Center for Advanced Healing

Top 10 List of Evidence Based Design Features

A large body of evidence attests to the fact that the physical environment impacts patient stress, patient and staff safety, staff effectiveness and the quality of care provided in healthcare settings. Just as medicine has increasingly moved toward “evidence-based medicine,” where clinical choices are informed by research, healthcare design is increasingly guided by rigorous research linking the physical environment of hospitals to patients and staff outcomes and is moving toward “evidence-based design” (Hamilton, 2003). Several studies document the impact of design characteristics, such as single-rooms versus multi-bed rooms, reduced noise, improved lighting, better ventilation, better ergonomic designs, supportive workplaces and improved layout on improved outcomes among patients, families and staff. Hospital decision makers are increasingly aware of the benefits of incorporating these evidence based design elements into their design. As hospitals all over the country gear up to invest millions of dollars to replace old outdated facilities, create additions or renovate existing units, they are challenged with difficult decisions - How do they make best use of their available resources to get the improved outcomes they aim for? 

Which key evidence based design elements should healthcare organizations consider as they embark on healthcare building design projects?
Based on the best available evidence from literature reviews conducted at the Center, we have compiled a list of top 10 evidence based design features that have been proven to impact one or more desirable outcomes in healthcare settings. The key criteria for inclusion on this list were the strength of the evidence linking the evidence based design element with positive outcomes in healthcare settings. The strength of the evidence was gauged by the number of studies examining the relationship as well as the quality of those studies.  The following list is organized in order of the strength of evidence: 

• Single patient rooms
• Installing HEPA filters
• Providing access to nature
• Installing ceiling lifts
• Installing sound-absorbing ceiling tiles
• Family areas within patient care spaces
• Providing access to sunlight
• Promoting the use of visible and accessible handwashing dispensers
• Promote visual access and accessibility to patient
• Providing areas of respite for staff

However, it must be noted that this list is not exhaustive. Depending on the type of healthcare setting (e.g. NICU, outpatient clinic, ICU) and specific project needs, different types of issues might gain priority and some of these elements might move off the list and others take their place. The purpose of this document is to provide a list of key elements that are supported by research evidence.

Single patient rooms
Shared patient rooms lead to higher nosocomial infection rates, more medical errors, increased patient transfers, privacy violations, lack of family involvement in the care giving process, and stress associated with noise and poor quality of sleep.  Studies have shown that patient outcomes from shared patient rooms have increased costs, reduced quality of care, reduced satisfaction, and reduced staff productivity (Joseph 2006; Landro 2006, Ulrich et al, 2004).

Research has revealed that patients recover faster in private rooms; Infection rates are lower due to the lack of exposure to airborne pathogens originating from a roommate while medication errors and privacy issues are reduced from not confusing patients and sharing confidential patient information in others’ proximity. Other documented benefits of all private patient rooms include: far less noise, better communication from staff to patients and from patients to staff, superior accommodation of family and consistently higher satisfaction with overall quality of care.

When comparing an all private patient room model to a semi-private room model the Pebble project Bronson Methodist Hospital in Kalamazoo, Michigan reduced infection rates 45% respectively (The Center for Health Design, Chaudhury, 2003; Landro, 2006).  The reduced infection rates resulted in savings in operational costs which offset the initial capital expense of more space per patient in building private patient rooms. The acuity adaptable model within single patient rooms potentially addresses the patient transfer problem by providing different levels of care in a single room to minimize the need to transfer patients as patients’ acuity level changes. Researchers found that the Pebble project Clarian Methodist Hospital in Indianapolis, Indiana after installing acuity adaptable patient rooms patient transfers decreased by 90%, medication errors by 70% and there was also a drastic reduction in the number of falls (Hendrich et al., 2004).

The projected $30 billion dollars in new hospital spending will focus on all private patient rooms (FMI Corp, 2006) as the 2006 AIA Guidelines for Design and Construction of Health Care Facilities recommends single bedrooms in all new hospitals under construction in the United States.  

