Richard Dallam

Richard Dallam

Managing Partner, NBBJ
Rich helps people and communities design for health, healing and well-being, all in support of a good life. Integrating the arts, humanities and sciences in design, he brings a love of music, philosophy, gardening and food to all occasions. It’s your life, he reasons — so enjoy it!

The Re-Socialization of Patient Care

True Patient-Centered Care Requires a Holistic Approach to Meeting a Patient’s Physical, Mental, Spiritual and Social Needs

October 28, 2019

Managing Partner, NBBJ

Editor’s Note: This essay was originally co-authored by Rich Dallam and Ryan Hullinger for the December 2018 issue of A+U. It is reprinted here with the permission of the publisher.

Healthcare has seen a widespread shift in focusing on the patient experience. While this encompasses many, sometimes competing, priorities, for NBBJ a major concern is the social aspect of care. Hospitals today are increasingly building single-patient rooms to reduce infection and improve the patient experience; however, true patient-centered care requires much more than maximizing comfort: it requires a holistic approach to meeting a patient’s physical, mental, spiritual and social needs.

This approach brings many different clinical specialties — physicians, nurses, mental health professionals, dieticians, physical therapists and more — together to work for the patient’s benefit. As a result, examination and patient rooms are frequently expanding in size, even as cost concerns drive healthcare providers to reduce square footage wherever possible.

To accommodate these diverse specialties without inflating space needs and construction costs, NBBJ has adopted rapid prototyping in the planning of examination and patient rooms. This process engages clinicians, patients even cleaning staff to role-play within full-scale mockups of a proposed room, and then to quickly reconfigure and iterate the layout to not only better accommodate staff workflows, but also to holistically meet patients’ needs.

In an April 2013 workshop with the Canterbury District Health Board in Christchurch, New Zealand, rapid prototyping aimed to design a multi-patient room that would improve healing by increasing socialization amongst both staff and patients, while still meeting contemporary needs for privacy and infection control. NBBJ is now using three-dimensional scanning to import physical mockups like this into digital models — a process referred to as digitally augmented rapid prototyping — which enables designers to document, analyze and make adjustments to a layout in real time and arrive at solutions faster.

Working with Native populations — particularly in Alaska and the Pacific Northwest, in addition to the Maori of New Zealand — challenges the prevailing notion that de-socialized, private patient rooms are always the best solution. In tight-knit Native communities, the social aspect of a person’s well-being is tied to their cultural identity. That’s why several integrated healthcare clinics designed by NBBJ for Alaska Natives and the Umatilla people of eastern Oregon are organized around a central gathering space, where people can connect and support each other through their healthcare journeys.

Lessons from this work with Native populations are now informing other projects, by finding new ways to incorporate patients’ families in the healing process. This has long been done, and amenities are continually improving, but new design concepts take this further by enabling the patient room to flex throughout the day to accommodate work, socializing, family meals and overnight guests — allowing daily life to continue even during an extended hospital stay.

For times when families are unable to join their loved ones in the hospital, NBBJ is now prototyping an augmented reality patient room that will enable them to be virtually present. The concept utilizes projection mapping and surround sound to create an immersive, 3D environment customized to the fixed perspective of a patient lying in bed. With this technology, the patient room can virtually disappear, replaced by a live view into the home that allows patients to remain connected to their families. This technology can also create immersive natural environments, as exposure to nature — even if only simulated — is proven to reduce stress and help people heal faster.

Like digitally augmented rapid prototyping, the augmented reality patient room utilizes the newest design tools and features. Most importantly, however, that technology is always employed in the service of increasing social connections and improving the human experience.

The potential — and challenge — of integrating new technology into the patient room suggests a new frontier for patient care: flexibility. When social demographics and technology are undergoing massive changes, too quickly for fixed infrastructure to keep up, how can we design an environment for rapid adaptation? Only when healthcare environments are flexible enough to keep pace with our evolving communities, as the ways in which people live and socialize inevitably shift, will we truly be prepared to provide the healthcare of the future.

