Healthcare Public Spaces and the Power of Design

More than 150 architects, designers, healthcare consultants, and owner representatives gathered in Chicago in mid-July 2007 for a discussion titled "Healthcare Public Spaces and the Power of Design." The discussion was part of the annual Academy of Architecture for Health (AAH) Summer Leadership Conference.

A number of conclusions can be drawn from this discussion. One is that healthcare public space is not just one kind of space; it takes different forms or patterns, five of which our discussion identified. Another conclusion is that although healthcare public space is usually thought of as background or support space, it can be just as important as clinical space to the healing process. Architects, when designing healthcare public space, typically describe it functionally. Our discussion made it clear the design process must look beyond physical parameters. A possible tool for doing this is a matrix that integrates the type of healthcare public space with healthcare’s unique identity attributes.

Because of the importance of healthcare public space, solid research about it is needed. Participants in the discussion agreed that they want to continue the dialogue that we started about this space.

Poster Power
First, how do we define healthcare public space? How can we use this space to enhance the design of healthcare facilities? Before beginning our discussion, we viewed a PowerPoint presentation (some slides from which are shown below) to help establish a vocabulary and a tool to facilitate audience dialogue.

To stimulate thinking about healthcare public spaces, attendees were asked in advance to create and submit an 11” x 17” poster representing their favorite public space. No other limitations or definitions were given.

St. Mark’s Plaza, Venice

The response was rewarding and revealing. More than 20 posters were submitted and displayed. Among the spaces chosen were such monumental, well-known sites as St. Mark’s Plaza in Venice, the Mosque of the Prophet in Saudi Arabia, Chicago’s Crown Fountain Millennium Park, the beach in Venice, Calif., and Boston’s Fenway Park. The posters also included smaller, more personal spaces and healthcare public spaces. It was clear that the spaces identified by those submitting posters were the product of a fond memory or experience. Reviewing the posters, I observed human emotion, spirit, magic, and the importance of place.

The variety of public spaces represented by the posters underscored the difficulty of defining healthcare public space. Indeed, the posters made me realize that the topic of healthcare public space is more abstract than I had initially realized. But the posters also were a huge help in advancing our discussion. Those submitting posters were personally vested in them, so they were able to explain their selection criteria (e.g., the space made me feel good, evoked a memory, was spiritually uplifting). They also were able to articulate how the space selected related to the topic of healthcare public space.

Defining Public Space
The term “public” suggests a place providing access to all, a place where people can congregate and engage in multiple activities, a place of movement and flow, or a place of cultural collectiveness. How then to define “public space”? We can do this in two related ways.

The first is through formal typologies such as

• Organizing elements (plaza, courtyards, lobbies)
• Dynamic conduits (streets, passages, transit)
• Transition zones (boundaries, edges, parks)

The second way is through attributes such as

• Environmental factors (light and air, energy, habitat)
• Users (purpose, together/alone experience)
• Public-to-private relationships (parameters, defining condition, animation)
• Architectural character (proportion, materials, scape)

The History of Healthcare Public Space
When attempting to define healthcare public space, it’s useful to recall some history. Initially places for healing were truly public, sought out for their special qualities of place and environment. One example was the Asclepieion at Epidaurus in ancient Greece, the most celebrated healing center of the classical world. After spending the night there in a big hall, the sick reported their dreams to a priest the following day. He then prescribed a cure, often a visit to the baths.

In the Middle Ages, the Catholic Church assumed the role of caring for the sick and dying. In its healing centers, patient wards opened to gardens and chapels, and active public spaces were used by patients and the general public.

During the Industrial Age, medicine realized that germs cause illness and that pollution can trigger disease in immune-stressed patients. The sick were separated from the healthy. Buildings became more compartmentalized and hermetically sealed. Private space became more important than public spaces, which were largely confined to the front of buildings.

Today, the assumption that patients should always be separated and isolated is no longer the prevailing wisdom. Instead, we find increasing emphasis on patient rights and on family participation in caregiving and healing. Given our contemporary healthcare environment, how does public space in general relate to healthcare pubic space? What is similar? What is different?

How do healthcare needs fit into public spaces?

