 Let's get started. So welcome everyone to today's session of the Harvard Medical School Organizational Ethics Consortium. I'm Kelsey Berry. I'm one of the co-chairs of the consortium, along with Charlotte Harrison. Sarah, if you would advance the slide. And today I have the honor to be your moderator as we're hearing from our panel of experts on the bioethics of the built environment and how we as health and ethics leaders can advance design for dignity and health. So first just a warm welcome to the Organizational Ethics Consortium and happy new year to all of you. This is our first program of 2023 and we do have several more coming up as you can see on the right. So this consortium series originated by doctors Jim Saban and Charlotte Harrison now about eight years ago, zeroes in on challenges and opportunities that arise for health organizations. Issues that typically can't be addressed by an individual or individual practitioner alone, but that demand organizational action and also organization level ethics. So we've looked at everything from how hospitals can responsibly integrate social needs programs into their strategic efforts on health equity. To how health tech companies can build structures and culture internally to facilitate ethical practice in health innovation and to the legitimate use of vaccination mandates in health systems and a lot of stuff in between. And through it all what we aim to do is support a learning community of practitioners and scholars building better health organizations and systems, and as a result also better societies. So we hope that you will consider yourselves part of this community and join us again for upcoming programs this spring, which Charlotte will mention at the end of the session today. But back to today. I would advance the slide Sarah. I like to think that by now we've probably all heard about the social determinants of health. And it's likely that many of us in the health sector have spared at least a moment, thinking about how to screen measure intervene on or ultimately shift these social factors. And while this work on the social environment is still very much mainstream, and there's a lot that's left unanswered. There's a paradigm shift, right, and the mobilization of health systems increasingly over the past three decades to address these long invisible health factors has been very remarkable. So it's amazing what a little awareness can actually set in motion. And today we have that opportunity again. So we're joined by an interdisciplinary group of physicians, ethicists and healthcare architects to bring us into the emerging science of the built environment. And particularly how the very buildings in which we practice can shape the health and well being outcomes we're able to achieve for patients. So how should health care respond to this proposition, what role should help organizations play in testing and acting upon it, and what values should inform particular design interventions. We are joined by four experts and an esteemed commentator today who are going to plant the seed with us, so to speak and really bring us into this puzzle and this opportunity. So, meanwhile, before I go much further, let me say a word to you all about your participation in the program today. On the next slide you'll see there are a few ways to participate. First of all, please go ahead and submit your questions at any time using the q amp a feature that you can access at the bottom of your zoom screen. We will discuss selected questions at the end of the discussion. And you could also use the chat box to share your thoughts at any time and in fact, we hope you'll give it a try now by introducing yourselves. So there are way too many of us here to do that verbally, unfortunately, but this platform is really supposed to be a space for initiating collaboration and opportunity and we start that by actually knowing who's in the room. Okay, so with all of that, as you all introduce yourselves and they give you a little example in the chat there. I have the privilege of introducing our speakers and our commentator today. So on the next slide, you'll see their pictures you can see them live as well. We're welcoming Diana, Dr Diana Anderson. So Diana is a board certified healthcare architect, an internist and a geriatrician. We can call her a doc attack. Diana has worked on hospital design projects globally is the co founder of the international clinicians for design group and a principal at Jacobs where she provides thought leadership at the intersection of design and health. Diana is also an instructor of neurology at Boston University School of Medicine, a research fellow in geriatric neurology at the VA Boston healthcare system, and a past fellow of the Harvard Medical School Center for bioethics. So with all due respect, we're welcoming her home to the center. So welcome Diana. We're also thrilled to welcome Stowe locked Teddy back to the Center for bioethics, where he was just recently one of our core faculty and executive editor of the Harvard science journal. Stowe is an ASPH certified clinical ethicist, a bioethics educator and current editor in chief of pediatric ethics scope, the journal of pediatric bioethics. Stowe has a track record of creating program initiatives in healthcare settings to support practice improvements that fundamentally benefit patients, families and staff, and he's currently a clinical ethicist at Innova Fairfax Medical Campus. We're also welcoming Bill Hercules, founder and CEO of WJH Health, a global consultancy that guides health systems C suite teams in shaping their places of care. Bill is a global expert in healthcare architecture with more than 100 publications and speaking engagements globally, most recently at the intersections of design with finance and ethics. He's past president of the American College of Healthcare Architects, and currently serves on the National Strategic Council of the American Institute of Architects. Just recently Bill served on their COVID rapid response task force, and on the hospital surge capacity task force of the International Facilities Guidelines Institute, shaping global facility responses to COVID-19. And then rounding out this team, we're also welcoming Dr. David A. Deemer. David is a bioethicist and an internal medicine resident at the University of Wisconsin. He has published and spoken widely on a variety of topics at the intersection of research, healthcare practice and ethics, including on methodology and bias in medical education surveys, the ethics of public procurement and COVID-19 hospital visitation or no visitation policies. So really thrilled to have this team of presenters at the forefront of healthcare design and bioethics with us today. We also have, as I mentioned, an expert with us to provide commentary from his perspective and experience in improvement science, that's Dr. Pierre Barker, chief scientific officer of the Institute for Healthcare Improvement. I'll say a few more words about Pierre a little later, but wanted to start us off with our presenting team first. So with that, I'll turn it over to Bill and Diana to take us away. Great. So we'll just pull up our slides. Thank you so much for the warm welcome home, Kelsey. I used to attend all these sessions as a fellow and it's a real honor to be back to speak to all of you today. So we're very excited to be here. We're going to be talking about what is essentially three years of meeting almost every weekend on a Saturday morning or late on a Sunday, talking about bioethics, healthcare and architecture, and what that means. Next slide. Because I think we have quite a varied audience today. I'm seeing everyone's introductions, which are so helpful. Thank you for posting in the chat. I thought we'd provide a quick sort of overview of what we'll talk about. And I see there are some design and architecture professionals but probably many or not in their clinicians, students, bioethicists, so we'll give a brief crash course in healthcare architecture and the current state of healthcare designs research. We'll also then take you into what we're calling sort of two big categories of ethical issues, both in acute care and in long term care, and we'll give you various examples from the research to try to convince you of some of our central thesis that we've explored over the last few years. We're going to talk about the built environment without also touching on the clinical operations and policies. So we'll also delve into that towards the end and we'll round it out with some ideas of how we can go forward how we can create change and foster interdisciplinary connections with all of these fields, especially in order to address the concern that concerns that we've identified in some of the evidence. So our central thesis what we started talking about just over three years ago is the fact that the built environment as Kelsey alluded to is a parameter of care. And we need to consider that alongside other parameters of care. You know when I was a medical student a number of years ago we took a course that spanned all four years called doc or determinants of community health where we talked about social determinants of health at length. This was something we brought into the research sphere into the clinical space with our patients, but nobody was talking about the physical determinants of health. Now our main hypothesis and thesis is really that the built environment has as much impact on us as other medical interventions and essentially it is a medical intervention so it can affect us just as much as a medication might swallowing a pill or having a procedure done in a clinical office it's that important we spend 90% of our time indoors in North America at least. Next slide. So through our discussions and meetings we've been speaking and writing on a lot of these thoughts we started out a couple of years ago with a blog for the Hastings Center we've also been trying to write in the architecture engineering space and we've appeared in some of the popular science magazines like health facilities management. And most recently we're very proud