Installing HEPA filters
Hospital air quality and ventilation affect infection rates through the transmission of pathogens.  Ventilation system contamination and malfunction, the accumulation of dust and moisture in Heating, Ventilation and Air Conditioning (HVAC) systems, the failure or malfunction of HVAC systems, and construction and renovation activities have all been identified as sources for airborne pathogens (Joseph, 2006).  Many incidents and outbreaks of nosocomial infections have been linked to malfunctions and contamination of the ventilation system in hospitals (Abzug et al., 1992; deSilva & Rissing, 1984; Kumari et al., 1998; Lutz, 2003; McDonald et al., 1998; Simmons, Price, Noble, Crow, & Ahearn, 1997; Uduman et al., 2002).

Preventing and controlling airborne infections in healthcare facilities through good air quality (providing clean filtered air and effectively controlling indoor air pollution through ventilation) is crucial in delivering patient safety and quality. Several studies show that high-efficiency particulate air (HEPA) filters, in particular, are highly effective in filtering out harmful pathogens and are strongly recommended in areas housing immunocompromised patients. Some special precautions to prevent infection during periods of construction and renovation include using portable HEPA filters and installing barriers between patient care and construction areas (Joseph, 2006).

Many hospital facilities are installing HEPA filters to reduce the impact of infections.  The Pebble project, Columbia St. Mary’s Hospital in Milwaukee, Wisconsin is currently studying the impact that HEPA filtration and U/V air sterilization systems has on indoor air quality (The Center for Health Design).  HEPA filters are suggested for healthcare facilities by the Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC), but are either required or strongly recommended in all construction and renovation areas (Sehulster & Chinn, 2003).

Providing access to nature
(views to nature, healing gardens, virtual reality)
Spending long hours in a hospital, either as a patient, family member, or employee, is stressful.  Providing access to nature through gardens in hospital settings have been proven to increase patient, family, and staff satisfaction (Ulrich et al., 2004; Cooper-Marcus & Barnes, 1995) as well as foster access to social support, positive escape and recuperation from stressful clinical situations.  Healing gardens in hospitals can provide a setting for staff to conduct various therapies with patients, for staff to retreat from the stressors within the walls of the hospital, and provide an opportunity for patient-visitor interaction (Cooper-Marcus, 2005).  Positive mood change and reduced stress was reported within several post-occupancy studies of patients and families who use hospital gardens (Ulrich et al., 2004).  Key design considerations to consider for optimal garden use in hospitals include: visibility, accessibility, familiarity, quiet sound environment, comfort, and unambiguously positive art (Cooper-Marcus, 2005).

If direct access to nature is not available, windows that let in natural light have the additional benefit of providing views to the outside that orient patients and staff to the time of day as well as provide positive distraction. Ulrich (1984) found that patients recovering from abdominal surgery recovered faster, had better emotional well-being, and required fewer strong pain medications if they had bedside windows with a nature view (looking out onto trees) than if their windows looked out onto a brick wall. 

The presence of artwork within a hospital is a component of a healing environment.  Images of nature through artwork in healthcare settings have been linked with being restorative (relieving stress) for diverse groups of people (Malkin, 2005).  The Pebble project, St. Luke’s Episcopal Hospital in Houston, Texas and American Art Resources conducted a study which revealed patients’ preference was for landscape art over figurative art, or art containing animals (Nanda, et al., 2007).  Recently, computer simulations for cancer patients have been implemented at several cancer centers (Duke Comprehensive Cancer Center, University Hospital in Cleveland, University of Virginia Health system) to use virtual reality as a distraction during patient procedures. Studies have shown that cancer patients while exposed to a virtual-reality nature walk within their hospital room, anxiety and symptomatic distress is reduced (Schneider, et al., 2004; Mace, 2004).  Additionally, one study revealed that while using virtual reality as a distraction during chemotherapy patients experienced fewer adverse effects and fatigue (Oncology Nursing Forum, 2004).

