operation of different beds, visitors' preferences about the location of restrooms in relation to waiting areas, and clerical staff's preferences for different office landscape systems.
Although every information-gathering technique has its strengths, there are always corresponding shortcomings. For example, guided interviews with open-ended questions can produce large amounts of data that are rich in detail and yet time-consuming to code or quantify. Selecting more than one technique, however, can often compensate for the shortcomings of each.
Information about users' design needs can also be provided by behavioral consultants. This approach may be desirable when a project's success depends on balancing the needs and preferences of multiple user groups, when the schedule and budget do not allow for either direct participation or systematic research, or when users are either unknown or unavailable. Consultants can contribute expert information based on their experience with the design of similar projects, familiarity with relevant design research literature, and/or previous research on and experience with similar facilities. They can act as user advocates, they may have skill at interpreting and reviewing design documents from a behavioral point of view, and they can offer a clear perspective on the design process that insiders might not have (Sommer, 1983).
Gathering information through user participation can be considered a two-phase process. During the first and preparatory phase, user participation managers need to become as knowledgeable as possible about the relevant design issues. During the second phase, they will gather and analyze users' design-related information about use, needs, and preferences.
For example, consider the design of a private (single-occupancy) inpatient room. First, participation managers will identify relevant codes and regulations. This might be followed by gathering books, articles, and other relevant materials and conducting an online literature review of published studies, unpublished reports, conference presentations, and so on, to discover what is already known about users' design needs and the current state-of-the-art (or ongoing controversies) about meeting these needs. The manager might then review minutes of meetings and other organization records to learn about the history of the design project, discover whether some informal decisions have already been made, and gauge whether or not certain decision-makers favor certain design approaches. The initial learning period could be supplemented by visits to other hospitals for a brief overview of how well their patient rooms appear to function. Finally, the manager might consult with experts. This reconnaissance effort will make it easier and more efficient to plan user participation since key assumptions, preferences, issues, realistic design alternatives, internal political realities, as well as local and national context should all be clear.
In order to gather and analyze information in a way that will provide useful information to design decision-makers and be satisfying to users, realistic design alternatives must be presented in ways users can easily understand and respond to (Kaplan and Kaplan, 1983).
For example, asking nurses or others without architectural training to review a two-dimensional floor plan of a private patient room would not be a useful approach. These nurses would have no alternatives to compare (other than patient rooms where they have worked), they might not be able to make sense of a two-dimensional floor plan, and they might doubt their own expertise on the topic. In this scenario, the nurses might not be able to contribute much of substance and would probably end up feeling frustrated with the exercise.
However, if these same nurses were shown a video or digital images of several three-dimensional arrangements or small, shoebox-sized 3D models, the participation exercise would probably be more successful. They could assess the different design alternatives; they could virtually manipulate the beds, walls, and other features in the images; and they could more easily visualize how different activities would be accommodated. This approach would generate pragmatic design responses and ideas, be more enjoyable, and leave participants feeling satisfied that they had made useful contributions. A group of designers who used this approach in designing hospital rooms for children found that models with moveable parts offered a useful way for participants, particularly children, to provide feedback. Family members and caregivers were also among the participants (Spohn, 2007).
Three-dimensional simulations or games can also be useful and engaging. These simulations allow the viewer to “fly” or “run” through the building and see the space from multiple perspectives. Designers can present the simulations in person or post them online (Dewulf and van Meel, 2002). Computer simulations may facilitate users' abilities to visualize proposed designs; however, their effectiveness in promoting participation satisfying to the user and useful for the designer is not yet well understood.
There are many opportunities for gathering feedback and sharing information online. Online user surveys are easy to develop, send, and analyze. Websites can contain password-protected areas for group communications. And, of course, huge amounts of information can be gathered using various search engines (Dewulf and van Meel, 2002).
