Designing Inclusive Healthcare Facilities
By Arunima Rajan
Patient-centric design for marginalised communities may come. It just will be a bumpy ride to get there.
*Ganga began experiencing symptoms of depression nearly immediately after her diagnosis of GI cancer.
"Dark waiting rooms, the sense of being lost in the hospital, noise of machines are some things which don't leave the memory of aged patients,” says *Anil, Ganga's son.
Healthcare design can have disastrous, unintended consequences. At least that’s what caregivers of many geriatric patients think.
1. Marginalised Groups
Rahul Kadri is a partner and principal architect at IMK Architects.
He notes that marginalised groups have been defined as 'populations outside of "mainstream society". and 'highly vulnerable populations systemically excluded from national or international policymaking forums'. "It is, therefore, essential to create safe spaces where such individuals feel at ease, prioritised and respected," he adds.
Kadri says that hospitals are usually designed as a single block that houses all the departments and functions together, ranging from procedures, IPD, OPD, imaging, cafeteria, administration, public lobbies, waiting rooms and receptions, as well as building service. "Such buildings provide no buffer zones, which amplifies the hospital's rate and magnitude of cross-infection. It also creates spaces that cannot be ventilated naturally. Hospital rooms in a single building often have corridors in the centre with functional spaces flanking them.Patients, healthcare workers, families, and visitors all use the same spaces, thus creating no barriers between the sick and healthy. The corridors inevitably lead to crowding and congestion, leading to cross-contamination. The absence of natural light and ventilation results in artificially lit and ventilated corridors that increase the risk of cross-contamination by recirculating air. Mechanically ventilated spaces also make the design unsustainable with respect to energy consumption, increasing maintenance and operational energy costs. Service blocks located inside the departments occupy more usable floor space and cause hindrance to workflows in the event of repairs and maintenance. There is also a shortage of positive green spaces that facilitate the psychological aspect of the overall healing process. Double-loaded corridors, lack of positive spaces, zoning issues, and an abundance of touch-points invariably aid the spread of disease in a place of treatment and recovery," adds Kadri.
Biophilia, the future of architecture?
Kadri points out that Biophilia, a hypothesis put forward by noted American biologist Edward O. Wilson in 1984, states that humans possess an innate tendency to seek connections with nature and other forms of life. "Hence, we can create approachable and accessible environments by connecting hospital spaces with nature. We can also create trigger-free spaces using soft colours, materials, and textures, to make individuals feel safe and comfortable. Easy way-finding and legible signages can also play a significant role in easing the users' disposition,” explains Kadri.
2. Good design = Understanding Need of Patients
Srushti Adani is the Founder and CEO of Wellnest, a health tech startup that aims to bridge the gap in the cardiac health segment. She thinks that a good healthcare design must be simple, intuitive, and user-centric. "A good design must apply to all aspects of healthcare ranging from multi-building hospital architecture to a dynamic medicine packet. For instance, when we designed our first medical product, the 12 channel Tele-ECG solution 'Wellnest 12L', we spent weeks interviewing our target users, who were mainly medical professionals and technicians. Through this activity, we understood their workflow, needs, and wants. We were then able to distil the problem and create simple interventions for them. This facilitated an elevated user experience and a smooth learning curve for our users, leading to our product being one of the top products in its segment," she explains.
3. Features of Good Healthcare Design
One of the common arguments that one might hear is that patient-centric design is expensive. Is it true? Dr. Harish Pillai, CEO, Metro Pacific Hospital believes that patient centric design doesn’t always mean it's more expensive. According to him, a good healthcare design in 2022 needs to have the following features:
Environment friendly with lesser Capex and Opex in its life cycle maintenance
Follow Green building norms
Follow all national and local regulatory codes
Should adopt cost-effective modular design elements
Enablement of quicker construction and flexible design
Future proof by incorporating soft spaces that facilitate future expansion
Should accelerate the healing process by maximising natural elements and light
Usage of less toxic and non-aerosol generating building and interiors materials
4. Vernacular Sign Boards and Non-Elite Spaces
What are the essential features of the patient-centric design for marginalised communities?