of our feature story feature article in the Hastings Center report called the bioethics of built space healthcare architecture as a medical intervention. And we're very happy to share any and all of these publications with anyone listening just send us a quick email afterwards. And with that I'll turn it over to bill to give us a crash course in health design and the current state of architectural research. In doing this, I'm not going to make anybody a healthcare architect. As a former president of the American College of Healthcare Architects we, we thought that the baseline education within the healthcare space beyond architectural licensure was at least five years. And many of us have been practicing much longer than that. But what I am going to do is is talk about healthcare design as a context to why we're even talking about this. And the sort of qualities of the built space that are reasonably well documented and generally inferrable associated with how space might affect us, how it how it looks, whether or not we have access to views of nature it's various lighting effects, you know, acoustic effects that sort of thing, inherently will have some sort of positive or or negative effect on our mood, our, our wellbeing, etc. So what we're going to be doing is diving into what some of this is, and then really what we're going to be doing about it but before we do that. I'd like to talk through the essential lack of structure that we have in this space. And this is a pretty bold statement, but unlike medicine which you might say enjoys but is clearly regulated in pharmaceutical development or therapeutic procedural development, the practice of architecture really doesn't enjoy that other than what's contained in building codes or various other guidelines and to be clear, those building codes and guidelines are developed with very altruistic intent this is this is intended to keep people alive to not empower people, etc. But the practice of design, which is wide and varied and includes many more people than just architects that includes engineers and constructors. It also includes people that are using the space and informing the design decisions along the way. And most design projects have literally millions of decisions that that shape it. So, none of those things are generally as well regulated as pharmaceutical development. And if we understand sort of the context of a phrase that is well repeated by many architects we shape our buildings are then they shape us it sounds wonderful in August. And of course it came from Winston Churchill who had wonderful stage presence and a magnanimous statesman quality, but the context associated with that statement in my opinion is even more interesting in that. The houses of parliament had been destroyed in the Second World War. The question arose, well, should we rebuild and his statements in parliament were not just about yes, we should because we need to but the form of the architecture really did develop his qualities as a through the House of Lords and House of Commons and and how all of those the bifurcated are the bicameral form of government how that how that came together what it essentially meant. And all of those qualities really kind of kind of intersected at the point of the architecture. So, he concluded his statement what with we shape our buildings and then they have this tremendously powerful effect on us. So, we could look at this, even historically in the medical space 150 or so years ago, Florence Nightingale wrote about this and journaled the, the, the deaths of soldiers in the Crimean Wars, and they didn't die from their battle rooms they died from the environments of care, the cross contamination from patient to patient the lack of air circulation or the lack of isolation between patients they didn't necessarily all die of their war wounds in fact more of them died because of that environment of care. So if we look ahead in the succeeding decades, we see that there were very deliberate steps to try to correct this and systematize this and become very organized and how we plan hospitals and other places of healing. All of these things have their own historical context, which are much beyond what we're going to be talking about today, but even within the practice of healthcare architecture. In the AIA, the American Institute of Architects which began, even before the Civil War, had very deliberate steps forward in developing its own Academy of Architecture for Health and those architects that are specifically focused in, in the space of healthcare the business administration, for example, had begun to develop its own guidelines associated with care for those that came back initially from the Second World War various state departments of health did a similar kind of thing. The Academy of Architecture for Health began to adopt some of these bigger ideas and codify them in creating model codes. These were generally adopted by the American Hospital Association fast forward to the turn of the century, the American College of Healthcare Architects was born as a specialty, similar to the American College of, I don't know you name the medical specialty. Even the Center for Health Design began as a way to assemble data associated with the environment's care. But if we look at a single publication that somebody might have, and we begin to analyze what that means against all the other publications in healthcare space, they're 7,700 of those. Some of those are not even peer reviewed. But if we look at that against the composite of all 29 million articles which are all peer reviewed in PubMed, we see the significant disparity between the amount of research specifically around architecture and its effects against all other types of medical practice. There are a number of organizations that are feeding into this. And again, these are very well intentioned organizations, very well intentioned professionals that are trying to make things better, but the infrastructure overall is still significantly lacking. In fact, across the United States, the Facility Guidelines Institute, which represents most states adoption of healthcare or hospital design codes is not even 100% across the country and even those have varying stages of previous editions of the codes. So, last year, the International Union of Architects and the World Health Organization declared the year 2022 as the year for design for health. This is a very significant kind of event. This brings health and its effects and the architecture of health to the forefront globally. There was not one dissenting vote in all of the countries, the 104 countries that are supporting this. And within the United States, the American Institute of Architects has made similar kinds of proclamations at various stages and even abroad in the UK, these are discussions that are still going on. There are a number of people that are very interested in this, but it's a larger question of how do we significantly change the tie. So, as was stated in the introduction, I participated in what was originally to be a white paper on addressing hospital surge brought on, principally by the pandemic but having a much wider lens than just pandemic medicine related to natural disasters or even man made disaster, mass shootings, God forbid. And what emerged from that was a 700 page advisory tome, which is ultimately going to be used for shaping future business or future building codes. And it was essentially around the hazards and the harms and safety associated with this. And it ultimately made it into CMS to shape how what their expectations might ultimately become, but these are far reaching forward looking documents that will have their own development cycles, and their effects really won't be baked into the codes. And really for the next 812 16 years. So, the quote, the real question then is what are we going to do about it, and even well intentions interventions, we have to recognize that those interventions are enormously costly. We could look at lessons learned from SP 1953 in California where after the Northridge earthquakes hospitals were mandated without funds of course, to modify their their infrastructure to withstand earthquakes, which is not an unreasonable request, except there were no funds associated with it so those requirements kept getting extended and extended and extended. And the code changes are really about minimum compliance. So how many of you actually drive the speed limit. The bigger bigger idea is that the codes themselves are not transformational. We need a different kind of infrastructure and organizational infrastructure to really transform how we do these things. And the reality is, even if we start now by the time we get the idea, have projects funded go through planning and design and construction that might be an eight to 10 year kind of window. So, this is a very longitudinal approach that we're trying to take here, but we have to, we have to get it started. When we first started thinking about this issue, one of the questions was, well, with so little to go on what kind of framework can we even apply to this. And so one of the most basic ontologies that came out of this was there seem to be two types of ethical issues that roughly correspond to well known ethical issues we see in clinical care. And those are roughly the incidental sorts of issues that we're going to discuss, which involve things like the nursing home deaths we've all witnessed with COVID, some data about hand washing and how we can promote better practices and then ICU room design. That's one set of concerns on the other are deliberate actions that are being taken where things like floor patterns are being used to control wandering of dementia patients, placing dementia patients in immersive settings where they think they are in a different time period, or in a different location. And then whether it's appropriate to do research on the built environment outside of any research context, right, there's no IRB or oversight required to put people in a different sort of physical setting to do an experiment right now. Next slide. So, the, we are