Sustainable Design: a Systemic Approach to

Healthcare

Timothy Lalowski, MPH and Deborah Wingler, MSD-HHE

IndexAbstract 4Overview 5Conceptual Framework 9Social Sustainability 10Equity 16Economic Sustainability 20Viability 28Environmental Sustainability 32Stewardship 38Case Studies 42

Abstract

Sustainable Design: A Systemic Approach to Healthcare

Timothy Lalowski, MPH; Deborah Wingler MSD-HHE, EDAC

Current trends are moving the United States healthcare system towards a preventive, primary care, patient-centered model in response to rapidly rising costs and consistently poor performance when compared to other developing nations. By the same token, the role of public health is emerging from the shadows and demonstrating the need for broader, more global understanding of the mechanisms of human health, dictating its function in healthcare. As initially proposed in 1979 at the International Conference on Primary Health Care of Alma-Ata, the changes we are seeing today address the initiatives of the Triple Aim: to improve experiences, reduce cost, and improve population health. Our current understanding demonstrates that human health cannot be limited to the individual, nor should it be a response to disease, but it should rather be global, pre-emptive, contextual, and longitudinal consideration. In fact, heathcare is a complex system which mandates a systemic approach to its development, one that looks at all environmental, social, and economic factors. Our approach must consider the global scale rather than the individual, longevity over capital, and symbiosis beyond conservation. Our design must demonstrate stewardship, equity, and viability. No longer should we divide healthcare into factions of patients, providers, organization, community, and environment. Each of these are cogs of the larger machine, where none can be understood without the acknowledgement of their interaction. The paradigm must be shifted; our forward path must be a systemic approach to healthcare through sustainable design.

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Overview

On September 25, 2015, the United Nations resolved to adopt the 2030 Agenda for Sustainable Development, a set of seventeen goals directed at comprehensively improving the sustainability of human activity. These goals, seen in figure 1, address a multitude of real concerns that threaten our present and future alike. We have already begun to see the effects of global warming, environmental contamination, unsustainable world economics, and broken social systems (Briggs, 2003)(CDC, 2011)(NRDC, 2016)(Reblin & Uchino, 2008) These crises are the reason why the seventeen Sustainable Development Goals address issues not only of environmental conservation, often perceived as the extent of “green” movements, but also economic and social factors (UN, 2015). It is the combination of these three pillars: environmental, economic, and social, that provide a truly sustainable system, one where each pillar supports the next. (UN, 2010b) Time and time again, it has been witnessed that failure of one pillar is detriment to the others: poor environmental conditions lead to increased healthcare costs, (Harvard Kennedy, 2015) low socio-economic status relates to pollution, pollution shapes community development (Lehtonen, 2004) , social support determines income and mental health (Brummet et al., 2003), and all of these are determinants of health (WHO, 2016b). “The Green Building Movement is guided by a simple, yet revolutionary, idea: that buildings in which we live our lives can nurture instead of harm, can restore instead of consume, and can inspire instead of constrain” (Guenther & Vittori, 2013). Nevertheless, the reality is that we are far from this goal. Our healthcare system is wholly missing the mark when it comes to sustainability, meaning that it cannot continue in its current form. The United States healthcare system is the most expensive in the world, consumers are unhappy with the quality of care they are receiving (Davis et al., 2014), and our human activity is damaging the health of the environment, which is necessary for our continued survival (WHO, 2016). One pillar is certain to fall unless something can be changed and we can advance into a sustainable system.

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Sustainable Development Goals

1. End poverty in all its forms everywhere2. End hunger, achieve food security and improved nutrition and promote sustainable agriculture3. Ensure health lives and promote well-being far all at all ages4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all5. Achieve gender equality and empower all women and girls6. Ensure availability and sustainable management of water and sanitation for all7. Ensure access to affordable, reliable, sustainable, and modern energy for all8. Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all9. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation10. Reduce inequality within and among countries11. Make cities and human settlements inclusive, safe, resilient, and sustainable12. Ensure sustainable consumption and production patterns13. Take urgent action to combat climate change and its impacts14. Conserve and sustainable use the oceans, seas, and marine resources for sustainable development15. Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss16. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable, and inclusive institutions at all levels17. Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development

Fig. 1 United Nations 2030 Agenda for Sustainable Development Sustainable Development GoalsSource: (UN, 2015)

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Overview

Evidence based design (EBD), or the “process of basing decisions about the built environment on credible research to achieve the best possible outcomes” (CHD, 2015) has led to the exploration and association of design features to human health, with a wealth of knowledge being collected in the healthcare setting. Patient and staff health, satisfaction, safety, and productivity have been linked to design features such as views of nature, natural lighting, private and adaptable rooms, effective ventilation systems, appropriate interior lighting, layout of workspace, and noise reducing finishes (Ulrich, 2012). A well-designed environment supports the effective and efficient delivery of care, all while promoting health for patients and staff alike. These seemingly individual influences contribute to the overall health of their community’s population. The design of the space in which we live is inextricably tied to behaviors, transmission of disease, and immune response (Zimring, 2013), Space has the ability to impact human biology and psychology on both micro and macro scales (Ulrich et al., 2010). In short, the space in which we live is nothing less than the immutable context for the lives we live. Conscientious design for these spaces has the power to improve the overall sustainability of healthcare delivery, from the design stage to the end-of-life point. It promotes effective and efficient care, responds to the needs of society, all while minimizing environmental impact (CHD, 2016), chemical toxicity from human pollution, and antibiotic resistance within the pathogen community (CDC, 2015). In a recent study assessing the current evaluation strategies specifically within the patient-centered medical homes (PCMH), researchers found that evaluations often failed to acknowledge healthcare as a longitudinal process, a factor on the entire population, or within context (Wingler et al., in preparation). This practice, traditional to how the healthcare system is managed, is not sustainable, in that it does not promote development which reflects a necessary coordination between social, economic, and environmental needs among the global population. Our ability to assess and evaluate the healthcare system, dependent on the strategies we deploy, dictates the direction and success in

