sailing in the wind - the International Academy of Design and Health

Architecture | Culture | TECHNOLOGYContributorsNicola BertrandStakeholder engagementwas a key theme of theDesign & Health Australasia2010 InternationalSymposium, says BVNarchitect Nicola BertrandJohn Wells-ThorpeAs chair of the judgingprocess, John Wells-Thorpeintroduces the winnersof the Design & HealthInternational AcademyAward Winners 2010Ray PentecostThe stage is set for TheDesign & Health WorldCongress 2011, supportedby the AIA Academy ofArchitecture for Health andpresident Dr Ray PentecostDr Debajyoti PatiA study by HKS Architectsand the University of Texasat Arlington, led by DrDebajyoti Pati examineshow same-handed patientrooms impact on workflowChristine HancockA new book that looks atthe changing role of nursingand the role and impactof design is reviewed byChristine Hancock, nurseand founder of C3InfectiousHealth reform, it seems, is infectious. The presentpredisposition of Western governments towardsoverhauling not just the practice of delivering healthcareto modern society’s increasingly demanding healthconsumer, but also the very principles upon whichit is provided, is arguably more revolutionary thanit is evolutionary. The new coalition Government’sannouncement in the UK this month of a £1.7 billionreform that will place purchasing power into the handsof 500 GP consortiums overseen by an independentboard, is viewed by many as the beginning of the endof the NHS,with private providers widely expected tothe great beneficiaries. The UK reforms come fast onthe heels of comprehensive health insurance reformsin the US that aim to make healthcare more affordableat the same time as expanding coverage to cover allUS citizens. It seems these two countries may meet inthe middle.But are we missing the point? Is our point ofdeparture wrong? This month’s launch of the preliminaryprogramme for the 7th Design & Health World Congressin Boston, from 6-10 July, 2010 demonstrates a field ofwork that is focused on health promotion by design asa means of improving global population health morecost-effectively through prevention rather thancure. Up to 2,000 delegates and 100 exhibitorswill be attending from more than 80 countries.Make sure you start planning your trip now!.Cover ImageThe Jersey Shore UniversityMedical Cente in theUS, designed by WHRArchitects (see pp24-25).Photo: Woodruff/BrownArchitectural PhotographyMarc SansomEditorial directorwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 03

ContentsEditorial DirectorMarc Sansom MBAT: +44 (0) 1277 634 176E: marc@designandhealth.com52PresidentPer Gunnar Svensson PhDDirector GeneralAlan Dilani PhDT: +46 70 453 90 70E: dilani@designandhealth.comMarketing DirectorJim Benham CIMT: +44 (0) 1277 634176E: jim@designandhealth.comEditorial Advisory Board:Chairman: Dr John Zeisel PhD, USProf Clare Cooper Marcus, USProf Jacqueline Vischer, PhD CanadaProf Young Sook Lee, PhD KoreaDr Eve Edelstein PhD, USProf Noemi Bitterman, IsraelMike Nightingale, UKAlice Liang, CanadaMartha Rothman, USProf Romano Del Nord, ItalyProf Mardelle Shepley, PhD, USDr Ray Pentecost, DrPH, AIA, USGunnar Ohlen MD, PhD, SwedenProf Paul Barach MD, MPH, AustraliaJain Malkin AIA, USDiana Anderson, MD, MArch, USJohn Wells-Thorpe, UKMikael Paatela, FinlandDr Linda Jones, PhD New ZealandContributing writersKathleen Armstrong, Veronica Simpson, Liz GriffinSubscriptions and advertisingT: +44 (0) 1277 634 176E: WHD@designandhealth.comPublished by:The International Academy for Design and HealthPO Box 7196, 103 88 Stockholm, SwedenT: +46 70 453 90 70F: +46 8 745 00 02E: academy@designandhealth.comwww.designandhealth.comInternational Academy for Design and Health UK8 Weir Wynd, BillericayEssex CM12 9QG UKT: +44 (0) 1277 634 176F: +44 (0) 1277 634 041E: WHD@designandhealth.comDesign and production:Graphic Evidence Ltdwww.graphic-evidence.co.ukVolume 3: Number 3ISSN 1654-9654Subscriptions:To receive regular copies of World Health Designplease telephone +44 (0) 1277 634176 to place yourorder, or email WHD@designandhealth.comYearly subscription rates:1 year £70; 2 years £115; Single Issue £25World Health Design is published four times a year bythe International Academy for Design and Health UKNo part of WHD may be reproduced or stored ina retrieval or transmitted in any form, electronic,mechanical or photocopying without prior writtenpermission of the Editorial DirectorPrinted in the UK byThe Magazine Printing Companywww.magprint.co.ukBRIEFING06VISIONARIES TAKE THE STAGEFour preeminent leaders in designand health are set to take the stage at the2011 Design and Health World CongressOpinion03LEADER Marc Sansom looksforward to the 7th Design & HealthWorld Congress in Boston in July 2011, nowless than a year away13STANDPOINT A recent experiencein an Australian hospital has convincedMarc Sansom of the importance of personalpreference in the designed environment17EVENTS & AWARDS11INTERNATIONAL SYMPOSIUM Apreview of Design & Health Europe 2010launching in Brussels in October 201017AWARDS Presenting the winners ofthe 2010 Design & Health InternationalAcademy Awards, announced in Toronto last month51WORLD CONGRESS 2011 The 7thDesign and Health World Congress &Exhibition, to be held in Boston in 2011, will featurean exciting array presentations and posters frominternational experts in design and healthPROJECTS14HEART OF GLASS An undulating wall ofglass and a central cafe have helpedto create a distinctive identity for the KaiserPermanente Los Angeles Medical Center44CHILD IN MIND Healthcare design isbecoming more responsive to the needsof children and their families, writes Liz GriffinMARKET REPORTS52SLOW BUT STEADY The US healthcaremarket may be going through a cautiousperiod but ambition and creativity abound in recentdevelopments, says Veronica Simpson04 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

64ARTS & CULTURE82EXHIBITION REVIEWColin Martin enjoys a celebration of Frederick CayleyRobinson’s paintings in an exhibition at London’s National Gallery85THE ARCHITECTURE OF HOPEColin Martin reviews a new book celebrating the designand philosophy of the Maggie’s Cancer Caring Centres in the UK86nurse: past, present and futureChristine Hancock discusses a book that looks at thechanging role of nursing from Florence Nightingale to today andhow design impacts on the care that they giveSCIENTIFIC REVIEW63SYSTEMS AND STANDARDS A reflection on twostudies from across the Atlantic that seek to explore theimpact of design on the patient room and the operating theatre64PATIENT SAFETY Research commissioned by the UK’sNational Patient Safety Agency looks at how design canminimise patient safety incidents in the operating theatre74ROOM HANDEDNESS A study from HKS Architectsand the University of Texas at Arlington examines howsame-handed patient rooms and standardised mirror-image roomsimpact on process and workflow standardisation74SOLUTIONS59 SOLUTIONSNew developments in technology and design include auser-friendly integrated operating theatre, a sleep sofa designed forthe small footprint in patient rooms, a tree planter for rooftops andstreetscapes and a hospital ward designed for dementia patients59www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 05

BriefingFour global visionaries taketo the stage in Boston 2011Four of the most preeminent global visionaries and leaders in the field of design and healthare set to share the same platform during the opening session of next year’s 7th Design &Health World Congress and Exhibition in Boston, USA.Anticipation of the congress is already growing with a year still to go, following the news thatDr Julio Frenk, dean of the faculty at the Harvard School of Public Health, Mohsen Mostafavi, deanof the Harvard Graduate School of Design, and Richard Joseph Jackson, professor and chair ofEnvironmental Health Sciences at the School of Public Health, University of California, are set totake to the stage in an opening session chaired by Lord Nigel Crisp, former CEO of the NationalHealth Service in England and a member of the House of Lords.Keynote speakers at the congress will include(L-R): Lord Nigel Crisp (UK House of Lords),Dr Richard Jackson (UCLA), Dr Julio Frenk(Harvard University), Mohsen Mostafavi(Harvard University)The announcement follows the publication of the preliminary programme of the congress, which will be held at the Boston MarriottCopley Place Hotel, from 6-10 July 2011. With up to 2,000 delegates from 80 different countries worldwide expected to attend, supportedby over 100 exhibitors, the event is set to have a significant political as well as professional impact on future infrastructure development inthe USA and beyond.Professor Alan Dilani comments: “At a time of rapid upheaval in healthcare systems in the USA, the UK, Australia and many other areasof the world, the commitment of four leaders of such outstanding pedigree demonstrates the importance that is being attached to therelationship between design, architecture and the health of our future society.”For more information, see pages 51 and 56. Copies of the preliminary programme are available with this issue of World Health Design,by visiting www.designandhealth.com, or by e-mailing info@designandhealth.comUAE: Al Maktoum takes top awardThe Al Maktoum Accident and EmergencyHospital in Dubai, UAE was awarded ‘BestHospital Design’ at the Hospital Build MiddleEast 2010 Awards. Designed by PerkinsEastman for the Dubai Health Authority, itwill be the Emirate’s first dedicated A&Efacility when completed in 2013. It sharesthe award with the Cleveland Clinic inAbu Dhabi.China: Super greenA new 36,000sqm ‘super-green’ urbandesign and masterplan scheme, developedby Woods Bagot in Hangzhou in China, is setto transform the city into an internationaleco-tourism centre.UK: Liverpool gets go-aheadThe new £451m development of the newRoyal Liverpool University Hospital hasbeen given the go-ahead, ending weeks ofspeculation following the announcement ofa government spending review.Australia: Best public buildingThe Royal Women’s Hospital has recentlyalso been awarded Best Public Building inAustralia for 2010.USA: Work starts on cancer centrePerkins Eastman has begun work on the newTisch Cancer Institute for Mount Sinai Schoolof Medicine, a 60,000 sq ft state-of-the-artoutpatient facility designed around MountSinai’s multidisciplinary approach to cancercare coupled with translational research.USA: Reducing hospital energy useA US$1.2 million grant has been awarded toNBBJ and the University of Washington toinvest in extending nationwide research intoidentifying strategies for reducing hospitalenergy use by 60% in seven regions outsidethe Pacific Northwest.USA: Firsts for LEED certificationThe new Laguna Honda Hospital &Rehabilitation Center has become the firstLEED-certified hospital in California, whilethe Women & Infants Hospital of RhodeIsland has become the first LEED Goldcertifiedhospital in New England. Bothhospitals are designed by Anshen + Allen.USA: LEED for Jersey ShoreThe sustainable design of the award-winningJersey Shore University Medical Center,designed by WHR Architects, has led itto be awarded Leadership in Energy andEnvironment Design (LEED) certification(see pp52-57).China: Teaching hospital investmentAcademy advisors, Mike Nightingale andMichael Paatela, were two of eight speakersat an international healthcare symposiumorganised by the Union FriendshipExchange Center of Architecture in Beijing,China. The Chinese government has begun aprogramme of investment which includes acommitment to build 800 teaching hospitalsacross China over the next 10 years.UK: Peterborough designers namedWSP and Devereux Architects have beenappointed to design a masterplan andprocurement strategy for Peterborough andStamford Hospitals NHS Foundation Trust.UK: Greenery boosts self-esteemFive minutes of exercise in a ‘green space’ suchas a park can boost mental health, accordingto a study published in Environmental Scienceand Technology. UK scientists looked atevidence from 1,250 people in 10 studiesand found fast improvements in mood andself-esteem.06 July 2010 | WORLD HEALTH DESIGN

Global message goes localThe delivery of the International Academy for Design & Health’s global message,that environmental design needs to be given wider recognition as a context forhuman health, wellbeing and quality of life, has this year successfully gone local.The network’s global reach has extended rapidly in 2010 as a new series ofinternational symposiums, designed to promote understanding of the global issues ofdesign and health within the local context of health infrastructure planning, finance,design, construction and management, have been launched to great acclaim allaround the world.In late April, the Academy’s network came together in Sydney at Design & HealthAustralasia 2010. And in early June, in Toronto, speakers and delegates gathered at Design & Health Canada 2010, which also hosted the2010 Academy Awards and Gala Dinner.At both events, speakers all over the world blended with experts from the local region, to debate a range of topics that examinednew health perspectives and theories, such as salutogenesis, health planning models, patient environments and ward design, research andevidence-based design, as well as demonstrating case studies of some of the most influential healthcare projects recently completed.Nicola Bertrand, an architect with BVN in Australia, who attended the event in Sydney, commented: ”The conference clarified for methe importance for all stakeholders to work closely together right from the beginning of a project. There is a need for us as architectsto work more closely with hospital administrators and health professionals both at a bureaucratic and a clinical level in order to achievedesign excellence.”One of the highlights of the Sydney symposium was a pro-con debate on single versus multi-bed rooms. Mike Nightingale, who chairedthe debate, said that patient needs were evolving so fast that ways needed to be found to design new and refurbished environments thatwere able to change from between 50% and 100% single rooms, or create the advantages of single rooms in other ways.Later in the year, the Academy will launch Design & Health Europe in Brussels, from 7-8 October (see p11), to be followed by Design& Health Middle East 2010 in Abu Dhabi in December.A lifetime of leadershipEb Zeidler (pictured above right) has been awardedthe Lifetime Leadership Award by the InternationalAcademy for Design & Health at a prestigiousceremony held at the University of Toronto in Canada.Awarded for the first time to a visionaryindividual who has demonstrated an ongoing, lifelongcommitment to enhancing the health, wellbeing andquality of people’s lives through their dedication tohealthcare design, the award recognises Zeidler’sinspirational career, which has influenced many oftoday’s architects who are shaping the next generationof hospitals. For more information, see pp18-19.A diverse set of winners from across the globe, including an arts, culture andheritage centre in South Africa, a children’s rehabilitation unit in Mexico, amixed-gender inpatient facility for adults with acute mental illness in the UK, adigital arts programme and a commode, led the celebrations at the prestigiousDesign & Health International Academy Awards in Toronto, Canada on 9 June.Presented by Dr Ray Pentecost, president of the American Institute ofArchitects, Academy of Architecture for Health on the final evening of theDesign & Health Canada 2010 International Symposium, 22 awards were madeacross 12 categories to winning projects and teams.Chaired by John Wells-Thorpe, anarchitectural writer and historian andformer chair of an NHS Trust, the awardswere judged by some of the leadingresearchers and practitioners in the field.Prof Alan Dilani, director general of theInternational Academy for Design & Health,commented: “We have been honouredthis year with a remarkable set of winners,providing inspiration to future generationsand demonstrating the importance ofdesign as a tool for improving humanhealth, wellbeing and quality of life.”For full details of the award winningschemes, see pp17-41Left to right: Mike Nightingale, founder, Nightingale Associatesand Nicola Bertrand, architect, BVNAcademy Award winnersset new benchmarksProf Alan Dilani introducing the awardsWORLD HEALTH DESIGN | July 2010 07

Meyer Children’s Hospital (Italy), by CPSE and Anshen and AllenNew Stobhill Hospital (Scotland), by Reiach & Hall ArchitectsDesign & HealthEurope 20107-8thOctober2010Global Perspectives. Local Identities.An International Symposium & Gala DinnerBrussels, Belgiumwww.designandhealth.comRavelo Medical Clinic (Spain), by gpy arquitectosAltnagelvin Area Hospital (Northern Ireland), by HLM ArchitectsSupported byMedia partnerArchitecture | Culture | TECHNOLOGY

BriefingPPP awardedfor NewKarolinskaSolna hospitalA joint Swedish-British consortiumhas been awarded the public-privatepartnership (PPP) contract to buildthe New Karolinska Solna UniversityHospital (NKS) in Stockholm. Theconsortium is comprised of Swedish construction company Skanska, British investmentfirm Innisfree and Coor Service Management which is based in Solna and will beresponsible for facilities management. The PPP project includes facilities managementuntil 2040, with the option of extending it for a further 15 years.The controversial SEK14.5bn building was designed by Tengbom architects, based ona design concept created by White architects (see image above). Construction is dueto start this summer with the first patient expected to be admitted in December 2015.The new hospital will provide healthcare, research and education in collaboration withthe Karolinska Institutet and other universities and life science organisations in Swedenand internationally.“This is truly a great day,” said Catharina Elmsäter-Svärd, finance commissioner forStockholm County Council. “We have signed a long-term agreement minimising the riskof delays and rising costs for taxpayers. The New Karolinska Solna, university hospitalwill catapult us into the future of healthcare.”“Now we can start to create one of the world’s most modern university hospitalsfor healthcare, research and education,” added Stig Nyman, assistant County Councilfinance commissioner.Six shortlisted for London CancerTreatment Centre designSix consortia have been shortlisted for theopportunity to design and construct thenew Guy’s and St Thomas’ Hospital CancerTreatment Centre in London, UK. The £90mcentre is the first phase in the broaderdevelopment of the Guy’s Hospital site.“The building will be required to lift thespirits for those who use it and achieve thehighest standards of sustainability,” the trustsays. “The successful team will recognise theneed to strike a balance that considers cost,long-term value and architecture.”The six consortia shortlisted for theproject are:• Woods Bagot / BDP / Brookfield;• Anshen & Allen Associates / Rogers StirkHarbour & Partners / Laing O’Rourke;• Hopkins Architects / Skanska ConstructionUK;• Grimshaw / Jonathan Bailey Associates /Bovis Lend Lease;• Allies & Morrison / Devereux Architects /Kier Regional; and• Make / Mace.Mark Kelly, director of Australia-basedWoods Bagot, sees the emergence of‘translational research’ as a key plank inthe design of cancer facilities around theglobe. “Translational research involves theintegration of basic science discoveries arisingfrom the laboratory, clinical and or populationstudies into clinical applications – and hencethe functional design of the facility to supportthis integration becomes paramount,” he says.“Our experience from our recentinternational study tour of 16 world-leadingcancer centres further supports this asthe future direction for all majorhealthcare facilities.”The winning bid is expected to beannounced in September 2010, following anextensive consultation process.Oxford researchfacility topped outThe completion of the main constructionstage for the new £23m, 5,750sqmOxford Molecular Pathology Institute(OMPI), adjoining the Sir William DunnSchool of Pathology at University ofOxford in the UK, was marked by atopping out ceremony in May.The research facility, which was jointlydesigned by Nightingale Associates andMake Architects, will provide muchneededflexible laboratory spacesand new computer services to theuniversity.Head of the Sir William Dunn Schoolof Pathology, Herman Waldmann, saysthe OMPI will offer “fantastic facilitiesfor carrying out frontline research intothe causes of diseases such as cancer,HIV, flu, Alzheimer’s and heart disease”.The design of the new facility aimsto provide a calm and respectfulcounterpoint to the William-and-Marystyle of the school with a moderninterpretation of external detailing,such as cornices and plinths, while thehorizontal expression on the facades,the windows and the materials willecho the details of the original building.“The building will complement andrespond to its setting yet still providea modern and contemporary structurebenefitting a high-tech interior,” saysJustin Nicholls, architect and partnerat Make.“This new building for OxfordUniversity will add a vital research facilityto the university and help it to remainat the top of the tree in terms ofscientific research provision,” addsAdrian Gainer, Nightingale Associates’practice science lead.The OMPI is due to be completed inearly 2011.WORLD HEALTH DESIGN | July 2010 09