Dr. Harish Pillai implies that the design should be warm and welcoming and adopt cultural motifs prevalent and well known in the local communities. "It should not be an intimidating and an 'elite' space more in tune with alien cultures. Hospitals could adopt more open-air and natural ventilation spaces in ambulatory and outpatient areas. Amble usage of visual signages that aid and navigate through the space with liberal usage of vernacular signboards is also vital," he clarifies.
5. Geriatric Community and Design
Why is it important to focus on design for the geriatric community?
Dr Pillai notes that the growing burden of ageing is currently being seen in South India but soon will become a pan India challenge. He says that the design specifications of hospitals should be wheelchair friendly for easy mobility. "The choice of flooring materials, lighting and handrails should be designed keeping this age group in mind to prevent falls within premises. The signages should be visually appealing and easy to read for those with poor eyesight. Space planning should adopt zoning concepts that reduce intrahospital distances. Hospitals should also reduce the usage of staircases that will hamper movement. The restrooms and toilets in public areas should be designed to enable easier usage and have non-slippery elements," he adds.
"As far as design elements go, this building can be gender, behaviour and age-neutral, facilitating easier access for elective and acute care yet become customised in areas where specialised services need to be provided like emergency, outpatient, inpatient, radiology, restrooms etc. Besides the civil structure and interiors, the choice of colour palette, signage and furniture - both movable and fixed can accentuate sensitivity towards marginalised groups," adds Dr. Pillai.
6. Impact of Pandemic on Hospital Design
The pandemic has revealed the flaws in Indian healthcare design. "It's obvious that the pandemic has re-emphasised the importance of proper space planning and zoning within a hospital. The space planning elements should avoid overcrowding and the spread of a potential infection.The HVAC systems should cater to the needs for the specified ratio of fresh air changes and usage of negative pressure zones /rooms with HEPAR filters. All contact surfaces should be easily cleaned and not facilitate dust, bacterial and fungus growth. There can be a holding area close to the emergency department for safe triaging and screening/ testing. The emergency department for acute care needs a separate space for safe handling of respiratory infections with a tendency for spread via airborne droplets. Non-infectious cases can be zoned separately. It should be possible to easily isolate specific Inpatient and ICU areas to prevent cross-contamination and the development of disease clusters. Similarly, all ancillary and support spaces such as kitchen, dirty utility, laundry and biomedical waste management should incorporate elements of safe segregation at source and transportation and cleaning," Dr. Pillai explains.
7. Dignity of Care
Mehak Malik, co-founder and CEO at Uvi Health, a women's health startup, says that an inclusive healthcare facility should prioritise accessibility, privacy, convenience, and experience. "To deliver a women-centric healthcare experience, doctors and other members of the medical team should ensure a non-judgmental diagnostic and triage experience. For example, a woman should not have to disclose her marital status to seek care," she says.
Soumya Supekar is a healthcare architect at Cannon Design. She says that it is crucial to design safe spaces for female patients that provide them with the dignity of care. "Privacy is a highly complex aspect of safety, and non-ambulatory patients should be visually accessible for medical reasons and ensure that no mishaps happen behind the walls. On the contrary, ambulatory patients admitted must be given a sense of privacy to feel comfortable. Although these parameters don't ensure a 100 per cent success rate, they can reduce the number of such mishaps. In general, while designing a hospital, it should be kept in mind that no space is blocked visually, and doors should have vision panels even for janitors' rooms," she explains.
Supekar says that Indian healthcare is not just as inclusive as it can be. "Hospitals tend to divide wards/ICUs as beds for male and female patients, and even the national building code has only two genders under consideration. All the statistics like bed count and number of toilets per bed are bifurcated into male and female users," she states.
Supekar also points out that hospital design should avoid negative spaces where somebody can hide/harm oneself or another. "Restrooms, consultant rooms, offices, any space should provide visual access. A stressful environment can never motivate patients for quicker recovery, physiologically or psychologically," adds Supekar.
