2014 in review

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog was viewed about 2,800 times in 2014. If it were a cable car, it would take about 47 trips to carry that many people.

Click here to see the complete report.

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First Impressions: Waiting room design

image_dune_42“Waiting Rooms:  How to Design to Impress”  is in the latest HEALTHCARE DESIGN magazine issue and focuses on the ultimate demise of the prototypical waiting room featuring long rows of seats.  This more nuanced approach to thinking about adding value to the patient experience is long-overdue.  The sizing for such waiting spaces is a function of the facility type, with smaller outpatient facilities featuring larger, more hospitality-like designs and larger in-patient facilities downsizing wait spaces and moving the hospitality features into the private patient room itself.  Not surprisingly, a 2011 study discussed in the article, notes that TV-watching was the least-desired feature indicated by waiting patients and their families and friends.  And privacy is discussed as one of the features that will be important in most waiting areas of the future.

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Healthcare Waiting Room Design Ideas

Copyright 2014 Patrick Flanigan

Copyright 2014 Patrick Flanigan

This new article by Anne DiNardo of Healthcare Design magazine offers some very good design suggestions for waiting areas.  What is missing from her piece, however, is the hard evidence behind each of her suggestions.  This article should just be a jumping off point, however, as design interventions should not just be anecdotal or experiential.  To justify the expense of re-designing a waiting area, providers want some strong data indicating the correlation between certain design choices versus others and patient and staff satisfaction.  That’s an area in which researchers need to do more work.  Here is DiNardo’s article:  “5 Design Ideas for Healthcare Waiting Rooms”.

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New Op-Ed Piece by Prof. Roger Ulrich Addresses Design and Mental Health

Mills Health Center, San Mateo, CA - New Behavioral Health Department Rendering

Mills Health Center, San Mateo, CA – New Behavioral Health Department Rendering

Given the recent attention of Americans’ focus on mental health issues, it was heartening to see this prescient New York Times op-ed piece by Professor Roger Ulrich. In it, he introduces to mainstream media his key principles of healing design, this time as they apply to mental health facilities.  While our society grapples with how to deal with the shame still sometimes associated with mental illnesses, designers and architects can use the hard evidence that exists (and continue to do research to generate even more hard evidence) to design and build spaces that contribute to patients’ and staff’s improved mental health.  We already know a lot about what works in designing facilities for the treatment of illnesses of the body.  Let’s apply some of those concepts to designing and renovating our mental health facilities. Read more of Dr. Ulrich’s ideas reprinted in full here (from page SR12 of The New York Times):

“January 11, 2013

Designing for Calm


IT should come as no surprise that violence in mental health facilities causes psychological and often physical harm to health care workers and patients. What’s shocking is how prevalent it is.

Globally, a third of all patients admitted for psychiatric care are involved in violent incidents, according to a 2011 analysis by researchers at King’s College in London. In Sweden, where I teach, it’s estimated that more than half of psychiatric care staff members are exposed to physical violence each year, an experience mirrored in many other countries.

Efforts to reduce violence in psychiatric hospitals have focused on identifying potentially aggressive patients through clinical histories and improving staff training and care procedures. But these approaches, while worthy, are clearly not enough. While definitive numbers are hard to come by, the incidence of violence in care facilities appears to be going up.

Research suggests, however, that there’s an effective solution that has largely been overlooked: designing hospital spaces that can reduce human aggression — to calm emotionally troubled patients through architecture.

Currently, questions about design at psychiatric care facilities are viewed through the prism of security. How many guard and isolation rooms are needed? Where should we put locked doors and alarms? But architecture can — and should — play a much larger role in patient safety and care.

One prominent goal of facility design, for example, should be to reduce stress, which often leads to aggression.

For patients, the stress of mental illness itself can be intensified by the trauma of being confined for weeks in a locked ward. A care facility that’s also noisy, lacks privacy and hinders communication between staff and patients is sure to increase that trauma. Likewise, architectural designs that minimize noise and crowding, enhance patients’ coping and sense of control, and offer calming distractions can reduce trauma.

Thanks to decades of study on the design of apartments, prisons, cardiac intensive care units and offices, environmental psychologists now have a clear understanding of the architectural features that can achieve the latter — and few of these elements, if incorporated into a hospital design from the outset, significantly raise the cost of construction.

Providing day rooms and other shared spaces with movable seating, for example, gives patients the ability to control their personal space and interactions with others. Sound-absorbing surfaces reduce noise (and stress), as do designs that offer more natural light.

Some features, like single-patient bedrooms with private toilets, do increase the building cost — but that is arguably offset by the reduced trauma for patients and hospital workers. Violence, after all, isn’t just a danger to well-being, its effects — from medical care to lawsuits — are frequently expensive, too.

Colleagues from Chalmers University of Technology and Sahlgrenska University Hospital and I recently performed a study using a psychiatric hospital, Ostra Hospital in Gothenburg, that opened in 2006. Of the 10 architectural features researchers have identified that are likely to diminish stress and aggression, Ostra has nine.