Design & Health Europe 2010Shaping the futureA new international symposium in Brussels will explore global ‘salutogenic’perspectives on the planning, procurement, finance, design, constructionand operation of health facilities in Europe, writes Professor Alan DilaniAs Europe struggles to address a trio of economic challenges in the shape of debt, demographic decline and lower growth,the potential for political crises similar to the problems faced recently by Greece grows, as Europeans fear for their jobs andsavings, banks continue to fail, companies forecast lower investment levels, and governments across the continent promotesavage ‘austerity’ cuts to public spending.Faced with these contextual challenges after many years of capital investment in healthcare infrastructure, there has never beena better time for a new paradigm in understanding how to improve the health status of Europeans and recognising that health andwellbeing are the foundation for a productive society, economic development and social and political harmony.In 1997, the World Health Organization stated that the ‘health arena’ should be a priority. It said frequently used spaces, such asworkplaces, schools, hospitals, correctional institutions, commercial offices, public spaces within our towns and cities – and, indeed,our homes – should be at the centre of health promotion activities in the 21st century.From a research perspective, health can be divided into a pathogenic and salutogenic starting point. Pathogenic research focuseson explaining why certain etiological factorscause disease and how they are developed inDesign & Health Europe 2010:Global Perspectives. Local Identities.An International Symposiumand Gala DinnerBrussels, 7-8 October 2010Design & Health Europe 2010 is an internationalsymposium organised by the InternationalAcademy for Design & Health that aims to bringa global perspective to health infrastructuredevelopment in the region by:• Evaluating different international models ofcare, health theories and perspectives• Reflecting on the socio-economic factorsimpacting on European health infrastructure• Learning about regional service modelsdelivering real and measurable benefits• Assessing the design of specialist care servicessuch as mental health and elderly care• Identifying the socio-economic drivers for thedevelopment of healthy communities• Recommending actions and initiatives toimprove design quality and operations• Exploring how to create a sustainableinfrastructure that supports human health,wellbeing and quality of life and meets the region’ssocial, environmental and economic goalsSpeakers will include (top to bottom): John Cole, EuropeanHealth Property Network, UK; Dr Liz Gale, health consultant,Australia; Christine Hancock, C3 Collaborating for Health, UK;Michael Roughan, HDR Architecture, USAthe physiological organism. The primary aimof pathogenic research is often to find medicaltreatments. Salutogenic research is based onidentifying wellness factors that maintain andpromote health, rather than investigating factorsthat cause disease. Together, salutogenic andpathogenic approaches offer a deeper knowledgeand understanding of health and disease.A new paradigm that recognises that humanhealth is significantly related to the designedenvironment is needed. A ‘salutogenic approach’to health infrastructure development, embeddedat the core of a public health strategy focused onpreventative care, changes the focus from riskfactors and the treatment of disease to wellnessfactors and a more holistic understanding ofhealthy environments.A focus on health promotion by design inEuropean countries can be used to inspireinnovative design and infrastructure solutionsthat facilitate an active lifestyle and enable thesuccessful management of physical, psychologicaland emotional stress in our daily lives.Design & Health Europe 2010 is beingdeveloped with the support of the Ministry ofHealth in Flanders and VK Group. Internationalspeakers from across Europe, but also fromCanada and Australia will participate in anexploration of how to provide Europe with amore cost-effective context for enhancing humanhealth, wellbeing and quality of life.To register, visit www.designandhealth.comwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 11

StandpointAfter six months of work, including three long haul trips to Australia and many weeks of workingnights to launch the inaugural Design & Health Australasia 2010 International Symposium, needlessto say the last thing I expected was to be spending the event 3km down the road researching theimpact of hospital design on the patient experience personally and with my own health at risk.As a regular business traveller, I had never before displayed any signs of a predisposition to Deep VeinThrombosis (DVT), but as the pain in my left calf developed over the flight, and I found my mobility severelyrestricted on leaving the airport, I sensed that this may be more than just some temporary muscular pain.After a night’s sleep on arrival at my hotel and finding the pain even worse on wakening, I called thedoctor, who immediately arranged for me to visit the nearest private clinic for a vascular ultrasound on mycalf and a CT scan on my chest.Highly professional, the staff should becomplimented on the speed and attention theypaid to my condition. Being asked to wait dressedin a typically undignified patient gown betweenscans in a changing room no bigger than a shoePersonalpreferencescupboard was less to my liking, however. Oneof the staff kindly left the door of my cupboardopen, but swung out into the corridor, it onlyserved to create an obstacle for other staff tonegotiate every time they walked past.This was also the first moment I started toappreciate the seriousness of my condition, asthe consultant nervously explained that theywould be sending me straight to emergency atthe local hospital, where as it turned out I wouldspend the next eight days of my visit to Sydney.I have always been aware of the risk of DVTfrom long haul flights. I was less aware, however,of the risk of a Pulmonary Embolism (PE), whichoccurs when the clot breaks off from the leg and travels up the main artery to the lung.On arrival at St Vincent’s Hospital, a ten year old facility designed by BVN, I made my way through the front doors of theEmergency Ward (ED). Initially unsure of whether to introduce myself at a small window for people wishing to see the doctor orthe administrative reception window a few paces on through a set of swing doors, my anxiety began to build amidst the managedchaos of the ED.I waited for ten minutes as my quiet frustration increased andA recent experience in an Australian hospital has leftWHD’s editorial director Marc Sansom convinced thatpatient choice is central to recovery and wellbeingaround me patients and their families competed for the attentionof the staff. When seen, I can’t fail to compliment the efficiency,professionalism and attention given to me by the clinical staff.Within minutes I was in a bed with nurses buzzing around, allmy vital signs being monitored, blood being taken for tests andsupplementary oxygen being given. A physician also arrived soonto inform me of the consultant who would be taking on my case,whilst she explained the process of scans, diagnostics and treatmentin store for me.As more tests were performed, the diagnosis of a 17cm clot in asuperficial artery, a 3cm clot in a deep vein on my leg and the moreserious clot blocking the lower and upper regions of my left lungwere confirmed.A heart echo also revealed an abnormal heartbeat on my leftventricular caused by the strain of pumping around the clot.These moments were perhaps the most traumatic of the experience, when uncertainty and confusionreigned. I felt strangely comforted therefore by the noise and distraction of activity around me in the ED, andit was important to me that the curtains around my bed were left open so I could see what was happeningaround me and understand more about the context in which I had found myself. Isolation at this stage was mygreatest fear. With the curtains open, I found distraction in the chaos of the ED.The ‘dirty brown’curtains aroundthe patientbeds gave littleinspiration forrecovery12 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

I was in the ED for 24 hours until my vital signs had settled and the immediate danger to my life hadpassed, after which I was taken up to the stoke and neurology ward. I found myself in one of six 4-bedbays within the ‘racetrack’ designed ward. There were also eight single rooms. On arrival, the stunning viewsover Sydney and the abundance of natural light coming through the large ‘ceiling to (almost) floor’ windowshad an immediate impact on how I felt after the noise and darkness of the chaotic ground floor ED. ButI still felt grateful for the distraction of the other patients around me, and the visibility I had of the nursesresponsible for our bay.I was less impressed with the interiors of the ward however, which were generally drab, colourlessand highly clinical. The ‘dirty brown’ curtains around the patient beds gave little inspiration for recoveryand when drawn around my fellow patients, blocked the natural light and views from the windows. Handwritten name boards above the beds gave the experience an amateur feel, even though the overall nursingcare was professional and expert at all times.The nurses themselves too often foundthemselves unnecessarily visiting the bay as myfellow patients and I regularly sat on our nursecall systems for which there was no natural placefor them to be clipped. Most frustrating of allpersonally was the lack of somewhere to clip myoxygen lead, which meant that every time I visitedthe toilet, I had to leave it on the bed from whereit inevitably fell to the floor. One erroneous nurse’scomment that the “floors were clean” did not allaymy fear of infection.From the nurses’ perspective, they complained tome about the lack of ventilation in the drugs room,but agreed that the decentralised nurse stationdesign worked, even though it had proved to be acultural challenge at first. Having the medical notesclose to the patients had certainly made the nursing more efficient, said one nurse. The work stations were however toosmall, and when the doctors were conducting their rounds, competition for seats to perform paperwork became a challenge.The location of the linen cupboard closer to one end of the ward also increased walking distances for the nurses, whilst thelack of storage elsewhere meant the large shower room at one end was being used to store cleaning materials and buckets,a patient bedside unit and other equipment. One nurse also commented how nice it would be for patients to have a shelfto place pictures of families or for flowers which had no natural place to help brighten up the patient environment.Did the designed environment assist my recovery andimprove my sense of wellbeing? In respect of the views, thenatural light and the visibility and attention of the nursesdue to the decentralised work stations, I believe so. Againstmy expectations, I also found that I was pleased to be inamongst other patients recognising that addressing theemotions of fear, confusion, uncertainty and the prospect ofisolation were critical psychological factors in my recovery.I am certain I would have found the experiencepsychologically more difficult to deal with in a single room,despite the greater control I would have had over myenvironment. Less positively, the highly clinical and drabinteriors, lack of design detail in and around the patientbedside and general maintenance of the facility left a lotto be desired.More importantly however, the experience gave me atimely reminder of how important the work we do at theThe managed chaos and noise of the emergency departmentprovided distraction from the seriousness of my conditionThe stunning viewsover Sydney and theabundance of naturallight had an immediateimpact on how I feltAcademy and the work of all our readers and stakehoderstruly is, but that we still have a long way to travel.Marc Sansom is editorial director of World Health Designwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 13

PlacemakerHeart of glassCompleted in December 2009, the US$10.5m refurbishment and expansion of theKaiser Permanente Los Angeles Medical Center aimed to transform what was acollection of unremarkable, disparate buildings into a unified campus with a façade thatcreated a recognisable identity, as well as creating a new staff and visitor cafeteria.The 16,000 sq ft medical centre spans five city blocks on Hollywood’s Sunset Boulevard.To develop the exterior into a visual gateway for the campus, architectural firm Taylor usedcolour, landscaping and streetscaping to develop a sense of place. A notable feature wasthe undulating glass sculptured glass curtain wall system of the new Rejuv(e)nate Cafe.“I saw an opportunity to do something more playful with the streetside façade of thecafe-to-be and challenged contractors to come up with a cost-effective alternativeto flat glass,” says Taylor’s project manager, Harbans Ghatoade. “When thescaffolding was removed, people saw it as a work of art.”The 400-seat, 1,500 square foot cafeteria includes a 500 square footterrace, and offers space for both dining and relaxation. Its circulationplan leads people from food stations and a coffee bar to the diningarea and to lounge-style seating with upholstered chairs andcoffee tables. Transparent resin-formed hanging ‘clouds’ and adecorative rippled ‘water wall’ help define the spaces and addvisual interest, as well as helping to create a calm, relaxingatmosphere. A programmable lighting system adjustslight levels throughout the day to maximise daylightand support energy efficiency.The cafe acts as a hub for the medical centre,carrying people through rather than past thespace. “Creating a clear connection fromthe parking garage to the concourse, andthen extending the concourse rightthrough the cafe and into the medicalfacilities let us have an inviting spacethat many people can see,” saysMark Costa, Kaiser Permanente’sexecutive director. “Even if theydon’t stop, they note what itis and how they might use itwhen they can.”14 July 2010 | WORLD HEALTH DESIGN

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Academy Awards 2010The winning formulaThe Design & Health International Academy Awards recognise professionalexcellence in the research and practice of designing healthy built environments.This special report profiles the winners announced in Toronto in JuneBy setting standards and benchmarks, the Design & Health awards progamme has a significant influence on the global design anddevelopment of humanistic environments that support health, wellbeing and quality of life. Comprising 12 categories across thekey areas of international healthcare delivery, the awards were presented during the Design & Health Canada 2010 InternationalSymposium at a prestigious ceremony at the University of Toronto.The 12 categories were:• Lifetime Leadership Award• Special Judges’ Award• International Research Project• International Health Project (over 40,000 sqm)• International Health Project (under 40,000 sqm)• Mental Health Design• Sustainable Design• Elderly Care Design• Interior Design• Use of Art in the Patient Environment• Product Design for Healthcare Application• Low-cost Project in a Developing EconomySetting new benchmarksReflecting important aspects of the exceptional work undertaken byresearchers and practitioners at the forefront of the field, the recipients ofthis year’s awards are those who, through unique and outstanding efforts,The glass trophies were awarded to this year’s winners have contributed to the progress of knowledge, and demonstrated visionand leadership in exemplary initiatives and projects.Chaired by John Wells-Thorpe, writer, architect, historian and internationaladvisor to the International Academy for Design & Health, the awards are open tointernational organisations and individuals in both the private and public sectors participatingin either research or practice, including the planning, procurement, design, construction andmanagement of healthy built environments.Judging processConstructed from a group of independent experts from Europe, Asia, Africa, Oceania andthe Americas, the judging panel comprised specialists in their field from multidisciplinarybackgrounds, bringing with them a breadth of experience.While each award category had its own criteria, the judges were alsoasked to consider the following key aspects of any built project: concept;fitness for purpose, originality, application of research findings, benefit tothe community, life cycle costs, client satisfaction, value for money, buildingperformance, procurement, and the quality of design and construction.The academy’s director general, Professor Alan Dilani says: “We aregrateful to all our judges for their critical contribution to this year’soutstanding awards programme, and offer our congratulations to all thefinalists and winners for their exemplar work.”Please turn to the following pages to view the criteria, finalists andwinners for each award category.Chair of theAcademy Awards2010, John Wells-ThorpeDr Ray Pentecost, president of the AmericanInstitute of Architects, Academy of Architecture forHealth, announces the award winners at this year’sawards ceremony in Torontowww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 17

Academy Awards 2010Lifetime Leadership AwardChair of judging panelJohn Wells-Thorpe, International Advisor, International Academy for Design & Health (UK)CriteriaAwarded to a healthcare leader and visionary who has shown an ongoing, lifelong commitment toenhancing the health, wellbeing and quality of people’s lives through their dedication to healthcare design.The award recognises the human and personal qualities needed to push back the boundaries of progressand inspire future generations.Judges’ Citation“Eb Zeidler has designed numerous healthcare projects in the USA, Germany, Hong Kong as well as Canada. He hasreceived over 80 national and international awards and over 400 articles on his work have been published. Beyondpractice, he has shared his ideas academically and in his writing, having completed four books and lectured widely.Three seminal healthcare projects – McMaster University Health Sciences Centre, Hamilton; Walter C. MacKenzieHealth Sciences Centre, Edmonton; The Hospital for Sick Children, Toronto – from the 1960s, 1970s and 1980srespectively, have captured imagination, opened eyes and sparked debate among the healthcare architecturalprofession. All have received international acclaim for their visionary approach to raising the status of hospital design beyond providinga purely technical solution.Eb Zeidler was a pioneer in showing the world that modern, operationally efficient hospitals need not be mere ‘factories’ for treating thesick. Instead, his innovative design recognised the physical, psychological, aesthetic and intellectual needs of patients, staff and visitors alike.He showed the way to future generations of architects and masterplanners by dealing practically with the reality of ongoing change in thedelivery of healthcare. His approach to the use of interstitial space and modular planning as a means of increasing flexibility and reducing lifecycle costs was widely regarded as having set a new standard for ‘futureproofing’.Whereas many healthcare architects are known solely for excelling in this area of this specialisation, Eb Zeidler’s pioneer work spans theboundaries of commercial, retail, entertainment, education, healthcare and places of worship. Indeed, his ability to apply holistic expertise inall these human spaces attracted wide admiration.He has influenced many of today’s architects who are shaping the next generation of hospitals. For many architects, the time working withEb stands as a significant episode in their career – inspired by exposure to his unique foresight, his attention to detail and his capacity tocombine human sensibilities with practical requirements.”18 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerEb ZeidlerWinner of the inaugural Lifetime Leadership AwardEb Zeidler (centre) receiving the Lifetime Leadership Awardfrom Prof Alan Dilani of the International Academy for Design& Health (right), and Cliff Harvey, chief architect at the OntarioMinistry of Health (left)Clockwise from top: Toronto Eaton Centre, Toronto;Princess Margaret Hospital, Toronto; The Atrium,Hospital for Sick-Children, Torontowww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 19

Academy Awards 2010Judges’ Special AwardChair of Judging PanelJohn Wells-Thorpe, International Advisor, International Academy for Design & Health (UK)CriteriaAwarded to a project entered into any category that delights the judges by demonstrating unrivalledinnovation, displaying salutogenic qualities and setting new boundaries and aspirations for architecturalquality in healthcare design.Sponsored byStantecWinnerCentro de Rehabilitación Infantil Teletón, Tamaulipas(Mexico), Sordo Madaleno ArquitectosThe judges said: “This unique project for children of all agessuffering from neuromuscular skeletal disabilities, demonstratesa highly sensitive respect for human dignity. The use of colourcomplements the visual expression of an idea, not only describingthe form, texture and size but also adding an expression ofhuman emotion.”Talia Finsod (right) of Sordo Madaleno Arquitectos receiving the award for theCentro de Rahabilitación Infantil Teletón, Tamaulipas, from Michael Moxam (left)of sponsor Stantec Architecturewww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 21

Academy Awards 2010International Research ProjectLead judgeDr Paul Barach, Department of Anesthesiology and Center for Patient Safety,Utrecht University Medical Center, Utrecht (Netherlands)PanelDr Eve A Edelstein, MArch, PhD (neuroscience), Assoc AIA, F-AAA, University of California, San Diego,NewSchool of Architecture & Design, San Diego Academy of Neuroscience for Architecture (USA)Mungo Smith, director, MAAP Architects (UK)Sponsored byMAAP ArchitectsCriteriaAwarded for a completed, innovative, independently assessed piece of research focused on a particularaspect of the design, function, construction, financing or maintenance of a healthcare facility oraddressing a relevant topic concerning public health in the context of the working environment.FinalistsThe Effect of Art on Patient Agitation in a Psychiatric Holding Unit & Implications for the Business Case(USA), Upali Nanda, Sarajane L Eisen and Deborah Owen, Texas A&M UniversityAn Empirical Examination of Patient Room Handedness in Acute Medical-Surgical Settings (USA), DrDebajyoti Pati (HKS), Thomas E Harvey Jr (HKS), Jennie Evans (HKS), Dr Carolyn Caso (University ofTexas Arlington)How to Implement the Healing Potential of the Built Environment: The Emergency Department as aSignificant Case Study (Italy), Daniela Sorana, TESIS InterUniversity Research Center, Department ofArchitecture, Technology and Design, University of FlorenceLight, Health and Wellbeing: Implications from Chronobiology for Architectural Design (Switzerland/UK), AnnaWirz-Justice and Colin FournierResearching the Relationship between Patient Safety and the Provision of Single-Bed and Multi-Bed Rooms(UK), Patricia Young (National Patient Safety Agency), Kate Fairhall (Arup), Laura Bache (Arup), PeterDodd (Arup)WinnerAn Empirical Examination of Patient Room Handedness in Acute Medical-Surgical Settings (USA), Dr Debajyoti Pati, Thomas E Harvey Jr, JennieEvans and Dr Carolyn CasoFor the full paper, see pp 74-81Dr Debajyoti Pati (centre) and Dr Carolyn Cason (right) receiving theiraward from Chris Shaw of sponsor MAAP ArchitectsNominator’s Citation“This study is the only empirical research that systematically addressed the questions of standardisation and same-handedness, developedobjective definitions of complex concepts and drew meaningful inferences. A trans-disciplinary approach with representatives fromarchitecture, environmental design research, nursing, nursing research, kinesiology and statistics, and a strong stakeholder participation byRNs, renders this study one of the highest quality. The authors employed all rigours employable in a design research project, includingrandomly sequenced tasks and configurations, and multiple analytical procedures involving quantitative and qualitative data analyses. Theuse of real caregivers (RNs) maintained the ecological validity of the data.” Jaynelle F Stichlerwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 23

Academy Awards 2010Health Project(Over 40,000 sqm)Lead judgeKirk Hamilton, Associate Director, Center for Health Systems & Design, Texas A&M University (USA)PanelProf Ian Forbes, Architect and Health planner at Design Inc and adjunct professor, University of TechnologySydney (Australia)Craig Dixon, director – health practice, Tribal (UK)Sponsored byZeidler Partnership ArchitectsCriteriaAn award for an outstanding acute or non-acute healthcare building where patient-centred considerationsare as evident as clinical and managerial priorities. The project must demonstrate an understanding of thetherapeutic effect of a ‘healing’ environment, and show how innovative design permits ongoing flexibilityof use, addresses issues of sustainability and recognises the broader civic context.The finalists3430 Burnet Avenue Medical Office Building (USA), DNK ArchitectsAbbotsford Regional Hospital and Cancer Centre (Canada), Silver Thomas Hanley/Musson Carrell MackeyHenry Ford West Bloomfield Hospital (USA), Albert Kahn AssociatesJersey Shore University Medical Center (USA), WHR ArchitectsMontfort Hospital Redevelopment (Canada), Stantec ArchitectureUniversity of Arkansas Medical Services Bed Tower (USA), HKSHighly CommendedMontfort Hospital Redevelopment, CanadaDesigned by Stantec ArchitectureThe judges said: “A clearly articulated design that transformedthe patchwork fabric of the existing hospital into a contemporaryenvironment of wellness.”Michael Moxam (right) of StantecArchitecture receiving the awardfrom sponsors Zeidler PartnershipArchitects (left)24 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerJersey Shore University Medical Center, USADesigned by WHR ArchitectsThe judges said: “The transformational impact of this stunningproject could only have been achieved through wide stakeholderengagement and a commitment to strong guiding principles focusedon improving the patient experience through evidence-based design,advanced technology and a responsive environment.”WHR Architects and the project team for Jersey ShoreUniversity Medical Center receiving the award from sponsorZeidler Partnership Architects (far left)www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 25

