Initiating Change in Baby Steps
Editor’s note: In January 2009, the author joined a U.S. architectural firm at its offices in Doha, Qatar. Several months later, she was offered a position with the national healthcare system in Qatar, where her current position is the director of interiors and research for Hamad Medical Corp., a Joint Commission International-accredited organization.
“Change” comes in many forms and at many speeds in this part of the world. The almost overnight political changes in Egypt and Tunisia were unimaginable dreams 12 months ago, while protests and upheavals still continue in Libya, Syria, Bahrain, and Yemen. Social change, as Saudi women patiently protest for the right to drive, has been a documented battle since the early 1990s, with just a small glimmer of movement on the near horizon. Cultural recognition and appreciation of local arts has been a more rapid change: I.M. Pei’s highly acclaimed Museum of Islamic Art opened in Qatar in late 2008, and the new branches of the Guggenheim and Louvre will be opening in Abu Dhabi in the future.
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Changes in the region’s public healthcare systems tend to follow a slow projectory. While some new facilities are planned, designed, tendered, and constructed according to schedules similar to those in the United States, many more suffer through years of redesign, retendering and, unfortunately, reconstruction prior to their opening. The causes for the delays are familiar to Western ears: poor communication, poor documentation, and poor workmanship, as well as those not as common, such as when tradition, religion, culture, and politics intersect with a proposed change.
Adding to these issues are the backgrounds and cultures of the thought leaders and decision-makers. In most cases, the highest level of administration, the managing directors, are native citizens of their countries and highly desirous of change to keep up with the best of Western traditions, while the management tier of nonclinical staff is composed of expatriates with a specified-term employment contract. In Qatar, expats compose 87% of the population.
The majority of healthcare professionals are from the United Kingdom with years of experience in the National Healthcare System, a government-run, universal care system. Others are from Canada, Australia, and the United States. Of these, only the United States doesn’t offer universal care within a government-run system. While private hospitals can be found in large population centers in Great Britain, Canada, and Australia, they form a minority option. The competitive nature of healthcare systems in the United States and the subsequent drive for innovation in design is quite foreign to the rest of the world.
There also are a number of clinical staff who have a seat at the decision-making table. These could be male and female physicians trained in the United Kingdom or the United States and who are well-connected politically, as well as nurses in administrative positions born and educated in another country. Traveling and attending school in another part of the world affords the opportunity to expand one’s vision, while remaining in one country often supports a more traditional perspective.
The mix of decision-makers is significant, as their philosophies and visions integrate into the system’s culture: a background in public, government-owned, large city hospitals continually faced with budget cuts, facilities in poor condition, high patient acuity rates, and stressed staff brings a different mindset to the design presentation than an individual with experience in large and well-funded private U.S. hospitals. This is not to say that one is correct and the other not, but rather is a recognition of the experience “soup” and how that affects reaching design consensus of what a hospital “looks like,” the value of evidence-based design, and the development of an environmental script for an optimal patient experience.
Another aspect of change is the “pendulum effect.” When there are no or very lax policies in place, change brings a full pendulum swing to the other extreme, and it takes some time for the new policy to be adapted before it finds its reasonable center. As decision-makers choose to embrace change, well-meaning staff downstream often interpret the requirements to support the policy change more stridently and produce detailed operational procedures.
A new infection control policy dictated all architectural products, and furniture and fabrics specified had to be tested and approved by the infection control committee. Providing MSDS documents, copies of independent laboratory fire ratings and compliances, and explaining symbols supplied on all U.S. commercial fabrics proved insufficient as the use of forged documents is very common.
Change was initiated with the establishment of The Center for Healthcare Improvement to coordinate system change and the supporting facility renovations necessa
ry to support those changes. Other than routine maintenance, there had been no renovation projects since the facilities were opened in the 1980s. The first change project initiated a patient referral and appointment system in the Women’s Hospital Outpatient Clinic. The design direction was to create a “five-star hospitality environment” in an area with bright green vinyl flooring, pierced metal ceiling panels, and 60-inch-high concrete block walls for privacy around the waiting area furnished with black plastic chairs.
Tradition dictated privacy for females in waiting areas, but male visitors never were allowed in the clinic. The walls had been built because the design concepts were adopted from the General Hospital, built a few years earlier, where men and women had separate waiting areas. The first change was securing the decision to remove the block walls to create one large area. Some staff felt strongly that the patients should be protected from male staff members who might occasionally walk through the area. But administration realized new public facilities and hotels don’t have walls in their lobbies, so the walls were removed: the first baby step. The second design decision was to delete the metal ceiling tile panels, which proved much more difficult.
In the United States, it is standard for public waiting areas of hospitals to have acoustical ceiling tiles as they are relatively inexpensive, control sound transmission, and contribute to a more restful and quiet environment. The tradition of the region, however, called for pierced metal ceiling tile panels as it was believed more efficient for the engineering staff to find water leaks when the air-conditioning or plumbing systems failed. As the leaks occurred, the clinic staff placed a call to building engineering and the staff arrived in due time, removed the panel, repaired the leak, and replaced the panel.
To support this practice, the metal ceiling panel manufacturers in the region provided detailed information on the carcinogenic effects of acoustical ceiling tiles. After a delay of several months, many hours of research translating MSDS sheets, documentation from the World Health Organization, and a final presentation to the top levels of administration, the project continued with acoustical ceiling tiles as originally specified—a second small step for change.
Another design issue was the specification of carpet in the waiting area. The infection control committee of the hospital had declared all carpet unacceptable, but from the design perspective, achieving a five-star hospitality environment was compromised without it. Again, evidence was collected on studies of carpet use in public waiting areas in hospitals and copies of the studies were presented to the committee. After another delay, standard system politics, and several meetings, the carpet was accepted—yet another small step for change.
Similar objections continued to occur during the life of the project, originally projected for six weeks and eventually completed in 19 months. Each concern was met with copies from the applicable regulatory handbook or journal.
The completed project has been highly successful, and the complaints and questions eventually ceased. Administrators wondered why the busy clinic was so much quieter, and the new ceiling tiles, carpet, and upholstered seating received the credit. The extended political battles and project delays were forgotten as the waiting patients began taking short naps in the new lounge chairs as they waited for their appointment.
The second round of change, the Patient Care Environment Project, has now begun with renovation to all public spaces in the three largest system hospitals: Hamad General, Hamad Women’s, and Rumailah Hospital. All public corridors, lobbies and waiting areas, food service options, and each hospital’s admissions departments are currently being renovated with expected completion by the end of this year.
The five senses of restorative design are incorporated wherever possible:
- A sense of place greets visitors upon arrival in the public lobbies and at all decision-making points in the corridors where regional artwork is exhibited.
- A sense of security offers private and confidential admission rooms in all hospitals.
- A sense of community is found in the addition of multiple cafés and coffee shops throughout the facilities.
- A sense of compassion is supported in the new family centers in Women’s Hospital and Hamad General with comfortable lounge seating areas with cafés and access to landscaped gardens.
- A sense of life is celebrated in the many new landscaped gardens and courtyards with water features.
Without the baby steps, the design initiatives of the Patient Care Environment Project would not have been possible. HCD