Executive Summary of Key Concepts

Lesa Lorusso, Jae Hwa Lee, Elisa A. Worden

The need for Design Thinking in healthcare steadily increases as the healthcare system and its care environments continue to grow in complexity. These complicated environments have been further challenged by the capacity surge and critical infection control requirements of the COVID-19 pandemic. Now, more than ever, Design Thinking and the innovative, human-centered solutions it enables are needed within healthcare design. All existing models of Design Thinking originate from the same basic framework and have been molded in different ways within various industries to meet a problem-solving need. Each Design Thinking model begins with identifying and understanding a problem or opportunity for improvement, followed by brainstorming to generate and test possible solutions to the problem. Design Thinking has adeptly morphed in successful applications within various fields of advertising, industrial design, environmental design, and medicine. It is a powerful systematic research method that can be applied within the realm of healthcare design to bridge the gap between medical team members and their design teams to improve the lives of the communities they serve. If Design Thinking is integrated into the healthcare architectural design, there may be more innovative solutions and deeper insights into today’s healthcare problems.

David Gordon, Jane Ward, Christopher J. Yao, Joyce Lee

When hospitals neared capacity due to an influx of patients with SARS-CoV-2, facilities expanded to alternative care field hospitals for additional care beds. Modeling anticipates that COVID-19 cases may once again increase, prompting field hospitals to be constructed once again. Developing additional capacity in alternative facilities, including hotels and convention centers, into field hospitals requires careful consideration of the existing space constraints, infrastructure, and modifications needed for patient care and infection control. The authors discus how hospital planners, administrators, and clinicians can consider evidence-based strategies implemented in biocontainment units and infection isolation rooms to decrease infection transmission risk in the alternative care facility. The authors identify how innovative air handling systems adapted from these environments can contribute to infection control in the field hospital.

Marco Gola, Monica Botta, Anna Lisa D’Aniello, Stefano Capolongo

This study explores benefits of 20/30 minutes in contact with nature for hospital staff during a stressful moment, as well as the COVID-19 pandemic. The survey was conducted during the lockdown by an Italian multidisciplinary working group, using the Profile of Mood States (POMS) methodology.

Starting from the comparison and the correlation with different items of the survey, the results highlighted the benefits that users have obtained from the experience in nature, in particular of Force. The data analysis took in consideration the type of stresses they were subjected to, and compared with the type of green in which the healthcare staff did the survey, the healthcare areas in which they worked during the pandemic emergency, and the moment in which the survey was conducted.

Jennifer Finkel, Bellamy Printz, Lisa M. Gallagher, Adrian Au, Kelly Shibuya, Francois Bethoux

This study was done to determine the effect of artwork in hospital corridors on patients undergoing and recovering from heart surgery. It also investigated the use of abstract art work as compared to landscapes. Three hospital units were curated with different art – Abstract, Landscape, or Mixed. Patients who are encouraged to walk in the halls as part of their recovery were invited to complete surveys and participate in interviews. A total of 45 patients participated, and results indicated that Landscape art had a higher positive impact on the participants. However, 82% of responses from each of the units were positive. Although Landscape was preferred, Abstract and Mixed art had positive responses, and perhaps more importantly, Abstract did not have a negative effect.

Nicola Grignoli

Humanization is a challenge for the future of healthcare. Architecture can play a major role in designing spaces which enhance communication and help the patient to maintain mental health during physical illness. Psychologists, however, struggle to find adequate space for taking care of their patients. Adequate relational space, defined here as potential, needs to be better defined. The author relates to his work as a health psychologist in a consultation-liaison psychiatry service operating in a general hospital in Lugano (Switzerland). An autoethnographic method is applied through calling on childhood memories on architecture and analyzing insights regarding healthcare space. Data show that interiors can be a metaphor for an inner dimension and spaces in hospital settings can be perceived as depersonalized. Proximity, confidentiality and privacy are healthcare design requirements to be considered for favoring potential space and health psychology intervention. Fostering potential space represents an outstanding challenge for the hospital of tomorrow in order to humanize healthcare spaces and promote a person-centered approach.

Jane Carthey

Participatory design is a form of collaborative creativity carried out with user groups who work with consultant teams to design healthcare facilities. The current user-centered design approach often regards users mainly as subjects, or information sources, whereas genuine participatory design values them as true partners in the process. “Users” are defined as the workers, patients, their families, and other community members, i.e., those who “use” a facility. Previous research explored the views of a broad range of Australian and New Zealand user group participants, including defining and achieving goals and objectives for their healthcare projects.