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Overview

achieving sustainable systems. These evaluations shape our understanding and, in turn, our capabilities. We must strive for a better system: a system which works with us, the planet, and itself, to not only slow down or halt our destructive practices, but to reverse them completely and foster an environment of human prosperity and of planetary vitality. We must be stewards of our environment and take charge in creating a symbiotic relationship with our planet, design with the intent of longevity, and acknowledge the rights of all people in order to maintain a perpetual, harmonious system. No longer can we assume that isolated efforts will propel us into an advanced state of human health. For healthcare to be sustainable, we must acknowledge the larger system, its context, and the components that make it work. This is a matter of addressing the financial system, the public social structure, the built environment, the delivery model, and the natural environment as a singular entity. (UN, 2010b) This understanding has led to the following conceptual framework, as seen in figure 2, where the three pillars of sustainability (UN, 2010) have been expanded into six sectors: social sustainability, equity, economic sustainability, viability, environmental sustainability, and stewardship, illustrating the interdependency of the pillars. Within this framework, each sector consists of three levels. The lowest level represents current initiatives, whereas the outer ring represents the goals and values of a truly sustainable system. This conceptual framework relies on the fact that healthcare is a systemic issue in which each partition balances itself on the next. Focusing these efforts in the design stage of healthcare environments initiates a broad dialogue and supports a preventive approach to human health.

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Conceptual Framework

Fig. 2 A conceptual framework for sustainable healthcare design

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Social Sustainability: the capacity of a social system to support its own development through positive reinforcement. (UN, 2010b)

Individual Tier: the holistic well-being of a single patient, including his or her physical, psychological, and social health.

Community Tier: the collective health of a group of people sharing similar location and/or traits.

World Tier: the wellness of humanity as a whole.

Social SustainabilityDialogue Social sustainability is the least defined or understood of the three pillars, yet many could argue that it is the most important for the success of sustainable implementations. Robert Goodland of the World Bank defines social sustainability as such:

“Social sustainability means maintaining social capital. Social capital is investments and services that create the basic framework for society. It lowers the cost of working together and facilitates cooperation: trust lowers transaction costs. Only systematic community participation and strong civil society, including government can achieve this. Cohesion of community for mutual benefit, connectedness between groups of people, reciprocity, tolerance, compassion, patience, forbearance, fellowship, love, commonly accepted standards of honesty, discipline and ethics. Commonly shared rules, laws, and information (libraries, film, and diskettes) promote social sustainability” (2002).

In essence, social sustainability is the combined efforts of all people towards a common goal and for the greater good. Distress within this pillar may result in a disruption of progress towards any one goal, especially a goal as complex as sustainability. As a result, regions of the world with the highest rates of poverty and lowest social cohesion tend to have the highest resource waste. (Agarawal & Narain, 1990) Social Capital: cohesion, trust, and buy-in are necessary for the success of any project or implementation (Seibert et al., 2001).

Patients in the healthcare setting are the initial opportunity for influencing holistic well-being. Each individual’s well-being involves physical, psychological, and social needs, which must first be addressed separately and then cumulatively. Culminating in holistic wellness, this goal is the first step for achieving social sustainability.

Naturally, and necessarily, humans develop communities based on location or common characteristics in order to create something that is greater than the sum of the parts. As communities, individuals are able to propel each other towards greater development. (Macrfarlane, 1999) Advancing our concerns into the health of these communities supports their social development and creates a positive feedback loop. A cohesive community is successful at reaching a common goal, whereas communities of low cohesion or trust, lack direction and often work against each other. (Woolcock & Narayan, 2000)

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Optimization of social sustainability requires a focus on the global scale, fostering health and social ties which transcend borders. International distress is unsustainable. Distrust of foreign culture leads to inefficient business practices, costly and destructive wars, mismanagement of resources, and limitation of knowledge-sharing (Dillard et al., 2009)

Practical ApplicationsPatient Satisfaction and Activation: Patient satisfaction not only provides a business incentive, but also a public health incentive. Satisfied patients have been shown to have better health outcomes, independent of service, as well as improved patient activation, or motivation to achieve wellness. Interior spaces have been linked with both satisfaction and activation, meaning that space has the ability to improve motivation towards better health and attitude towards healing. The linkage between attitude and health has been resounding in the medical community for decades. (Quan et. al., 2011b) (Eich et al., 2014)(Greene et al., 2014)

Patient-Provider Relations: “Successful, sustained practice development requires strengthening of both internal relationships within the practice and external relationships with the local community and patients.” (Miller et al., 2010) Some health practices have begun to add talking rooms and consider the expansion of shared spaces as a way to foster these relations. Supporting community outreach programs through allocating community spaces has also been a growing trend (see Adelante Mesa case study)

Healthcare Access: Access to care has long been a driving factor for individual health and is easily quantified at the community level. Where to build, what to provide, and how to approach a healthcare service are important decisions which begin at the design stage. Simply changing the location or orientation of a healthcare building affects the community’s capacity to access those services. (Anderson, 1995) (Healthy People, 2016) (Eich, n.d.)

Family Presence: Supporting family presence in design has been shown to improve health outcomes in patients. This has been achieved through providing single-family rooms and patient-centered unit layouts. (Bosch et al., 2012) (Choi & Bosch, 2013)

Space Syntax, Flow, and Wayfinding: “Individual spaces in the built environment, and the connections between them, create specific opportunities for movement and visibility.”(Haq & Luo, 2014) Space Syntax, or the theory dealing with building layout, is a complex system of space and connection. The syntax, flow, wayfinding, are all integral features of the building which affect the movement of people, visibility, privacy, perception,

Social Sustainabilityefficacy of care, relationships, and in essence, social capital within the building’s internal community. (Pati et al., 2015)

Provider Well-being and Support of Delivery: Often providers are forgotten when considering improvements to healthcare, yet consideration staff-burnout, staff satisfaction, efficiency of care, and the overall well-being of staff is vital for the successful delivery of healthcare and improvement of human health. Healthcare is a stressful occupation, and consideration of provider needs and supporting the delivery model is instrumental in improving quality of care. (Zadeh et al., 2015)(Wingler & Hector, 2015)

Flex Space: Flex space is a term used to quantify the ability of a space to adapt to changing needs and context. People are not static, they do not continue to demand the same needs over time, and those needs shift, requiring space to adapt. Flexible spaces meet this requirement, reducing the environmental impact of rebuilding or fabricating a space while adapting to the changing needs of the community. (Horwitz-Bennett, 2014)

