Salus journal

Healthy Planet. Healthy People.

Healthcare / Quality improvement


Which parable for healthcare design?

06 Jun 2017 | 1

Stephen Wright unpicks the virtues of evidence-based and patient-centred design, and process-flow thinking, and concludes that design for change requires an understanding of where in the hospital system these approaches are best suited, and how and where they can be integrated.

The theme of this year’s European Healthcare Design Congress is ‘Visioning the future:  Designing for change in people-centred health systems’. All right-minded observers would applaud this objective, and indeed similar ones previously expressed in other forums. But the nature of healthcare and its particular system-flow characteristics create the potential for seemingly competing perspectives on how the design of people-centred design might be achieved.

For the purposes of my argument, and considering it from the vantage point of the hospital system rather than a broader health system per se, I will focus on the term patient-centred design (PCD) as opposed to people-centred design. Allied to PCD, and covering largely the same themes and concepts, is evidence-based design (EBD). 

Motherhood and apple pie?

Both PCD and EBD reflect a broad consensus that healthcare should be aligned principally to the interests of the patient, and that the design of facilities should be predicated on evidence of what works. Who could possibly object? Indeed, motherhood and apple pie come to mind. However, I’d like to suggest that, as the main guidance on designing and building hospitals, PCD and EBD doth, perhaps, appropriate a little too much.

Proponents of EBD, of course, accept that it’s not about making the hospital a nice place to be – the justification can start with the patient experience but it needs to show benefits beyond the psychological. Classic attempts to illustrate this are the Center for Health Design’s ‘Pebble’ initiative, and the associated Hastings Center ‘Fable’ project.1 This hypothesised new-build hospital incorporates large single-bed acuity-adaptable rooms with large bathrooms, ceiling-mounted lifts, noise and energy reduction, patient window views, and comprehensive ICU monitoring. These features are oriented to fostering reductions in: patient falls; room transfers; medical errors; length of stay; hospital-acquired infections; nursing turnover and injuries; and utilities use. The business case for Fable shows a return on an incrementally higher investment within three years.

An alternative perspective on ‘the hospital’ to that of EBD – not, of course, in a wholly different universe – is rooted in a recognition of the sheer complexity of the facilities, the staff competences, and the processes that take place internally. Hospitals are not just boxes; some activities can be heavily systematised, others require more craft and rely on professional judgement. The intricate process flows – of patients, staff, visitors, goods, services and utilities – are information-based, multidirectional and even work in reverse. Hospitals, particularly acute ones, are dangerous places, and the name of the game is to minimise latency (the time spent in there), either by admission avoidance or by rapid discharge. Classic examples of this flow-based reasoning are the Aravind Eye Care System and the Narayana Health (formerly Narayana Hrudayalaya) cardiac hospitals – the epitome, arguably, of frugal but high-quality innovation in India.

An issue with these two competing paradigms for what drives good organisation in hospitals is that they don’t talk to each other very well. Moreover, healthcare architects seem to be much more comfortable in their public pronouncements of EBD rather than with the process-flow story. Each of these narratives offers a powerful description of what a good hospital should look like, but there is a suspicion that there are trade-offs in the implications of the opposing design principles. Indeed, an explicit statement of the respective domains where the ‘opposing’ concepts of healthcare design hold sway would help decision-makers comprehend what exactly they should build.

Models of care – process and people

In that context, I suggest that the overarching principle in decision-making in hospital development should be the institutional and system ‘models of care’: the pathways and organisation of supply and demand for healthcare. This is not just about technocratic structuring of flow of patients but, rather, allows for the fact that the raw material of this very particular process industry consists of individual people, whose reaction to the setting they find themselves in will greatly influence how safely and efficiently they pass through it.

Patients’ awareness of their environment differs across the facility. In that sense, it’s important that the ‘people-facing’ areas of the hospital are as congenial as possible, quiet, provide views of nature, and are conducive to staff/patient interaction.

For a typical modern new-build acute hospital, the people-facing areas are office space (administration, reception, consultation rooms) and the hospital wards; these amount to around half or a bit more of the total floor area. The other half is hot floor (surgical rooms, ICU, imaging – the signature medical areas) and utilities of one kind or another (HVAC, diagnostic, laundry, catering, etc).

But while the non people-facing areas comprise roughly half of the space, they cover a far greater proportion of the capital cost incurred in the building. Recognising, of course, that staff work in these areas for around eight hours a day and 220 days a year, we simply don’t need to spend too much effort in making these areas pleasant. What is of overriding importance, however, is that they function at the highest possible level of process-flow efficiency.

The bi-lingual approach

What the above indicates is that there isn’t much of a conflict between EBD and system-flow perspectives on hospital design. They just apply, in a broad sense, to different parts of the hospital as a system. The art lies in integrating the two domains; a hospital designer who isn’t encompassing both languages is not going to be generating a state-of-the-art facility.

My intention is neither to invoke a straw man (ie that EBD is only about humanistic design) nor to throw a red herring (that efficiency is only a process-flow issue). But if we don’t get both of these concepts right, patients will spend more time in a place where they shouldn’t, in more discomfort and in greater danger.


  1. Sadler, BL, Berry, LL, Guenther, RD, Hamilton, DK, Hessler, FA, Merritt, C and Parker, D. Fable hospital 2.0: the business case for building better healthcare facilities. The Hastings Center Report. 2011; 41(1) 13–23.