Healthy Communities, Healthy People
Susan S. Szenasy talks with representatives from HKS, Inc., Kaiser Permanente, and Children’s Medical Center of Dallas about the shifts in the health-care industry.
For the past two years, Metropolis’s publisher and editor in chief, Susan S. Szenasy, has been leading a series of discussions with industry leaders on important issues surrounding human-centered design. On July 14, she talked to representatives from HKS, Inc., Kaiser Permanente, and Children’s Medical Center of Dallas about the shifts in the health-care industry. The conversation was sponsored by DuPont Surfaces, Sunbrella, Teknion, USG, and USGBC. What follows is an edited transcript of the conversation, prepared by Dora Vanette.
Community-Centric Health Care
Susan S. Szenasy (SSS): Let’s begin by discussing the shift in health care toward community-oriented health resources. Kaiser Permanente, for instance, is a health-care organization, but it is broadening its scope and attempting to reach communities in a new way.
John Kouletsis, vice president, national facilities services, Kaiser Permanente (Kouletsis): We’ve talked for some 15 years about patient-centric design, but we’ve actually done an outstanding job with provider-centric design. That served us well in the past, but it is not serving us well now.
The typical patient at Kaiser doesn’t use our services very often; somewhere around 2 to 3 percent of patients account for 80 percent of our revenue. Unless we can find a way to engage the total person, to reach beyond the once-a-year health encounter, to reach into the community in a meaningful way, to change lifestyles and behaviors, we will lose this battle. There is a tidal wave coming at us, and we are not going to be able to stop it if we continue to cling to today’s paradigm. We’ve spent the last four or five years radically rethinking what it means to receive care. For Kaiser, that has meant an understanding that health care is about mind, body, and spirit.
SSS: What models are you looking at? How do you go about creating this community-oriented health-care approach?
Kouletsis: In our model, if you keep people out of the hospital and keep them healthy—if they lead active lifestyles and are eating healthy food—those are the people who don’t need an intervention. When people come to us for an intervention, that’s fine, we’ll do the best we can, but the game has got to be played on a broader stage than that. There’s a piece of this that is philanthropic, but there’s also a piece of it that’s solid business. If we are just putting Band-Aids on ouches, we are going to lose the battle very quickly.
There is a lot of evidence that there is a growing underclass of poorly educated people who don’t have access to healthy foods or healthy lifestyles. Unless health-care organizations recognize that this is the source of a lot of our trouble, we’re going to be in a really bad situation.
SSS: What about Children’s Medical Center of Dallas—what is your community outreach program and how do you structure it?
Judson Orlando, senior director, facilities development and operations, Children’s Medical Center of Dallas (JO): We’re trying to get out into the community to develop a network, both in underserved and more commercial pay markets. We’re starting to manage health, going all the way down to the root of why children are unhealthy. We need to educate people about health, wellness, and well-being so that we can focus on the more chronic population. We need to focus on the most complicated cases because that’s what health care at a major hospital should be about. It shouldn’t be about using a doctor’s visit because you have some low- acuity issue that is preventable.
SSS: Can you give us an example of the questions that reveal the kind of information you need so you can bring it to the design team and discuss it with them?
Dr. Upali Nanda, director of research, HKS, Inc. (UN): The questions that we ask come from the vision, and the vision comes from the problem we are trying to solve. The questions will differ for Kaiser or for Children’s Medical Center, but it really starts with asking, why is the patient there? You ask questions about the continuum of health and not about a single event. You try to understand what got the patient there, what’s going to make them come back, and what’s going to make them stay away—because our goal is to keep them out of the hospitals.
We try to balance human experience and technology, empathy, and evidence. We have anthropologists and technologists on the same team. The other thing that we focus on is a research-integrated process. The questions often come from design. Research is a way of answering those questions, and the solutions are then manifested back in design.
We also invest in deep-dive studies. For example, we recently researched what today’s health-care consumers want and how to design for an ever-changing health-care environment. The results, which are in our “Clinic 20XX” report, were not what we expected.
The Future of Clinic Design
SSS: How do you design for the clinic of the future?
Jennifer Kolstad, IIDA, ASID, associate AIA, director of interior architecture, HKS, Inc. (Kolstad): A couple of months ago, we asked the question “What does a future-focused health-care model look like, from a bricks-and-mortar perspective?” This could put us out of business, because the answer was that it doesn’t look like bricks and mortar.
The answer is deployment, which is an access question. When you’re talking about health care or wellness within the community, it is about all these things. It’s about food and exercise, but it’s also about access.