Stress and Mental Well-being: High levels of anxiety and stress are common in healthcare settings, and many design features have been identified that reduce this: layout, decor, inclusion of family rooms, lighting, noise, and views of nature. (Cartland, 2013) Lighting has been one of the most studied features within healthcare design, and has been linked to health outcomes, patient satisfaction, mental health, medical errors, stress, sleep, healing, length of stay, mood and perception. (Joseph, 2006) Noise reducing fixtures and application of music within medical rooms have been shown to reduce stress, anxiety, medical errors, blood pressure, pain, (Quan et al., 2011b) Views of nature have been shown to significantly reduce stress, anxiety, and pain. Natural sunlight has even been shown to reduce the need for analgesic medication, dramatically cutting medication costs. (Ulrich, 2012) (Laursen et al., 2014)

Social Support and Cultural Sensitivity: “Persons who receive higher social support generally experience less stress and have better health than those who are more socially isolated.” (Ulrich, 2012) Improving patient connection with personnel, family, or even other patients has been shown to improve health outcomes. “In Feng Shui, a balance of mass and void is important, as is the orientation of entrances and exits. In Native

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American cultures, access to the outdoors for traditional healing is critical. In Abu Dhabi, for example, where family members may wait in outdoor waiting rooms for days at a time, adequate preparations for cooking may be necessary, including facing these spaces towards the prevailing winds.” (Eich, n.d.) Understanding the social structure and culture of the patients using a service is extremely important in design, as it impacts their reception of the space and their perception of the services.

Health Implications As a social species, humans have always relied on a social dynamic for our own development, well-being, and survival. Understanding this dynamic pillar of sustainability is vital for the success of healthcare and design. Supporting social needs not only improves human health, but it strengthens the social capital, the driving force of a healthy population. It is the determining factor of our own success in creating a sustainable system and ensuring our survival.

Social Sustainability

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Equity: The mitigation of socioeconomic disparities in order to alleviate social and economic tensions which threaten the stability of the healthcare systemLiteracy Tier: understanding and acknowledging the diversity of needs and assets within the population.

Efficacy Tier: the ability of a healthcare system to promote holistic health within the given resources and context.

Prosperity Tier: the ultimate state of an equity driven system which promotes the success of patient and provider alike, and therefore, society as a whole.

Equity

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Providing equitable healthcare involves the elimination of disparities on all levels of social and economic factors, optimization of the healthcare system within the given contextual environment and available social and economic resources, and the cultivation of social and economic growth for all. Equity is defined as “fairness or justice in the way people are treated”. (Webster, 2015) It differs fundamentally from equality, as equal access appeals to the democratic process by demanding all people are treated identically. However, equality fails to acknowledge crucial differences in social and historical context. “Having begun from the assumption that all men are created equal, the logical derivation of this postulate requires that access be made available on even terms to all, thereby promoting equality of access….” (Schement, 2001) However, through a deeper understanding of human reality, delving beyond theory, one can see that the equal distribution of resources does not ensure fairness. “...though equality of access promises a level playing field, the promise fails when some Americans lack the knowledge, income, equipment, or training necessary to play the game. Thus, to continue the pursuit of a democratic ideal where all enjoy access to those public discourses through which participation becomes sovereignty, government must seek to overcome the obstacles to access experienced by affected groups…”(Schement, 2001).

Fig. 3 Social Progress Index vs GDP Per Capita

Source: (Porter & Stern, 2015)

In order to reach equitable care through design, three stages must first be achieved: literacy, efficacy, and then prosperity. Literacy in healthcare design involves the acknowledgement and understanding of the diverse needs and assets of the target population receiving services. The social and cultural context is a mediating factor of heathcare design outcomes, and understanding the population interacting with the design is a vital first step for providing a space which supports equitable care (Betancourt, 2002). The second stage, efficacy, is achieved when the space supports holistic health while cognisant of the available social and economic capital. This mandates the effective and efficient delivery of care within the given context (Guindo et al., 2012). Context is the cultural, economic, social, and physical environment of the community which mediates the effect of design features on healthcare delivery and health outcomes (Litaker et al., 2005). A truly prosperous system advances beyond efficacious care and fosters social and economic capital, promoting the success of the community, supporting patients and providers alike. (Baumol et al., 2007) At this stage, disparities have been eliminated, the healthcare system has be optimized for the given context and resources, and the system encourages social and economic growth simultaneously. (Treuhaft and Madland, 2011)

Socioeconomics is the study of the intersection of social and economic factors. According to the American Psychological Association, socioeconomic status, or SES, “is commonly conceptualized as the social standing or class of an individual or group. It is often measured as a combination of education, income and occupation.” (2016) Utilizing both social and economic metrics illustrates a clearer picture when trying to understand a public health problem, as researchers have found the two sectors to be very tightly linked. Furthermore, socioeconomic status has been deemed as the fundamental determinant of health. It is both absolute and relative, creating health disparities across the globe. (Link and Phelan, 1995)

Social Capital is a vital component to the economic development theory (Woolcock, 1998). It is argued that an increase in social capital results in the greater chance of economic growth and success. However, the same can be said of the opposite; that economic stability results in a more plentiful stock of social capital. Both truly are strongly linked and piecing them apart reveals the complexities of their relationship. (Woolcock et al., 2000) Social Capital is composed of trust, cohesion, cooperation, and other factors that characterize a social network’s ability to work towards a common goal. Not only does economic capital mediate this ability, but it has been shown to mediate the factors of social capital itself. Economic equity has been linked to social cohesion and trust, resulting in a positive association with cooperation. (Francois, 2003) However, due to the implausibility to determine the temporal relationship between the two, the relationship is associative rather than

Equity

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causative, further illustrating the complex and often cyclic nature of the two. The bottom line is that social and economic capital are intertwined factors of human health, fundamentally impacting the public (Kawachi et al., 1997).

Economic Sustainability: the capacity of an economic system to support its own development through compounding growth. (UN, 2010b)

Capital Tier: the initial value of a healthcare system.

Investment Tier: A healthcare system whose services result in economic growth.

Longevity Tier: the quality of a healthcare system that is powered by the economic growth it initiates.

