PLAINSBORO, N.J. — Can good design help heal the sick?
The University Medical Center of Princeton realized several years ago that it had outgrown its old home and needed a new one. So the management decided to design a mock patient room.
Medical staff members and patients were surveyed. Nurses and doctors spent months moving Post-it notes around a model room set up in the old hospital. It was for just one patient, with a big foldout sofa for guests, a view outdoors, a novel drug dispensary and a bathroom positioned just so.
Equipment was installed, possible situations rehearsed. Then real patients were moved in from the surgical unit — hip and knee replacements, mostly — to compare old and new rooms. After months of testing, patients in the model room rated food and nursing care higher than patients in the old rooms did, although the meals and care were the same.
But the real eye-opener was this: Patients also asked for 30 percent less pain medication.
Reduced pain has a cascade effect, hastening recovery and rehabilitation, leading to shorter stays and diminishing not just costs but also the chances for accidents and infections. When the new $523 million, 636,000-square-foot hospital, on a leafy campus, opened here in 2012, the model room became real.
So far, ratings of patient satisfaction are in the 99th percentile, up from the 61st percentile before the move. Infection rates and the number of accidents have never been lower.
Often ignored by front-rank architects, left to corporate specialists who churn out too many heartless buildings, hospitals are a critical frontier for design. A British charity for cancer care, Maggie’s Centres, has taken one approach, enlisting a Who’s Who of stars like Rem Koolhaas, Frank Gehry, Snohetta and Norman Foster to devise bespoke facilities. In Brazil, the architect and urbanist João Filgueiras Lima, known as Lelé (who died in May, at 82) devoted his final years to a remarkable series of rehabilitation hospitals: simple, airy and visually arresting.
But maybe most interesting, some young design firms are getting into the act. Not long ago, Mass Design Group in Boston made headlines with a hospital in Rwanda — “way too cool to be a hospital,” The Atlantic cooed — that provoked some debate in professional circles about whether socially concerned design can also be Architecture with a capital A.
In many ways, this is the central argument in architecture today, with a new generation more attuned to issues of social responsibility and public welfare. The discussion has posed a larger, fundamental question about the role of architects, and to what extent they can or should be held responsible for how buildings work.
Here, the goal of the new hospital was not to devise a visual landmark off Route 1 in New Jersey. The building is a dull, curved glass block facing a parking lot. The ambition was inside — in the remodeled patient room.
Several hundred decisions, major and minuscule, common-sensical and arcane, went into configuring the room. Many of them may sound so obvious that one can wonder, financial and real estate constraints aside, why they haven’t always been standard. For starters, the rooms are singles; there are no double rooms. Research shows that patients sharing rooms provide doctors with less critical information (even less if the other patient has guests). Ample space is given to visitors because the presence of family and friends has been shown to hasten recovery.
Ditto the big window: Natural light and a view outdoors have been regarded as morale boosters since long before Alvar Aalto designed his famous Finnish sanitarium in the 1930s (a “medical instrument,” as he called it), bragging about curative balconies and a restorative sun deck.
There are also some fine points to the Princeton plan, like a sink positioned in plain sight, so nurses and doctors will be sure to wash their hands, and patients can watch them do so. A second sink is in the bathroom, which is next to the bed, a handrail linking bed and bathroom, so patients don’t have to travel far between them and will fall less often.
A luxury of building from scratch is that the rooms can all be “same handed.” In many hospitals, adjacent rooms are “mirrored” because they share a head wall, the one behind the bed with all the equipment and attachments in it. Mirror rooms are cheaper and take up less space, but they require that everything — the position of the bed, the IV tubes, the call buttons — be reversed, right to left or left to right, from room to room, increasing the chance that nurses and doctors will make mistakes when they reach for buttons or equipment. A recent study showed that medical errors were the third most frequent cause of death in the United States.