Academy Awards 2010Health Project(under 40,000 sqm)Lead judgeSusan Black, Principal and Director, Perkins Eastman Black Architects (Canada)PanelJohn Cooper, chairman, Architects for Health and Principal, John Cooper Architects (UK)Mike Nightingale, Founder, Nightingale Associates (UK)Stephen Tattle, PRISM Partners (Canada)Sponsored byHDR ArchitectureCriteriaAn award for an outstanding acute or non-acute healthcare building where patient-centred considerationsare as evident as clinical and managerial priorities. The project must demonstrate an understanding of thetherapeutic effect of a ‘healing’ environment, and show how innovative design permits ongoing flexibilityof use, addresses issues of sustainability and recognises the broader civic context.The finalistsAssuta Medical Centre (Israel), Zeidler Partnership ArchitectsThe Alfred Hospital ICU (Australia), Billard Leece PartnershipBristol Heart Institute (UK), CODA ArchitectsCentro de Rehabilitación Infantil Teletón, Tamaulipas (Mexico), Sordo Madaleno ArquitectosChristus St. Frances Cabrini Hospital (USA), WHR ArchitectsThe London Clinic Cancer Centre (UK), Anshen + AllenMansfield Community Hospital (UK),by Swanke Hayden Connell ArchitectsMass General/North Shore Center for Outpatient Care (USA), Shepley BulfinchMater Calvary Hospital (Australia), Suters ArchitectsMiller Children’s Hospital Addition (USA), by TaylorNew Stobhill Hospital (UK), Reiach & Hall ArchitectsNew T&O Facilities, Craigavon Area Hospital (Northern Ireland), Milligan Reside Larkin ArchitectsQueens Centre for Oncology and Haematology, Castle Hill Hospital (UK), HLM ArchitectsRoyal Manchester Children’s Hospital (UK), Anshen + AllenSkypad: Teenage Cancer Trust Unit, Cardiff (UK), ORMS Architecture DesignHighly CommendedAssuta Medical Centre (Israel)Designed by Zeidler Partnership ArchitectsThe judges said: “The design of this outstanding project successfullymerges patient expectations with the hospital’s objectives by integratingthe site with the clinical systems and the culture of the organisation.”Bristol Heart Institute (UK)Designed by CODA ArchitectsThe judges said: “The visually stimulating and human-scale design of thisproject has created a modern, efficient and accessible cardiac centre thatpromotes a sense of dignity as well as organisation.”26 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerNew Stobhill Hospital (UK)Designed by Reiach & Hall ArchitectsThe judges said: “This project is truly world class, placing people atthe heart of the design process within an architecture embedded inlocation and in the psyche of its community. The hospital creates adignified, calm environment for healing patients and staff alike.”Andy Law (right) of Reiach & Hall Architects receiving the awardfrom lead judge Susan Black (centre) and Steve Goe (left) ofHDR Architecturewww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 27

Academy Awards 2010Mental Health ProjectLead judgeChris Liddle, chairman, HLM Architects (UK)CriteriaAwarded for a mental health facility where an effective reconciliation between issues of security andperceived ‘openness’ are evident and where the operational need for supervision does not overwhelmthe imperative to provide a civilising and humane setting to support therapeutic intervention. The projectshould appear community-friendly. Evidence of safe landscaping is important, as are levels of constructionspecification to meet informed standards of sustainability.Sponsored byHLM ArchitectsThe finalistsMaroondah Mental Health Unit (Australia), Silver Thomas HanleyRoseberry Park, St Luke’s Hospital Site (UK), MAAP ArchitectsSister Margaret Smith Centre (Canada), Montgomery Sisam Architects in association with KuchStephenson Gibson Malo Architects & EngineerWandsworth Recovery Centre (UK), MAAP ArchitectsHighly CommendedRoseberry Park, St Luke’s Hospital Site (UK)Designed by MAAP ArchitectsThe judges said: “Despite being the UK’s largest newly constructedmental health facility, the innovative design has created buildings thatare functional, flexible and affordable. At the same time, the design isconsistent with the client’s model of care, providing a sympatheticdomestic environment that promotes security, dignity and independancefor residents and staff.”28 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerWandsworth Recovery Centre (UK)Designed by MAAP ArchitectsThe judges said: “This comprehensive project sets a new internationalbenchmark for mental health facilities, demonstrating how designis concerned with more than just the aesthetic, supporting a majorredesign of the way mental health services are delivered in thisarea of London.”Chris Shaw (right) of MAAP Architects receiving two awardsfrom Cliff Harvey (left) of the Ontario Ministry of Healthwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 29

Academy Awards 2010Sustainable DesignLead judgePhi Nedin, Global Healthcare Business Leader, Arup (UK)CriteriaAwarded for a completed healthcare project where issues of sustainability are achieved at a levelconspicuously above the present mandatory norm and which set a new standard of attainment tosatisfy legislative, technical, financial and moral imperatives. The award will only be made for exceptionalsolutions which must have been in full operation for a minimum of one year.Sponsored byArupThe finalistsAbbotsford Regional Hospital and Cancer Centre (Canada), Silver Thomas Hanley/Musson Carrell MackeyAssuta Medical Centre (Israel), Zeidler Partnership ArchitectsCentro de Rehabilitación Infantil Teletón, Tamaulipas (Mexico), Sordo Madaleno ArquitectosHenry Ford West Bloomfield Hospital (USA), Albert Kahn AssociatesJersey Shore University Medical Center (USA), WHR ArchitectsMater Calvary Hospital (Australia), Suters ArchitectsMedical Center of the Rockies (USA), Heery InternationalNew Stobhill Hospital (UK), Reiach & Hall ArchitectsSt Anthony Hospital (USA), ZGF ArchitectsHighly CommendedMedical Center of the Rockies (USA)Designed by Heery InternationalThe judges said: “The project successfully combines sustainable design,circulation and wayfinding ease, expandable infrastructure, a hospitalityenvironment with patient amenities against the backdrop of the RockyMountains in a world class healing facility.”Russell Sedmak (right) of HeeryInternational receiving the awardfrom Alisdair McGregor (left) ofsponsor Arup30 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerSt Anthony Hospital (USA)Designed by ZGF ArchitectsThe judges said: “The design approach of this outstanding projectfocused on the interconnection between nature, health andwellbeing, reflecting and making use of the stunning local backdropof wooded forests, panoramic landscapes and views to the water. “Jennifer Mountain (right) of ZGF Architects receiving the awardfrom Alisdair McGregor (left) of sponsor Arupwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 31

Academy Awards 2010Elderly Care DesignLead judgeDerek Parker, Anshen + Allen (USA)PanelMikael Paatela, Sweco Paatela Architects (Finland)Ninotschka Titchkosky, principal, BVN Architecture (Australia)Sponsored byAnshen + AllenCriteriaAn award for accommodation designed specifically for the elderly, physically and/or mentally frail, wherea balance has been struck between operational efficiency and the ‘domestic’ atmosphere necessaryfor long-term care and support. The demands of sympathetic landscaping and levels of constructionspecification to meet informed standards of sustainability are important.The finalistsBelong Wigan (UK), PozzoniNewBridge on the Charles (USA), Perkins EastmanHighly CommendedNewBridge on the Charles (USA)Designed by Perkins EastmanThe judges said: “The architectural excellence of this community centredemonstrates a more public identity that does not promote ownershipby any one group, providing cues to residents and visitors that this is anenvironment where everyone is welcome and encouraged to interact.”Brad Perkins receiving a highcommendation on behalf of PerkinsEastman from Annie Coull ofsponsor Anshen + Allen32 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerBelong Wigan (UK)Designed by PozzoniThe judges said: “This project is a new lifestyle concept for elderlypeople that sets new benchmarks for the design and shape offuture environments, delivering care and support within schemesthat prevent social isolation and promote people’s sense of controland independence.”www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 33

Academy Awards 2010Interior DesignLead judgeAnnette Ridenour, President, Aesthetics (USA)PanelSusan Francis, Special Advisor for Health, Commission for Architecture and the Built Environment(CABE) (UK)Kate Bishop, Researcher and Design Consultant (Australia)Sponsored byFarrow Partnership ArchitectsCriteriaAn award to recognise a therapeutic space that enhances the health, wellbeing and quality of life of thepatients, staff and visitors. Preference will be shown to projects, which respect the privacy and dignity ofpatients, and illustrate originality in the design approach and environmental sustainability.The finalistsBristol Heart Institute (UK), CODA ArchitectsEvelyn H Lauder Breast Center, Memorial Sloan Kettering Cancer Center (MSKCC) and MSKCC ImagingCenter (USA), Perkins EastmanMount Sinai Centre for Fertility and Reproductive Health (Canada), Montgomery Sisam ArchitectsNew T&O Facilities, Craigavon Area Hospital (Northern Ireland), Milligan Reside Larkin ArchitectsRadiation Treatment Suites and Waiting Areas, Credit Valley Hospital (Canada), Farrow Partnership ArchitectsRainbow Babies & Children’s Hospital Neonatal Intensive Care Unit (USA), Array HealthcareFacilities SolutionsSkypad: Teenage Cancer Trust Unit, Cardiff (UK), ORMS Architecture DesignTrillium Health Centre – West Wing (Canada), Perkins Eastman Black Architects, Parkin ArchitectsHighly CommendedRainbow Babies & Children’s Hospital Neonatal Intensive Care Unit (USA)Designed by Array Healthcare Facilities SolutionsThe judges said: “To promote a soothing, hopeful experience for all families,the design team successfully developed a themed environment incorporatingboth whimsical and enduring elements.”Evelyn H Lauder Breast Center, Memorial Sloan Kettering Cancer Center(MSKCC) and MSKCC Imaging Center (USA)Designed by Perkins EastmanThe judges said: “An outstanding and innovative interior in a sensitive settingthat enhances the patients’ experience and helps to maintain their dignity. Inthis, the scheme has succeeded admirably.”34 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerTrillium Health Centre - The West Wing (Canada),Designed by Perkins Eastman Black Architects / Parkin Architects (JV)The judges said: “The vision of this project successfully embraced thepatient perspective to bring staff closer to patients while giving themmore control in a holistic environment of wellness.”The team from Perkins Eastman Black receiving its award fromlead judge Annette Ridenour (far left) of Aesthetics Inc and TyeFarrow (far right) of sponsor Farrow Partnership Architectswww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 35

Academy Awards 2010Use of Art in thePatient EnvironmentLead judgeBlair Sadler, Senior Fellow, Institute for Healthcare Improvement (USA)PanelDamian Hebron, Director, London Arts in Health Forum (UK)Margret Meagher, Arts in Health (Australia)Sponsored byPerkins EastmanCriteriaAn award that recognises the effective application of creative endeavour (of any type or in any medium)which further advances knowledge of the potential of the arts to assist significantly in the therapeuticprocess. Preference will be given to conspicuous success in new approaches, stretching still further theboundaries of possibility in the wide creative field.The finalistsArts at Callington Road (UK), Willis NewsonCatherine Mayer Ambient Art (USA), Catherine Mayer Ambient ArtKadlec Regional Medical Center – Pediatric Center (USA), Curtis Group Architects & Skyline Art ServicesMercy Regional Breast Care Center (USA), SCW Art ConsultingNew Hospitals Development, Central Manchester University Hospitals NHS Foundation Trust (UK),LIME ArtsRadcliffe, Ashton and Moorgate Primary Care Centre Artwork Scheme (UK), LIME ArtsSaint John’s Welcome Artwall (USA), Roundtree VisualsSouthmead Hospital: Learning, Research & Pathology Buildings Public Art Programme (UK), Willis NewsonHighly CommendedRadcliffe, Ashton and Moorgate Primary Care Centre Artwork Scheme (UK)LIME ArtsThe judges said: “This project created an ambitious series of contemporary andoriginal artwork that is exciting, vibrant, modern and unique, but based aroundthe participation of the communities that will make use of the buildings.”36 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerSaint John’s Welcome Artwall (USA)Roundtree VisualsThe judges said: “Enhancing the patient experience and supportingthe creation of a restful, calming environment, this unique artprogramme has proved to be flexible, informative and provides thevisitor or patient with a fresh experience. The project was deliveredwith full engagement of the community and staff, with a very efficientuse of resources.”Deborah Roundtree (centre) of Roundtree Visuals receiving theaward from lead judge Blair Sadler (right) and Susan Black (left)of sponsor Perkins Eastmanwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 37

Academy Awards 2010Product Design forHealthcare ApplicationLead judgeColum Lowe, Founder, Being (UK)PanelBill Rostenberg, Principal, Anshen + Allen (USA)CriteriaAwarded for a manufactured product or item of equipment that adheres to human factor principles andwhich is integrally installed in a healthcare environment, advances levels of technical performance andintegrates satisfactorily with the setting designed to accommodate it.Sponsored byHLM ArchitectsThe finalistsDBO Commode (UK), PearsonLloyd / Kirton HealthcareGrand Island Sleep Sofa (USA), David EdwardHandwashing Unit (Canada), Farrow Partnership ArchitectsOpus Overbed Table (USA), Nurture by SteelcaseSafevent Antibacterial Systems (UK), BritplasSeniors Living Domain (Australia), Thomson AdsettSonata (USA), Nurture by SteelcaseSYNC (USA), Nurture by SteelcaseHighly CommendedGrand Island Sleep SofaDesigned by David EdwardThe judges said: “The Grand Island supports the caregiver in the patientenvironment to ensure a continued level of support throughout thehealing process. “John Crawford (right) ofDavid Edward, receivingthe award from lead judgeColum Lowe (left) of Being38 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

WinnerDBO Commode,Designed by PearsonLloyd and manufactured by Kirton HealthcareThe judges said: “The DBO Commode represents a paradigm shiftin commode design and the reduction of infection transfer. The teamof PearsonLloyd, Kirton Healthcare and the Human-centred DesignInstitute at Brunel University created an elegant and robust designfor bedside use that is also easier and quicker to clean.Marc Sansom, editorial director of World Health Design, acceptsthe award on behalf of PearsonLloyd and Kirton Healthcare fromlead judge, Colum Lowe (left) of Being Designwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 39

Academy Awards 2010Low-cost Project ina Developing EconomyLead judgeGeoff Abbott, Director – Health Facilities, CSIR Built Environment, Centre for Scientific and IndustrialResearch (CSIR) (South Africa)PanelMike Nightingale, Founder, Nightingale Associates (UK)John Wells-Thorpe, International Advisor, International Academy for Design & Health (UK)Sponsored byNgonyama Okpanum & AssociatesCriteriaAn award for completed health projects in developing countries where resource constraints posespecific challenges. Projects should demonstrate design ingenuity in achieving an optimum, cost-effectiveand locally appropriate functional health service environment. Designs should recognise user rights,dignity and safety, be locally maintainable and environmentally appropriate.The finalistsCentro de Rehabilitación Infantil Teletón, Tamaulipas (Mexico), Sordo Madaleno ArquitectosGuga S’Thebe Arts & Culture Centre (South Africa), CS Studio ArchitectsHelderstroom Prison, Caledon: Housing for Single and Married Personnel (South Africa), CSStudio ArchitectsVryburg Hospital (South Africa), Bartsch ConsultWinnerGuga S’Thebe Arts & Culture Centre (South Africa)Designed by CS Studio ArchitectsThe judges said: “Situated in the oldest township of the WesternCape, this uplifting project celebrates cultural diversity supported bya multi-purpose environment. This centre successfully acts to preventthe degeneration of the community through arts and culture.”www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 41

Project Report: Children’s HealthChild in mindChildren are not little adults.They are different physically,emotionally and socially. Sosays Derek Parker, former president ofAnshen + Allen – and this differenceis perhaps most apparent in the wayin which children expect to interactwith their surroundings. For example,they prefer an active use of space,as Australian researcher and designconsultant Dr Kate Bishop notes: “They approach any environment with the question ‘what can I do here?’ – as soonas they are well enough.”Bishop acknowledges that while both children and adolescents may respond to a vibrant environment, adolescentsplace a greater emphasis on being able to alter and personalise their surroundings to reflect their own interests andidentity. While both groups need age-appropriate distractions, “children tend to have a smaller wandering range thanadolescents who travel further and seek more sophisticated activities”.This has clear implications for physical range, spatial requirements and layout. Anshen + Allen director JonathanWilson cites the futuristic recreation pods implemented in teenage cancer units in Leeds and Newcastle in the UKas one way to provide personal space. Flexibility is also important due to the fluctuation in patient numbers, as wellas children’s differing medical needs and personal preferences. Wards that can be configured to allow for single andshared rooms, so that those who prefer to share with another patient can, while others are given the space theyneed, are increasingly in demand.Healthcare design is becoming more responsive to theneeds of children and their families, reports Liz GriffinAssassi ProductionsAge-appropriate designThe opportunity to vary, personalise and engage with their environment offers children a valuable coping strategy.However, overstimulation is a common pitfall.“We say we are designing for children, but what does that mean?” questions Parker, citing a diverse patient groupranging from newborns to toddlers, school-age children, teenagers and young adults returning to hospital withchronic childhood diseases such as cystic fibrosis. “The common approach ofprimary colours and a Disney-like carnival atmosphere is inappropriate andnaïve.”He favours a subtler solution: “A neutral, friendly environment, as devoid ofdesigner ego as possible.”Similarly, Blair Sadler, senior fellow at the Institute for HealthcareImprovement in Cambridge, Massachusetts, feels that for teenagers withcancer, chronic conditions or orthopaedic problems a baby-like environmentcan be distinctly unhelpful.A considered use of colour can be seen in Mexico’s award-winning TeletonTampico, a centre for disabled children (see WHD, January 2010). The centreprovides medical, educational and psychological care for children and youngpeople up to the age of 18 and designer Sordo Madleno Arquitectos sawcolour as key way in which to promote wellbeing. A bold palette in intensepinks, yellows and oranges, set among gently landscaped surroundings, waschosen to relax, motivate and elicit positive emotions. There are also sportscourts, fountains and special therapy gardens.A world away in urban south London, UK, children are also benefiting froma brush with nature. Brixton Water Lane child and adolescent mental healthteam, with funding from NHS Lambeth, has responded to feedback fromchildren and their families by transforming a concrete yard into a garden andrelaxing play area.Both staff and children tend the raised flowerbeds and eat the strawberriesthat are grown there. The children enjoy the freedom that this new openenvironment gives them, and it also allows staff to observe as they interact orplay independently. One parent commented that the new garden “has offeredmy daughter the space she needs... it allows us to talk about our family.”Whether a child or young person is in for a short stay, a regular visitor orSurgery in-take area, undersea level, Miller Children’s Hospital44 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Assassi Productionslikely to remain in hospital or hospice care, facilities suchas cafes, cinemas, computer rooms, play and sports areas,enable social interaction and encourage peer support. Andthis can make an enormous difference to their experience.Keeping connectedTeenagers and, increasingly, younger children need theaccess to computers that has become part of everydayschool and home life. The ability to communicate withthe ‘outside world’ and to keep in touch with friends andinterests has real implications for wellbeing, particularly forthose who need longer term care. Such provision is bothexpensive and invaluable.Social facilities also enable young people to form newfriendships – as UK architect John Wells-Thorpe says: “Achild may have become physically isolated at home andcan re-engage with someone who is equally pleased tosee them.”Likewise the opportunity to go the cinema can helpchildren feel connected. The charity MediCinema openedits flagship site at London’s St Thomas’ Hospital in 1999.Over the following ten years two further cinemas haveopened (at Glasgow’s Royal Hospital for Sick Childrenand Newcastle’s Royal Victoria Infirmary). Patients canattend in wheelchairs and even beds, allowing them toescape their normal surroundings. An installation at SouthGwent Children’s Centre in Newport, Wales is underdevelopment, and funding for the completion of theconstruction and internal fitting out has been negotiatedbetween the local NHS trust and the Welsh Assembly.Further potential MediCinema sites throughout the UKare under discussion.Good design supports good clinical practice, says Parker,citing Anshen + Allen’s first children’s hospital – the LucileMiller Children’s Hospital, Long Beach, CaliforniaThe ‘Hero’s Journey with a Castle Refuge’ forms the central themefor the expanded paediatric facilities at Miller Children’s Hospital,which opened its doors in December 2009 following completion of aUS$150m, 120,000 sq ft expansion project. “Inspired by the often-toldstory of the hero’s journey, and also by the way Long Beach’s shorestouch the lands of children all around the world, we began to imagine amagic castle by the sea,” says architect Linda Taylor. “Our building wouldrise up from the street like a castle rising from the rocks on the shores.It would glow like a warm light and be a welcoming beacon. It would bea fitting refuge for a hero.”Children were consulted at a visioning event and their ideas fed intothe final design, reflecting the experiences and cultures of the diversepopulation. Artwork complements the themes on each of the hospital’sfour levels: under the sea, the shore, the garden and the city/citadel. Thelobby is filled with sites and images of the beach and there is a playcentre in which siblings can play and be supervised.The hospital includes a dedicated paediatric surgery suite with sevenoperating rooms, a dedicated paediatric imaging centre, 24 additionalneonatal beds with a further 24 shelled in and 24 general paediatricprivate patient rooms shelled in.Miller Children’s Hospital, Long Beach,CaliforniaClient Long Beach Memorial Medical CenterCost: US$150mArea: 120,000 sq ftCompletion: December 2009Architecture and interior design: TAYLORContractor Turner ConstructionConstruction manager: Cleo Enterprises, LLCStructural engineer: TMAD Taylor & GainesLandscape Architects: Rabben Herman Design Officewww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 45