Economic Sustainability

Dialogue The United States is the most expensive healthcare system in the world, spending $8,508 per capita annually. Norway, in second place, only spends $5,669 per capita. Yet, when ranked in terms of quality against 10 other developed countries (Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, and the UK), the United States is dead last. (Davis et al., 2014) Above that, healthcare costs continue to rise at a rapid pace, increasing by $45 per capita in 2014 alone. (HCCI, 2015) Healthcare costs now consume over 1/6th of the United States Economy (AHIP, 2016), making it the second largest sector of government spending (NPP, 2015) Needless to say, the United States healthcare system is wholly unsustainable, unwieldy large, and cumbersome, economically straining those who need it. (Squires, 2015) Any and all innovations to reduce cost should be explored. Figures 3 and 4 illustrate the magnitude at which the United States healthcare system is burdening the economy.

Fig. 4 Total Health Expenditure per Capita and GDP per Capita, US and Selected Countries, 2008

Source: KFF, 2011

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Yet, with the enormous sums of expenses the United States pays for healthcare, there seems to be little or no payoff. Quality is low, consumers are unhappy with services (Davis et al., 2014), and there is a strong disconnect between healthcare expenses and the United States life expectancy, as seen in figure 5 (Monroe, 2012).

Fig. 5 Healthcare Spending per capita vs. Average Life Expectancy Among OECD Countries

Source: Monroe, 2012

Fig. 4 Growth in Total Health Expenditure Per Capita, U.S. and Selected Countries, 1970-2008

Source: KFF, 2011

Economic Sustainability

“The widely accepted definition of economic sustainability is maintenance of capital, or keeping capital intact. Thus Hicks’s definition of income–the amount one can consume during a period and still be as well off at the end of the period–can define economic sustainability, as it devolves on consuming value-added (interest), rather than capital” (Goodland, 2002) Economic sustainability is a growth, rather than stagnation. However, it also requires that growth to be self-sustained, without requiring the input of diminishing resources. The United States healthcare system is not sustainable for this reason. Creating new technologies at the expense of jobs and the rise of costs creates a toppling system in which the stakeholders can no longer partake. Eventually, the amount of people unable to afford basic care and defaulting to government assistance will be too great for the federal economy to handle, and the entire system will crash. (Ungar, 2011)

“Economic growth is the most powerful instrument for reducing poverty and improving the quality of life in developing countries. Both cross-country research and country case studies provide overwhelming evidence that rapid and sustained growth is critical to making faster progress towards the Millennium Development Goals – and not just the first goal of halving the global proportion of people living on less than $1 a day.” (DFID, 2008) On a global scale, the eradication of poverty is vital for a sustainable economy and for a healthy and sustainable planet. According to the United Nations, “Eradicating poverty in all its forms and dimensions, including extreme poverty, is the greatest global challenge and an indispensable requirement for sustainable development.” (2016) In the United States and around the world, the existence of poverty prevents systems from achieving sustainability and has a detrimental impact on health.

From a design perspective, there are many ways to improve economic sustainability. The design stage can be utilized as the first steps in reducing the cost of care through the reduction of capital expenditures (LCI, 2016), improving the efficiency of care (Zadeh et al., 2012), creating better healing environments (Laursen et al., 2014), providing a space which support the provider’s services (Zadeh et al., 2015), and creating a community investment (Taylor, 2014). These design decisions transform the healthcare environment from a capital investment, being replaced quickly, into an investment, and eventually into a space with longevity.

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Traditionally, healthcare and all other structures were designed as capital costs, as a setting to provide care. They were designed for a basic function. However, we quickly realized, as buildings are estimated to have a lifetime of 40 years, they were not just capital costs, but investments as well. The design could create better financial returns. In an article from the IIDA, Anjali Joseph, PhD states that “Many of today’s hospitals were built in the 1950s and aren’t adequate for the needs of the population now,” (Bowles, 2006) Hospitals designed in the 50s must now be renovated and more costs will be accrued. Now, designers are realizing that buildings can account for this; that they can construct building that are adaptable, thus proving to be better investments. The goal then is, how do we give our designs longevity, so they can continue to sustainably support economic growth?

Practical ApplicationsLean Design and Construction: Lean Design and Construction is the practice of utilizing minimal resources while providing full functionality. This reduces capital costs and allows improved access to care by reducing the required seed money for new services. (LCI, 2016)

Flex Space: Flexible space is adaptable to changing needs and healthcare trends, meaning the space can continue to exist without requiring additional expenses for renovations or demolition and reconstruction. (Horwitz-Bennett, 2014)

Improving Staff Efficiency: Through the analysis of spatial flow, researchers have found ways to improve the efficiency of services. Space has been shown to support movement patterns and reduce fatigue, improving the overall productivity of staff. (Zadeh et al., 2012)(Haq and Luo, 2014)

Reducing Length of Stay: Certain design features such as appropriate lighting (Joseph, 2006) have been found to reduce the length of stay in hospital settings. There are many other suspect features, however, they have not been thoroughly studied and confounding issues such as the economic repayment structure may be disrupting this metric.

Reducing Medication Use: Studies have shown a reduction in analgesic medication use with an increase in natural sunlight. Stress, anxiety levels, and pain have also been linked to window views, noise, and inclusion of nature, and music, however no research has been conducted to connect this with medication. (Laursen et al., 2014)

Patient Satisfaction Activation: Interior spaces have been linked with both satisfaction and activation, meaning that space has the ability to improve motivation towards better health and attitude towards healing. (Quan et. al.,

Economic Sustainability

2011b) (Eich et al., 2014)(Greene et al., 2014) Patient Activation has not only been linked to positive health outcomes, but also reduced costs (Greene et al., 2014)

Healthcare Access: Improving healthcare access through the ACA is expected to reduce unemployment and foster economic growth (Furman, 2014) Extending this to the community level, areas with better healthcare access tend to be stronger economically. Economic barriers to healthcare create strong health disparities (Devoe, 2007), and improving healthcare access works to reduce health disparities, a main indicator of poorer health outcomes (Schoen et al., 2013)

Reducing HAIs: Large changes in air pressure between spaces (Gustafson et al., 1982), antimicrobial-finished textiles (Takai et al., 2002), high-efficiency particulate air filters (Hahn et al., 2002), laminar air-flow (Barnes & Rogers, 1989), single room occupancy (Ben-Abraham et al., 2002), surface cleaning (Carling et al., 2006), and natural ventilation (Escombe et al., 2007) have all been associated with Hospital Acquired Infections (HAI), an additional healthcare cost and a detriment to patient well-being.

