The Death and Life of Great American Healthcare

How Jane Jacobs’ Urban Design Insights Can Improve Healthcare Strategy and Planning

April 24, 2014

Healthcare Strategist, NBBJ


In college I was inspired by the book “The Death and Life of Great American Cities” by Jane Jacobs, and I think much of what she taught in that book applies today to healthcare strategy and planning.

About planning, she said, “The pseudoscience of planning seems almost neurotic in its determination to imitate empiric failure and ignore empiric success.” Ouch, that cuts right to the bone, doesn’t it? Of course she was referring to urban planning, but I think the criticism applies to healthcare planning as well. How often do we in health planning and strategy simply copy, or react to, what other folks are doing? Even if what they are doing isn’t all that good. Admit it, we do it all the time. And this is one of the reasons why all our organizations look the same, why our marketing is not very effective, and why it’s hard to achieve competitive advantage.

Jacobs had four urban planning principles, each of which can be adapted to health care. (I will add healthcare words in parentheses to show how these principles can be translated to our discipline.)

  1. “The district (healthcare provider), and indeed as many of its internal parts as possible, must serve more than one primary function; preferably more than two.” In our world I’ve always taken this to mean that we have to embed our functions into the neighborhoods we serve rather than making the neighborhoods come to us. This is ironic because that is how health care began. Your doctor was in your neighborhood, and a lot of communities had their own hospitals. But as healthcare changed we consolidated more and more functions to singular locations that served the provider well but not the patient. We talk a lot about scale these days, and I think we are blindly applying that to the buildings we erect. CVS has scale, but they know how to distribute it to where their customers are. We need to get back to this in healthcare and put our services in with other services. In my neighborhood the CVS is next to the post office, dry cleaner, hardware store, etc. I’d love it if my primary care provider was there too.
  2. “Most blocks (healthcare buildings and departments within them) must be short; that is, streets (corridors) and opportunities to turn corners must be frequent.” Jacobs’ point is that long streets breed neighborhoods that cut people off from each other and from the services they need. It creates sterile areas prone to crime and blight. Short streets and blocks provide natural gatherings and crossing spots that bring people and services together and provide vitality. Traditional hospital buildings, and now some of these huge ambulatory buildings, are plagued by the same things. By pulling services out into smaller neighborhoods we can create a wholly different, and wonderful, feeling in our facilities. And I bet patient satisfaction will increase.
  3. “The district must mingle buildings (departments) that vary in age and condition, including a good proportion of old ones so that they vary in the economic yield they must produce. This mingling must be fairly close-grained.” This is a follow-on to Principle 1. She was arguing here that not every function can produce the greatest economic benefit, but yet there are functions that are crucial and must be supported. So in healthcare we want to be careful to keep that department that does not produce a return in good company with departments that do. If you isolate the not-so-good service from everything else, you magnify its losses and people will begin to question its usefulness. These departments often include behavioral health, obstetrics and breast care, considered low-margin, but mission-sensitive, service lines.
  4. “There must be a sufficiently dense concentration of people (patients) for whatever purposes they may be there for…” I think this speaks for itself. We are probably taking it too far with our big buildings that are getting even bigger. Jacobs uses the word “sufficient,” which means enough or adequate according to my dictionary, on purpose. I wonder how our planning would change if we did sufficiency studies when planning new buildings instead of trying to stuff as much as possible in them?

Consider one final quote from Jacobs, with a couple of little changes in brackets: “There is no logic that can be superimposed on the [healthcare organization]; [patients] make it, and it is to them, not buildings, that we must fit our plans.”

Imagine changing the way we do things by involving patients from the ground up, rather than from the building down. Let’s ask them where, how, and when they want their healthcare provided. Let’s allow them to tell us how they run their lives and how we should fit into that. I bet we will be surprised by the results.

Image courtesy of Flickr.

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