FACILITIES & OPERATIONS MANAGEMENT
Healthcare Design
The need for consumer-driven research
The pivotal role of healthcare design in the improvement of healthcare delivery has become widely accepted under the rubric of evidence-based design. However, there is a need for consumer-driven, comprehensive programming methodology applicable to healthcare design projects in Asia and the United States.
Nicholas J Watkins
Director,
Research,
Cannon Design,
USA
The sheer number and magnitude of healthcare challenges in Asia offer a compelling argument for conducting research with findings applicable to the structure and design of healthcare organisations. China’s gross domestic product has grown at 8% the last 25 years, but this has not translated into improved healthcare for the 900 million Chinese living in rural areas and who largely go uninsured (Blumenthal & Hsiao, 2005). Overall, there are not enough healthcare facilities located in the right places.
Other countries in Asia fair as well. India supports privatised healthcare with 82% of all healthcare expenditure being private (Arellano, 2007). Though profitable, investing in high-tech medical equipment and cutting-edge drugs caters to Indian expatriates and foreigners who contribute to the projected US$ 1 billion “medical tourism” industry. Also, a recent study of 12 Intensive Care Units (ICUs) in India found that device-associated infections accounted for 22.5 infections per 1000 ICU days (Mehta et al., 2007).
Figure 1 : The Lawrence and Idell Weisberg Cancer Treatment Center outside
Farmington Hills, Michigan, uses several EBD principles. Private infusion bays
open to the outdoors so that treatment can occur in the gardens.
Image courtesy of Cannon Design. Many Asian countries eagerly adopt precedents from the United States to resolve their healthcare challenges. Is the United States a good role model? It ranks 37th in overall health performance when compared with 191 other countries, yet its healthcare spending is 15% of gross domestic product (World Health Organization, 2006). The United States is the primary example of how high-tech medical services have contributed to the overuse of and exorbitant cost of healthcare (Blumenthal & Hsiao, 2005). Finally, in the United States, medical errors account for 44,000 to 98,000 deaths a year (Kohn, Corrigan, & Edelson, 1999).
Evidence-based design research offers solutions
Healthcare organisations in the United States have taken strides toward improving all aspects of healthcare. The pivotal role of healthcare design in the improvement of healthcare delivery has become widely accepted under the rubric of Evidence-Based Design (EBD). Evidence-based healthcare designs, “...are used to create environments that are therapeutic, supportive of family involvement, efficient staff performance and restorative for workers under stress ” (Hamilton, 2003).
It has been argued that healthcare organisations have seen a decrease in nosocomial infection rates, medical errors, length of stay and nurse turnover by adopting basic EBD principles like private patient rooms, family zones and nurse respite areas. EBD permeates organisational structure and operations since it encourages design principles that foster a patient-centered culture. For instance, it is believed that EBD features like sub-nursing stations improve staff and patient relationships and the efficiency of healthcare delivery.
EBD’s popularity continues to rise among healthcare organisations in the United States. The American Institute of Architect’s Guidelines for Design and Construction of Health Care Facilities, 2006, stipulates the use of private rooms for med / surge and post-partum beds. Attendance at the Healthcare Design ‘06 in Chicago exceeded 2,400 healthcare executives, design professionals, product manufacturers, educators, students, and others (Center for Health Design).
Yet, EBD has not taken off at a faster rate. Why? One of the first studies credited as EBD research is Ulrich’s study of the positive impact of window views of nature on gall bladder surgery patients’ recovery time (1984). However, the study’s findings were published more than 20 years ago.
Figure 2 : The Baptist Medical Center-Heart
Hospital at Baptist in Jacksonville, Florida,
includes all-private, acuity-adaptable rooms that
can accommodate surgery, interventional
radiology, and cardiology services. Centralized,
clustered, and decentralized nursing stations
are strategically positioned throughout the
floor plan to allow for increased patient-staff
interaction without sacrificing collegiality among
staff. Image courtesy of Cannon Design.
Obstacles to evidence-based design
The below table summarises some of the challenges to EBD and EBD research in the United States. These challenges follow from a lack of goals and processes for EBD research shared by designers and EBD researchers. I will briefly explain the obstacles listed in the Table 1.
EBD research is “lost in translation” between research findings and their application to building projects. The “lost in translation” obstacle could be for a variety of reasons including little consensus over the definition of EBD, the lack of EBD research findings, and a history of EBD research that does not use proven research methodologies (Watkins & Keller, 2007).
Second, despite the growing interest in EBD research, most building projects involve a separation among researchers,
designers, clients and end consumers like patients and healthcare staff (McCormack & Shepley, 2003). As a result, end consumers have minimal or no say in design decisions.
These obstacles reflect a conflict over EBD research’s role in the United States healthcare design market and one that is evident with medical tourism in Asia. Simply put, should healthcare design be market-driven or research-driven? (Watkins & Keller, 2007) For an example of how research can influence the market, design practitioners cite studies of window views and healing gardens when promoting EBD to clients. However, these studies and their findings might be too broad for designers who need to know whether an enclosed or exterior healing garden is better for a specific facility.
Research that is entirely market-driven can forego rigour for quick and dirty research findings that might not hold water, but capture interest (Rostenberg, 2007). For example, currently there are no peer-reviewed, published findings of same-handed patient rooms. Yet, it is easy to find sources that make strong arguments for or against their use (Kong, 2007). Also, results from conjoint analyses are appealing to clients and marketers, but do not measure the impact of design since the research relies on consumer preference and is performed outside of healthcare settings.
