During this period of rapid and accelerating change in our health care system, as it shifts from a volume-based to a value-based model, are we as designers for healthcare keeping pace? How is the role of the healthcare institution changing, and how should this change how we design for healthcare? What can we do as designers to help guide our healthcare clients through this disruptive paradigm shift?
It is clear that health systems are now more outwardly focused than ever before. Many are pushing as much of their care as possible into outpatient settings that are closer to the communities they serve. Many are developing more comprehensive health systems through acquisition and collaboration. These are all ways in which they are responding to the new incentives for prevention and wellness, and the need to gain efficiency and reduce unnecessary healthcare costs.
The increasing focus on population health means that we, as designers, need to look beyond the four walls of the facilities we design. How should hospitals and healthcare facilities relate to their communities? How can their design have a positive impact on the community and on population health? Sustainable design has been one way that we have been able to reduce the external impact of what we design on our environment. By focusing on the scientific evidence of material health, energy efficiency, mechanical system selection, and building envelope design in a systematic way, we have been able to bend the curve of our environmental impact downward. We can extend this way of thinking to also help bend the curve of chronic disease rates and rising healthcare costs downward by reducing the negative impact of what we build on public health using the same evidence-based approach.
So let’s, for a moment, imagine that we are the healthcare client, struggling to decide how to best utilize our resources to increase wellness and reduce the cost of healthcare within the community we serve. When considering the next facility to invest in, what strategies would be most effective in health outcomes? An interesting resource to help answer this question has been provided by County Health Rankings & Roadmaps, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. Their roadmap —“What Works for Health”—identifies the strategies that work, and rates their effectiveness on health outcomes, based on scientific evidence. In their methodology, clinical care accounts for 20% of what drives health outcomes.
Wait, what? All of that clinical care in all those facilities that we have built over the years impacts a mere 20% of health outcomes? What accounts for the other 80%? Well, according to their outline, Social and Economic Factors — such as education, employment, income, family & social support, and community safety — have a 40% impact on health outcomes (twice the impact of clinical care). Health Behaviors — such as tobacco use, alcohol and drug use, diet and exercise, etc. — account for 30% of health outcomes, and the Physical Environment — including air and water quality, housing, and transit — accounts for the remaining 10%. Based on this understanding, how should we spend that facility dollar? What should our programmatic and design priorities be? What design features should our facilities include to be most effective in health outcomes, beyond the clinical care that will be provided within their walls?
By seeing in this way, through our client’s eyes, and through the lens of what really effects health outcomes, we can gain a whole new way of understanding of how design can bend the health and wellness curve. We are already focused on sustainability at the scale of material choices and building system selection. Next, we can begin to look more outwardly at the scale of the block, campus, community, district, and region — as our clients are beginning to — to better understand the impact of our design decisions on population health.
Using the weighted strategies outlined in “What Works for Health” as a starting point, we can identify the most effective strategies that we can employ as designers. Designing great and efficient settings for clinical care (20%), while using the best evidence-based strategies to impact health and healing is what we are good at, and where we have been focused for some time. Check! But how can we go beyond that 20%? What about Social and Economic Factors (40%)? What if we designed healthcare facilities to be more welcoming and integrated into the community? Could our designs encourage staff to shop locally or go out to the local café for lunch instead of the hospital cafeteria? What are the design features that can increase safety in the community surrounding the facilities we design? Are we integrating safe and inviting pedestrian and bicycle paths into our projects? Do we concern ourselves with strategies to calm traffic and to create safe pedestrian refuges?
And what about Health Behaviors (30%) and the Physical Environment (10%)? The strategies outlined in the Active Design Guidelines reveal opportunities for physical activity in our projects. Incorporating healthy food venues, community gardens and farmer’s markets into our projects can encourage healthier diets. As Richard J. Jackson, Professor and Chair of the Department of Environmental Health Sciences at UCLA, points out in the book Making Health Places, “More than ever before, Americans today are faced with poor nutrition and lack of physical activity, both of which are leading to serious health consequences.” Integrating green spaces in out projects can also encourage engagement with nature. Including corner stores and designing great streetscapes and pedestrian-focused public realms can add vitality and safety to the community. Rather than assuming that cars are the preferred means of access, we can allow for more active means of commuting.
The emerging focus on population health is challenging our clients to find new strategies that go beyond business-as-usual. This rapid change offers an extraordinary opportunity to utilize our unique skill set as designers to impact public health and wellness in innovative ways. As our clients widen their horizons to consider how they can impact the health and wellness of the community as a whole, so should we. “Build it and they will come” no longer makes sense. What we need to do is to build so that fewer will have to come.
This article originally appeared in Contract Magazine.