Semi-structured interviews were conducted with project clients, representing various organizations that procure public healthcare facilities. Questions were asked regarding influential stakeholders (potentially the “real” project clients), the history and rationale for mandating user groups, evaluation of user group processes, alternative design processes, successful project examples, and how to improve the user group process.

Findings suggest the need for:

better governance with clear Terms of Reference, to manage all stakeholders and the influence of the real project clients,

Marietta M. Squire, Gareth K. Sessel, Gary Lin, Edward N. Squire, Jr., Takeru Igusa

In this study it is shown that 11% of patients in ICUs and step-down units become colonized with an MDRO and 25% of colonized patients will progress to infection. Herein we consider the effectiveness of the following paired environmental interventions: hand-washing with negative pressure and hand-washing with controlled relative humidity. We estimate the cost-efficacy of each of these pairs of interventions, including the treatment cost of MDROs, as well as the costs of the interventions themselves. With the hand-washing – relative humidity intervention pair, we projected cost-savings as high as $1.5M per year for a large acute hospital. This was primarily due to a 69% reduction in MRSA infections. For additional perspective, we compared the incidence rates from the model, literature, and nine-affiliated hospitals. The model without interventions closely predicted rates for MRSA and VRE reported in the literature. The CRE incidence rates in the literature between affiliated and non-affiliated hospitals varied widely (0.0033% - 3.27%) and the model result was well within this range. We observed the incidence rates for MRSA, CRE, and VRE in the nine-affiliated hospitals were significantly lower than rates the rates in the literature, which are predominantly from non-affiliated hospitals (p<0.00001).

Jeanette Lindahl, Hans Thulesius, Mikael Rask, David Edvardsson, Carina Elmqvist

The physical care environment is an important part of a comprehensive caring approach for multiple users’ different needs of support, not only for patients but also for family members and staff. Much environmental information comes from light and color giving crucial perceptions of the complex physical care milieu. For the patient it means a temporary stay or an accommodation, for the family member a visit and for the staff a working place. An easily understood physical care environment promotes safety, independence and well-being for all users. Today’s healthcare increasingly focuses on person-centered care and we need instruments that are developed for and evaluates this. However, no existing self-report questionnaire assessing the extent to which light and color are perceived as being supportive in the physical care environment from the users’ perspective were found. Therefore, we developed and evaluated Light and Color Questionnaire - a self-report instrument measuring patients’, family members’ and staff’s perceived support from light and color in the physical environment. This knowledge may be useful for architects, administrators, and researchers of healthcare environments.

Yue Wu, Jingyi Mu, Shanshan Zhang

According to the 2019 China health statistics yearbook, at the end of 2019, China had 987 thousand medical institutions, out of which 675 thousand were located in rural areas, and 6.6 billion visits to nationwide medical institutions, but only 0.9 billion in rural medical institutions. Townships hospitals represent the highest hospital grade in rural areas; however, despite their expertise in treating common diseases varies little, people still choose to go to tertiary hospitals in urban areas. In particular, due to the sparse population distribution in these rural areas and the constraints posed by low socioeconomic levels and medical service levels in the cold regions of China, townships hospitals have been operating with low accommodation for a long time. Such a wide gap is unprecedented on an international scale. In choosing a hospital, patients are influenced by multiple factors. Studying these influential factors is necessary for gathering patients’ opinion on satisfaction. Hence, this research can provide reliable data and analytical results for formulating policies for health administration departments and the allocation of medical resources to reverse this undesirable trend and improve the medical environment. Furthermore, it can also provide suggestions for hospital managers to better support hospital development.

Shabboo Valipoor, Mohsen Hatami, Hesamedin Hakimjavadi, Elif Akçalı, Wendy A. Swan, Giuliano De Portu

Crowding in emergency departments (EDs) is a widely reported problem leading to increased service times and patients leaving without being seen. To address prolonged lengths of stay in a level-1 trauma center, we examined the impact of implementing two strategies with a focus on the physical environment. Using a modeling analysis software, ED historical data, and expert estimates, we simulated the flow of patients in the ED. We analyzed the likely impact of initiating care and boarding patients in the hallway (hallway care), instead of exam rooms, and adding a dedicated triage space for patients who arrive by emergency medical services (EMS triage) to decrease hallway congestion. The scenarios were compared in terms of length of stay (LOS), time spent in exam rooms and hallway spaces, service time, blocked time, and utilization rate. The combination of two simulated scenarios resulted in significant improvements in flow metrics. Our findings discourage boarding of admitted patients in ED exam rooms and encourage establishing a triage area dedicated to EMS patients. For boarding, priority should be given to alternative locations with similar level of privacy and clinical utilities as are available in inpatient rooms. Designers may also provide enabling hallway environments in the ED for boarding in case other strategies cannot be implemented.

