Executive Summary of Key Concepts

Joyce Durham and Ann Kenyon

The purpose of this article is to explore and compare how different types of experiential simulation models or mock-ups are being used in the healthcare design process and suggest a methodology for the process. Historically, physical mock-ups were used in healthcare design primarily to test construction techniques, but newer forms of mock-ups have evolved to expand the user input provided in the decision-making process. These newer techniques, including rapid prototyping, early build-out, virtual reality, and enhancements to the traditional physical mock-up technique, focus on challenging the functionality of the space, testing new operational concepts, and increasing user input.

This article includes five case studies in which different types and combinations of mock-ups were used in the design process. For each mock-up type, the case studies describe the purpose of the technique, the advantages and disadvantages, the most appropriate phase for its use in the design process, the estimated cost, and the process logistics. Then, these findings were used to suggest a methodology framework for selecting and implementing mock-ups in the healthcare design process.

Anoop Mayampurath, Christopher Ward, John Fahrenbach, Cynthia LaFond, Michael Howell, and Matthew M. Churpek

Being admitted closer to the nurse’s station might be beneficial to a patient’s outcome. To explore this hypothesis, we conducted a retrospective cohort study of over 80,000 adult patient admissions to the general ward in an urban tertiary care center. Every ward had a centrally located nurse station. We found that there was no association between proximity to nurse’s station at the time of admission and risk of patient developing critical illness, dying, or experiencing increased length of stay (LOS). However, patients admitted away from the entrance of the ward had a higher risk of developing a critical illness event, in-hospital mortality, and had a higher LOS by 13 hr compared to patients admitted closer to the ward entrance, after adjusting for potential confounders. Our study results point to areas within care management and hospital operations that could be improved for better patient outcomes.

Avery Plough, Deb Polzin-Rosenberg, Grace Galvin, Amie Shao, Brendan Sullivan, Natalie Henrich, and Neel T. Shah

In this study, we developed a novel methodology for assessing quantitative and qualitative design metrics based on annotated floor plans and manager interviews and applied this methodology to study the design of childbirth facilities. Childbirth represents an ideal case to examine the role of design in healthcare because it is a discrete and well-defined episode of care. It is ideal as it also accommodates a wide range of patient needs, from healthy patients who only need support in natural labor to acute patients who need emergency cesarean delivery. We measured substantial variation in unit design among a set of 12 diverse facilities. For example, the number of annual deliveries per labor room ranged from 75 deliveries per room per year (less than one delivery every 4 days in each room) to 479 (more than one delivery per day in each room). Associations between design metrics and cesarean delivery rates suggest that these differences may be clinically impactful and that design may not be well aligned with service delivery needs. Our findings provide hypotheses for future investigation into the impact of design in childbirth facilities, and our methodology provides a basis for deeper exploration of evidence-based design in healthcare more generally.

Margaret Broom, Zsuzsoka Kecskes, Sue Kildea, and Anne Gardner

A tertiary neonatal intensive care unit (NICU) transitioned from an open plan to a dual occupancy (DO; two cots per room) NICU in 2012. The aim of the new design was to provide a developmentally appropriate, family-centered environment for neonates, and their families. A prospective longitudinal study was undertaken from 2011 to 2014, to explore the impact of the DO design on staff workflow and activity, comparing the distance walked, minutes of activity, and staff perceptions. Results highlighted no significant difference in the distances clinical nurses walked nor time spent providing direct clinical care. Staff perceived the DO design created an improved developmentally appropriate, family-centered environment that facilitated communication and collaboration between staff and families. Staff described the main challenges of the DO design as maintaining effective staff communication, gaining educational opportunities, and the isolation when compared to the OP design. Our study provides new evidence DO provides a developmentally appropriate environment and has similar benefits to SFR.

Juan López-Tarruella, Carmen Llinares Millán, Juan Serra Lluch, Susana Iñarra Abad, and Helle Wijk

Hospital design plays an important role in the experience of patients. In this regard, many studies have attempted to find relationships between design variables and healthcare facilities users’ response. Color has been frequently examined because it is always present in the environment and can be easily changed. Most of these studies acquire users’ affective response by assessment questionnaires developed by experts. This approach could lead to erroneous results since nonexperts may misunderstand concepts set by experts.

The present study aims to examine the impact of environmental color hue variation in a lactation room at a health center on users’ affective response and preference, following the basis of Kansei Engineering. In a first phase, users’ specific affective factors for lactation rooms were determined using semantic differential. In a second phase, the influence of nine different color hues on users’ affective factors was obtained. An immersive display system was used to visualize the room altering hues in an isolated and controlled way. Results show six user’s affective factors with respect to the lactation rooms: safety, elegance, cosiness, spaciousness, simplicity, and luminosity, of which cosiness has the most impact on the assessment of the space. Warm colors like orange and yellow tend to score well for cosiness which puts them in leading positions when users assess lactation rooms.