Banner image courtesy Benjamin Benschneider/NBBJ.

All other images courtesy NBBJ.

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How Can Healthcare Institutions Become Disaster-Ready?

A Conversation About Healthcare Resiliency and Design in Seattle

September 6, 2017

Managing Partner, NBBJ

The Pacific Northwest is a beautiful place to live and work. But with that beauty comes the potential for natural disasters — everything from earthquakes to volcanic eruptions. Combined with the uncertainty associated with climate change, how should local healthcare systems address these issues to protect their patients, safeguard their assets and conserve resources?

We decided to convene a “Disaster Ready” series of panel discussions, design workshops, articles and papers to address this important topic of resiliency. This summer in Seattle, Puget Sound Business Journal healthcare reporter Coral Garnick moderated a lively discussion on the importance of resilient healthcare facilities.

The panelists — John Hooper (Magnusson Klemencic Associates), Christine Kiefer (Harborview Medical Center), Onora Lien (Northwest Healthcare Response Network) and Mackenzie Skene (NBBJ) — shared their expertise, including resiliency best practices from healthcare projects located in areas vulnerable to natural disasters.

The following is an edited recording of that discussion. From designing “upside-down hospitals” that protect against rising sea levels, to advocating for policies that require more from critical care facilities, learn what healthcare systems can do locally and beyond to withstand the unknowns of a changing environment.



Here are a few highlights from the conversation:

The definition of resiliency
“I’ve also had the chance to work in New Orleans, following up on Katrina and replacing the hospital damaged by Katrina, and it changed my whole view of resiliency at that point, because it was less about buildings, and it was more about the people, and the operations, and the continuity of the mission.”
—Mackenzie Skene

The importance of practice — and community
“The drilling, the practice, the scenarios and learning the communication… I can’t say enough: it shouldn’t just be us practicing in isolation, but the system practicing together.”
—Christine Kiefer

Who’s responsible
“I worry a lot that the work of preparedness often lives with one champion within an organization, one emergency manager or part-time facility person who’s tasked to do a lot of this. While I recognize there’s a lot of competing demands, in order for us to really move the needle, there has to be a more inclusive strategy within the organizations, and the accountability and the responsibility needs to live much broader than just an emergency manager.”
—Onora Lien

What we can fix, today
“There’s one or two [older buildings] on a campus … that the infrastructure may go through, the medical gasses, the power, the water, et cetera. That’s what I worry about. It’s that small percentage that, if you fix that one or two buildings, you’ve improved your resiliency by a factor of two or three. If you’re going to pick a low-hanging fruit, do those.”
—John Hooper


Image courtesy of Wikimedia.

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Design Is Still Essential to Patient Satisfaction

Fancy Flourishes at Hospitals Don’t Impress Patients, Study Finds — Or Does It?

March 11, 2015

Managing Partner, NBBJ

Kaiser Health, in reporting on a Johns Hopkins study recently published in the Journal of Hospital Medicine, claimed that design features had little effect on patient satisfaction in one specific building, the Sheikh Zayed Tower on Johns Hopkins’ Baltimore campus. Quite to the contrary, however, the Hopkins study indicates that design does cause patient satisfaction to rise.

For example, the study found that satisfaction with noise reduction rose almost 20%. This is important, as reduced noise has a scientifically proven correlation to a patient’s ability to heal — we know from neuroscientist Dr. John Medina that stress hormone levels go up when sound levels exceed 55 dBA, which can not only slow the healing process, but can also lead to mistakes and lack of concentration on the part of care providers. The study also found that visitors’ satisfaction in their accommodations and comfort rose 20%, which is important in light of research demonstrating that family has a profound impact on their loved one’s healing.

