Estimated reading time: 10 minutes
Monika Smith, IIDA, RID, NCIDQ, has led Apex’s Design phase since founding the firm’s interior design department in 2014. She touches 100% of Apex’s healthcare projects during programming and schematic design, splitting her time between direct client work and collaboration with the internal team. She’s regularly in the room for early rough-order-of-magnitude budgeting discussions, informing the numbers that Apex’s preconstruction team ultimately owns. Her organizing philosophy, “function before form,” means every design conversation starts with code compliance, staff flow, and patient flow before a single aesthetic decision gets made. In this conversation, she talks through the most common friction point she sees, the code detail that surprises even experienced physicians, and how her background shapes the way she designs for patient privacy.
What’s the pattern of friction you see most often before a project even starts?
Monika: “One thing that comes to mind is budget. If they come with a preconceived idea about how much a project should cost, and that thought is based on something they heard from a friend who did a build-out 12 years ago, or five years before COVID, that’s always a bit of a hurdle in the beginning of the project, just getting everyone to play in the same universe.
Smaller hurdles are things like a client coming with a vision that’s already set in stone, especially with ground-up building design, but it doesn’t fit on their site or the flow doesn’t work inside the building they’re purchasing. Usually we can work around that pretty easily and explain why. It’s just not fun to dash somebody’s dream.”
How do you handle that conversation without just telling a client no?
Monika: “I always like to understand the why, and that’s why I explain it with a why. We never come with just the problem, like ‘no, we can’t do this.’ It’s always, ‘that’s a great idea and I love it, but because of X, Y, and Z, we’ll have to pivot a little bit, and let me explain why.’ I always come with solutions, more solutions than problems. Most of the time we come out the other end with something even better.
For example, we sometimes have clients arrive with an ambitious, multi-use vision, a practice combined with additional retail or residential space that goes well beyond what their budget can actually support.
We’re not telling them no. We’re saying, that sounds exciting, but let’s work backwards from your budget. Maybe we start with a smaller footprint now, and you add on in a few years once business is going well. Let’s make a project happen, not just a dream, because if the budget isn’t there, nothing will happen at all.”
What does “function before form” actually mean in a design meeting?
Monika: “We always break early design meetings into two parts: function and form. Function means anything I show a client layout-wise has to adhere to all the codes, local, national, and healthcare-specific. Then we look at flow: staff flow, patient flow, instrument flow. How do instruments get in and out of an OR? What path are they taking, what other path are they crossing? We also look at the site in relation to the interior, like where patients exit and how they’re picked up, because we want patients to have a private exit after surgery. They might not look or feel their best, and we don’t want them crossing paths with someone who’s just arriving for their own procedure.
Then we have a separate conversation about aesthetics: how do you want patients to feel, how do you want staff to feel, and how much are you allocating toward the staff experience. That last one is where the dollars quite often run out.”
Staff spaces losing budget priority sounds like a recurring theme. How often does that surprise clients?
Monika: “It depends. I think the younger generation of practice owners sees it a little more, maybe because they’ve been an associate doctor themselves, so they understand the retention piece better. Some of the more senior doctors treat it as their “last hurrah” project and brush it off a bit more.
At the end of the day, they pay the bills and we take the direction, but we try to educate people. If you’re trying to hire an associate, someone who might take over your practice one day, giving them a private office with a window could be what attracts them to your practice over the one down the street. It’s a little bit of longevity planning.”
Is there a code requirement that reshapes designs more than clients expect?
Monika: “Corridor widths, especially in ASCs, are very much dictated by code. Certain corridors have to be a minimum of four feet, then six feet, then eight feet, depending on what they lead to and from. A doctor might have worked in an ASC or a hospital for years and still not understand this, because knowing the space doesn’t mean you understand the code behind it.
People are often surprised that circulation space in an ambulatory surgery center can easily be 30 to 35% of the total square footage needed, compared to about 25% for a standard medical office. I’ve had doctors come to me with a list: ‘I need a treatment room, 120 square feet, and I need eight of those.’ They’ve calculated the rooms, but they haven’t accounted for the circulation space to actually get to those rooms. That adds up fast.”
Is there ever a point where aesthetics have to lead instead of function?
Monika: “Not so much lead, but there’s one place where they have to be designed simultaneously: the exterior of a ground-up building. Doctors don’t always realize that you can’t just design all the interior rooms and then plop a window into each one, because you’ll end up with windows scattered across the facade with random spacing between them, since each room is a different size.
Sometimes you have to sacrifice a little bit of interior function for the sake of the building looking cohesive as a piece of architecture. That can mean the interior ends up with a wall jog here or there because the window isn’t exactly centered in the room. It’s a small compromise, but it’s a real one.”
What’s a moment where being in the room early changed a project’s budget or design before it became a problem?
Monika: “We talk about budget early and often. It’s not a taboo subject. Usually in the first meeting, we either educate the client or ask what numbers they’ve already heard in the field, and business development helps establish a baseline in the room.
