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Using Design To Improve The Quality Of Clinical Practice
By Charles M. Kilo, MD, MPH
March 1999

A gap exists in ambulatory care services for those interested in improving the built environment. As a clinician, this gap is not dissimilar to one with which I routinely struggle -- achieving improvements in clinical care based on existing scientific knowledge that is not currently being used in the routine care of patients. A gap exists between knowledge and practice. This knowledge, if employed, could significantly improve clinical outcomes and reduce costs.

Examples of such knowledge include the use of appropriate medications in asthmatics known to reduce morbidity and mortality. Such medications, proven in the literature and widely available, are not properly used in a large percentage of asthmatics, which leads to unnecessary asthmatic exacerbations, emergency department visits, hospitalizations, and even deaths. Although one would hope that clinicians would be concerned about this problem, most clinicians are not. They do not perceive, nor truly understand, the problem or its solution. My challenge is in creating methods of engaging busy clinicians in clinical improvement when my issue is not currently on their list of priorities.

Likewise, for those planning and designing healthcare facilities, a gap exists between knowledge and practice. Despite the impressive knowledge connecting the built environment with improved clinical outcomes and patient satisfaction, this knowledge is not being routinely used to improve care. This issue, like my own, is not on the priority list for most heathcare professionals.

Should those planning and designing healthcare facilities give up, or change their approach? Lessons learned from my experience as a presentor at the Symposium on Health Design in November suggest that they should change their approach. If we were to survey busy office-based clinicians, they would probably voice the following concerns: access to care is poor, incoming phone calls are overwhelming, the paperwork demands are consuming, office efficiency is poor, and the demand for care exceeds their capacity. Each of these statements would be followed by the statement "but I don't know what to do about it." Clinicians are currently beleaguered with daily office performance problems that outweigh the issues upon which planners and design professionals want them to focus.

To change this, planners and designers should start by building a few bridges. They should listen to customers, understand their existing concerns, and work with them to solve immediate problems. In doing so lies the opportunity to educate these customers on what planers and designers deem important. It also provides the opportunity for their own education about healthcare. While planners and designers may be frustrated with a lack of understanding by healthcare professionals, those healthcare professionals may also be frustrated by a lack of healthcare knowledge on the part of planners and designers.

Our issues are not so far apart. Design is central to addressing patient flow and office efficiency. Flexibility in design is critical to improving access and to creating new care models. If we can focus on issues of common interest first while building understanding and trust, we will achieve all of our goals in the end. We should start by building bridges.

Dr.Kilo, who is with the Institute for Healthcare Improvement in Boston, Mass., is currently heading a research project to re-design office-based care. He can be reached at CKilo@ihi.org