Can good design help heal sick people? In the US, the University Medical Center of Princeton, New Jersey, realised several years ago that it had outgrown its old home and needed a new one. So the management decided to design a mock patient room.
Medical staff and patients were surveyed. Nurses and doctors spent months moving Post-it notes around a model room set up in the old hospital. It was for one patient, with a big foldout sofa for guests, a view, a novel drug dispensary and a bathroom positioned just so.
Equipment was installed, possible situations rehearsed. Then real patients were moved in from the surgical unit – after having had, mostly, hip and knee replacements – to compare old and new rooms.
After months of testing, patients in the model room rated food and nursing care higher than patients in the old rooms did, although the meals and care were the same.
But the real eye-opener was this: patients also asked for 30 per cent less pain medication. Reduced pain has a cascade effect, hastening recovery and rehabilitation, leading to shorter stays and diminishing not just costs but the chances for accidents and infections.
When the new $523 million (€397 million), 636,000sq ft hospital on a leafy campus opened in 2012, the model room became real.
Patient satisfaction
So far, ratings of patient satisfaction are in the 99th percentile, up from the 61st percentile before the move. Infection rates and the number of accidents have never been lower.
Often ignored by front-rank architects, left to corporate specialists who churn out too many heartless buildings, hospitals are a critical frontier for design.
A British charity for cancer care, Maggie's Centres, has taken one approach, enlisting a Who's Who of stars such as Rem Koolhaas, Frank Gehry, Snohetta and Norman Foster to devise bespoke facilities.
In Brazil, the architect and urbanist Joao Filgueiras Lima, known as Lelé (who died in May, at 82) devoted his final years to a remarkable series of rehabilitation hospitals: simple, airy and visually arresting.
But maybe most interestingly, some young design firms are getting in on the act.
Not long ago, Mass Design Group in Boston made headlines with a hospital in Rwanda – "Way too cool to be a hospital," the Atlantic cooed – that provoked some debate in professional circles about whether socially concerned design can also be inspiring architecture.
In many ways, this is the central argument in architecture today, with a new generation more attuned to issues of social responsibility and public welfare. The discussion has posed a larger, fundamental question about the role of architects, and to what extent they can or should be held responsible for how buildings work.
At Princeton, the goal of the new hospital was not to devise a visual landmark off Route 1 in New Jersey. The building is a dull, curved glass block facing a car park. The ambition was inside, in the remodelled patient room.
Several hundred decisions, major and minuscule, commonsensical and arcane, went into configuring the room. Many of them may sound so obvious that one can wonder, financial and real estate constraints aside, why they haven’t always been standard.
For starters, the rooms are singles; there are no double rooms. Research shows that patients who share rooms provide doctors with less critical information (and even less, if the other patient has guests). Ample space is given to visitors because the presence of family and friends has been shown to hasten recovery. Rooms also benefit from views and natural light.
There are also some fine points to the Princeton plan, such as a sink positioned in plain sight, so nurses and doctors will be sure to wash their hands and patients can watch them do so.
A second sink is in the bathroom, which is next to the bed, with a handrail linking bed and bathroom so patients don’t have to travel far and will fall less often.
A luxury of building from scratch is that the rooms can all be “same-handed”. In many hospitals, adjacent rooms are “mirrored” because they share a head wall: the one behind the bed with all the equipment and attachments in it.
Mirror rooms are cheaper and take up less space, but they require that everything – the position of the bed, the IV tubes, the call buttons – be reversed, right to left or left to right, from room to room, increasing the chance that nurses and doctors will make mistakes when they reach for buttons or equipment.
Patient approval
While smart design can reduce the chance of such errors, nobody claims buildings cure disease. But how much each or any of the design moves in the University Medical Center of Princeton contributes to reducing pain or improving patient approval ratings is also not clear, which frustrates Barry S Rabner, the hospital’s chief executive.
He gives the example of antibacterial flooring, which cost $1 per sq ft more than equivalent flooring without the antibacterial agent.
“Sounds like a good idea,” he says. “So we did it. But that’s about a $700,000 [€533 million] difference. And where’s the evidence that it works?”
He believes architects should provide more hard research and be paid more if their designs improve health.
Christopher Korsh, the principal architect on the Princeton project, works for HOK, the global design firm. “It is very difficult to get conclusive results when it comes to hospital design,” he says.
“We employ researchers to study outcomes of what we do. But because every hospital facility is different, and because there are so many other variables, it’s hard to isolate some particular design metric and say it’s responsible for a certain health outcome.”
Korsh also cites a culture of habit that stands in the way of some design no-brainers. “When we have innovative ideas or ideas that we back up with research, we talk to doctors and nurses, and very often, they will say, ‘But that’s not how we have done things in the past.’ ”
Healthcare is a trillion-dollar industry just discovering the medical and economic benefits of better design.
“It’s a significant part of our GDP,” Korsh points out. “Patients say they won’t come to a facility because they don’t like it, and if there’s a building that can save 2 per cent on the cost of delivering healthcare, that’s huge. Plus, good design really can make you better faster.”
Rabner puts it another way: “Architects are right to say they alone can’t control outcomes. But neither can I, and I’m the chief executive. My point is that they should want more control,” he stresses, “and be a more integral part of the medical team.”
Simple idea
He says his hospital staff, working with Korsh’s team, came up with a simple but elegant idea for a double-door lock box, like a hotel-room safe, in which to store drugs in each room.
The box can be unlocked by nurses from inside the patient room but also from the hallway outside.
So instead of the traditional method of dispensing drugs – nurses sorting drugs from one dispensary for all patients on a floor, a system prone to error – pharmacists can now deliver drugs from the hall directly to specific patient rooms, like postmen delivering to private letterboxes. Nurses retrieve the drugs from inside the room, with the patients watching.
So, is the room beautiful? No. It’s less antiseptic, cluttered and clinical than your average patient room and more like what you find in a chain hotel: anodyne and low-key, with a modern foldout sofa under a big window; soft, soothing colours; and a flat-screen TV.
But the room is dignified, which matters to a patient’s mental health. And it works, mostly.
Like pain reduction, architecture has its own cascading effects. New architecture always requires different patterns of movement and behaviour. Because single-patient, same-hand rooms take up more space, the new Princeton facility has a wider footprint than the old one. Labour and postpartum nurses who used to work together at one end of the old building have been separated.
Nor could the head wall, the one with all the equipment, be designed entirely from scratch. The project team had to settle on a standard, off-the-rack panel of flat buttons that put the emergency signal inexplicably close to other, more commonly used buttons.
There have been more than 150 false alarms since the new hospital opened, nurses say. They have had to fit a makeshift cover for the emergency button.
“We love the new room,” is how Donna Covin, the hospital’s clinical nurse leader, sums things up.
“But when it comes to healthcare,” she says, “there is clearly no regulatory body to prevent idiotic design.”
– (New York Times service)