Designing the health care environment

There are ten low-cost and high impact design changes that can be made that will improve the well-being of patients, staff and visitors in your hospitals and clinics. Each of these small steps has its own reward; a few modest initiatives in sequence will help change the outlook and expectation of staff, patients and the public.

When times are tough design matters most. Each crisis creates its own opportunities. Become your own design champion, bang the drum and focus relentlessly on small things that will make a difference. In the past decade I have met inspiring individuals, nurses, managers and Trust chairwomen who have helped turn their hospitals into more confident and positive organisations during a period of austerity. Don’t feel bad about investing in better places for staff. A happier and more professional workforce makes for better care.

The award-winning Kings Fund ‘Enhancing the Healing Environment’ programme which provided modest grants for projects that improved the environment where care was delivered is no longer active. However, the database of completed projects provides a great place to look for what can be achieved.

Welcoming and reception
First impressions matter. Research shows that people make up their mind about organisations and individuals very quickly. For a person arriving at your clinic or hospital for the first time, the first 15 seconds will determine what they think of your ethos. This conditions both nervous patients, and prospective skilled staff. Understanding arrival can be a blind-spot to those who work in the environment on a daily basis. It was a shock to me to be told that my office doorbell label was unreadable, although I walk past it each day I simply hadn’t noticed. Look again at that journey with fresh eyes. Take a camera and notepad; imagine yourself as a patient, a wheelchair user, or a potential staff member. You will be surprised at what you find.

Key points to keep in mind include: a clean and clear view of site signage; obscure unsightly features with low-level landscaping; illuminate the entrance and remove inducement for smokers to hang around; ensuring the reception or at very least the next place a visitor is to go to is clearly visible and you approach the entrance; and make the reception area accessible and ensure it communicates the kind of welcome your organisation should give.

Communication and wayfinding
Hospitals are complex and confusing environments for visitors and many staff alike. Imagine your clinic or hospital as a strange city rather than the place you know. As a stranger you build a sense of orientation through directions and landmarks.

Signage can have a part to play, but without being seen as a whole system it can be confusing and rapidly becomes outdated. Confused visitors are under stress and cost you money by wasting staff time. Look at your signage with a fresh eye. Does the language make sense to someone unfamiliar with a medical environment? Is it consistent and easily understood by someone who may have poor eyesight?

Hospitals and clinics are full of redundant signs and pointless messages which contribute to a sense of institutional chaos. Safety or statutory information should be minimal and grouped to be relevant. Very occasionally it is vital for temporary signage but this should be short term. A sensible plan is to exert control over ad-hoc signage and ensure it is someone’s responsibility (particularly effective if it is a board member) to remove unnecessary signs.

Signage is a comparatively cheap but important tool in creating a legible and efficient estate asset. There is a large body of material available to help you including standard NHS Guidance. When considering the use of signage it is important to recognise inefficient movement and flow is frustrating, wastes time and costs money. You should look at signs as a whole system of wayfinding, check the coherence of your guidance, and remove irrelevant messages, signs and notices, as they undermine the quality of your organisation.

A good signage strategy provides a set of stepping stones. Just as we navigate a city by streets, parks and squares, a health setting needs places for individuals to construct their journey. This rule applies equally to a GP practice and a large teaching hospital. Any redecoration cycle offers the chance for some place-making. At the most basic level, panels of strong colour can delineate a place. More time should be spent on planning, local lighting, artwork or modern photographic wall finishes which can provide a strong memorable impact.

Frail and elderly people or those with dementia will benefit from using ‘landmark’ places as locations to rest and gather ones thoughts. Make sure that directions to toilets are clear and consider providing handrails and seating at these important places if space is available. Waiting and sub‑waiting spaces are ‘destinations’ and need distinct characteristics – use colour, lighting and materials to endow the place with an identity distinct from the surroundings.

Make placemaking part of the normal redecoration cycle, walk the routes and identify the main decision points or destinations, select distinct colours or materials to make the place distinctive and consider how best to reassure patient’s and visitors through simple information and comfortable seating.

Daylight and views
There is a vast body of evidence that daylight and view are therapeutic and speed recovery through a variety of physiological effects. For example, daylight is calming, helping to reduce anxiety or stress which lowers blood pressure. Daylight provides a familiar representation of subtle skin colour and facial modelling, helping communication and lending to better diagnosis.
A sense of the time of day and season which a view of sky or an attractive garden helps circadian rhythms which are produced by natural factors within the body. Light is the main cue, turning on or off genes that control the body’s clock. Resist the short-term desire to fill in courtyards with ‘useful’ space. The downside of lost quality, inadequate lighting and ventilation regularly outweigh the promised benefits. Thus it is vital to make the best of the windows you have. Consider how you can maximise interest with a few potted plants and solar powered lights and, if possible, contemplate installing a roof light in dark deep spaces.

Art and ageing
Many hospitals and clinics have art exhibitions and artists working to improve lighting, wayfinding, gardens and clinical areas. In 2011, the British Medical Association published a paper on ‘The psychological and social needs of patients’ which found that creating a therapeutic healthcare environment extends beyond the elimination of boredom.

Arts and humanities programmes often have a positive effect on inpatients. The measured improvements include inducing positive physiological and psychological changes in clinical outcomes, promoting better doctor-patient relationships and improving mental healthcare. If you don’t have an arts programme then establish one. If you have an existing arts programme re-energise the work by linking exhibitions to other initiatives and make well-lit display spaces to exhibit the best items of art therapies.

Our increasingly elderly population means that care settings need to respond to the needs of older patient’s visitors and staff. There are a number of common themes that should be part of the design champion’s toolbox. For example, slips and falls by frail older people are debilitating and costs the NHS millions of pounds. Small changes in lighting, décor and handrails can deliver immediate dividends.

Dementias and reduced cognitive range means that the environment needs to work harder. Contrasting tones and colours should be used to delineate doors, floors and skirting boards and familiar signs and symbols used instead of words where possible. There have been positive initiatives such as the King’s Fund ‘Environments of care for people with dementia’.

Furthermore, accessibility and safety of the environment are core CQC standards, and should form part of any new work or cyclical maintenance. Note that reductions in slips and falls is as important as lowering the incidence of hospital acquired infection.

Brand identity
In the last few months, the closure of an NHS hospital and likely demise of the Trust was blamed by the chief executive on a ‘tarnished brand’. In a turbulent world any organisation needs to cultivate a consistent and positive identity. Nurturing small things that sit outside the core function of delivering healthcare makes a difference to public perception.

It would be beneficial for you to use design to articulate your organisation’s professional ethos and recognise that the NHS ‘brand’ is a valuable partner. Consider standardising on a well matched palette of materials, furniture, fixtures and fittings as good landscape communicates a calm quality.

Caring for carers
Don’t feel bad about investing in the work environment. The quality of clinical staff has the greatest impact on patient well-being, while the calibre of the workplace plays an important role in recruitment and retention of staff. NHS workplaces are generally less attractive than those found in other sectors. It costs up to £50,000 to recruit a clinician in the NHS.

A review of non-health workplaces can be worthwhile and can show the way to providing an environment that is professional and helps your workforce feel valued. It is vital to remember that experienced NHS staff are valuable, so consider ‘business lounge’ rather than ‘hot-desk’. In addition, think about ways to maximise utilisation of space by making it look and feel valuable, share space wherever practical and provide ‘oasis’ places for frontline staff to de-stress.

Further Information

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