Project Report: Children’s HealthPackard Children’s Hospital at Stanford in California, now over 20 years old – where innovative design and clinicalpractice go hand in hand.Striking a balanceWe’re now seeing a more sophisticated approach to the role of art and landscape. Parker also points to the MeyerChildren’s Hospital in Florence, Italy, which Anshen + Allen designed with CSPE (Centro Studi ProgettazioneEdilizia), drawing on the expertise of consultants in environmental psychology, ergonomics, visual art and landscapearchitecture (see WHD, July 2009). Opened in 2007, the partially EU-funded hospital is sensitively housed in a1930s villa set among mature trees and surrounded by the Florentine hills. Patients and visitors enter through anarbour-like serra (or greenhouse) of dappled light and shade – and this quality of light and airiness is maintainedthroughout. The architects also sought to ‘humanise’ the facility (formerly a TB institution) by enhancing theacoustic signature of the site and introducing subtle sound into the child’s environment to reduce stress.At Tallahassee Memorial Hospital in the US, music is now used instead of anaesthesia to aid relaxation priorto treatment in a large proportion of cases. SadlerThe challengewith the artsin health is toremember whowe’re doing it forsays this type of work is aided by the wide availabilityof low-cost technologies and is part of a growinginterest in arts in health in general, with significantdevelopments in the US, UK and elsewhere, and withchildren’s hospitals often leading the way.Likewise, Wells-Thorpe believes that sensoryperception therapy incorporating light, music ortexture is becoming more sophisticated and can helpchildren to achieve an equilibrium that an adult mightgain from aromatherapy, for example.CHEX, the Children’s Hospital Explorers initiative,was founded when Anshen + Allen was appointed to design the Lucile Packard Hospital. The organisation brings together poets, artists,landscape architects, lighting designers, sculptors and environmental psychologists to discuss and form best practice in children’s healthdesign. Parker feels the group’s work has led to better understanding of how a sense of discovery can be incorporated in design, of detailas a visual distraction, of the roles of play and socialisation, and of the dilemma of privacy and supervision. “One member of CHEX said,‘Is it fair to expect sick children to be happy?’ Children feel sad, bored and scared, and sometimes angry. So we use design to address themind, body and spirit of the child in authentic and holistic ways while allowing individual expression,” Parker explains.CHEX also explored the role of visual arts, acoustic environments, poetry and kinetics in the healing environment at Comer Children’sHospital at the University of Chicago – and these techniques are now being applied to the design proposals for the Alder Hey Children’sHospital in Liverpool, UK.Dr Bishop is currently embarking on a pilotstudy of adolescents’ experience of acute mentalhealth units. She says: “Participatory research withchildren and young people in healthcare settingsis limited in general, however very little is knownabout the experience of this patient group in thiskind of healthcare setting.”Indeed Bishop believes that until children andyoung people are consistently allowed to influencethe design of healthcare facilities, there is likely tobe a huge variation in the child-friendliness of theseenvironments. “Design teams often claim thatelements in their designs are for children and thatthese features will work a certain way in children’sexperience – with little or no reference to childrenand young people themselves,” she comments.Sadler agrees. He says the focus must alwaysbeen on children and their needs. “The key thingis to get the clinicians and nurses interacting withan artist and get full understanding and buy-in.”He also emphasises the value of getting childreninvolved and making the decisions where possible.“Like all of us they can be incredibly anxious and Meyer Children’s Hospital was designed with a sense of light and airiness throughout46 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Chestnut Tree House Children’s Hospice, Sussex, UKCompleted in 2003 with a contract value of £3.45m, Chestnut Tree Househospice is an inspiring example of child- and family-focused healthcare design.Caring for children with complex and severe conditions and families underenormous pressure, Chestnut Tree offers an invaluable respite environment;it is also, by design, set up for coping with the last days of a child’s life.Project architect Neil Holland Architects took great care in developing abuilding that would be in keeping with its sensitive rural site, opting for theform of a traditional settlement, broken down into smaller scale forms, withlow eaves, in the style of traditional agricultural buildings. Natural materials,some locally sourced, and bricks and tiles in warm tones continue thisaesthetic and promote patient and family wellbeing.Developed on “a scale and aesthetic that is absolutely reminiscent ofhome”, Chestnut Tree House features open domestic kitchen and diningareas, with parents’ bedrooms upstairs, “well-developed but invisible securityand the minimum of healthcare paraphernalia”. Children’s rooms are separatefrom the parents’ areas, but have sofa beds and space for another bed forparents or siblings, as well as communicating doors. There is also a youngperson / teenage bedroom wing to ensure these patients have the privacyand independence they need. As all major care areas demand full access forseverely disabled children, and most areas require full bed access as well, allhave been sited on the ground floor.There are many communal and private areas as well as specialist facilities– wet and dry play areas, and music and computer rooms, a hydrotherapypool room, quiet room and multi-sensory therapy areas. The hospice alsohas a chapel area and bereavement suite, with its own private and secludedwalled garden.Chestnut Tree House Children’s Hospice,Sussex, UKClient: Chestnut Tree TrustArchitect/designer: Neil Holland ArchitectsCompletion: 2003Cost: £3.45mscared about the environment so being aware of that is job one. The challenge with arts in health is toremember who we’re doing it for,” he says.In terms of arts in health, Sadler feels that there is still is a lack of awareness by healthcare leaders of thepositive impacts such projects can have on patients, families and staff. This is something that his recent book,Transforming the Healthcare Experience through the Arts, co-authored with Annette Ridenour, seeks to address.Of course, there is also the financial barrier to overcome, whether a project is funded from a hospital’soperating budget or by philanthropy. Yet, as Sadler says: “Such programmes are relatively low cost with fundsavailable if one has the creativity and commitment to look for them.”Going forwardSo what next for children’s healthcare design? Wells-Thorpe believes the typology is changing, and citesdevelopments like the Maggie’s Centres in the UK as an inspiration for this shift. There is a drive to respondmore effectively to the needs of communities with polyclinics, smaller, more localised sites, and those thatbridge the gap between hospital and hospice care. Yet he notes that it is difficult to compare internationaldevelopments: “Many of the US facilities are breathtakingly expensive and private so it’s very difficult to makea fair comparison with other countries.”However, he also expresses concern that post-occupancy appraisal often doesn’t happen, as by the timeit is appropriate, teams have moved on or are too busy. He says this is deeply regrettable as architects aregenerous in admitting in retrospect what they would have done differently. “We need to talk to chief execs andsay if you had the opportunity what would you do differently next time? You need to build in time for that.”Liz Griffin is a healthcare writer and journalistwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 47

Project Report: Children’s HealthSerenity Suite, City Hospital, Birmingham, UKClient: City Hospital, Sandwell & West Birmingham NHS Foundation TrustCompletion: April 2010Architect: Simon Houldcroft, RPS Planning & DevelopmentStructural engineer: Chris Perry, SDP DesignMechanical & electrical consultant: Engineering Services Design PracticeMain contractor: Stan Hughes, E MantonCity Hospital project manager: Paul ScottSerenity Suite, City Hospital,Birmingham, UKThe Serenity Suite is a midwife-ledunit in Birmingham’s City Hospital,designed to provide a home-likeenvironment where mothers cangive birth with a high degree of privacyand dignity. The suite has five individuallydesigned rooms, a dedicated entranceand a secure garden patio area formothers to use. All external windowshave uplifting murals which screenthe rooms from the semi-publicexternal spaces. The use of soft tones,natural looking materials and the largefull-height murals of bluebell woods,the Norfolk coastline and otherscenes to reduce the institutionalfeel and create interest in corridorsand rooms.“I particularly wanted this facilityto stand apart and for families to beable to have a day they feel holdsspecial memories for them in termsof the environment and also the carethey receive,” says consultant midwifeKathryn Gutteridge.www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 49

7th Design & Health World Congress & ExhibitionA rapidly changing healthcare environment in the USA and around the world is reflected in thescientific programme of the 7th Design & Health World Congress & Exhibition (WCDH 2011),set to be the most progressive and challenging event in the field in 2011Prof Alan Dilani, International Academy for Design & Health,and Dr Ray Pentecost III, president of the American Instituteof Architects, Academy of Architecture for HealthWhen it transports the world of Design & Health to Boston in 2011, theInternational Academy for Design & Health, in partnership with theAmerican Institute of Architects, Academy of Architecture for Health, willbring with it a leading-edge scientific programme that will underpin future professionalpractice in health promotion by design.The partnership with the AIA-AAH has attracted a high level of submitted abstractsfor WCDH 2011, resulting in a programme that includes world-renowned speakersfrom research and practice in government, business and academia from every partof the globe. With further contributions from Harvard University’s School of PublicHealth and School of Design, expectations are rising for what is shaping up to be themost significant congress in the field of design and health throughout the world formany years.Boston, as a city of knowledge and science, is one of the most inspiring environmentsfor healthcare innovation. The venue has been carefully chosen to reflect the values of design and health and to ensure the congress offersan enriching experience for participants.The scientific programme of the congress will offer delegates innovative and stimulating topics, including a broad range of plenary sessions,challenging the community to discuss the factors that contribute to the successful creation of a healthy society. We will present technicalshowcases, posters and an exhibition of thelatest innovations and solutions in the field,providing a unique opportunity for participantsto network and exchange knowledge.Sessions will include presentations byphysicians, psychologists, designers, architects,planners, artists, nursing professionals andeconomists, bringing together as wide arange of perspectives on design and healthas possible. The rich selection of conferencesessions highlights the importance and value ofthis interdisciplinary approach.Topics addressed at the congress will includethe latest research findings in the field including:health-promoting facilities, sustainable design,research-based design, mental health, postoccupancyevaluation (POE), senior care andpublic-private partnership financing models.In addition, the trends and influences ondesign and health will be considered in sessionscovering different global locations, including:Australia, the Middle East, China, India, SouthEast Asia, Africa, Europe and the US.Keynote speakers will include (L-R): Lord Nigel Crisp (UK House of Lords), Dr Richard JacksonThe high quality of scientific research,(UCLA), Dr Julio Frenk (Harvard University), Mohsen Mostafavi (Harvard University)presented in combination with a fascinatingrange of powerful case studies, a major tradeshow and a varied social and cultural programme, will ensure participants enjoy a unique knowledge-enhancing experience.The annual Design & Health International Academy Awards has also been developed to incorporate 12 award categories. Supported bya well-structured judging process, the awards perform a vital advocacy role internationally, rewarding and recognizing excellence in designand health among researchers and practitioners and creating opportunities to benchmark design quality at an international level.We look forward to seeing you in Boston, to greeting old friends and to making new ones. Join us at the opening ceremony to celebratethe 7th Design & Health World Congress and Exhibition at the Marriott Copley Place Hotel in Boston from 6-10 July 2011.Prof Alan Dilani is director general of the International Academy for Design and HealthA platformfor changewww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 51

Market Report: USAWoodruff/Brown PhotographyWhile new, state-of-the-art, multimillion-dollar medical campuses have been thin on the ground in the United States inrecent months, there have been plenty of US$100m projects focused on expanding and upgrading the facilities ofolder hospitals, specifically in emergency and cancer care services, to competitive levels.As that wave crests, another is surfacing, according to Richard Sprow, principal at Perkins Eastman: “The interesting thing abouthealthcare is that the need for capital projects never goes away. Sometimes it’s technology that has to be upgraded. Sometimes it’sthe level of service and quality that patients now expect that has to be met. Sometimes it’s obsolescence. They know they have tokeep their facilities up to scratch.”The mood of the moment is of pragmatic, conservative decision-making, he says. “A hospital that needs to replace 100 obsoletebeds still needs to do that. It’s just a matter of when.”At a time when more ambitious plans have been scaled back, there are always strong arguments for replanning or rationalisingwhat exists and transforming buildingusage with clever expansions – and thereSlow butis plenty of such work around. Architectsare bringing to it all the skills they’velearned in creating the newest patientfriendly,technology-assisted and ergonomicmegahospitals of the boom years. SayssteadySprow: “In the same way that the phrase‘green/sustainable’ has gone from beingsomething Al Gore talked about tosomething everyone talks about, on thedesign side, the idea of designing healthcarefacilities that are friendly to patients and theirfamilies, that offer a healing environmentand relationship to the outdoors, is now anexpectation. Hospital executives are verymuch alert to these issues that once wereseen as softer. Now in every discussion,they are asking us what’s happening withevidence-based design (EBD).”One strongly EBD-influenced project isAlthough caution has underpinned the US healthcaremarket over the last 18 months, Veronica Simpson findsplenty of ambition in new and current schemesWHR Architects’ transformation of Jersey Shore University Medical Center. This US$300m project was characterised by a strongcommitment by the client to maximise wellbeing for all concerned, according to WHR principal and lead architect on the project,Tushar Gupta: “The hospital CEO was looking for nothing less than a transformation – he wanted us to reorganise everything aboutthe hospital around the patient.”This included a commitment to 100% single patient rooms and the desire to create an impactful and welcoming building –including devoting more thought, care and budget to the look and feel of its busy level-one trauma centre than Gupta has seenanywhere else in the US. An elected PebbleProject, ergonomic layouts are designedto reduce staff ‘hunting and gathering’ time.Crisis areas, such as the urgent care area,feature a ‘zen room’ for decompression (forstaff or patient families). There are hybridoperating rooms which combine surgicaland imaging capability, reducing surgicalprocedures required to diagnose and correctvascular deficiencies.WHR also worked with the client tocreate a more responsive nursing layout forthe single patient rooms: there is a centralnursing unit for each 12-bedroomneighbourhood, but there are alsodecentralised stations outside the rooms,“taking the nurse closer to the patient whenrequired,” explains Gupta. The efficacy of thisscheme is currently being researched, withresults due in summer 2010.Jersey Shore University Medical Center comprises 100% single patient roomsSustainability, not only for the benefit of52 July 2010 | WORLD HEALTH DESIGN

Photos: Woodruff/Brown PhotographyJersey Shore University Medical Center,Neptune, New JerseyClient: Meridian HealthArchitecture and interior design: WHR ArchitectsArea: 378,361 sq ft new construction,plus 38,000 sq ft renovationCost: US$300mCompleted: July 2009Structural engineer: DiStasio & Van BurenMechanical & electrical engineer: PWI EngineeringCivil engineer: Dewberry-GoodkindLandscape architect: Melillo & Bauer AssociatesConstruction manager: L F Driscoll CompanyProject manager: Granary AssociatesLighting consultant: Bos Lighting DesignJersey Shore University Medical Center,Neptune, New JerseyA US$300m expansion and renovation programme sees JerseyShore University Medical Center enter a new, ambitious phase tobe one of the region’s leading teaching hospitals. Doors openedon the WHR Architects-designed facilities last August, revealing anew patient care pavilion with all private rooms, a state-of-the-artdiagnostic and treatment building offering surgical suites, a newemergency department and level-one trauma centre capable oftreating 100,000 patients. The trauma centre has its own, daylit andwelcoming entrance, looking onto a small healing garden. WHRprincipal and lead architect Tushar Gupta says: “After all, it’s in theemergency department that the most stress is experienced.”There is generous provision of public space throughout the newbuildings. Gupta explains: “With a diverse variety of spaces, fromintimate family accommodation in the rooms to big gathering spacein the atrium and central healing garden, the idea was to providepositive distraction and an opportunity for healing, respite andrejuvenation whether you are patient or staff.”For the design, Gupta was inspired by the image of a sailingboat, its sails caught by the wind, as the motif of ‘transformationwith a path in mind’, and he used this motif in the central nodeof the T-shaped building to create a ‘wow factor’ orientation pointand vertical circulation space. The centre has achieved LEED Goldcertification for its sustainability and energy-efficiency measures,including the use of recycled, durable materials, low volatile organiccompound (VOC) paints, fabrics and non-PVC vinyls, and 100%outdoor air use for ventilation.• Featured on this issue’s front cover, the Jersey Shore UniversityMedical Center is also the winner of the Best International HealthProject (over 40,000 sq m) at the Design & Health InternationalAcademy Awards 2011 (see pp24-25).WORLD HEALTH DESIGN | July 2010 53

Market Report: USAthe environment but also for patients, staffand the business itself, was also a keyobjective in the design and constructionprocess. Low-flow water systems wereintroduced wherever practical, reducingwater consumption by around 30%. Twogas-fired co-generation units that converton-site waste into steam heat brought abouta 32% reduction in energy costs. Recycledmaterials made up US$6.5m of the materialsused in the project. In addition, light pollutionto the surrounding areas was reducedand the provision of100% outdoor air wasincorporated into the design. A continuousmeasurement and verification plan wasalso implemented to ensure that all energyefficiencystrategies were being realisedthroughout the lifetime of the building.As a result, Jersey Shore became the firstLEED Gold-certified healthcare facility inNew Jersey.Elsewhere, the RTKL-designed Banner Del E Webb Medical CenterPatient Care Tower in Arizona has used EBD theory to plan for apredicted massive growth in population, as young families are movedinto a traditionally retirement-aged community. Services have beenexpanded strategically to allow for better and faster treatment at all ages,with additional overflow space facilitated in its new tower to providemore patient rooms, operating rooms and another intensive care unit(ICU) as demand dictates.In another example of creative re-use, and possibly the first instanceof its kind, an expansion programme at Stanford University Hospital andClinics saw executives decide to convert four former dot-com boomoffice buildings in Redwood City for outpatient premises rather thanbuild new, bespoke facilities on their own sprawling Palo Alto campus.Less of a renovation than a reincarnation, Anshen + Allen worked hardto utilise the best aspects of these entirely glazed, four-storey, steel andconcrete buildings’ daylight provision while ensuring appropriate levels ofprivacy and heat control (see case study on p57).The continuing emergence of spa-influenced design has foundoutlets in both small and large facilities. In Rexburg, Idaho, Ward + BlakeArchitects’ design for the Teton Radiology Center is light years awayfrom the sealed boxes that these imaging centres have traditionallybeen housed in. With slate floors, no-glare natural lighting,cedar-clad ceilings and even a fireplace in the lobby, the spacious andlight-filled facility has been designed to calm and reassure its largelyfemale clientele, as well as to minimise energy use. Sustainable featuresinclude Solarban windows, skylights and solar tubes, and sensors thatshut down electrical lighting when they detect adequate natural light.It is clear to see that although the market may be cautious, innovationis still thriving in the US healthcare market.Veronica Simpson is an architectural writerSt Vincent’s Medical Center,Bridgeport, ConnecticutA major modernisation project, expanding andreprogramming a community teaching hospital,Perkins Eastman created a four-storey 125,000 sq ftlink between the existing lobby and nursing school,to provide a new cancer centre and expand theemergency department. Natural light floods intothe building via a stacked central spine with atriumroof. On the second and third storeys, the spinecreates a double-height internal winter gardenwhich offers communal public space, and privateexterior courtyards used by patients for healingand recovery while undergoing chemotherapy.Skylights into the ground floor below illuminatethe critical care rooms of the expanded emergencydepartment. Perkins Eastman’s masterplanfor St Vincent’s also includes a renovation andmodernisation of the surgical and medical ICUs, anew patient tower and medical office building.St Vincent’s Medical Center,Bridgeport, ConnecticutClient: St Vincent’s Medical CenterArchitect: Perkins EastmanCost: US$550mSize: 125,000 sq ftCompletion: January 2010Construction manager: Gilbane BuildingCompanyMEP engineer: Van Zelm Heywood & ShadfordCivil engineer: Tighe & BondChris Cooper54 July 2010 | WORLD HEALTH DESIGN