While smart design can reduce the chance of such errors, nobody claims that buildings cure disease. But how much each or any of the design moves in the University Medical Center of Princeton contributed to reducing pain or improving patient approval ratings is also not clear, which frustrates Barry S. Rabner, the hospital’s chief executive. He gave the example of antibacterial flooring, which cost $1 per square foot more than equivalent flooring without the antibacterial agent. “Sounds like a good idea,” he said. “So we did it. But that’s around a $700,000 difference. And where’s the evidence that it works?”
He said he believes architects should provide more hard research and in turn be paid more if their designs improve health as promised. Christopher Korsh, the principal architect on the Princeton project, works for H.O.K., the global design firm. “But it is very difficult to get conclusive results when it comes to hospital design,” he replied. “We employ researchers to study outcomes of what we do. But it’s still not like doing drug development. Pharmaceutical companies can have control groups, placebos. But because every hospital facility is different, and because there are so many other variables, it’s hard to isolate some particular design metric and say it’s responsible for a certain health outcome.”
Mr. Korsh also cited a culture of habit that stands in the way of some design no-brainers. “When we do have innovative ideas or ideas that we back up with research, we talk to doctors and nurses, and very often, they will say, ‘But that’s not how we have done things in the past.’ The best answer to Barry’s question is that, as architects, you can help bring to the table a process that will yield better results.”
There’s another issue, says the architect Michael Graves: “Most hospital architects are not experts at health care design, because they have probably never been in a wheelchair.” Mr. Graves has had to use one since he fell ill 11 years ago, at the age of 69, with viral meningitis. To many of his well-known colleagues, the notion of focusing on health care seems as remote as Miuccia Prada turning her talents to hospital scrubs. But health care is a trillion-dollar industry just discovering the medical and economic benefits of better design. “It’s a significant part of our G.D.P.,” Mr. Korsh pointed out. “Patients now say they won’t come to a facility because they don’t like it, and if there’s a building that can save 2 percent on the cost of delivering health care, that’s huge. Plus good design really can make you better faster.”
Mr. Rabner put it another way: “Architects are right to say they alone can’t control outcomes. But neither can I, and I’m the C.E.O. My point is that they should want more control,” he stressed, “and be a more integral part of the medical team.”
It was his hospital staff, he said, working with Mr. Korsh’s team, that came up with a simple but elegant idea for a double-door lock box, like a hotel room safe, in which to store drugs in each room. The box can be unlocked by nurses from inside the patient room but also from the hallway outside. So instead of the traditional method of dispensing drugs — nurses sorting drugs from one dispensary for all patients on a floor, a system prone to error — pharmacists can now deliver drugs from the hall directly to specific patient rooms, like mail carriers depositing mail in private mailboxes. Nurses can then retrieve the drugs from inside the room, with the patients watching.
O.K., but is the room beautiful?
No. It’s less antiseptic, cluttered and clinical than your average patient room, more like what you find in a Marriott hotel, anodyne and low-key, with a modern foldout sofa under a big window; soft, soothing colors; and a flat-screen TV. Creative designers will discover plenty of ways to improve on its aesthetics.
But the room is dignified, which matters to a patient’s mental health. And it works.
Like pain reduction, architecture has its own cascading effects. New architecture always requires different patterns of movement and behavior. Because single-patient, same-hand rooms take up more space, the new Princeton facility has a wider footprint than the old one. Labor and postpartum nurses who used to work together at one end of the old building have been separated. The old arrangement encouraged teamwork and made medical sense. Now, nurses rely on cellphones to communicate, which annoys many patients. Nurses must constantly make clear that they’re not suddenly taking calls from friends.
Nor could the head wall, the one with all the equipment, be designed entirely from scratch. The project team had to settle on a standard, off-the-rack panel of flat buttons that put the emergency signal inexplicably close to other, more commonly used buttons. There have been more than 150 false alarms since the new hospital opened, nurses told me. They have had to jury-rig a cover for the emergency button.
“We love the new room” is the way Donna Covin, the hospital’s clinical nurse leader, summed things up. “But when it comes to health care,” she said, “there is clearly no regulatory body to prevent idiotic design.”
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