Walkability

One reason I enjoy living in New York is the ability to walk around the city. It provides activity for both the body and mind. Jeff Speck, a city planner/urban designer describes a theory of walkability in his book, Walkable City: How Downtown Can Save America, One Step at a Time

“… to be favored, a walk has to satisfy four main conditions: it must be useful, safe, comfortable, and interesting. Each of these qualities is essential and none alone is sufficient."

As a thought experiment, I wonder could these essential conditions for a good walk describe the essentials for a good healthcare experience?

“Useful means that most aspects of daily life are located close at hand and organized in a way that walking serves them well.”

We proliferate ED clones - general, pediatric or orthopedic urgent care centers that are focused, niche driven services. We increasingly integrate our offices and hospital units reflecting our workflow needs. This latter is more difficult to achieve because of legacy buildings and work spaces, too expensive to discard requiring refashioning. ‘Useful’ is the operational metric of efficiency, easily measured and addressed.

“Safe means that the street has been designed to give pedestrians a fighting chance against being hit by automobiles; they must not only be safe but, feel safe, which is even tougher to satisfy. “

Being and feeling safe are two different qualities, but Speck makes it clear that these two qualities are both necessary for the good walk. Being safe can be measured by never events, surgical site infections, or complications and while we may wish the context of these events were more explicit, e.g., risk stratified, we can agree with the general measures. But feeling safe is a more ethereal, more cultural, more a one-on-one patient-provider experience emerging from a safe environment. The surveys of healthcare professional’s “culture of safety” and patient satisfaction surveys are our current measures. I wonder if we might be more accepting of HCAHPS data if viewed through the lens, of how safe our patient’s feel, rather than their satisfaction? Much of the discussion about HCAHPS is that they do not measure quality; and we dismiss their message. But if they reveal patient’s feelings, then their veracity as measures is unimportant; I cannot argue one’s feelings.

“Comfortable means that buildings and landscape shape urban streets into 'outdoor living rooms,' in contrast to wide-open spaces, which usually fail to attract pedestrians.”

The movement from double to single occupancy, room-service meals, softer lighting, making our specialized equipment less obvious and intrusive all address the issue of comfort. While operating rooms or MRIs will always be alien, their surround need not be. The same holds true for our offices. While, the physical representation of comfortable is easy, the emotional representation of comfortable is more challenging. It is more difficult to invite the patient into our emotional ‘living room’ than to decorate our office or provide ‘comfort services’ in the hospital.

“Interesting means that sidewalks are lined by unique buildings with friendly faces and that signs of humanity abound.”

Patients are need driven and do not seek us for our ‘interesting’ qualities. Metaphorically, as individuals, we are the ‘unique buildings’, our demeanor with peers, team members and patients are our ‘friendly faces’. Opening up emotional ‘living room’ comforts and reflects our humanity. Providing that level of emotional openness on a daily basis may be, in part, the seeds of burnout; but that is a discussion for another day.