Setting the Stage for Humanistic Design in the Healthcare Industry

During the shift from formalistic design to EBD, the healthcare sector increasingly focused on operational efficiencies to deliver healthcare with increased speed and improved safety and quality. Lean and Six Sigma are among the tools borrowed from the manufacturing industry to improve operational processes as the industry was based on a manufacturing problem—capacity. When transferred to the health care setting, these tools resulted in the ideal outcome of an increased number of patients through the door: merely another sort of increased capacity. The tables have now turned to focus on the experience of the delivery of care. An answer to this has been to build more space that increases revenue by appealing to patients’ experiences, based upon their subjective perceptions of care. The industry will no longer be paid according to how many procedures are completed, or the number of people the hospital has seen, but on the quality of care delivered. This means that the patient’s own reported outcomes play a significant role. This transformation is historic, as it allows for the entire industry to reexamine the science of how care is delivered and how quality outcomes are measured.

A similar transformation can be seen in office environments and knowledge based work, where there is a significant shift in where and how employees work. In the early 1980s we witnessed a transformation to cubicles and an open office concept. Today these open offices have to support the need for increasingly rapid technological development, organizational changes, and a shifting balance of privacy and collaboration (Lee and Brand 2005). Studies have shown that people who are more satisfied with their work environment are more satisfied with their jobs (Veitch et al. 2007). Returning to healthcare, quality is now considered as meeting both the subjective and objective experience of wellness in the hospital visit (Hill 2002). It is the intent of all healthcare systems to deliver high quality care. However, this metric is impossible to evaluate with solely quantitative measures. There is now the need for a collective analysis of both the objective and subjective.

At the level of human interaction, (Harris et al. 2002) healthcare delivery happens at the interface of the patient and the practitioner during the care experience. At a tactical level, it is the interaction of the patient’s presented symptoms and the practitioner’s treatment regimen. At the level of perceived meaning, it is the patient’s subjective account of their entire experience. The convergence of the changing operational focus in medical care with the need for supportive environments to provide a meaningful engagement between patient and care provider, has provided a perfect platform for a complete and holistic transformation of the patient experience, up to and including the physical environment in which this experience occurs. Being able to meet the needs of all aspects of a human being—body, mind, and spirit—is now considered a successful outcome. Other industries refer to this as the “Disney Customer Service” Model (Lee 2004), which has been adopted in multiple hospitality and service industries due to the excellence in the experience of the user. The Disney Institute teaches that there are six key elements that need to be clearly integrated in the delivery of customer service. Relevant to our discussion, the setting is one of these key factors. In many instances, practitioners are unaware of the impact of the built environment on the delivery of quality patient centered care. This transformation has given rise to the need for humanistic design.

Quantifying health care quality has become a hot topic in the past decade and, more recently, with the adoption of the Affordable Care Act in the United States on March 23, 2010. In 1995, the National Committee for Quality Assurance developed the Consumer Assessment of Healthcare Providers and Systems program (CAHPS) (Goldstein et al. 2005). This program provided tools to evaluate healthcare quality equally at every hospital in the nation, for the purpose of improving the quality of care at key points in the healthcare delivery process. It has also provided visibility to the patient experience and empowered patients to view the performance of their hospital through the Hospital Compare website (hospital.compare.gov). These developments have provided a new key indicator of healthcare quality through the experience of care, which goes far beyond patient falls and injuries.

Healing is a process that occurs over time; it is not a sudden discrete event. Positive change within the patient, finding meaning in one’s medical experience, and the realization of physical and psychic wholeness occur in the home, community, and even in nature. However, this report focuses on the outcome of healing and its precursors that occur in the hospital. For many people hospitalization is the beginning of the healing process. Schweitzer et al. (2004) have said, “.. .it might be helpful to reframe the clinical encounter as a place to facilitate healing. The encounter may not necessarily be where healing occurs, but it can become an important catalyst for helping the patient move toward healing within their life space”. Focusing on healing spaces provides a basis for understanding necessary elements and developing metrics that can be used to evaluate the broader range of spaces that support healing as an outcome in healthcare and promotion of dignity as an outcome in other industries.

The Samueli Institute sought to define what healing means by conducting a thorough concept analysis review (Walker and Avant 2011; Baldwin 2008). They identified 99 key terms and phrases that were then refined to 14 higher order concepts. Findings of this review resulted in the following definition, “[h]ealing is a holistic, transformative process of repair and recovery in mind, body, and spirit resulting in positive change, finding meaning, and movement towards self-realization of wholeness, regardless of the presence or absence of disease” (Firth et al. 2015). This definition supports the concept that healing is a process and not an end state. The role of the literature review was to more fully understand the contributors to or detractors from healing, as healing occurs in many ways and in various forms. There are elements that can support the sensory being’s innate ability to heal themselves (Jonas et al. 2014). The optimal healing environment (OHE) framework (Sakallaris et al. 2015) identifies four environments—internal, interpersonal, behavioral, and external—that fall into eight constructs (Fig. 11.1).

An OHE surrounds individuals with elements that facilitate the innate healing process. It is possible to create OHEs in any situation by attending to each of the four environments and their supporting constructs. Individual healing intention and personal wholeness interventions support the internal environment. The interpersonal environment is supported by the relationships and organizations that facilitate healing. The behavioral environment is supported by the actions we take ourselves, and those of others that contribute to a healthy lifestyle and integrative care. Further, the physical environment where we work, live, and play supports the external environment. The four environments build upon the previous norms of formalistic design and EBD. For example, affordances that are a key to formalistic design are no longer focused on only function, but also on healing. Additionally, looking at the pathogenic responses to things such as stress and finding a way to further remove stress through the four domains of healing environment. The EBD research works to further define the spatial influencers, both positive and negative, that could contribute to the process of healing.

Fig. 11.1 Optimal healing environments (OHE) framework

Sadler et al. (2009) made the case for the link between the physical environment where patients receive care, patients’ quality of care, and patient safety. Since the publication of their paper, research has continued to support the important role that the built environment has on improving the quality, safety, and health of patients. In addition to contributing to highly reliable care, key attributes of healing spaces include the following characteristics: relaxing, restorative, and calming; nature filled; mentally, physically, and spiritually engaging; empowering; evoking a sense of well being; improving one’s sense of health. Samueli Institute continues to explore the gap between EBD and the creation of a healing space that evokes a sense of cohesion of the mind, body, and spirit—of the entirety and dignity of a human being.