Installing ceiling lifts
Patient lifting is a major cause of injury to healthcare workers. According to Fragala and Bailey (2003), 44% of injuries to nursing staff in hospitals that result in lost workdays are strains and sprains (mostly of the back), and 10.5% of back injuries in the United States are associated with moving and assisting patients. This is an issue of great concern today with the increasing bariatric population in US hospitals.  Reducing injuries that result from patient-lifting tasks can not only result in significant economic benefit (reduced cost of claims, staff lost workdays), but also reduce pain and suffering among workers (Joseph, 2007).

Ergonomic programs, staff education, a no-manual lift policy, and use of mechanical lifts have been successful in reducing back injuries that result from patient-handling tasks. When the Pebble project, PeaceHealth in Eugene, Oregon installed ceiling lifts in most patient rooms in their intensive care unit and neurology unit, they found that the number of staff injuries related to patient handling came down from 10 in the two years preceding lift installation to two in the three years after lift installation (Joseph & Fritz, 2006). The annual cost of patient handling injuries in these units was reduced by 83% after the lifts were installed.

Installing sound-absorbing ceiling tiles
Hospitals are extremely noisy, and noise levels in most hospitals far exceed recommended guidelines. The high ambient noise levels, as well as peak noise levels in hospitals, have serious impacts on patient and staff outcomes ranging from sleep loss and elevated blood pressure among patients to emotional exhaustion and burnout among staff.  Poorly designed acoustical environments can pose a serious threat to patient confidentiality and patient safety as well as impeding effective communication between patients and staff and between staff members by rendering speech and auditory signals less intelligible or detectable. A well-designed acoustical environment is critical in addressing these problems related to noise and communication of information. Research suggests that environmental interventions may be effective in reducing the noise levels in hospitals and improving the acoustical environment; a key intervention includes installing high-performance sound-absorbing ceiling tiles (Joseph, 2006).

The impact of modifying room acoustics was recently assessed by periodically changing sound-reflective ceiling tiles to sound-absorbing ceiling tiles within an intensive coronary care unit and revealed that patients sleep patterns were better with sound-absorbing ceiling tiles in place (Blomkvist et. al., 2005).  Studies have shown that installing high-performance sound-absorbing ceiling tiles and panels results in reduced noise levels and perceptions of noise and impacts other outcomes such as improved speech intelligibility and reduced perceived work pressure among staff (Berens and Weigle 1996; Blomkvist et al. 2005; MacLeod et al. 2006; Hagerman et al. 2005). Though decibel levels were not greatly reduced as a result of the ceiling-tile intervention in these studies (reduction of 3 to 6 dB(A)), reverberation times and sound propagation were significantly reduced. This impacted the perception of the unit being less noisy and also improved speech intelligibility, which has implications for staff communication (Blomkvist et al. 2005; MacLeod et al. 2006).  The Pebble project, Jersey Shore University Medical Center in Neptune, New Jersey along with Pebble partner Armstrong Ceiling Systems and Tocci Acoustics consultants is currently studying hospital noise levels with the installation of high-performance acoustical ceiling tiles.

Family areas within patient care spaces
Patients and families have traditionally been viewed as passive recipients of care rather than as active experts in their own life and health conditions. In contrast, a growing body of evidence demonstrates that healthcare work happens most effectively when practitioners work highly interdependently in well-functioning teams, with active participation by patients and families (McCarthy & Blumenthal, 2006; Uhlig, et al., 2002). As care moves from simply ‘treating disease’ to healing the individual in a holistic sense– physically, emotionally and psychologically–health care teams must increasingly work seamlessly together and include the patient and family as integral team members. Further, studies show that environments (i.e. physical environment, culture and work processes) that include patients and families as active participants in the care process (as opposed to passive recipients of care) result in higher levels of satisfaction among patients and families (Sallstrom, Sandman, & Norberg, 1987; Uhlig, et al., 2002).