Mette Blicher Folmer, Architect, Karin Jangaard, and Henrik Buhl

The article is based on a project in a Danish hospital where two midwives have worked to set up an experimental, full-scale mock-up for a new delivery room. Their approach to the physical environment is important for behavior in the ward, and new ways of organizing and performing midwifery are emerging, as a consequence. We find that midwives use both the latest research in the field, but they are also guided by intuition. Based on interviews with the midwives about their work processes, a review of research on the maternity ward environment and Tim Brown’s readily available theory of innovation and design thinking—we find, inter alia, that it makes sense to let research and intuition go hand in hand and that you benefit from the involvement of participant orientations by including patients and relatives in the development process.

Deborah Wingler, Herninia Machry, Sara Bayramzadeh, Anjali Joseph, and David Allison

Healthcare facilities are complex buildings. To ensure the built environment can effectively support clinical end users' work processes, it is critical to facilitate effective communication between the architect/design team and clinical end users when designing healthcare facilities. Design communication media traditionally based on 2-D drawings (i.e., floor plans) are increasingly being complemented by 3-D representations of space through physical and virtual environments. However, it is unknown how these different media help clinical end users understand varying aspects of the design. This study compared floor plans, perspectives, and physical and virtual mock-ups in terms of their effectiveness in communicating critical spatial and functional information to clinical end users and in acquiring their design feedback. Results suggest the physical mock-up facilitated more holistic design comprehension, whereas the virtual mock-up presented challenges in sensation and force, conveying barriers to movement and spatial awareness. Although floor plans and perspectives were least effective, they served as complementary tools to, respectively, understand flow and design details. This study will assist architects and design educators when choosing different design communication media for engaging clinical end users during the design process and eliciting design suggestions at varying scales.

Lucio Naccarella, Michelle Raggatt, and Bernice Redley

Interprofessional communication is crucial to patient safety and effective collaborative practice in emergency departments (EDs). EDs are complex work environments where staff from multiple disciplines must frequently share patient information to coordinate timely patient care. Many interprofessional communication exchanges are informal, unplanned, spontaneous, or opportunistic; however, little is known about how the environmental design of ED spaces influences informal communication. ED staff reflected on balancing competing tensions in their workspace design, specifically related to (1) balancing feelings of personal safety with a design to enhance ED operations and patient outcomes, (2) balancing connectedness to patients with the need for privacy to communicate with other staff, and (3) balancing the functionality of available workspaces with the need to adapt these spaces for unexpected, unusual, or just-in-time communication. ED workspace designs need to provide visibility and connectedness, support communication about patients between staff, enable private communication between staff when needed, and optimize staff proximity without compromising safety. Innovative spaces are needed in EDs to facilitate informal exchanges that contribute to a safer and more effective workplace for ED teams.

Michelle Pearson, Kristi Gaines, Debajyoti Pati, Malinda Colwell, Leslie Motheral, and Nicole Gilinsky Adams

When pediatric patients are admitted to a hospital, most will experience fear or stress which may manifest itself in a number of negative physiological markers including increased heart rate and blood pressure. One way to alleviate patient stress is to provide a supportive environment that includes access to views of nature. In situations where a hospital window does not overlook a green space, enhanced window views may be incorporated to replicate the proven benefits of actual nature scenes. The purpose of this research is to explore the impact of nature themed window murals on the physiological processes of pediatric patients. Findings supported the idea that patient stress is heightened at the time of admission. The results of this study indicated that the installation of nature themed window murals were linked to improved physiological markers including heart rate and systolic blood pressure. Patients in tree mural rooms had the most improved health-related outcomes.

Rebecca McLaughlan, Ahmed Sadek, and Julie Willis

This article examines whether, in the context of a pediatric hospital, holding attention is a necessary component of positive distraction, as Ulrich’s (1991) definition implies. Data were collected from 246 children and young people at Melbourne’s Royal Children’s Hospital (Australia) that included 178 surveys, 43 drawings contributed by patients/siblings within the outpatient waiting room, 25 photoresponse interviews with patients, and 100 hr of spatial observations. A discrepancy between what children and young people told us they did, and valued, within the hospital, relative to the time they spent engaging in, or paying attention to, these same features motivated a closer interrogation of the relationship between well-being, distraction, and socialization within the pediatric context. These findings suggest that the mechanism by which we have understood positive distraction to contribute to well-being within the pediatric hospital environment is more complex than existing models accept. The capacity of a distraction to hold attention may not be as relevant as its potential for reframing expectations of a hospital visit. Environmental features that can ignite the imagination and incite a desire to return could offer significant benefits to well-being, particularly in the context of absenteeism from outpatient appointments and in reducing patient resistance to future, or ongoing, treatments.

Marietta M. Squire, Takeru Igusa, Sauleh Siddiqui, Gareth K. Sessel, and Edward N. Squire Jr

The intent of this article is to reveal how hospital design decisions can directly reduce the incidence of healthcare-associated infections, including drug-resistant “superbugs” such as Methicillin-resistant Staphylococcus aureus. Accordingly, this article will model two interventions, comprised of three alterations. One alteration, hand hygiene, is familiar and well described in the literature. The other two alterations, control of indoor air hydration (relative humidity) and use of negative pressure rooms, are less well described and their importance may be unrecognized or underestimated. This research provides a road map for the optimal allocation of dollars among these three preventative measures. Suggestions for best practices are provided in relation to facility size, type of pathogens, and available budget.