Data on aggressive incidents were compiled for the hospital and compared with those from two other psychiatric facilities. One was an older facility replaced by Ostra, which had only one of the stress-reducing features. A third institution located in the same region also had just one of these architectural elements. Despite the wide differences in design, though, the three hospitals were similar with respect to the number of beds, types of patients, treatment protocols and staffing levels.

The drop in the use of patient restraints — a proxy for incidents of aggression — was striking. The number of patient sedations at Ostra was 21 percent lower than at the hospital it replaced, and the use of physical restraints fell by more than twice that (44 percent). At the third facility — which operated during the years of both the old and new hospitals in Gothenburg and therefore served as an experimental control — the use of both forms of restraint continued to rise, suggesting that the difference was probably not because of a general improvement in care procedures over the period examined.

Comparison studies like this one have limitations, certainly. It’s hard to know for sure that there weren’t major differences in patient care and training between the old facility in Gothenburg and the new. But evidence from myriad studies and design research strongly supports the notion that architectural design can reduce violence.

The principles, moreover, have implications for the wider health care system. Aggressive behavior and violence in health care are by no means limited to psychiatric wards; they are also common in emergency rooms and other hospital departments. If you have the misfortune of needing to visit the E.R., expect to feel even more stress if you find yourself in a crowded waiting room with fixed rows of seats and a blaring television whose channel cannot be changed.

Environments like these increase the chance that one patient or family member may accost another person in the waiting room, or speak or gesture angrily to a nurse or doctor.

To reduce the odds of such aggression, it’s time we put our growing understanding about stress-reducing design into architectural practice. At a time when health care payment policies are changing to reward better quality, reducing emotional trauma in care facilities should not only improve the lives of patients and health care workers, but perhaps even lower the cost of care as well.

Roger S. Ulrich is a visiting professor of architecture at Chalmers University of Technology, in Gothenburg, Sweden.” © 2013 New York Times

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2012 in review

The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 4,900 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 8 years to get that many views.

Click here to see the complete report.

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The Story of Waiting

Radiology Waiting Room, Penn Medicine

Radiology Waiting Room, Penn Medicine, Perelman Center for Advanced Medicine

I attended a session entitled, “The Story of Waiting”, at the recent Healthcare Design Conference held this past November in Phoenix, Arizona.  Researchers presented their findings, grounding it on a review of existing studies related to design’s impact on waiting.  This new research attempted to quantify visitor involvement and patient control within the context of the waiting area.

The researchers used a variety of different research methods:

  • Patient, visitor and staff questionnaires,
  • Behavior observation (electronic tablet-based notation of activities and physical position — standing, sitting, lying down, etc. — of patients and visitors), and
  • Analysis of spatial syntax (i.e., space utilization, visibility and connectivity, where low connectivity, for instance, denotes less view to the rest of the space).

Their findings were intriguing and have useful implications for the design of waiting areas.

People who ate or took refreshment were three times more likely to talk to a patient.  This suggests that having an area with beverages and light fare accessible provides a space for social support, one of Professor Roger Ulrich’s five tenets for healing design.

Corners or nooks were where visitors spoke the most.  Patients were 15 times more likely to speak to a visitor in such nooks and corners.  Again, nooks and corners provide the privacy needed for social support, while also satisfying the hard-wired need for “prospect and refuge” or a feeling of protection from physical harm.  Sally Augustin, PhD. of Design with Science has spoken of “prospect and refuge” — darker spaces with lower ceilings that are adjacent to larger, more open spaces.  Examples are inglenooks, canopy beds and cupboard beds.  Prospect and refuge is a concept that is highly applicable to designing specialized areas within waiting spaces from which patients can see the rest of the environment from a safe distance.

Related to the concept of “prospect and refuge” is that of “defensible space”.  People like to have their backs protected, especially where they feel high levels of stress.  Seating that provides defensible space should be provided in areas where patients consult with providers and others, such as in nooks.  This concept also must force designers to re-think placing rows of seating, theatre-style or back-to-back in waiting spaces.  Such arrangements create in-defensible spaces in which patients may feel even more vulnerable.

People don’t just wait in “waiting areas”. They also “wait” in patient rooms, outdoors and in hallways.  Those other spaces could be designed mindful of the fact that visitors and patients move around and use connector areas and outdoor areas that could be, in the case of corridors, designed with views to the outdoors and additional occasional seating and, in the case of outdoor areas, landscaped to include unobtrusive places to sit in nature, such as a simple garden.

Some people who waiting are waiting “passively”.  They’re worrying over missing information. They’re restless or worried about losing their seat.  Or, they’re just observing other people.  Design of waiting areas should provide effective positive distractions — another of Professor Ulrich’s five tenets of healing design — for such passive waiters.  It would interesting to know if the researchers were able to determine what percentage of people tend to wait passively so that particular design interventions targeted to them could be allocated in a finite space proportionately.  For such individuals, design should also reduce or eliminate environmental stressors.  By their very nature, people who are waiting passively are more sensitive to the environment and to how it is affecting them.