West Chester Medical Center, West Chester, OhioLocated to serve a fast-growing suburban community between Cincinnati and Dayton, West Chester MedicalCenter is designed to serve the needs of the 65,000-strong population now and into the future. Designed fromscratch as a ‘new market hospital’, the project evolved through brainstorming with clinicians and consultants as towhat the healthcare environment of the future would offer and look like.The result is a 162-bed (all-private) acute care hospital, which can accommodate a 144-bed expansion withfuture addition of a second tower. The hospital is organised in a concentric fashion around the rotunda atriumlobby, with growth planned to expand outward from the central radius point. The lobby provides registration pluselevators to both first phase tower and the second phase tower when it arrives. The first bed tower’s graceful,contemporary, curve provides a longer radial line at the patient corridor than at the exterior wall – it also giveseach room a slightly pie-shaped design. The room sizes exceed requirements for ICUs, so that they accommodatethe movement of beds and equipment access, and allow for larger care teams when necessary; they also have apull-down couch for family members, plus a chair and desk for reading or computer use.Incorporating the latest healthcare technologies, the facility is 100% digital, and includes a first-of-its-kind nursecall system where a patient uses a bedside touch screen that reaches out via VoIP to find the patient’s lead caregiver,uses infrared locator tags to find the closest nurse if the main one is not available, and allows nurses to answerquestions remotely via wireless phone. And since RTKL designed the hospital architecture and the technologies,high-tech tools are highly integrated throughout.West Chester Medical Center,West Chester, OhioClient: The Health Allianceof CincinnatiArchitects: RTKL AssociatesCost: US$116.5m (construction); $195m(approx total project cost)Size: 389,520 sq ftCompletion: May 2009Medical equipment planning:RTKL Healthcare TechnologiesLow voltage systems: RTKL SpecialSystems Design GroupConstruction manager: Mortenson-MesserHealthcare ConstructionMEP engineer: Fosdick & HilmerStructural engineer: Zinser GrossmanStructuralCivil engineer: Woolpert LLPLandscape architect: Vivian Llambi& AssociatesPhotos: Jeffery TotaroWORLD HEALTH DESIGN | July 2010 55

Call for registrationTo download the Preliminary Program and RegistrationForm please visit www.designandhealth.comThe Marriott Copley Place, Boston July 6-10, 2011An international forum for continuous dialoguebetween researchers and practitionersMedia partnerArchitecture | Culture | TECHNOLOGY

Market Report: USAPhotos: Joe Fletcher PhotographyStanford Medicine Outpatient Center,Redwood City, CaliforniaThe adaptive re-use of a former dot-com office complex intothe Stanford Medicine Outpatient Center (SMOC) is a storyof transformation for building, client and community. The firstproject to successfully transfer clinical departments from themain university campus to a new satellite campus, SMOC housesseven specialty outpatient clinics. The primary goal was to createa world-class healthcare destination of choice that reinforcesStanford University’s reputation for exceptional care andclinical excellence.The project also represents the first step of renewal for thelight industrial and small business district of Redwood City. Theadaptive reuse of this complex of abandoned office buildings wasas much about revitalising a community and providing exemplary,affordable healthcare as it was about providing a cost-effective,eco-friendly design that demonstrated responsible stewardshipof the client’s (and the earth’s) resources.Added elements such as a new porte cochère, connectivewalkways and a triple-height main lobby help to create a senseof arrival, announce a concise entry sequence and establish apositive, reassuring impression for patients. Self-registrationkiosks, equipped with EPIC technology and able to accommodateindividualised wayfinding, further facilitate patients’ access to care.Planning prioritised daylight and views in patient care spacesto assist orientation and organise distinct patient flows. Clinicentries and waiting areas have views to the garden and adjacentstaff work areas are screened from public view. Transoms andclerestory windows draw abundant natural light from theperimeter into the staff workspaces and diagnostic imaging areasthat occupy the core of the floorplate.Several measures were necessary to make the site appropriatefor clinical use, including upgrading the envelope’s energyperformance through sunshading louvres and a high-efficiencydirect/indirect evaporative plant with heat recovery to reduceenergy costs and improve thermal comfort.Stanford Medicine Outpatient Center,Redwood City, CaliforniaClient: Stanford Hospitals and ClinicsArchitects: Anshen + AllenArea: 270,000 sq ft, set in 12 acresCost: US$110mCompletion: opened October 2008Design consultant, public spaces: Brayton HughesDesign StudiosConstruction manager: DPR ConstructionStructural engineer: ESE Consulting EngineersFaçade analysis engineer: ARUPMechanical engineer: Guttmann & BlaevoetElectrical engineer: The Electrical EnterpriseCivil engineer: BkF EngineeringLandscape architecture: Hargreaves AssociatesWORLD HEALTH DESIGN | July 2010 57

SolutionsPlant a treeThe Urban Tree Planter provides a simple solution for healthcare facilities wanting toincrease the number of trees in the built environment. The planter allows mature andsemi-mature trees of up to 12m to be installed in structurally sensitive locations such asrooftops and streetscapes. A wide variety of trees can be grown with the root ball prunedand securely contained without damaging the tree. An integrated irrigation, drainage andlifting system allows the planter to be hoisted or lowered into position and easily accessedfor maintenance. In addition, the internal collar design allows the planter to be fully or halfsubmerged to accommodate external facades, such as communal seating, solar panels oradvertising panels.www.urbantreeplanter.co.ukSleep easyHighly commended at the Design & HealthInternational Academy Awards 2010, (seepp38-39), the Grand Island Sleep Sofa serieswas designed by US furniture manufacturerDavid Edward and architects HDR to enablehealthcare facilities to provide a sleep sofafor caregivers in a patient room with a verytight footprint.The sofa can be easily converted fromsleeping to sitting position without the needfor a mechanical metal mechanism and itsseat cushions are made of highly resilientfoam for long-term support, with nylonzippers to enable the covers to be reversedand easily cleaned. The Grand Island can becustomised to fit in different sized patientrooms and to provide storage for linensand pillows.www.davidedward.comwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 59

SolutionsSafety and simplicityMedical technology supplier Karl Storz has taken its OR1 integrated operatingtheatre to the next level with the launch of the OR1 NEO. The new systemcombines all functions in a newly designed user interface. “OR1 NEO expands theuser’s capabilities and protects against human error, with a focus on the safety of thepatient and the operating room team,” the company says.The system’s user interface has been optimised for touch control with simplecontrols to help make it more intuitive. Its colours have been adapted to lightingconditions in the operating theatre and the World Health Organization (WHO)surgical safety checklist has been integrated into the system to help surgeons identifythe next steps they need to take. The checklist can be adjusted to different standardprocedures and is accessible for both skilled and non-skilled users.“We strive to help surgeons and nurses feel safe and concentrate in a safeenvironment,” the company says. “This calm mood is also noticed by the patientsand it increases their perceived and actual safety.”www.karlstorz.comA senseof placeDementia patients in Longreach Hospital’sCove Ward, part of Cornwall PartnershipNHS Foundation Trust in southwestEngland, are benefiting from an improvedenvironment, thanks to a redesign of theinterior of the ward by Boex 3D CreativeSolutions. “We wanted to create a spacewhich would help patients with orientation,give them a sense of wellbeing, calm andmaximise their recovery,” explains thehospital’s modern matron Ian Bartlett.Teal blue walls contrasting with brownupholstery and ash wood help patients todefine doors, windows and seats. Ceilingpelments, local images from the 1920s and1930s and speakers disguised as 1930sradios all help to reduce the institutional feeland create a sense of time and place.The ward also features new uplighting,seating which can be dismantled for easycleaning, a ward-based interactive sensoryboard and a range of everyday objects tostimulate the senses.www.boex.co.ukwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 61

Design&HealthInternational Academy for Design and HealthDesign & Health Scientific ReviewSystems and StandardsMarc Sansom is editorialdirector of World HealthDesign and CommunicationsDirector at the InternationalAcademy for Design & HealthOne of the most influential reports in the last twodecades set in motion a global push for improvedpatient safety that continues today. To Err isHuman: Building a Safer Health System, which was publishedin 1999 by the US Institute of Medicine, was a wake-upcall for the healthcare industry, identifying that between44,000 and 98,000 people in theUS died every year as a result of avoidable and preventable medical errors.Since then organisations such as the World Alliance for Patient Safety,established by the World Health Organisation, and the National Patient SafetyAgency in the UK have worked tirelessly to embed new cultures and supportthe design of new systems and processes to minimise the risk of adverseerrors occurring.More than a decade on from the report, however, and the contrast in thedeparture points of the two papers published in this issue of World HealthDesign perhaps go some way to demonstrating how far the industry has, ormay not have come. In their 2010 Academy Award winning paper for BestInternational Research Project, ‘Room handedness: Patient Room Layout inAcute Patient Care’, Pati, Harvey, Evans and Cason, are clear in their objectivesto provide a comparison between two types of standardised patient rooms interms of their impact on process and workflow.Despite few empirical studies in healthcare to demonstrate the value ofstandardisation both in terms of workflow and patient safety, the work of theaviation industry to establish the role of human factors as a major cause oferror, and the opportunity that standardisation of equipment, system layout,displays and colour philosophy, creates to minimise this risk, is an argumentthat is already won.By contrast, the paper by the Imperial College Healthcare NHS Trust and theRobens Institute for Ergonomics, ‘Operating Theatre Design and its Influenceon Patient Safety’ raises implicit concerns from the outset that ‘design practiceand understanding in the NHS is less advanced than in other safety-criticalindustries’, such as for example, the airline industry. It calls for ‘better, evidencebasedphysical design’, and an ‘improved awareness of psychological needs inOperating Suite environments’. These implicit concerns are given substance inthe findings of the report which clearly demonstrate ‘no systematic or longtermapproach to the design of operating theatres’, which as a result are64-73Patient Safety: Operating Theatre Designand its influence on patient safetyImperial College Healthcare NHS Trust and theRobens Institute for Ergonomics74-81Room handedness: Patient room layoutin acute patient careDebajyoti Pati, PhD, FIIA, LEED AP, Thomas EHarvey, FAIA, MPH, FACHA, LEED AP, JennieEvans, RN, BS, LEED AP; Carolyn Cason, PhD, RNcausing, ‘problems with safety, such as the risk of infection, efficiency and physical health problems of theatre staff’.The authors of both papers should be congratulated on two thorough studies that systematically address theirobjectives and apply an interdisciplinary approach with a wide group of stakeholders engaged through multiple analyticalprocedures involving quantitative and qualitative data analyses, including data mining, focus groups and workshops. Thereality suggests however that the importance of standardisation in addressing issues of patient safety are yet to beaddressed in the UK, whilst arguably in the US, the debate appears moved on to efficiency of workflow and process.This contrast demonstrates the significant value of this journal help create a better understanding of the current statusof different international health systems and the critical role of design.www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 63

Design & Health Scientific ReviewPatient Safety:Operating theatre design and its influenceon patient safetyDesign that aims to minimise the increasing problem of patient safety incidents must start byconsidering the behaviours of staff, patients and relatives under stress. This study has shownthat currently, well-intentioned design, may be breached through behavioural requirementsImperial College Healthcare NHS Trust andthe Robens Institute for ErgonomicsThis study was commissioned by the UK’sNational Patient Safety Agency (NPSA) inorder to develop a better understanding ofthe safety risks associated with the designof the physical environment in operatingsuites (OS). One objective was to use thefindings to assist in the development ofrecommendations about how to designa safe operative environment for surgicalinpatients.A series of small studies were undertakenduring which the experiences of patients,relatives, surgeons, other clinicians and arange of healthcare staff were considered.These were complemented by workshopswith architects, designers and equipmentmanufacturers and epidemiological analysisbased on two sources of patient safety data,adding further insights into how and wherepatient safety incidents arise.Part of the NPSA’s work is to lead andcontribute to improved safer patient careby informing, supporting and influencingthe UK health sector. It is also responsiblefor the National Reporting and LearningService (NRLS), which aims to improvepatient safety by enabling staff to reportand learn from patient safety incidents. Thestudy was able to use data from this source,as well as from the NHS Litigation Authority(NHSLA) database to further examine thesafety of the OS.What has emerged is a complicatedand often unsatisfactory picture. There isa need for better, evidence-based physicaldesign of operating suites – but the benefitsof enhanced physical design can onlybe realised with improved awareness ofpsychological factors in OS environmentsand a fuller understanding of the interactionsThe Karl Storz OR1 NEO integrated operating theatre has been consciouslydesigned to improve the user interfacebetween physical and psychological needs.The study has demonstrated thatsometimes simple needs have beenoverlooked with attendant consequencesfor performance and patient safety.The work follows the approach originallyestablished in the Design for Patient Safetyreport 1 , which demonstrated how designcan be used to minimise the risk of patientsafety incidents – making hospitals safer forpatients and improving environments forhealthcare workers. The report found thatthe NHS was “seriously out of step withmodern thinking and practice” on design.It also found that design practice andunderstanding is less advanced in the NHSthan in other safety-critical industries. Italso demonstrated that any design initiativeneeded to be seen in the light of the ‘bigpicture’ of the healthcare system and how itrelates to patients.Goal of the studyThe basis for commissioning the researchwas that compromises in patient safety havearisen as a result of recent rapid advances insurgery which have redefined the function ofthe present-day OS. The design of the OS haslagged behind technological advances, leadingto a widening hiatus between the structureand process of surgery. A considered,ergonomics approach to the design, structureand function of the modern OS was thereforerequired to redress the issues.Further research was also needed tounderstand the role that the physical factorsor procedural and communication factorsmight play in the following incident types:• objects left in situ;• preparation requirements prior to surgeryas failure to identify defective/inappropriateequipment leading to patient safetyincidents; and64 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Operating Theatre Design• the physical layout and design ofequipment in theatres.The objectives of the work were to:1. undertake a literature overview relatingto the physical aspects of the OS thathad been identified relative to patientsafety issues;2. develop a framework for undertaking anappropriate study of OS ergonomics andpatient safety;3. analyse a patient safety incidents samplefrom the NRLS to establish an appropriateframework and taxonomy;4. review NHSLA sample data to establishand prioritise areas of concern;5. undertake focus groups to establish theperceptions of OS safety and physical design;6. undertake a risk assessment of theperioperative process using failure modeeffect analysis (FMEA); and7. undertake a prospective hazard analysis(PHA) of the perioperative process usinga prototype risk assessment tool beingdeveloped by a Department of Healthresearch study.MethodologyAn ergonomics approach was adopted anda number of short studies conducted to helpassess current experiences and documentconcerns relating to the operating suite. Theprincipal researchers spent considerabletime familiarising themselves with the layoutand functions relating to the operatingsuite and the tasks involved in surgery.This included observing complex surgery,meeting with clinicians and facilitatingfocus groups.A literature overview was undertakenwith the aim of providing backgroundmaterial to inform the study rather than tobe a systematic critical review. The literaturereviewed has been drawn from recent, peerreviewedliterature and the short reviewpresented in the report provides a usefulintroduction to the topic.A framework to study theatre ergonomicsand patient safety was developed using theNRLS database, from which a purposivesample of 700 patient safety incidents wereextracted and analysed.The NHSLA shares data it collects on allclinical negligence claims with the NPSA.Between April 1995 and 31 December2006, there were just over 40,000 (openand closed) claims in this database, includingall open and closed clinical negligenceclaims made to all trusts in England. It wasdecided that this project might benefitfrom an analysis of a sample of this data toidentify potential design issues. The NPSAwas approached to provide an overviewof the total claims according to locationof incident and cause of claim. An analysisof the overview data helped to prioritisecases for further analysis and also identifiedpotential useful data in 10 separate causeclassification categories. These were furtherrequested from the NPSA.A series of four workshops wereconducted with a wide range of personnelwho were involved in the design or use ofoperating suites. These included:• architects, manufacturers and equipmentsuppliers (n=11 );• clinicians (surgeons, theatre nurse,intensive therapy unit (ITU) nurse,anaesthetist, consultant in critical care) (n=7);• patients, relatives and carers (patients andtheir spouses) (n=10); and• maintenance staff (carpenter, electrician)(n=2).The focus groups were facilitated by anexternal researcher using a predeterminedschedule of prompts to ensure adequatecoverage of key issues. The schedule of‘prompts’ was agreed by the researchers,the NPSA project officer and the workshopfacilitator. The sessions were audio-recordedand were subsequently transcribed andanalysed by an independent researcher.Two risk assessments were conducted.The first used an established method, FMEA.This analysis was undertaken using ‘thesurgeon’s journey’ as the process element.The FMEA was carried out with a teamof laparoscopic surgeons and developeda process map, identified failure modesand produced a derivation of estimates ofrisk (ratings of severity and frequency) foreach failure mode. No attempt was madeto proceed to solution finding for thesefailure modes.In order to provide feedback to theparticipants at each stage, the research teamdeveloped the use of an existing softwarepackage, Mind Manager 2 to represent thefindings at each stage of the risk assessment.This software was found to be an excellenttool for the visualisation of both the processmap and the failure modes.A second risk assessment was conductedusing a prototype risk assessment toolspecifically designed to prospectively identifyhazards. This tool is being developed aspart of a research study funded by theDepartment of Health to provide guidanceto NHS organisations for conductingprospective hazard analyses. A frameworkfor risk assessment, established processmapping and PHA methods form the tool.The toolkit consists of two parts: apreliminary risk review and a comprehensiverisk assessment. Both were conducted inthis study. The same process element as thatused in the FMEA, ‘the surgeon’s journey’,was risk assessed. The risk assessment wasfacilitated by an external facilitator andinvolved a team of surgeons. A preliminaryrisk review and a comprehensive riskassessment were conducted in the firstsession to identify and prioritise risks.The facilitator guided the participants toselect one of the prioritised risks for afurther comprehensive risk assessment.The toolkit contained templates for eachstep of the risk assessment and these wereused in the sessions.Literature reviewTransformations in surgical techniques,including the advent of minimally invasivesurgery, endoscopic surgery, bioroboticsand imaging, have revolutionised thesurgical realm in terms of capability andprocedure. But, while there is little doubtthat technological breakthroughs themselveshave contributed to patient safety 3 , anunacceptable number of avoidable patientsafety incidents are resulting from thewidening disparity between surgicalinnovation and the environment in which itis applied. Trailing wires leading to trips andfalls, monitors inhabiting the perioperativespace, leading to cramped workingconditions and patient and staff injuries, areexamples of the hazards accompanying thelag in OR redesign.Ten percent of all patients treated inan acute setting are likely to experiencea patient safety incident 4 . Patient safetyincidents are thought to be the eighth mostcommon cause of death in America 5 .It is essential to stress that patientsafety incidents rarely result from a singlefactor. Data from the Australian IncidentMonitoring Study 6 places a vast emphasis onsystem -based and organisational factors aswww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 65