Fredrika Sundberg, Isabell Fridh, Berit Lindahl, Ingemar Kåreholt

Intensive care units enroll critically ill patients, and therefore, constructed and organized to save lives. Consequently, the healthcare environment involves advanced technology, and the high-tech environment is rather unfamiliar for visitors. It may seem frightening at times when a loved one is experiencing a life-threatening condition and the individuals spends time in an intensive care unit as a visitor. Previous research has shown that family members to critically ill patients not infrequently experience anxiety, depression, and fatigue, which sometimes even leads to post-traumatic stress disorder. Therefore, as an intervention, a refurbishment was made to a two-bed patient room to enhance patient and visitor wellbeing according to the principles of evidence-based design. Visitors were asked to participate by completing questionnaires concerning the ward climate and the impression of the architectural environment. The data collection was performed in the refurbished intervention room and two patient rooms of regular design. The results showed that the visitors in the refurbished intervention room scored higher on the dimension of everydayness, and ward climate in general was significantly higher. This study also showed that the intervention room was perceived as more pleasant and less complex than the control rooms. These important results indicate that illbeing can be reduced through an improved healthcare environment; moreover, they illustrate the importance of the design of healthcare facilities.

Qichao Ban, Bing Chen, Jian Kang, Yiping Zhang, Jie Li, Jiawei Yao

This research investigates the user behavior patterns of noise sources in healthcare environments and summarizes such information as evidence that can inform the design of maternity wards for indoor noise control and patients’ well-being.

Some behaviors of users are identified as the major contributors of noises. A noise control that consists of smart bracelets, mobile terminals and monitors is designed, and its feasibility is tested in this research. Comparative studies are used to analyze patients’ sleep quality and satisfaction. Finally, the experts who are from the fields of healthcare environment design, medical treatments and hospital administration are invited to shed an insight into the findings of this research.

It is found that enclosed waiting areas are considered as the appropriate design strategy for maternity wards to prevent the excessive levels of noises. Moreover, the statistical information of user behaviors from patients can be used to moderate visitors’ behaviors. User behavior information should be included in building information management, which can be used to achieve a balance of medical efficiency and environmental satisfaction.

Lindsay J. McCunn, Sarah Safranek, Andrea Wilkerson, Robert G. Davis

Qualitative results are reported, compared, and interpreted against existing literature to understand more extensively how nurses conceptualize med-surg patient rooms as productive work settings in relation to lighting, as well as the ways in which they believe these spaces could be enhanced for patient satisfaction. Two of the three items asked nurses to report their perceptions of patient room lighting in relation to their professional duties, both positive and negative. The third asked for their perspectives on what may benefit patients with respect to the lighting environment in these rooms. Three of the facilities (i.e., Hospitals A, B, and C) had older, more traditional lighting systems installed, while one (i.e., Hospital D) had a more contemporary lighting framework. A general theme of environmental control over both overhead and task lighting in patient rooms emerged from words and phrases offered in response to all three items. Although controllability was reported as being among the ‘best’ lighting attributes in typical patient rooms, it was also something that nurses thought ought to be considered further by designers, facilities managers, and other decision-makers to refine these spaces for the productivity of staff, as well as for the satisfaction of patients.

Valerie Greer, Emily Johnson, Josephine Hsu

Architects and designers increasingly engage patients and practitioners in the process of designing patient rooms. Design hypotheses that speculate on how variables in the patient room environment will work, or what kinds of behaviors they will promote, often underlie why spaces are designed in particular ways. Significant to the advancement of patient room design is the need to document design hypotheses and collect data to empirically assess outcomes. An observational study was conducted to assess the design hypotheses around four key components of patient rooms: the headwall configuration, charting computer location, the storage unit for personal protective equipment (PPE), and the mobile supply cart. Researchers obtained permission to shadow clinicians into rooms of consenting patients in existing and newly designed patient rooms on an oncology unit, in order to collect data that measured use of these four variables. Data strongly supported design hypotheses related to the headwall configuration and mobile supply cart, partially supported the charting computer location hypothesis and did not support the PPE storage unit hypothesis.

