Salus journal

Healthy Planet. Healthy People.

Healthcare / Service redesign


Hearing hoofbeats: time to think zebras?

13 Apr 2016 | 0

In medicine, the old adage goes: “when you hear hoofbeats, think of horses not zebras”.

This nugget of wisdom is attributed to Dr Theodore Woodward, professor at the University of Maryland’s School of Medicine, as he instructed his medical interns during the late 1940s on diagnosing an illness based on the presenting of symptoms.

The logic of Dr Woodward’s advice follows that since horses are common in Maryland while zebras are relatively rare, one could reason confidently that the sound of hoofbeats is more likely to derive from a horse than a zebra. Medically, this translates as doctors analysing symptoms and checking initially for common ailments, not rare conditions. By 1960, the aphorism was widely known in medical circles. Diagnosticians have noted that “zebra-type” diagnoses must nonetheless be held in mind until evidence conclusively rules them out.

But applying this adage to architecture reveals a key question: are we too often considering “horses” for our hospital designs? Can we push the boundaries of design and convert healthcare design from a reactive process to one that is proactive, planning for what is to come? I propose three disruptive design ideas in order to challenge a relatively unchanged healthcare model.

Should the patient bed be the focal point of the room design?

In his 1993 article, ‘The hazards of elderly hospitalisation’, Dr Morton Creditor stated: “I know of no therapeutic value to strict bed rest.” In fact, we now know that bed rest can be detrimental and lead to deconditioning – most notably in the elderly population, who might lose up to 5% muscle mass per day compared to a younger male losing 1-1.5% muscle mass per day. When we undertake rounds, our clinical rule of thumb is for every day an elderly patient – particularly those over 80 years of age – is in bed, it will take about a week to recondition them with physical therapy. Critical care units are now ambulating patients on ventilators, in order to avoid ICU-acquired weakness.

Traditionally, the patient bed has been the focal point around which we design the room. Should this continue to be the case given our evidence on the detrimental effects of ongoing bed rest? Could a bed model that changes to a seating position be considered, or could the room be reconfigured around a chair as its central element rather than in a corner as a design afterthought?

Can corridors become more than an eight-foot wide wayfinding path?

Hospital corridors take on a dynamic dimension of activity, perhaps more so than intended in the planning stages. Owing to increasing sizes of patient care teams, rounding (a time to communicate and share data) occurs often in corridors, sometimes for the greater part of the day in a critical care environment. Nursing staff may carry out charting in decentralised stations outside the room and in the corridor. Often the place to store all the PPE/personal protective equipment, the corridor may also be the area where staff and visitors don their gowns and gloves prior to entering a care zone. In addition, the corridors are where patients undergo their physical therapy; in some units, numerical hallway markers indicate progress so patients can track themselves. The corridor is also a place for impromptu consultations among providers, between family and providers, and between family or patients with each other.

Can a corridor become more than a long narrow space with equipment spilling over and laundry bins scattered throughout? One might imagine a more dynamic space with benches in seating alcoves and therapy zones, encouraging mobility and conversation, while perhaps single-patient rooms become smaller in order to lend the square footage back to the hallway zone.

On-stage/off-stage – is separation of flows the answer?

The notion of the on-stage/off-stage concept, made popular by Disney, has become best practice in healthcare design over recent years. Does this model make sense? Or is it disconcerting to families and patients to walk into an emergency department or an ambulatory centre and see no staff members at all, given they have a separately accessed corridor and work zone? As a theme park guest, I might enjoy my stay by never running across workers doing maintenance or characters without their costumes. But healthcare is moving in the direction of the patient becoming advocate of their own health and care, with clinicians providing the expertise to aid patients in their decision-making. Under such a model, should the physical design separate what the clinical model is trying to unify? Medicine is also becoming more transparent as an industry, so should design reflect this shift?


In respect of the clinical built environment, do we need to consider some healthcare design zebras? Should we be thinking about, for example, smaller patient rooms that devote greater focus to space for chairs and mobility zones? Should we be designing corridors that encourage patients to: leave the room (when infection control permits); sit on benches and plug in their devices to stay connected with the outside world; and have dynamic discussions in alcoves with their providers, but within increased corridor work-zone space for staff. And should we be exploring how to increase visibility and interaction with clinical teams via common wayfinding paths and flows, so that healthcare design truly reflects the changing nature of the physician-patient relationship – a unified collaborative team.

Hospital activist Leland R Kaiser once stated: “The hospital is a human invention and, as such, can be reinvented any time." Although in medicine, hoofbeats often imply that whatever is going on is far more likely to be the usual than the extraordinary, as healthcare designers, let’s not forget about the possibility of zebras, and the opportunities they may give us in progressing the next generation of hospital designs and related architectural thinking.