Design at the margins

Ambitious MWBE and DEI initiatives are important, but it’s easy for these efforts to become numbers in a spreadsheet, charting progress toward a spending goal. Truly equitable and inclusive design engages people at the margins—those who are rarely represented in the design process—and elevates their voices equally at the table with the doctors, nurses, frontline workers, support services, facilities leadership, and myriad other stakeholders we work with. Not only to get their reactions to design options ‘A or B,’ or send out a one-time survey, but to actually craft the building programs and spaces together and keep stakeholders engaged throughout the design process as that shared vision is realized.

We often use the 80/20 rule in hospital design: if we can get it right for the 80% of activity that will occur in a space and not overdesign for events that are less likely to occur or users less likely to use the space, then we’re being fiscally responsible. At this moment, however, we need to focus on the 20% on the other side of the margin—the people who our healthcare systems have been failing.

For instance, what if we take a foot out of every patient room to tighten up the program? It might not affect 80% of users or care being delivered most of the time, but that foot can make all the difference for someone who has a medical emergency and needs additional equipment and people in the room, or the patient who needs a support person to translate or advocate for them, or needs assistance in their daily living.

Let’s reframe the 80/20 rule: if a space meets the needs of the 20% who traditionally are marginalized, it will only enhance it for the rest of the 80%.

Who are we not hearing from?

We also like to say ‘we need to get the right people in the room’ for these conversations, but that can mean different things to different project stakeholders. In this context, we mean the marginalized populations we’re not hearing from in the design process.

Health systems want to do the right thing, but many don’t know how to integrate diverse communities into the design of their facilities. Historically, it hasn’t been done. By the time we kick off a new project, it’s almost too late. Perhaps there’s not enough square footage allocated to programs that are desperately needed, or the project has been so narrowly scoped that addressing what happens just on the other side of the door is off the table.

To truly move the needle, community outreach must start earlier. Ideally, we’re having those conversations six months to a year before programming and design even begin and engaging on a much deeper level. Outreach should include the most vulnerable community members—the uninsured who lack primary care, non-English speakers, neurodiverse individuals, people with disabilities or mobility issues, those experiencing homelessness, addiction, or mental illness, and the families and support systems that are impacted. These groups face very different issues and experience healthcare in different ways. For some, their only healthcare happens in the emergency department because they have nowhere else to go.

So, if we’re designing a new hospital meant to serve everyone, let’s ask: who are we not hearing from and what are we missing when we don’t hear from them?

Ask—and listen

The solutions don’t need to be expensive or require additional space. It’s about asking the right questions at the right time and truly listening so we can better utilize the space we do have. Early in schematic design, it might sound like this: Where do you feel safe? Where do you feel joy? Do you feel welcome there? Do you feel it’s ‘for you’? What’s the biggest obstacle to seeking care? Can you find where you need to go once you get there? Marginalized communities seldom get asked these questions.

In design development, it might be: Is this solving the problem for you? What’s missing? What would make this space better for you? Sometimes it’s as simple as a well-placed convenience outlet to charge a phone. Sometimes it’s a place to cry as you process and re-group to face the challenge ahead. Hearing diverse perspectives and experiences helps us pinpoint what the built environment can (or can’t) solve for and then make the experience better, not worse.

Small changes add up to big impact

Let’s take this opportunity to approach healthcare design with a fresh perspective. It's imperative that we design buildings that accommodate everyone; otherwise, meaningful change will never happen. We’ve learned through decades of healthcare design that small changes add up to big impact. There’s no formula for integrating diverse populations and voices into the design process, and it doesn’t work perfectly every time, but we move the needle a little more with each project. We are more powerful in overcoming challenges when we work collaboratively, and our collective efforts can pave the way for a more equitable and inclusive healthcare future for all.