Chapter 1
Introduction

Learning Objectives

• Understand how ongoing demographic and lifestyle changes in the United States affect demand for and expectations about healthcare.
• Become familiar with some ways in which economic forces and developments in medical practice are transforming the healthcare field and giving rise to an era of healthcare competition.
• Realize how the delivery of high-quality healthcare, in terms of both medical outcomes and human experience, requires attention to supportive health-facility design.
• Grasp the nature and purpose of each phase of the design process, from predesign programming to design, construction, concurrent planning, design review, activation, and post-occupancy evaluation (also known as "Facility Performance Evaluation").

In the coming decades, healthcare will continue to be an issue of major concern in the United States as it is worldwide. The uncertainties are many. The capacity of the medical professions to treat illness and injury is continually growing, as are the costs associated with such treatment. New legal mandates and constraints upon healthcare delivery are regularly brought into play. The character of society-demographics, experiences, and expectations-is, as always, in transition. Our very understanding of health itself, its sources and conditions, is expanding and evolving.

The healthcare systems of tomorrow will look different from those of the past. Those of us involved in planning and designing healthcare facilities have many issues and questions to consider. No matter how diligent and well informed we are, we cannot know with certainty the nature and rate of future change. Yet some of today's decisions must be based on projections about medicine and society in the year 2030 or 2050. The better we understand the issues involved, the better prepared we will be to meet tomorrow's healthcare demands and contribute to the development of effective, efficient, caring healthcare delivery systems, in the United States and abroad.

Projections and the Direction of Healthcare

Health is an indicator of overall quality of life. The growing popularity of exercise, proper nutrition, and stress-reducing activities shows that many people have a strong interest in health. Individuals in first-world countries, including the United States, are becoming more knowledgeable about their own health and are taking more responsibility for it (Panther, 1984; Spreckelmeyer, 1984).

In addition to less quantifiable developments in social norms and issues, such as customer expectations, ideas about customer experience, gender roles, the role of family and friends in the hospitalization of a loved one, and marketing trends, we can study changes documented by demographers and the US Bureau of the Census. Changes in age distribution, fertility rates, urbanization, work status, and education, too, will all profoundly influence the future of healthcare. What our society looks like, how we live, and how long we live will determine the demands on the healthcare in the next few decades.

Perhaps the most significant demographic trend is the change in age distribution. Because we are living longer and our fertility rate is decreasing, the proportion of older citizens in the US population will continue to grow. In fact, there is a distinction between the "young old" in their sixties and the "old old" in their eighties and above. Whereas in 1930 only 5.4 percent of the US population was over 65 years old, the 2010 figure was 13 percent (Panther, 1984; US Census 2010). In 1930, the median age of the population was 26.4, but by the year 2012 that figure had risen to 37.1 (CIA, 2012; US Government, 1984).

Healthy lifestyle choices, including exercise and good medical care, mean that many seniors live longer and more actively than ever before.

Our longer lifespan is due primarily to an improved standard of living and advances in healthcare. Yet, because of its unique needs, an older population will demand greater services from the healthcare system. Older people tend to have a greater number of chronic health problems, require more visits to the doctor, require a longer period of recuperation after an illness, and need more hospitalization. As a patient grows older, the types of illnesses experienced often shift. And in addition to treating particular illnesses, physicians treating geriatric patients must be concerned with the physiological, sociological, and psychological changes directly related to the aging process (Godfrey-June, 1992).

However, healthcare will have to contend with more changes than just those related to serving an older population. Choices made by couples regarding how many children to have, or whether to have them at all, are profoundly affecting healthcare. In the post-baby-boom years between 1957 and 1973, there was close to a 50 percent decrease in the fertility rate (number of births per 1,000 women of childbearing age) (US Government, 1984). Family planning decisions-to have fewer children, to delay childbirth, or to have no children at all-aided by the availability of effective contraceptives, have already affected the demand for obstetric and pediatric units.

The number of infants born each year does not tell the whole story. Partly because childbirth is now more a matter of choice for many, it is reasonable to speculate that parents-to-be will also want to make more decisions concerning the healthcare their children receive. Both parents, as well as other family members, have already become more involved in the delivery and in infant care. These shifts in birthing participation and the increased popularity of alternative birthing arrangements, such as midwives and birthing rooms, are reshaping obstetric and pediatric healthcare.

Other demographic trends-including greater numbers of women in the workforce, the continued urbanization of America, increases in the number of immigrants and ethnically diverse populations, higher levels of education, and changing occupational profiles-will also put pressure on the healthcare system. With regard to urbanization, not only is the geographic distribution of the population shifting, but residents of urban areas also tend to use physicians' services more often than do their rural counterparts. Changes in the workforce, such as higher levels of education, will also affect the healthcare establishment. As the level of education rises, basic knowledge about medical care also rises. A knowledgeable patient has particular expectations, which may alter the accepted definitions of high-quality care. Changes in these definitions-changes from the patient's and family's points of view-may also result in a public re-examination of the basic policies and practices of healthcare.

Keeping a vigilant eye on lifestyle and demographic trends seems to be a prudent strategy for healthcare decision-makers. Some of the shifts and their effects are easy to track and speculate about, but others are far from certain. Nevertheless, because society is unquestionably in transition and because its changes, the slow as well as the revolutionary, will affect healthcare, it is essential for healthcare leaders to plan for these shifts.

The previously mentioned demographic changes, uncertainties in the general economic climate, and the challenges of healthcare reform make it increasingly important for healthcare organizations, whether engaged in renovation or new construction, to "start smart, design smart, and build smart" (Managing Construction Costs, 2012). Since capital improvements and building costs are significant, planning for the long term is essential. Whether planning is for long-term or short-term goals, however, it must not be considered a static process. The long-term strategic plan must have enough elasticity to be altered as the need arises (Michael, 1973). Meeting the needs of consumers requires a dynamic approach to planning.

Fitness centers offering a variety of exercise options are an important feature of many health facilities.

Photo credit: Courtesy of Chelsea-Area Wellness Foundation

Healthcare: Changing Within

Rapid developments in science, medical practice, and medical technology, changes in population and age distribution, and the increased role of government regulation are causing a revolution in healthcare. "Old-style" healthcare, dominated by the individual physician's practice and the not-for-profit hospital, is rapidly becoming a thing of the past. Rising healthcare costs, an increasing supply of physicians, an uncertain future for Medicare and Medicaid, limited resources, and other trends have transformed the healthcare field. The age of healthcare competition is upon us (Johnson and Johnson, 1982). Birthing centers, health maintenance organizations, hospices, and big-city hospitals must vie for a piece of the hundreds of billions of dollars ($2.7 trillion in 2011) spent on medical care each year in the United States (NHE Fact Sheet, 2015).

In the competition for patients and their healthcare dollars, the nature of the healthcare facility is changing, too. Some for-profit and not-for-profit hospital chains are springing up, some hospitals are going out of business, and others are being acquired by multi-hospital organizations. Specialty facilities such as substance abuse treatment centers, diagnostic clinics, outpatient surgery centers, sports medicine centers, and freestanding urgent care centers are...