The Physical Determinants of Health: the Building as a Health Intervention?

 The Physical Determinants of Health: the Building as a Health Intervention?

Lucas DiLeo, Contributing Writer for Boston Orange

A growing body of research suggests that the design and architecture of a health care facility substantially influences the health outcomes of the patients in it.  Yet there are few formal experiments to develop and test these ideas about the physical determinants of healthcare and incorporate them into design practices.    This was the conclusion of an interdisciplinary panel of bioethicists last week at the Harvard Medical School Center for Bioethics. 

The speakers, summarizing their three years’ collaboration, called for a more ‘systems based’ approach to exploring, testing and evaluating how design can enhance the care delivery environment and patient health outcomes. And that these insights be brought into the formal health facility design process. 

How can buildings shape the well-being of patients? 

There is an effort to understand how the buildings in which clinicians practice can shape the health and well-being of patients, according to Kelsey Berry, PhD, Associate Faculty Director of the Master of Bioethics Degree Program at HMS and panel Moderator. 

Kerry noted the industry’s increasing focus upon the social determinants of health. There has been a paradigm shift.   And we have the opportunity to do this again. 

So how should healthcare respond?  What the role should health groups play in testing and developing design solutions?  And what values should shape particular design interventions? 

The built environment as a parameter of care 

The built environment is a parameter of care in the view of Diana C. Anderson, M.D., M.Arch., Geriatric Neurology Research Fellow at the VA Boston Healthcare System.   And needs to be considered alongside other parameters of care.   As medical students they took courses on determents of community health.  But no one was talking about the physical determinants of health. 

Their view is the built environment has as much impact on us as other medical interventions, and essentially it is a medical intervention.  It can effect us as much as a medication or a procedure.     

Healthcare design and its impact upon the care environment 

There are a number of qualities of built space that are reasonably well documented, and generally inferable as to how they would affect us, according to William J. Hercules, M.Arch., CEO of WJH Health and former President of American College of Healthcare Architects.   

Such as how it looks; access to as view of nature; lighting or acoustic effects that may have a positive or negative effect on our mood or well-being. 

Hercules’ view is that architecture could benefit from a bioethics lens.  Outside of building codes or various guidelines there is a lack of structure around the health implications of design. Design projects have millions of decisions by many more people than just architects, but these decisions are not well regulated like pharmaceutical development. 

He quoted Winston Churchill: “We shape our buildings and they shape us”.   And Florence Nightingale wrote about how soldiers did not die from battle wounds but from the environment of care. 

However, code changes are really about minimum compliance.  The bigger idea is the codes themselves are not transformational.  We need a different kind of infrastructure and organizational Infrastructure to do these things. 

What is the framework that can be applied to design and healthcare? 

Stowe L. Teti, M.A., Clinical Ethicist at Inova Health System discussed examples of the impact of design on health practices and outcomes.   

Stowe framed the design-ethical issues in clinical care:  incidental events around facility operations and deliberate actions that are taken in terms of physical design.  And he raised the question: is it appropriate to do research on the built environment outside of a research context. There is no oversight required to put people in a physical setting. 

One example from Canada about people living in long term care facilities - approximately 2.1 million, a tiny percentage of the total population.  But around 40% of COVID deaths were from such facilities.  Upon further analysis one third of the nursing homes had multiple occupancy of rooms and communal design.  Those facilities were responsible for 2/3rd of those deaths.  So it is not just the settings but the features of those settings that can have an impact, 

Sometimes our decisions are being influence by the space we are in.  Another study researched the impact of design upon clinical care and child birth. They found facilities which had more surgical suites performed more c-sections than those that devoted more space for natural birth.   

And COVID illustrated how in solving one problem they created another - such a moving IV pumps outside of rooms to lower staff exposure risk.  Which led to patients being less closely monitored, which also coincided with visitation restriction.  During this period they saw increases in pressure ulcers and hospital acquired illness.  

Evidence Based Design leading to differential outcomes.  