If a client brings inspiration images or a Pinterest board that’s not in the same universe as their budget, we can say, that’s fantastic, but if your budget is a fixed number, let’s look at how we get a similar look for less. Maybe we enhance one moment, like the main lobby, and simplify the finishes everywhere else. Our designers come up with creative alternatives: a painted treatment instead of stone, a textured wall covering played up with lighting instead of a custom 3D concrete panel.
We also use a wishlist system. During design development, ideas come up that are a little above the baseline budget. Rather than just saying no, we break those out as optional line items, and our preconstruction team attaches a real dollar amount to each one. If a client wants a fireplace with a stone wall in the waiting room, we tell them what that actually costs, and they get to choose. It gives them a sense of control. They’re not locked into every upgrade, but they’re not locked out of them either.”
Your background includes international design work. What does that perspective bring to U.S. healthcare design?
Monika: “I grew up in Germany, and I’m still very influenced by the scale and history of European architecture, partly because I travel there often with my family and I still talk regularly with designer friends back home.
One example: waiting rooms. In Europe, when you walk into a clinic, you check in with the receptionist, but you’re not standing in the waiting room while you do it. The waiting room is walled off, usually with glass, so there’s privacy between the person checking in and the people already waiting. In the U.S., you’re often checking in right in front of everyone else waiting, saying out loud why you’re there, while people are also taking calls about insurance claims in the same space. Everyone talks about HIPAA, but I don’t think people always realize how much that open layout works against it. Bringing that European privacy model to U.S. clients is often a genuine ‘aha’ moment for them.”
You started Apex’s interior design department in 2014. What’s different about how you approach a project now versus then?
Monika: “I have a much greater support team now. When I started, I came from a global design firm where every office had different standards, some used CAD, some used Revit, there was very little consistency. So when I got to Apex, I made sure we standardized on Revit from day one, a 3D modeling platform where architects, designers, and engineers all work in the same file. As the team grew, every person we added brought different experience, and that made the whole team better with each addition.
What I had to unlearn was letting go. In the beginning, when the team was just me, I was closely involved in every detail of every project. Now, once a client is engaged, I assign the project to the team and I let go. That was harder early on. You fall in love with every project and want control over everything. Learning to trust the team to carry it forward was the real shift.”
What’s a recent project where function-first thinking told a story form alone couldn’t have told?
Monika: “We’ve had clients come to us wanting a small, hospital-mindset facility, and they’re hesitant to go the ASC route because they’re worried about the code differences. One solution we can offer is designing the space to comply with both hospital and ASC codes simultaneously, so when they’re ready to switch from a hospital model to an ASC model, they’re already covered code-wise.
Another example: we’re working on a smaller historic building in Chicago for a plastic and facial surgeon opening an office-based surgery center. She doesn’t occupy the whole building, there are other tenants, but we’re not just designing for her current footprint. We’re also building a master plan for how the building could serve her as a wellness center down the line, with a second floor that converts into conferencing and admin space. It’s not just a project for now, it’s planning for how that building serves her business over the next ten years, not just the next two.”
Do you apply that same longevity thinking to finishes and aesthetics, not just function?
Monika: “Absolutely. Our baseline standards are durable and healthcare-approved, but sometimes we’re honest with a client: this is a good choice for the next five years, and if your budget only allows for that now, know that you’ll likely want to upgrade once the practice is doing better.
The office furniture package is a good example. If you go commercial grade, you get 20 to 25 years of use, but that might run $100,000. A lot of practices only have $10,000 budgeted for that. So we educate them: you can go to a retailer and get something that lasts three to five years instead, and there are also residential-contract lines, like West Elm’s contract furniture, that split the difference. Same logic applies to flooring: luxury vinyl tile in a bathroom might last five to ten years, while real porcelain tile lasts far longer with less maintenance. It comes down to being honest about the tradeoff, not just specifying the most expensive option by default.”
FAQ
Budget misalignment. Clients often arrive with cost expectations based on outdated references, such as a friend’s build-out from years earlier or pre-COVID pricing.
Design meetings are split into two parts. Function covers code compliance, staff flow, patient flow, and instrument flow. Aesthetics, including patient experience, staff experience, and finish selection, are addressed separately, after function is resolved.
Roughly 30 to 35%, compared to about 25% for a standard medical office, a detail clients frequently underestimate when calculating their space needs.
Ideas above the baseline budget are broken out as optional line items with real dollar amounts attached by the preconstruction team, giving clients the choice to selectively upgrade rather than an all-or-nothing decision.
About Monika Smith, IIDA, RID, NCIDQ
Monika Smith is Principal of Strategy and Design at Apex Design Build, where she has led the Design phase of every Apex healthcare project since founding the firm’s interior design department in 2014. Her approach, function before form, prioritizes code compliance and operational flow before aesthetic decisions, informed by an international design background shaped by growing up in Germany.
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