Cross-posted from the Global Health Ideas blog:
In October 2007 I was working in a place called Suhbaatar, a province in the flat and often dusty steppes of eastern Mongolia named after the hero of the 1921 revolution. The primary activity of this trip was to hang out with community health workers in different sums (counties), a few days in each place, in order to better understand the role information played in their provision of services. The last sum I visited normally has about 4000 people, largely pastoralist nomads, living across an area 1.5 times the size of Rhode Island, with roughly half of them concentrated at the sum center during the fall months. A rough spring for the local pastures meant that many of these 4000 had left on otor, pasturing livestock up to 300km away, making it downright desolate.
On my third day in this sum, I asked the doctor managing the local clinic for a tour of the new clinic being built across the street. GTZ and Lux-Development had both been here recently on health infrastructure projects, but this time the money was coming from the Mongolian government. The doctor, a nurse practitioner, and I walked across the street where we met the foreman, a man who had come here from the capital Ulaanbaatar (photo). Though the work crew was already working on the roof – the construction had started two months earlier – I was surprised to hear the doctor, who had worked here for more than 10 years, asking some critical questions about the layout of the new hospital. After several minutes of interrogation, the exasperated foreman claimed this hospital was the same design as one being completed in another sum. What the doctor knew and the foreman didn’t was that I had just visited that sum. “Is this true?” the doctor asked me. “Does it have the same number of beds?” “Will our hospital be as big?” “No” was the answer on all counts. In consultation with the nurse, the doctor quickly realized this new hospital wouldn’t provide enough space to meet their patient demands. So they would have to keep parts of the old hospital working to meet their needs. So much for the touted energy efficiency of the new vakuum sunh (double-paned windows). This was the result of a top-down approach to hospital design.
Earlier this week the New York Times reported on how health outcomes are driving hospital design in U.S. settings (thanks Dr. Marwah for the article pointer):
In many new hospitals and pavilions … semiprivate rooms have vanished. Single-patient rooms are now viewed as an important element of high-quality health care. The benefits of the single room emerged through evidence-based hospital design, a new field that guides health care construction. More than 1,500 studies have examined ways that design can reduce medical errors, infections and falls — and relieve patient stress.
The idea is simple: change the design of the physical environment to reflect the needs of the people in the system - patients, visitors, administrators, caregivers, insurers - with an eye towards improving health outcomes. There are opportunities both for new construction, but also for retrofits. And the solutions are often simple. From the Times article, Princeton’s University Medical Center is installing larger windows “because studies suggest that natural light can reduce depression and that scenes of nature can reduce reported levels of pain”. From a 2007 SFGate article, Kaiser-Permanente is changing the color of the paint on the walls “to cheery spring shades of pale blue, yellow and green” in an effort to be more patient-focused.
All good and well, but what do systems with limited resources have to take from this approach? Quite a bit it seems…
As an example, consider the recent PLoS study from Peru (Escombe et al., 2007) that showed how natural ventilation - an low-cost alternative to negative-pressure isolation rooms - could be used to reduce intrahospital transmission rates of tuberculosis. The recommendation of the study? Open the doors and windows: “Even at the recommended ventilation rate, the calculated risk of airborne contagion was greater in these mechanically ventilated rooms [in modern facilities built 1970-1990] than in naturally ventilated rooms with open windows and doors [in older facilities built pre-1950]“.
As this research shows there are plenty of opportunities to change the way we work within existing facilities to improve outcomes. And there are plenty of opportunities with systems that are renovating and building new hospitals and clinics. A couple current examples: (1) the Millennium Challenge Corporation is renovating 150 health centers in Lesotho; (2) the Asian Development Bank is building 17 new clinics and renovating 7 facilities, including 3 provincial hospitals as part of the Third Health Sector Development Project in Mongolia (PDF).
The human-centered approach can improve health outcomes with simple innovations derived from a better understanding of the needs of a facility’s users. The open question is whether we’ll take advantage of such an approach or whether - in the words of Roger Ulrich from Texas A&M’s Center for Health Systems and Design - we’ll simply “pay lip service to the evidence”.