Selecting optimal information-gathering techniques for a specific situation is part of the art of managing user participation. One should also consider the expertise available; the schedule; the numbers of users who need to be involved; the relevance, quantity, and quality of information needed; and the budget. Box 11.1 describes some techniques that can provide background information about the design problem at hand (Boisaubin et al., 1985; Brill et al., 1985; Madge, 1965; Michelson, 1975; Reizenstein et al., 1982; Stern, 1979; Webb, 1966; Wohlwill and Weisman, 1981; Zeisel, 2006). (See Box 11.2 for recommended reading.)
In order to have real impact on the design of healthcare facilities, user participation should occur throughout the design process, from conceptualization through post-occupancy evaluation (also known as “Facility Performance Evaluation” or FPE). (See chapter 1 for a detailed description of phases of the design process.) Recommendations growing out of the participation process must be provided in a timely manner—while design alternatives are being considered—and be geared to key milestone dates in the project schedule. The ways in which participation occurs may vary with the particular stage of design (Frey, 1989; Kaplan and Kaplan, 1983; Kernohan et al., 1992; King, Marans, and Solomon, 1982; Lawrence, 1982; Madge, 1965; Moser and Kalton, 1985; Sanoff, 1977, 2000; Zeisel, 2006).
Users' needs and preferences should be articulated at the earliest stages of a healthcare-facility design project, and be reflected in a mission statement, types and sizes of spaces required, and associated performance criteria (Lickhalter, 1988). Early in the participation effort, users need an overview of the design process for their areas. This mental road map can help clarify where their contributions fit in. Once they have an overview, participants will know when certain types of functional information will be most useful, enabling them to work productively and efficiently (Sommer, 1983).
Once the design process begins, users and/or behavioral consultants can perform periodic design reviews; helping assess the probable performance of the proposed designs, according to a variety of performance criteria. Users can review design progress in person or online by annotating floor plans, providing written comments, attending actual or virtual meetings, and the like. Users may respond to questions, images, scale models, or full-scale mock-ups (Kaplan and Kaplan, 1983; King, Marans, and Solomon, 1982; Reizenstein and Grant, 1982; Sanoff, 1992).
Participation can also occur during the construction phase of a project, when last-minute design changes may occur. If design decisions need to be revisited at this late (and costly) stage, users can weigh-in using all the mechanisms and techniques described above. If participation occurs this late in the process, there need to be mechanisms in place for quickly summarizing user input and revisiting design decisions, as needed.
Post-occupancy evaluation (POE), assessing how new or renovated facilities perform, is another stage of the design process when user participation is valuable. (This is also known as Facility Performance Evaluation—FPE). User participants can contribute to POE planning by helping identify which aspects of the design should be evaluated. They can give feedback on the performance of design features they regularly use and make recommendations for changes in design and related policies (Manasec and Adams, 1987; Ogrodnik, 1985; Preiser, 2002; Reizenstein and Grant, 1982; Zeisel, 2006; Zimring, Rashid, and Kampschroer, 2010; Zimring and Reizenstein, 1980, 1981).
Users are all the people who come into contact with the physical environment. In healthcare facilities, users include inpatients and outpatients; family members and visitors; medical, nursing, and care staff; allied health professionals; medical, nursing, and allied health students; managers and administrators; staff who provide a range of needed patient care, administrative, clerical, maintenance, information technology, and other services that keep the healthcare facility running; as well as others who use the buildings, including salespeople and delivery workers. All of these users' voices should be reflected and respected in the design process. When selecting users to participate, consider the type and extent of knowledge they bring, their motivation to participate, their availability, and their ability to represent the views of others (Baek et al., 2008; Brill et al., 1985; Brunnquell, Balik, and Pearson, 1991; Sidhu et al., 2002).
Users can be categorized according to their roles in the facility. For example, the renovation of a department head's office may only require the participation of that physician and an administrator, whereas the renovation of an obstetrics and gynecology clinic may call for the involvement of patients, companions, nurses, clerical staff, physicians, technicians, maintenance staff, housekeeping staff, administrators, and others.