Ethan Graves, Robert G. Davis, Jennifer DuBose, Gabrielle C. Campiglia, Andrea Wilkerson, Craig Zimring

Advances in the field of lighting research, design, and technology reveal new possibilities for the use of lighting in hospital rooms which can improve everyday experience and cause us to ask a new set of research questions about the effects of lighting on patients, guests, and staff. In this study, the team explores relevant aspects of lighting in patient rooms and how they are experienced and evaluated by nurses while performing simulated work tasks under 13 different lighting conditions. Perceptions of each of the lighting conditions were evaluated by nurses using rating scales for difficulty of task completion, comfort, intensity, appropriateness of the lighting color and naturalness of the lighting during the task. Our findings provide insight into lighting design to support circadian synchronization, lighting at night, the distribution of light in the patient room and use of multiple lighting zones, and the use of colored lighting in the patient room. Results uncover gaps in the existing evidence base that will inform future investigations and offer insight into the potential benefits as well as the concerns of these new features for patient room lighting systems.

Lisa Lim, Ruth Kanfer, Robert J. Stroebel, Craig M. Zimring

Recognizing the importance of teamwork, many primary care clinics are moving toward team-based care. Healthcare organizations are adopting various team-based clinic design characteristics, including clinic layouts that visually open up the staff work areas to patients and that entirely separate patients from staff work areas. Focusing on the representational role of physical spaces in conveying values to the visitors and inhabitants, this study investigated whether the visual exposure levels of team work areas would predict teamwork perceptions of patients and staff members by looking at four clinics that varied the visual exposure levels of these team spaces. The results showed that there are significant associations with visual exposure level of team work areas and teamwork perceptions by both staff and patients. Clinics providing more visual connections between staff workstations reported higher teamwork perception of staff members; however, surprisingly, more visual connections between patients and staff workstations were associated with lower teamwork perceptions from the patients’ perspective. The findings of this study illustrate the representational role of clinic space, especially team work areas, in relation to teamwork perceptions of the visitors and inhabitants.

Hui Cai, Intisar Ameen Tyne, Kent Spreckelmeyer, Jennifer Williams

Existing studies have identified the importance of the physical environment on improving hand-hygiene behavior and reducing nosocomial infections. However, limited evidence is available on how visibility and accessibility of hand sanitizer dispensers (HSD) impact hand-hygiene behaviors. Through a comparative study of two nursing units (Unit A and B) with similar patient acuity levels and care model but different layout and shape, this study empirically evaluated the impacts of nursing unit layout and the resulted visibility and accessibility of HSDs on healthcare workers’ hand hygiene behavior. The study applied space syntax analysis, onsite observation, and secondary data analysis on hand hygiene compliance report, and C.Diff rates. The results demonstrated that higher visibility and accessibility of HSDs can predict the higher frequency of hand hygiene behaviors. When compared to Unit B with the compact layout, the linear shape of Unit A and its bended corridor has resulted in lower visibility and accessibility of HSDs and is associated with lower hand-hygiene frequencies, even with higher HSD to bed ratio. Given similar patient profiles, staffing model and hand hygiene protocol, the results indicated that unit design and strategic placement of HSDs could have a bigger impact on hand-hygiene frequencies than the number of HSDs.

Joanna Sun and Richard Fleming

There is a lack of culturally appropriate, validated, and reliable environmental assessment tools for facilities providing high levels of care for people living with dementia in Singapore. This study outlines the development and testing of the Singapore Environmental Assessment Tool (SEA), a Singaporean version of the Australian Environmental Assessment Tool High-Care (EAT-HC). The study comprised of a multi-stage sequential mixed-methods approach. A total of 22 (stage one n =16, stage 2 n=6) participants tested the tool in the same eight nursing homes. The study assessed the usability of the tool, inter-rater reliability, and the validity of the tool. The System Usability Scale (SUS) and the Questions to Assess Barriers and Facilitators survey assessed the tool for usability. Qualitative data provided participants’ insight into cultural sensitivities. Psychometric properties of the tool, such as interrater reliability and internal consistencies were measured using Percentage agreement, Fleiss’ kappa and Cronbach’s alpha. Findings from the study indicate that the Singapore Environmental Assessment Tool is reliable and valid with an acceptable level of usability when utilised by individuals with knowledge of dementia enabling environments. For the tool to be used with confidence, evidence indicates that education and knowledge of dementia enabling environments should be a prerequisite for users of the SEAT.