Design & Health Scientific Reviewcausal factors for over 95% of patient safetyincidents. Nevertheless, there is a strongtendency to direct or divert human blame inthe reporting of such an incident.The Design Council and UK Departmentof Health conducted a study to developdesign ideas and recommendations with aview to improve patient safety 7 . The studyfound little evidence of an appreciationwithin the NHS of the implications ofdesign on the provision of safe healthcare.It concluded that the latter could not beachieved in isolation of the system or theenvironment in which it belonged and calledfor a better understanding of healthcaresystems and the needs of the professionalsthat work within it.New technology often affects the wayin which a job is conducted or perceived 8 .Innovations that may reduce the likelihoodof patient harm have at times beenabandoned because of design issues whichimpact on workflow and lead to generaldissatisfaction 9 . Changes perceived to beunfavourable are often resisted and thecombination of the technology with theenvironment and interpersonal influencetogether with previous negative results oftechnological implementation can lead torejection of an alteration or addition whichhad the potential to improve patient safety 10 .The importance of human factors haslong been recognised in complex, stressed,scientific working environments. Humanerror has been held responsible for morethan two thirds of accidents and incidentsin such domains 11,12,13 . Large amounts ofcollected data (eg. via the Operating RoomManagement Attitudes Questionnaire)have shown problems in the OS to parallelthose associated with aviation 11 . This makesaviation an excellent model from which togain insight into improving safety within theOS, through advances in both technologydesign and the study of human factors.Yet in comparison with industries such asaviation, with respect to safety performance,healthcare remains at an early stage ofdevelopment 14 .The range of supporting equipmentrequired for routine surgery has considerablybroadened in the last two decades. It hasbeen difficult to physically accommodatesuch technology due to services limitationsand lack of structural support in conventionaloperating room (OR) constructions 15 . Thetrolleys which serve as the cradle for suchinstruments result in overcrowding andcreate suboptimal working conditions. ButIncreasing the size of the OR does notalter the amount of space immediatelysurrounding the operating table. In fact, toolarge an OR makes a wall-mounted screenharder to view and may in fact waste spacewhich could be better utilised. Emphasisshould be placed on organisation and layout.Minimally invasive surgeryThe advent of laparoscopic surgeryis a profound change which has beenimplemented with a rapid sequence ofminor changes with little thought of theroom in which it is conducted 16 . Despite thebenefits to the patient, it is argued that thehuman factors of minimally invasive surgeryhave had a significant impact on the surgeonthat subsequently influences outcome. Thereis a need to understand these human factorsand adjust for them in the development anddesign of operating rooms in an evolutionaryrather than revolutionary manner 17 .Some disagree, saying the importance ofphysical design pales in comparison to theneed for a radical overhaul in the concept ofthe operating room 16 . This school of thoughtviews laparoscopic surgery as a transitiontechnology leading to the widespreadimplementation of robotic and image-guidedsurgery, performed through computerassistance. It stresses the importance ofenhancing the underlying informationtechnology infrastructure, rather than theergonomic placement of wires and booms.With the adoption of minimal-accesssurgery, surgeons tend to be looking awayfrom, rather than at, the surgical site. Screensneed to be placed in an area allowingboth the surgeon and their assistant anunobstructed view of the tasks. The angleat which screens are viewed have an impactnot only on the comfort of the surgeon 18 butalso surgical performance 19,20 and, ultimately,patient safety.Minimally invasive techniques also presentsurgeons with a new host of posturalchallenges, influenced by screen positionand instrument design, the use of footpedals to control diathermy and the heightof the table 21 . Eighty percent of respondentsto a survey targeting laparoscopic andthoracoscopic surgeons experienced back,neck and/or shoulder discomfort, and almost90% were unaware of the existence ofergonomic guidelines, despite 100% statingthat ergonomics was important 22 .The importance of medical devices isalso not to be underestimated. A decadeago, the FDA estimated that the poordesign of medical instruments may beresponsible for half of the 1.3 millionpatient injuries occurring in US hospitalseach year 23 . The purchase or replacement ofan item of equipment must be consideredin view of the encapsulating OR design. Acertain degree of sensible standardisationfor the modern OR is necessary, bothwithin brands, by eliminating the possibilityof incorrect connection and producingbetter user-friendly manuals – and, acrossbrands, reducing errors associated withmistaken familiarity.Fundamental to the design of anycomponent of the OR 24 is ease ofmaintenance of a sterile environment.Designing to aid the process and increasethe effectiveness of sterilisation mayenhance patient safety beyond the scope ofmedical error. Basic structural modificationsand intelligent devices operated throughremote and voice control may ease andimprove sterility.The OR is a highly specialised piece ofa large, complex process. Interrelationshipsbetween people, structure and processmust be fully considered. The functioning ofthe OS is largely dependent upon the rapidexchange of information, services, resourcesand staff. Disruptions lead to uncertainty,wasted time and increased pressure. Thismay push staff to work ‘quickly’ ratherthan ‘safely’ 25 . However, developments intelecommunication will allow intraoperativeworldwide interaction with colleagues andexperts, increasing teaching possibilitiesand procedural safety 26. In addition, the useof common technology such as wirelessnetworks and mobile phones may be anefficient manner by which to improvepatient safety 27 .The OR is a high-pressure dynamicstructure whose design has lagged behindthe technological innovations in surgeryover the last two decades. This hasresulted in medical errors, which couldbe markedly diminished by intelligentOR design. Understanding the interplaybetween environment, technology and thehuman factors which govern surgery is66 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Operating Theatre Designessential to the modern OR. The need toimprove current outcomes, the desire toincorporate new practices and innovationare all of equal importance.NRLS data analysisSeven hundred patient safety incidentsreports were selected from the NRLSdatabase. These comprised a sample of20 patient safety incidents from each ofthe 35 subcategories of reported patientsafety incidents in the operating theatre,anaesthetic room and recovery room.Patient safety incident reports were selectedfrom the following categories:• access, admission, transfer, discharge (foursubcategories examined);• clinical assessment (three subcategoriesexamined);• consent, communication, confidentiality(two subcategories examined);• infection control (two subcategoriesexamined);• infrastructure (staffing, facilities,environment) (11 subcategories examined);• medical devices/equipment (fivesubcategories examined); and• patient accident (eight subcategoriesexamined).A framework was then developed usingthe findings of the literature review andthe NRLS incident reports. Main themesrelating to the operating suite wereextracted and further categorised to formthe framework. It is envisaged that in thefuture, the framework will be able to aid thecategorisation of patient safety incidents inthe operating suite.The framework consisted of five maincategories:1. structure;2. procedure;3. movement;4. communication failure; and5. impact on the surgeon.Each of the main categories were furtherdivided into different elements.NHSLA dataThe NHSLA database contained almost25,000 cases where the ‘location’ of thepatient safety incident was noted. Of these,problems associated with the operatingroom environment accounted for 10,122(40.5%), the anaesthetic room 115 (0.5%)and the recovery room 47 (0.19%). WhileTable 1: Recorded causes of NHS litigation claimsCause n %Intraoperative problems 4711 12.44Surgical foreign bodies left in situ 417 1.10Operate on wrong patient/body part 303 0.80Application of excessive force 275 0.73Equipment malfunction 193 0.51Lack of facilities/equipment 162 0.43Intubation problems 118 0.31Diathermy burns/reaction to preparations 118 0.31Infusion problems 97 0.26Inadequate monitoring in recovery room 55 0.15Total 6449 17.0it is likely that the location of the origin ofany particular patient safety incident may behard to specify, it remains evident that theoperating room itself should be the focus ofgreatest enquiry regarding design issues.There were 37,874 cases in the databasewhere the ‘cause’ of the patient safetyincident was noted. Of these, 6,449 (17%)cases were related to the operating suite.A breakdown of these causes is shownin Table 1.Further analysis was undertaken tounderstand the nature of these problems. Asubset of 20 cases from each of the causelisted was randomly selected for the analysis,although limited to patient safety incidentsthat occurred in the operating theatre orrecovery room. The findings of that analysisare presented here.Operating theatreIntraoperative problems: The 20 casessampled did not contain sufficient detailedinformation to enable a thorough analysisof design implications. This is perhapsunsurprising given the nature of litigationclaims. Many of the failures recordedrelated to failed components (eg. screws)or incorrect placement of clips and screws.The extent to which theatre design maybe implicated in these failures cannot beestablished. These issues were discussed inthe focus groups.Surgical foreign bodies left in situ: Thecases selected for analysis (n=20) includeda high proportion where swabs had beenleft in situ (n=8), although a wide variety ofother objects were also cited. These issuesrequire a separate analysis to examinehow other aspects of theatre design mayincrease or decrease the likelihood of theseevents occurring (eg. lighting, team andequipment positioning), as well as furtherresearch into how the design of the objectsmight be improved in the context ofthe whole operating room system.Wrong-site surgery: Errors wereof limited use in the context of design.The reports cited issues such as notetranscription, misplaced clips and left-rightconfusion. These were explored further inthe focus groups with clinicians.Application of excessive force: The mostnotable feature here was the high frequencyof issues relating to orthodentistry.Equipment malfunction: This categoryoffers significant scope for furtherinvestigation. Examples of problemsidentified included faulty operation of theoperating table as knee-knocked adjustmentlever, the need to reboot imaging equipment,detachment of the insulating beak of aresectoscope and faulty leads leading toburns. It is recommended that a full analysisof these data be undertaken.Lack of facilities/equipment: The moststriking aspect of this analysis was the lackof checking regarding the availability ofappropriate equipment, tools or prostheticsprior to the patient being anaesthetised.Further consideration of how and whenthese failures occur is required with a largerdata set and through focus groups.Intubation problems: In one instance thewww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 67

Design & Health Scientific Reviewventilator tube had become caught underthe bed head. Frequent damage to teeth wasalso recorded as a direct result of intubation.Infusion problems: Only six cases wereidentified in this category and little directrelevance to the systems design of theoperating theatre could be deduced.Diathermy burns/reaction topreparation: These were a significant causefor concern and should be explored furtherin the healthcare professionals focus groupas it is recognised that equipment layoutis likely to play a role in determining thelikelihood of burns occurring.Recovery roomThe number of cases in each category wasTable 2: Surgeon’s journey FMEA analysisTask Sub-task Failure modeCheck theatre listVisit patient and/orspeak to relativesConfirm patientready for operationOperate on patientCheck patient fit foroperationCheck blood resultsCheck patient’s notesFollow routine steps forthe specific operationlow, with none reaching the sample size of 20.Intraoperative problems: None of thereports (n=4) contained information helpfulfor further understanding of the designissues in recovery rooms.Lack of monitoring in recovery room:Nine reports were identified and a themerelating to patients falling was identified, ie.patients may fall from their beds followingan operation. Examples of design ideas thatcould be considered include better design ofbeds, monitoring facilities and ensuring thatpatients have the ability to attract attentionwhen in need.Application of excessive force: Therewas only one report and it did notcontain information that contributed toOperation cancelledOverbookedInaccurate informationUntimely distribution of informationPatient does not attendPatient delayedResults not availableNot done properlyLetter unavailableICU beds not availableICU beds delayedEquipment failureScreenDiathermy does not heat up,connection faultyPhysical tiredness, in same positionfor long periods of time causingpain/numbnessPhysical problems – ache in theback, arms, shoulders, neck, joints,legs (clots)further understanding the design issues inrecovery rooms.Intubation problems: None of thereports (n=3) contained information helpfulto further understand the design issues inrecovery rooms.In summary, the data currently held inthe litigation database provided importantinsights into the role that the operatingroom and associated infrastructure mightplay in the generation of the reportedpatient safety incidents. However, thelimited nature of the reports and the lackof an appropriate classification systemmake interpretation difficult. Certainly,the incidence of objects left in situ needsfurther research to understand the rolethat the physical factors or proceduraland communication factors might play. Inaddition, preparation prior to surgery is alsoa topic requiring in-depth examination, asfailure to identify defective or inappropriateequipment has led to incidents. Finally, thephysical layout and design of equipment intheatres has been identified as a priorityfor further investigation, most notably withrespect to burns associated with diathermy.Surgeon’s journey FMEA analysisA large number (n=72) of failure modes wasidentified by the surgeons when undertakingthe FMEA. Additional failure modes wereidentified by others during the focus groupsand were also highlighted by architects,designers and equipment providers. Andmany of these need to be addressed now– their identification was an unintendedby-product of the research. This is becausethe research was originally envisaged to bea means of identifying where future designrequirements would be needed, not wherea need currently exists.Table 2 has been constructed to providea simplified overview of the top prioritiesrequiring attention as a result of thisresearch. This table shows only those failuremodes that had a high probability rating atleast several times a week.The model has been used to guide themapping of those issues that emergedin the focus groups. It enables areas ofdisagreement, congruence and omissionto be identified. We feel this could beextended to form an audit of existingguidance and become the basis for thestructure of future audit tools.68 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Operating Theatre DesignFor example, design that aims to minimisethe increasing problem of hospital-acquiredinfection must start by considering thebehaviours of staff, patients and relatives,especially during stressful periods. Thisstudy has shown that, currently, wellintentioneddesign may be breachedthrough the behavioural requirements ofindividuals and teams. These, coupled withthe physical limitations of equipment andfacilities, can greatly enhance the likelihoodof noncompliance with well-intendedguidelines or protocols. Use of the Moraymodel can quickly help identify the issuesthat should be considered surroundingany patient safety problem. Importantly,the model also shows what factors maybe important to sustain the wellbeing ofthe healthcare professional working withinthese constraints.Prospective hazard analysisPreliminary risk review: The purpose of thisreview was to identify poorly managed risks,from when the decision is made to operateon a patient to when the patient leavesthe operating department. A high-levelprocess map of the surgeon’s journey wasconstructed. Four hazards were identifiedfrom the process map using a systematicapproach. There was general consensus notto focus on the process step of operatingon the patient as it was accepted that therewere many hazards at this stage of theprocess and time constraints did not allowa full analysis of the hazards. Those hazardsthat were identified hazards were furtherassessed for risk. The hazard related to theuse of the WHO checklist, ‘Harm to patient’,was identified to be of high risk. Actionsproposed to reduce this risk included bettertraining, encouraging correct signing practiceby surgeons and checking that the signatureis present.Another step that had not beenconsidered in the preliminary risk review –‘write operative notes’ – was identified forfurther analysis.Comprehensive risk assessment: Thepurpose of this part of the risk assessmentwas to consider the process of filling outan operative note. Downstream effects ofthe process were included in the scope butnot the downstream details. The structuredwhat-if (SWIFT) method was identified tobe a suitable method for risk assessment.Each process step was further examinedto identify what could go wrong. Currentdefences that exist within the system toreduce these hazards were identified.Participants proposed several actionpoints to reduce the risk of problemsassociated with the writing of operativenotes. These included:• Use the WHO checklist to suggest addingmore prompts to the operative record.• Encourage theatre team participation.• Create deliberate blanks on the formto show that they were not inadvertentlyleft blank.• Create space for specialty-specificinformation.• Stock each specialty theatre with itsown forms.The outcomes of this PHA exerciseillustrate the importance of involving endusers in risk assessment, as well as providingreal insights into sources of potential risksto patient safety. The time and resourcesnecessary for such assessments meanthat only limited, carefully selected anddelimited issues can be analysed in this way.Nevertheless, the potential for developingand utilising this approach in future work onthe physical design of the OS is very great.Results integrationA large amount of data was collected inthis study, including both quantitative andqualitative data. The aim was to identify salientissues relating to safety in the operatingsuite that had emerged from the dataset.There were differences in the aims of thestudies, the sample size, the methods usedand what the data afforded. For example,some of the focus groups and the riskassessment sessions were constrained by thesmall number of participants. The data wasalso dependent on the participants’ range ofexperiences. Table 3 provides a summary ofthe datasets requiring integration.Given the nature of the data obtained inthis study, a narrative review approach wasconsidered to be most appropriate. Thisapproach does not aim to generate newinsights or knowledge but rather servesto summarise and interpret available data,usually using a form of thematic analysis.Each dataset was analysed in sequence,starting with the reports of the four focusgroups, followed by the NRLS incidentreports, NHS litigation data and, finally, therisk assessments. As the narrative reviewaimed to summarise and interpret availabledata, we did not think that the order inwhich the data was analysed would affectthe findings of the analysis.A thematic analysis was conductedfor each of the focus group reports withclinicians, patients and carers, maintenancestaff, and architects and engineers. A tabularsummary of the findings was developed.The analysis of a sample of incidentreports to the NRLS was reported asthe number of incidences relating to thecategories in the framework developed aspart of the study. These categories wereadded to the table developed in the analysisof focus groups.ResultsThemes were categorised as issues beforeentering the operating suite, within theoperating suite including intraoperativeproblems, beyond the operating suite,management issues and general commentsand suggestions. The majority of themesrelated to issues within the operating suite.The following are some of the key themes.Anaesthetic room: The anaesthetic roomis currently situated next to the operatingtheatre, presenting a conflict betweenefficiency, patient experience and patientsafety. It is more efficient to have a separateanaesthetic room so that patients can beanaesthetised before the completion of thesurgical procedure on the previous patient.However, in doing so, there is a greater riskto the patient as some wires or monitorsmay have to be removed for a short periodof time while transferring the patient to theoperating table in the operating theatre.There were also complaints about thelack of space in the anaesthetic room andthat it was not designed to be sterile. Asuggestion was given for a dedicated scrubssink and sensor taps. Patients in the focusgroup reported a very positive experiencein the anaesthetic room describing it ascalm and clean, and thought staff were veryreassuring, friendly and inspired confidence.Maintenance access: Access to theatreswas reported to be poor both on weekdaysand weekends, when maintenance workersare required to perform urgent and routinemaintenance work. This means that staff arenot able to complete required repairs.Doors: There were many complaintswww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 69

Design & Health Scientific ReviewOperating Theatre DesignTable 3: Summary of data collectedFocus groups(n=4)NRLS patientsafety incidentreportsNHS litigationdata 4Risk assessmentusing failuremodes and effectsanalysis (FMEA)Aim(s) Method Nature of dataEstablish how the design of the Qualitative elicitation of experiences around Narrative descriptions of aphysical environment influences issues affecting safety in the operating suite. thematic analysis based on thepatient safety during the pre-, Participants were encouraged to talk freely questions asked in the workshops.peri- and postoperative process. around the issues rather than respond to aseries of preset closed questions.Develop a framework tocategorise critical incidents intheatres.Analyse a sample of incidentsusing the developed framework.Identify causes and locations ofproblems in the operating suitebased on both open and closenegligence claims.a. A risk assessment of thesurgeon’s journey through theoperating suite.b. The framework was developed based ona literature search and the nature of reportedpatient safety incidents to the NRLS.700 incidents (20 random incident reportsfrom each of the 35 subcategories of reportedpatient safety incidents in the OR, anaestheticroom and recovery room) were analysed andcategorised using the developed framework.a. A request was made to the NPSA toprovide the relevant information. A further 20cases from each of the causes identified, wherethe location was given as the OT or recoveryroom, were requested for further analysis.Surgeon participants were guided byexperienced facilitators through an establishedmethod of conducting FMEA.A framework to categorise criticalpatient safety incidents.Categorisation of 700 patientsafety incidents using thedeveloped framework.Total number and percent oflocations where problems werereported to have occurred, andtheir causes. A brief narrativedescription of the analysis.A process map of the surgeon’sjourney through the operatingsuite.A list of potential failure modesassociated with the journey ateach point in the process.A severity score of each of thepotential failure mode identifiedregarding doors in the operating theatre.They are heavy, do not stay open, do notopen fully, don’t seal or do not have a seal.Physical space: Rapid changes in the waythat surgery and surgical education aredelivered have contributed to the currentpoor use of space. There is no systematicor long-term approach to the design ofoperating theatres. The consequencesare problems with safety, such as the riskof infection, efficiency and physical healthproblems of theatre staff. Suggestions giveninclude the use of wireless equipment,providing a separate room for those whoare not directly involved in surgery andtailor-made theatres.Lighting: Issues with lighting were raisedin four of the seven sets of data. Theseincluded lights being heavy, difficult tomanoeuvre, issues with mobile lighting, poordesign of switches, brightness, maintenanceproblems, access to maintain lights andthe need for natural light to help boththe recovery of patients and improve thewellbeing of staff and patients.Noise: Sources of noise in the theatreinclude background noise from thetheatre equipment, building work aroundthe theatres and general chatter that isirrelevant to the operation. These noisesdisturb the surgeons and can also be tiringafter long periods of time. There werealso complaints about noise beyond theoperating suite; patients in intensive careunits and general wards commented thatthese wards were noisy all day long and thesnoring habits of other patients affectedtheir ability to sleep.Temperature and ventilation: Issues withtemperature and ventilation were raisedin both the focus groups and the NHSlitigation data. Focus group discussionssurrounded the difficulty of determining theoptimal temperature in theatres. In theatresthat are cold, theatre staff may wear sterilegowns for warmth. But this can be misleadingas they are not sterile. If the theatre istoo hot, staff can feel exhausted. A conflictexists between the comfort of the patientand the surgeon.Utilities: The issue of electrical systemoverload was raised by maintenance staff.This problem is acute in old buildings. Costconstraints were reported to be a majorcontributing factor to changing the currentsystem. However, maintenance staff alsoreported difficulties in finding spare partsfor very old equipment.Cleanliness and infection control:There were comments on the lack of strictguidelines or discipline on the sterility ofsurgical instruments and where not to wearscrubs. The problem with the wearing ofscrubs largely stemmed from poor designof the theatre complex. There was alsofrustration surrounding cleaning roles andresponsibilities.Communication: There were commentson the lack of communication andfeedback from other theatre staff. Otherissues included not knowing how to useequipment, not communicating clearly orperforming wrong actions such as giving thewrong equipment.Physical and cognitive problems:Physical tiredness and problems such asaching limbs, numbness and pain werereported by clinicians. Issues with lighting,noise, temperature, ventilation and thephysical space of theatres were reportedto be contributing factors to physicalwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 71