proposing that the accidental or the incidental findings. We engender new responsibilities as we learn about them right so sometimes, you know, I will say we don't want to ask a question if we don't want the answer to it, but some of this information is coming to us, and then it's engendering that responsibility we argue to deal with it. And COVID is a great example of this. So here is some data from Canada. On the left, you see the percentage of the population living in long term care facilities, 2.1 million people. On the right, you see the proportion of deaths between those living in long term care and those not. And so if anyone questions the idea of whether or not the built environment has an impact on death. This isn't even taking into account elderly people who have risk factors who don't live in long term care. This is a specific death in long term care itself. Next slide. If we dig a little deeper into the data, we see that roughly one third of the nursing homes in Canada were grandfathered into a 1972 design standard, which allowed for multiple occupancy rooms, more communal dining, and several things that are no longer done. And that one third of those grandfathered designs was responsible for nearly two thirds of the deaths within nursing homes in Canada. So it's not just the overall setting, it's very specific features of the setting that can have profound effect on health outcomes. Next slide. A source of another example of what we're talking about is this work that was done by Ariadne labs and mass design where they studied the impact of the built environment on clinical care and childbirth. And what they found was that the, it's long been known that C sections are often done for non clinical reasons, and they found a correlation between the design of the facility and the percentage of cesarean sections that were done. So for example, a facility that has more surgical suites, it's going to have more C sections than one that has more spaces for natural birth. And even the location within the facilities how much transport is required to move a patient from a birth suite to an operating room can affect this. And normally, from a clinical perspective, we think these decisions are made based on clinical criteria on patients wishes on shared decision making. We don't stop to think that some of our decisions are being influenced by the space that we're in. That we're not as autonomous as we think we are. Next slide. And so, I had a labs and mass design looked at several different aspects of the built environment, and they were, they came up with this model of a pressure tank of the patient flow and what resulted in cesarean births that might otherwise have been vaginal deliveries. And so they looked at these categories of what's the capacity, the volume of labor and delivery beds, the nursing staff model, the length of the shift, the workloads, productive incentives, and then the motivation of the facility, the operations of the facility itself, which David will talk about later. Next slide. And you can see here on the screen. I don't expect you to read all of these. All these are different aspects of the built environment that the study found related to the built environment that affected clinical care. And so when we think about shared decision making, when we think about deliberation with patients and families, what we are suggesting is that we need to step back and realize that we too are being influenced by the space we're in. That building we walk into every day has an effect on our thinking and thus on our decision, our decisions that we make. Next slide. The other set of ethical issues revolves around deliberate efforts to alter behavior. And this is generally done and with very beneficial, beneficent goals to help with issues of housing. Older, older patients, patients with cognitive impairments, and some evolving science on how impact to certain centers of the brain that accompany dementia can be sort of leveraged to help promote or limit wandering behaviors, which Diana is going to talk about. Next slide. But before we get on to that, in the midst of COVID we would see something like we see here where the drips have been moved outside of the room because of shortages and PPE. So one of the things that this did though was mean there were less eyes on the patient. And this also coincided with visitation restrictions. And so we saw during this period and increase in pressure ulcers and increase in other hospital acquired injuries because of adaptations we made to the built environment in solving one problem, we create another problem. And so we've got to be very careful about how we think about changing these things that have evolved through time and practice. And so we really are arguing a systems approach is really necessary for this is on the fly solutions can create problems that we're not aware of until after the fact. Next slide. All right, so I'm going to take you through a few more examples. That's still alluded to examples around evidence based design that improve hospital outcomes or might affect outcomes and then I'll show some examples around the science of control specifically in long term care settings around behavior management for those with dementia by using illusion and deception. So this first example is within the intensive care unit acute care setting. This is a really interesting study published in chest in 2008. This was done by a co resident at Columbia Presbyterian where I did my residency and this is the medical ICU. So what we're showing here graphically is a bird's eye view of the ICU the intensive care unit. And it's a very traditional what we call a racetrack design and healthcare architecture so you have a centralized staff station. And then you have a corridor that runs around it like a racetrack and then around that the perimeter of the building you've got the patient rooms. But you'll notice with our yellow cones of vision, we're basically demonstrating that the corner rooms have less visibility. And what this resident doctor noticed as he was practicing in this unit is that some of his patients he found who went into these corner rooms didn't seem to do as well and he noticed a pattern. So he wanted to learn more this was a retrospective study. And he found that if the patients were sicker based on the Apache scoring system within critical care, if they had a higher score and went into the corner room specifically that lower one to the right where you only have 4% visibility from the staff station. Those patients had higher rates of morbidity and mortality during their subsequent hospital stay. And so I'll just pause and have you digest that fact and also to say that when we go into the hospital and into a particular room for a procedure or for care. We expect and hope that the care we receive from the staff will be equal to the person in the next room. But what if every room in the hospital doesn't actually allow the same opportunity to get better. Next slide. Thanks have, you know, been talked about a lot with respect to hand washing during COVID-19 pandemic. This was an interesting study done by some researchers at McGill University, they actually quantified it. So they found that for every additional meter that a health care provider needed to walk to a sink, their likelihood of hand washing decreased by about 10%. And you might think that this is pretty intuitive in terms of the numbers and the ratio, but I found that when we present as architects to health care executives to the decision makers the people with the dollar signs it's very important to bring quantitative data like this with us in order to substantiate our design decisions and ideas. Next slide. Here's an example, a stow talked about an incidental ethical issue, which probably was done with the best of intentions but actually has caused quite a bit of harm for probably many people this is a geriatric acute care hospital unit in San Francisco. And I want you to notice that all the doors are shut and if you ask any neurologist or geriatrician on this unit they will tell you that patients don't come out of their room they do not walk in this corridor. So with good scientific data that bed rest especially if you're older is bad there's no therapeutic value, and most older people who get admitted to hospital, end up in nursing home not because of why they came in we can certainly treat pneumonia and urinary tract infections, but it's because of the bed rest, right we immobilize them. And as architects we tend to design the patient room around the bed as the focal point, you don't necessarily think a lot about mobility. This corridor is actually impeding mobility in two ways. For one, it's quite shiny and reflective, and we know also based on what happens to the brain with cognitive impairment. And as you age there's a higher incidence of cognitive impairment that this is interpreted as wet or slippery and can be kind of scary to walk along if you're old and frail, so you might not. But I want you to look at the floor pattern and the colors as well you'll notice this sort of alternating horizontal striping pattern. Now this was probably a very well intentioned design decision probably for aesthetic reasons made early on in the schematic design process, but it's actually inhibiting anyone from mobilizing outside their rooms and walking down the corridor. And while this is an accidental or incidental ethical issue. There's actually good evidence that exists. And so the question is, you know, whose responsibility is it to access this evidence. And as the doctors and nurses talked to me about when I was rotating through here they said you know what should we do now do we have a duty to actually rip out this flooring and put in a new one. I became so interested in this issue that I actually just published a literature review on about a dozen of these studies that actually study design interventions at egress doors or exit doors in secured dementia facility so locked units. How can we use design to inhibit people from leaving with the intention of keeping them safe. We don't want them to walk outside