Who thinks about the way a hospital hallway is designed, and the implications for how long it takes to clean the floor? Or how frequently the air is turned over in an operating room, regardless of whether such an energy-intensive system is needed at all times? Or if that hospital needed to be there in the first place?
Dr. Andrew Ibrahim does. And he’s tired of being lonely in the pursuit.
Ibrahim, a general surgeon with architecture planning and design training who completed his surgical residency at Michigan Medicine, is launching a fellowship to close the gap between designers and clinicians—and, he hopes, improve healthcare outcomes along the way.
Bridging two specialities
Ibrahim’s interest in architecture and design came about in the usual way for him: Unusually.
He’d always been interested in architecture and medicine and had a hard time deciding between the two up until after he’d been accepted to medical school.
“When I got into medical school, I was 20 and a nerdy Type A kid. I went to medical school to shadow for a day and thought, ‘I’m way too young to do this. I can’t even buy beer legally. I’m not ready to cut open a cadaver,’” Ibrahim said.
He shared his feelings with the dean of the medical school and she asked him what he’d do if he wasn’t a doctor. He’d be an architect, he said. She said he should try it, so Ibrahim spent a focused year at The Bartlett in London, where he did the foundation course work in architecture and planning.
Now old enough to buy beer, he returned to medical school, and started to think about healthcare and design as one field. He wondered who in the medical school thought about regional planning of healthcare delivery and was steered to public health. Toward the end of medical school he took a year off and worked in health policy at Johns Hopkins as a Doris Duke Fellow.
“The Affordable Care Act had just been passed and led me to focus on the policies. If you can create the right financial incentives, that’s how you move public healthcare delivery forward,” Ibrahim said.
After completing medical school, and part of his surgery residency, Ibrahim joined the Robert Wood Johnson Clinical Scholars program at the University of Michigan. He studied policy evaluation and health services research and was mentored by Dr. Justin Dimick, the current chair of surgery at Michigan Medicine. During that time he used the tools of healthcare research to evaluate policies impacting rural access to care and to redesign healthcare systems’ delivery models.
Wanting to connect his measurement and evaluation work more directly to architecture practice, Ibrahim approached major design firms and asked to be connected with the clinicians in their firms. There were no connections to be made, which stunned Ibrahim considering the dollars at stake —in the case of new hospital builds, billions.
“You are the top firms short-listed for every billion dollar project and there’s no one on your side of the table who understands day-to-day clinical care, the logistics of healthcare delivery, or policy frameworks of the Affordable Care Act? They said no,” Ibrahim said.
Did they think it would be valuable to have someone like that in the room? They did. How valuable, exactly? Ibrahim was trying to feel out whether he was onto a feasible career trajectory and whether developing more architecture-health hybrids could help advance design practice.
He finished up his surgery residency at Michigan and saw a clear work pathway.
Ibrahim was appointed to the American Institute of Architects Design and Health Leadership Group to build out continuing educational modules connecting health and built environment. It became clear the project would take much longer than weeks or months.
It was also more than structural. It was cultural. He’d need to embed himself in a firm to make it happen and found a home at HOK, a top-five firm doing large-scale design work around the world. In 2018, he was named their first chief medical officer.
Bringing measurement and accountability to design
For as much as architecture and design involves calculations about capacity, materials, air exchange and other variables during planning, there’s little accountability after a building is stood up and the lights are turned on. Promises of efficiency and post-build occupancy are rarely followed up on.
Ibrahim found during his time working with design firms that designers weren’t accustomed or equipped to measuring outcomes as routinely and rigorously as healthcare systems. Instead, designers focused on innovation, creativity and custom work, seeing clients as unique entities demanding from-scratch solutions, he said.
The surgeon in Ibrahim wants to take a scalpel to that way of thinking and fix it.
“Would you ever come to a surgeon if you had a problem that was known, asked them how they were going to fix it and heard ‘I’m going to ignore everything I’ve done in the past and start from scratch because I want a truly creative and innovative solution for you’? Nobody would come to my practice,” he said.
A fellowship to create a new hybrid workforce for health and design
The consolidation of hospitals into networks has increased the cadence of building for those systems. Where a single hospital entity would build a new hospital every 30-40 years, networks are looking at projects every 3-5 years. That increased rate of investment puts more emphasis on outcomes, Ibrahim said.
“Some clients have started getting their heads around that. They know they need to need to think about multiple projects in a row and ask, ‘OK you’re the architect, we have multiple projects, how are you going to evaluate the first one to make sure we’re better on the second and third projects?’ Most firms just aren't equipped with the workforce to do that.”
To help build up that workforce, Ibrahim is joining the faculty in the Department of Surgery at Michigan Medicine with a joint appointment in the Taubman College of Architecture and Urban Planning and launching a fellowship in Health & Design.
The fellowship is a two-year program geared to architects and urban planners in practice. They’ll be armed with the tools of health health services research and measurement science, which Ibrahim hopes they’ll connect to the patient experience to inform design at whatever firm they return to—and spread that discipline throughout the industry.
Key areas of optimization to target
Once this new concept is unleashed, Ibrahim anticipates two key domains of measurement and impact.
One is sustainability in terms of heating and cooling, which comes with built-in measurements—and a responsibility on the part of hospitals to try to be good stewards of resources.
Another is on patient outcomes. We’ve got loads of data on how patients fare, but we don’t currently link them to location of care; how does a patient fare in a corner room with a roommate versus in the room with no roommate closer to the nurses’ station?
“On a broader scale, when you’re a network of 12 hospitals trying to optimize care for the population, you have all the data for those people in those hospitals. The number of sudoku puzzles you can create for how to optimize the different hospitals, the referral patterns, and where patients go for specialty care...it’s a whole new science we have to figure out,” Ibrahim said.
Designers could best come up with innovative options, and people with healthcare knowledge could evaluate them, Ibrahim said.
Current events are highlighting how the marriage of design and healthcare is essential to health systems and structures.
“With the Coronavirus pandemic, we’re struggling in real time to quickly redesign healthcare delivery systems. I wish we already had a trained hybrid health-design workforce to deploy,” Ibrahim said.
Back to the design of the hallway in a hospital and what it means for cleaning the floor.
On a walk through one of Michigan Medicine’s buildings, Ibrahim pointed out a curved hallway, with rooms flanking one side of it and nurses’ stations positioned intermittently on the other.
The geometry provides better visibility for nurses into more rooms. It’s the same reason a conversation at a round table is easier than at a rectangular one.
The same geometry creates challenges for maintenance. The team that cleans the floors with the ride-on machines has to make more passes because the machines aren’t designed with the same angles. It’s taking more people, more money and more supplies to accommodate well-intentioned new designs.
Can Ibrahim fix it?
Will he be less lonely thinking about it soon?
By Colleen Stone