Publication type: "Blog Post"

Hastings Center Bioethics Forum: The Bioethics of Built Health Care Spaces

January 13, 2021 / Dochitect / Health Design & Ethics

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Publication: Hastings Center Bioethics Forum
Title: The Bioethics of Built Health Care Spaces
Publication Date: January 13, 2020
Authors: Diana Anderson, Bill Hercules and Stowe Locke Teti

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It is time for the built environment to be considered alongside other parameters of care.

In recent decades, our understanding of the role the environment plays in shaping us and our interactions has expanded immensely. Researchers have examined the profound effect social and environmental factors can have on ethical behavior and decision-making. Yet, design choices in the built health care environment raise substantive bioethical issues that demand the attention of bioethicists and ethical inquiry.

Read the full essay HERE.

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Ethical Dilemmas in Dementia Care Design

January 31, 2020 / Dochitect / Design for Geriatrics, Health Design & Ethics

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Publication: CLOSLER.org, Johns Hopkins Medicine
Title: Ethical Dilemmas in Dementia Care Design
Publication Date: January 31, 2020
Author: Diana Anderson, MD

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The Seven Lamps of Architecture, written in 1849 by the English art critic and theorist John Ruskin, embodies the principles that good architecture must meet. One of the lamps is truth. Do our dementia care designs break this core architectural value?

Closler.org has an email subscription of ~6,000 healthcare providers
and is regularly visited by thousands of individuals from 70 countries.

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Clinic room designs must fit care models

October 9, 2019 / Dochitect / Design for Clinical Staff, Health Design & Ethics

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Publication: The Medical Post, Canadian Healthcare Network
Title: Clinic room designs must fit care models
Publication Date: October 9, 2019
Authors Diana Anderson, MD

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“Where should I sit?” my geriatric patient asks as he enters the clinic room, his walker just barely clearing the doorway.

I glance around at our choices—there’s the clinician’s chair-on-wheels positioned towards the desk with the computer monitor, the examination table itself, or the designated patient chair. I know that today my priority is to discuss advance care planning and goals of care—a discussion that warrants equal footing and a potential surface for reviewing paperwork. Sitting on the exam table for these discussions can be physically challenging for frail patients and is not conducive to discussion equity. The patient chair is an option, only its position next to the desk or across from it implies a hierarchy and awkwardness in formulating conversation.

And wait—my patient has brought a family member, where will they sit?

As medicine increasingly becomes a family affair, especially in the realm of pediatrics and geriatrics, how can clinic room design foster these new models of care? As the emphasis on advance care planning grows with communication of difficult topics now being taught as a clinical skill, there is immense value to re-envisioning the primary care clinic room to support these changes. As a health system we have mainly concentrated on throughput and outcomes required by clinic encounters and not necessarily the experiences of the various user groups—space design and care appear to be more divergent than ever. Now I believe it is the time to focus on the clinic environment to better support all-inclusive care.

Innovative clinic room design can (and should) advance the practice of collaborative thinking and decision-making in medicine by abolishing the “doctor behind the desk” phenomenon. The round table makes an appearance in rare instances of new clinic design, but could become a standard with some clinician advocacy—at least three chairs around it, all of equal design (sturdy, with arm rests). Reminiscent of the Arthurian legend around which knights congregated, the implication was that everyone who sits there has equal status. A computer screen can be used to support the discussions, preferably mounted in a way to be referred to if needed or even retracted—but should not dominate or obstruct the physician-patient interaction.

Clinic rooms should expect family members and be prepared—foldable chairs can be hung on the wall or stored in custom-designed millwork, for quick and easy access. And the examination table often feels like the awkward elephant in the room in its size and placement. In busy clinics where patients rarely undress and gown for a full physical exam, this design element could transition to a specialized reclining chair model. A single procedure room elsewhere in the clinic can be maintained when specific examinations are required.

And while I am reflecting on my “clinic design wish list”, a few wall hooks for patient canes, outerwear and bags, are simple enough and would enhance the encounter. Effective patient encounters do not happen by chance—the impact of design should be realized.

