Equity in Healthcare:
Healthcare in Black America

“Where We Hope to Be”

A Proposal for Healthcare Architects

By Roderic Walton AIA, NOMA; Associate Principal at Moody Nolan

This blog is the third and final chapter of a three-part series about equity in healthcare for Black communities in the United States.  In Part One “Where We Were” The History of Healthcare in Black America (Franklin, 2020), my  colleague Valarie Franklin discussed  the history of race and healthcare.   Part Two continued with “Where We Are,” establishing the case that Covid-19 related disparities have deep historical roots.  This final essay entitled “Where We Hope to Be” will explore solutions that healthcare architects and designers can employ to position ourselves as advocates at our places of work, as well as in partnership with our clients.

SECTION ONE:

THE HEALTHCARE DESIGN INDUSTRY’S RESPONSE TO COVID-19 IS INSUFFICENT

“The most important thing to remember is this: to be ready at any moment to give up what you are for what you might become.” – W.E.B DuBois

Learning objectives for this section:

This section IDENTIFIES the challenges with the architectural and design industry’s response to Covid-19:  After reading this section, the reader should evaluate the appropriateness of the current design industry’s response to the challenges at hand.

Part Two of this blog series established a historical context for the pandemic we are facing today. I would like to begin Part Three by restating the primary conclusion from Part Two: Isolated Black communities that exist today in major metropolitan cities throughout the country are a direct result of racist federal, state and local  housing policies that were initiated between 1929 and 1953, and extended through both formal and informal policy  for decades thereafter. Financial disinvestment is common in these communities today because they are identified categorically as “high risk” investment areas. As a result of this disinvestment, residents suffer from abject poverty, mental health challenges, and food and transportation challenges. These disadvantages, in turn, result in less frequent engagements with the healthcare system. Preventative healthcare opportunities are limited due to employment challenges and lack of insurance. As a result, pre-existing conditions along with comorbidities often go undiagnosed and untreated.  Covid-19 is much harder to treat in patients with these underlying health conditions.

The reader may conclude that the Covid-19 pandemic is indeed a crisis for many Black patients.   One may further conclude, however, that these are inherently socio-economic disparities that have nothing to do with architecture.  I do not believe this to be the case.  Minority representation in the field of architecture does not reflect the broader racial composition of the country. This means that disenfranchised Black communities are often relegated to the role of outside observer when it comes to their representation in architectural discourse and practice.  As healthcare architects and designers, we are in a unique position to influence the discussions that occur with our colleagues and clients early in the design process. If we position ourselves as thought leaders and trusted advisors for our clients, our voices can become transformational agents for changes in how architecture is practiced.

It is my opinion that the architecture and design communities’ response to date has fallen far short of what this pandemic demands. Since this crisis began, I have observed a general lack of knowledge regarding the history of segregation in this country, and the implications for healthcare generally, and Covid-19 specifically, within the architectural field. This needs to change in order to move forward.   I also believe that there needs to be far more compassion and empathy for the needs of Black patients from the architectural healthcare community. As healthcare architects, we have received extensive training regarding “universal” care delivery models and minimum guidelines. These strategies have been adapted to meet the crisis at hand from a design perspective, but to defer operational considerations entirely to our clients. For example, the first Federally sponsored, minimum healthcare standards were developed in 1946 with the establishment of the Hospital Survey and Construction Act.  Since then there have been multiple reference standards developed with one primary goal in mind: to establish a minimal standard of care that ensures the safety and wellbeing of all patients. We have been trained to design spaces for triage and isolation, to maximize flexibility in our designs, and to engage predictive modeling and patient actors to test hypotheses. This type of clinical response is well-positioned within the boundaries of traditional healthcare practice and has been the industry standard for generations. While firmly grounded in an evidence-based context, this approach does not require the designer to step outside of one’s safety zone, assume nontraditional (or unpopular) positions, and move the needle on the industry’s response. It does not require us to evolve beyond what we already know how to do well to meet the demands of times we are living in now. In short, our collective response to date simply does not expand the healthcare architect’s traditional role in the face of an unprecedented healthcare crisis.

SECTION TWO - HOW CAN ARCHITECTS EVOLVE OUR PRACTICE?

“Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek.”  - Barack Obama

Learning objectives for this section:

This section CONNECTS the challenges and historical context above to a solution:  After reading this section, the reader should want to know more about his/her own role in the evolution of an implementation plan to address the challenges raised in this essay.

What is it exactly that is being proposed? How do we evolve our practice as healthcare architects? Below are some recommended steps, categorized into advocacy and practice that I would like for healthcare architects to consider as we position ourselves to formally respond to Covid-19.

ADVOCACY

1. Study and acknowledge the history of housing segregation in America and advocate for forums to discuss its healthcare implications with colleagues and clients.

2. Advocate for an accurate portrayal of American history at primary, secondary and post- secondary levels. This includes a candid conversation about racist and segregationist constructs: how they are formed, what their intent is, and how they are shaped into law.

3. Advocate for diversity training at your organization.

4. Advocate for “true diversity” at your organization by supporting the promotion of diverse ethnic and cultural groups throughout the entire leadership structure, with authority to help shape the organizational and operational strategy of the firm.

5. Advocate for recurring programs that invite young minority students to visit your organization to learn about architecture and design, and possibly become architects themselves.

6. Advocate against residential zoning policies that keep communities segregated in the neighborhood where one lives.

7. Foundational design references (FGI guidelines, well as state and local HC codes) should not continue to defer operational considerations exclusively to owners. Advocate for the inclusion of proven tools and resources to help designers address the specific needs of minority communities and patients through programming,  design and operational strategies.

