Return to Fable Hospital: The Frustrating Search for Elusive Design Quality

The Fable Hospital

In a 2004 paper about better healthcare buildings, Leonard Berry and a group of colleagues interested in the advancement of evidence-based design principles wrote about a hypothetical hospital, the Fable Hospital, that incorporated several successful architectural elements described in prior studies but never assembled in one place (Berry et al, 2004a). I was one of the co-authors. The paper calculated conservative projections of the potential savings from an evidence-based design and was explained again in another article (Berry et al, 2004b).

Several years later, the premise was updated as Fable 2.0 in a paper that provided new calculations to elaborate on the original idea (Sadler et al, 2011). The authors were promoting a premise that one could interpret credible evidence as a way to improve design decisions. The unstated implication might have been that to follow such a path would lead to greater design quality, and that following an evidence-based or research informed path might lead to the Holy Grail of quality in healthcare buildings.

Does the use of an evidence-based process lead to design quality? I think not, without data from outcomes measures to validate the design hypotheses. Positive outcomes might be only one of many criteria on which a project’s quality might be based. For one thing, the use of an evidence-based design process does not guarantee positive results. The Center for Health Design has introduced the Touchstone Award program to recognize projects which have used an evidence-based design process emphasizing collaboration, improved outcomes, and sharing of lessons. The winners exhibit one important aspect of design quality in the realm of healthcare. There are many more aspects.

Aesthetic judgement

What often passes for evidence is the accumulation of design awards for the project; the more the better. Since the awards are granted based on the opinion of jurors, the evidence gained by one or more awards is weak and still mainly subjective. One award may lead to another and it is possible to say that they begin to represent some sort of consensus, rather than an individual opinion. A consensus about quality design can be interpreted as cultural approval for aesthetic or artistic forms, or if it doesn’t represent the taste of the broad culture, awards may take the form of the intelligentsia and avant garde pushing to introduce new ideas and change the prevailing culture. Celebration of Frank Gehry’s work, for example, represents a shift in popular taste, as did the work of Le Corbusier in another time. The architectural aesthetics of our time may be a reflection of critics who alternately promote or decry some aspect of design or a particular designer.

There is a long tradition of critical evaluation of architecture on the basis of proportion, scale, harmony, style, and perceived beauty (de Clercq, 2011). Honesty and authenticity are words sometimes used in the context of evaluating a design. I was privileged in the late 1960s to sit at Louis Kahn’s feet when he repeated his famous question, asking “what does the brick want to be?” I have forever since been opposed to bricks used as a lintel while supported by an unseen steel angle. But there is little in the way of evidence to determine authenticity or honesty.

Universal sources of inspiration

There are theories suggesting universal foundations for design that inspire some architects and designers. The proportional relationships described by the Golden Mean, occurring naturally or by design, is one example. Some cultures adopted sacred geometries as guides to their finest architecture, as in the case of Gothic cathedrals or Renaissance churches and palaces (Lawlor, 1989). Geometry is also sacred for Japanese temples (Fukagawa & Rothman, 2017) and Islamic architecture (Hosseinabadi, 2011). Nikos Salingaros (2006) has studied mathematical relationships and proportions in architecture widely described as beautiful, and he contends there are consistent mathematical patterns and ratios that constitute beauty.

Inspiration from forms found in nature is another theme adopted by designers. There are studies of plants, shells, bones, and the structure of plant growth that suggest there are repeating forms and geometries which can be understood mathematically (Fonseca, 1993; Thompson, 1952). The relationship of the Fibonacci series and the Golden Mean ratio to natural forms is well understood (Rehmeyer, 2007). These relationships are used by some designers to provide a rational order and logic in their work.

Another inspiration for architects that comes from nature is the human form with its ergonomic measurements, ratios, and proportions. Le Corbusier’s Modulor (1954) describes his use of human proportions and measures in making design decisions based on human scale. His largest projects were proportioned based on his understanding of human dimensions and ratios between the body’s parts.

