Time And Space: An Interview With Jain Malkin
With a prolific output of books, articles, and presentations—in addition to the indelible design stamp she’s left on numerous healthcare facility projects, large and small—Jain Malkin is one of the best-known and most respected experts in healthcare design, particularly when it comes to evidence-based design. Her book Hospital Interior Architecture, published in 1992, was the first to propose a research-based approach to design. And her very first work, Medical and Dental Space Planning (first published in 1982), is now in its fourth edition—clocking in at almost 700 pages and updated with “95 percent new material,” according to the author.
That’s not hard to believe, considering the last edition came out in 2002, and the healthcare landscape has changed just a bit since then. But change is something Malkin is used to, having started her healthcare design career in 1970, when there was very little to go on in terms of healthcare-specific design guidelines. At that time, she spent a year doing field research, going into hospitals and trying to observe facility operations as if she were a patient. “My degree in psychology prepared me well for this and also made me very comfortable reading research,” Malkin told Healthcare Design in a 2012 interview. “I came away with hundreds of photos and many pages of notes and interviews by the end of that year. I spent another year visiting physicians’ offices, observing flow, asking lots of questions, and taking many photos.”
Malkin closed her eponymous design firm in 2012, but she remains very active in the industry as a consultant, writer, and speaker. Healthcare Design spoke with Malkin (who sits on our editorial advisory board) about the new edition of Medical and Dental Space Planning, to take her pulse on the industry’s current challenges and discuss where everything may be headed.
Healthcare Design: You’ve been designing medical spaces for more than 40 years now. What are the top five most significant changes you’ve seen in healthcare design thinking from the time you started to today?
Jain Malkin: When I started researching the first edition of this book, it was a lot easier to get permission to observe in practitioners’ offices and in hospitals than it would be today. I recall clearly that there was no design per se in these offices; they were very basic and what we’d call institutional. By the time the second edition of the book came along about 10 years later, there was much more interest in design and a greater understanding that a relaxed patient is a good thing.
Probably the five most significant changes are:
- The Affordable Care Act (ACA), which has led to considerable rethinking of clinic space planning to achieve quality outcomes. Through the years there have been many major shifts in healthcare finance, which led to forecasts of doom and predictions about access to care and how clinics would be designed. But nothing compares with the impact of the ACA. The ACA has paved the way financially and philosophically for the rapid growth of community health centers, also known as safety-net clinics. The ACA also ushered in patient-centered medical homes.
- Considerable changes to the exam room and how it’s used, including “talking rooms,” which are devoid of exam tables. There had been very little change in the basic building blocks of a clinic until a few years ago. Now you’ll see many changes in these exam rooms in size, configuration, and design.
- The shift from episodic care to a collaborative care model, in which physicians get paid more for thinking smarter and connecting all the dots within the system. This embraces the shift to a patient-centered medical home in primary care and a major focus on value-based care and the ability to document effectiveness.
- The explosion of mHealth (mobile health devices), which will reduce the number of face-to-face office visits as people are able to self-monitor vital functions and metrics associated with chronic conditions in their homes. Secure networks enable the information to be transmitted to physicians’ offices or the equivalent of nursing “call centers” for interpretation. The smart phone will increasingly be used with medical apps and devices to monitor blood sugar, cardiovascular activity, oxygen levels, and more—in real time.
- Miniaturization of diagnostic equipment, including high-quality ultrasound that can fit in a pocket or be carried in one hand, which affects space planning and the places in which tests can be carried out. In dental offices, a handheld X-ray machine can be carried from room to room and many offices now have computer-aided design systems that allow restorations (crowns, veneers, etc.) to be designed in 3-D and sent to a milling machine within the office for manufacture.
Regarding mHealth and technology, what are providers and designers doing to stay ahead of the curve in this rapidly changing new reality?
Electronic medical records, while offering many advantages, leave much to be desired in compatibility between individual providers, and between those providers and the bigger hospital system. Private practice physicians are often frustrated by the cost of developing a system and the inherent problems of getting at the data that’s really useful. Ideally, having a built-in clinical database is a huge advantage in treating patients, but the consensus is that it’s still a work in progress. The trend is for exam rooms to have a large monitor that enables the patient and provider to sit side-by-side, to review radiographs, lab tests, and educational material.
In dental offices, patient practice management systems seem to work very well with many treatment rooms having three monitors: one behind the patient’s head for the dental assistant, one straight ahead in front of the patient or placed directly overhead, and a third where the dentist can view it. Many dental instruments and tools have digital output that can be viewed on the monitor. These are very sophisticated systems with good connectivity.
