HP: Health care design seems to be undergoing a lot of change, especially in the thinking and planning stages. Please talk a little about what's going on in the field.
Plater-Zyberk: There's a wide range of concerns. At the smallest level, we could talk about the interior design of a health care facility. A lot of work is being done to improve the hospital room, its safety and the relationship between the nurse and the patient. The next step relates to the design of the building as a whole, the relationship of that building to the community — whether a medical complex or a surrounding neighborhood — and then, at the next stage, the design of communities for the health of their residents. A lot of questions are being asked across the spectrum. For instance, how green is a building if people have to drive to it?
Lombard: There can be a lot of waiting time at health care facilities. Anyone wanting to take a walk during that time might find that the only place to walk is the parking lot. We need to do more thinking about the health care campus and how it reinforces community. Studies show that people are more productive when they have more face-to-face interactions. How does the campus make that possible? Does it facilitate people from different parts of the hospital coming together? Then, if you think about the Catholic mission, which is built on the value that life is relational, are we creating spaces that nurture relationships?
HP: Some might argue that the trend to focus more on design is really about attracting more patients to pretty buildings, making more money. How would you respond to that?
Plater-Zyberk: That may be, but there are more important considerations. At the scale of the hospital as a whole, good design has a lot to do with making people more comfortable in a situation that is inherently stressful. It's a misplaced modesty to suggest we shouldn't waste money on buildings, that the function of a hospital is for improving your health, so what it looks like doesn't matter. That misses the point of how buildings represent human aspirations. We're lucky that most of our state capitols were built before we started thinking that way. In America we've neglected our public spaces while focusing on the embellishment of private places. In the past, the shared space of public life was embellished because of the respect for the common good and the desire to represent it in the most aspirational manner possible. It's time for us to think again about the spaces we share.
Lombard: Design has a measurable impact on people's lives. That is evident when we observe the way people treat beautiful spaces. Elements of the environment that add beauty send the message that somebody cares and remind us that we are linked to other people. Catholic hospitals, in particular, represent God in the world. They express a fundamental message: "I am here, and I care."
HP: What are some of the important elements of good design?
Lombard: Daylight and landscape views are at the top of the list. There have been many studies that document the importance of access to natural light. When hospitals shifted from their historic garden courtyard designs to focus on interior spaces, patients still received some daylight, but many staff members worked inside the building core with little or no access to natural light. Roger Ulrich's pioneering study in 1984 reviewed research in a variety of areas related to health care design and found, among other things, that surgical patients with views of treescapes healed faster and with fewer anesthetics and signs of stress. Since then, numerous studies have focused on the relationship of light and views of nature to healing.
HP: What can you say about the timing of this upsurge of interest in health care design? Why now?
Plater-Zyberk: I see a series of coincidences. People have studied safety in hospitals: motion, distance, the way walls, doors, equipment and furnishings are placed. All of this affects safety. For instance, a surprising number of hands are not washed because the sink isn't in a convenient place. Other studies have shown the beneficial effects of light and landscaping on healing, so consciousness has grown that you can't just keep building hospitals like some enormous pancake spreading out, with almost no windows. On an urban scale, we have a greater consciousness of urban design and the way that hospitals, especially those that have been around for a while, interact with their surroundings.
We are constantly learning how to make better places for people to inhabit, so it is only natural that hospitals would at some point come into that perspective. Hospitals have often been bad neighbors in the past, buying up huge plots of land — land banking — for parking lots and expanding buildings. There's greater public awareness of the effects of walking, through studies about obesity, asthma and so on, and the ability to increase walking through appropriate community design. By the way we embed a hospital in the community, we may actually be helping people to be healthier. By the way we design the hospital, people might heal faster and leave a day earlier, all of which lowers costs. Ten years ago, most people wouldn't have put design and health together in one phrase, but there are many reasons they are doing so now.
Lombard: The New Urbanism movement, which Lizz [Elizabeth Plater-Zyberk] co-founded in the 1990s, addresses the growing problems related to sprawl and laid the foundation for thinking about health care settings as communities and developing more effective site plans and buildings that integrate and relate to one another and to their neighbors. Think about, for instance, main-streeting the gift shop and the eating places that are now on the interior of hospitals. If hospitals built on New Urbanist principles in an organized way, they could enhance their mission as well as increase land values, not only for the hospitals, but also for their neighbors and communities.
HP: Is better design good for business as well as for health, or should we just assume it costs more, but it's worth the cost?