A study of Columbia Presbyterian ICU indicated that sicker patients assigned to the corner rooms did not do as well, according to Dr Anderson.   Those had greater morbidity and mortality due to the lower visibility from the staffing stations.   Our expectation is that the care is equal to what the person in the next room receives- but what if not every room in the hospital does not allow the same opportunity to get better. 

Another is a study of sink availability by McGill University.  They found that every additional meter that must be walked by healthcare workers decreased the likelihood of hand washing by 10%. 

To discourage dementia patients from leaving the facility, one home applied masking tape in horizontal bars on the floor in front of the doors.   Where the stripes were applied vertically the patients would walk right past them.  Patients misperceived the horizontal bars as a 3-dimensional stairs which may not be welcoming to someone frail.  The question raised: is there a difference between using medication to limit wandering vs using architecture to induce a psychological state to achieve the same end? 

The natural progression of using illusions that deceive is complete immersion.  An example of a dementia village - the original is in the Netherlands and others have popped up around the globe.  They permit permissive wanderings by the patient.  An artificial reality of a community of streets and retail shops.   An illusion of freedom but does not lead to the outside world.   One can go to a supermarket or barber or pub, but ultimately it is a gated dwelling unit. 

Is there a right to reality for patients with advanced dementia?  

These are examples of the emerging ethical issues in long term care design for which there are no research or oversight but they believe should.  Such as the perception that the patient is free to leave, when they are not.  Or the immersive settings that convince residents they are somewhere else or in a different time period.   Controlling behavior thru design interventions: not different than interventions undertaken in medical pharmaceutical development in their opinion. 

Institutional policy and the built environment 

Do healthcare systems need to rebuild hospitals?  Not necessarily, according to David A. Deemer, M.D., Bioethicist and Internal Medicine Resident at University of Wisconsin, Madison. 

Policies are another tool.   They govern how we operate within buildings and can mitigate harmful effects of a given space.  They offer flexibility and can be rapidly implemented.  And cost a lot less than a new hospital building. 

For instance, a study on visitation polices by 32 hospitals found that strict no visitation policies led to more effective disease isolation.  However, patients experienced increased rates of pressure ulcers, falls and sepsis.  And loss of patient’s connection to ‘reality’. 

Allowing some degree of limited visitation may mitigate some of these adverse association but may cost more. 

Takeaways and Next Steps 

Teti concluded by offering a set of recommendations. 

·       It is time for the built environment to become part of the same calculation as other physical and psychological factors affecting care.

·       funding and research is required to investigate the curative efficacies of specific architectural interventions.

·       The Ethical issues in healthcare architecture experimentation requires an ethical rubric to clarify intent, risks and expected outcomes.

·       Bioethicists need to engage with health architects around issues of equal access and treatment, prevention of co-morbidities, and use of space to influence people. 

Where does the field go next? 

Pierre M. Barker, MD, MBChB, Chief Scientific Officer, Institute for Healthcare Improvement, offered a commentary on the presentations and his thoughts on where the field goes next. 

First is the extent of family and patient engagement in the design process and testing of the design changes.  The starting point is what matters to the patients we are trying to serve   Those closest to the patients have the best ideas for how to respond to the needs identified.  

Second: what can we learn from using the tools of improvement science - particularly iterative learning and systems thinking to guide the designs.  There is an opportunity to incorporate ideas learned from the studies and move into perspective design that use rapid cycle thinking. 

One final point, using improvement study designs to test the interesting data accumulating in this field.  The studies we saw today are observational, and all retrospectives.  He did not see much in terms of good matching.  So, they do risk that the evidence on which some profound decisions are being made are potentially at risk of bias.  

The next step is what do you do with that data.  The idea of co-design and that we can perturb the environment in a prototype way while looking at the results of those tests before committing to expansive, more lasting design changes. 

There is a lot that can be done with the data at hand.  He wondered if there isn’t a lot of opportunity for more testing of ideas and more manipulation of the existing spaces.  

Lucas DiLeo, Contributing Writer for Boston Orange