By contrast, others are waiting “actively”. These individuals are eating in a hallway or talking with other people.  They may also be actively helping the patient.  In essence, they are taking control of the waiting experience and not sitting back and letting it happen to them the way passive waiters do.  This is not to pass judgement, as individuals could wait passively in certain circumstances and actively in others.  For such individuals, design needs to emphasize social support spaces and providing not merely a “sense” of control over their environment, but an actual means to control and to change the environment to meet their needs.

Staff have different goals than patients and visitors in their waiting experiences.  Staff don’t want any distractions in their break rooms.  They want to separate from work and are in search of a respite.  So, distractions of any kind — positive or not — can be omitted from waiting spaces that staff use.  On the other hand, any design features that can provide a respite should be considered.  Providing access or a connection to nature is one example.  Such connection with nature can provide a positive distraction in a patient or visitor waiting area.  Nature is also a de-stressor that can promote restoration and rest.  So, an over-sized photographic nature image, such as those made by Henry Domke, is an appropriate addition to both a staff break room and a waiting area — in the latter instance, especially, for passively waiting patients and visitors.

The researchers also presented some interesting findings in connection with waiting in patient rooms — instances where visitors waited with patients in in-patient areas.

Patient disclosure was higher in rooms having artwork.  Patients reported that more visitors sat with them and that it was easier to share thoughts and concerns with visitors when there was artwork in the room.  Apparently, artwork doesn’t just reduce stress and anxiety.  It also contributes to improved communication between patients and visitors.  This finding suggests a rationale for including appropriate artwork in traditional waiting rooms, especially in those areas allocated as social support spaces.  For instance, artwork in a nook can encourage social support and engagement while acknowledging patients’ affinity for safety through prospect and refuge.

Patients wanted nature images.  This finding is consistent with other preference studies that show that most patients prefer realistic art having nature themes.  In addition to the preference for nature themes, staff and visitors further demanded “hopeful, encouraging and inspiring” images.  Most wanted artwork in front of the bed on the “footwall”.  In placement of artwork, installers sometimes forget that a patient lying in bed cannot see artwork hung on the “headwall”, which only benefits caregivers and visitors.

Empathy is the key to providing patient-centered care:  putting oneself in the shoes of the patient when thinking about many things, not the least of which is whether a design intervention is ultimately more about pleasing you OR about pleasing the patient, the visitors and staff.

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Ft. Belvoir Community Hospital: Using Evidence-Based Design to Change Culture

The new Fort Belvoir Community Hospital in Northern Virginia had sought Silver-Level LEED certification, but instead was awarded the more prestigious Gold Level.  In addition to striving for sustainability in its construction and building systems, the hospital’s planners wanted to integrate evidence-based design (EBD) principles into the overall design.  One of the unexpected results noted by the new commanding Colonel was a change in institutional culture.

Ft. Belvoir Community Hospital

Ft. Belvoir Community Hospital

Focusing on a core EBD principle, the designers stressed patient- and family-centered care and care for the whole person.  In order to reduce stress and to increase social support, they provided light through the use of courtyards and themes of nature as positive distractions.

The designers developed an EBD checklist after the project was underway and included a daylong “visioning” session as a first step.  For instance, in this session, they decided to think of innovative ways to provide patients with a greater sense of control.  They came up with a “smart room” concept in which an RFID (radio frequency ID) tagging system would permit patients to determine who is coming into their rooms.   The visioning session also involved participants developing ways of creating a positive work environment for both staff and patients.  A simple idea they came up with was the use of carpet tiles to reduce noise.

Another EBD principle is to improve healthcare quality and support.  They focused on ways to reduce hospital-bound infections and patient falls. In the latter case, they decided to include patient lifts for staff.

The designers then focused on designing for maximum standardization, future growth and adjustability.  This led to the development of modular planning in outpatient areas.

Ft. Belvoir Hosp_ProjectImage In public spaces they designed welcoming entry areas with double-height window walls, “connectors” (i.e., concourses) with natural light and artwork and “staging areas” (i.e. waiting areas) that wrap around courtyards.

The commander of the Ft. Belvoir Community Hospital, Colonel Charles Callahan, notes that the design contributed to a change in the culture of the staff of the new hospital.  Most of the staff, many of which came to the new 1.3 million square-foot facility from the now-closed Walter Reed Army Medical Hospital, embraced the new hospital as a “home” and “neighborhood” for the hospital’s community and patients.  Col. Callahan describes the new hospital’s “capaciousness” as contributing to a culture of egalitarianism and of abundance that leads to optimism.

The ideal to be achieved is the creation of a “patient-centered medical home” that provides continuity of care – relationships with individual practitioners over time –, coordination of care – a team approach –, and access to care – after hours and electronically.

Ft. Belvoir Community Hospital - Interior Staircase

Ft. Belvoir Community Hospital – Interior Staircase

The new Ft. Belvoir Community Hospital is well on its way to achieving this ideal.

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