It is important to provide spaces for families in the patient room and on the unit where they can spend extended periods of time. It is equally important to provide spaces for families where both patients and families can be effectively included in the healthcare team.  Single rooms have clear advantage over multi-bed rooms in this regard due to increased privacy for patient-family interactions, more space and furniture to accommodate family presence (Chaudhury, Mahmood & Valente, 2006; Ulrich, et al., 2004). In addition to these factors, organizational policies such as those that limit family visitation hours might influence family involvement and satisfaction with care (Joseph, 2007). 

When the Medical College of Georgia (MCG Health system) in Augusta, Georgia planned to build a Neurosciences Center of Excellence family members were the key advisors in design process.  Through a family driven design process the new 20-bed unit provides ample space for families throughout the unit including space within each patient room with sofa beds, a family lounge, areas for quiet conversations (family consult rooms) and a small resource center (Information derived from the Institute of Family Centered Care case study, 2007). 

Providing access to sunlight
There is strong evidence that light is critical to human functioning and can be extremely beneficial to patients as well as staff in healthcare settings. Exposure to daylight helps reduce depression among patients with seasonal affective disorder and bipolar depression, decrease length of stay in hospitals, improve sleep and circadian rhythm, lessen agitation among dementia patients, ease pain, and improve adjustment to night-shift work among staff (Joseph, 2006).  Additionally, sunlight plays a key role in benefiting from vitamin D intake.  Research shows that most of the vitamin D in the blood can only be derived by exposure to light (McColl & Veitch, 2001).

Patients undergoing elective cervical and lumbar spinal surgeries were admitted to the bright or the dim side of the same hospital unit postoperatively during a study to assess whether the amount of sunlight in a hospital room modifies a patient’s psychosocial health, quantity of analgesic medication used, and pain medication cost (Walch et al., 2005). Patients staying on the bright side of the hospital unit were exposed to 46% higher-intensity sunlight on average. This particular study found that patients exposed to an increased intensity of sunlight experienced less perceived stress, marginally less pain, took 22% less analgesic medication per hour, and had 21% less pain medication costs (Walch et al., 2005).  A Canadian study found that myocardial infarction (heart attack) patients mortality were significantly lower when assigned to sunny intensive care rooms verses north-facing dull rooms within the same unit (Beauchemin & Hays, 1998).  One study revealed that agitation among dementia patients was reduced with exposure to bright morning light (Lovell, Ancoli-Israel, & Gevirtz, 1995).  Using sunlight as an intervention for the treatment of depression has shown positive results (Ulrich et al., 2004).  Daylight has proven benefits in reducing energy consumption; 50 to 80 percent reduction of energy use during the sunlit part of the day has been achieved through thoughtful lighting design (USGBC; 2007).

When designing healthcare settings, natural light should be incorporated into the lighting design.  Daylight entering through windows can be extremely beneficial to patients, provided there is no glare and it is possible to control light levels. Optimize exposure to early morning sun though the orientation of patient rooms. Provide windows in patient rooms, staff break rooms, and family lounges to maximize access to beneficial sunlight; Natural daylight is delivered at no cost and in a form that is preferable to most people (Joseph, 2006).  Connection to daylight is a concept supported both by evidence-based design research as well as sustainable building practice. 

Promoting the use of visible and accessible handwashing dispensers
Surface transmission of pathogens accounts for a majority of nosocomial infections and low handwashing frequency among healthcare staff (generally below 50%) is the key factor contributing to this problem. Environmental factors that discourage handwashing include: difficulty of access, poor visibility, poor height placement, lack of redundancy, and wide spatial separation of resources that are used sequentially (Joseph, 2006; Larson et al, 2005; Lankford et al, 2003; Boyce, 2001).