Applying Public Space Principles to Healthcare
Both public space and healthcare public space share the same typologies and attributes described earlier. However, healthcare public space has its own set of special patterns. (In developing a vocabulary for healthcare public space, we owe a debt of gratitude to Christopher Alexander’s A Pattern Language: Towns, Buildings, Construction, required reading when I was in graduate school.)

It was our observation that healthcare public spaces embodied the following space patterns:

• Collector space: accepting and orienting space, high population, active and increased noise levels
• Introspective space: accepting but calming space, high populations, personal, more quiet and highly passive
• Purpose space: places of specific functions, service based, varying user volumes, moderate noise level and dynamic space
• Mover space: places of constant movement, ebb and flow of user volumes, moderate noise levels and highly dynamic
• Switchboard space: places of orientation and wayfinding, constant high population, clarity of building organization, moderate noise levels and dynamic

Healthcare public space patterns and representative icons

These spaces, however, must be integrated with healthcare’s unique identity attributes:

• Environmental factors: natural light, air quality
• User group: diverse and health focused
• Public-private relationships: defined by a single entity, cohesive mission with clear interface and boundaries
• Context of body health: people needing care are the norm not the exception, diversity of ailments
• Passage of time: time is unpredictable, perceived differently by patient, family, and staff
• Emotional dispositions: uncertainty and vulnerability, emotional highs and lows

Healthcare’s unique identity attributes and representative icons

Using a Matrix as a Tool
In the grid below, the horizontal axis displays icons for healthcare’s unique identity attributes. Displayed on the vertical axis, also with icons, are healthcare public space patterns. Using the grid, a particular type of space could be designed to reflect one or more factors on the horizontal axis.

As an example, take collector space, represented by the top icon on the vertical axis. Now consider it in relationship to the horizontal axis. Should the space be designed to take into account environmental factors? Should it deal with the passage of time, which can be agonizingly slow for patients and families awaiting test results? What other combinations are important? By asking such questions, the grid above becomes a matrix that can serve as a work sheet or check list of sensitivities. Indeed, using this tool amounts to a sensitivity exercise.

Grid for combining healthcare public spaces with identity attributes

Conclusions
A number of conclusions can be drawn from our discussion about public healthcare space. One is a new appreciation for the relevance of healthcare public space. It is not one kind of space; it can take different forms or patterns. In addition, although healthcare public space is usually thought of as background or support space, it is just as important as clinical space. Indeed, it may be some of the most relevant space in the healing process, especially when it is purposeful. By that I mean the space is planned to promote nurturing, privacy, safety, and reassurance.

Another lesson learned from our discussion is that healthcare public spaces do not exist in isolation. Instead, they stitch together the entire healthcare experience, which includes the five different healthcare public space patterns we identified. Some of these spaces constitute seams of human interaction; others constitute a formal stage for this interaction. Both can change human experience in life-defining ways.

How then should we account for these spaces in the design process? Should we have a new line item in a functional program for the spaces? When creating healthcare public space program, architects typically describe it functionally—20’ x 20’, for example. Our discussion made it clear we must look beyond these physical parameters. We must take into account the emotional content of space. To be honest, I’m not at the point where I can articulate precisely what tools we need to accomplish this objective, but the grid we examined seems to be a good starting point.

The posters introduced during our discussion emphasized the significance of a positive memory. Is it possible to create such memories with healthcare public space? Often the birthing experience creates a positive memory. But what about a cancer patient that has had a tumor removed and just wants to go home and forget about the hospital experience? How do we create a positive memory for that patient?

As the questions posed above demonstrate, defining healthcare public space and using it to enhance the design of healthcare facilities presents challenges. Our Chicago meeting was an important step in identifying those challenges. And because I know of no more dedicated individuals than members of the AAH and the American College of Healthcare Architects (ACHA), I am confident that eventually we will successfully meet these challenges. As we do this, I expect healthcare design to become increasingly interdisciplinary. At NBBJ, our healthcare staff includes nurses, landscape architects, lighting experts, industrial designers, an environmental psychologist, and even an anthropologist.

Where do we go from here? Participants in the Chicago event made it clear they want to continue the dialogue we started, emphasizing that we only scratched the surface of an important design topic. Another Power of Design agenda must be created. Also, we need research on healthcare public space. As the following graphic illustrates, there is still much we do not know. Let’s not lose the momentum we established in Chicago. Let’s keep talking.

The architectural character of public space