When designing for the built environment – its structures and surrounding spaces – the movement of people through, between and around these structures is paramount to its functioning successfully. At the level of urban design, effective and comfortable connections between people and spaces can ensure investment in and the enjoyment of an area, with all the economic and social benefits this entails. Within buildings, these spatial relationships can translate to improved health, wellbeing and productivity.
At Foster + Partners, we draw on the expertise of a variety of disciplines and industries in order to design more efficiently, sustainably and effectively. For this reason, a number of our projects have applied a set of theories and methods that directly address the movement of people within the built environment. Developed by University College London during the 1970s, space syntax studies how spatial elements – streets and squares in a city, or rooms and corridors in a building – are interconnected in a spatial network, and how the resulting system influences people’s movement and visibility within this network. Using surveys, data analysis and computer forecasting, the Space Syntax Laboratory has subsequently developed models that can be used to inform and shape design for optimal end-user benefit.
So far, these forecasting models have proven most effective at the level of urban design. But perhaps unsurprisingly, movement patterns within buildings are very different to those in outdoor spaces. Unlike in urban areas, where users’ movements are relatively random and predominantly directed by the spatial configuration, buildings are affected by a host of different factors, such as the distribution of focal points of interest in offices (such as tea points or water coolers) or the irregular and dynamic working patterns of doctors and nurses in hospitals. Current assessment models have not so far taken these variables into account; however, their integration could have the potential to markedly improve layout design in these areas.
It is within the area of hospital design specifically that I have focused my research over the last few years. As recent events have demonstrated, the importance of a robust, well-functioning and successful healthcare system – of which its architecture is a significant part – is essential to the survival and thriving of society. Past priorities in healthcare design have largely focused on environmental factors that are known to contribute to patient recovery, such as certain aesthetic properties (colours and textures) and sensory stimuli (light and temperature). However more recent research has directed the focus towards healthcare providers, and how their environment affects their work process, and subsequently the quality of care they provide.
Studies have shown that interaction and communication with fellow employees is essential to the effective functioning of medical professionals – healthcare is a distinctly collaborative effort, based on the exchange of knowledge, mutual trust and cooperation. As designers of the spatial configuration in which these workers operate, we have the ability to encourage and nurture such exchanges – and using analysis tools such as space syntax can help us to do so. In a bid to expand the collective and analytical capabilities of the methodology within buildings, I spent several years studying the movements of healthcare workers in various NHS hospitals across England. The aim being to generate a new tool for designing optimal spatial configurations for nurses and patients that architects might harness in their shaping of our future healthcare environments.
The layout of a space has a direct impact on how people move about in the resulting configuration, and in turn how they experience it. When designing buildings or urban spaces, we can use analysis models like space syntax to quantify a space and assess how complex or simple a layout proposal is in terms of the connections and distances between spaces. We can determine areas of high connectivity or isolation and subsequently integration and segregation. Professor Bill Hillier – founder of the Space Syntax Laboratory – and his colleagues found that more connected, integrated urban spaces attract more people, and as a result retailers and other such economically or socially driven initiatives are positioned to take advantage of their presence.
Similarly, predicting the movement and behaviour of people within a building type can help us design a system that best complements its function. For example, in office buildings it is important to combine both connected, integrated spaces with more private, segregated spaces. Integrated areas foster social interactions and the exchange of ideas and knowledge, while segregated areas are useful for work that requires focus and minimal distraction. This variety caters not only to different task types, but similarly different worker preferences, which can have a direct effect on employee wellbeing and productivity.
However, research has shown that the movement and behaviour of individuals within buildings is quite different to that in the urban realm – the most connected area in a building might not always attract more movement. Dr Kerstin Sailer conducted studies in eight office buildings and found that movement flows did not always follow the spatial configuration of the building, but the allocation of different functions. The placement of attractors such as photocopiers, printers, tea points etc. can deflect movement and introduces a pattern to people’s movement that would not be taken into account in traditional space syntax models used to assess design proposals.
Comparable problems with current analysis models can be found in hospitals, where connected, integrated spaces are even more important. However, the issue with modelling behaviours in healthcare settings is somewhat different from the one in office buildings. While people in office buildings usually have their own desks and move back and forth to focal points of interest along established routes, nurses and doctors in hospital wards have very dynamic working patterns. They are usually assigned to a different patient or group of patients daily and constantly walk back and forth from one patient to another, to the nursing station and to the medicine cabinet. The variable here is not attractors, rather multiple, often unpredictable, movement patterns.
In light of these observations, spatial modelling tools for healthcare settings have primarily focused on efficiency; they measure distances between main functional areas and the frequency of traversing these travel paths, with the aim of minimising walking distances and thus increasing time spent with patients. One such measure was the Yale Traffic Index developed by Thompson & Goldin in the mid-1970s, which gave a numeric score to hospital wards. The measure was used to evaluate thirty wards where the smaller the Yale index score, the shorter the travel distance and thus the more efficient the layout. However, such models fail to relate ward layout to outcome variables such as quality of care – does more time with patients actually lead to better quality of care?
In a workspace, spatial analysis can help to identify the most effective layout to complement worker preferences with the ultimate aim of increasing worker productivity. But in a healthcare setting, there is more at stake. Studies suggest that creating opportunities for chance encounters and unplanned interactions between colleagues improves performance and can lead to better quality of care. One study of an inpatient ward showed that verbal miscommunication between nurses and doctors was responsible for 37 per cent of all errors. Another study of 5,030 patients in twelve nursing units found that collaboration among healthcare workers was the strongest factor contributing to observed differences in patient outcomes.