Looking deeper, the study shows patient satisfaction rose in 32 of 33 indicators, including satisfaction with nurses’ attitudes, the time physicians spend with patients and the friendliness of staff (all up 2-3%), as well as overall rating of care (up 6.2%) and the likelihood that patients will recommend the hospital (up 5%). But these increases should be greater. Such minor gains reinforce the need for further study into why the design of this building did not have a greater impact on patient’s satisfaction with providers.


Sheik Zayed Tower, on the Baltimore campus of Johns Hopkins. (Courtesy SEAPCI)

More importantly, the reaction to the Hopkins report reveals a cognitive bias toward binary thinking: between what I call “wretched excess” on the one hand and “austere functionalism” on the other. The former assumes that design consists merely of “fancy flourishes” (to borrow Kaiser’s language), which excite people at first, but which cost a great deal yet provide no lasting value. The latter assumes that a just-the-basics approach is sufficient for healing, while ignoring our very real human needs for nature, socialization and beauty.

What often remains ignored is an essential aspect of design: behavior. That is, how can design positively affect behavior in ways that improve clinician performance and satisfaction, as well as patient satisfaction? This ability does exist, through rigorous, experientially-focused process improvements. But are those processes fully integrated into the design; are they experientially focused; and is there follow-through prior to moving in, so all staff are trained in the processes the built environment was designed to support?

As architects and environmental designers, we evaluate the success of our built environments using both quantitative metrics and qualitative professional judgment. We quantitatively know that designing for exposure to natural light, ease of movement and regulation of sound has a profound positive effect on the healing process. We also qualitatively know that design — by providing access to nature and fresh air, and by balancing places of quiet reflection and restoration with places for social connection — can also affect the way a patient, family or staff member feels. The beauty of good design is that it applies the best of science insights to the environments in which we work and live.

Ultimately, design must strike a dynamic balance of function, experience and expression. In an era of reform, every dollar we spend must provide value. We do not want our environments to wallow in wretched excess nor do we want the austere functionalism of old: the former suggests a lack of responsibility and accountability; the later dehumanizes us. Design, however, provides a powerful, quantitative, qualitative tool for a healthcare system renewing its focus on health and well-being.

Image courtesy of Sean Airhart/NBBJ.

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A Good Death

Why Is It So Hard to Find Solace in Intensive Care?

March 20, 2014

Managing Partner, NBBJ

The intensive care nurse hovered outside my father’s room, trying to be discreet, but watchful. It was awkward for her.

Inside the room, just a few hours before, my father had recited some of his poetry to his two grandsons over the phone. Even though his deep, resonant voice was impaired due to intubation, he was determined to share his perspective and wisdom on life until the end. My sister and I sat on either side of the bed, reaching up to make physical contact with the man who had held us in his arms as children. His arms were still surprisingly strong.

It was a brand-new intensive care unit with all the marvels of modern technology, but lacking a soul. Hours spent in discomfort while trying to comfort our father in his last hours made it painfully clear that the designers had focused on the technical brief but had forgotten that it is people who inhabit these places of extreme emotion. The bed was in position for medical staff access; our chairs were at sitting height. The only way we could look at our father was to stand. No one had thought about the long, long hours the family spends at the bedside.

Was this a good death? Perhaps. But we seem to collectively forget that death is for the dying and for the living. When my father finally took his last breath, we were overcome with his loss. My sister and I held each other and wept. It was now just the two of us, both parents now being gone. The nurse who had been hovering for most of the night quietly entered the room, having seen from her monitor that our father had died. “We will take care of all the arrangements,” she said. Suddenly, after a long vigil of ups and downs, we realized in a very different way that it was over. We were being gently prompted to move on.