8.  Advocate that agency accreditation requirements (Joint Commission PDC and others) include metrics for identifying challenges and suggesting solutions for addressing needs and expectations of minority patients.

9. The Affordable Care Act has firmly established the concept that population health and quality of care are paramount considerations over cost margins and profit. Advocate for population health considerations as an operational standard during programming and design meetings with clients.

10.  Partner with marginalized community advocates when their healthcare is at stake.  Advocate that the end-result of the pre-design and functional programming process for projects serving minority communities should be quantifiable operational improvements that directly address social determinants of health for that community. 

11. Encourage local and state leadership to gather data regarding health disparities and race and make the data publicly available. Advocate that the Certificate of Need (i.e. C.O.N) process use these data to directly address disparity.  For example, developers can be encouraged to construct facilities and add beds in communities of color based on data driven metrics and established need with the full support of these agencies.

12. Partner with community advocates to address enhanced ease of access and better navigation of the of the healthcare system for Black patients.  

PRACTICE

1. Combine established clinical process with empathy and compassion, with the goal of advancing a more culturally sensitive design strategy where minority community interests are involved.

2. Consider the real-world implications of potential Covid-19 solutions on underserved communities. For example, when considering changes to existing pre-registration policies and waiting room configurations for enhanced infection control, include the voice of community advocates in the evaluation process.

3. Encourage clients to incorporate and empower established community leaders (residents + community/faith leaders) who are often eager  to participate in the planning/programming process via a community advocacy board or council.

4. Actively participate in community engagement and outreach activities that have been created and programmed by representatives of marginalized communities. Incorporate lessons learned into your practice.

5. Consider access to preventative healthcare and healthcare education as a fundamental patient right. Position this as a critical operational component of any service offering for minority patients, and work with clients to address these needs during programming.

6.  Design facilities that are more accessible to minority communities (access to public transportation, accommodations for patient advocates, accessible outreach staff, etc.)

7.  Use what we’ve got! Healthcare architects have robust design tools at our disposal, but they are often perceived as non-applicable to addressing issues of disparity. This is not the case. For example, Lean Design and Guiding Principles (enhanced quality of care, elimination of waste in process, and focus on efficiency) can be refocused to address the needs of minority patients by identifying processes that have measurable and quantifiable results for their community.

○ Kaizens, Gemba Walks, and 3P transforming events can be reframed to include discovery within the context of communities of color.

○  Robust Process Improvement (RPI)  Models that acknowledge the value of the voice of the customer can be similarly re-framed.

8.  Use research already available to us as architects, often initiated by our own clients. Community Health Needs Assessments (aka CHNA’s) are published every three years by 501c3 healthcare institutions and contain studies where the institution has self-assessed the challenges faced by their patient populations.

·         CHNA’s are mandated by the Affordable Care Act (ACA) of 2010 for many institutions.

·         CHNA’s are instructive, critical tools for healthcare designers, as they can be used to frame the designer’s response to the challenges at hand, often from the perspective of the client’s own published data.

CONCLUSION

This three-part series has been designed to take the reader on an emotional, yet informative journey of discovery. It has been difficult to write without deep sorrow, frustration, anger, and despair on the part of the authors. However, these sentiments are combined with a resolute sense of hope towards a common goal: Better outcomes for every marginalized healthcare patient, regardless of the circumstances in which one is born, or where one lives.

I believe that our response to the Covid 19 crisis should be far more progressive, forward-thinking, deliberate, and impactful than it has been to date. Instead of delegating the responsibility for operational considerations to our clients exclusively, I propose that we should fully engage the role of change agent.   Operational decisions in today’s racial and pandemic-era climate should take bias and segregation into account throughout the full spectrum of care, and that includes architects. The practice of healthcare architecture can either be used to reinforce or expand racial bias and discrimination (and this includes being silent about it), or it can be used to acknowledge and dismantle it.

By establishing this series, the authors contend that the question before each of us should be “What can I do to make a difference in this unprecedent time for our profession?”. The answer to this question is personal, and unique to each reader. The response requires each of us to see ourselves as fully accountable for the next chapter of healthcare design, delivery, discourse, and strategy.  This in turn necessitates that each of us step beyond the traditional role of service-oriented professionals and look beyond the traditional tools that we use to problem solve.  Now is the time to discover our role as advocates for change who acknowledge our past, and critically evaluate how that past can inform our future. We hope that you will join us for the journey ahead. 

While this essay concludes our three-part written series, the conversation will continue. Please stay tuned for more details regarding a panel series that will feature speakers from multiple facets of the healthcare industry, combined with Q+A dialogue.

Roderic has twenty-five years of experience in building design, is a licensed architect, and has practiced in both Ohio and Illinois. Most of his portfolio is focused on healthcare projects.

 Roderic has dedicated his career to addressing the needs of healthcare clients and the communities they serve, with particular focus on those in under-served and disadvantaged areas in the south side of Chicago, Illinois.

 Roderic holds a master’s degree in architecture from Miami University in Oxford, Ohio, and actively participates in both local and national organizations including NOMA, AAH and AIA.

 He is currently an Associate Principal at Moody Nolan Architects.

 The thoughts and opinions reflected in this blog are the authors’ own, and do not reflect the views of any firm or other organization.

Work Cited:

Franklin, V. (2020, June). Where We Were; The History of Healthcare in Black America [Web log post]. Retrieved August 8, 2020, from https://www.nomanash.com/healthequity

READ MORE

GO BACK TO PART 1 IN THIS SERIES: HEALTHCARE IN BLACK AMERICA - WHERE WE WERE

GO BACK TO PART 2 IN THIS SERIES: HEALTHCARE IN BLACK AMERICA - WHERE WE ARE