We cannot expect a generic room design to adapt to the changes in medical practice. Can health architects design the clinic room for equitable patient interaction and incorporation of family? Yes, we most definitely can. But a paradigm shift in thoughtful healthcare design is needed with the incorporation of clinicians at the drawing board. This will ensure patients and their families enter clinic rooms which intuitively invite a seat at the table—supporting, not hindering, patient-centered and team-based care.

Dr. Diana Anderson is a Canadian currently doing her geriatric medicine fellowship in the U.S. She thinks of herself as a “dochitect” as she is a board-certified internist, a licensed architect and also a board-certified healthcare architect. Find out more at www.dochitect.com.

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Is Hospital Design Equitable?

September 16, 2019 / Dochitect / Design for Clinical Staff, Health Design & Ethics

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Publication: CLOSLER.org, Johns Hopkins Medicine
Title: Is Hospital Design Equitable?
Publication Date: September 16, 2019
Author: Diana Anderson, MD

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There is increasing recognition and understanding of the impact built space has on people. While healthcare architecture has strongly advocated for patient-centered design, can the resulting fragmentation and concealment of clinical spaces devalue the role of medical professionals?

Closler.org has an email subscription of ~6,000 healthcare providers
and is regularly visited by thousands of individuals from 70 countries.

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What can healthcare providers learn from architects?

December 11, 2018 / Dochitect / The Physician-Architect Model

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Publication: CLOSLER.org, Johns Hopkins Medicine
Title: What can healthcare providers learn from architects?
Publication Date: December 11, 2018
Authors Diana Anderson, MD

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Five Lessons From Architectural Design

Closler.org has an email subscription of ~6,000 healthcare providers and is regularly visited by thousands of individuals from 70 countries.
Emerging professionals in architecture and medicine are moving beyond infrequent intersections and seek a convergence of career models. What can clinical practice learn from the design field of architecture?

Here’s what I’ve learned in my career as both architect and physician:

Lesson 1: “Always design a thing by considering it in its next larger context – a chair in a room, a room in a house, a house in an environment, an environment in a city play.” – Eliel Saarinen, Finnish Architect, 1873-1950
Architects are taught to respect context and design for the experience of being in a place. As providers, learning the context of our patients and their social determinants of health is key to the biopsychosocial model of care. It becomes more than just the pathophysiology of presenting illness or symptoms.

Lesson 2: One size does not fit all.
At a recent design meeting for a critical care renovation project, the intensivist noted the provision of a large conference room in the proposed floor plan which could be used for both rounds and to break bad news to families. The physician recounted that from his experience, under or oversized rooms can have an effect on the experience of these difficult conversations – a separate smaller room is often needed. As providers, we know that patients and disease effects are not created equal. Patient health burdens can be unequal within a similar pathophysiological framework.

Lesson 3: In architecture a “parti” is the central idea of a building, usually represented as a diagram in shapes to explain the design concept.
As designers, we need a way to explain the idea of our product. We use the parti as a guidepost in designing the many aspects of a building, and always consider how its design can express and reinforce the essential idea of the building. In medicine, our patient histories involve a chief complaint and history of present illness, but what would happen if our clinical parti was the social history and the patient’s overall narrative as our foundation – who they are, what is important to them. These should never become lost and should always ground us in the care of a patient.

Lesson 4: “We shape our buildings: therefore they shape us.” – Winston Churchill
Architects design for experiences by developing spaces for people. Indoor and outdoor spaces, buildings, landscape architecture, and city planning have important effects on us – design can promote exercise and health, keep us safe, inspire us and made us feel good or bad. As providers, we care for people and in the process impact their lives. In return, patients can profoundly impact our practice and lives as well. Just like architecture, medicine is not only a science but also a craft.

Lesson 5: “The Sun does not realise how wonderful it is until after a room is made.” – Louis Kahn, American architect, 1901-1974
In architecture, the concept of void or negative space is something we incorporate into design of buildings. There is a well-known series of black and white photographs which capture the sky by viewing upwards within narrow European streets. The building facades are in silhouette around the edges and the sky becomes a form, shaped by the buildings. One cannot have a building without the framing of abstract spaces/voids; the negative can become the positive and the two work in harmony to create the whole. As clinicians we cannot forget this “negative space” in addition to the positive. Sometimes not pursuing a treatment may be the best option for a patient, or even just a silent pause during a patient history can give someone a chance to mention something important.

