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During the Industrial Age when it was learned that germs cause illness and that pollution can trigger disease in immune-stressed patients, public spaces for healing were replaced with private spaces. The sick were separated from the healthy and buildings became more compartmentalized.

Today, the assumption that patients should be separated and isolated is evaluated in the interests of safety and best practices. And there is also much more emphasis on the patient as a customer with rights and desires for self-direction, family inclusiveness and participation in caregiving and healing.

Clearly, health care's consumer-driven agenda has architectural implications, not the least of which centers on the total experience. Health care public spaces have a role in forming that experience.

Memorable and positive

Health care public spaces have been examined at least since 2007, when a group of health care design professionals thought it worthy of exploration. In the ensuing years, health care architects have come to view public space as a vital player in the overall health care experience.

Health care public space can create a memorable and positive experience by providing orientation, instilling pride, building confidence and helping the healing process.

A public space is defined as one that provides access to all. It's a place where people can congregate and engage in multiple activities, a place of movement and flow, and a place of cultural collectiveness. Favorite public spaces might be described as grand or intimate, quiet or loud, public or private, but in all cases they are memorable and enhance the human experience.

So, how might general public space relate to health care public space? What is similar and what is different? Both general public space and health care public space share the same characteristics, but health care public spaces also have their own special patterns.

Typologies. The unique functions of health care public spaces can be categorized over the following formal typologies:

• Collector spaces. These are accepting and orienting spaces with high populations. They are active and have increased noise levels.

• Introspective spaces. These are accepting but calming spaces. They also feature high populations, but are personal, quieter and highly passive.

• Purpose spaces. These are spaces with specific functions. They are service-based and feature various user volumes. Noise levels are usually moderate in these dynamic spaces.

• Mover spaces. These spaces feature constant movement as well as ebb and flow of user volumes. These highly dynamic spaces are characterized by moderate noise levels.

• Switchboard spaces. These are spaces of orientation and wayfinding with consistently high populations. These dynamic spaces feature moderate noise levels and organizational clarity.

Attributes. Once the typology is defined, the following unique identity attributes of health care must be considered for each space:

• Environmental factors. These include the healing powers of natural light and air quality.

• User groups. These include diverse user groups and health care-focused user groups.

• Public and private relationships. There are public and private boundaries that must be respected and clearly defined for best care practices.

• Context of body health. People needing care for a diversity of ailments are the norm in these spaces.

• Passage of time. Time is often perceived differently in the health care environment by patient, family and staff.

• Emotional disposition. Patients in a health care setting can feel uncertainty and vulnerability, and experience emotional highs and lows.

A number of conclusions can be drawn from these elements. First is a heightened awareness and appreciation of the relevance of health care public space in the healing process. Second is the knowledge that health care public space can take different forms, serve different functions and express different patterns of use. Health care public space can be a primary space, such as a lobby, or a background or support space. But, most importantly, it also can be clinical space.

Another lesson is that health care public spaces do not exist in isolation. Instead, they stitch together the entire health care experience, which includes the five different health care public space typologies. Some of these spaces constitute seams of human interaction while others constitute a formal stage for this interaction.

How should designers build on the power of the public space experience in the design process? The answer is to look beyond just physical metrics like the square footage of the space and consider the emotional content of space. One way to do this is to assign one of the five typologies to a health care public space, and then determine which attributes should apply to the design of that space.

Defining health care public space and using it to enhance the design of health care facilities present challenges, but given the importance of the health care experience to patients and their families, it's worth the effort.

Cost-to-benefit

While assessing the role of public space, one must also assess the relative investment to make. Health care public spaces can pay big returns in promoting a positive experience, and they also come at a relatively low cost in terms of space.

The typical architectural space program often is organized around departments and services that allow business to happen and care to be given. For a typical 150-bed community hospital, a space program would be driven by a business plan that translates into space allocation for such elements as beds, emergency stations and operating rooms.

Traditionally a space program comprises:

• a room-by-room, department-by-department or service-by-service listing;
• a functional program — specific clinical spaces should be functional;
• an operational intent document.

Ultimately, the space for a 150-bed community hospital might total about 235,000 square feet, and there is often a line item in the space program for "Lobby and Public Amenities."

However, during a recent program analysis for facility designs, it was discovered that only a small portion of the factors actually represents a line item or place holder for overall public space. Some public space might be hidden in the interdepartmental circulation space.

This is not the optimal way of tracking and recognizing the importance of public space and the power of this space in the healing process. It is time to move beyond the assumption that, except for the main lobby, all circulation space is assumed to be in the space program's net-to-gross. It is time to track it around the five typologies.

And some organizations are starting to do exactly that. Many recent projects have demonstrated that some clients are actualizing "public space" and "public amenities space" in the space program as line items.

Most importantly, this designation of public space is only about 2 percent of the entire space program. Again, the potential for a "big bang" experience enhances return for a small investment. Some designers report that the unbundling of this space from the net-to-gross factor is not costing them more in the makeup of the space program.

Another recent example on a completely different scale is an award-winning children's clinic and surgery center. It is slightly more than 86,000 gross square feet but, nevertheless, big enough to accomplish some significant public spaces and make a big impact on the patient experience. On this project, designers made a case for unbundling public spaces as they became smarter about valuing and accounting for space and what was traditionally buried in the net-to-gross factor.

The bottom line is to rethink the space program in a way that recognizes and tracks the public space opportunities.

Tools to use

In addition to redefining the space program, the following tools might be used to enhance the investment, importance and success of health care public space:

Experience mapping. This makes it personal by creating real-life personas and scenarios and, in effect, mapping the story of the event.

Operational mapping. While being sensitive to experience, clinical and equipment flows should be mapped to assure the most efficient and effective medical outcomes or best practices.

Photographic story boarding. This brings an idea to life by documenting in pictures a chain of events that make up the sequences of the intended experience.

Strategic branding. Brands can build confidence and increase comfort. How might a brand instill confidence in the patient's experience?

Conceptual planning mapping. During conceptual planning, circulation paths can be overlaid, highlighting the public spaces of importance along the way.

Matrix mapping. This means plotting or arraying the appropriate typology with the appropriate attributes to define the physical public space.

Worthy of attention

Public and private health is a powerful and important topic in aggregate as well as personally.

Traditionally, most people seem to want to receive their health care needs close to home with minimal disruption to their everyday lives. Even a routine checkup can seem an intrusion. So a designer's solution to even the smallest thing can make a difference.

A very small percentage of space can have a large impact on the care experience, and it can accomplish this without adding to the space program. However, quality space must be defined carefully.

Architects and designers must create programs that redefine the health care experience. While health care public space is not technically revenue-generating, it does generate goodwill and, therefore, is worthy of attention. HFM

John R. Pangrazio, FAIA, FACHA, is consulting partner at NBBJ, Seattle. He can be reached at jpangrazio@nbbj.com.