and get hit by a bus we want them to to maintain their safety. So what's really interesting is if you take masking tape and place it in horizontal bars like you can see on the left hand graphic people with dementia will not approach the door. If you turn that tape 90 degrees to be more vertical as I'm demonstrating with the graphic on the right. They will just pass those stripes and exit right on out that door. Design based approaches are actually using vision and perception changes that happen in the brains of those with dementia we know there's a visual variant now Valzheimer's disease posterior cortical atrophy. They basically using these changes in the brain to decrease dangerous behaviors, and these interventions are relying on creating a misperception of the space we believe that the horizontal stripes to someone with dementia might appear like a three staircase that might not be so welcoming for someone who's old and frail to cross. So what does it mean to be a medical intervention. If the floor pattern actually causes a state that's quite similar to using medication, right to prevent wandering we can sedate someone we can use physical restraints which we have come away from. But is there a difference between using medications to limit wandering for people who live with dementia or using architecture to induce an psychological state to basically achieve the same end. And what we suggest in our Hastings Center manuscript is that this requires ethical oversight that we don't believe exists today. Next slide. We use other techniques to try to pacify long term care residents if they become agitated or upset, you know the memory impairment isn't the most concerning symptom to most caregivers, it's the BPSD the behavioral and psychological impairment. So these are assisted living facilities out in California and one of them has used an old car so if someone becomes upset or agitated they're escorted to the car, and they sit in an older car which we believe they probably used at some point in their life in their younger years. And as soon as they're calm they're escorted back. Same thing with that fake bus stop. Right. So these architectural elements are really designed to avoid avoid any indignities of sedation if they don't want to use sedation if we can help it and give people who might not be able to act safely on their own a sense of autonomy and control. But the natural progression of using these types of illusions that deceive is actually complete immersion, which has also been done architecturally. And the next slide shows you the dementia village so the original village is in the Netherlands, the and this is quite different as a model there these are not locking doors are using floor patterns. Instead of limiting wandering the dementia village actually promotes permissive wandering to combat any confusion or spatial disorientation by means of creating an artificial reality, and some scholars have likened it to the Truman show. Right. The design creates a sense of freedom but that's entirely an illusion. There's no actual open door to the outside world. You have your own little apartment, you're free to come and go. You can go down to the supermarket and buy a real Apple take a real bite that the money you're using is artificial. You can go to the barber to a pub, but ultimately this is a gated dwelling unit. Is this right to reality for these people living with dementia, or is living in this false sense of reality in some cases appropriate, and some scholars have even written about advanced deception directives, thinking about advanced care planning with some of these issues in the clinic setting, or even informed consent when you're looking at nursing homes for your loved one, are you being told, we use floor patterns to prevent wandering to incite fear or discomfort, instead of medication and typically we're not told about any of that. So after some of the emerging ethical issues we've seen in long term care design that don't really have any researcher oversight but we believe should the illusion that people are free to leave but they're not carrying out plans or goals when that's not possible. These immersive environments convincing people they're in a different place or time, and then controlling behavior through different design interventions. And so these aren't really different. We believe than any interventions we undertake in medical or pharmaceutical development. And with that, I'm going to move on to another example that actually has good data, right the dementia village doesn't have good evidence there are anecdotal reports. But we don't have good available evidence but we do have great evidence for the greenhouse model for nursing home design or the household model. So briefly, this is a graphic that illustrates the concept. Again a floor plan birds I view 10 to 12 single resident rooms with adjoining private bathrooms around a smaller decentralized living space always with direct outdoor access. Next slide and if you look at the data from COVID it's it's quite shocking. Every time I look at it I'm just surprised. What we're looking at here is a B and C we're looking at COVID cases per thousand resident days and a COVID 19 admissions and be and COVID 19 deaths and see. And you can see the far left purple bar which you really don't see at all, or all of these bad outcomes in greenhouse model units, which there's almost none, versus traditional nursing homes of less than or over 50 beds and it's quite striking the difference. And you might say well, that's probably pretty expensive to do, but actually greenhouse homes have great evidence around them for improved quality of life or not just talking about infection control we're talking about people enjoying their day to day time, less hospital admissions and less staff turnover. So there's a lot that's been written about patient and resident experience but almost nothing about staff burnout and the physical environment. So it's fairly more expensive. One paper actually showed that operational costs are pretty similar, and that there's actually some return on investment based on some of these additional benefits. And so I think on that note of costs and operations I'll turn it over to David to take us through some of the policy concerns when we think about architecture. Thanks Diana. So does the evidence and reasons we've outlined mean that your healthcare system needs to rebuild their hospitals. I would say not necessarily policies govern how we live and work within spaces and can mitigate the harmful effects of a given space on the care provided. They're flexible, these can be rapidly implemented and cost a lot less than a new hospital building. So in the next slide here we're going to talk about some policy in the coming slides. And I'd really like to emphasize this point for those in the audience, who are students are in leadership positions, because the policies that you make can recognize and mitigate the harms of a given environment. You know the ideas that we're sharing today don't always demand a new facility. What they do demand is that we recognize the impact of the built environment on health and take steps to promote the best care environment possible for our patients. So with this schematic here I created to kind of help organize several different built environment related interventions cited in the popular press, you may have read articles about the X axis is flexibility, the why is time to implement. So you can see here certain interventions are flexible. Some are less flexible. Some can be implemented quickly some take time and planning. I've highlighted example from visitation policies as an example of something that's flexible, rapidly implemented, fairly inexpensive, yet relates to the visible environment in respects. And I'm also going to talk about this because I think it's something that most everyone in the audience, either directly or potentially, you know, second degree has known someone who had a very strong experience related to hospital visitation policies during the pandemic. So I'd like to highlight this study. This is co authored by Quint Studer some of you may be familiar with him. It was looking at the impacts of visitation policies on h caps on patient safety indicator outcomes for a sample of 32 hospitals. During the initial stages of the COVID pandemic. These ranged in size from small community hospitals to tertiary academic medical centers. This first graph here that I'd like to highlight shows the months of 2020 and the percentage of facilities in this sample that reported a strict no visitation policy implementation during those months. You can kind of remember the ebb and flow and the surges of COVID. In many respects this very much matches the times of intense COVID intensity and health system strain. We can go to the next slide. And some of the outcomes I'd like to highlight here that still alluded to earlier. There were some changes in h caps domain measures you can see the three columns open visitation open limited visitation and then strict no visitation. The most significant difference was in responsiveness of hospital staff, fairly small percent differences really between the h cap scores but where we really saw significant differences was related to patient patient safety composite measures related to pressure ulcers in hospital falls with fractures and then also development of sepsis. And I was just struck when I read this the first time about the size of the percentages, you know even the 28% increase with pressure ulcers is remarkable, having a rate where things are doubling is very, very, very significant and I found very compelling. Let's go to the next slide. And so as you think about the pros and cons related to, you know, a strict no visitation policy versus some degree of visitation allowed, you know, strict no visitation policies can allow for more effective disease isolation, particularly if your PPE is limited. And if the hospital is in a financially difficult position where they cannot afford to maybe increase PPE to facilitate that. But as I mentioned here we can see that