“If an error is possible, someone will make it.” A maxim espoused by one of the forefathers of modern human factors, Donald Norman, threaded through keynote speaker Dr Paul Barach’s talk at European Healthcare Design 2023, as he underlined the importance for healthcare systems to be true learning systems.

The evidence, according to Barach, is telling us that our health systems are simply not reliable, and the pandemic has done great damage to perceptions of safety and wellbeing, particularly among staff. 

Nearly a quarter of US hospitalised patients experience harmful events, one study has found. Moreover, central-line-associated bloodstream infections in US hospitals had decreased by 31 per cent in the five years preceding the pandemic. This promising trend was almost totally reversed by a 28-per-cent increase in the second quarter of 2020, compared with the second quarter of 2019.

In his book, The Design of Everyday Things, Norman argues that all systems fail because the designer caused them to fail. According to Barach, Norman asserts that all systems should be infallible so that even if humans make mistakes, the system should mitigate and modulate to counter such errors. 

“The work system, which is the primary job of health system designers, architects, engineers and planners, is highly constrained by the physical built environment, the cognitive workload, and the organisational culture,” explained Barach. “What we’re struggling with in healthcare that other domains have understood is workflow redesign – the work as is versus the work as imagined.” 

Failing trust

He asked the architects in the audience how often they have been given access to the risk register of the facilities of the building – the collection of adverse events that have happened to patients in recent years.

The low number of hands raised backed up his claim that healthcare clients don’t trust the architects to share this information. “Please design us a new hospital, use average data, use national data, but not our data,” he said. “Why don’t hospitals trust architects?”

The lack of trust is also evident among healthcare staff, he noted. In April 2020, a month or so into the pandemic, German doctors posed naked in protest at PPE shortages and to show how unprotected and exposed they felt to the virus.

Healthcare workers were told to reuse PPE, yet this was not designed for long-term use. According to a 2020 study published in BMJ on the risk of hospital admission with Covid-19 in healthcare workers and their households, this group contributed a sixth of Covid-19 cases admitted to hospital. Patient-facing healthcare workers experienced a threefold increased risk of admission with Covid-19; and healthcare-worker household members had a twofold increased risk of admission with Covid-19.

“According to the World Health Organization, 115,000 healthcare workers died during the pandemic,” said Barach. “This has never happened in the history of modern healthcare. And that’s only known numbers.”

Reflecting that the “design approach to protecting health providers failed in a dramatic way”, he suggested that these events had led to some healthcare workers suffering from ongoing PTSD and that this could be contributing to workforce shortages in health systems, as their trust had been breached. And because workers don’t trust management, they’re not being candid about adverse events and management can’t mitigate the problems, he added. 

“It’s not about buildings, it’s the organisational culture,” said Barach. “It’s about organising principles – co-designing with patients and staff all the time. Do we think that after we’ve spoken to them, and value-engineering everything out that they asked for that they won’t be angry with us? Why not do it up front instead of breaching their trust? Why not negotiate honestly with them?

“That trust continues after you leave and when the building is occupied. Our staff do not trust us and until we deal with that, we will have a massive nurse shortage.”

Technology and culture

Smart technology and mobile health may offer some solutions to rebuilding trust and improving communication and openness between staff, patients and families. One example he highlighted is in Austria, where an interactive medical education design installation is used to teach families about their loved ones’ procedure while they’re undergoing surgery. “We gamify the process,” explained Barach, “and we bring the kids in to help them understand what daddy has.”

Ultimately, culture is the number-one reason why people leave an organisation, he noted. “Culture will trump rules, standards and control strategies every single time. Safer health will depend far more on major cultural change than on a new regulatory regime.”

Finally, he shared with delegates some research he and colleagues had undertaken to analyse data from applicants to the 2021 Wolfson Prize, which challenged design teams to visualise what a future hospital might look like. From these submissions, he highlighted several potential changes to the current health model that would alter the experience for patients, visitors and staff, as well as services and the wider health system.

Concluding his keynote talk, Barach underlined that the quadruple aim during Covid-19 and in the years ahead revolves around patient safety and experience; population health; health worker safety, wellness and satisfaction; and reducing costs and preventing loss of revenue.

“The science of human factors tells us that telling people to try harder does not stop them from making errors,” he said. “We have to redesign these problems out of the system and that means moving from very simplistic, tokenistic guidances for reducing infections or falls to a whole different way of thinking about design and falls.

“It’s the science of understanding why people fail, in spite of good designs – human factors needs to be part of the design of hospitals and health systems.”

And in a closing rallying call to architects, he cited the late Derek Parker, of Anshen + Allen fame and one of the great thinkers and practitioners in healthcare design: “If somehow we can take the creativity, the credibility, the integrity of our [architectural] profession, and feed that into the political mainstream, maybe we can start making a difference.”