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Did Architects Really Ruin Healthcare?

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Want to raise the ire of healthcare architects worldwide? Then publish an opinion piece titled “How architects ruined healthcare” on Toronto’s The Globe and Mail newspaper website. Judging from my colleagues’ responses on social media, this piece really hit a nerve and, I felt, deserved a response.

The author Dr. Joshua Landy, a Canadian critical care physician, blames a host of healthcare industry issues on how architects design hospitals. He decries that “a well-intentioned effort to make things better for patients (i.e. a patient-centered approach) ended up making them worse for everyone.” His epiphany: The paper “Building patient-centeredness: Hospital design as an interpretive act,” published Sept. 1, 2012 by Dr. Elizabeth Bromley, a UCLA medical anthropologist and psychiatrist, in Social Science & Medicine. Because Dr. Landy draws his conclusions from this paper, I decided to read the source myself.

In the paper, which studies one unidentified hospital completed in 2008, Bromley notes, “Hospital designs reflect the sociocultural, economic, professional, and aesthetic priorities prevalent at a given time” acknowledging, where Dr. Landy does not, how the architect responds to the needs of their hospital client in a given time and place.

This particular hospital administration chose to hyper-prioritize
patient-centeredness through the “Disney Effect” of all clinical spaces being
off-stage. The hospital emphasized a concierge approach to patients and
scripted communication like the hotel industry. Unfortunately, this one-sided
approach located staff spaces remote from patients and didn’t provide enough
conference rooms and staff lounge space. The study didn’t include if patient
experience or clinical outcomes improved in the process.

Citing this one 10-year-old study, Dr. Landy states in his op-ed that “Modern hospitals are specifically designed to eliminate collegiality.” It’s true that many projects do prioritize patient space over staff support when economics drive a Lean approach, but I don’t know of any projects that intentionally sought to reduce clinician interaction.

Instead, I see today’s healthcare designers and clients seeking a more balanced, research-based approach, recognizing patient-centered care means bringing caregivers closer to patients and that supporting a team-based approach is the future of healthcare—something I hope Dr. Landy will  recognize. (For more on workplace design in healthcare, read “Workplace Meets Healthcare: Mix & Match,” or check out Healthcare Design’s June/July issue.)

Another troubling assertion from Dr. Landy is that “healthcare that does not look like healthcare is not healthcare—it is a sort of theatre created to distract an audience of anxious patients. It doesn’t serve their interests.” He doesn’t say what healthcare shouldlook like, but he doesn’t value “muted pastels, potted plants, and plenty of places for patients and families to occupy themselves.” Apparently, Dr. Landy isn’t familiar with the studies that have shown the healing effect of nature, positive distractions, and family support in reducing patient pain and anxiety, which ultimately could improve patients’ medical conditions.

One intriguing issue I found is his op-ed was the comment that physically hiding the “messy part” of healthcare devalues medical professionals. Bromley’s studies also indicate that in a consumer-driven environment, clinicians can feel their technical skills are unappreciated, especially when behind closed doors. Nurses especially felt marginalized because much of their work was behind the scenes and not visible to patients. I agree this is worth further study. Most patients are accepting of staff, equipment, and technology in view, if the environment feels organized and competent. On the other hand, a hotel-like aesthetic can create dichotomy with these necessary elements causing incongruity instead of harmony.

Understanding staff psychology is an important factor in hospital design, especially as their own health and well-being is threatened. Longer hours, increased documentation requirements, and the stress of ever more medically complex patients are contributing to staff burnout. Despite Dr. Landy’s strident tone, as healthcare designers we need to listen to and unbundle the concerns of all constituents, especially as medicine transforms.

Finally, Dr. Landy asks, “Is this place built to make us healthy—or to distract us from thinking about our health?” I don’t believe the two are mutually exclusive. People, process, and place must all support care delivery, the patient’s recovery and emotional well-being, and family involvement in a balanced approach. Dr. Landy’s op-ed does disservice to the dedicated healthcare designers who work tirelessly to meet these goals.

Sheila Cahnman, FAIA, FACHA, LEED AP, is president, JumpGarden Consulting, LLC. She can be reached at sheila@jumpgardenllc.com.

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