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Design & Health Scientific Reviewtiredness. Cognitive fatigue reducesthe ability of clinicians to think clearlyduring operations.Equipment: There were many issuesassociated with equipment and its useincluding equipment failure and equipmentnot being available. Comments were alsomade about the variability in the way thatequipment is used by different surgeons,which can lead to mistakes. Checkingsystems are required to ensure that thenecessary equipment is available prior to thepatient being anaesthetised.Privacy: There is a need for a private placeto speak to relatives following an operation.The lack of privacy was also raised by patients.This was particularly problematic when theywere in the admissions lounge, hospital liftsand wards, dressed in a hospital gown.General layout: Lifts presented abottleneck in the operating process. It wassuggested that the admission lounge belocated nearer to theatres to reduce delays.A hub-and-spoke approach to designing theoperating suite was also suggested.Recovery room: Patients werenot forewarned of the possibility ofhallucinations, related to post-anaestheticrecovery. They also complained of a rigidsystem of communicating with nurses,where they were required to press a belland there was no other option. Patientswere also reported to have fallen from beds.ConclusionThis exploratory research has shown thevery real benefits of academic institutionsworking closely with staff at NHS institutions.It also demonstrates the importance ofworking not just with patients but also theirrelatives or other carers.However the researchers feel that datataken from one small sample should notbe used as indicative of all theatre suites,although the experiences of those who havecontributed to this study have suggestedthat similar concerns occur within otheroperating suites within the NHS.The research has utilised contemporaryergonomics/human factors thinking. As such,a systems model (see Figure 1) may prove auseful starting point for developing a betterunderstanding of the relationship betweenphysical design and behaviour in modernoperating suites (OS).The outcomes of this research areperhaps best considered as the start ofthe work required. Our methods andresults are not yet ready to be considereda finished product nor are we yet able todeliver solutions to the problems that areemerging. Nevertheless we are in a positionFigure 1: A systems model of ergonomics 28to develop this understanding of the designrequirements and feel we have developed apragmatic methodology for capturing issues.AuthorsImperial College Healthcare NHS Trust isan academic health science centre based inLondon, UKThe Robens Institute is a registeredconsultancy of the Institute of Ergonomicsand Human Factors.References1. Department of Health/Design Council. Design forpatient safety. 2003. See http://www.nrls.npsa.nhs.uk/resources/collections/design-for-patient-safety.2. Mind Manager is a commercial mind mappingsoftware application developed by Mindjet Corporation.See http://www.mindjet.com.3. Haugh R. High tech tools transform the operatingroom. Hosp Health Netw 2005 Jan; 79(1):52-6, 24. Vincent CA, Lee ACH, Hanna GB. Patient safetyalerts: a balance between evidence and action. Arc DisChild Fetal Neonatal Ed 2006;91:314-5.5. Kohn LT, Corrigan JM, Donaldson MS (Eds). To Err IsHuman, Building a Safer Health System. Washington DC:National Academy Press; 2000.6. Cooper JB, Newbower RS, Long CD et al.Preventable anaesthesia mishaps: a study of humanfactors. Anesthesiology 1978;49:399-406.7. Clarkson PJ, Buckle P, Coleman R et al. Designfor patient safety: a review of the effectivenessof design in the UK health service. J Eng Design 2004Apr;15(2):123-40.8. Hurley JJ. Towards an organisational psychologymodel for the acceptance and utilisation of newtechnology in organisation. IR j Psychol 1992;13:17-31.9. Karsh BT. Beyond usability: designing effectivetechnology implementation systems to promote patientsafety. Qual Saf Health Care 2004;13:388-94.10. Szajna B, Scamell RW. The effects of informationsystem user expectations on their performance andperceptions. MIS Quarterly 193;17:493-516.11. Helmreich RL, Davies JM. Human factors in theoperating room: Interpersonal determinants of safety,efficiency, and morale. In AA Aitkenhead (Ed), Balliere’sclinical anaesthesiology: Safety and risk management inanaesthesia. London: Bailliere Tindal; 1996.12. Reason J. Human Error. New York: CambridgeUniversity Press; 1990.13. Davies JM. Critical incidents during anaesthesia. InHealy TE & Cohen PJ (Eds), Wylie and Churchill Davidson’sA Practice of Anaesthesia. Boston: Edward Arnold; 1995.14. Hudson P. Applying the lessons of high risk industriesto health care. Qual Saf Health Care 2003;12:7-1.15. American Institute of Architects. Guidelines forthe design and construction of hospitals and health carefacilities / the American Institute of Architects Academy ofArchitecture for Health. Washington, DC: The AmericanInstitute of Architects; 2006.16. Satava RM. Disruptive cisions. Surg Endosc2003;17:104-7.17. Gallagher AG, Smith CD. From the operationroom of the present to the operating room of thefuture. Human factor lessons learned from the minimallyinvasive surgery revolution. Semin Laparosc Surg 2003Sept;10(3):127-39.18. Berguer R. Surgery and Ergonomics. Arch Sur 1999Sept;134:1011-6.19. Hanna GB, Shimi SM, Cuschieri A. Task performancein endoscopic surgery is influenced by location of theimage display. Ann Surg 1998;227:481-420. Ames C, Frisella AJ, Yan Y et al. Evaluation oflaparoscopic performance with alteration in angle ofvision. J Endourol 2006 Apr;20(4):281-3.21. Van Veelan, Jakimowicz, Kazemier. Improvedphysical ergonomics of laparoscopic surgery. MinimInvasive Ther Allied Technol 2004 Jun;13(3):161-6.22. Wauben LSGL, van Veelan MA, Gossot D,Goossens RHM. Application of ergonomic guidelinesduring minimally invasive surgery: a questionnaire surveyof 284 surgeons. Surg Endosc 2006 Aug;20(8):1268-74.23. Burlington DB. Human factors and the FDA’s goals:improved medical device design. Biomed Instrum Technol1996;30:107-924. Schurr MO, Buess GF, Wieth F et al.Ergonomic surgeon’s chair for use during minimallyinvasive surgery. Surg Laparosc Endosc Percutan Tech1999 Aug;9(4):244-7.25. Waring J, McDonald R, Harrison S. Safety andcomplexity: inter-departmental relationships as a threat topatient safety in the operating department. J Health OrganManag 2006;20(2-3):227-42.26. Reijnen MM, Zeebregts CJ, Meijerink WJ. Future ofoperating rooms. Surg Technol Int 2005;14:21-7.27. Ruskin KJ. Communication devices in the operatingroom. Curr Opin Anaesthesiol 2006 Dec;19(6):655-9.28. Moray N. Culture, politics and ergonomics.Ergonomics 2000; 43(7):858-68.www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 73

Design & Health Scientific ReviewRoom Handedness:Patient room layout in acute inpatient careThis US study asks whether standardised same-handed patient roomscontribute any more to process and workflow standardisation thanstandardised mirror-image rooms in acute medical-surgical settingsDebajyoti Pati, PhD, FIIA, LEED AP, ThomasE Harvey, FAIA, MPH, FACHA, LEED AP,Jennie Evans, RN, BS, LEED AP, Carolyn Cason,PhD, RNSince the publication of the Institute ofMedicine and Agency for HealthcareResearch and Quality reports highlightingunsafe conditions in American hospitalcare 1-5 , the healthcare design industryhas responded with a number of designconcepts that are hypothesised tocontribute to safety and efficiency. One ofthe design concepts proposed is the ‘samehandedpatient room’ 6-8, with an increasingnumber of hospitals adopting the conceptat all levels of patient acuity.Despite the safety assertions 6,8,9 , thebalance between perceived premiumin capital expenditure and perceivedenhancement in efficiency and safetycontinues to be the focus of debate.Empirical data on the true premiumin capital expenditure is not available.However, anecdotal estimates on additionalcosts per room range between US$2,500and US$5,000 (see Schneider, for instance 8 ).This premium is attributed to, amongothers, the additional medical gas lines andbathroom plumbing chases and lines whichin the case of mirror-image configurationsare shared by two rooms. Figures 1 and 2show typical configurations of mirror-imageand same-handed rooms.Human factorsThe key question here is not aboutstandardisation. While empirical studieson the impact of physical environmentstandardisation in inpatient care settingsare not available, there is considerableevidence in the aviation industry supportingstandardisation. In aviation, human factorshave been shown to be a major cause oferrors 10,11 and are associated with 80%Figure 1: An example of the standardised mirror-image patient room configurationof fatal accidents 12 . The standardisationof processes and workflow throughstandardisation of flight deck controls andinterfaces has been shown to improve safeperformance, and has been examined andcodified in standards 13-15 . Among those arethe standardisation of equipment, systemlayout, displays and colour philosophy 16 .In essence, the standardised physicalenvironment supports the standardisationof processes and workflow, which in turnimproves safety and efficiency.Physical environment standardisationis defined in this study as the process ofconfiguring the attributes of a physicalentity in relation to one or more axesfollowing one or more universal rules,to maintain certain type of uniformityacross multiple instances of the entity. Inthis framework, standardisation could beattempted at multiple scales or levels –from headwalls and the interiors of supplycabinets to the caregiver zone, the patientroom and the entire unit. Both the samehandedconfiguration and the mirror-imageconfiguration can be standardised, andconstitute two variants of standardisedpatient rooms.The physical environmentA standardised same-handed room isdefined in this study as the result of a typeof room standardisation where attributesof the physical elements (chiefly location,assuming the design of individual elements– headwall, supply cabinet and so forth – isalready standardised at lower scales) in thepatient room are standardised in relation74 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Patient Accommodationto three axial plains – the midsagittal, thecoronal, and the transverse planes of astandard patient lying in bed (Figure 3).A standardised mirror-image room isdefined in this study as the result of a typeof room standardisation where attributesof the physical elements (chiefly location,assuming the design of individual elementsis already standardised at lower scales)in the patient room are standardised inrelation to two axial planes (Figure 4).One is the coronal plane of a standardpatient lying in bed. All vertical positioningof elements in relation to this axial planeis maintained as a constant across allinstances of the room. The second is thecentral line plane of the common wallbetween one set of two patient rooms.The horizontal positioning of the physicalentities in the two rooms is symmetricalaround this central line plane.Thus the fundamental question isnot whether physical environmentstandardisation promotes safety andefficiency, since that notion is intuitivelyappreciated and used in healthcare design.Rather, the fundamental issue is the extentto which the standardised same-handedconfiguration contributes more to processand workflow standardisation as comparedto the traditional standardised mirror-imageconfiguration. Currently, stakeholders basetheir assessments on subjective perception.There is little empirical evidence toprovide an objective assessment ofthe alternative concepts. The aim ofthis study was to empirically examinethe two variants of patient roomstandardisation from the viewpoint ofprocess and workflow standardisation.Key questionsPhysical design standardisation of the patientroom environment can provide two kindsof support. It can support the standardisedphysical execution (behavioural support) ofclinical tasks – the physical position, actionsand biomechanics involved in a care task –by optimising the configuration of physicalelements. Both variants of the standardisedpatient room can be designed to supportstandardised physical execution of clinicaltasks. The fundamental difference betweenthe mirror-image and same-handedvariant is in the approach and positioningof caregivers vis-à-vis the patient. In thesame-handed configuration (specificallyright-handed, which is most commonlypromoted in literature 9 ), the standardisedapproach is from the patient’s right and thecaregiver location is standardised on thepatient’s right.Figure 3: The reference planes used forcreating standardised same-handed roomsFigure 4: The reference planes used for creatingstandardised mirror-image roomsFigure 2: An example of the standardised same-handed patient room configurationwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 75

Design & Health Scientific ReviewWhile standardised caregiver approachand location can help better optimisation ofthe physical entities around the caregiver, theconcept is entirely dependent on whethercaregiver position can be standardised onthe right of the patient. The first question,therefore, is whether the caregiver positioncan be force-functioned.The second type of support is cognitive.Standardisation improves familiarity withthe physical environment of care, andthus, predictability. During emergencyand life-threatening situations, familiarityreduces search-and-locate actions anderrors. The second question, therfore, iswhether the same-handed configurationprovides better familiarity with the careenvironment compared to the mirror-imageconfiguration.The study focused on the following twoquestions, outlined above:• Can the caregiver location be successfullyforce-functioned to be always on the rightof the patient?• What is the essence of familiarity in thepatient care environment?Setting and subjectsThe study focused on the acute medicalsurgicalsetting. Since same-handedenvironments are promoted for all levelsof acuity, the medical-surgical settingconstituted a logical starting point. Further,the medical-surgical setting represents thepredominant care environment in an acutecare hospital, both in terms of physicaldesign as well as care procedures.An experimental setting was used toconduct the study. The team training room(Figure 5) in a simulation training laboratoryof a nursing school was used for setting upand manipulating the physical configurations.It was equipped with an identical arrayof redundant medical gases, provision forsuction and power outlets on both sides ofa Hill-Rom bed. The adjoining control roomwas linked through a one-way mirror tounobtrusively observe, record and monitoractivities in the team training room. Videoand audio feed from the ceiling-mountedcameras were received and processedTable 1: Key attributes of the nine configurations included in the studyScenario number Direction of approach IV locationScenario 1 (S1) Open No IVScenario 2 (S2) Open IV on patient’s leftFigure 5: View of the team training room in which the study was conductedScenario 3 (S3) Open IV on patient’s rightScenario 4 (S4) Approach from patient’s left No IVScenario 5 (S5) Approach from patient’s right No IVScenario 6 (S6) Approach from patient’s left IV on patient’s leftScenario 7 (S7) Approach from patient’s left IV on patient’s rightScenario 8 (S8) Approach from patient’s right IV on patient’s leftScenario 9 (S9) Approach from patient’s right IV on patient’s rightby custom-made software installed oncomputers inside the control room.Twenty registered nurses (RNs) wererecruited to perform simulated care. Ofthe 20, ten were left-handed and ten wereright-handed. The nurses fairly representedattributes of typical RNs working in UShospitals. The age of the nurses rangedbetween 21 and 62 years, with a medianage of 53 years. The median age of 53 yearsis proximal to the mean age of 46.8 years(as of March 2004) of American nurses 17 .Of the 20 subjects, one had a Bachelor ofScience in Nursing (BSN) degree with theremaining having at least a master’s degreein nursing. Work experience as a nurseranged from less than one year to morethan 30 years, with a median experience of25 years.The protocolNine different physical configurations of thecaregiver zone were created using flexiblerope partitions (Figure 5). The zone includedthe patient bed, the headwall medicalutilities and five feet of space around theremaining three sides of the bed. Thephysical configurations ranged from an openscenario (no forced approach direction) tothe approach being forced from the leftand right of the patient. In addition to themanipulation of approach, the location of anIV pole was also manipulated. That ranged76 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Patient Accommodationfrom no IV pole to placement of the IVpole on the patient’s left and right sides.Attributes of the nine settings are outlinedin Table 1.Nurses were instructed to conductthree frequently conducted tasks in eachof the nine physical configurations. Thetasks involved checking vital signs using aDynamap for blood pressure measurement,suctioning the patient using a hand-heldsuctioning kit, and helping the patient situp, dangle their legs off the bed and returnto semi-Fowler position. These tasks aretypical tasks conducted by nurses and canbe performed entirely within the caregiverzone. Furthermore, the tasks representedthe need of a dominant hand in conductingsuctioning and sitting up the patient. Apatient actor served as the patient inall simulated care scenarios. The patientattributes were controlled; no patientvariable was introduced in the study.Each simulation run was videorecorded.The three tasks and nine physicalconfigurations totalled 27 simulation runsfor each nurse. With 20 nurses in thesample, a total of 540 simulation runs wasconducted for the study. The sequence oftasks and configurations were randomised.Irrespective of the task, the nurses startedfrom a makeshift nurse station located onthe footwall of the room to provide anunbiased (neutral-handed) starting point. Allaspects of the environment other than theones manipulated were standardised at thebeginning of each simulation run, namely:• height of patient bed set at minimum;• bed angle set at 30 degrees;• bed rails in the up position;• over-bed table centered at the footof the bed;• suction canister on platform on bothsides of the bed;• Dynamap at nurse station; and• suctioning kit at nurse station.Tasks were assigned to the nursesusing standardised instructions that wererepeated uniformly before each scenario. Astructured interview was conducted witheach nurse at the end of the 27 simulationsto obtain triangulation data to supplementthe observational data. The interviewswere also video-recorded for separatecontent analyses.The video segments were provided to ateam of experts in nursing and kinesiology,Table 2: Operational definitions of posture termsPosture typeStretchBendUnstableLiftTwistRepositionOperational definitionPerform tasks outside a 30-degree radius from one’s neutral position(erect position) without bending, and applying forceMoving the spine (lower back) away from the erect position andapplying force. Includes all directionsBending or stretching while standing on one leg, and applying forceLifting patient from a height outside the range of one’s waist toshoulder areaTwisting any part of the body or the entire body to accomplish a task,with or without applying forceChanging one’s physical location (distinctly) once a task is in progress,to achieve better body posture or controlNote: Definitions are based on (with modifications) descriptions provided by Felettoand Graze 18 . In the definitions, ‘applying force’ means either lifting an object or personor pushing or pulling an object or person, or bothwho separately coded the segments todocument nursing behaviour and potentiallystressful or harmful actions. Nursingbehaviour comprised a predeterminedlist including direction of approach, anyhesitation in approach, over-bed table use,bed rail adjustment, bed height adjustmentand bed angle adjustment. In addition,the nurses were instructed to count thenumber of times the following postureswere observed: stretch, bend, unstable, lift,twist and reposition. Operational definitionsof the postures are included in Table 2. Alldata coding and statistical analyses wereconducted by external parties to avoid bias.Force-functionThe first question of interest was whetherthe caregiver position can be forcefunctionedto be consistently on the rightside of the patient. A series of logisticand Poisson regressions were conductedon the nurse-coded data to examinedifferences between left-handed and righthandednurses. In addition, an analysis wasconducted to identify issues influencingthe nurses’ decision to position vis-à-visthe patient.Data analysis revealed two majorphenomena. First, left-handed and righthandednurses behaviour was significantlydifferent on several dimensions, althoughwithin each group there was uniformity ofbehaviour. Table 3 provides a summary ofthe statistical significance from a regressionanalysis to examine differences betweenleft-handed and right-handed nurses. Asignificant estimate indicates a differencein the exhibited behaviour between theleft-handed and right-handed subjects. Amajor area of difference was in approach.The model examined was (where ßrepresents the predicted coefficient, sets1-8 are dummy variables representingthe nine physical configurations, andthe variable right-handed representinghandedness of the subject): behaviour =ß0 + ß1 set1 + ß2 set2 + ß3 set3 + ß4set4 + ß5 set5 + ß6 set6 + ß7 set7 + ß8set8 + ß9 right-handed.The second key finding was that thedoor location (approach direction) wasnot a factor that consistently determinedthe nurse’s final positioning vis-à-vis thepatient. Other factors that influenced theirdecision regarding positioning includedthe location of the IV, their preferred side(preferred side was not consistent withtheir handedness), their dominant hand(for precision tasks such as suction as wellwww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 77

