S6 EP6: Dr Elke Miedema on the Future of Health

Dr Elke's research analyses future healthcare building design, paying attention to aspects of health promotion.

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Transcript

[00:00:00] David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go. I'm your host, David Cummins, and today we are speaking to Dr Elke Miedema, who is an architect and researcher based in Amsterdam. 

[00:00:27] Dr Elke focuses on healthcare building design processes for reneging models of health and care, including attention for patients, other building users, and the planet.

[00:00:38] Elke understands the importance of designing hospitals for improving healthcare quality.

[00:00:43] We welcome Elke today to discuss the future of health and to discuss new models of care and how influences design solutions. 

[00:00:50] Welcome Elke, thank you for your time. 

[00:00:52] Elke Miedema: Thank you, David, for having me. 

[00:00:54] David Cummins: You've done a lot of research with hospitals and architecture and especially outcomes. What I found interesting about your research as well is that it really incorporated the patient experience and the models of care, which as a designer, a lot of designers don't actually get to that granular level, they are more focused on the building itself. 

[00:01:11] What drove you to more focus on the patient itself and the models of care and those clinical outcomes? 

[00:01:17] Elke Miedema: I always started from a human perspective. So my interest in architecture was there when I started studying. But then because many of my friends were doing social science or anthropology I became like really intrigued with what my role as an architect is to contribute to human life and society.

[00:01:36] So that's actually where it started, and I wanted to learn about how architecture plays a role in that. And then I found out that most of the research in relation to positive outcomes and architecture actually take place in healthcare. So it's not that I started out from healthcare, but I started out from a human perspective and I ended up in healthcare. 

[00:01:59] I could actually say that right now there's a tendency more and more to think about the human and patient perspective but thankfully, we're also moving away from just patients to their relatives, their staff, and even the community that is not yet ill. And to see how that changes how we design hospitals and healthcare facilities.

[00:02:20] David Cummins: Yeah. You're a hundred percent right. 

[00:02:22] Through these podcasts, a lot more people are talking about the human experience, as well as a patient experience. It's important to make sure the staff and the patients and the neighbours and the whole community's looked after. So what do you think is some of the things that designers and community groups get wrong when it does come to patient care?

[00:02:39] Always people talk about just one thing about patient care and one outcome, but it seems like there's a few things that people could improve on in that area. 

[00:02:47] Elke Miedema: First of all, it's really good that they start to think about that. But at the same time, since it's in a medical context, it's very easy to only focus on avoiding people getting sick or facilitating the treatment process, right?

[00:03:02] Or the caring process. Whereas it would be important, especially now, we have so many more people that have a non-communicable diseases or preventable diseases that we focus on stimulating lifestyles, that we focus on inclusivity and not just the standards person. And that also requires that we're not just looking at this pathogenic focus, right?

[00:03:26] So what is causing illness and disease, but that we really focus on how can we stimulate quality of life so that's more a "cellgenic focus", they call it. 

[00:03:37] David Cummins: Yeah, I don't know what it's like in Amsterdam, but certainly in Australia things like sustainability is becoming much, much stronger and it's all about preventative health.

[00:03:45] Knowing that the population is going to double, or the aging population is going to double in the next few years, and we don't have as many staff, we really have to keep challenging our design thinking and also how we're actually going to provide care. So your research does touch base on that as well, about how to improve these new models of care for the future generations as well. 

[00:04:05] Do you mind just talking about that a bit? 

[00:04:07] Elke Miedema: Yeah, I think that prevention is already, again, a good step, but often prevention still focuses on people who are in risk groups, whereas health promotion really aims to focus on the general population, everyone in a sense, but actually even more so on people that have been marginalised.

[00:04:24] So populations with lower socioeconomics status or that have been overlooked previously in public health policies and changes. So what does that actually mean in terms of architecture? 

[00:04:35] Sometimes that means that if you have a meeting room where you would normally on your own, meet a doctor and have a conversation about your health, that these rooms are a bit bigger, so there's room for a family member to translate or maybe an interpreter.

[00:04:52] So then it's just about making the room a bit bigger, maybe that's not so much architecture yet, but there can also be other ways where you co-locate, for instance, primary care with specialist care so that a lot of people, who may be immigrants, they may not know the healthcare system that they now landed into so that they don't have to navigate it themselves, but they can go to one reception for one building. 

[00:05:17] And on that reception there is people that speak different languages and they help them to where to make the appointments. So again, it's not necessarily the architecture alone, but it's also the co-location of buildings that makes collaboration between primary and specialist care better.

[00:05:35] And then in terms of how that reception then can look like. Maybe it has lower and higher parts so that people that that sit in a wheelchair or cannot stand that long or people that want to stand up like the personnel as well, that's all possible, that it can go up and down.

[00:05:52] David can see I'm going with my hands and explaining a lot, but of course you cannot see that. Yeah, so there's lots of simple, small solutions, but they all add up to making it much more inclusive. Lots of small solutions that make it more inclusive for many different population groups that now have much more distance to healthcare often. 

