Words by Katie Puckett
Healthcare workers are the heroes of the pandemic; hospitals the epicentre. These buildings, always freighted with emotion, have become even more symbolically charged at this time of societal trauma and crisis. As telemedicine replaced in-person consultations and elective procedures were cancelled, going to the hospital in most cases became the preserve of the sickest – an often terrifying journey, with loved ones left behind and forbidden from visiting.
These measures were essential to free up bed capacity and to prevent COVID-19 from spreading, but the unfortunate side-effect has created the impression that hospitals are not safe places to be – an impression we urgently need to dispel, both for the health of the population and the sustainability of the institutions themselves. There is growing anecdotal evidence that people in need of urgent medical care are choosing not to go to hospitals, prompting concern that “COVID-phobia” could lead to a second wave of deaths indirectly caused by the virus. A study published in the Journal of the American College of Cardiology in June showed that the number of severe heart attacks being treated in US hospitals had fallen by nearly 40% since March. Doctors in other specialities treating conditions such as strokes have described a similar decline. Meanwhile, a poll by Incisive Health of 2,000 adults across Europe, in France, Germany, Italy, Spain and the UK found fear of COVID-19 impacting on willingness to engage with the healthcare system, with 49% scared to go to an emergency department and 42% scared to consult a hospital-based specialist.
Awareness of infection risks has certainly increased across the population, a change that is likely to be long-lasting, if not permanent. Every building owner will need to respond to this, but for healthcare providers, the stakes are higher than most.
“There is a public perception that hospitals are dirty and germ-infested,” says Steve Eiss, executive director of facilities development at Banner Health in Arizona. “Every time during this pandemic I mentioned that I was going to the hospital people thought I was crazy and I had to explain that I felt safer there than I do at the grocery store. Those of us who understand hospitals know that they are already designed to be inherently cleaner and safer than most buildings, and to filter and circulate air better.”
So how can we communicate that to the wider population?
"There is a public perception that hospitals are dirty and germ-infested"Steve Eiss, Banner Health
Colum Lowe, now director of the Design Age Institute at the Royal College of Art in London, has faced this challenge before. He was head of design and human factors for the NHS’s National Patient Safety Agency from 2003 to 2007, when hospital-acquired infections and MRSA became a cause celebre for the press and an election campaign issue. “Every day there seemed to be another headline about the NHS ‘superbug’, and people were worried about going into hospital because they thought they were going to get an infection,” he remembers. In the case of COVID-19, this anxiety is compounded by uncertainty: “The science is not absolute at this minute, and as evidence grows, we’re frequently getting what appear to be conflicting stories even from reputable news channels. Add social media to that, and nobody knows what to look to.”
Clear messaging is vital to maintaining public confidence. Some of this is outside of healthcare providers’ control, but they do have control over the messages that patients receive when they seek care and during their visit to the hospital. Then as now, one of the main strategies was a handwashing campaign, which both reduced infection rates but also provided reassurance to patients. Details matter, says Lowe, because in the absence of clear messaging, we are hyper-sensitive to information from our environment. “The world is a complex place, so as humans we pick up cues of quality from everything around us. In the FMCG [fast-moving consumer goods] sector we call it ‘brand’, but of course the same is true in healthcare environments.” While he was at the NHS, he drew on research from the aviation sector showing that if the seat on an aeroplane toilet was broken, passengers were more likely to think the plane would crash: “If you cannot look after a toilet seat, what chance of a Rolls-Royce jet engine? If you walk into an A&E department and you see litter on the floor, a bed in the corridor, people getting angry because they’ve been waiting too long, everything looking just a little bit out of control, your perception is that the whole place is in crisis.”
"Details matter because in the absence of clear messaging, we are hyper-sensitive to information from our environment"Colum Lowe, Royal College of Art
"We need to be talking about how we manage infection prevention and control as part of our business-as-usual, and how we are managing the differences in this virus"Suzanne MacCormick, WSP
Interventions that can’t be ignored
Design interventions can act both as pattern interrupters to encourage better habits and to engender trust. A relatively simple step is to install more hand hygiene stations for visitor use throughout hospitals, including at the entrance. “When you walk into a healthcare facility, there’s a sink with soap and paper towels or some other way to dry your hands, and signage telling you to wash your hands,” says Kevin Chow, senior associate and healthcare specialist with WSP in Dallas. “Instead of just trying to change behaviour when it’s a health crisis, we need to make sure people are washing their hands all the time.” We also need to design out shortcuts, says Tomer Zarhi, mechanical manager in WSP’s Canadian healthcare team. “Don’t put a hand sanitiser dispenser right next to a handwashing basin, because people will use that instead of washing their hands properly.”
Another powerful visual cue at the entrance of a hospital would be a display showing the air quality inside. Air-handling systems are not traditionally a mainstream preoccupation, but COVID has thrust them into the limelight. One of Zarhi’s friends is a dentist: “Patients are calling him and asking ‘what is your air change rate, what level is your filtration’.” Hospitals could use this extra scrutiny to help tackle the perception problem, by displaying air quality monitors to patients as they walk in, he suggests. “There are inexpensive technologies that can monitor the air quality in rooms and in larger spaces such as an atrium. It adds transparency – we need lights and whistles to show patients it’s safe to be inside.” This could become a point of competition for hospital owners and managers, in the same way that publicly displaying energy consumption has influenced the market for greener buildings. “Hospitals can already say they’re doing well on in-house infection rates, but that’s just a number. If you see a monitor walking into a hospital, that’s a big deal.” This would also help to underline hospitals’ higher performance in comparison to other types of buildings such as offices or restaurants.
"We need to design out shortcuts. Don’t put a hand sanitiser dispenser right next to a handwashing basin, because people will use that instead of washing their hands properly"Tomer Zarhi, WSP