For designers and architects, what’s the significance of the shift toward more community clinics?
The ACA has allocated significant funds for expansion of community clinics, which means that design professionals need to know how to design these facilities, which have more comprehensive services and are more multidisciplinary in nature. The goal is to do as much as possible at each visit, including vaccinations, gender-appropriate screenings, mental health assessments, dental care—for adults and children. With a population of patients who may be hard to reach by phone or email, or who may not show up for future appointments for a variety of reasons, this care model has a proactive focus, characterized by collaborative team care that leads to more informed decision-making.
In addition to understanding how these clinics are typically organized in terms of space planning, one must be familiar with their funding and regulations as well as the unique combination of psychosocial issues that inform the design. Some community health centers are considered Federally Qualified Health Centers (FQHC), a designation that brings with it additional funding for serving specific groups of underserved populations, such as seasonal agricultural workers, residents of public housing, or the homeless. There’s a high priority to educate all patients about cessation of smoking, good nutrition, and making lifestyle changes that will result in better health. These programs may result in space allocation for a café or juice bar, a farmers’ market where patients can buy fruits and vegetables
, or offices for clinical navigators to connect patients to programs available in the community.
Within the examination area of the clinic, there may be a combination of large exam rooms (accommodating several providers) and talking rooms without exam tables. Although the latter may not functionally need a sink, in some jurisdictions the room must have a sink in order to bill for the consultation—which is an example of knowing which regulatory agencies have jurisdiction (and there may be several). Many of these clinics have patient-centered medical home status, which may be designated by a number of accreditation agencies, each with a set of standards and specific criteria.
Depending upon geographic location, clinics typically serve immigrant populations, many of whom may not yet speak English, have a fear of “modern” medicine, and may have little education. This brings with it many psychosocial challenges for clinical staff who have to understand the nuances of each of these cultures—and some of these may have implications for space planning.
You’re a big proponent of color in healthcare spaces. How have the trends in color evolved over the years, and do you have any predictions for where they’ll go over the next 10 years?
Color is the elixir of life and is an inexpensive way to create an environment that, depending on the selection of hues and values, can express serenity, vibrancy, or a comfortable balance of those two extremes. I don’t like the idea of color “trends,” because this is a marketing concept that has no place in healthcare design. A better approach is to apply color theory and research to the selection of what’s appropriate for a specific healthcare setting. For example, color can influence performance and also the way we experience a space: It can create the illusion of distance or size, making an architectural element seem shorter or taller, closer to us or farther away. The human response to color may have behavioral, physiological, psychological, and perceptual influences. The Center for Health Design published a document called “The Application of Color in Healthcare Settings” in November 2012, which contains many photos of healthcare interiors, annotated with research.
As for trends we’ve all had to suffer for far too long, there’s the mauve craze, which can still be found in older medical offices and hospitals that haven’t been renovated in a long time, and the orange and gold trend. Certain colors actually never look dated, including burgundy and various shades of green, but it’s all a matter of the designer’s skill in combining them with other colors and in getting the right values. Color is a highly subjective subject, needless to say.
Any other predictions on how the interiors for healthcare spaces may evolve aesthetically over the next 10 years, and why?
I think there will be much more emphasis on green materials and more sophistication in design features and color palettes, and certainly the use of LED lighting. The array of great-looking LED fixtures of all types is wonderful.
In your preface, you say, “The field has now reached maturity. No longer concerned with discovering the basic rules and principles, healthcare design specialists can devote themselves to innovation and refining what has been learned.” What do you see as the most pressing needs in terms of innovation in our industry?
Many designers who work in medical office design follow the same cookbook recipe that’s been around for many years, because they may have been engaged by the building developer, whose goal is to get the tenant in quickly and at the lowest cost. Space planners are often paid minimal fees to do this type of work, and sometimes these space planners have very limited knowledge of the field, having come from the general office design arena. They don’t have the time to really sit down with a physician and develop something innovative. If you ask physicians what they want in a new office, they tend to recreate what they have now, but a bit larger. They don’t know what other options may exist. In writing this new edition, I sat down with numerous physicians in various specialties and led a discussion about what might be an optimal space plan if they were free to dream. I also asked this of the techs and nurses who work in these offices, who often have to do inefficient workarounds because their space planners never asked the right questions or really understood the equipment they use.
The basics of medical and dental office design have been around for 40 years, but now the objectives of the ACA, with a rigorous attention to quality metrics and safety, and the evidence-based research available offer engaged professionals a chance to rethink everything.