Design and Health World Health Design

Inquiry: Crunch time

As the global economic crisis deepens, three leading experts assess the impact on investment in health and public infrastructures around the world in 2009.

Eve A Edelstein, MArch, PhD (Neurosci) is senior vice president of research & design at HMC Architects and a visiting scholar at the University of California, San Diego

Medicine is a constantly changing field informed by research and measurable outcomes. However, today’s ominous economic changes threaten to undermine worldwide progress towards improved healthcare. Restricted funds may jeopardise mandated changes in healthcare facilities, and improvement of clinical staff to patient ratios.

As the global economy struggles so does investment in building improvements, capital projects, research and design. The timing of this economic upheaval may play to our advantage if we clarify our focus on demonstrating measurable outcomes from design improvements.

Now, both design and healthcare communities have the opportunity to reflect on design trends developed in more abundant economic times. Healthcare executives have begun to ask: “How can I justify additional design costs when I am struggling to meet equipment and staff costs? What are the benefits and consequences of ‘super-sizing’ hospitals? What is the value of an atrium? How will the proposed design function if electricity or technology fails?”

We must advance the means and methods to answer such questions.  This economic constraint on healthcare design occurs just as the field of evidence-based design has achieved an important goal. Efforts have attracted the attention of a number of leaders who now understand that the built environment can have a direct and measurable impact on the quality of care. Concurrently, researchers have begun to apply more rigorous methods that reflect scientific methodologies held in high regard by physicians, nurses and executives.

Emerging and novel technologies may also offer savings in both research and design. Virtual reality and micro technologies now enable us to measure the response to design before the first brick is laid. Sustainable methods provide the means to lessen costs by reducing energy consumption, and at the same time enhance human health and improve function.

The correlation of design features with economic, health, and market outcomes is now critical if we are to demonstrate a return on investment in better healthcare environments. To assert such claims, we must commit to an architectural process that allocates more time to build a deeper knowledge of the constantly changing world of healthcare. Success could be measured in terms of the reduction in change orders achieved by in-depth planning.

As the constantly changing field of medicine responds to new research, designers must in turn respond to the ever-changing needs of their clients. The achievements of the evidence-based design movement is driving healthcare providers to share their world with the design community.

With a solid base in research, we can take advantage of an economic lull in building, by increasing our knowledge of clients’ needs and the value of the research-based design solutions we can offer.

Debajyoti Pati, PhD, FIIA, Clinical Solutions & Research Group, HKS

The global financial meltdown has raised questions on the sustenance of evidence-based design (EBD) and research. When the healthcare industry was riding on the wave of an unprecedented investment in new and replacement facilities, EBD quickly emerged as the preferred design paradigm for many. With project funds shrinking, can evidence-based design and research be sustained?

A more pertinent question concerns relevance. How will the new investment climate impact on the relevance of the EBD approach? In my opinion, EBD will only increase in value. A key driver will be the increasing concern for patient safety.

In 2008, the Center for Medicare & Medicaid Services (CMS) introduced an unparalleled condition in the reimbursement system for healthcare providers in the US. Costs pertaining to several types of hospital-acquired infections and medical errors (including treatment, legal and other costs) will not be reimbursed in a new pay-for-performance logic. That means that healthcare providers will bear the burden of several harmful outcomes resulting from either unsafe practices or the physical design – or both. Among others, the safety issue will be the fuel that propels research into physical design and cultural factors in healthcare design.

Healthcare systems and other stakeholders recognise the importance of understanding the implications of design on safety to optimise the physical environment. For instance, among the continuing and upcoming HKS research projects, four focus on safety issues. These studies involve major healthcare systems such as Texas Health Resources, INTEGRIS Baptist Medical Center and Trinity Health. Collaborators include leading academic and research entities including The University of Texas’ Arlington School of Nursing and Texas Health Resources’ Research and Education Institute. Industry players, like Herman Miller, are also actively contributing to these studies.

A shrinking financial climate will only increase the necessity for research focused on the physical design as well as organisational culture. Specifically, since safety is not a binary concept but a function of the degree of risk a particular culture is willing to take, a major impetus to healthcare research will be a matter of necessity. Evidence to help optimise capital investment for the desired degree of risk will constitute one of the most sought-after items of information.

Patient safety is a global problem, meaning that the relevance of EBD research will grow worldwide. However, it will be more prominent in the US due to the reimbursement climate. Evidence-based design has been viewed in different ways by different people, but the fundamental characteristic underlying all definitions is the use of the best available evidence to support a design decision. Developing the best evidence base will increase in importance when project funds are limited – allowing healthcare providers to make the best use of funds in pursuit of a safe and responsive healthcare environment.

Alistair Cory, principal, NBBJ London

The deepening economic crisis will not necessarily create barriers to the delivery of effective healthcare design and associated research in 2009, but I would predict a distinct refocusing of priorities. The overarching emphasis will not change dramatically – it has always been an imperative of healthcare design to do more with less, to deliver tangible performance improvements within tight budgets, particularly on public projects.

This emphasis may have intensified, but it need not limit the quality or scope of healthcare design in the coming year. True, the global nature of the recession will eliminate many opportunities for lavish experimentation – in the Gulf, for example – but prudence will breed its own distinct form of innovation.

Health providers will refocus on preserving and improving existing estates. We will learn to extract the very best functionality and performance from existing facilities through intelligent retrofitting, modifying and adapting, not only saving money, but improving long-term sustainability in the process.

Against a backdrop of volatile energy supply and prices, designers will need to collaborate more closely with engineers to continually improve the energy efficiency of their buildings. These lessons learnt in striving to do more with less will not be forgotten as the economic frosts thaw – indeed, the bar will have been raised for the future.

Finally, I expect a shift in procurement towards processes that encourage health providers and development consortia to work in closely collaborating partnerships. This will hopefully not require the invention of new processes, but will rather entail a shift in favour of those that avoid stifling bureaucracy and put the focus on delivering genuine change – enhanced performance, improved environments and better healthcare outcomes.


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