Healthy Hospital Design

Healthy Hospital Design

The healthcare surrounding has substantial effects on patient health and safety and staff effectiveness and morale. Nayantara Som suggests that Evidence-based Design not only enhances the look of the hospital, it also makes better business sense.

In 2003, California-based not-for-profit organisation, The Centre for Health Design, conducted, reviewed and analysed around 600 major projects to show the direct link between the physical environment of the hospital and medical outcomes. Some of the revelatory results were:

  • Patient falls (accidental encounters for patients due to faulty hospital architectural designs), declined by 75 per cent in the Cardiac Critical Care Unit at Methodist Hospital in Indianapolis, which made better use of nursing staff, stationing them near patients’ rooms.

  • The rate of hospital acquired infections (HAI) decreased by 11 per cent in new patient pavilions due to the introduction of single patient rooms.

  • Medication errors by staff fell by 30 per cent in two patient rooms that allocated more space for their medication rooms, re-organised medical supplies and installed acoustical panels to decrease noise levels.

“One unique element of EBD is the scientific examination of documented lessons


– Henning Lensch
Architect, RRP Architecten, Munich

Welcome to a new era of Evidence-based Designing (EBD), where creativity coupled with long-term research is the new mantra for today’s health architect. EBD is a deliberate attempt at creating healthcare buildings using the best available evidence in order to improve patient safety, enhance staff productivity and get better financial outcomes. A better design also ups the image of the hospital. EBD can improve hospital environments in three key ways by:

  • Enhancing patient safety by reducing infection, risk, injuries from falls, and medical errors.

  • Eliminating environmental stressors, such as noise, that negatively affect outcomes and staff performance.

  • Reducing stress and promote healing by making hospitals more pleasant, comfortable, and supportive for patients and staff alike.

“EBD is an offshoot of evidence-based medicine, where clinical choices are guided by informed research and scientific data”

– Gaurav Chopra,

Leed AP Assoc

AIA, NBBJ, Seattle, USA

Says Henning Lensch, RRP Architecten, Munich, “An evidence-based designer, together with an informed client, makes decisions based on the best information available from research and project information from the past. Critical thinking is required to develop an appropriate solution.” This helps to convince clients to invest time and money to build better buildings and realise their strategic advantages as well. Lensch further reiterates: “One major element of EBD which distinguishes it from the normal research work is the scientific examination of documented lessons conducted.”

Experts draw a parallel between EBD and evidence- based medicine. Gaurav Chopra, Leed AP, Assoc, AIA, NBBJ, Seattle, US emphasises, “EBD is an offshoot of evidence-based medicine, where clinical choices are guided by informed research and scientific data.”

Some components of EBD

1) One Patient to a Room

Single patient rooms score over wards as they allow patient privacy and the much-needed emotional support from his family

Single patient rooms score over wards as they allow a patient privacy to get the much-needed emotional support from his family. Research has indicated better outcome for patients who are close to their family. “A multi-patient room can be a source of immense distraction for staff employees. A rise in medical errors by staff employees is observed. There is evidence that there are more patient transfers in multi-patient rooms, which leads to rise in medication errors,” explains Lensch.

However, the concept of single-patient room vs multi-patient room remains contentious because of cost. Joseph G Sprague of HKS, Texas, USA, opines, “The classic concern that single private rooms cost more than multi-bed rooms is offset by the fact that private rooms facilitate achievement of a higher overall occupancy rate.” But experts believe that although the up-front cost of private rooms is higher, significant savings will accrue from lower rates of infection, re-admission and transfers, as well as shorter hospital stays.

2) Sound-absorbing tiles and carpeting

The cacophony of paging systems, shrill alarms, machines sounds and the pandemonium from loud voices and television upsets patients and distracts staff. Typical noise levels in hospital range between 70 decibel to 100 decibel, whereas the optimum noise level should be only around 40 decibel. Additionally, environmental surfaces—floors, walls and ceilings usually are hard, non sound-absorbing and allow noise to travel long distances.