Patient AccommodationTable 3: Summary of statistical significance of the variable ‘right-handed’ in the models tested to identifydifferences between the behaviours of left-handed and right-handed subjectsApproachdirectionHesitationOver-bedtable useBed railadjustmentBed heightadjustmentBed angleadjustmentStretchBendUnstableLiftTwistRepositionVitals 0.07+ 0.85 0.05+ 0.41 0.83 0.81 0.84 0.57 0.49 0.0***Suctioning 0.0*** 0.70 0.00** 0.1+ 0.28 0.76 0.00** 0.58 0.25 0.14 0.18Sitting up 0.04* 0.87 0.83 0.01* 0.96 0.96 0.02* 0.40 0.60 0.01* 0.77*** (significant at .001), ** (significant at 0.01), * (significant at 0.05), + (significant at 0.1)Note: Blank cells imply zero observations of the behaviouras sitting the patient up) and the walkingdistance involved. Figure 6 illustrates thispoint, using the case of suctioning task. Ascan be noticed, the right-handed nurseswere not always on the right of the patient,nor were the left-handed nurses always onthe left. Moreover, the pattern of switchingbetween the two sides of the patient, acrossthe nine configurations, was very similarfor both categories of nurses. Each switchwas influenced by one or more factorsmentioned above. The same phenomenonwas observed for the other two tasks.This finding has significant implicationsin the context of force functioning thecaregiver location only on the right side ofthe patient. Transcripts of the interviewssupported the observation data regardingfactors influencing nurses’ positioning vis-àvisthe patient.LEFTPatient’s HeadRIGHT100%50%50%100%S1 S2 S3 S4 S5 S6 S7 S8 S9Nurse positioningThis raises a pertinent question. As notedpreviously, the standardised location of thecaregiver on the patient’s right is the keydifference between the standardised samehandedand standardised mirror-imagerooms in terms of behavioural support toworkflow and process standardisation. Inthat context, considering the inconsistentand non-standardised positioning ofcaregivers vis-à-vis the patient, theadditional contribution of the same-handedconfiguration over the standardised mirrorimageconfiguration is not evident.One could assert that the provision ofa same-handed environment will resultin the consistent right-side positioning ofcaregivers. However, considering the hostof external factors influencing nurses’decisions regarding positioning, it could bechallenging. It implies that the contributionof room handedness to process andworkflow standardisation is conditional onthe extent to which the physical executionaspect of processes and workflow can bestandardised. This is not a design question.It is a process question that is yet to beexamined in the medical discipline. Onthe other hand, if force-functioning thecaregiver position is not an objective behindroom handedness, then designing handedFigure 6: Position of left-handed and right-handed nurses vis-à-vis thepatient during suctioning task, across the nine configurations (S1-S9)Left HandedRight Handedconfigurations has little value in the domainof process and workflow standardisation.Care environment familiarityThe second question of interest waswhether the standardised same-handedconfiguration offers better familiarity withthe patient care environment compared tothe standardised mirror-image configuration.The study scope and methodologyprecluded any objective examination ofcognitive load. The focus of the examinationwas on understanding what the nurses seekin terms of familiarity with the patient careenvironment.The nurses were asked to orderthe physical configurations in terms ofperceived supportiveness to their tasks. Itis noteworthy that the set of configurationsthat were identified most frequently bythe nurses were neither same-handed normirrored, but were the open configurations(70% of the subjects) where approach wasnot forced. The reason for the higher ratedsupportiveness of the open configuration,as self-reported by the subjects, was thatit provided them with an immediate globalview upon entry of the entire patient careenvironment – both sides of the patient.That global view provided them with aninstant familiarisation with the patientcare environment.From the perspective of cognitivesupport, the concept of immediateglobal view upon entry warrants specialattention. That is because variabilityoriginating from the patient (woundsite, type of injury, stage of recovery,number and type of equipment and theirlocations, and so forth) could contributewww.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 79

Patient Accommodationa considerable degree of complexity tothe physical environment around patientcare. Even in highly standardised physicalenvironments such complexities couldpose considerable cognitive challenges tocaregivers. The advantages offered by theglobal view is directly linked to the notionof familiarity with the care environment.Since the physical configurations andtasks were randomly sequenced, theglobal view offered an instantaneousadvantage in terms of improved familiarityto the nurses.Adopting handed configurationsSo, do standardised same-handed patientrooms contribute any more to process andworkflow standardisation than standardisedmirror-image rooms in acute medicalsurgicalsettings?While the issue of cost premium is important,a more vital issue is of comparativeeffectiveness. Which configuration providesbetter support to safe and efficient care?From a behavioural support perspective,study data suggests that in acute medicalsurgicalsettings the notion of a consistentcaregiver position vis-à-vis the patient isnonexistent. Thus, configuring the physicalenvironment to provide support to a practiceof consistent caregiver location on the rightof the patient may not be meaningful in thecurrent operational context.Comparatively, the standardised samehandedconfiguration may not offer anymore than the traditional standardisedmirror-image configuration. Severalassociated physical execution issues needto be addressed. Specifically, could thecaregiver position vis-à-vis the patient beforce-functioned? Will force-functioningthe caregiver position improve or reduceprocess efficiency and safety? How willindividual flexibility be impacted?From a cognitive support perspective,the notion of an immediate global view ofthe patient care environment upon entrywarrants further examination in the contextof comparing the two variants of thestandardised patient rooms, since it appearsto have significant value. Since considerableadditional complexity (or unpredictability)is introduced by patient-related factors, theextent to which the familiarity differencebetween the two standardised roomvariants impacts on overall predictabilityor unpredictability is an important questionto examine.Moreover, whether the familiaritydifference between the two standardisedroom variants is of any consequence tocognitive support in the overall level ofunpredictability resulting from patient factorsis an issue warranting examination. This isspecifically important since issues relatedto the physical execution of workflow andprocesses are also potentially impactedthrough the two different avenues ofroom standardisation.During a period of difficult financialmarkets and increased awareness regardingthe safety and efficiency of patient care,comparative assessment of alternativeconcepts are warranted for the optimisationof capital resources. From that perspective,this study creates the preliminary foundationfor further examination of standardisationconcepts in healthcare design.AcknowledgmentsThe authors would like to thank HKSArchitects, Dr Nancy Rowe, manager,statistical services, Office of InformationTechnology, University of Texas at Arlingtonand Dr DL Hawkins, associate professor andassociate chair, Department of Mathematics,University of Texas at Arlington, for theirsupport; Sipra Pati for editorial criticisms andcontributions during the development ofthis manuscript; the Academy of Architecturefor Health Foundation and Herman MillerInc for research grants; and the Universityof Texas at Arlington, Smart Hospital for itsin-kind contribution.AuthorsDebajyoti Pati PhD, FIIA, LEED AP is vicepresident and director of research at HKSArchitectsThomas E Harvey FAIA, MPH, FACHA,LEED AP is senior vice president at HKSArchitectsJennie Evans RN, BS, LEED AP is vicepresident and a clinical advisor at HKSArchitectsCarolyn Cason PhD, RN is a professor inthe College of Nursing at the University ofTexas ArlingtonReferences1. 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Proceedings of the IEEE International Conferenceon Systems, Man, and Cybernetics; 1997. Retrieved 20June 2008 from ftp://techreports.larc.nasa.gov/pub/techreports/la.12. Noyes J, Starr A, Kazem L. Warning System design incivil aircraft. In D Harris (Ed) Human factors for civil flightdeck design. Surrey UK: Ashgate Publishing; 2004.13. Department of Transportation. Safety standardsfor flight guidance systems. Federal Register: 13 August2004 (Vol 69, No 156). Washington DC: Federal AviationAdministration; 2004.14. Lande K. Standardization of flight decks –Operational aspects. In HM Soekkha (Ed) Aviation safety:Human factors, system engineering, flight operations,economics, strategies and management. Boston MA: VSPBooks; 1997.15. Sulzer R. Transport aircraft cockpit standardisation(Federal Aviation Regulation Part 25). Washington DC:Federal Aviation Administration; 1981.16. Spitzer C. Avionics: Elements, software and functions.Boca Raton FL: CRC Press; 2006.17. American Nurses Association. Nursing shortage.2009. Retrieved 30 June 2009 from http://www.nursingworld.org/nursingshortage.18. Feletto M, Graze W. A back injury prevention guidefor health care providers. CA: CAL/OSHA ConsultationServices; 1997.www.worldhealthdesign.com WORLD HEALTH DESIGN | July 2010 81

Arts and CultureFrederick CayleyRobinson – Acts of MercyNational Gallery, London, UK14 July – 17 October 2010http://nationalgallery.org.uk/whats-on/exhibitionsWhen he was 50, FrederickCayley Robinson (1862-1927) was commissionedby Sir Edmund Davis, a governor andbenefactor of Middlesex Hospital, topaint four large pictures for the entrancehall of James Paine’s imposing 18thcentury building. Their collective title,Acts of Mercy, derives from Christianteachings, including feeding the hungryand attending the sick, which historicallyguided the development of hospitals.By 1915, Cayley Robinson had paintedthe first pair of pictures – Orphans I and II. Originally they hung on the wall facing the front door, separated by a door leading to the hospitalwards. They show a continuous interior scene, with uniformed orphan girls filing down a staircase into a dungeon-like refectory lit by asingle lamp, where others are seated at a table, with already nourished orphans departing.Although movement is implied, the gracefully posed orphan girls and woman attendants appear suspended in a timeless scene, togetheryet separated by a pervading stillness. It might seem that the artist’s intention in this site-specific composition was to calm agitated orworried patients, while they waited for medical attention, but it is typical of all of his works.Mural paintings by the French artist Pierre-Cécile Puvis de Chavannes(1824-1898), which Cayley Robinson saw while studying in Paris, exertedThese smallacts of kindnessreflect CayleyRobinson’sallegoricaldepictions ofActs of MercyScenes ofmercyFor 70 years, the paintings of Frederick Cayley Robinsongraced the entrance hall of Middlesex Hospital in the UK.Now they are being celebrated in an exhibition at London’sNational Gallery, as Colin Martin reportsa potent and lasting influence. This is demonstrated in his frieze-likearrangements of outlined figures, painted in flat colours, inhabiting austerelandscapes or sparse domestic interiors.Although the second pair of paintings, The Doctor I and II, ostensibly depictexterior scenes, they appear more like stage sets than reality. They weredesigned to be hung on the side walls, facing each other across the entrancehall – so, unlike Orphans, they do not present a single scene. The Doctor I,completed in 1916, depicts a timeless classical landscape with figures dressedin an archaic style. A woman kneels before a male healer or doctor, in apose reminiscent of adoration or crucifixion scenes, thanking him for having82 July 2010 | WORLD HEALTH DESIGN

treated her daughter who stands nearby. The healer’s right hand is raised in a Christlikegesture of benediction.The Doctor II, completed in 1920, depicts a contemporary scene. Convalescentsoldiers, clad in the distinctive blue flannel of First World War military patients,enjoy a breath of fresh air (or, in one languidly posed case, smokes a pipe) at thehospital entrance. As Nicholas Penny, director of the National Gallery, observes, thispainting is among the most interesting of the immediate post-war period, showingthe impact of war on the home front, rather than the horrors of trench warfare.Two retired nurses visiting the exhibition, who trained at Middlesex Hospital from1950 to 1954, commented that Matron always insisted that patients were treatedas household guests, to the extent of their being served individually with cups of teaon trays. These small acts of kindness reflect Cayley Robinson’s allegorical depictionsof Acts of Mercy, paintings which they saw every day. A photograph taken in 1930shows three smiling nurses forming a guard of honourwhen Cayley Robinson’s paintings were removed beforedemolition of the old hospital.Appropriately, for paintings in which architectureitself predominates, Acts of Mercy were reinstalledin specially designed niches in the art deco foyer ofthe new Middlesex Hospital, built on the same site(1930-35), where they remained for 70 years.When Middlesex Hospital was decommissioned in2007, there was a public outcry when University CollegeLondon Hospitals NHS Trust consigned the paintingsto auction. Curators in 20th century British art at TateBritain helped find a solution, which enabled the fourpaintings to remain on public display, rather than beingdispersed into private collections. They were acquiredby the Wellcome Trust in 2009 and are permanentlyhoused at Wellcome Library, only a few hundred metresfrom the now vacant site for which they were painted.“This is the first exhibition devoted to the work ofFrederick Cayley Robinson since 1977,” says Penny.“He is a distinctive artist, who had one superlative 20thcentury moment.”Colin Martin is an architectural writer and journalistImages of Acts of Mercy above (left to right):Orphans II, about 1915, oil on canvas (199 x 339 cm)Orphans I, 1915, oil on canvas (198.7 x 339 cm)The Doctor I, 1916, oil on canvas (198.5 x 339.5 cm)The Doctor II, 1920, oil on canvas (198.5 x 339.5 cm)All images © The Trustees of the Wellcome Trust LtdMiddlesex Hospital entrance with the Cayley Robinson painting Acts of Mercy – Doctor Ibeing moved during building works, 1930 © University College London Hospitals NHSFoundation TrustWORLD HEALTH DESIGN | July 2010 83

Arts & CultureThe Architecture of Hope: Maggie’s Cancer Caring CentresCharles Jencks and Edwin Heathcote with Laura Lee and Katy MahoodFrances Lincoln, 2010Price: £35.00 / US$60.00“A diagnosis of cancer hits you like a punch in the stomach,” wrote Maggie Keswick inA View from the Front Line in 1995. “Other diseases may be just as life-threatening, butmost patients know nothing about them.” Although breast cancer, first diagnosed in 1988,threatened to overwhelm her, she was determined not to allow it to do so. Her feisty responsewas to work with her oncologist Bob Leonard, oncology nurse Laura Lee and husband,architect and writer Charles Jencks to found a charity which now provides non-clinicalspaces adjacent to hospitals, where cancer patients can rest before or after their clinicalappointments and also access information and psychological and social support, within informaldomestically-scaled environments.The first of what are now known as Maggie’s Cancer Caring Centres opened in a convertedstable building at the Western General Hospital in Edinburgh in 1996, a year after Maggie’sdeath in 1995. There are now six Maggie’s centres operating in the UK and seven more willopen within the next two years. The buildings are the work of high profile architects, whowaive their design fees. Given the competitive nature of the architectural profession, each newcentre lifts the bar higher. “They are all great buildings, not a bummer among them,” said Jencksat the launch of The Architecture of Hope. Maggie was a landscape architect and the couplecounted many of the stellar architects of the centres among their friends.“The NHS is obsessed with cutting waiting time – but waiting in itself is not so bad, it’s thecircumstances in which you have to wait that count,” wrote Maggie. This astute observationinforms the architectural brief for the centres: to provide functional buildings with spatial qualities which make patients and their families feelvalued. The well-designed and illustrated book introduces the thinking behind Maggie’s centres and profiles the designs of existing buildings,those at planning or building stages and three unrealised centres.Maggie’s Cotswolds at Cheltenham Hospital, designed by Sir Richard MacCormac, will open this autumn. Its design includes architecturalfeatures that are generic to all centres, such as welcominghearths. Here the hearth is flanked by inglenook seating, a localarts and crafts tradition. Light-filled kitchens form the heart of allMaggie’s centres. Here patients, relatives and carers can eat anddrink, while sharing their experiences of coping with cancer arounda large communal table. Although patients’ clinical records are notavailable to Maggie’s carers, they are trained to provide informationand counsel in response to concerns expressed by patients andtheir families.Natural landscaping is another feature common to all Maggie’scentres. Even on a cramped corner site at Charing Cross Hospital,Rogers Stirk Harbour & Partners has provided a secluded gardensetting, screening Maggie’s London from noisy traffic. Other centresMaggie’s Gartnavel © OMAare less constrained, often providing inspirational views.The book’s title undersells the impact of architectural healthcaredesign on the wellbeing of ill (or indeed healthy) people. Maggie’s centres provide more than the oftenfallacious “new hope for cancer victims” promised in the headlines of yellowing press clippings depicted in thebook. The centres actively support cancer patients and their families, but ‘architecture of support’ would bemisconstrued as structural engineering. ‘Architecture of healing’ is unverifiable, but it is important to establishadditional health benefits for users of the centres.In 1995 Maggie’s applied to Cancer Research UK (CRUK) for funding to compare the benefits to users ofsimilar support services provided from non-purpose-designed buildings (in Swansea and Oxford) with thebenefits provided to users of two of its purpose-designed centres. CRUK turned down the application, advisingthat its remit was medical research and not architecture. Undaunted, Maggie’s plans to initiate a self-fundedprospective, observational study using matched controls within two years. The results should provide evidencebacking its intuitively sensible provision of support for cancer patients within specifically architecturally designedand landscaped buildings.Colin Martin is an architectural writer and journalistWORLD HEALTH DESIGN | July 2010 85

Arts and CultureNurse: past, present and futureKate Trant and Susan UsherBlack Dog Publishing, 2010Price: £19.95 / US$29.95Kate Trant and Susan Usher have produced a bookthat is as good to look at as it is to read – a bookin which the photographs are as interesting as thewords. It will be of interest not only to nurses of all agesbut also to those who know and care about nursing – andto those who’ve never given it much thought.Florence Nightingale’s centenary provides theinspiration. It takes the reader from the nineteenth to thetwenty-first century, from Camberwell to Chad, learningfrom the past and predicting the future. This incrediblejourney is illustrated with the stories of nurses themselves:Zena Edmund-Charles, one of thousands of youngwomen who came from the Caribbean to the ‘mother’country in the 1950s; Carol Etherington who worked inDarfur; Veronica D’souza who was in charge of operatingtheatres in Mumbai; Geoff Hunt, a district nurse in England for 40 years; Flavia Simphronio Balbino, who developed the Kangaroo Motherapproach in Brazil; and many others whose stunning photographs illustrate their incredible tales.The chapters on hospital design are an unusual feature of this book and will be of special interest to nurses who instinctively know thatdesign affects the care they can give, how they feel about their work and the recovery of their patients. Many studies show how differentcare environments can reduce anxiety and lower blood pressure and ease pain. The fundamentals of healthcare design are clearly spelledout in a way that can be followed by clinical staff, architects and planners. The redevelopment of Montreal General Hospital demonstratesthe value of engaging nurses in the design of hospitals. Sadly, a study in England reveals that less than half the nurses thought they couldinfluence hospital design.Florence Nightingale bequeathed to the UK the Nightingale ward: an open and well ventilated ward of 32 beds in two rows. Generationsof British and other nurses grew up working with a characteristic sweep down the centre, casting their skilled eyes from right to leftobserving the slightest change in their patients’ condition. No wonder they resisted their patients being tucked away in single rooms outof sight. However, what was right over a century ago is not right for the needs and standards of today – although it took Nightingale’shome country, the UK, longer than most to understand this. It is amazing that we would never share our bedroom with strangers whenwe are fit and well but assume that this is an acceptable thing to do when we are ill! Single rooms are now the preferred norm whennew hospitals are built – but in the poorest places we will continue to see notjust the sharing of rooms but also of beds.The book draws on the wisdom of some outstanding leaders ofnursing, such as Canada’s Helen Mussallem. It also bravely tackles someof the biggest issues in nursing: defining a nurse, the education of nurses,migration, telenursing, and working with physicians and other teammembers (movingly illustrated by the Japanese development of disastermanagement after the Kobe earthquake). It ends with a reference to theUK’s Royal College of Nursing campaign to ensure dignity for all patients,illustrated by two innovative designs: a ‘bed pod’, which provides privacyand soundproofing around a bed space, and an improved hospital gownNurses can be‘architects ofchange’ – butonly when theyare fully includedfor patients.The newly refurbished Florence Nightingale Museum at London’s StThomas’ Hospital is a testament to the impact Nightingale has had on nursingover the past century and this book illustrates thatimpact through the words and pictures of nursesthemselves. Today, when healthcare reform is onevery government’s agenda, it is clear that nurses canbe ‘architects of change’ – but only when they arefully included.Christine Hancock is director of C3Collaborating for Health86 July 2010 | WORLD HEALTH DESIGN www.worldhealthdesign.com