Growth Prospect: Healthcare Design Liaison

Posted on January 12, 2011


In the Fall 2010 issue of the Health Environments Research & Design Journal, D. Kirk Hamilton wrote a well-argued piece on the lack of rigor in healthcare design. Hamilton’s article is self-effacing, forthright and nothing short of courageous for questioning not only the design profession’s service to healthcare, but his own body of work. In the end, Hamilton lobbies for more design hypotheses, research, and hard data to back up design decisions so that design solutions for healthcare evolve based on successful spatial performance.

In a self-reflecting moment on his 30-plus years of healthcare design, Mr. Hamilton openly states:

“I am embarrassed to say that I don’t know which rooms [I designed] have the lowest rates of hospital-acquired infections, medication errors, falls, or sentinel events. I wonder if some of those rooms have a better record of healing that might me measured by a reduced length of stay. I cannot identify the rooms with either a good or poor record of staff injury. I suppose my clients might not have been willing to provide me with some types of data, but I did not request it…Is care easier to deliver in one room than another?…If the rigor of my practice and the cooperation of my clients had supplied most of these answers, I must believe that I could have designed better, safer, more effective patient rooms.”

Hamilton rightly supposes that the architecture profession is a little lazy and unprepared to design with the rigor to which healthcare should demand. To wit: “there is minimal effort to record design hypotheses and measure related outcomes.” In addition, most architects are not skilled in the techniques of eliciting data from their clients pre-, and post-design to formulate design concepts. Part of Hamilton’s argument is that there are not enough discussions about design-as-hypothesis, where a concept is totally unproven and should be argued, defended and ultimately proven as the best approach for the given problem. I have an MBA and regression analysis with its mean and standard deviations are still not a rote subject.

And this is the other problem: the clients—users, system CEOs, risk management, facilities directors—have not demanded this rigor of the design profession, yet. When they do, the market will respond. Until they do, design-as-usual will continue. The message is not that current design is substandard, but it can and should be so much better when backed by research. Hamilton backs this up: “I sincerely hope there will be a change in what will come to be described as an acceptable level of competent practice.”

For Hamilton, this means quickly getting up to speed in mining and using data to create and test designs for greater efficacy. This is what the author calls “knowledge-driven practice”:  part based on design rigor, part based on understanding a client’s business and problems. This is more than evidence-based design. A good example of knowledge-driven practice is sustainable design which utilizes environmental data to elicit and affect a design solution. Through past history of climate knowledge, building program, and real-time environmental data, building designs can respond to changes in conditions yet still perform optimally, functionally for users and economically for owners.

Design in architecture schools is, as Hamilton relates, relatively generic. Only a handful of programs like Clemson and Texas A&M choose to offer healthcare-focused design studios. This is not wrong because most architectural design is not data-driven, save for healthcare, and I for one support the ‘generalist over specialist’ argument. Nevertheless, there should be choices for those who want that option, and it proves the profession is not learning how to use empirical data in an academic setting to prove or defend design hypotheses in the real world. Conducting traditional research—collecting data, measuring for proof, analyzing results—is currently not part of the architect’s skill set.

Interestingly, Hamilton feels the healthcare design realm will evolve to include design around data as business-as-usual, much as CAD technology infiltrated design and became standard operating procedure. Although recognized as a long-term benefit, there was initial denial from an expense justification standpoint to not use CAD. A few trailblazers would need to do it, and prove not only its feasibility in competitive advantage, but its affordability in a business model. Then the masses adopt, absorb the costs and adapt their operations to accommodate it as “a necessary and fundamental cost of doing business.” Ultimately, the market will decide its value and pace of penetration.

We designers need help from our healthcare clients to help us understand the most pressing issues, and also to provide the data that is most important to design solutions. I think architects will need to learn analytical skills to apply to healthcare design in the future. Where once there seemed to be three skill profiles within architecture—design, technical, business—the profession of architecture continues to gain granularity; it is not uncommon for firms to have architects with sympathies for construction administration, sales, project management and soon-to-be, research. Yet it will take compliance on the client’s end to assist in supplying access and / or data that will facilitate this evolution.

I see a definite need for a Design Liaison that will work under the CIO or Director of Clinical Administration. This person’s job will be to understand healthcare well enough to collect, measure and formulate the data generated by a hospital each day, and also understand design well enough to work with designers and engineers to supply or translate data into useful information based on the project demands. In the end, this helps the facility reduce risk while achieving more useful designs that solve problems tailored to the exact needs of a client. Not every project will require this rigor, but as Hamilton relates: “In the case of healthcare, we should be more deliberate with critical decisions and base them on the best available evidence.”

The architecture profession is in many ways like the medical profession, where we are educated, formally or in the job setting, to be omnipotent at times toward design: we know best. However, the tide is turning in business; it is ok for leaders to admit they don’t have all the answers. Let’s own up right now:  we cannot say with definition which design solution is best, Mr. CEO, because we don’t have the data. The time of faking it is over; we need to be able to say, with certainty and fact as back-up, why we are making design decisions.

Posted in: Growth Prospect