Architecture and Healthcare
The glass doors slide open quietly just past the edge of your stretcher which is being rushed into the emergency bay. The fluorescent lights bathe you, burning your eyes slightly as you fight to maintain consciousness. You are wheeled past a stoic receptionist behind a tall and unremarkable counter as two ICU nurses begin to assess your condition and take notes from the EMTs who brought you in. Your family, emotionally distressed and worried for you, are herded to a cramped waiting room with old and uncomfortable furniture, all covered in the same blinding fluorescent shade and left to wait. Does this feel like a place of healing? It shouldn’t, but the frustrating reality is that this is the experience that the majority of emergency patients experience when arriving at a major hospital, a supposed place of healing. After years of experiencing the healthcare system as both a patient and a “provider” myself (Nurse coordinator, clinical volunteer, etc.), not only is this disappointing on a personal level, but also on a physiological level. As it turns out, hospitals and clinics with poor and antiquated design philosophies (read as 95% of hospitals in the United States) are actually damaging our health, lengthening recovery times, and overall hindering our healing. Not only are current design philosophies harming patients, but they are also contributing to the rising rate of physician burnout, nurse and professional dissatisfaction, as well as providing declining financial benefits.
From the harsh lighting to the whitewashed reception area and the unbearably uncomfortable furniture, many of the features of current and past hospitals seem to neglect the patient in favor of uniformity and cost reduction. For a facility that is supposedly designed first and foremost to treat patients, this standard of neglect is appalling — yet at the same time understandable given their current business model. In the status quo, hospitals are designed with one thing in mind: profit margins. Hospitals bill patients more than $3.1 trillion per year, only ~30% of which is actually received by these organizations. Of the remaining ~$897 billion that is actually paid out to hospitals, most is covered by insurance companies as well as the Medicare and Medicaid programs. Hospitals are able to bill such outrageous numbers based on the number of patients they treat, the estimated (and usually inflated) cost of each procedure, as well as compensation for operating costs. In this system, hospitals are rewarded for treating the most patients in the shortest amount of time, while also making sure that costs are as low as can be. Administrators and clinicians prioritize the most lucrative procedures over other less expensive, but often equally as important, procedures. With these restrictions considered, it doesn’t take a veteran financial mind to see how the cost reduction measures are benefitting hospital administrators financially.
As you continue to be wheeled down a narrow, eerily white, and sterile hallway deep into the heart of the hospital, you pass other patients in small cordoned off areas. Some patients cough and wretch, while others groan in need of pain medication, all separated by a thin blue curtain. You arrive at your “room” and are backed into the space as the curtains are pulled around you and your care team. You can still hear the coughing and the voices of nurses and doctors all over the floor, but you try to concentrate on your breathing, still trying to fight off waves of darkness. Eventually, you succumb to your body’s need to shut down for a while. When you awaken again, you are back in a similar place. The treatment area is slightly larger now, but the curtains still surround your bed and the attached monitors. You still hear the coughing, the moaning, the pain. One of your family members is curled into a nearly anatomically impossible position, attempting to sleep on a chair that is much too small and not nearly cushioned enough to be even remotely comfortable. A nurse walks in, tired from a long and arduous shift, but puts on a smile and tells you that she’s glad you’re up. You’re in the recovery area of the emergency department, heavily dosed on anesthetics and awaking after an emergency operating room procedure. Although you’re too tired and disoriented to think about this now, in retrospect, it seems ridiculous that your room of healing wasn’t much more than a glorified (and sterilized) tent. As mentioned earlier, this design allows hospitals to cram as many patients into an emergency room floor as possible at any given moment, you begrudgingly admit. It is also a low-cost option for most hospitals to set up, so it maximizes profits yet again. This can’t be healthy or fair to patients for that matter, right? No, it’s not.
Before we can see the benefits of a more patient-centric design philosophy quantitatively, it may benefit us to understand first what “patient-centric design” actually looks like in practice. Patient-centric hospital design includes placing a focus on patient comfort, ease of access by family, ease of care delivery, and a number of other recovery focused aspects. Hospitals designed for patients rather than for profit often include larger patient rooms, warmer colors (both in terms of wall color and in terms of lighting), more organic personnel flow between care points, among many other features (Reiling et al., 2008). Out with the piercing white light, and in with a warmer flicker- free gentle white light. Down falls the thin curtains, replaced by single patient care rooms. Rather than white and sterile walls, warm colors and artwork adorn the walls. Tall and imposing nurse stations and desks are replaced with sleek and inviting open counters with low profiles and gentle curves. Patient rooms are clustered around central nursing stations rather than aligned down a long hallway or in a labyrinthian tangle of intersections. Larger patient rooms provide ample space for family members to rest and assist in healing.
To some, it may seem illogical or irrelevant to make these design changes since maximizing efficiency is the priority of most hospitals. Research results from as early as 1975 indicated that unit efficiency within a medical care facility was more closely dependent on the design of the unit than room size, occupancy, and a number of other factors (Thompson & Goldin, 1975). In practical design and testing, we can see that clustered patient rooms reduce the number of steps a nurse or care team member has to take to service each patient, which reduces the down time in between care delivery. At the Heart Hospital in the Swedish American Health System in Rockford, Ill., an innovative cluster design for patient rooms actually reduced the distance traveled by nurses and doctors by over 50% compared to the traditional room layout (Eagle, 2014).
Other facilities take this philosophy a step further by placing imaging units, operating rooms, Cath labs, and other treatment specific resources close to certain patient rooms. Ronald Reagan UCLA Medical Center in Los Angeles, CA has created a singular facility with 23 operating rooms, 6 cardiac cath labs, and 8 imaging suites all directly connected to 60 pre-op and post-op care rooms. This reduces the amount of time required for moving through a full battery of diagnostic tests and increases downstream efficiency exponentially. Some facilities have designated patient waiting rooms while in between outpatient imaging tests, thus freeing up consultation rooms for a more rapid patient flow.
