Commentary: Exercising Design Leadership

By Wayne Ruga

Why are healthcare buildings generally so unremarkable when it comes to supporting the performance of their intended purpose—providing humane care and measurably improving health? In an attempt to find an answer to this question, I've concluded that some contributions from the architecture and interior design professions have improved the overall performance of these buildings, while other influences have worsened their performance. For example, there are two very specific ways that healthcare design professionals have improved the ability of healthcare buildings to support enhancements to health. First, during the '70s, as the complexity and scale of these buildings dramatically expanded, architects and interior designers were extremely successful in employing industrial engineering-type thinking to increase floor plan efficiency to reduce footsteps that directly translated into better care delivery. Second, in the late '80s, design professionals utilized the concept of the "healing environment" to provide emotional and psychological support to the patients, care providers, families, visitors, and local communities and to reduce stress levels as well as enhance the efficacy of care delivered.

Meanwhile, the unremitting pressure for all those involved in the healthcare delivery enterprise to do more with less has intensified. These providers work under constant pressure to deliver more and better quality care with reduced staff levels. Similarly, architects and interior designers work under increased pressure to deliver higher-performing buildings, in less time, for rock bottom and highly-competitive fees.

A gap has become apparent to me, as I persist in trying to understand why these buildings continue to underachieve— particularly in the face of such well-intentioned staff who work in these facilities and the design professionals who so enthusiastically design them. Isn't it odd to realize that an architect or interior designer designs and delivers such a highly-refined and highly-specialized healthcare building to their client, and yet they provide little or no on-site orientation or training to assure the most effective possible utilization of the building? This is a gap that I have identified as the separation between the completion of construction and the actual operational protocols of the building. The closing of this gap, I believe, requires the seamless merger between the design of the building and its ongoing, day-to-day operation— a merger that healthcare architects and interior designers are extremely well positioned to facilitate as an extension of their standard professional services.

To be fair, this gap is not the result of an oversight in professional design practice. Rather, I believe it is the result of the constant pressure to deliver more with less—both for the clients and the design professionals—and the consequential assumptions that this thought process engenders. However, there seems to be a false economy that accompanies this 'do more, faster, with less' approach. In cases where I have observed no gap, those particular healthcare enterprises substantially exceeded their industry's performance norms, whether the measures were financial, health improvement, patient and staff satisfaction, community engagement or industry recognition. The term I use to describe this type of setting-specific enhanced performance is "generative space." A generative space is a place where the quality of the experience within that space—both in terms of the physical and social dimensions of that space—fulfils its core functional purpose and serves to improve people's lives. The ability to systemically and sustainably improve health with generative space is directly related to the presence of these experiential qualities within the physical and social space.

My opinion is that a primary function of an architect or interior designer is to be an educator. It is this educative role that enables the design professional to fulfil their obligation of serving as a professional. In this regard, I am a passionate advocate for design leadership. I believe that the architect or interior designer must lead the client through educative processes and professional best practices—to support them in accomplishing their intended purposes. For example, if a client engages a design professional to design a maternity unit, they must understand that the client will be requiring more than just the provision of the technical settings necessary to support this functional purpose. The architect or interior designer would be wise to begin this new commission with the provider's vision, mission and purpose statements in mind. After all, the maternity unit is the technical setting that enables the service that supports and reinforces these foundational statements. It is precisely within this correlation that the design professional can exercise design leadership and lay the groundwork for the development of generative space.

Clearly, exercising design leadership and developing generative space is not for all clients or all design professionals. The day-to-day pressures of producing more with less, results in a highly-competitive and fast-moving industry where the level of risk, rigor, and novelty of this approach may place it outside of the possibility matrix for practical consideration on most projects. However, in the face of this rationale for maintaining the unremarkable status quo, it must be noted, again, that the most highly-accomplished organizations are the same ones that employ design leadership and generative space to effectively accomplish its goals.

This proposal to advance the practice of healthcare architecture and interior design by exercising design leadership to close the gap between building design and operations, and by developing spaces that are truly generative, calls upon the pioneers of healthcare architecture and interior design to expand their own personal practices. It implores them to counsel their clients and prospective clients to see the gap and work together to close it; to engage those professional collaborators—such as organizational development practitioners— to assist with developing working practices and training; and to provide those additional professional design-related services that can support these generative activities.