that's been associated with increased, you know, adverse medical outcomes. The other studies that I've cited here have noted that the strict no visitation require policies resulted in increased staff communication burden, less goals of care changes, you know, from a more philosophical level loss of patients life line to reality. I would argue to a certain degree of disconnect between the public life and the realities of illness and death that many of the medical practitioners were seeing on a daily basis in the COVID pandemic but many people, you know, who were not in the medical field, I think were somewhat shielded from, whereas, you know, allowing some degree of limited visitation allows you to mitigate some of those adverse associations. You know, with the understanding though that it may cost more you may have to purchase additional PPE to facilitate that. Let's go to the next slide. I highlighted the study to show how policy can affect outcomes in a given space. It relates to the build environment because a hospital's ability to safely allow visitation is related to its design. A hospital has, let's say, less HRAT capabilities, smaller room sizes, they may legitimately be able, less able, I should say, to offer safe visitation. Design therefore can either promote or make more difficult activities conducive to good patient care. I think each patient's body is unique, follows the principles of physiology, each hospital is unique, and the principles of design and health may not change but the way they play out within a given space can vary. And so this needs to be studied intentionally and consistently. And that's kind of the emphasis here of the policy action slide. We're going to go to one final example and we can go to the next slide. Let's try to apply this to a real hospital unit. I'm going to use my home institution's medical ICU here. This image is part of a public press release during the COVID surge. You can see people gown up. And you can see a similar variant of the racetrack design that Diana mentioned. This is triangular, we'll get a better schematic here in just a second. But I'd like to highlight a few design elements here that are kind of unique. Bill, if you can click through a couple of these. You'll see here several elements circled in red. And then one more bill if you could click through. You'll also see what's unique is that around this racetrack design, there's a skylight above that and you can see the light coming in there. And then the patient rooms are around the outside. You can actually see windows from the patient rooms facing up towards that sunlight to bring the natural light in. Why is this a part of this ICU's design? This ICU is unique because it is centrally located deep in the hospital several levels down. And many of the patient rooms around the outside do not have windows to the outside. So we can go to the next slide. And you can get a kind of a better, you know, visual representation of this. The red areas here are our natural light wells that can bring in natural light. And so the rooms that are next to those do have some windows. The yellow triangular racetrack. You can see there's some lights coming in from there and coming into the rooms. There's a lot of rooms that beyond that natural light from the racetrack do not have any, you know, significant connection to the outside, which can make, you know, rates of delirium sometimes higher in these rooms. And so this is kind of an interesting question if we go to the next slide. Overall, what's the net effect of this design, right? This is there are pros to this design. This particular racetrack, all the rooms have pretty equal visibility from this central nursing station model. The ICU is centrally located and easily accessible from the rest of the hospital. There's a lot of natural light in the hallways, which is very beneficial for staff which are usually sequestered kind of in the middle of a building without much of indication of day and night cycles. So this, you know, allowing for an interprofessional collaborative space in the middle is also a pro. However, there is a lack of windows and many of the patient rooms and temperature control can sometimes be difficult, which is not uncommon in older facilities. And so we can go to the next slide. And so, you know, how does this play out. And I actually advanced this bill if you can go back one more. Let me figure this out. What, what is the overall net effect of this right specifically here does the improved visibility result in a net positive impact on patient care, even without the external windows. I think we're going to be able to answer this question and those like it when we treat things like lines of sight floor patterns natural light and other design elements like medications, PPE nursing ratios. There are elements of care that influence patient outcomes and therefore warrant continuous institutional research. And this is really the next step that we're advocating for. And once we can understand our care environments better. We believe that hospitals can make better decisions, both in of course building better designs but also in implementing policies that can mitigate the harm the environment poses to patient outcomes, and can kind of serve as a bridge to these more permanent built interventions. And with that, we'll go to stow to do a summary. Yeah, I'm looking at the time so I want to wrap this up quickly. There are sort of these three takeaways that we're, we're going to leave you with here and one is the primary one is that the funding and scholarship. Examining these questions, discerning if there is a there there is really needed in this. You know, these these ethical issues are things that have parallels as Lachlan pointed out in the chat to well known well understood ethical concerns like nudging. And so we suggest that bioethicists need to engage with both healthcare architects and healthcare community in general to raise this issue as something that can be examined alongside the other parameters of care, which are already routinely studied. And so with that, thank you very much and turn it back over to Kelsey. Thanks so thanks David bill and Diana. This is an incredible way to plant the seed with a lot of people who I imagine have not really looked carefully at the holes that they walk and ask these kind of critical questions. What do we know, right about how they might impact what we do and what we're able to do for others. So with that, I think what I'd like to do, there's plenty of opportunity to turn to questions and to unpack but I wanted to turn it over first to our commentator Dr pierre Barker for his initial reflections on this topic and so just a word about pierre before he gets started. As I said earlier he's the chief scientific officer of the Institute for healthcare improvement, and is also clinical professor of pediatrics in the maternal and child health department at Gillings School of Global Public Health at UNC Chapel Hill. And so with IHI peers had a lot of extensive and deep experience, designing effective health improvement interventions for health systems globally, and then also cultivating our learning community around improvement science and methods for healthcare. So he's done this in a variety of different settings and takes the economies working closely with the World Health Organization, as well, we're really thrilled to have pierre with us. He's not going to correct me but I sometimes think about the nature of what IH does is something like where the rubber hits the road or where ideas become effective strategies and actions right and a commitment to actually studying what we do so that we can continually do it better. But with that little preamble let me turn it to pierre for your thoughts. Thank you very much, Kelsey and thank you to this remarkable presentation, which is really fascinating and I am grateful on the one hand to have an opportunity to weigh in on this amazing fascinating subject but I think I need to start with full disclosure. I'm deeply curious about the topic I am certainly not a trained ethicist and I have amateur aspirations to be an architect. But I am learning phenomenal amount from this presentation and Diana I will definitely be talking about physical determinants of health going forward. I do feel a bit more confident when reflecting on my experience both as a clinician and also as a systems improvement scientists. I've worked in a number of healthcare environments across the world. And this topic really has come up and I'll talk a little bit about that so I personally as a clinician. I have great awareness about how my working environment affected both the effectiveness and safety of what I was doing. But most importantly I think it affected the happiness of my work and I remember the day I stepped into the newly built Children's Hospital in Chapel Hill at UNC, and it's sort of huge spaces which were filled with light and color and it was just a completely transformational experience for me, and one which I remember very, very clearly. So, but I'd like to reflect on today's presentation in my sort of with a hat of an improvement scientist. And I think there is some of our work at IHI in the realm of particularly in the realm of where does this field go potentially next, where we bumped into the built environment and some of the questions about bioethics. I'll focus my commentary on three areas that I think came up on the presentation. I think Stowe highlighted some of them in this summary that relate to this intersection of the built environment, bioethics, and importantly for me, the opportunities maybe that improvement science has to offer. The first of the three is rarely the extent of patient and family and family engagement in the design in the design process and in the testing of the design changes and for us, the starting point of any really design processes to answer the question, which is what matters most to the patients that we're trying to serve. And I see Lachla and Foro already put in the chat a reference to the spirit of nothing about you without you. At IHI we start with