Healthscape [r]evolution: using science, imagination and design to improve healthcare quality

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How science, imagination and design can be used to improve healthcare quality at healthcare facilities is shared by FRANKLIN BECKER from the College of Human Ecology at Cornell University.

In the US, daily news stories and media coverage about healthcare in America have left little doubt that the country’s healthcare system is in trouble. Somewhere between 50,000 and 98,000 patients die each year from medical errors, 20 to 50 percent of surgeries are unnecessary, and there are 7000 deaths annually from medication errors alone, in or out of hospital. These are dismal statistics. Something needs to be done.
As is true of any ecological system comprising a dense web of interdependent factors, one can break into the system and intervene at any point in an attempt to shift its direction, disrupt its current trajectory and improve its performance.
Here, I want to explore how just one segment of a healthcare system, hospital or any other facility in which healthcare is delivered can be physically redesigned to transform the quality of healthcare. For policy experts and financial analysts this may seem like trying to extinguish a forest fire with a glass of water, but US$20 to 30 billion a year are being invested in new hospital design and major renovations. That’s not pocket change. This is being done because a burgeoning body of research is telling us that new approaches to designing hospitals can help reduce medical errors and near misses, enable healthcare providers to work more safely and effectively, and make the patient and family experience during their hospital journey more positive and rewarding.

We are, in fact, in the midst of a [r]evolution in how we plan and design hospitals. Some of the changes occurring are small and are more a refinement or small fix of the existing system, such as using new antimicrobial finishes and materials or providing more readily accessible washbasins that help reduce infection. Other changes are paradigm busting, such as viewing the hospital as a community health and wellness centre – a place that not only treats the sick, but also seeks to promote health and well-being, for instance by growing some of its own food and showing children and their parents how to prepare this fresh food in a demonstration kitchen. As important as evidence is in helping guide us to make better facility decisions, equally critical is imagination. Knowing how to put evidence to good use is also vital. Evidence and imagination are the flip sides of the quality improvement facility coin.
The commitment to using evidence to inform design decisions is part of a growing movement called evidence-based design (EBD). EBD has been defined as “a process for the conscientious, explicit and judicious use of current best evidence from research and practice in making critical decisions, together with an informed client, about the design of each individual and unique project” (Stichler and Hamilton, 2008, page 3). The fundamental premise is straightforward: better-designed solutions, ones that are more likely to support valued outcomes, will result from using the evidence generated by high quality, formalised and rigorous research processes.
The EBD movement has existed for some time in practice, if not in name. Predecessors include military and industrial studies of human factors and ergonomics and the work in small group ecology that helped spawn the field of environmental psychology and post-occupancy evaluation (POE).
The term EBD itself comes from a parallel development in medicine called evidence-based medicine. Evidence-based medicine is defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Hanes and Richardson, 1996, page 71). It makes sense. Who wants to base decisions with serious financial and health consequences on personal whim, fashion or preference?

The concept is spot on. The reality is, however, that the amount of research available, while growing exponentially, remains limited. A recent review of the evidence guiding decisions about appropriate flooring in hospitals illustrates the point. In a thorough 42-page review of the published research literature on flooring intended for healthcare designers and practitioners, the paper identified eight EBD goals related to flooring. These ranged from reducing slips, trips and falls to noise levels and improving the patient experience. For each goal, the paper marshalled the research evidence.
Overall, the studies are very good and quite rigorous, and terms are clearly defined. For example, slip resistance is “defined by the coefficient of friction (COF), which relates to the ratio of normal force holding two materials together and the maximum force necessary in shear to reduce sliding”.
At the end of each section, the authors summarise key design factors based on the evidence that, for example, help reduce trips and falls. For instance, slips and falls are likely to be reduced when “contrast in flooring patterns is low” and “exposed edges of carpet are fastened to floor surfaces”. But, such seemingly clear guidelines based on good research are more complicated in practice.
The final line of each of the summary design sections concludes that the “overall level of evidence linking flooring properties to” slips, falls, fatigue and the like is “low”. The gap between the apparently solid research and complexity of interpreting the research in the form of specific design guidelines is the practitioner’s dilemma.
While the research focuses on specific environmental factors, how it works in practice depends on other system characteristics such as maintenance and cleaning, user characteristics and location within the facility. A design feature that is good for one thing, like a hard surface for ease of cleaning, may be bad for something else, like fatigue or falls.
What can practitioners do in the face of published evidence that always needs to be interpreted and filtered and adopted for implementation in their own specific facility? They can supplement the published research that provides general direction by conducting their own small, fast studies that provide insight grounded in empirical data relevant to their own context and organisation. I call this form of inquiry practice-based research.