Reducing Medical Errors: Acuity adaptable rooms (Hendrich et al., 2004), illumination level (Crowley et al., 2003), and noise reducing surfaces (Flynn et al., 1996) have all been associated with medical errors, an event which can cost healthcare systems and individuals a great expence.

Reducing Patient Falls: Subfloor material selection (Simpson et al., 2004), bathroom design (Calkins et al., 2011), noise reducing finishes (Flynn et al., 1996), floor cover selection (Calkins et al., 2011), and bed rail usage (Capezuti, 2002) have all been associated with patient falls, another additional healthcare cost and detriment to patient well-being.

Investment in Green Technologies: Green technology and production has been indicated as an economic stimulant, by creating jobs, creating more efficient processes, and reducing lifestyle costs. Investment in green technology is expected to generate tens of billions of US dollars in the United States alone. (Reno, 2012)

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Health Implications As discussed earlier, socioeconomic status is the fundamental determinant of health. It is both absolute and relative, creating health disparities across the globe. (Link and Phelan, 1995) Strengthening an economic system is crucial for the improved health of the population. This involves the eradication of poverty and the transformation of healthcare into an economically sustainable system. The achievement of economic sustainability then leads to superior support of human physical, mental, and social well being and the overall health of the planet.

Economic Sustainability

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Viability: the feasibility of a healthcare system to meet our medical needs without straining the economy or the environment.Calibration Tier: the process of adjusting a healthcare system to meet the needs of the local economy and environment.

Endurance Tier: the ability of a calibrated healthcare system to withstand use and maintain its worth without depleting the environmental or economic resources from which it draws.

Perpetuity Tier: the ability of a perfectly calibrated healthcare system to indefinitely withstand use and changes in context, through the appropriate allocation and use of resources.

Viability

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What is viability with respect to healthcare design? Something that is viable is capable of working successfully. This means that the healthcare design must be feasible not only economically, but also environmentally. In order to be sustainably viable, it must also be feasible in the future rather than just the present. Viability represents the intersection between environment and economics. Conversely, healthcare systems which are not viable could be defined as those whose operations cannot be sustained financially or environmentally, those which eventually exceed the allowable budget or the available natural resources.

Fig. 7 CO2 Emissions Per Capita vs GDP Purchasing Power Parity Per Capita (logometric)

Source: United Nations, 2005

Figure 7 illustrates the relationship between GDP per capita and CO2 emissions. The current state follows a near linear model of positive association. That is to say, that as countries become wealthier, they pollute more (UN, 2005). However, many environmental and economic researchers have continued to support the Kuznat’s Curve for economic growth and environmental impact. Kuznat’s curve represents a hypothetical for the purchasing power of a strong economy to invest in sustainable technology and infrastructure (Ho and Wang, 2015). The dissociation of this reality from the model truly illustrates the imbalance of our economy with the environment. Although we are able to viably finance our growth and production of healthcare, the tipping point for the environmental capacity is

inevitable unless changes can be made.

This issue can be looked at from a perspective of model countries, ones that ‘decouple’ for global trends of growth. Figure 9 illustrates the growth in GDP of select countries from 1991 to 2007 against the growth in CO2 emissions. Countries such as France, Great Britain, and Germany increased their GDP while also reducing CO2 emissions from 1991 to 2007. Countries such as Japan, the United States, Italy, Mexico, Argentina, Turkey, India, and China all saw improvements in GDP, but also increases in CO2 production. However, they were able to produce a larger improvement in GDP than increase in CO2 production, indicating that these countries may be reaching the pinnacle of the Kuznets curve.

Fig. 8 The Environmental Kuznets Curve

Source: Ho and Wang, 2015

Investing our economy into sustainable technology and infrastructure and shifting the paradigm of design to focus on economic and environmental sustainability is key for humanity’s viability in the future. With the growth and capabilities of the United States economy, we must now turn investments towards the environment to ensure that it can sustain our country before the degradation of the environment leads to net losses both in profit and human life.

Calibration takes place as researchers and stakeholders perform evaluations on healthcare performance. The results of these evaluations assist in streamlining processes and improving the efficacy of healthcare delivery, reducing both the economic and environmental burden. Providing better quality, more effective care and improving health has an overall positive impact on healthcare spending and the environment (Link and Phelan, 1995)(WHO, 2013)(NRDC, 2016). Knowledge gained in these evaluations can help health systems improve their programs, lead to refabrication of the building to support changes, and ultimately, inform designers on better practices. Evidence-based design is a growing field of research which aids the

Viability

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dissemination of this information to design teams resulting in better, more effective design (CHD, 2016).

Fig. 9 Growth in GDP vs Growth in CO2 emissions of select countries

Source: Raworth, 2012

Buildings that have been effectively calibrated to the environmental and economic context, with a design mindful of of resource limitations, are more likely to endure the test of time. Design which disregards the wealth of knowledge which seeks to align practice with reality, are likely to reach a point where either economic or environmental resources are depleted. This is often illustrated with the vehicle and oil industries. The conscious decision of car designers has long neglected the limited oil reserves of the planet, and as a result, this resource will eventually run out. We consume well beyond the biocapacity of the planet to renew this natural resource. Estimates from BP in 2014 place a temporal limitation of 53.3 years for current production, not factoring in population growth (DiLallo, 2014). Many other estimates have been even less. This same ideal can be applied to any resource, environmental or economic. Any physical resource has limitations as does financial. The calibration of consumption and design resilience to resource availability and renewal directly determines the design’s endurance. A perfectly calibrated design will exist in perpetuity. Having been constructed to respond to resource requirements will ensure the ability of the structure to function and be maintained.

Environmental Sustainability: The capacity of an environment to flourish while supporting both itself and the communities built in it. (UN, 2010b)

Resources Tier: the availability of all elements of the natural environment which support life and offer opportunity for healthcare development.

Footprint Tier: the ultimate impact of the healthcare system on the environment’s capacity to support life and development.