Studies have revealed that loud noises worsen patient outcomes like increasing blood pressure and sleeping disorders. “For hospitals that took steps to cut noise levels, patients were more satisfied with their care, slept better, had lower blood pressure and were not likely to be re-hospitalised,” Chopra says. Noise level can be greatly reduced by the use of sound absorbing tiles on ceilings and carpeting.

3) Adequate Ventilation

Rooms that are identical in design also significantly reduce staff error

Studies link infection to the environment of the hospital. Informs Debjyoti Pati, Director of Research, HKS, Texas, USA, “Infection is a major menace in the hospitals and leads to longer stay and also mortality. Such cases result in substantial cost to the hospital.” EBD enhances patient safety by improving the air quality. EBD has also shown that the use of HEPA filters in hospital ventilation systems reduces infection rates significantly. Appropriate location of air supply diffusers, location of air intake, laminar vis-à-vis non-laminar air flow in rooms and appropriate precautions of insulating ventilation systems from construction activities have a major impact on infection rates.

“Use of silver anti-microbial technology in hardware and sanitary fixtures are currently being investigated for their impact on infection rates. Reduction of joints in fixtures and finishing also contributes to enhanced patient safety,” informs Pati.

One World Hospital, a project of the Bangalore-based One World Hospital and Healing Centre Trust, seeks to alter the concept of the traditional Indian hospital. Coming up within the premises of St John’s Hospital, the 200-bed corporate hospital is established through collaboration between St John’s and One World.

Maureen Berlin, CEO, One World Hospital, was fascinated by the concept of EBD while she was at a conference at Hawaii. Says Dr Anita Arockiasamy, Hospital Administrator, One World, “Architecture has an effect on patient outcome and staff performance.”

Distinctive features which differentiate this upcoming hospital from other hospitals include:

  • Design that facilitates patient movement and operational efficiency.
  • Work areas with natural light and an outdoors view.
  • Windows and skylights to keep everything in sync with the principles of chronobiology.
  • Doors and windows that enable fresh air to circulate throughout the hospital.
  • HEPA filters to circulate air at night.
  • Noise reduction through reduced paging and sound-absorbing materials.
  • Different colours of light to improve healing.
  • Serene landscapes and water bodies.

4) Easy Navigation

Extra-wide hallways and well-thoughtout staff stations benefit both the staff and the patients

Patient falls is another avenue which is a major hindrance to patient safety and has the potential to become a great source of financial burden to hospitals.

Due to faulty design, both of hospital exteriors and interiors, an exponential increase in the number of patient falls in hospitals has been observed. Most patient falls occur around patient beds, toilets and during their trips to and from toilets. The never-ending long winding corridors and the long distance between patient rooms is also a cause for patient falls. “EBD suggests that people tend to move through corridors that are easily accessible from neighbouring spaces. This approach with fewer turns proves to be quite effective in way finding and enhances patient safety,” Chopra asserts.

5) Natural light

Lighting conditions and environmental irritants have negative impact on medical errors. Ensure adequte ventilation and natural lighting

Hospital conditions have also resulted in a drop in staff productivity. “Staff members often have to do their charting and fill medication orders in crowded, busy and makeshift areas which can increase medical errors and lead to staff burnout,” says Lensch. Medical error, however, is not just restricted to the nursing staff. It can occur in pharmacy as well as in patient units.

In the past, the impact of the physical environment on medication errors was the least-researched topic. But today it is observed that they emanate from innumerable sources. Lighting conditions and environmental irritants have negative impact on medical errors.

A major source of error is associated with mental and physical fatigue of pharmacists and the nursing staff due to large walking distances, stressful lighting and lack of stress release mechanisms for staff. A change in these avenues can lead to positive changes on the staff and the patient.