Shami Raj is the co-founder of Loop, which provides value-based healthcare services to companies' employees and health insurance coverage. He points out that good healthcare design always focuses on driving outcomes from a patients' health perspective. "This is an alternative to solving minor problems such as access to care, electronification of data and profit expansion for service providers. It should also be based on human-centred design (HCD), which includes all the stakeholders, including patients, to design innovative solutions,” he explains.
8. Anonymous Surveys
He also points out that involving patients from marginalised communities in the design and making of healthcare would be one of the first things to do, as this would enable their inputs.
"However, there have to be practical considerations of the manner of inclusion of these communities in these design processes, starting from selecting the samples to the insights collection process. Enabling the right selection of the cohort design that allows for coverage and accommodating for intersectionalities is critical. While a standard approach to research in HCD would be 1:1 interviews, this would be untenable because of barriers and trauma faced by these communities in the form of language, social stigma etc. In these cases, using other methods such as anonymous surveys might be good approaches," he explains.
He also says that the adoption of service design would be a significant input into this. "It includes the hospital's staff and marginalised communities in co-creation, which will enable the design of inclusive, empathetic spaces. "One of the key deliverables in this process is to build service blueprints that would enable hospitals to look at their entire service journey starting from the reception, public areas, examination procedures, to operative and post-operative care to identify touchpoints and drive patient goals. This kind of exercise allows large multi-service point hospitals to identify areas of exclusion and come up with fixes.
“Some of the interventions that have worked are creating visually welcoming spaces using imagery and reading material that caters to these communities. Also, the adoption of tele-health will enable marginalised communities to access care without the fear of entering spaces that may not be friendly. This is something we saw at Loop's telemedicine service. We found that sexual health as a speciality saw a lot of uptakes as patients, especially women found it safer and more comfortable to do virtual consultations rather than visiting offline care providers," he concludes.
Ravideep Singh is the associate director at Creative Designer Architects. Singh suggests that patient-centric care in healthcare is more important than ever. "Patient centrism as a principle allows caregivers to curate specialised and informed healthcare experiences for various patient types. A generalised approach towards healthcare design is perhaps a dubious phenomenon, with debatable efficacy. The focus on marginalised communities is still nascent within the healthcare space. It needs reinforcement through further research on the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues. At a broader level, patient centralism pivots around more versatile, supportive and culturally informed caregivers while ensuring the inclusion of the patient's loved ones in the process," he adds.
He believes that the answer to design friendly to marginalised communities lies in the study and implementation of psychoneuroimmunology in the design, use of responsive colours, textures and anthropometric elements that comfort the specific patient types. "Moreover, the entire thread of marginalised community identification has a lot of work. It is important to analyse the global population and lifestyle trends and accordingly curate a 'universal healthcare design ethos' that is inclusive, flexible and responsive. Another growing trend is the design for bariatric patients with the global obesity Index rising acutely," he adds.
9. Lack of Research on Marginalised Communities
Swapnil Puranik works for Cytiva. He argues that if COVID-19 isn't agnostic to age, gender and demographic, healthcare design should also be agnostic to population segments. Puranik says that one of the issues with providing healthcare products for marginalised communities is the lack of research done for such communities. "Most studies done at a public health level have tended to miss out on underserved communities. Thus, before getting into patient-centric design, the ecosystem needs to quantify and document the needs and problems of these communities. With needs identified and quantified, patient-centric features can be developed to ensure the design is (a) hyper-localised (language or dialects, for example), (b) affordable (novel pricing models that support marginalised incomes) and (c) personalised," he explains.
Puranik points out that a design for marginalised communities is a bonus. "By design, it would seek to improve features to improve accessibility, usability and affordability. When design meets these features, they also tend to be more than welcomed by larger communities. About a decade ago, I was involved in healthcare product design under the banner ‘In India for India' which aimed to develop affordable med-tech. In less than three years, this banner changed to ‘In India for World’ because ‘who doesn't like high quality and affordable products!’ It's a misconception that affordability compromises quality, and designing products keeping marginalised communities in mind will help further burst this myth," he concludes.