Cultural and climatic regionalism

Aesthetic values can be cultural and geographic, often responsive to the regional climate (Olgyay, 2015) and availability of local building materials, as the architecture of Japan differs from the architecture of Sweden, and the architecture of Morocco differs from the architecture of Ireland, or North America. The steep roof of the Swiss chalet sheds the snow and the deep, shady overhangs of the house in Sri Lanka manage the heat and humidity while encouraging the light breezes. The sense of proper scale and harmony may vary widely from one culture to another. Some choose to celebrate vernacular architecture in its many forms, produced by individuals other than trained architects.

What is it about European cities and architecture that captivates visitors from the United States? I tend to think that the long-term growth and incremental improvements over the centuries have produced something especially pleasing. It is possible to contrast delightful medieval European cities that have preserved their best and consistently added new structures compatible with the original with our mostly artificially planned environments best suited to the automobile culture. It is a bit of an excuse to say our cities haven’t had time to mature, but we build poorly – not for centuries, but for the shortest possible time to reach a return on investment. What is probably fair is to say that each represents the culture of the time in which it was developed; walkable European cities with horses, carts and robust social interaction will be different from low density American cities of cars, trucks, and impersonal social media.

Building performance

There are criteria beyond aesthetics which can be used to define design quality. Energy use, thermal comfort, and ease of maintenance are criteria that are found in the realm of building performance. These and other measures that lean toward the engineering side of architecture are more likely to be quantifiable and reported in numerical forms. If one values the long-term view, life cycle costing may offer a meaningful comparison with first cost.

Resilience of the engineering and building construction is a category found in a paper by Anna Anåker and colleagues (2017). The resilience of building designs in the presence of earthquakes, storms, and natural disasters apparently grows more important every day. This seems to be a potentially important criterion, depending on the circumstances of specific buildings in locations that include potential risk.

Practitioner evaluation of facilities

Mardelle Shepley writes about building evaluations, not limited to the period after a building is occupied (2011b). She remarks that “The methods for conducting facility evaluations are as diverse as the universe of all research methods, because the assessment of an environment can be achieved in a variety of ways. Some of the common techniques include surveys, interviews, and behavior mapping” (Shepley, 2011b, p.7). She goes on to mention physiological measures, medical record analysis, and calibrations of light and noise, among other methods. She reports that evaluation often consists of a hybrid that combines multiple measures.

Post-occupancy studies are the simplest form of evaluation (Shepley, 2011a; Vischer, 2009). Shepley describes pre- and post-occupancy studies as a way of evaluating a facility by testing the environment before and after a design intervention (2011b). She notes that evaluation studies can be qualitative, quantitative, or both. She mentions experimental studies and quasi-experimental studies as tools for evaluation. Shepley points out the problem of confounding variables and unexpected conditions when evaluating an environment with so many elements that might impact the outcomes.

One element of an evaluation of a health facility is the question of intent and purpose (Shepley, 2011a). The question is whether the completed facility properly and effectively serves the intended function and purpose that was described when design had yet to begin. The intended purpose of a building, particularly a health facility, has relevance to the evaluation. One hopes that the intended purpose was laudable and that the evaluation shows that the building amply meets its purpose and effectively serves its intended function.

Purpose can be defined as the intended purpose of the facility or building, but the word can also be used to define an organization’s beliefs about values (Montgomery, 2019). A possible element of an evaluation might be whether or not the building serves a higher purpose and demonstrates the moral responsibility and accountability of the owner. Does serving a higher purpose mean receiving a higher score on design quality? Is there evidence found in the designed facility of that accountability to society? Without measurable evidence, the answer becomes subjective opinion.

Avoiding bias

One important issue for evaluations by practitioners is the question of potential bias. When an architect or organization reviews and evaluates their own work, there is always an implication of bias or favoritism. This is why I have always recommended post-occupancy evaluations be performed by an independent third party.