[00:06:14] David Cummins: You're talking a lot about the difference in heights and people with disabilities and different cultural backgrounds. So a lot of that comes down in Australia, certainly to the planning and as I always say, 90% planning, 10% execution. 

[00:06:27] How important is it to be inclusive and collaborative and diverse in your thinking when it comes to planning of health care.

[00:06:35] Elke Miedema: It's absolutely crucial.

[00:06:36] I've been extremely lucky to have been able to do my PhD in Sweden where there's a very strong culture of co-planning and participatory design processes. 

[00:06:46] And I've done a case study in Angereds Närsjukhus, it's a small community hospital in Gothenburg in Sweden where they made a very intensive collaborative process where they invited people from the community, but also from different healthcare organisations, primary care specialist care, different types of specialists. 

[00:07:07] For instance people that would work with children and then also with the architects. They were involved in an early in the process and what that really showed is how they could, when they are aware of these multiple perspectives because they're collaborating, that actually architects are quite good in then finding those solutions together with everyone who is involved. 

[00:07:30] But it was also so important the pre-planning indeed. 

[00:07:34] They clearly wrote down what their expectations were and not just saying we want to have a welcoming environment, but we want to have a welcoming environment that is accessible for different abilities, but also what that could mean in terms of outcomes in the end, so that it could actually also be measurable.

[00:07:54] They opened a building in 2015, it's some time ago, but it's still a very special project to me. 

[00:08:00] David Cummins: Yeah, and I assume a lot of those principles that you've learned, have you ever been able to apply on future projects as well and certainly with your team being able to apply those principles for future projects is the same principles like collaboration, understanding, respect, diversity. 

[00:08:15] It's basic principles, but you can apply them to every hospital, correct?

[00:08:19] Elke Miedema: Yes, I think definitely, there's a lot that you can scale up to other projects as well, but there's also a risk in thinking that what works in one place also works at another, right? I mean, this hospital especially, it was designed in a neighborhood that is dealing with a lot of societal difficulties.

[00:08:37] So for instance, there's a really diverse group of ethnicities, and in Sweden it's not allowed to be recorded ,what kind of ethnicities are there. It's quite visible that the different cultures that live there, they have different expectations of what healthcare is or should be.

[00:08:55] And by involving them from the start, at first was quite some friction about why are we not allowed anymore to go to your hospitals, and why do we get separated even more so, And through the conversations, it became part of empowering them to have a voice in their own neighbourhood and to have a voice in what their healthcare should look like.

[00:09:16] And while the architects may have thought in the beginning, let's design something that has a more, non-Scandinavian look, ended up going for a very Scandinavian look with a lot of white and wood types of materials because they said, well, that's actually what combines us now what combines the community.

[00:09:32] We are all in Scandinavia now. I'm not sure if that's a very fluffy story. 

[00:09:37] David Cummins: No, no, that makes sense because, as you just said, every hospital is unique and it has to represent the community you're in. And certainly rural hospitals in Australia are very different from city hospitals because of the community groups that we're aiming for.

[00:09:49] So keeping on that theme of inclusivity, what are some of the design principles that you think we should adopt when it comes to designing healthcare, especially like front of house and even back of house as well, to be inclusive for healthcare for all?

[00:10:04] Elke Miedema: The most obvious that most architects, thankfully, have to think of now these days for the regulations is accessibilities in terms of wheelchairs, et cetera.

[00:10:13] But of course is also much better for people that have strollers or other things. What we tend to do is think that if we make the patient areas accessible, that's enough but don't forget that staff can also have such disabilities. 

[00:10:27] Also in terms of other things economic accessibility. So making the hospital accessible in terms of, not making a super exclusive building and pushing the cost even further. 

[00:10:39] Making it impossible to use the healthcare but also information accessibility. So do people even know what is out there, that the building facilitates, for instance, maybe a library so that people can learn themselves about their own health as well.

[00:10:54] In Angereds Närsjukhus they also had simple like LGBTIQA flags on the reception, but it immediately literally flagged people to say like, "yeah, you are welcome here, and we understand that you may have different needs". 

[00:11:09] Again, that's not all design related. One of the things that really struck me as well is child-friendly design of some hospitals. 

[00:11:17] So, for instance, sometimes you have playgrounds in the middle of healthcare facilities for children psychiatry to check for children care, right, to see how the children are playing and play therapy. But those playgrounds are very visible for other children, and they may think, oh, I wanna play also.

[00:11:36] But then they're not accessible, which creates a lot of tension, often between a parent and a child that are already in a tense situation because they're in a healthcare facility, which brings a lot of stress. So, yeah it just adds up. 

[00:11:50] But I think that as soon as you are aware, as an architect that you cannot have the perspectives of everyone. Even though I spoke to so many different people about their perspective and read about it, I'm still blissfully unaware of all the needs different people have. 

[00:12:08] So by understanding and also reflecting on when you are planning and when you're designing, like who is on our team and what kind of identities do they have and what kind of identities are we missing in that sense and trying to complement for those perspectives in some way. That's very important. 

