What does the perfect hospital look like? In today's evidence-driven field of health care design, an ideal space is much more than sunlit atriums and well-appointed patient rooms. It also has to function efficiently to provide a smooth workflow that promotes the well-being of both patients and clinicians.
Researchers from health care and design backgrounds have been increasingly focusing on how the layout and allocation of space in hospitals can influence these outcomes.
“We collected floor plans from across the country and found that there are some common design elements that have a big impact on care,” said Neel Shah, MD, lead author of a recent study by Ariadne Labs at Harvard T.H. Chan School of Public Health/Brigham and Women's Hospital and MASS Design Group. “However, design is often something that we as clinicians take for granted and don't consider how it impacts our work.”
As an assistant professor of obstetrics and gynecology at Harvard Medical School and director of the Delivery Decisions Initiative at Ariadne Labs, Dr. Shah has focused on issues such as how labor and delivery unit design affects rates of Caesarean sections.
Such findings about the importance of design extend to other areas of hospital practice, leading many different types of clinicians to become more involved in the issue. In a system that rewards efficiency and value but struggles with clinician burnout, hospitals are looking for more effective ways to use space without necessarily adding beds—such as creating areas for walking, visiting, and collaborating.
“Hospital designs are incorporating high-efficiency technologies so that buildings are more sustainable, as well as strategies that are linked to health and well-being,” said Liz York, an architect who is chief sustainability officer and associate director for quality and sustainability at the CDC. “Clinicians who are thinking about healthier work environments for their staff are contributing to a happier, healthier team who then provide better service to patients.”
Getting clinicians involved
Philadelphia-based Penn Medicine's Pavilion—a $1.5 billion project scheduled to open in 2021—provides a model of an inclusive design process. The design team has actively sought clinician input and is making significant changes in response, according to two staff nurses who serve on the team as clinical liaisons.
“Typically, users are brought in much later in the process, but we were involved from the start, in July 2015,” said Kate Newcomb-DeSanto, RN. “A big part of our role is to involve users at large, and the feedback we've gotten so far has totally changed the original concept.”
After creating an initial design, the architects rented a downtown warehouse and installed a full-scale model of an inpatient floor. Clinicians were then brought in for tours and participated in simulations of actual work processes.
“The designers carefully reviewed all feedback—recorded in conversations, videos, notes, and surveys—and returned to the drawing board to redesign the entire building,” said Ms. Newcomb-DeSanto.
Alterations involved shifting the locations of storage areas, equipment rooms, and elevators and changing the size of some rooms to promote more efficient and effective workflows, said Kathryn Gallagher, RN.
Other tweaks to the original design included reducing the average unit size from 36 to 24 beds, moving the bathroom from the headwall to the footwall in patient rooms to make it more accessible, and eliminating the atrium space to make more room for patient care and clinician workspaces.
“After all that, the team rebuilt the mockup and brought everyone back to re-do the simulations,” said Ms. Gallagher. “The staff has been very appreciative that the design team listened to their suggestions and made changes.”
Relatively simple design elements can have a big impact on the work environment but are often overlooked by nonclinicians, said Bon Ku, MD, assistant dean for health and design at Thomas Jefferson University in Philadelphia. Many of these can be implemented in existing hospitals without major renovations.
“I go into so many patient rooms where the computer terminal is facing away from the patient, making it impossible to conduct an interview and chart at the same time,” he said.
Similarly, ACP Member Diana Anderson, MD, an internist and board-certified health care architect, has often found herself in an exam room with the bed pushed up against the right wall, preventing her from examining patients from the right side, as is traditionally taught in medical school.
“It's an example of a disconnect between design intent and user experience that could have been avoided by collaboration,” said Dr. Anderson, who is currently a fellow in the Human Experience Lab at Perkins+Will, an interdisciplinary, research-based architecture and design firm. “Clinicians have not been involved in design to the extent they need to be.”
Building flexibility into hospital design can also be helpful, noted Dr. Shah. In the Ariadne Labs/MASS Design study, for example, facilities with a higher ratio of overflow beds to labor and delivery rooms were better able to accommodate unexpected surges in volume.
“The way rooms are used really matters,” he said. “Facilities that can be flexible with space are under less pressure to intensify treatment in order to move patients through faster.”
Designing a better work environment
The physical layout of a unit influences how staff members interact with each other, as well as patients, said Dr. Shah. For example, it's much easier for nurses and physicians to communicate and cooperate when patient rooms are grouped in clusters versus lined up along long hallways. In the case of the latter, clinicians in the Ariadne Labs/MASS Design study reported running between rooms, significantly adding to their workload.
The study also found that space allocation affects teamwork and collaboration. Having designated support or work areas accessible to and used by both physicians and nurses was associated with a more positive work environment, whereas dividing up staff areas or positioning them far away from work areas often stirred up negative feelings.
In one hospital, for example, a common lounge designated for nurses was rarely used because it was so far away from the nursing station. Nurses actually preferred to “perch on a trash can” in the nearby patient kitchen, according to the study. In another hospital, a lounge designated as “physicians only” created jealousy and resentment among the nursing staff.
“Reserving spaces for clinicians to communicate and collaborate says a lot about how a facility values their frontline staff,” said Dr. Shah. “In many hospitals, lounge space has been retrofitted for other uses over time or relegated to a windowless room in the core of the building.”
Somewhat ironically, hospitals tend to be behind the corporate world in providing spaces that promote staff well-being and satisfaction, said Dr. Ku. For example, many hospitals do not offer lactation rooms for nursing mothers to pump or breastfeed, or quiet rest areas for staff.
“There's often no place to go to decompress after a bad case because every square foot of the hospital is accounted for,” he said. “With burnout an epidemic, designers need to think more about creating places where clinicians can get away from the chaos.”
However, there has been a recent shift in the design world toward promoting clinician wellness, said Dr. Anderson. What was once known as the physicians' lounge is now sometimes referred to as a “reset room” where clinicians can go to relax or connect with colleagues.
With the growing emphasis on healthy, healing environments, hospitals of the future may actually harken back to the sanatorium model common in the early 20th century, augmented by modern technology and medical science, noted Dr. Anderson.
“Sanatoriums didn't offer any medicine—the building was the treatment,” she said. “Thinking about that model can help us demedicalize the architecture of our hospitals as we shift to focusing on not just the cure but the care.”