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Architects, engineers and project managers are confronting the complex and challenging task of health facility development. With a few notable exceptions, design is failing to engage with the contemporary realities of health service delivery. Functionality in health service design is often stated as the primary objective. I argue here that the functionality is indeed critical, yet functionality in health services is often poorly conceived.
The questions are: How do people populating a health facility interact, behave, and coordinate in the interests of the patient? How can we understand behaviours within a health facility and at what level can we hope to understand these behaviours?
Contemporary health planning diagrams are informed by planning documents that attempt to answer these questions. However, these attempts either prescriptively tell professionals how care should be coordinated or attempt to understand health service behaviour based on ontological assumptions ill-suited to health services, such as lean thinking.
During the course of our research, we often encounter design professionals who express frustration with the vagaries of planning language. Presented with motherhood statements urging the design of facilities to promote patient- or family-centric care, design professionals often respond by providing comfortable spaces for family interaction. For many reasons these efforts are to be applauded. I would argue, however, that such designed embodiments of an ideal do not address health service functionality.
Design can only address functionality if the core processes of the service are understood. Yet our conceptions of the core processes of health services have failed to appreciate the mundanely obvious. Healthcare is a human service and can only be delivered through social interactions. Health facility design has a role to play in accommodating, promoting and eliciting these types of social interaction.
Yet existing approaches view service delivery as atomised actions occurring in linear relationships. Such approaches do not provide the analytical depth required to comprehend the ecology of organisation. Understanding organisational interaction and its complexity is increasingly recognised as the keystone of addressing safety, quality, and coordination of health service delivery. The development of these understandings requires an intellectual shift.
The essence of organisational complexity resides in social junctions; we find that the most effective handle on these junctions is to comprehend organisational communication. Communication, of course, is the most pervasive factor in the delivery of health services often leading to the perception that it the most mundane. I, however, believe that it is the pervasiveness of communication that makes it the single most important factor for understanding how health services are delivered, and therefore how the built environment can accommodate, promote, and elicit behavioural types.
As a healthcare professional myself, it is the chance meetings with colleagues/ patients that exert the most influence over the development of a plan for patient care. Additionally, a quiet moment in a corridor with a patients relative can achieve profound therapeutic effects. Design professionals are experts at formulating junctions of spatial form. Is it then possible to extend these formulations to encompass the spatial-temporal contexts of care and cater for the real complexity of clinical work?
Understanding organisational ecologies and how they evolve through space, place, and time can greatly enrich our ability to design facilities with agency. In our research, we seek to observe and listen to the what, where, and when of health service delivery. With communication providing the handle we can radically reconceptualise the agency of health facilities. I recognise that design professionals are often constrained by improvised planning documents, political imperatives, and fiscal limitations. Yet there are workable solutions. These solutions will require genuine collaboration between patients, health professionals, and the design industry. There is need to recognise that health services are essentially human services. Functionality in a human service stems from the quality of social interaction. Can we then provide facilities that accommodate, promote, and elicit functionality?
Eamon Merrick is a senior researcher at the Centre for Health Communication at UTS. His expertise is in communication research, health services policy, and organisational ecology.
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