Both the size of the user group and the frequency of facility use should be considered when selecting participants. To continue the example of the obstetrics and gynecology clinic, the nurses on duty every day should each have an opportunity to contribute ideas and review the design's progress, because they will use the renovated clinic frequently. On the one hand, although more than 25,000 patients may visit the clinic each year, a manageable sample of participants could be systematically drawn from this group. Sampling patients, rather than including all of them, is preferable since it would be neither time- nor cost-effective to involve every patient in the design process, and the potential findings are not likely to differ widely within the group. On the other hand, involving only a few patients would probably not result in an accurate representation of the range of experiences, ideas, and opinions (Brunnquell et al., 1991; Walsworth-Bell, 1986).
Political power is another consideration when selecting participants. A rule of thumb is that the more powerful the individuals, the more likely they will participate in the design process anyway. Even so, it is important that these persons be sought out, because they can contribute useful information based on experience and their approval of the design is often necessary. At the same time, it is important to seek out the expertise of less-powerful user groups, such as nurses. They, too, will have important views of how the facility should be designed. Because they are often the people most directly involved in day-to-day operations, their contributions are critical to the long-term success of the project (Dewulf and van Meel, 2002; Hardesty, 1988).
When planning new or renovated facilities, it is not always possible to involve individuals who will still be there when the project is completed. People in working groups may retire or move on to other jobs. In addition, there may be some turnover within working groups over the course of the design process. There is no foolproof solution to this common problem, but it pays to be aware of it before the process begins. One approach is to involve current users with characteristics similar to those of future users. Another option is to refer to research on users in similar types of facilities.
User participation in a design project, whether small scale or large scale, requires management, either by in-house staff or consultants. These managers should be familiar with the design needs of healthcare-facility users, ways in which design decisions are made within their organization, the timing of these decisions, and the role of user information in this process. Managers should also be skilled communicators, researchers, advocates, meeting facilitators, interpreters of design graphics, and project managers (Fiedler, 1978).
A manager's biggest challenge is likely to be handling competing design needs and preferences. Users themselves may disagree, users and design decision-makers may disagree, or external constraints such as budgets or codes may make user groups' needs impossible to meet. As a result, user participants must be made aware of the often extensive negotiations that go on among the affected parties and the likelihood that users' recommendations will not always sway design decisions.
When users and design decision-makers come together in working groups, users have the opportunity to lobby for their own recommendations. They might argue from personal experience, bring in relevant literature and data, or report the consensus of their colleagues. In addition to a recommendation's objective merits, other factors may play a role in influencing a design decision, such as timing, capital and operating costs, internal politics, values, personality, personal relationships, and organizational norms (Carpman, 1983).
When users participate in design through systematic research, the results of their efforts, including their recommendations, may reach design decision-makers in meetings, presentations, reviews of documents and design graphics, and written reports, as well as in online communications. A detailed study of participation through research in a large-scale design project (the Patient and Visitor Participation Project of the University of Michigan Medical Center) indicated that multiple, face-to-face contacts between users' representatives and design decision-makers were the most effective way of influencing design decisions (Carpman, 1983). On this large-scale project, periodic design reviews were important, and written reports that documented research findings promoted credibility, but neither process was sufficient to ensure utilization. The advantage of face-to-face settings, such as meetings, is that recommendations become better understood through two-way conversations. Troublesome issues can be clarified, and recommendations can be elaborated on and reinforced using visual aids. In addition, alliances can be formed and compromises forged.
It is important to document user participation because it may be the source of many recommendations reflected in the final design. Without such documentation, important information may be lost and some aspects of the design may not function as intended. Users who were not involved in design decision-making may be curious about why certain decisions were made. Documentation also provides a record of design intentions that will be important to understand when the relationship between the facility's design and performance is assessed during post-occupancy evaluation (Facility Performance Evalvation).