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Book Review: Efficient Healthcare: Overcoming Broken Paradigms

Efficient Healthcare: Overcoming Broken Paradigms (2009), David Chambers. Houston, TX: Rice University Building Institute. 104 pages. ISBN 978-0-9842221-0-0Manifestos, statements, and proclamations have been issued imploring a wider recognition of the impact of healthcare design on the quality of healthcare delivery (ASHE, 2008; Hendrich, Chow, & Goshert, 2009). Each document has advanced an argument on how research does or does not help us understand that impact. David Chambers's manifesto, Efficient Healthcare: Overcoming Broken Paradigms, contributes an architect's voice to the discourse. Published in 2009 by the Rice University Building Institute, the manifesto is introduced as "the first in a series on the health care crisis that is viewed always from the perspective of the built environment" (p. 6).The first section, entitled "A Call for Change: (Incrementalists Need Not Apply)," is brief and powerful. The purpose of this section is to identify the real task at hand, to pull us from our diversions and urge us to consider solutions that are proportionate to the monumental task ahead of us. Chambers's inspirations follow from forces that converge on what could be a pivotal moment in the history of the United States and, perhaps, of global healthcare. First, Chambers is a survivor of a recent heart attack. During his experience, he had firsthand exposure to-and proof of-a broken healthcare system. Second, Chambers references the mind-numbing statistic that a mounting bulk of the U.S. gross domestic product is dedicated to a healthcare system whose gluttony is disproportionate to the value it struggles to deliver. In short, the road ahead is rocky and will not be easily traversed by light-duty vehicles that offer only incremental solutions. Chambers directs our attention to talented architects as our overlooked saviors.The author cogently argues that the first cost of a capital project is a small slice of a healthcare organization's total direct expenditure. In the larger scheme of things, appropriately designed hospitals are cheap but significant value-adds to the long-range sustainability of a healthcare organization. To help us understand the consequences of our oversight, Chambers invites us to look under the hood of healthcare at its "engine" or hospital design. When we lift the hood, we see fragments. Hospital departments are designed and encouraged to work in isolation, thereby creating redundancies in workflow and impediments to interdisciplinary collaboration.Chambers argues that patient-centered care and evidence-based design (EBD) movements are culprits that perpetuate fragmentation. Patientcentered care fails/failed because it shoves a model of care into a physical and social environment not built to encourage it. To Chambers, EBD repeatedly addresses narrow topics without seeming to incite or inspire innovative design solutions.In "Work Flow: A Reevaluation of the Value Stream," Chambers introduces workflow mapping as a technique for visualizing complex operations across departments. Workflow maps viewed through the lens of Lean manufacturing ideals can help us frame worthwhile questions, target solutions that mend a hospital's workflow woes, and facilitate buy-in for design solutions among multiple user types. With a workflow map, we can wrap our minds around a seemingly impossible geography of operations and plan the journey toward an actionable solution.Chambers argues that a wholesale and superficial use of Lean manufacturing is as unproductive as the patient-centered care and EBD movements. Lean ideals that are limited to departmental improvements perpetuate the fragmented hospital for two reasons: First, benefits to one department are not shared with other departments; second, a Lean intervention is performed without consideration of the organizational ecosystem as a whole. This lack of coordination translates into a system whose movement of services or flow does not revolve around the recipient of care, the patient. …