Tiina Jouppila and Tarja Tiainen

In this paper, we study how nurses’ work-related knowledge can be transferred to the design process of a healthcare facility. This is one part of an action research study of a practical design process, single-patient rooms for a new general intensive care unit (ICU) were designed with co-design as a method. The virtual mock-ups of the new ICU were presented using walk-in virtual environment (VE). The nurses visited the walk-in VE and evaluated the virtual mock-ups in multi-occupational groups. The design was processed in three evaluation cycles, and the virtual mock-ups were redesigned after the groups’ feedback before the next evaluation cycle.

The nurses were able to evaluate and improve virtual mock-ups and contribute to the design of the new ICU despite involving themselves for the first time in design. The nurses were satisfied with the process and the opportunity to participate in the design in a VE. The visualization helps the nurses to understand the design and to express their work practices and practical requirements for spaces, furniture, equipment, and accessories. The nurses’ comments helped the designer to understand spatial requirements and to remodel the spaces to support the working processes of the nurses. Co-design with VE increases mutual understanding and respect in collaboration and democratizes s teamwork in design.

Linda Struckmeyer, Jane Morgan-Daniel, Sherry Ahrentzen, Carlyn Ellison

The home is increasingly becoming an environment for health care as the majority of people with disabilities desire to remain in their homes. This study sought to identify assessments that deliver a systematic approach to addressing the environmental needs of those with disabilities. Results identified 33 distinct assessments, including 18 assessments evaluating the accessibility of home modifications, three assessments examining usability, 15 assessments addressing activities of daily living or functional activities, and five assessments addressing comfort and/or satisfaction. No assessments for aesthetics were located. The bathroom and kitchen are key areas where persons with disabilities need accessibility to participate in activities of daily living to remain or return home. This study contributes to the understanding of available assessments or tools to evaluate the home as a health care environment for people with disabilities in terms of accessibility, usability, activities of daily living, comfort/satisfaction, and aesthetics.

Sai Saran, Mohan Gurjar, Afzal Azim, Indubala Maurya

There are many risk factors for hospital acquired infections especially in areas like intensive care unit, like patient related (old age, poor sensorium), procedure related (invasive lines) and infection control (hand hygiene) related. Apart from this there are lot of hidden risk factors which were highlighted in this article as “structural risk factors”, like the physical space surrounding the patient (congestion around the patient bed will lead to difficult surface disinfection), the construction and finishing materials used (furniture which has porosity retain moisture and microbes and furniture without smooth finish and with seams are difficult to clean and surfaces that are corrosive can harbour microbes), and the heating ventilation and air conditioning (HVAC) systems (recirculated air without adequate filtration can lead to spread of infections) surrounding the patient.

Through this article we highlighted these risk factors and proposed preventive measures with the help of illustrative figure and table with a particular focus on intensive care unit. We expect that these factors find an appropriate place in various infection prevention guidelines.

Angela Mazzi

Salutogenesis is a term that is used frequently in healthcare design. However, it is used ambiguously and design labeled salutogenic is not always backed by research showing what specific elements of the design are considered to be salutogenic or why. Because the built environment does impact well-being, it is beneficial to develop a good understanding of how stress effects people physiologically and cognitively and what environmental resources can aid in neutralizing stress. Additionally, developing a common language about what physical characteristics contribute to a salutogenic environment will help architects, designers and clients to make informed and deliberate decisions that will have a return on investment.

Roya Sabbagh Novin, Ellen Taylor, Tucker Hermans, Andrew Merryweather

The role of the environment is recognized as a factor that contributes to the risk of falls in hospital patient rooms, but there is not adequate empirical data to support evidence-based decision-making for stakeholders. We propose a computational model for fall risk evaluation of patient rooms. The proposed model consists of two major parts: (1) the room baseline evaluation, which considers room design and layout as static factors; and (2) motion evaluation, which includes dynamic factors based on expected patient movements within the room.

We focus on factors defined in the physical environment and believe that in conjunction with other fall risk assessment tools, we will gain greater knowledge of the risk of falls in a hospital patient room.

The comprehensive fall risk model and its application is a significant step in understanding and solving the problem of patient falls in hospitals. It can be used to provide guidance for healthcare decision makers to optimize effective environmental interventions to reduce risk of falls while promoting safe patient mobility in the hospital room environment. The model is structured to allow for integration with other competing demands in a patient room to achieve an optimal room design.