the assumption that patients can best inform us about what the true needs of the situation are, but we do need to ask them and involve them very deeply in that inquiry and that those who are closest to taking care of those patients probably have the best ideas for how to respond to those needs that have been identified. So I think that some of the bioethical questions that were raised during the presentation and more generally in the field may be addressed, especially and I think I'm thinking about the long term care geriatric dementia space. I think it might be addressed through more intentional design collaboration with families, and even in the case of the long term care homes and pre dementia patients maybe about the intended design and certainly going forward about the effects of the designs, especially some of the more edgy examples that we saw today. We've had some experience of really thinking about very intentionally about the built design environment we worked on the pervasive issue of lack of dignity and respect and women giving birth in low middle income countries and we are working in both Ethiopia and Bangladesh on that and we had an opportunity to collaborate with mass design who you've seen referenced in the chat. In collaboration with two local architectural firms in those two countries, as well as the ministries and importantly providers and patients. We had a very thorough inquiry with a very deep discussion with patients and families and patient companions on this topic in order to really understand the impact specifically of the environment on our goal of improving dignity and respectful care. The conclusion was with these deep inputs that there were in fact opportunities in these contexts for amending space rather than rebuilding, although both were required in different contexts and for the adaptation of spaces. This is exciting because it does offer opportunities for doing much more adaptive design and much more testing. We would be able to amend existing spaces to try to accommodate the needs that were identified by patients and their families. But even for the situations and we've heard about the expense of sort of the big time so a really good example in that situation is because of the distances as mothers have to travel. So there are maternity waiting homes where mothers would come in the last few weeks of their pregnancy, so that they'd be right there. That requires a new building and new type of building and you can't adapt existing buildings to that. But even in that process, there was a deep iterative design even at the prototyping phase that involved patients, families and their companions. So for me that's the kind of number one potential ad I think is this intentionality around involving patients and their families and I, and I think when it comes to the ethics of this I think, and especially when you get to these dramatic designs that we saw today. I can't imagine how you could test something like that, especially in the situation where the, the patients themselves can't engage in the discussion on the outcomes I think engaging families and, as I say might might be good as well as that so the second idea really is just what can be done from using the tools of improvement science particularly learning, iterative learning and systems thinking to guide these designs and I've spoken a little bit about our experience in in Bangladesh and Ethiopia but I think there is more of an opportunity here I think to create the, the ideas that you that that we've learned from from the, from the studies. Now to move those into perspective designs that actually use rapid cycle improvement thinking. For example we've been very deeply involved in the problem of Caesarean section and I mentioned this because of the work of Neil Shars who was mentioned in the presentation. We've worked in the country of Brazil, Brazil has the dubious distinction of having the highest rates of Caesarean section in the world if you, if you are a woman who wants to deliver in the private sector you have a 90% chance that your baby will be delivered by a Caesarean section. The work showed the importance of them, both the numeric and spatial relationships of labor wards and operating rooms. There is an extreme example in the in the main hospital partner that we worked with in Sao Paulo, where the labor room every labor room was a potential operating room so you could convert the labor room into an operating room in Neil's calculation of steps between rooms, there was zero steps at the flick of a switch this room turns into an operating room so you can see the incentive by the built design for driving the labor room into Caesarean section. The solution, which was testable by a small adaptive design, let's move low risk woman four floors up, okay into into into a different space completely. But this gets again into the methodology of improvement which is we couldn't have done this without intensive collaboration, not just from the patients and their families but from the obstetricians who immediately raised multiple objections saying this was a dangerous thing to do. Despite all the evidence from around the world that that's actually how many many obstetric units work. And so, really this process of, of, of getting everybody on the same page and, and, and arriving at a design that is testable because we said okay let's just try this out it's not a big deal to move a woman into existing spaces. Let's try it out. Let's see what happens and we then had data to show that the woman who were moved there. Same match woman had much lower Caesarean section of it so we were able to do that without the risk of a massive build out that was expensive and potentially irreversible. So the final thing I want to say which just sort of builds on this is using improvement study designs to really test a lot of the good and interesting data that is accumulating this field. I mean we heard about the fact that there is their small numbers of studies. I would argue that the studies that that we saw presented today are pretty much all observational, and even some of them were anecdotal they're all retrospective. I didn't see much in terms of good matching. And so they do risk that the evidence on which some very profound decisions are being made are potentially at risk of bias. And, and I think the men the next step is what do you do with those data, and, and, and that every opportunity I would say that there should be both in terms of the co design that that idea that we started with but also this idea that we can perturb the environment. We should both in a prototype way and also in a, in an actual way, while looking at the results of those tests, before committing to, to massive expansive does more lasting design changes. I think that there is a lot that we could be doing with with the, with the data at hand I understand I'm speaking about something that I have limited understanding of, but I'm just wondering as I'm hearing the presentation whether there isn't a lot of opportunity for actually much more understanding of ideas and much more manipulation of the existing spaces. So, in summary, two ideas deeper engagement of patients and families and secondly more iterative adaptive designs for tension for the ideas that that that exists. So back to you, Kelsey. Thank you so much for. So we are, we've got plenty of time for questions and exchange. I do remind those who joined us late. If you've got a question please put it in the Q&A box. If we don't get to your question we're going to capture all of them, because the aim of this is to have continuing work rather than today to be the last moment in which you get to think about this and we all get to work on it together. So just before we turn though to the audience questions so wanted to give Bill Stowe, Diana, David, an opportunity to reflect back on what Pierre shared. I've got a few thoughts but I will, I will first open it up to our speakers in thinking about what they can take away from from peers comments and questions that they might have as well. I might make a quick comment and sort of ask Bill to weigh in as our seasoned healthcare architect and Pierre I, I completely agree about user involvement and we do that to a certain degree as healthcare architects but I guess the comment back to Bill is we really don't have a standard way to do that and it becomes very project specific whereby that feedback is owned by the client. How can we make that much more like clinical medicine research where the results might be generalizable into something that is very successful how can that be accessed by other projects, other architects. And I don't know whether Bill we think that maybe the process of design needs to change and that user engagement needs to change at the architecture level or at the client level. I just wanted to throw that out but I definitely agree that is something we've talked about at length in our group. Someone is comes into a hospital for knee replacement there are standard protocols associated with that knee replacement. There, it's not dependent on the titanium parts that make up the replace me, the protocols are very well orchestrated, even to a point of, if you vary from them you risk malpractice. Those kinds of controls, and those are tight controls, simply don't exist in the design space and the culture of design is such that it demands an enormous amount of freedom. But even within that freedom is an enormous responsibility to accept a very clear process around this. So consequently, from one firm to the next firm or from one project team within a firm to another project team within a firm, the process of that design has some level of variation, some small some rather significant, but Diana to your point there is typically not a process around. This is how you do it, other than an iterative kind of level of discovery. Similarly, there is within that project itself, not a financial mechanism to support a deeper level of research inquiry. So at best project teams are reliant on previous research that they've become aware of or if in the middle of design project emerging