Instruments measure quality of physical environments

Marie Elf and colleagues (2017) have performed a systematic review of instruments used to measure the quality of physical environments in the healthcare domain. They review 23 instruments covering a range of criteria. Four instruments addressed healthcare buildings, or buildings in general, mainly using self-assessment. Nine were focused on environments for persons with Alzheimer’s or dementia. Seven dealt with settings for older people of long-term care. One instrument was meant for birthing environments. The LEED and BREAM instruments are for sustainability and energy performance. None of the instruments provide a universal answer to design quality in healthcare buildings.

The authors report that there is a lack of literature on the topic of measurement instruments for healthcare environments, and that “the instruments demonstrated a rather weak empirical base. The instruments have not often been used outside of their period of development, or by actors other than their original developers or authors” (Elf et al., 2017, p.2810). They further comment that the instruments studied are more practitioner and humanities oriented than oriented towards scientific proof.

Broader measures impacting society and the environment

There are scholars who suggest that environmental sustainability and ecological values are relevant criteria for evaluation design (Anåker et al., 2017). These criteria seem to resonate with our times. While some projects from the past have been celebrated for their attention to the ecology and sustainability, we need much more attention to these values as we face accelerating climate change and global resource limitations.

Anåker and colleagues (2017) also discuss the importance of a design’s relationship with and support for social and cultural interactions, as well as community values. This seems to make perfect sense in light of the recent emphasis on social determinants of health and population health. Our buildings should contribute to the common good rather than perpetuate the inequities in our existing systems.

Clinical measures and safety performance

There is a growing body of research linking elements of the physical environment with clinical outcomes (Ulrich et al., 2008). For health-related settings, it seems some measurement of clinical outcomes that can be attributed to an aspect of design would be helpful in establishing quality of the design. The same could be said of safety related outcomes as another category of useful criteria. If a building has a healthcare purpose, then clinical and safety outcomes measures would be useful indicators of the design’s functional performance.

Adirim and colleagues describe quality measures in the context of medicine and pediatrics (Adirim, Meade & Mistry, 2017). “Most quality measures are 1 of 3 types: structure, process, or outcome. Health care quality measures should address the domains of quality across the continuum of care and reflect patient and family experience” (p.1). It is interesting how close this comes to the firmness, commodity, and delight of Vitruvius. The authors go on the state that quality measures do not exist in a hierarchy; they say one cannot be ranked above another.

Conclusion

It does seem that attention to how a building performs from the standpoint of patient and staff safety, as well as from the assessment of clinical outcomes should be relevant to evaluating design quality in healthcare facilities. Perhaps design for health changes the ranking of criteria for quality, yet it is difficult to convincingly identify a hierarchy amongst the numerous ways to evaluate healthcare buildings. On the other hand, my colleagues complain that health facilities are too often judged only on the criteria of aesthetics without attention to functionality.

I’m not sure a single hierarchy of criteria for evaluation of design quality in healthcare facilities is worth seeking. As soon as I declare my preference for a weighted order of criteria, someone else will propose a different and equally valid model. The range of measures is broad and goes well beyond the 23 instruments Elf and her colleagues reviewed. It all seems to depend on the perspective of the observer and their peculiar interests.

To discover design quality in health facilities, there must be a balance of objective and subjective measures, as unbiased as possible, using quantitative, qualitative, and mixed methods. These methods will be applied by persons or groups, each with a particular perspective; clinical outcomes, energy consumption, community service, beauty, structural elegance, use of a particular product, evidence-based design, or something else. When the Fable Hospital is finally built, there will be many ways to measure its quality.

No single measure/instrument will apparently cover the range of potential quality criteria found in healthcare building projects. This suggests we must become content with a group of criteria and related instruments to measure the quality of our architecture. We must recognize that multiple points of view will always contribute to recognition of design quality, and be prepared to celebrate achievements in multiple categories. Perhaps we must ultimately recognize that the perception of quality lies in each individual rather than in some well-intended measure.