More than purely efficiency related benefits, the design and layout of a medical facility can have a profound impact on the dynamic between doctor and patient. One of the first fields in which this phenomenon was observed was Psychiatry. In psych-wards, much research has been completed on the relationship between spatial ordering and the patient-caregiver interactions that follow. Gavin Andrews, a leading geographic healthcare specialist at McMaster University, finds that specific spatial orders had targeted and unique therapeutic outcomes (Andrews, 2006), although he admits that a static order will not be perpetually effective at generating these positive patient outcomes. This means that the healing spaces of the future must incorporate an adaptability into the design, enabling a continual ‘tinkering’ of spatial order that continually maximizes patient experiences as well as efficiency. The landscape of a healthcare facility as well as that which surrounds it also directly impacts the psychology of patients as well as providers, resulting in impacts in the delivery of care as well as the body’s overall ability to heal (Curtis et al., 2016). From a purely psychological standpoint, the impact of patient-centric design is well defined.
These psychological benefits do not stand alone, however, as the impacts of innovative design philosophies extends to the physiological as well. According to Robert Wachter, MD and Chair of the Medicine Department at the UCSF School of Medicine, “Preventing infections is… the most important design feature for patient outcomes. Providing space in these rooms for families to stay comfortably also makes a difference”. The open designs of some emergency departments (as well as some longer-term care facilities) create a substantial risk of virus and infection transmission with very little recourse for containment and lockdown. With the Covid-19 pandemic only the most recent in a long line of examples of rampant infection claiming millions of lives, infection control must be a top priority of hospital designers. Single patient rooms outfitted with negative pressure systems are currently the best solutions to creating an environment safe from infection. These rooms substantially reduce infection rates and virus transmission to both patients and healthcare workers (Lateef, 2009). Designing a higher number of single patient rooms with negative pressure capabilities enables hospitals to adjust the number of isolation rooms needed at any point in time based on patient volume. This flexibility is vital to ensuring that even in unforeseen crises, the healthcare facility will always be equipped to pivot and to deliver care. The Harvard University’s T.H. Chan School of Public Health affiliated Ariadne Labs in partnership with MASS Design Group set out to test other clinical outcomes past infections at Brigham and Women’s Hospital and a number of other facilities around the United States. Looking at the number of Cesarean sections (C- sections) ordered at a variety of facilities, the Ariadne team looked compared the designs and layouts of hospitals compared to procedure rates. Data suggested that facilities with greater patient access to space had reduced number of c-sections in comparison to those with more restricted patient mobility. Certain facilities which featured outdoor walking paths, gardens, and large patient rooms showed a statistically significant decrease in the number of c-sections compared to older facilities with low walkability and tighter rooms.
The Ariadne group also looked at the presence of technology in patient rooms, the penetration of daylight into both patient rooms and provider spaces, as well as a number of other factors and found strikingly similar results (Shah, 2018). The effect of stress and psychological pressure on physiological healing is also well documented, and these open spaces and innovative hospital designs have the added effect of reducing stress and by extension improving recovery. To quantify the impact of stress on wound healing, an NIH study found that sampled mice experienced a 60% increase in wound healing after 7 days post-injury in low stress environments. In humans, the impact was slightly less pronounced but still clinically significant (Gouin & Keicolt-Glaser, 2012). Patient-centric hospital design pushes for the creation of highly tranquil areas with large windows allowing high daylight penetration opening on to calm outdoor spaces. Overall, we can clearly see that the design of a healthcare facility can have quantifiable impacts on patient’s recovery that extend past the psychological and into the physiological, improving patient outcomes and reducing recovery times.
With such strong data indicating a need for patient focused design, it is only logical to wonder why these changes haven’t been implemented on a wider scale in healthcare systems around the world. Previously, it was thought to be too expensive for existing healthcare facilities to be upgraded and redesigned while still being economically feasible. New estimates from Dennis Kaiser, the managing principal at Perkins & Will (one of the most prolific healthcare design firms in the United States) bring costs down to as low as $8 Million, which pales in comparison to the old estimates of more than $40 Million per facility (Kaiser, 2014). Additionally, there is little concrete data that can isolate hospital design as a driving factor of improved outcomes in more complex and advanced procedures. This lack of concrete data has acted as a stumbling block for a stronger push towards holistic design in healthcare spaces. Additionally, the changes require a substantial initial investment which hospital administrators have to cover before they can see the extended benefits in the long term. This issue, however, is indicative of a systemic misconception within the healthcare industry that maximizes short term and personal gain to long term health and growth. When our healthcare system is so focused on immediate benefits, we lose sight of the larger potential of long- term health and we fail to reach our immense potential to treat patients and promote healing.
Overall, I argue that we shouldn’t wait until the next time we are wheeled into a substandard emergency department or have a truly frustrating clinic visit to start fighting for patient-centric design changes in our care facilities. Without a dedicated group of people willing to stand up to hospital administrators and argue with facts and passion in favor of holistic design philosophies, we will continue to be neglected and disenfranchised as patients. Without our voices, no changes can be made, and no progress will be seen. The roadblocks are surmountable and our goal at the end of this fight is to make everyone healthier, and to make our road to healing more pleasant for all. The healthcare field as a whole has been, in recent decades, hesitant in regard to change and innovation, which is beginning to show its negative effects. Change and evolution is necessary to continue to provide cutting edge care and to improve patient outcomes on all fronts, and it is the younger generation of doctors, nurses, educators, and patients who are responsible for bringing that change.
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