Together, clinicians and architects can find a balance between illness, health, and design, inspiring the emergence of a new mode of practice. Therapeutic design as a form of treatment and support requires participation of both the clinician and the architect.

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Why your practice needs a makeover

December 6, 2018 / Dochitect / Design for Clinical Staff, The Physician-Architect Model

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Publication: KevinMD.com, Blog Post
Publication Date: December 6, 2018
Authors: Diana Anderson, MD, MArch & Keith Mankin, MD

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Why your practice needs a makeover

The spaces where we live and work can exert both strong and subtle influences on the way our brains function. They can make us anxious, distracted, inefficient or tired, affecting not only our cognitive ability but also our emotional state, mental stability, and physical well-being. Clinical medical practice, like much of life in our society, is tethered to indoor space, so physicians, staff and patients alike are particularly prone to these psychological effects.

The good news is that continued study of the effects of design on our well-being, and of those we work with, has led to better recognition of “trouble” points and ways to improve them. Many of these improvements are easy and inexpensive to accomplish and may lead to a better environment for engagement and healing.

The first step is an honest assessment of the clinical space and the throughput from the focus of the physician, the staff and the patients. Look at the surroundings, listen to the ambient noise, feel the amount of room and the sense of space. Let your staff do the same thing and compare responses. Even consider a simple survey of the patients.

5 design flaws that can hurt your practice

Lack of space for staff-to-staff interactions
Lack of “reset” rooms – a place where staff or provider can step away from the practice work and recharge for a couple of minutes. Many clinicians have offices, but their desks are full of distractions. A reset room should be the opposite
Inefficient and clumsy exam room design
Lack of natural lighting (or an alternative if the space doesn’t allow windows to the outside)
Noisy, overly hectic waiting rooms

So what can be done about these and other problem areas in the practice design? The following is a list of suggestions, but the most important factor is a willingness to try changes. Most of these are easily reversible if they don’t work. They are workable even in shared environments (although compromises about stylistic designs may need to be made). Most importantly they will not fundamentally change the organization of the practice, although clinicians should be open even to more drastic changes if necessary. The entire healing system may be in the balance.

8 simple ideas to improve your practice

Find the clinic’s quiet spaces and use them. Recent guidelines have called for stricter control of blood pressure, but many practices do not even have a quiet spot to measure vital signs. A small comfortable room can be set aside for BP measurement, or even as a “coping” room for patients or staff
Design the patient (and staff) flow for efficiency and convenience. The goal should be to minimize steps and prevent everyone from having to retrace their steps
Make the waiting rooms productive spaces. Patients don’t really want the television blaring at all times. Having a usable Wi-Fi, having a small library, presenting informative information, setting up the chairs so people can interact can all go a long way towards minimizing stress and improving the mood and receptivity of the patient.
Choose colors carefully
Use the windows for natural lighting whenever possible
Invest in artwork
Design the clinic for universal use. Unless the space is dedicated to one age group or type of patient, or if it is truly a solo practice, it is useful to pick colors, furniture, and lighting that will be useful and engaging to a broad range. This doesn’t mean the palette needs to be olive drab
Develop spaces for education and engagement. The ambulatory care experience is not just about the doctor/patient interaction anymore. It now encompasses teaching, prevention, and resources for making healthful decisions. A resource center (as simple as an orderly selection of booklets or as complicated as video and computer learning stations) can be incorporated into the clinic setting. A small conference area can allow teaching sessions

In summary, the key to making a clinic work better is to first, understand what doesn’t work; second, know what the research suggests; and third, make small incremental changes (or even large ones if necessary) that will put these practices into effect. We as clinicians must understand that the healing process is not just the “laying on of hands.” It is the entire scope of a patent’s experience from the moment they step through the office door.

Diana Anderson is an architect and physician. She is principal, Steffian Bradley Architects, Boston, MA. She can be reached at Dochitect. Keith Mankin is a pediatric orthopaedic surgeon and host, PeerSpectrum Medical Podcast.

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