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?
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.”
Every detail counts
So hospitals need to look conspicuously safe, in every respect. “To reassure the public, we need to show a strength of response,” says Suzanne MacCormick, global healthcare lead at WSP. “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. People need to see visual cues that we are doing everything we can. We’ve put in extra layers of cleaning but we need to make that very visible. Equally, there needs to be exemplar behaviour from the staff to encourage compliance from the public.”
Every premises has had to install notices informing people of the measures that have been taken to protect them, and how to comply. But this isn’t enough.
“The problem with signage, says MacCormick, whether reassuring or instructional, is that we cease to notice it after we’ve seen it a few times – it becomes part of the landscape. This is also why it is so hard to change ingrained habits. The subconscious mind is much more powerful than the conscious mind and constantly searching for clues to make sure we’re safe, but it also determines our behaviour – most of the time, we’re on autopilot.” She has visited hospitals where the corridors have been decked with one-way and no-entry signs: “So you are always supposed to walk on the left-hand side of the corridor. But when you watch the staff, they take no notice of the signs because they no longer see them.”
MacCormick has a clinical practice focusing on the neuroplasticity of the brain and works with patients who have a psychological component to their illness. “Once learned, all behaviour is done subconsciously,” she explains. “You’re going to walk the same route because you’ve always walked it, even if there’s a sign saying otherwise. So we need to bring people back to the conscious state, make them aware of what they’re doing and nurture them to do it more effectively.” One technique is “pattern interrupt”, changing something in the environment to jolt the brain and disrupt automatic behaviour. Opening doors, for example, is something we learn at an early age and then continue to do subconsciously. “We know that you push a handle down, twist a knob, pull a looped handle and push a flat plate,” says MacCormick. “If we try to pull a looped handle only to discover it requires pushing, we’re snapped into reality. This interrupts our learned behavioural pattern and demands conscious thought, so we can use this technique to challenge and change behaviour.”
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.
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Providers can also use digital technology to supplement environmental cues and make the hospital experience more transparent, says Nolan Rome, director of WSP’s US healthcare practice. “The long-term plan was that access to healthcare would start from your couch, from your iPad,” he says. “Preparing for your visit reduces your anxiety and gives you more control over your environment and your experience.” This has been accelerated during COVID-19, as providers turned to smartphone apps to help manage the flow of people into a facility. Patients wait for their appointment in a virtual queue at home, and the app lets them know when to leave and provides directions to help them navigate through the hospital. “Healthcare systems have been talking about the concept of ‘concierge healthcare’ for a while, as a way to enhance the experience, so that you weren’t inconvenienced or wasting your day. Before COVID, that was just a really whizbang thing to do, but now it’s a requirement because you can’t just show up and congregate in a lobby like you used to.”
For those who are still very anxious about going to hospital, video consultations could potentially be a lifesaver. “The healthcare industry has been slow adopters of some technologies, but for most things, a video consultation does work,” says Lowe. With his Design Age Institute hat on, he thinks more needs to be done to give older people alternative means of seeking help. He recently spent three months seconded to NHSx, the UK health service’s digital agency, installing tablet computers in care homes. “It’s a myth that older people can’t use technology – 77% of them are online, and by the end of this pandemic, it will be even higher. They want different ways of accessing healthcare, so we need to find innovative ways to reassure them and allow them to stay well.”
Broadening the options so that it’s not always necessary to go to hospital will also make systems more resilient in the event of future pandemics or other crises. But resilience in healthcare stretches far beyond the walls of any single facility – a system is only as resilient as its weakest link, and it may not always be apparent exactly what that is. We’ll consider what true resilience looks like in a post-pandemic age next in the series.