6) Room with a View

Having a room with a view and windows make hospitals seems more hospitable

Apart from calming patients, rooms that overlook gardens also improve patient outcomes and enhance the healing process of the patient. Roger Ulrich of Texas A&M University conducted a pioneering study in 1984 disclosing that surgery patients with a view of nature suffered fewer complications and used fewer medications to reduce pain. Higher levels of daylight exposure in patient rooms are effective in reducing depression and pain.

“We avoid site plans where some of the buildings block light and at the same time are cautious of planning building designs with a large proportion of windowless rooms because the evidence implies the lack of daylight exposure may worsen patient depression and pain and have adverse effects on staff in windowless spaces,” Chopra says.

7) Operating Rooms & ICUs

An identical design for all operating rooms can reduce errors as it takes away stress from the doctors allowing them to concenrate on the patient

Operating rooms are one area where not much study has been conducted to provide evidence supporting any specific design. This is due to the fact that in OTs and ICUs, patients and doctors are more focused on surgery and treatment they are implementing, that aesthetic interiors are not a priority.

Says Naresh Mathur, Vice President at HKS, Texas, US, “We believe it is important to establish an identical design for all operating rooms with doors, scrub stations, medical gases and equipment in the same location in an attempt to reduce errors.” Standardised or identical layouts reduce the possibility of errors and free caregivers to concentrate on patient care and not divert their attention looking for various medical devices.

However, surgeons are so used to operating within the facilities available to them, that there is no consensus among them for adopting facilities to reduce the number of medical errors.

Since patient privacy is an important issue for ICUs, having single rooms within ICUs is quickly becoming a norm in the West.

“Neonatal Intensive Care Units (NICU) have traditionally been designed as open spaces. There is ample evidence that active participation of parents in medical care and decision making fosters development of parent-child relationships,” says Mathur.

As a result, a majority of NICUs in the US are now being designed with single-patient rooms to allow families to spend time with the baby.

Renovating or building new hospitals is costly, particularly for hospitals that operate in competitive environments and generate low profit margins. To help address the issue of financial viability of evidence-based design, researchers at the Center for Health Design conducted quantitative modeling of a ‘fable hospital’, based on design elements incorporated into various Pebble Project Partner hospitals. They estimated that therapeutic design innovations, such as single-patient rooms and decentralised nursing stations, added almost $ 12 million in cost (about six per cent) to the hospital reconstruction. However, researchers also determined that the hospital would recoup these costs in as little as one year through operational savings and increased revenue.

The Indian Perspective

“Indian architects feel their creative skills are restricted if they have to consider aspects like patient outcome and


– Hussain Varawalla Director, Design Services

Hosmac, Mumbai

Unfortunately, despite its many advantages, EBD has not yet managed to capture the mindshare of decision makers in the Indian healthcare industry and some architects like Arshad Ankolkar, Senior Associate with Mumbai-based architect Hafeez Contractor feel it is because: “Indian hospitals work on a very tight budget, and would rather spend on medical equipment than on consulting past research and success stories.”

Indian architects engaged in designing mega healthcare projects have not caught on to this novel concept. At present, firms like Hosmac India Private Limited, Mumbai are involved in providing hospital management solutions and ambitious projects for groups like Fortis Healthcare, New Delhi, Sterling Hospital, Ahmedabad and even with UNICEF projects in Bihar. However, they have not yet considered EBD.

Avers Hussain Varawalla, Director, Design Services, Hosmac, Mumbai, “EBD has not yet made an impact in India as few architects in the country are interested in healthcare designs. Moreover, architects feel it is a constraint on their creative skills if they even have to consider aspects like patient outcome and performances.”

Unlike the hospitality sector, structuring of interiors is not a priority for healthcare institutions. “Maintaining the interiors is another issue. Old habits in India like spitting and littering within the hospital premises are some habits that persist,” says Ankolkar.

However, consultants like Monika Kejriwal, Medical Planner with UK-based Anshen/Dyer are positive: “It is only recently that in India healthcare has become an organised sector. Attitudes are changing and the patient is beginning to be perceived as a customer. I am sure EBD will gain importance.”