Figure 3 : The University of Chicago Medical Center in Chicago, Illinois, usesa standardized grid allowing for the efficient planning and expansion of several hospital departments and engineering systems. RVA is the Executive Building Design Architect and Architect of Record for the University of Chicago Medical Center. Cannon Design is the Consulting Architect for Medical Facilities Planning.
Theoretical differences between designers and researchers pose an obstacle to the growth of EBD. Traditionally, researchers are taught positive theory. According to positive theory, there is an objective reality that can be tested, explained and predicted by revealing causal links (Groat & Wang, 2002). On the other hand, designers are trained with normative theory. As such, designers use facts based on intuition, convention and experience.
Positive and normative theories foster two different mindsets. Researchers want to contribute to existing knowledge, advance existing knowledge and reveal new findings. Findings should be publicly accessible for the greater good of society (Fisher, 2004; Kuo, 2002). On the other hand, designers want to make a profit from novel ideas.
Designers might prefer research methods and findings kept in-house and copyrighted as intellectual property.
Academia-industry partnerships could improve the relationship between design and research. For instance, the author’s healthcare design firm continues to support an annual healthcare design studio at the University of Illinois, Urbana-Champaign. Also, the firm’s staff includes a master’s level architecture student who assists the Director of Research with literature searches and data collection. Such partnerships assure future designers become sympathetic to research and know how to apply it.
Research could have a greater impact by including characteristics that interest designers and administrators (Kuo, 2002). For greater impact, EBD research should:
- Clearly define its audience. The audience can include hospital administrators, nurses, staff and others
- Be shared in a trusted and persuasive format such as a newsletter, at a conference, part of an exhibit or part of an instructional video
- Identify design interventions that affect the audience’s practices. These can include nursing unit configurations, nursing station types, sustainable systems, and electronic medical records (EMR)
- Prioritise design interventions. For instance, statistics might demonstrate the client would be wiser to invest in sustainable design before sub-nursing stations
Overall, research should be value-based where value is defined as the ratio of quality to cost (Evans, 2006; Porter & Teisberg, 2004). For example, staff retention can stand for quality. The expense to promote and maintain patient safety through design can stand for cost. Thus, value can be a useful and objective measurement of performance.
Table 1: Adapted from “Lost in translation:
Bridging gaps between design and evidence-based
design research,” by N.J. Watkins, and A. Keller,
manuscript submitted for publication.
Designers and EBD researchers have different standards for successful research. Designers judge research as either “good” or “bad” depending on its applicability to a project and whether it wins commissions. Researchers often judge research based on the limitations of its methods. For example, a study with a thorough literature review, large sample size, patients randomly assigned to control and experimental groups, and with a pre and post-occupancy format would get a lot of attention from EBD researchers.
Overcoming obstacles
EBD research should be integral to design process so that research findings translate into superior building projects. Under this premise, a building project becomes a value-based entity with which design practitioners maximise the client's return on investment. With this aim, EBD research should advance towards a methodology that resolves the obstacles listed in table 1 and assists with functional programming. By addressing all these obstacles, the programming methodology can be designated as comprehensive programming.
Comprehensive programming should be market-driven to reflect the healthcare organisation’s interest in attracting market share. Also, research should impact the market by advocating the needs of users (e.g., patients, staff, etc). To strike a balance, EBD research should investigate users as consumers of healthcare. Consumers make decisions on healthcare and are impacted by experiences during a hospital visit. The emphasis on consumer driven, comprehensive programming offers several advantages:
- Research and researchers assume a mediary role among designers, clients, staff and patients throughout programming.
- Theoretical differences between design practitioners and researchers are resolved
- Inferential statistics help establish causal relationships among several design features and outcomes (e.g., medical errors)
- Pre-occupancy measurements can establish a solid baseline with which to compare post-occupancy measurements
- Mixed methods using quantitative (e.g., questionnaires) and qualitative (e.g., focus groups) tactics support one another
- Research findings inform immediate and long-term solutions
Figure 4: The Tata Cancer Center in Kolkata, India,
will offer the best cancer services to all
patients regardless of socioeconomic status. The
300,000 square foot facility will house patients from
Bengal, India, Nepal, Bhutan, and Bangladesh. Ideas
for the Center include laptops for children and family
members and modular on-site housing that provide
families with temporary homes close to children
undergoing care.Image courtesy of Cannon Design.
Based on prior comprehensive programming efforts, the author’s healthcare design firm devised project-specific design solutions. These solutions considered nursing units as consolidations of several interacting design features. See Figures 2 and 3 for examples.
Currently, the author’s healthcare design firm uses aspects of comprehensive programming to evaluate infusion area designs, translational research facility designs and human interactions with sustainable systems.
Evidence-based design research in Asia
EBD-related research findings have already made an impact on healthcare design in Asia. The Alexandra Hospital in Singapore will be able to respond effectively to epidemics and disasters with thermal scans at the entry to its emergency department. Also, the hospital will dedicate two below grade floors to an autonomous treatment facility with its own mechanical and electrical system (Gifford, Green, & McCarter, 2006). Ongoing research in Taiwan of mall-like healthcare complexes demonstrates that “normalising” entire healthcare facilities attracts market share by appealing to patient’s wants without sacrificing patients’ needs (Kuo & Wang, 2007).
These and other research efforts demonstrate that Asian countries have every opportunity to achieve design solutions by performing rigorous EBD research. With the continued development of methodologies like comprehensive programming, Asian healthcare organisations can develop novel solutions tailored to healthcare market needs and the standards of research.