Vitality Tier: the capacity of the environment and healthcare system to thrive alongside each other indefinitely.

Environmental Sustainability

Dialogue Environmental degradation harms humans. The fact of the matter is that pollution, the destruction of ecosystems, contamination of the air, soil, & water, and climate change negatively impact our health, and that burden of disease is completely preventable. (Prüss-Ustün et al., 2016) As seen in figures 6 and 7, the global burden of disease due to environmental factors is astronomical.

Fig. 6 Total burden of disease and environmental portion, by sex, 2012

Source: (Prüss-Ustün et al., 2016)

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Environmental sustainability is defined as “A state in which the demands placed on the environment can be met without reducing its capacity to allow all people to live well, now and in the future.” (Financial Times, n.d.) Simply, it is a system in which the planet can continue to supply the required resources indefinitely to support optimal human health: physically mentally, and socially. This requires optimal air, water, & soil chemistry, the capacity to produce adequate shelter and abundant nutrition, the generation of positive mental health, and social support.

Environmental sustainability begins with resources, looking at material, energy, land, and water. In healthcare design, this focuses on building and construction materials, water use patterns, the physical footprint, and building performance. The footprint of the design goes beyond the first degree assessment of resources to look at total embodied energy, the health impact of material selection, indoor and outdoor air quality, and the overall environmental health of the site through life cycle assessments. Vitality, the optimization of environmental sustainability, ascends beyond the immediate consequences of resources and footprint in order to remediate the environmental damage, restore ecosystems, and produce new resources.

Fig. 7 Trend in the fraction of deaths attributable to the environment by disease group, 2002-2012

Source: (Prüss-Ustün et al., 2016)

Environmental Sustainability

Practical ApplicationsReducing Energy Consumption: Optimizing building processes can reduce the energy usage necessary for building function. This may include adding efficient mechanical and electrical equipment such as lower usage lightbulbs and appliances. (EPA, 2016)

Improving Building Performance: Building performance optimization considers the orientation, envelope, thermodynamics, and other internal processes of a building unrelated to electrical or mechanical equipment which can conserve on energy input for heating, cooling, ventilation, mechanical, illumination processes, or providing functional services. (EPA, 2016)

Reducing Water Usage: Implementing equipment such as water-use reduced toilets, showers, faucets, and other hydro equipment is used to reduce the overall usage of water in a building. (EPA, 2016 b)

Waste-Water Recycling: Greywater recycling can be used for on-site agriculture, flushing toilets, recharging local aquifers and soil, and irrigation. (NOWRA, 2016)

Rainwater Harvesting: Harvesting rainwater for use in non-potable applications reduces energy demands for the transportation and delivery for water. It also reduces the demand on the local water supplier. (Texas A&M, 2016)

Stormwater Management: Innovations which re-route or extend the utilization of stormwater reduce the load on the local stormwater management systems. This is especially useful in municipalities which incorporate a combined stormwater-sewage system, or one that is underdesigned for the increased loads of growing populations. (EPA, 2016b)

Material Selection: Selecting materials with low impacts on human health, low embodied energy, and renewable is crucial to conserving resources and minimizing environmental health impacts. (EPA, 2016)

Green Landscaping and Habitat Restoration: Design has the ability to incorporate the natural world, providing opportunity for plants and animals to grow and flourish. (Guenther and Vittori, 2013) 35

Low-Tech Innovations: Components such as natural mechanical ventilation, space which automatically controls air-pressure, skylighting, plant-based air and water remediation, and many others have the capacity to improve the overall quality of a space without requiring any electrical or mechanical energy input. (Baribeau and Breshears, 2013)

Local Sorcing and Fabrication: Reducing transportation and storage energy through local sourcing and fabrication reduces the environmental impact of materials and the design. (MASS Design, 2016)

Climatic Design: Designing to reflect the climatic context of a building helps to reduce energy input by taking advantage of the local conditions, such as natural ventilation in warm climates, rain-water collection in wet climates, and solar energy panels in solar-rich regions. (Guenther and Vittori, 2013)

Renewable Energy: Incorporating on-site renewable energy reduces the demand for fossil fuels, transportation energy loss, and has the potential to provide energy production back to the local community. (Reno, 2012)

Disaster Resilience: Designing spaces to be resilient against natural disasters prevents the demand on re-construction resources and waste management systems. (NIST, 2016)

Food Production: Food production on-site can provide healthier dietary choices, reduce production and transportation energy, and remediate the local environment. (Guenther and Vittori, 2013)

Environmental Sustainability

Health Implications The environmental impact of design decisions and human activity has long been studied. Energy and resource use, as well as environmental contamination have negative impacts on the environmental health, and ultimately, humans’. This can lead to the degradation of air, water, and soil quality, reducing the planet’s biocapacity and limiting the vitality of life. Air quality is a complex concept to define, mostly due to the insufficient knowledge on what optimal quality actually constitutes as. However, levels of criteria contaminants, as determined by the EPA (NOx, SOx, ozone, lead, particulate matter, and carbon monoxide) as well as 187 hazardous air pollutants have been extensively studied, and the resulting health effects are astounding. The changes in our atmospheric chemistry have been related to thickening smog, respiratory and cardiovascular disease, and increased mortality (NRDC, 2015). The quality and safety of drinking water is a major concern around the world, and water contaminated by chemicals or lacking sufficient sanitation continues to be a major cause of death worldwide (WHO, 2013)(NRDC, 2016) Pollution and chemical contamination eventually leads into soil as well, where chemicals can leach into the air and water, as well as offset the soil chemistry for plant life. This creates a major cyclic effect with agriculture, reducing the soil’s capacity for food production, which in turn increases the need for more chemical fertilizer and land use (EPA, 2016)(WWF, 2016). The culmination of this pollution has lead directly towards climate change, through the reduction of ozone in the upper atmosphere and the release of carbon compounds and volatile organic compounds, which all contribute to planetary heating, shifts in air and ocean currents, and changes in ecosystems. Climate Change has been associated with asthma, cardiovascular disease, changes in vector disease patterns, allergies, water borne diseases (i.e. cholera, cryptosporidiosis, campylobacter, leptospirosis, and algal blooms), malnutrition, diarrheal disease, and mortality by both the World Health Organization and the Center for Disease Control (WHO, 2015) (CDC, 2015).