There are of course multiple factors that feed into the quality of care that a hospital can provide, not least political and economic, and all will have an impact on our shaping of future healthcare environments. But ultimately, we must aim to design a future hospital that provides the best environment for patients to heal, and for healthcare providers to do their job efficiently and effectively. The above studies suggest that certain spatial configurations may be better than others in doing so. With this in mind, Dr Kerstin Sailer and I set about developing a new spatial measure that assesses layout proposals specifically for their impact on quality of care. Called Spaces for Communication Index (SCI), the tool builds upon an existing space syntax model, incorporating the dynamic nature of work patterns of healthcare providers and gauging communication opportunities arising from the layout. SCI analyses every space walked through to determine its dimension and size and therefore what viewshed (the area that is visible from a specific point) it provides to encounter others and engage in collaborative connection.
In the first stage of the development of our tool, detailed movement and communication patterns of 102 doctors, nurses and other healthcare professionals in six NHS wards across England were collected for a total of seventy-five hours to define frequencies of travel between key areas (such as patient beds, medical stores and nursing stations). Based on these observations, we identified the four most frequently traversed links between key areas and then constructed the shortest paths linking these key areas. We then calculated the size of viewsheds along these routes using space syntax. The greater the viewshed along the paths, the greater the opportunity for interaction and so the higher the score.
We used these calculations to develop SCI and then tested it on thirty-one NHS hospital wards. These were selected based on their quality of care as rated by the Care Quality Commission on a four-point scale ranging from ‘outstanding’ to ‘inadequate’, with the full score range accounted for within the selection. The size of the wards ranged in both size and number of beds, with an average of 817 square metres and twenty-four beds. Most cases consisted of a mixture of single patient rooms and multi-patient bays, with four case studies containing 100 per cent single patient rooms. All varied in their layout – from racetrack (where rooms are arranged around a central core of services) to single corridor and radial.
Results from the analysis showed that the SCI score had a positive correlation with the Care Quality commission score, thus proving its ability to assess layout proposals and anticipate certain levels of care quality. The higher the SCI score of a ward, the better the quality of care. In terms of design, these results identified the importance of spaces with large viewsheds that care providers pass through. The larger the area or path, the better, as this provides more opportunities for interactions. We also tested if the size of the ward or number of beds had any effect on healthcare quality however results showed that they were not related.
Naturally, the tool is a work in progress. Our initial database contains wards with more open bays, and so more case studies are required to understand how SCI can be specifically applied to enclosed environments – i.e. single patient rooms. These naturally have a lower SCI rating, although this does not necessarily translate to poor care quality. Of the four studied here, all varied in their Care Quality Commission score. And in fact, the ward that had the highest SCI rating in this study, and outstanding quality of care, was a ward with 100 per cent single patient rooms and a radial ward typology. What made the score of SCI higher than expected for an enclosed environment was the large circular space in the middle of the ward that connected all patient rooms. This space provided high visibility levels to nurses and doctors who had to pass through it on their way from one key area to another. This doesn’t necessarily mean that a radial typology is superior to any other, but it does indicate that larger viewsheds between interconnecting spaces are important, and these can be achieved by design in any ward typology. Moreover, these results showed that wards that consist of open bays, and thus provide naturally greater visibility, are not necessarily better than wards with single patient rooms – of greater importance is the spatial configuration of the ward.
The aim of this new tool is to build upon the pioneering analysis models that have informed and greatly enhanced many architectural design projects – both at Foster + Partners and elsewhere – over the past forty years. By helping designers benchmark layout schemes that maximise communication opportunities, we can shape the future of healthcare design to enable professionals to perform at their best and ultimately provide better care. Arguably, SCI can also be applied to other workplace settings with routinised practices, such as co-working spaces, where the degree of sociability and community is of high importance in encouraging the exchange of ideas that could lead to new business opportunities.
In the wake of Covid-19, layout proposals will be under even greater scrutiny. As with every other building typology – but particularly those in the public realm – future hospital design will require a flexibility thus far unseen in order to accommodate new regulations and unpredictable future scenarios. However, the need for enhanced caution and greater flexibility does not change the fact that social interaction is key to providing better healthcare. Spatial analysis tools provide a readymade and adaptable method for identifying the safest movement patterns and communication opportunities within these new spaces; those whose boundaries are set to be radically redrawn. They present a valuable source of information that can feed into new design strategies aimed not only at safeguarding the community, but ensuring continued productivity.
As multiple research projects have demonstrated, the spatial configuration of a building is still of importance in affecting movement and interaction within a space, and it can still be used strategically when designing a building. However, further tools must be developed if we are to continue designing environments for optimal end-user benefit. New measures such as SCI in healthcare, and targeted models for office environments, build upon existing formulas to account for external factors that redirect movement beyond the random movement patterns generated by a building’s spatial organisation. Additional measures must now also be developed to account for post-pandemic design considerations. Applied during the design stages, these tools can help assess various proposals to ensure the most beneficial one is identified and implemented.
19 June 2020
Associate Rosi Pachilova is part of the Workplace Consultancy team at Foster + Partners – a group of designers, analysts and researchers that work with the architecture studios to help address the business objectives and changing requirements of clients. Rosi recently completed her PhD at the Bartlett School of Architecture, UCL, where she studied the effect of ward layouts on work process and communication patterns of healthcare providers, and the subsequent effects on quality of care.