Vertically Integrated Healthcare Facility Design Consulting Services:
In What Ways is the Architecture Impacted?

On the occasion of the EPIC-2003, a national seminar on Excellence through Planning and Integration of Care, being held by the Department of Hospital Administration, Armed Forces Medical College, Pune, Maharashtra it seems appropriate to ask a question that any architect commissioned to design a healthcare facility would be interested in mooting:

In a healthcare facility design consulting firm that offers vertically integrated consulting services ranging from surveying the potential market for the project through architectural design consulting till advising on standard operating procedures and recruitment of staff, is the physical facility design (the architecture) positively impacted?

In my experience in my previous firm, HOSMAC India, which offers such vertically integrated services, described by us as a ‘one-stop shop’ for healthcare facility design, there seems little doubt that it is.

Immediately I hear the cry from my fraternity (fellow architects), what do you mean by “architecture”, define your terms!  How can a medical doctor add value to architectural design, how would a profit and loss statement for the proposed hospital projected into the foreseeable future help you (me!) to achieve Commodity, Firmness and (especially!) Delight?

Bob Dylan sang about it years back (albeit nasally): …the times they are a-changin’…Is it possible for us architects to accept that Vitruvius may not have much value to add to the design of an allopathic healthcare delivery facility in 2003?

This would bring us back to our aggrieved cry, how then would I define “architecture” in this context? Am I disposing of ‘Delight’ in my proposed hospital’s proposed incinerator?  This would be, to my mind, a simplistic way of viewing the problem solving process related to the design of this building type, the issue is complex and involves opening a Pandora’s box of medical, architectural, engineering, social, emotional and moral issues. How all of us professionals in HOSMAC India with varying academic backgrounds and skill sets go about chasing all these creepy-crawlies, trying to catch them and stuff them back into their box is what I am going to go on to discuss. Hopefully during the course of this discussion I will be able to give some definition to my viewpoint on the subject and to the positive impact that I know it has on the architectural design of healthcare facilities in the new millennium.

If you were to ask an architect in India today what is the single most important design factor he / she would consider while designing a hospital, the chances are the reply you would get would be ‘the functional requirements’. They well might say that the ‘form’ of their design solution would be derived from an analysis of medical / technical requirements of the hospital, that is, the ‘function’.

“Form follows Function?”

“Form follows Function” is an architectural dictum laid down by one of the Modern Movement in Architecture’s most well known practitioners, Ludwig Mies van der Rohe. He was born in Aachen, Germany in 1886.  A little simplistically put, he means that a building should be designed taking as the starting point for it’s design the activities that that building is meant to house. Hence the final shape (or ‘form’) of the building would be directly derived from its intended use (or ‘function’).

Le Corbusier, another famous Modernist architect, talked of a house as a “machine for living in”.

If Le Corbusier had been a healthcare architect, maybe he would have talked about designing hospitals as “machines for healing in”.

We all have an idea about the complexity of the functional needs of a modern hospital, and the specialized knowledge needed by its designer with respect to its engineering services and the needs of the medical equipment it houses. So we can see how a hospital, especially one being built in the 2000’s, could well be considered to be “a machine for healing in”.

In fact, many (if not most) of the hospitals built in India during the latter part of the last century seem to have been designed to provide a roof over the increasingly complex medical procedures being performed within, with their architects being little more than “doctor’s draftsmen”, translators of medical and technological requirements into built form. The result: grim and cheerless buildings that cannot be dignified with the word “architecture”.

What has changed in recent times is the very definition of the word “healing”, moving away from medical interventions to embrace a more holistic meaning, the focus moving away from treating “illness” to creating “wellness”.

When healthcare designers now conceptualize hospitals, they need to think of them as buildings designed to promote the “wellness” of not only the “patient” (replace with: “healthcare consumer”), but also of his / her family and friends who visit and the staff who provide the care.

In conceptualizing hospitals today, we need to take our cue from the hospitality industry, the patient needs to be treated as a guest, someone who is to be informed about what he / she will undergo during his / her stay in the hospital, and should be enabled to take active and meaningful part in taking decisions about his / her treatment.

‘Form’ could still follow ‘function’, providing we redefine the function of a hospital as an institution built to create a more holistic ‘wellness’, to consider the dignity, emotional needs and mental state of our ‘patient / guest’ to be every bit as important as his / her physical health.

We do not need more echoing green painted hallways with harsh, unforgiving fluorescent lights. Controlling noise, using pleasant colors, sufficient and comfortable waiting spaces, clarity in way finding, using natural light and greenery judiciously are just some of the imperatives in “patient-friendly design”. Polite and helpful staff, the ready availability of information about the status of the patient to their family and friends and concern about the patients mental state are just some of the imperatives in “patient-focused care”.

Healthcare Providers and their Social Conscience

Many successful new healthcare projects are taking shape throughout the developed Western countries today, calling into question the performance levels of more typical healthcare construction endeavors, both in the West and in India. This prompts us to ask just how far our conventional healthcare buildings are falling short of the mark, judged by the standards of ‘green’ architecture, the popular name given to environmentally responsive and ecologically sustainable building.

What we are discussing here is the social responsibility that healthcare providers need to feel for the community that houses their facility and provides them with their patients / profits. At the stage of conceptualization of the proposed facility, thought needs to be given to the environmental effects the proposal will have on its surroundings. Architects have always been taught that the buildings they design need to be ‘good neighbors’, but their clients, the healthcare providers, need to understand this in the macro and micro sense.