Lombard: Actually, it doesn't have to cost more. That's the irony. I recently reviewed architectural plans for a health care system in the Southwest. A hospital called for an extensive curved glass wall. That curved wall had enormous cost implications throughout the project. For instance, every room along the wall had an irregular shape, with cabinets and walls of different configurations and lengths. If all that money were re-allocated toward more focused site planning, the cost would actually be less and the impact on the overall quality of life on the campus would be higher. Beauty isn't just about the exterior skin of a building. It can be more cost effective in the long run. It requires strategic thinking, understanding that the mission has a physical dimension. If we say our mission is discovered and expressed in our relationships with one another, we need to make places that frame and support relationships. The entry points, the chapel, the gathering spaces — these are parts of people's generational memories of an institution, so they merit investment. And then the connection to community is an extension of this stewardship.
Plater-Zyberk: Good design is not only good for hospitals; it can also be good for the economic health of neighborhoods. As hospitals grow, take over their surroundings, build more parking lots, residents begin moving away because the area becomes unpleasant. A kind of urban deterioration frequently sets in around an urban hospital unless there is careful planning to integrate the hospital into the neighborhood.
HP: Is there any reason why Catholic hospitals in particular should be concerned about design?
Lombard: Catholic hospitals seek spiritual healing as well as physical healing. We want to bring people closer to God. That is foundational to our mission. Our caring about one another, for instance, is vital and real, and it's also an expression of God's caring about us. That's the light of eternity that shines on a Catholic hospital in a way that's distinct from a secular hospital.
When we talk about "the patient experience," we need to think not just about what happens when people cross the thresholds of our hospitals. We should think about where they live, how they get there, how we welcome them, whether the spaces they see first say "we care about you." If we are committed to our mission, we can't possibly ignore the value of good design. For centuries, people have understood beauty to be an earthly expression of God. Beautiful places have represented our highest aspirations, and hospitals are no exception. In Paris, for instance, the Hôpital Saint-Louis, built by Henri IV in the 16th century on what is now the Avenue Claude Vellefaux, is a significant landmark today. It's a truly beautiful and inspirational building. We need to reassess our investments in light of our mission to recapture both beauty and timelessness.
HP: Obviously not every hospital can rebuild just because new design trends emerged. Can any of this be done incrementally?
Plater-Zyberk: The good news is that hospitals are changing all the time. And small changes can make a big difference. For instance, a courtyard garden as part of an addition can improve the interior experience of a hospital, and the interface of a hospital with its neighbors can be enhanced by the addition of commercial frontage facing the street, serving hospital workers, patients and neighbors alike and improving the safety of the neighborhood. As hospitals make additions and add new technology, there are always opportunities to reshape those buildings.
HP: How interested are health care administrators in better design?
Lombard: They are actually very interested. Increasing numbers of studies are demonstrating the public health impact of the built environment, and researchers are specifically investigating aspects of health care environments. It seems that the more we do things virtually, the more distracted and busy we are, the more we value the face time we have for each other, and the places that provide those encounters become increasingly important. Administrators are discussing this work with increasing interest, and from a Catholic health care perspective, the studies are reinforcing our own commitments to mission.
NOTE
- Roger S. Ulrich et al., Georgia Tech College of Architecture, Center for Health Design, "A Review of the Research Literature on Evidence-Based Healthcare Design," Healthcare Leadership White Paper Series, 5 of 5. The study, available online at http://www.healthdesign.org/hcleader/whitepapers.html, assessed benefits of single-bed rooms, effective ventilation, a good acoustic environment, nature distractions and daylight, appropriate lighting, better ergonomic design, acuity-adaptable rooms and improved floor layouts and work settings.
ELIZABETH PLATER-ZYBERK AND JOANNA LOMBARD
Elizabeth Plater-Zyberk is distinguished professor and dean at the University of Miami School of Architecture. She and her husband, Andrés Duany, are principals of Duany Plater-
Zyberk & Co. The firm is a leader in the design movement known as New Urbanism, planned communities that strive to recreate walkable neighborhoods by integrating housing, schools, employers and retail businesses. (www.dpz.com). One of those communities, Seaside, Fla., was named by Time magazine in 1989 as one of the 10 "Best of the Decade" achievements in the field of design. Duany and Plater-Zyberk are co-founders of the Congress for the New Urbanism, described by the late Herbert Muschamp, former architectural critic for the New York Times, as "the most important phenomenon to emerge in American architecture in the post-Cold War era" (New York Times, June 2, 1996).
Plater-Zyberk holds a master's degree in architecture from Yale University and a bachelor's degree in architecture and urban planning from Princeton University. She holds honorary doctorates from two universities, including the University of Notre Dame.
Joanna Lombard, professor in the University of Miami School of Architecture, teaches and consults in the areas of New Urbanism and health care design. She holds a master's degree from Harvard University and a bachelor's degree from Tulane University, both in architecture. She is the author or co-author of three books and is currently working with an interdisciplinary national research team to study effects of the built environment on children and the elderly.