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Stewardship: humanity’s social responsibility to the planet and all the life it supports.Conservation Tier: a careful preservation and protection of the natural environment through design decisions and material selection.

Synergy Tier: a synergistic relationship is one where healthcare and the natural environment are both improved separately with the common goal of improved health.

Symbiosis Tier: a symbiotic relationship is one where the enhancement of healthcare or the natural environment also enhances the other, resulting in a compounded improvement in human health.

Stewardship

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“At the most basic level, stewardship means taking responsibility for our choices...We define environmental stewardship as the responsibility for environmental quality shared by all those whose actions affect the environment. This sense of responsibility is a value that can be reflected through the choices of individuals, companies, communities, and government organizations, and shaped by unique environmental, social, and economic interests. It is also a behavior, one demonstrated through continuous improvement of environmental performance, and a commitment to efficient use of natural resources, protection of ecosystems, and, where applicable, ensuring a baseline of compliance with environmental requirements” (EPA, 2005). Stewardship is a social characteristic of humanity which reflects on and influences the environment.

It is clearly evident that poor environmental quality is a social motivator for concern and action. In a 1981 study by Susan Cutter, solid waste levels were associated with collective community concern, resulting in social activation (Cutter, 1981). It is also a straightforward connection between social motivation and environmental action, as discussed in a 2010 review by Robert L. Ryan, Rachel Kaplan & Robert E. Grese (Ryan et al., 2010) However, this relationship between people (social) and the planet (environmental) is much more intricate and involved than either study can illustrate. Both social capital and environmental quality are directly and indirectly related to human health, yet also to each other. Their relationship is a complex web in which every element has a line drawn to every other element.

As mentioned previously, researchers have looked at what motivates and activates communities to partake in stewardship activities. The results are complicated and mostly based on observational inference, such as in one literature review which looked at stewardship activity volunteers and concluded that a strong motivator included altruistic association to environmental conservation. The review also noted educational benefits, social interaction, and reflection as strong motivators. They concluded that “Volunteer stewardship activities create a reciprocal relationship between people and the environment with signifcant impacts for both partners” (Ryan et al., 2010). In Cutter’s report, the environmental quality was the target motivating factor, however in both reports, environmental stewardship was a mechanism for increasing social cohesion. Furthermore, a 2004 study on earthquake rehabilitation looking at the effects of social

capital on environmental recovery found a strong relationship between social capital and the effectiveness of the recovery efforts (Nakagawa & Shaw, 2004). Though underdeveloped, the evidence does however seem to converge around the centralized idea that environment is a motivator for action and motivation improves environment, that is to say the they have a “reciprocal relationship” (Ryan et al., 2010).

Bandura’s Social Cognitive Model is an extremely simplistic, yet celebrated and long standing model for social theory. Behavioral Scientists have long based their work on this fundamental idea of human behavior and its relation to individual cognition and environmental stimuli (BU SPH, 2016). Our environments have a key role in our individual psychology and social development. Environmental Psychology, or the study of how environments influence our individual psychology is an ever expanding but complex field of study which identifies and measures variables such as color, heat, light, and sound as stimuli for emotional responses and cognition (Mehrabian & Russell, 1974). This has since been further developed to include metrics such as wayfinding and space syntax in the healthcare setting (Haq & Luo, 2012).

Fig. 12: Bandura’s Social Cognitive Model

Source: McGraw-Hill, 2010

The quality of the environment has a strong association with social development, and can be seen as social capital. Neighborhoods with green spaces, road sweepers, an artistic presence, etc. are not only economic indicators, but they are influences and social ties, cohesion, and trust. (Rogers et al., 2011) Neighborhoods with poor waste management infrastructure, broken windows, boarded up doors, and crumbling roads and sidewalks are associated with distrust, lack of social cohesion, and ultimately poor health. Taking this a step further, poor health aggravated by poor environmental conditions, both visual and biologic, reduce a community’s social capital by reducing their ability to cooperate and produce communal resources (Hale et al., 2013). The environment is social capital, as it was economic capital

Stewardship

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discussed earlier (Leyden, 2003)(Pretty & Ward, 2001).

Stewardship begins with conservation, the efforts of preserving and protecting the natural environment and resources in order to ensure their future ability to support human behavior and livelihood. Conservation maintains and prevents degradation of resources necessary for our survival and ultimately, the planet’s. It promotes a level of environmental quality which supports holistic health and acknowledges the currently depleting biocapacity of our habitation (EPA, 2005). Global warming is a real and concerning phenomena, and it is caused by human activity, resulting in changing weather patterns and rising sea levels. The terminal results are currently being studied, but many outcomes have been linked to global warming such as: shifts in vector disease patterns, destruction of habitats, specifically oceanic, the sinking of coast lines, aggravated cardiovascular and pulmonary disease, heat stroke, reduction in agricultural output, overall environmental degradation, increase in waterborne illness, and the decline in biodiversity (CDC, 2015)(NRDC, 2015).

Synergy goes beyond conservation to cooperate with the natural processes of the planet in order to develop a culture which sustains its own needs rather than driving itself into collapse. Currently, human consumption surpasses the natural resource regeneration by 50%, cutting the world biocapacity per capita in half from 1961 to 2008, a phenomena which is only growing exponentially more dramatic (Guenther & Vittori, 2013) (Global Footprint Network, 2013) Achieving a synergistic relationship with the natural environment can revert this depletion, which will eventually cease to allow human function in its current projection, and propel human development into a new age of progress.

A symbiotic relationship acknowledges the necessity of both parties for the other to survive and flourish, ultimately the reality of our existence on this planet. We as stewards, must create a system which promotes the health of the planet if we wish to continue our survival. (Margulis, 1998). Improving the environment is mutually beneficial to our development, and achieving symbiosis with the natural environment creates a system which can sustain itself indefinitely. This requires us to transcend from current movements in conservation, beyond environmental synergy, and into a system of promoting the natural planetary growth, in order to keep up with our own development.

Case Studies

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Butaro Hospital, 2011Burera District, Rwanda

Project Team: Mass Design Group, ICON, Partners in Health, EcoProtection, Sierra Bainbridge, and Maura Rockcastle

Butaro hospital is a 140 bed acute-care hospital with men’s and women’s wards, pediatrics, postpartum, isolation, operating rooms, imaging, obstetrics, neonatal ICU, and an ED with trauma bay.