research is discovered. There's very little opportunity to incorporate that emerging research into a project that's sort of half, half designed or half built. So, the, the overall process I think needs a significant shake up, but it's not just codifying that process in a professional kind of way. But it's, it's also developing the research infrastructure to support it, neither of rich, neither of which are are in well established norms yet. And that's not just about the architectural practice that's how the services are essentially procured. And that relates to how requests for proposals are written, or what the expectations are and typically when projects happen. And those have been secured, and those funding fights have taken years and, and there's some fatigue associated with that from an administrative standpoint so okay let's get a designer, let's get a contractor let's get on with it. So it by that point, it's a matter of executing a collection of ideas that might be based in research or not, but it's very difficult to sort of back the train up and ask some fundamental questions when, when the money has been secured and everybody's expecting that there are timelines and other project controls that have to be met. So it winds up being a very strange process, but in terms of the actual process of design, it really needs to begin much sooner than this is what we're going to design let's go. I think the culture is also quite different right that, you know, if you are a resident or a fellow, you can write up a really bad experience and that actually can help your career. Right. A hard time seeing an architecture from writing up how badly something went, and it being anything but disastrous. Right. And there's no sort of mechanism. And so that sort of leads us to this question that the four of us have talked about a lot which is, you can't be, you know, morally responsible for something you have no control over. So who is responsible for this. Right. I think you know bills talked about how the average hospital CEO as a tenure of what like five and a half years. And so most of these projects span a CEO numerous levels of high level management. So we sort of have a tragedy of the commons problem here. At least when it comes to new construction. Now one of the points that we really started with and you know at the very beginning was to say what if we were to think of the building as a medical intervention. You know, and what would it look like if health systems were to engage it as such. You know and exactly so as you said there is a difference in culture in health care versus other sectors and so really being able to ask critical questions about, you know what are the values that exist in health care that would be beneficial to move into collaboration with an architecture and where might there be some instances in which we've not been our best selves in health care such that we're not just looking to wholesale take over what is, you know, an architectural and design based practice. I did want to pick up on the idea that you know if health care were to consider buildings as medical interventions maybe the first responsible step would be to ensure that we're using them in these evidence based ways. And Bill just brought us through, you know, some of the challenges to developing evidence that projects don't necessarily have funds associated with further study of the impacts. As I said earlier, we were discussing this question of what might be some of the structures or, or ways of generating evidence that you that you thought about. Do you want to jump in on that. Yeah, yeah, absolutely I think this is a good time to kind of speak a little bit more to that. The COVID pandemic has impacted everyone in a variety of ways. And I think it is now is a good time to be thinking about these kinds of design related issues, because of the I think increased prominence that they've had in a lot of people's experience working in health care. And one of the things that our group has kind of talked about in terms of this responsibility in terms of next steps in terms of you know who could do the kind of research that we are advocating for. As Bill said, you know, it's, it would be great if it was an architecture it'd be great if it was a part of the culture if the funding existed it doesn't. You know, health care systems are already, you know, in a very difficult position coming out of the pandemic, you know, we have discussed with some architects. So, is this a potential source of liability coming up where we need to be worried about litigation in some respects if things are not updated to a certain standard. I think what I would propose as a as a good next step and a good home for this would be within the pre existing quality improvement and process improvement structure that already exists in hospitals. You know, we already look at a lot of patient outcomes and we're not necessarily saying the outcomes that we look at need change. You know, I think what would make sense is for the hospitals to conduct this kind of research under the umbrella of QI and PI. You know, we understand and already kind of have a culture that these activities are related to organizational improvement and thus have a different kind of level of both protection and you know they're not subject to the same kinds of IRB approval that other kinds of studies are. These are things that as Pierre has mentioned, lend themselves well to let's try this and see how it goes. They can be, I think, very successful when incorporating feedback from a lot of these different key stakeholders, families, patients, nurses, etc, who see and work in these environments from a firsthand basis. And, you know, the, the department is already there the infrastructures already there to really incorporate this with the other elements that we know go into clinical care and so I think that's one area that myself some of the other, you know, my colleagues on the line have seen as potentially a fertile, you know, planting ground for this idea, in terms of making it tangible starting to apply it starting to do the kind of intentional follow up on implementation that we advocate. So, David, though, the, the issue though of trying something and just seeing how it goes is really kind of fraught with all kinds of ethical issues that have to be sorted out in concert with the development of the research itself. As the only non ethicists within our team, so I have to join Dr. Barger here. This is, I think, a fundamental issue that we do have to wrestle with in terms of getting real patients in with with real diseases and real understanding of this is a continuous you're participating in a continuous process improvement. It's a continuous thing so we're going to be doing some things that we think are going to be more helpful than not doing them. But there may be some other things that we have to talk about so at least some some level of informed consent or something like that but maybe you and Stoke and discuss some of the ethical issues associated with that kind of approach. I'll, I'll comment briefly and see if still has anything else that you'd like to add to it. You know that I think, you know my understanding of, of why quality improvement and process improvement may not have to go through the same kind of IRB vetting as a lot of other types of institutional research, although it is related to patient outcomes that matter is related to the process that Pierre mentioned right that we start with these focus groups to try and identify the relevant changes that need to be made changes are made incrementally, and generally starting small with iterative changes being made at each kind of cycle of expansion and application. And so I, you know, there, I agree with you that transparency is is a great thing in health care, and overall, the movement of health care is moving towards increased transparency which I think is a good thing. And being more transparent with our patients and their families about the process improvement that's going on in our hospitals I think is also a really good thing in many respects. And this can I think be a part of that as well and I think it's something patients would largely appreciate, you know that's going on again it has to be done responsibly and that's been kind of discussed, I think for several decades within that space. I agree with all that I, I think though that some of these things we haven't really come up with the best ontology for carving these up because, like, in long term care, I have met patients who absolutely want to lock door. They don't want a mural that hides the door handle. They don't want stripes on the floor they want reality. And other patients that I've seen would absolutely be fine with it it's like if you can avoid sedating me and dragging me back to my room by all means. And so, you know how these things are you know one of the things that maybe Diana you can talk about the de aging mirrors like to give the audience an idea of how far this goes. The kinds of interventions are being considered. I mean I consult for a number of developers were considering ideas without any user intervention care but thinking about deploying magic mirrors or magic windows in assisted living facility so if you're in downtown Toronto and an assisted living facility with mild cognitive impairment or mild dementia. All of the windows will be controlled by someone else so you're looking at views of LA or Australia you don't necessarily see Toronto which is where you're living, or any mirror where you look at yourself. You won't see your reflection at your current age it will only be a version of a younger you in these magic mirrors and we have sort of made that decision without asking anyone and I should say that I do I do research with people who have dementia and it is possible to involve them in these research studies it's it's very possible and it's very appropriate. I'm certainly able to tell us what they like at a certain time and place in that moment. And I think that has value, but the magic mirrors took me by surprise and was quite uncomfortable to