West Coast evidence-based interior designer Jain Malkin meets East Coast evidence-based interior designer Rosalyn Cama with consensus that the trend toward the evolution of healing environments is in its infancy, but fueled by the acceptance of an evidence-based approach to interiors. Roz's From The Center column earlier in this issue (see page 8) maps how she sees best practices having a shelf life giving way quite regularly to the drivers of the next practice. Jain is quite pleased to be seeing great interest in the evidence-based design (EBD) methodology; she states, “I am on the Scientific Committee for the World Healthcare Congress. We recently reviewed a large number of submittals from all over the world from individuals who submitted papers for presentation at the conference. Virtually all of them referenced EBD.”

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Interior architecture: Jain Malkin Inc.; architecture: Boulder Associates

Photography: Ed LaCasse

Proposed children's hospital interior with changing light quality, CAMA, Inc.

This article addresses quite specifically the design trends these two leaders in interior design see coming in the evidence-based approach to healthcare interiors.

New vocabulary of healthcare archetypes driven by reform

Jain Malkin: We can learn much from Europe and Asia in terms of hospital design just as they learn from us. As budgets tighten in the United States, I think we will be influenced by projects from abroad that are functional and safe, as well as very attractive in design. They seem to accomplish this with less cost than we spend in our country. At the HEALTHCARE DESIGN.09 conference, I attended a terrific presentation on the design of healthcare facilities in Northern Ireland. I learned that they have instituted community-based wellness from an urban planning perspective to try to influence health lifestyles and then integrated this with their healthcare system in terms of clinics and hospitals. I saw beautifully designed architecture, buildings suffused with natural light, and an exuberant use of color and art.

Rosalyn Cama: The evolution of best practices for interior healing environments has been developing slowly. The obstacles toward developing a truly healing environment as evidenced by the literature are cost and a limited market for most manufacturers. To the contrary of an EBD approach we in healthcare have borrowed from other market sectors, particularly hospitality. The time has come to develop a healthcare archetype that becomes the envy of other market sectors. I see this opportunity strengthening into the next practice as more evidence supports the development of interiors that respond to our primal need found in nature. Interior elements that more efficiently and affordably offer the same variability as found out of doors will propel the healthcare interiors marketplace into a health prescription. Our piece of health reform.

Interior architecture: Jain Malkin Inc.; architecture: Boulder Associates

Photography: Ed LaCasse

Improved human factors and industrial engineering

Malkin: Medical equipment should be the next area of innovation. It has certainly lagged behind furniture and other products designed for healthcare. There needs to be more focus on reduction of noise, product design, and if it has wheels, concern about noise generated while in transport and ease of movement for those who push or pull it-wheels that are properly designed for carpet or hard-surface floors. And, of course, there are the ubiquitous IT concerns of lack of interface between monitors and other devices that have difficulty communicating with each other. Aesthetically, the design of numerous pieces of medical equipment commonly found in patient rooms leaves much to be desired. The housing of these devices is not as sleek and high tech as one would expect. They often resemble testing devices one might find in an automobile repair shop. I think Europeans do a much better job of product design than we do here in America.

Baystate Children's Hospital, Springfield Massachusetts, Welcome Center, CAMA, Inc.

Photography: Rick Scanlan

Interior architecture: Jain Malkin Inc.; architecture: Boulder Associates

Photography: Ed LaCasse

Medical College of Georgia Cancer Center storytelling board with tone of voice images

Heery/CAMA, Inc.

Cama: The new iPhone was released this week and it is amazing that Apple has thought about things I don't even know that I need yet. Like seeing the person I am talking to. Each time I buy a new car I marvel at the new ergonomically positioned controls that allow me to drive and do three other things at the same time without taking my eyes off the road. Walmart and other large distribution-based systems have elaborately automated inventory/just-in-time systems. Toyota taught us Lean, the aeronautical industry gave us checklists. Is healthcare ready to teach the rest of the world something about efficiency and safety? In our next practice I think our evidenced-based interdisciplinary teams will engage more manufacturers to develop unique mechanical and electronic support systems that will improve the quality of care delivery. Can you see the pent-up demand for the release of a new healthcare interior rivaling a new iPhone release?

Color and our primal need for nature

Malkin: A trend I have observed in some new hospitals in the last few years is a total absence of color. Many of these hospitals have been designed by our leading, and largest, healthcare architectural firms. It seems the more prestigious the firm, the less use of color and design features that may appeal to patients and families who are under stress and facing great challenges. Color is the elixir of life. Why are so many architects phobic about the use of color? It's really disheartening to walk through a 200,000-square-foot building and see nothing but white walls and neutral surfaces. It's a new version of the old hospitals that we all characterized as institutional. One of our leading architecture magazines a couple of years ago noted, in reference to the hospital they featured as an example of outstanding design, that it r
esembled a museum. Stark, white, cerebral architecture. Is that what we've achieved after all these years of studying healing environments?

Smilow Cancer Hospital at Yale-New Haven, Sol LeWitt Wall Drawing # 692, continuous forms with color ink washes superimposed. Architecture/interiors: Shepley Bulfinch; art consultant: CAMA, Inc.

Photography: Rick Scanlan

Cama: I often ask my audiences to remember a recent stressful period and if during that period they could have been transported anywhere in the world where they would be calmed, to imagine that environment and to focus on the elements that created a sense of well-being. I then ask one simple question and that is whether they were indoors or outdoors; 95-percent-plus say outdoors. And when I ask quite specifically about their environments they describe environments that engage all of their senses. What are we missing in our interiors that are the cues we seek as humans when we are stressed? In our next practice, we will have interiors that replicate nature's variability.

Environmental sustainability

Malkin: I foresee greater interface between LEED and EBD. As many know, LEED for Healthcare is under review and will soon be available. Yet there are many areas of conflict or, perhaps a better way to state it, is the law of unintended consequences. As examples: a focus on daylighting in LEED does not address the glare that can be harmful to the elderly or patients of any age undergoing certain types of treatment. Glare in healthcare facilities is an issue that must be considered. Reduction in light levels to reduce energy use can be dangerous in terms of patient safety. In nursing spaces, error rates double without high levels of lighting for tasks involving small detail. And this is certainly true in clinical areas like procedure or treatment rooms both in clinics and hospitals. In terms of finishes, it is still difficult, although certainly desirable, to find non-PVC hard-surface flooring appropriate for clinical spaces, especially if linoleum is not appropriate for the intended use. I am especially concerned about the attempt to reduce water use by deleting sinks in favor of handwash gel. Will that happen? Will patient safety be compromised by getting the LEED credit for something? LEED for Healthcare has tremendous potential to achieve optimal high-performance healthcare environments if we can achieve the proper balance between energy efficiency, sustainability, and patient safety.

Cama: If there is a lesson to be learned about the Gulf oil spill, it is that we need to be wiser about everything we do. The cost is too great to mess with Mother Nature. The next practice will be accountability for the planet earth and all who inhabit it. We need to design interiors with greater flexibility to endure the rapid changes in this industry and to not let enduring materials be demolished because the color trend has changed. We must do a better job. HD

Jain Malkin, CID, AAHID, EDAC, is President, Jain Malkin Inc., La Jolla, California. Rosalyn Cama, FASID, EDAC, is President, CAMA Incorporated, New Haven, Connecticut. Both serve on the HEALTHCARE DESIGN Editorial Board. Healthcare Design 2010 July;10(7):20-28