Social Sustainability: Burera District is one of the most impoverished districts of Rwanda, with extremely poor health indicators to reflect this. The construction of this hospital brought the community of 340,000 people together to build a healthier place to live. The community now congregates at Butaro Hospital as a place of great social wealth as well as a place of healing.

Equity: Prior to the construction of Butaro Hospital, the town had only a single community physician, but now that number has grown to 12 Ministry of Health doctors, 5 visiting Partners in Health (PIH) doctors, and a visiting PIH doctor in residency. The community has grown around this healthcare center and the two sustain each other.

Economic Sustainability: Using locally available materials and economically conscious design strategies, the Butaro hospital represents a feasible model of healthcare design for resource-constrained settings.

Case Studies

45

Adelante Healthcare Mesa, 2012Mesa, Arizona

Project Team: Crawley Architects, Jain Malkin Inc., LGE Design Build, and One Word Development

Adelante Healthcare Mesa is a federally qualified patient-centered medical home focusing on clinic family practice, internal medicine, OB-GYN, pediatrics, and dentistry. Mesa also includes integrated behavioral health and an urgent care clinic, with community outreach programs continually being developed and held in their central lobby.

Equity: As a Federally Qualified Health Center (FQHC), Adelante Healthcare Mesa serves a large population of low-income and medically complex patients, to whom they have pledged their dedication. Design decisions were centered around reducing costs while maintaining a high level of care quality and producing a welcoming environment for patient activation and health promotion.

Economic Sustainability: Reducing the long term and broad scale costs of healthcare is central to Adelante Mesa’s design. The design works to promote efficacy of care delivery, improve patient activation and strength the patient-provider relationship. These movements transform incident-reaction healthcare into preventive, holistic, and lifelong care, which is expected to reduce healthcare costs while improving population health.

Viability: Adelante Mesa is a one-stop shop for primary and preventive care, allowing patients to schedule all of their needed services consecutively without having to commute around the metropolitan area. This reduces transportation energy and lessens the burden on the community. As the first LEED platinum community health center in the country, the dedication to maximize services while reducing costs and resources makes this facility a viable solution for healthcare delivery.

Case Studies

47

Peace Island Medical Center, 2012Friday Harbor, San Juan Island, Washington

Project Team: Cascade Design Collaborative, CDi, Hargis, 2020 Engineering, and Howard S. Wright

Peace Island Medical Center is an acute-care hospital with 10 inpatient beds, an emergency department, diagnostic imaging, surgical suite, primary and specialty care clinic, medical oncology, and ancillary services.

Viability: Because designers have made design decisions that are both harmonious with the environment and reduce the long term energy and maintenance costs, the Peace Island center is a progressively viable solution for healthcare delivery. Reducing the strain on both the environment, which supports human health, and the stakeholder finances, is the goal of sustainable design.

Environmental Sustainability: Peace Island Medical Center focuses primarily on energy conservation and habitat restoration through an energy responsive facade, reclaimed water reuse, geothermal heat pumps, natural ventilation, low embodied energy materials, and the conscious decision only to build on previously developed land.

Stewardship: The center is the first carbon-neutral hospital in the U.S., but as stewards for the environment, designers and other stakeholders plan to continue their progress by adding solar thermal and photovoltaic panels, making the entire project net-zero energy.

Case Studies

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First People’s Hospital, Shunde District, 2013Foshan City, Guangdong Province, People’s Republic of China

Project Team: HMC Architects, Shunde Architectural Design Institute, SDADI, and ZheJiang ZhongYuan Constructio Design Co.

First People’s Hospital is a Tertiary Medical Center with a 2,000 bed inpatient tower, acute-care facility, 6,000 daily visit outpatient facilities, a Chinese medicine center, medical research labs, cancer center, infectious disease facilities, and a staff dormitory.

Environmental Sustainability: First People’s Hospital reduces its impact on the environment through several ingenious design choices, including natural ventilation and dehumidification utilizing stack effect and chilled beams, as well as specially designed operable windows in the atrium. Designers also implemented a photovoltaic system integrated into the facade shading screen, skylight, and roofing system while focusing on low embodied energy materials.

Stewardship: The designers of First People’s Hospital demonstrate their determination to be stewards of the planet by developing innovative stormwater management through bioswales and water catchments, along with their on-site wastewater treatment and reclaimed water reuse, which supports 25% of their total water use.

Social Sustainability: First People’s Hospital has a unique dedication to social structure, offering a dormitory for its staff to foster stronger relationships between employees and to support their social needs. The hospital also serves a civic function through the incorporation of on-site retail functions and a public transit system.

Deborah holds a Masters Degree in Healthcare Design Research and is the President of Healing Design Integration, a research consultancy firm in Scottsdale, AZ. Deborah’s recent work focuses on bringing high-quality care to vulnerable populations within the United States and internationally. As part of the project team, she led the research efforts for Adelante Helathcare Mesa, which opened as the nation’s first Platinum LEED certified community health center in 2012 and has received multiple industry and state awards for its innovative approach to healthcare and commitment to sustainability. Her research was instrumental in establishing a framework for a new model of care delivery that enhances the patient/clinician experience through innovations in operational flow, physical design, and program development.

In her current role, Deborah designs and develops patient centered outcomes research studies within ambulatory care settings that gain insight into the patient experience, and assess operational efficiencies. Through the findings from this research, she collaborates with healthcare executives to design innovative business solutions that achieve performance metrics, while enhancing the patient experience.

Deborah Wingler

MSD-HHE, EDAC

President, Healing Design Integration

Timothy Lalowski

B.S.Arch, MPH est. 2016

Environmental Health SciencesTimothy holds a Bachelor’s of Science degree from the Illinois Institute of Technology in Architectural Engineering and a Master’s of Public Health in Environmental Health Sciences from The University at Albany School of Public Health. Timothy’s recent work focuses on exploring the impact of the physical environment on healthcare delivery models and population health. His work strives to inform a holistic sustainability of healthcare delivery, focusing on creating supportive environments, streamlining delivery, and justifying fiscal investments to ensure optimal design with minimal negative environmental impact.

Authors

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