hear about that this is being employed in different projects. Maybe we could bring Pierre in on this and just wondering about you know here as you see some of the efforts unfolding to you know implementation strategies and are working with health systems that are trying new things. Do you see there being ethical oversight in the in the work that you're partnering with them on, and what allows, if you do, what allows that oversight to be constructive in that kind of process. Yeah. So as I sort of put in the chat I think the problem is and I don't know the field well enough, but I can talk in principle that the most of the quality improvement work, pretty much all the quality improvement work that we embark on where there is actual intervention where we're testing interventions that are exempt from our be review are ones which rely on standard evidence so we know that this works this is why we didn't need our be permission to move the patients to the seventh floor that Brazilian hospital because there is evidence that it's actually safer for low risk women to labor quietly without the risk of premature transfer to operating room that exists that exists so we could do that easily and test that. I think that's, you know, and I'm just thinking about some of the examples that we saw today around the effect of light or the movement of beds in an ICU. It's compelling and it's intuitively right but is there harm is there an unexpected harm that might occur from that I think that probably needs to be formally tested. And there is an opportunity to do that. So I think that it shouldn't. I think there's some things that if you haven't enough degree of belief in the evidence that you could subject to a pretty rapid testing to see how to do that those those good ideas and. Most of the qi work that we do is really about the how not about the what, but I think that there is some work that seems like needs to be done in this field with all the caveats about my limits of my knowledge that the that really the evidence base needs to be much more strongly built. So we're, we're coming up towards the end of our time together seven minutes left or so. I didn't want to turn to audience questions. And before we do do that this is the organizational ethics consortium after all. And so couldn't help myself but to mention, you know, just a few of the challenges of course that help organizations will face and taking this mantle on. This is an issue of priority setting right, which is usually wrapped up in the discourse about no margin no mission, right so these this work takes resources. And as architecture looks to partnership with health care to be able to move the needle on some of this research implementation and practice. So I think that help organizations consider the relative priority to give to the built environment and the opportunities to use it in different ways as part of their solutions to the mission of facilitating help for all of their patients. So I'm just kind of dropping that out there because it's a key organizational dimension that we can't help but to mention in this consortium. I did want to maybe raise up one of the questions that Christine Mitchell had raised which with respect to ethical oversight of built environment design. We've got a lot of emphasis in the room. So what kind of oversight do you think might be useful without being kind of unduly bureaucratic or without generating harmful effects. Right off the bat, I think we would all agree that at least disclosure of some of these things that are you being used in long term care would be appropriate informed consent where possible. But I'm not even sure ensure that surrogate decision making is sufficient for making the kinds of decisions of where you're subjecting a person not just to a medical intervention or a line of treatment, but to their entire lived experience. The entire their entire life is being orchestrated like I'm not sure you know we talk about the problems with surrogate decision making. That's one aspect of a person's life. I'm not sure that's sufficient for doing this so I don't know if I mean stepping away from Christine's question but I think that that what's important is that we look at this from the perspective of sort of an honesty about this and going back to Pierre's point we have to involve people. We have to involve people in these things because we don't really know how people feel about it. You know, and good facts make good evidence we don't have good facts about this. And so I think before we can answer that question about what sort of framework we'd have to evaluate these things. You know, the first obligation is to understand if there's something going on here what it is, what are the harms or what are the benefits, and then we can talk about what would be an appropriate way to have oversight of that. One of my mentors, Dr. Ray Pentecost, who is at Texas A&M University, taught me the value of a very well crafted question. And I would suggest that as administrators are evaluating the priorities associated with this, that they would be asking those kinds of deeper questions rather than how chiefly can we get this project done yesterday. So this relates ultimately to the things that David was highlighting with respect to quality improvement, but asking the deeper questions, I think will necessarily help the priority around investment into some of these answers. But I don't know that answering these questions within the urgency of getting projects done is the right space to do that. I think that is a predecessor exercise in really trying to solve some of this. Similarly, the results of these things good or bad really do need to be published and the infrastructure associated with that publication is not very robust yet as we pointed out. Nor is the funding generally available. There are foundations that are supporting this, the foundation for health environment research, for example. But they hand out grants that are fairly small and 10, 20, $30,000 at most. So within the healthcare research space, or within the architectural research space, those things simply don't exist yet. And we need much deeper research around this much deeper infrastructure. We've talked a lot Kelsey about health systems that already measure never events right there measuring measuring surgical site infections are measuring falls they're measuring different things in the healthcare environment. Could they go one step further which I don't think would add a lot of cost the current framework to measure whether those never events are happening in certain spaces versus others if delirium is truly happening more frequently in the window list rooms. And if that's the case, you might not need to spend all the money to move the intensive care unit or punch a hole in the brick wall but maybe a virtual window that could be tested quite cheaply might be an interim solution that might have some at least interim benefit. So I think adding on measurements related to the built environment that health systems already really do acquire data on might be a first step to think about. Well, thank you. I'm going to turn it over to Charlotte to wrap us up but this is, sometimes we have the conversation and ethics where it feels like technology is getting away from us it's moving too fast right we didn't have time to think about the values. And this is an example where we can partner right in real time thinking about what values ought to guide these interventions and what evidence ought to be generated to support them so Charlotte will you share with us what's coming up and all of that. Thanks Kelsey sure will I'm going to thank you first thank you and thank our distinguished panel Diana Stowe bill David Pierre, really for a very informative and thought provoking discussion. I think that the, the issues you've raised around the design of healthcare facilities and the differences you've shown can be made in clinical decision making patient experience patient outcomes are really a call to action for people here and I think we've seen in the audience that people are very interested in thinking further about these issues have already contributed some thoughts that are quite important and I trust will be involved in moving this kind of inquiry forward in people's respective institutions. And to the audience I also want to thank you, your thoughtful questions and comments will certainly inform the panel and there is an intention to get back in touch with people in the Q amp a. And the reason we continue a dialogue with the panelists is knowing that there is a plan already discussed before this session that panelists wanted to follow up with questions and so if by any chance, we wouldn't be able to tell it's you when we look at the emails of people who are attending. Please drop into the chat. You're a contact information. So, I do want to quickly before we close give people an idea of next one session with it which interestingly picks up on one theme from today's. One aspect of today's discussion is the involvement of professionals from a field that are not usually engaged in the kinds of ethical issues that we're discussing but yet have an impact on patient care. Next month we're going to explore another area like that that in this case our topic will be data ethics and related AI ethics. We'll hear from a multi state hospital and clinical system that has designed a data ethics checklist and a related organizational infrastructure, so that early consideration will be given to ethical issues in the development of projects using patient data. Details of that panel will be posted on our website soon. But I think one thing we found particularly remarkable was again, as in today, it was the data ethics professionals as the design professionals who brought to the attention of hospital leaders and the hospital service service, how badly they wanted a way of considering ethical issues that they could see in the work they were being asked to do. So once again, that'll be February 24. And we'll look forward to seeing you have a good weekend, and we are going to close now. Thank you very much.