I stood, tears still streaming from my face and asked the nurse how she handled being in an environment like this, filled with fear, sadness and grief? She quickly answered, “Oh, we’re all used to this.” I looked her in the eyes and told her that I design places like this for a living and asked again, “How do you handle this?” I could see her guard drop. She slowly and quietly said, “We don’t. This is a brand-new intensive care nursing unit,” she continued. “There is no place for the nurses to have a moment of respite, a place to gather ourselves, make peace and soldier on. There is no place to feel the sun during the day.” She turned away to attend to my father’s body.

My sister and I walked out into the hallway in a daze, not quite certain what to do. We wandered the mind-numbing maze of bland corridors trying to find our way back to the entry. These are the places we design; of life and of death; the most sacred of human events. We have such a rare privilege and responsibility. So why hadn’t someone thought to provide a place of solace at the intensive care unit? Didn’t they realize what happened here?

As we found our way to the lobby, holding onto each other, a young couple with their newborn, surrounded by friends and family were excitedly making their way to the door: the beginning of a new life. We smiled, simply, at the circle of life.

Image courtesy of Wikipedia.

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Healing Alone, Healing Together

What Is the Human Cost of Patient Privacy?

October 17, 2013

Managing Partner, NBBJ

The Affordable Care Act, now lurching forward in fits and starts in the U.S., puts a spotlight on healthcare costs and a renewed emphasis on patient outcomes. Embedded in this new course of action is the chance to re-assess some long-held assumptions about how people best heal. One area I have been studying: the benefits of healing alone versus healing together. When it comes to a stay in the hospital, most Americans equate a private room with higher-quality care and feel as though sharing a room with one or more patients would be overly stressful or an undue burden. We want our space, and we want our privacy — even if it means spending long periods of time alone and bedridden with no one to talk to but the TV.

This American sensibility around privacy, space and boundaries is now being coopted by many BRIC countries as they introduce more sophisticated healthcare models. Newly created institutions often associate American culture and social structures, including healthcare delivery, with having and being “the best.” A private room signals that patients are receiving the finest care available. And to be clear, in some instances it is absolutely imperative that patients convalesce in a private room. To that end, we have dedicated ourselves to rethinking the design of private rooms to improve patient experience, quality of care and safety levels. But more often than not, the need for a private room is a perception, not a reality.

What many fail to mention about single-patient rooms is that they are expensive, require more space, increase travel distances to provide care, and increase the number of staff needed to provide care in perpetuity. They also create an environment where patients are isolated and have limited contact with staff and other patients. All this calls into question whether moving to single-patient rooms is indeed the only “right” answer.

In a thought-provoking column for The Atlantic, Richard Gunderman, a doctor and Indiana University professor, questions the move toward such seclusion, arguing that the serious nature of health events taking place in hospitals creates the type of situations that most require companionship and human connection:

“Sometimes our zeal for privacy gets the better of us, short-circuiting opportunities for compassion and community. It is hard to be ill and in pain, especially seriously so, but such burdens are often magnified when we shoulder them alone… Typically, the events taking place in hospitals represent experiences when we need one another most… Shared suffering enables [us] to forge a common bond.”

In fact, there are many examples around the globe of cultures that prefer to heal in a communal setting when the level of care needed is low or recuperation time is long. Maternity wards in some countries are communal, for example, to allow women to socialize and provide comfort and aid to one another as they tackle the new and at times mysterious duties of motherhood.

At NBBJ, the design firm I work for, we have been experimenting with a hybrid room concept that allows for both privacy and a high level of human connection and community — a larger, modernized version of a traditional four-patient room. It allows for excellent lines of sight from staff-to-staff, staff-to-patient, and patient-to-nature. It also accommodates different levels of acuity of care and recovery needs and styles, while remaining highly conscious of cultural, budgetary, safety and efficiency needs.

As we “export” healthcare practices to other countries, we should be mindful of how healing practices mesh with the cultures they migrate to. Perhaps the idea of healing alone in the U.S. can be balanced with co-healing strategies. When we design, perhaps a little cultural empathy is in order — empathy to the cultures for which we design, and toward those who heal alongside us.

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