Health care institutions’ core mission of protecting human health provides the basis for them to speak with their words and actions on the health implications of building construction and operation. The healthcare industry has a leadership opportunity to move the larger building industry to a healthier approach by demonstrating the best in healthy, sustainable design, construction, operations and maintenance practices in it’s own facilities.

This approach to design is known as ‘green’ architecture. This design approach addresses concerns such as energy efficiency, the use of clean energy resources, an improved indoor environment through usage of green building materials and maximizing the use of controlled daylighting, encouraging recycling and waste prevention / management strategies and designing in ways that promote good building operations practices.

Healthcare architects need to redefine the facilities they design as healthy parts of a healthy regional ecosystem. The full range of practices to be followed in the pursuit of these socially responsible goals are beyond the scope of this article. HOSMAC works closely with an NGO named HOPES on promoting this ‘green’ initiative in healthcare delivery as a whole.

HOPES is networked with a global movement called Healthcare Without Harm, involving more than 300 NGO’s and professional organizations spread over 50 countries, working towards establishing environmentally sound healthcare practices and healthcare facility design and construction.

For more information on this and other related subjects, visit www.healthybuilding.net and www.noharm.org . We would also strongly suggest that you visit the web site of the City of New York, or do a search for ‘High Performance Building Guidelines, City of New York, Department of Design and Construction, April 1999.’

Moral Issues in Healthcare Facility Design

Every sensitive designer of buildings knows that during this process they are constantly called upon to lay their values on the line. This anyway sticky issue becomes positively gooey when designing healthcare facilities.

For example: A disquieting trend in the future of healthcare delivery systems– healthcare on a cost-versus-benefit equation. The physician’s Hippocratic Oath prevents them from putting any kind of price on human life. Until some time back, to do “everything possible” for a patient cost very little more than to do nothing at all, simply because there was not much that could be done.

To be sure, the ambition to do all one could to save a life is a noble one. In the past, it was also economically feasible. Today, however, there is much, much more that can be done for any given patient – and each of these procedures, drugs and interventions comes with a price tag, which the individual and ultimately society must pay. Indiscriminately paying “for it all” has already become crippling to society, and insurance providers and government agencies are now acknowledging that it is not merely crippling, but fatal.

Diagnosis Related Groups (DRGs) are already expressions of judgment about the effectiveness of procedures. Insurance providers and government agencies are saying that they will pay for procedures proven to be effective, but they will not pay for unproven or marginally effective treatments. Such cost-versus-benefit judgments will play a greater role in the delivery of healthcare, no matter who is paying for the treatment. No longer will healthcare providers have sacrosanct license to do “whatever is necessary” in each and every case.

The cost-versus-benefit goes beyond rupees and paise. Healthcare consumers will increasingly weigh the prospective benefit of a given treatment against the quality of life they may expect as a result of it. It is not only likely that more patients will opt out of treatments that prolong misery in order to merely prolong basic life processes, but that life termination will become a viable medical option.

No doubt the above is an issue involving medical ethics rather than design. However, if we consider ‘healthcare facility design’ in it’s larger context, beyond physical facility design (architecture), in the context of overall conceptualization of the entire project, in which the architect is but a team member rather than being in his / her traditional role as team leader, he may be called upon to contribute to a discussion on trade-offs in allocation of usually limited funds in which the above issue will very much on the mind of the client, though it may remain unarticulated. It would be time then, for that architect, to search his conscience for the right answer. His calculator may not be of much help to him in that situation. Doctor’s constantly make decisions involving life and death, many times with a very practical basis, like on a battlefield. The healthcare architect too has to realize that he is right there too on the front line; he has to make tough calls without the crutch of a dramatic situation. Moral issues are to be resolved between an individual and his conscience; no article in a magazine can help you do that. All the best! Hopefully there will be no more than one sleepless night per tougher decision.

I hope there is some better understanding of the medical, architectural, engineering, social, emotional and moral issues, and that this understanding is helping you to define ‘architecture’ as I experience it day after day in our office. (Engineering issues, of course, I have not discussed, best left to those specialists in the know.) There is a complex web of interactions between all of these, and the idea is that a positive change or contribution in one strand of this web should send a ripple effect of positive changes throughout. The task is to create an understanding within the organization of individual responsibilities and how these impact their colleagues’ work within this mesh of causes and effects. Ideally the whole team should work seamlessly, the project when built being the end result of a smooth, cohesive effort. We at HOSMAC strive towards this goal.

The Consulting Services Marketplace

There are forces at work in society today which seek to reduce all things to the marketplace (market-plaice (ouch!)…are we all just selling fish?) in which the cheapest objects and services are assumed to offer the best value. My experience in this marketplace gives me little reason to support the view that the cheapest and quickest design process is necessarily the best.  Our by-line in our design team is “value addition through specialized knowledge”, and I mean ‘value’ as in ‘VALUE!’ We are involved in a search for continuously adding to this ‘specialized knowledge’ through a process of solving other people’s problems. It can be painful and often frustrating, but it is ultimately an extremely satisfying process involving substantial intellectual commitment on our part. It flourishes best when there is an equal commitment from the client and clearly benefits from a close and trusting relationship between client and consultant.

The process of designing anything can be likened to a journey. As seasoned travelers will know, many things can go wrong on journeys. It helps if the territory is charted, and if you have made similar journeys before, you know what to pack! The relief of arriving is of course, welcome, and much anticipated, but we agree with Robert Louis Stephenson’s famous assertion that ‘to travel hopefully is a better thing than to arrive, and the true success is to labor’.

Viva le journeys! We look forward to the travelling, to the exploration of this fascinating field of endeavor; we can only hope we never get to the end. We hope we never find what we’re looking for.