Rigorous academic-based research that appears in a peer-reviewed academic journal can take three to four years from inception to publication. Practitioners cannot wait that long for just one study that may or may not be directly relevant to their own organisation and specific project.
Practice-based research typically takes a few months and is organisation specific. It lacks the scope, rigor and long time-frame reflected in academic-based research’s larger sample sizes and more sophisticated research designs and statistical analysis. It makes up for these limitations, however, in speed and organisational relevance. They complement each other.
Practice-based research takes many forms. The neonatologist in my local hospital conducted a study over a six-month period that identified design and technological factors that dangerously increased the time from when a baby with a serious health problem was born until they underwent surgical treatment.
The national standard for safe care for these conditions was 30 minutes from ‘inception to incision’. It was taking, in some cases, 38 minutes. By doing a ‘lean process’ study, in which every step of the journey and process was thoroughly mapped and timed, and the roadblocks along the way identified and removed, the time was cut to 18 minutes. Babies’ lives were saved.
This study’s sample size would not warrant publication in a peer-reviewed journal, but it made all the difference for a specific hospital and it was based on evidence, not estimates, personal experience or preference. The results were then fed forward into the design of a new neonatal facility currently being designed.

Evidence from academic and practice-based research can lead to more informed design decisions and higher performance. Many of the improvements range from quick fixes and continual refinement to significant changes in practice, such as the move from multi-bed patient rooms to single occupancy rooms. Occasionally, however, changes are paradigm-busting. Here, the role of evidence is not so much to justify a decision as to stimulate the imagination. Consider the Henry Ford West Bloomfield Hospital just outside Detroit and its chief executive officer (CEO), Gerhard Grinsveld.
The paradigm busting started when the CEO of the whole hospital system within which West Bloomfield resides hired Grinsveld as the CEO for a new hospital still in the planning stages. He was a senior executive from the Ritz Carlton hotel chain with zero experience or knowledge of healthcare. He was hired because of Ritz Carlton’s highly regarded customer focus. The goal was to bring that customer/patient focus to the hospital.
Grinsveld did that in a way no one could have anticipated. He started by collecting his own ‘evidence’. He realised he knew almost nothing about the African-American, Iranian and Jewish populations the hospital served. His staff suggested doing focus groups. Instead, he called people in the neighbourhoods surrounding the hospital and asked if he could make dinner and bring it to their house and talk. He knew he would get a much deeper understanding – better evidence – from personal visits.
With insights gained, he paid attention to making the hospital environment more welcoming and the rooms more home-like and comfortable. Many hospitals are doing that. What they are not doing is creating a hospital where members of the surrounding community come to have lunch at the hospital, not because they are sick or visiting a patient, but because the food is good and affordable, and the café environment inviting.
Rather than focusing on the hospital as a centre for caring for the sick, Grinsveld is transforming the hospital into a wellness centre for the community. The surrounding neighbourhoods are filled with children who are obese as fast food is the norm. They are not sick, yet. Few hospitals build greenhouses and test kitchens, and then invite busloads of children and their parents to visit them to see where vegetables are grown and to learn how to prepare food that tastes good and helps combat obesity.
These design intervention weren’t based on a ‘coolness’ factor or fad and fashion. Evidence about obesity, health and nutrition, as well as anthropology and sociology, were critical. At Henry Ford, however, all the evidence, including that from formal EBD studies and its own internal studies and projects, is fuelled by imagination and a deep vision of a larger role for a hospital in its community than treating those whose health has already declined.
Evidence is critical. More is needed and the published research literature needs to be complemented by practice-based research. Evidence by itself cannot drive game-changing innovation. Game-changing innovation takes people with imagination to interpret and apply that evidence in ways that fix small problems and invent new realities.

Franklin Becker, PhD, is professor of Human-Environment Relations and Facilities Planning and Management, and director of the International Workplace Studies Program in the College of Human Ecology at Cornell University. This article is based on a forthcoming book of the same title by Franklin Becker and Ziqi Wu.

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