The location of and access to handwashing dispensers is an important factor impacting handwashing compliance. Hand hygiene resources should be located where they are clearly visible, within easy reach, with unobstructed access, placed at comfortable heights, require minimal effort to be used, and placed in standard locations in all patient rooms (Joseph 2006; Lankford, et al, 2003; Boyce 2001). In particular, the evidence suggests that installing alcohol-based hand-cleaner dispensers at bedside usually improves adherence (Ulrich, et al., 2004). One study found touch-free alcohol sanitizer dispensers were used significantly more often than manual dispensers.

Promote visual access and accessibility to patient
Nurses spend close to one-third of their time walking on the unit between patient rooms, the nursing unit core and the nurses’ station which in turn results in fatigue (Joseph, 2007).  Bringing staff and supplies closer to patients is likely to reduce time spent walking and increase time spent in direct patient care activities. The impact of the unit layout on the amount of time spent walking showed that time saved walking was translated into more time spent on patient-care activities and interaction with family members in several studies (Shepley, 2002; Shepley & Davies, 2003; Sturdavant, 1960; Trites, Galbraith, Sturdavant, & Leckwart, 1970).

New designs are incorporating decentralized nurses’ stations and alcoves outside patient rooms so that staff is distributed around the unit (as opposed to being in a single central location), closer to the patient.  Consider work flows in relation to location of key spaces (patient room, nurse work space, location of equipment and supplies) with the goal of minimizing walking distances and number of trips; consider locating frequently used supplies in patient rooms to minimize walking trips for staff.

With decentralized nursing care becoming increasingly common, an opportunity exists to study the impact of this model on staff time spent walking, in direct patient care as well as the nature of the interactions between patient and staff and between staff members so as to understand how these changes impact patient and staff satisfaction, communication within the care team and staff effectiveness.  The Pebble project, Virtua Health in Voorhees, New Jersey worked alongside GE Healthcare management engineers to deploy an integrative process to chart travel distances around the flow of clinicians, physicians, and patients.  Staff interviews were conducted and care providers were shadowed to measure travel distances and frequency of trips. The process revealed to the design team the pathways of activity performance and pictured the non-value-added trips taken for activities such as “hunting and gathering” supplies in the process of delivering care (Fendrick et al., 2007).

Providing areas of respite for staff
Stress among healthcare providers, especially with nurses, is a major problem that contributes to nurse turnover and associated injuries.  In addition to being demanding and stressful from emotional patient events, healthcare workplaces are noisy, lack employee lounges or respite areas and hinder patient care activities.  The physical environment of the healthcare workplace, along with other factors such as culture and work processes, also impacts the health and safety of the healthcare workforce. According to the Peter D. Hart Research Associates’ (2001) survey of registered nurses (RN), the primary reason why nurses leave healthcare other than for retirement reasons is to find a job that is less stressful and physically demanding.

Healthcare environments should improve outcomes if designed to minimize stress.  The exposure to physical features and increased social situations that have stress-reducing influences can lead to improved outcomes for staff (Marberry, 2005; Ulrich, 1991).  According to the Whole Building Design Guide and the Academy of Neuroscience for Architecture there is recognized potential benefits for staff and caregivers in terms of satisfaction, effectiveness, and staff retention, from environmental factors such as: providing 'off-stage' areas for respite, proximity to other staff members, and appropriate lighting and the use of technology. The Pebble project, Banner Health in Phoenix, Arizona provided respite areas for staff to reduce caregiver stress. 

The staff lounges are large and feature windows with views to nature. The Children’s Hospital of Denver, Colorado (currently under construction) went a step above just providing respite/lounge areas for staff.  The hospital plans to implement a concierge service for all staff to utilize to take care of everyday needs such as arranging car repairs, picking up dry cleaning, and sending flowers to loved ones.  Staff amenities also include being able to order take out from nutritional food services, take a shower after working out on the hospital campus, and securely lock bicycles inside the facility all in which promote a healthier lifestyle.

E-mail inquiries: vision2010@sarmc.org

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