Hospitals are supposed to be places where healing happens, but in some ways they are dangerous environments and physical design can play a large role in making them safer. Since the Institute of Medicine drew attention to the dangers of hospitals and called for a more evidence-based approach to medical care in its landmark reports, “To Err is Human: Building a Safer Health System” and “Crossing the Quality Chasm: A New Health System for the 21st Century,” architects have changed the way they think about healthcare settings and are using design to improve patient safety and quality.
Evidence-based design emerges
Thinking about the relationship between healthcare design and the quality of care that patients receive is nothing new. Healthcare design was a main focus in Florence Nightingale’s Notes on Nursing, first published in 1959. which features chapters on lighting, ventilation, and bedding.
Nightingale’s observations would influence healthcare design for decades to come. They would lead to the development of Nightingale Wards in the United Kingdom and informed pavilion plans that emphasized natural lighting, ventilation, and surveillance. Her contributions affected healthcare design standards well into the 1900s.
Advancements in medical sciences, like the introduction of new surgical antibiotics and sterile procedures, and building technologies, like the development of elevators and structural steel frames, led to the construction of the first skyscraper hospitals in the middle of the 20th century, according to Craig Zimring and Jennifer DuBose. The hospitals were often designed to maximize the efficiency of staff, but didn’t necessarily consider how design would affect patients.
“Such designs have struggled to balance the need to house an ever-increasing variety of treatment and diagnostic equipment and spaces with the imperative for efficiency, especially nurses” they wrote in Making Healthy Places, a book published in 2011. “The emphasis on efficient use of nurse time sometimes appeared to regard patients as inert units of production, whose agency and participation in their own care were inconsequential.”
By the early 2000s, momentum was building in the field of evidence-based design, which the Center for Health Design defines as “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.” Outcomes considered by evidence-based design proponents include health, cost, energy efficiency, and aesthetics.
A growing body of evidence published throughout the 2000s linked healthcare design to quality and patient safety. This led to the development of new standards for hospital construction. The American Institute of Architects issued new healthcare building guidelines in 2006 and these were adopted as law in more than 35 states. These guidelines mandate, for instance, single rooms in acute care hospitals to reduce risk for infection, reduce unnecessary exposure to noise, and to promote private communication among patients and their providers.
As evidence-based design gained traction, it was accompanied by increased spending on healthcare construction. Around $25 billion was spent on healthcare construction in 2000 compared with more than $45 billion in 2008, according to consulting firm FMI’s 2016 construction outlook report. Spending on healthcare construction has dipped slightly since then, but is expected to grow in 2020 to more than $50 billion.
How does design affect safety, quality, and cost?
As evidence-based design research has expanded, researchers have revealed that a variety of design elements can affect many different outcomes. For instance, hospital construction that features simple views of nature can help to reduce patient pain, stress, lengths of stay, and increases patient satisfaction, according to a 2008 literature review published in the Health Environments Research and Design Journal.
OhioHealth partnered with the Center for Health Design to incorporate evidence-based design processes in the construction of Dublin Methodist Hospital, a $150 million project completed in 2008. The final product featured interior courtyards to allow natural light to reach 90% of all spaces, designated visitor areas in patient rooms, and windows that partially opened to provide fresh air.
By at least one measure, evidence-based design worked for Dublin Methodist Hospital. Through its first 15 months of operation, there were only five healthcare-acquired infections, a 95% reduction from the national average, according to Zimring and Dubose. At Emory University Hospital, another Center for Health Design partner, evidence-based design helped to increase family involvement in care, improved patient and staff satisfaction, reduced death rates, and improved discharge rates.
For healthcare decision-makers, accepting one-time capital costs to implement evidence-based design features in new construction projects could be offset by reductions in ongoing operational costs. According to one analysis, published in 2011 by the Hasting Center, an initial one-time investment of $26 million in evidence-based design innovations would lead to annual savings of $10 million by reducing infections, eliminating unnecessary patient transfers, minimizing patient falls, and lowering drug costs.
Healthcare settings are unique physical environments and their design affects patients, visitors, staff, and communities as a whole. As healthcare leaders attempt to improve quality while reducing costs and confronting problems like high staff turnover, design can clearly play a part.