[00:12:26] David Cummins: So keeping on the theme of exactly what you just said, but noting hospitals of the future and the importance of care for everyone and in inclusive care, but also noting that a limit has to be reached at one point, like we don't have as much staff, certainly in Australia, there's huge staff shortages but the population is increasing over time. 

[00:12:47] How do we reach that balance of being inclusive for all, but we've got a limit. How do we find that balance? 

[00:12:53] Elke Miedema: Yeah. I wish I know the exact answer to that. Of course I would be very rich. It's an important question of course, to ask how does it add up financially?

[00:13:01] One part of that is really shifting that focus from a curing model where we focus on people who are ill when they're ill, and we don't really take care of people's health when they're feeling great. And that means that right now, we need to work on two levels in parallel, which is very heavy.

[00:13:19] But as soon as we do make that shift in that direction, the pressure on the healthcare system will be very different. So it won't be as much acute, it won't be as much like super long stretched out. 

[00:13:29] But it's difficult. I'm not claiming to have any solutions, but I do think that by looking really to the current demographics, we cannot really do anything else than making sure that the people that are on this world right now, that they are not ending up in emergency rooms or in healthcare facilities with things that could have been prevented. 

[00:13:48] David Cummins: And in Amsterdam itself do your government decision makers take that on board? Do they realise that free healthcare is important, but everyone should have access to healthcare and everyone should have the ability to be treated for their condition regardless of price?

[00:14:03] Does the Netherlands government take that into consideration?

[00:14:06] Elke Miedema: The Dutch model is that everyone has to have healthcare insurance, that's a given, that's required. And that means that to some extent, you have access to healthcare, but then the reality is that access means in terms of do you know where to find it? Do you know what kind of care is good for you? That's still difficult everywhere. 

[00:14:29] But in general, we don't have a public/private healthcare system for instance so everything is there but there are some big discussions of course, with insurance companies on who pays for what. 

[00:14:40] And also in terms of the building, the financial model in Sweden is much more clear and easy to understand because there, the governments are responsible for healthcare. 

[00:14:51] So depending on some of them, it's on a regional level, some it's on a municipal level, but they are responsible for the healthcare, and the government pays for healthcare, and you only pay like 10 euros each visit up to a maximum of let's say a 250 Euros per year. 

[00:15:09] But it also means that since they are the owners of the healthcare building and the providers of the paying the wages and they benefit, right? 

[00:15:18] So if they invest in healthcare facilities, if they invest in good healthcare, they are the ones to benefit, which also means that's why there's so much research there on this topic, because also the governments are investing in that research because the financial loop is incentive for them.

[00:15:36] And right now in the Netherlands, I don't think the incentive for better healthcare, or healthcare facilities, is really at the place where the responsibilities lies or where the wins can be made. 

[00:15:47] David Cummins: Yeah, that's very interesting. 

[00:15:48] The difference between the two when they're so close countries, but I wasn't aware of that Swedish model, but it does make a lot of sense. I can see the absolute benefit for patients and governments alike.

[00:15:58] Just before we go, knowing that the next seven to 10 years, certainly the aging population, is going to double, what would you like to see designers, health professionals, developers, construction people, anyone within the health field to do, to try and help with hospitals of the future?

[00:16:14] Elke Miedema: One of the things that we do with our students at TU Delft is that we let them meet the population groups that they should be designing for. It's actually incredible and I feel so privileged that I can be part of that course since this summer. 

[00:16:27] So we have 24 students and they go out and do field work in either aging facilities or in psychiatric facilities, and they meet them and by meeting them, it doesn't become a population group that is homogenous, instead, it becomes people and you see the complexities within that group.

[00:16:46] I would advise everyone who does this, that if you're designing for these groups (sometimes it's even people in your own environment). Everyone has people around them that have been to the hospital or that are dealing with dementia, or that are dealing with Cancer or long-term illnesses and try to see the human aspect of it, but also if their environment is disabling them to be who they could be if the environment was differently. 

[00:17:11] And it really helps to see how that happens as an architect or as a planner to see. Sometimes it's actually quite simple solutions that make it much easier for them and then if we go beyond the simple solutions, thinking of like, okay, there is a lot of technological developments ongoing, where do we want them to go that we can backcast to. 

[00:17:35] What are the steps then that we need to take now to get there? Instead of just solving it as it happens. 

[00:17:41] David Cummins: Yeah, it's a good take home message. 

[00:17:43] Your level and understanding of patient care and human care is paramount. It's absolutely phenomenal, I've done a few of these podcasts, and to have someone so empathetic to the needs of the people who are providing care and the people receiving care is a credit to you and, and to your team and to your research.

[00:17:59] Because the more you understand the needs of the patient and those who are providing care, the better you can have a design hospital. So thank you so much for your research and thank you for your conversation today. 

[00:18:08] You're amazing and I can't wait to hear more about your research, wherever that ends up in the future.

[00:18:12] So thank you very much. 

[00:18:13] Elke Miedema: Thank you again for having me and really nice to be listening to your podcast. 

[00:18:18] David Cummins: You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. 

[00:18:23] If you'd like to learn more about the AHDC, please connect with us on our website or LinkedIn.

[00:18:28] Thank you for listening.