Revolutionising Healthcare (Part 2): The patient – caregiver interface

In an earlier post I have already described how a hospital in the Netherlands is attempting to revolutionising healthcare (by organising – among other things – a flexible working environment that actually works). In this post I want to elaborate on a different aspect of the hospital design of Orbis and investigate how the spatial layout of the building constructs an intelligent interface between patients and caregivers.

So what is an interface? According to Bill Hillier and Julienne Hanson (in their book ‘The Social Logic of Space‘) an interface is the relation between different categories of people using a building, or more specifically the relationship between inhabitants and visitors. An inhabitant is someone with control over the social knowledge that is produced in the building, for instance the teachers in a school, or the doctors in a hospital. In contrast, a visitors lacks this control, e.g. pupils in a school, or patients in a hospital. Of course, real life is more complicated than this, because first of all, there are always more user groups than just two, and secondly, because different types of users may hold varying degrees of control. You could argue for instance that a doctor in a hospital holds more control than a nurse, but a nurse has more control over what the building does than a patient or a family member visiting a patient.

Essentially all buildings, no matter what type – be they hospitals, offices or schools – have this in common: they generate or constrain patterns of movement flow and encounter between different groups of people with varying degrees of inhabitant or visitor status, and the structure of the building exerts a degree of control over these encounters, and this is what we call the interface.

So how does this work at Orbis? The image below shows a Space Syntax analysis of the ground floor of the hospital. As usual in Space Syntax visualisations, central areas with strategically short paths to all other areas in the building (so called ‘integrated spaces’) are shown in warm colours like red, orange and yellow, while more distant and inaccessible areas (so called ‘segregated spaces’) are highlighted in cooler colours like green, turquoise and blue. The typical path of an outpatient is highlighted from the building entrance (E), to the reception (R), to a waiting area (W), where patients wait to be called into an exam room (X), which are directly accessibly from the foyer. The majority of caregivers (apart from reception staff) spend their time in the knowledge centres (K), a back-of-house area shared among one or two outpatient clinics. A nurse would therefore come from the knowledge centre and proceed through the empty exam room into the foyer and waiting area to call the next patient.

This means patients move through a logic sequence of highly integrated to integrated spaces, while caregivers move from the medium to less integrated spaces of the knowledge centres to the more integrated areas of the exam rooms.

Space syntax analysis of ground floor of hospital: interface between patients and caregivers

How caregivers and patients interact within the building can also be seen in the series of images below: outpatients enter the building by accessing a large foyer and lobby area through which they proceed to reach the specific reception of the clinic they visit (image 1). After registration, patients wait in the large foyer space at waiting islands or small tables and seats (image 2) until they are called into an exam room by a nurse (image 3). Image 4 shows the back-of-house area of the knowledge centres, where staff can interact and discuss patient cases and files.

1) Large foyer and reception [photo by Rositsa Pachilova]; 2) Patient waiting areas [photo by Efi Kostopoulou]; 3) Exam rooms as main overlap of patient and caregiver areas; 4) Staff communication in the knowledge centre

This means the interface between inhabitants and visitors is well structured. Certain areas of the building are mostly dedicated to patients (for instance the foyer and waiting areas), whereas caregivers have sole ownership of the knowledge centres. Areas for caregivers and patients overlap mainly in the exam rooms. The movement flows and everyday usage patterns of outpatients and caregivers are therefore mostly kept apart.

Certainly, this is what buildings can do: constrain patterns of movement in such a way that different groups of people generally do not meet other than in carefully selected areas. The prime example of a building type where this is very common is the court room, since defendants, lawyers, judges, witnesses must not meet in the building before their encounter finally takes place in a highly orchestrated and ritualised way, as all groups face each other in the court room during a hearing or trial (for a wonderful analysis of the spatial and social structuring of relations in a court room, see Julienne Hanson’s The Architecture of Justice (1996), and her recent foreword and commentary (2012) on the original text).

You may ask yourself now whether this is a good feature for a building, or in particular, whether this aspect of the spatial layout of Orbis – that it tends to keep different user groups apart – makes it a good hospital.

It is never easy to make such a general statement, i.e. claim that spatial configuration contributes to the performance of an organisation, yet it can easily be argued that the interface as it is constructed in the hospital allows for the following:

  • Easy way-finding and orientation for patients: Even for patients entering the hospital for the first time, orientation could not be easier. They arrive in a large, welcoming and sun-lit foyer and move directly towards the reception areas. The different clinics have different reception areas (and some of them are on the first floor gallery spaces), but signage clearly leads outpatients to the right place. A front information desk immediately visible after entering the building (see image 1 above) is there to direct people, too.
  • Pleasant atmosphere for patients waiting: Since the waiting areas are placed within the large foyer, waiting is as pleasant as it can be. There is always movement and things to observe – a place for people to see and being seen. The large red signature pieces of furniture actually feel very cosy and create a pleasant atmosphere for outpatients.
  • Short ways for both patients and caregivers: Given the size of the hospital, walking distances are relatively short due to the intelligent placement of the exam rooms as a middle layer between areas for patients (foyer) and areas for caregivers (knowledge centres).
  • Easy communication among caregivers: With staff areas hidden away from the access of outpatients, communication among caregivers is made very easy. Caregivers can move around freely in the knowledge centre, can access patient files on each computer, can openly consult with colleagues on patient issues, can ask for help with complicated cases, or can offer knowledge to others (e.g. to residents, who are still in training) – all of this without the risk of being overheard by patients or family of patients. The importance of this should not be underestimated and it seems this is a crucial issue for many hospitals around the world, where areas of patients and caregivers are not separated as strictly (I remember visiting UCLH a couple of years ago and hearing announcements in the elevators that repeated ‘Please refrain from discussing patient cases, you may be overheard’).

In summary, by separating user groups through an intelligent spatial layout good care is made easier and this is what a hospital building should be about.

One thought on “Revolutionising Healthcare (Part 2): The patient – caregiver interface

  1. Pingback: Revolutionising Healthcare (Part 3): Privacy and Community in Wards | spaceandorganisation

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