Shannon Kraus, FAIA, principal, board of directors, HKS, Inc. (SK): We are trying to figure out if the clinic of the future is actually a clinic at all. That’s a little bit of a heresy, because I’m an architect and I’d like to believe that we do play a very important role in community health. But maybe the role is more than just designing buildings. Maybe the role is in helping owners, like Kaiser, understand where they can influence the community, where they can change things in the community that will have a ripple effect and impact the entire health-care industry.
SSS: It’s interesting to hear that it’s not necessarily about architecture. To me architecture represents the ideas, and the answer is both about buildings and spaces between buildings, land use, landscaping, connection with walkable areas—all these elements.
SK: The practice of architecture and design is shifting and evolving. Should we be talking to city public health officials about what communities need? Are physicians prescribing bicycle time in a neighborhood where there are no sidewalks? Are they prescribing outside time for kids, but there is no park in their neighborhood? We’re in the position to field these questions, to bring together these groups. We’re not experts in having the answers; we’re experts in facilitating the conversation that will arrive at the answers.
We have to make sure we are not dictating to a community what it should have. We have to bring the community together to find out what it needs. Most communities, especially urban ones, have health impact assessments completed by public health agencies that document what those health needs are. We can facilitate health design assessments, bring together the stakeholders, and figure out what projects and initiatives are needed. Altogether, you get a holistic solution that benefits the community.
SSS: This is really important because we’ve seen architects and designers getting involved with city community groups with varied results. A lot of the times people feel like they’re being put upon instead of part of the discourse. This seems like a very different way of engaging.
SK: We speak their language and we facilitate their events. One specific example is MetroHealth in Cleveland. We worked with more than 32 existing groups, all of which had things that they were passionate about. Each one historically worked within its own silo. Our proposal was to bring them all together to figure out what is best for the collective community, to see how we could leverage each group’s interests in a way that drives more value for all.
As designers we might say, “A market garden or a food market would help provide healthy food options for the community.” But perhaps one already exists or maybe there’s a local group already organizing that wants to create it, but needs a place to do it. We can help connect the dots. We’re not forcing them to fit into our preconceptions of what they need. What we’re trying to do is get at the heart of what their challenges are and understand what it is that they need. Issues need to be addressed systemically, working with the community.
SSS: You talk about silos. What are your thoughts on this silo-busting phase we’re entering, and what’s your assessment of where we can go with it next?
SK: The health-care industry is full of silos. Health providers specialize—you see one specialist for your hip, another for your heart—and you wonder who’s looking at the whole-body health system. I think there’s an opportunity for us to be disrupters in this process. We can get to the basics and take responsibility as a profession. We need to be more up-front with our clients, ask more critical questions, bring forth research, define programs, so that by the time we get to the clinic or we get to the building, it all makes sense.
SSS: Architecture is still a male-dominated profession, and so is the health industry. The diversity of solutions, connections, and ideas that we’re talking about requires more diversity in the industry’s ranks as well. How do we tackle this? How do we create a more egalitarian health-care environment?
Kouletsis: The good news is that today our young physicians are increasingly women. We’re also discovering that nursing, which used to be the most abused part of the clinical family, now includes a lot of men.
One of the things that we ask our architect consultants and our general contractors is “how much do you look like our workforce? How much do you look like the community? We all need to ask ourselves these questions. We’re supposed to be weaving a tapestry about the total life of a community, and we might not have a clue what that life is.
The power dynamic is sometimes made up of little things. One of the things we’ve insisted on is that doctors will not continue to talk to patients while sitting on the high chair, once they are done examining the patient. Doctors need to be looking eye to eye with patients, otherwise there is an implied power differential there. It is not okay for doctors to be looking down at the patient.
SSS: One thing I’ve noticed in these discussions is that your profession talks a lot about hospitality design and how it relates to hospital design, but to me it seems like they tackle very different types of circumstances.
Kolstad: When people discuss hospitality design in health care, they just assume that the hospital is going to start to look like a hotel. Hospitality design as a strategy is successful in health care because it is about the choreography of the patient experience—in hospitality, we call it the guest experience. This means that we’re considering the way in which a human being moves through the building. Health care has not been considering this holistically until now.
SK: We had an initiative to figure out how we could better infuse hospitality within health care. The hospitality industry has long researched how to reduce stress, how to craft an experience from arrival to departure. Health care has cherrypicked some of those things, but hasn’t researched how to destress people. And research has shown that people who are more stressed are slower to heal. There is actually an economic incentive for health facilities to want to know how to destress people. I think that’s really interesting for us to think about. How do we learn from these other industries, not in that visual superficial way, but in a really smart way?