Generative Space

Creating sustainable improvements

Annette Ridenour

Annette Ridenour

More about Author

Annette Ridenou is founder and president of Aesthetics, Inc., a multidisciplinary design firm creating healing environments since 1980. Annette is an internationally recognised specialist in interior design, wayfinding, arts and music for healthcare, and is a highly sought after consultant and lecturer. She is currently authoring books on wayfinding and evidence-based arts programs.

Wayne Ruga

Wayne Ruga

More about Author

Wayne Ruga founded The CARITAS Project in 1999 for the purpose of 'pioneering the next generation of resources to improve health and healthcare with design of the environment'. He is a US registered architect and a Loeb Fellow at Harvard University.

The Leading by Design research project is working with 11 case studies in three countries to operationalise generative space as a means to use the environment to make systemic and sustainable improvements in healthcare.

The CARITAS Project was launched in 1999 by Dr Wayne Ruga, who had also founded the annual Symposium on Healthcare Design and The Center for Health Design. The purpose of The CARITAS Project is to pioneer the development of the next generation of resources to systemically and sustainably improve health and healthcare delivery with design of the environment.

The Leading by Design research project is the third project that The CARITAS Project has initiated. Now on the verge of beginning its fifth year, Leading by Design is actively working with 11 individuals in three countries to demonstrate the tangible benefits that 'generative space' (see definition below) can offer to improve healthcare as a whole.

Each one of these 11 Leading by Design individual participants represents a different set of stakeholders within the healthcare industry. All the

Leading by Design participants represent non-competing stakeholder organisations. They holds a senior-level executive positions within their respective organisations, and several of these organisations are large multi national companies.

Research context

Leading by Design is an applied research project that is based on an action research methodology with an integral reflexive practice. It uses a case study format and conventional qualitative research methods to produce its evidence. he methods include: personal interviews diary writing and focus group meetings.

Leading by Design is based upon original research that was conducted by Dr Ruga as a four-year pilot study, funded by the UK government. The second stage of this research, currently in progress, involves the on going field-testing of these initial findings across a much larger industry-wide stakeholder group and geographical area.

Practical application

Leading by Design is a learning process that supports each participant in actively exercising 'health design leadership'. It is through this exercise that participants develop increasing mastery at cultivating 'generative space'.

The purpose of the 22 themes in the learning process is to enable deep personal learning in the ability to cultivate 'generative space', which can be measured and documented as a performance- effectiveness improvement strategy to make sustained improvements in health and healthcare with design of the environment.

The individual participant works closely with Dr Ruga to learn this process and then applies it to the contextual situations that are unique to his / her own respective situation. This practical personal approach, linked with the action research methodology and the reflexive practice, provides the real-world opportunity for the participants to practice the cultivation of 'generative space' in situations that can make sustainable improvements in health and healthcare.

Case Study: Annette Ridenour, President, Aesthetics

At Aesthetics, Inc., the company I founded in 1980, our 35-person interdisciplinary team leads interior architectural design programmes, creates way finding systems, assists with regional arts programmes, co-designs healing gardens, and provides a number of other arts-related services to healthcare institutions.

I attended the first CARITAS Leadership Summit, convened by Dr Wayne Ruga, I arrived with many questions and left with even more. What makes a healing environment? What is required to permit us to work harmoniously and with genuine collaboration across design disciplines and throughout the construction process? What will sustain a positive, healing vision for healthcare design in general and for my company in particular? The answers to those and many other questions lay in Dr Ruga's profound concept of generative space, I was sure. In 2003, I agreed to join Leading by Design and to make my life and practice an action-learning research project on how to create generative space.

I decided that if I was going to help others create generative space, I ought to start in my own backyard. I carried out a survey in my company, Aesthetics and was surprised to note that my staff were not nearly as satisfied as I thought they would be.

With guidance from

Dr Ruga, I turned over the resolution of many of the issues raised by staff to a task force led by an executive who was very vocal about the incongruence at Aesthetics.

As a result, we are now a much more aligned staff, focussing on learning how to deliver generative space to our clients. We have made exciting progress on several major projects, one of which, at the Atlantic City campus of AtlantiCare Regional Medical Center, I will briefly describe here.

AtlantiCare's hundred-year-old campus was tired and in need of an upgrade. The administration wanted the best of evidence-based patient-centric care, it wanted a technologically sophisticated medical centre, and it wanted to reinvigorate its relationship with the diverse community around it.

Asked to be involved from the beginning, we began our work of cultivating generative space throughout the institution by our guiding collaborative visioning sessions to capture everyone's aspirations. To keep those aspirations as focal points of the redesign work, a Partnership Agreement was created, expressing not only the key goals but also a set of communication guidelines to honour a commitment to hear and respect all members of the team.

We helped institute a process through which community members, using guidelines jointly created with AtlantiCare staff, selected and acquired all of the more than 500 original works by local artists that are displayed at the facility. A 400-foot display was installed to communicate the organisation's values, which also were reflected in the wayfinding design and in the building and pavilion names: Harmony, Heritage, Wellness, Friendship and Community.

A particular example of how an open-minded administration used design to engage with the community in a generative and sustainably lasting way occurred when leaders from all the area's faith communities were invited to oversee the design of the medical center's chapel. The physical outcome of that involvement is a beautiful, functional chapel design that serves all religions with respect. The larger outcomes for AtlantiCare have included a greater understanding of faith-based perspectives on healing and a deeper relationship with an influential group of community leaders to whom AtlantiCare can turn for advice on a wide range of topics.


Sustainability only occurs when you bring along people who have similar philosophies, train them, provide them with resources, and trust them to do the right thing-that is, when you empower them. This requires balancing feelings of vulnerability with the enormous value that comes from growing people and giving away power responsibly.

Leading by Design is a bold experiment. Now, almost eight years into its development, it is beginning to provide documentation of sustained improvements that reflect the robust character of the 22 thematic findings that are embedded in its unique learning process.