Executive Summary of Key Concepts

Jacqueline M. Burgette, Jacquelin Rankine, Alison J. Culyba, Kathleen M. Carley

Social network approaches afford opportunities to examine how both the structure and quality of relationships impact health outcomes; and this study puts forth best practices for health environment researchers considering using social network analysis methods to study the relationship between a social network exposure and a health outcome using egocentric network data.

Youngjun Park, Haekwon Chung, Sohyun Park

The COVID-19 pandemic accelerated another global pandemic, physical inactivity. Social-distancing and Stay-at-home campaigns, which were effective to prevent human-to-human transmission, resulted in reduced people’s physical activity. This study examined the change in regular walking during the first-cycle of the pandemic intervals. The situation of the pandemic in Korea has been developed through pre-outbreak, initiation, acceleration, and deceleration intervals for 15 weeks from January 2020. This study was based on weekly walking data, collected from users (N = 108,956) of the smartphone healthcare app, which was managed by 25 public health offices of the Seoul government. The result showed the changes in regular walking activities in response to the situations of the pandemic. According to the findings, the level of prevalence of regular walking had a significant difference in every interval of the four-stage COVID-19 phases. It dramatically decreased when the first confirmed case was reported and when the number of newly confirmed cases was at its peak. In the deceleration interval of COVID-19, the prevalence of regular walking kept increasing but it has not yet returned to the same level as the previous year, when the COVID-19 did not exist.

Yasuhiro Nakanishi, Kei Kasahara, Akira Koizumi, Junko Tokutani, Shingo Yoshihara, Keiichi Mikasa, Tomoaki Imamura

Hospital demolition work poses a high risk of Aspergillus dispersion. However, minimal attention is paid to infection control during hospital construction in Japan. This study aimed to verify the effectiveness of our infection control measures based on the ICRA to minimize the risk of Aspergillus dispersion before, during, and after demolition work in a university hospital. First, our facility management and infection prevention collaborative team held meetings to perform air sampling and culture outside the hospital building (balcony). We found a large number of fungi and bacteria, especially in the pre-demolition period. Therefore, we took measures, such as preventing patients from accessing the demolition site, keeping hospital windows closed, and installing prefilters. Despite these preventive measures, Aspergillus species were detected in the ward closest to the demolition site, although no cases of aspergillosis were reported. Statistical analysis regarding the relationship between Aspergillus dispersion, demolition work, and horizontal and vertical distances of air intake at the ward from the demolition area suggested that when large-scale demolition work occurs in hospital premises, Aspergillus spp. may increase in the ward where the air intake distance from the demolition site is close, even though infection control measures based on the ICRA are implemented.

Sumiyo Brennan, Therese Doan, Kirsty Bennett, Yumiko Hashimoto, Richard Fleming

This study describes the translation and validation process of an environmental assessment tool for small-scale group living facilities for older adults in Japan. Of the two main types of Japan’s welfare-based nursing homes, we focus on group care units (GCUs). Each GCU houses 9-12 persons over age 65, and 95% of GCU residents have some degree of dementia. We searched and selected the standardized Environmental Assessment Tool-Higher Care (EAT-HC) which originated from Australia. The EAT-HC assesses the environment of long-term care facilities for people with dementia in order to promote quality of life. EAT-HC was translated into Japanese using World Health Organization guidelines for translation of instruments. The validation process was conducted using evaluation by 12 Japanese experts in aging care and long-term care facilities and assessment of 30 GCUs by two researchers with specialty in gerontology and interior design. The results indicated that EAT-HC Japanese version is a valid and reliable tool to assess GCUs’ environment. The new tool will be modified in future study to adapt to Japanese cultural aspects. Likewise, this paper may open up conversation about the physical environment of the long-term care facilities for older adults in other countries with similar small-scale group living settings where EAT-HC is being used for environmental assessment.

Yue Wu, Lei Zhu, Tingting Yu, Shanshan Zhang

Due to geographical location and economic factors, development of township hospitals still has some key problems, such as inadequate construction, old facilities and backward technology, which are more prominent in the severely cold areas. According to the 2019 China Health Statistics Yearbook, there is a marked difference between urban and rural areas, with 6.24 hospital and health center beds per thousand people in urban areas, and only 2.80 in rural areas. There is a large gap between the level and quality of medical care in rural and urban areas, but studies were largely restricted to patients exclusively from rural areas of developed country. However, there is a large difference between the economic level in the severe cold areas of China and those in the mentioned literature research areas. Therefore, the research on township hospitals in different climate regions needs further discussion. Hence, this study established an evaluation system to find the existing problems in the architectural design of township hospitals in the severely cold areas of China. Furthermore, the establishment of a comprehensive evaluation system for building provides theoretical guidance and application references for the renovation of township hospitals in the severely cold areas.

Nirit Putievsky Pilosof and Yasha Jacob Grobman

The study examines the integration of an Evidence-based Design (EBD) approach in healthcare architecture education in the context of an academic design studio for a Maggie’s Centre, and evaluates the impact of the EBD approach on the design process and design outcomes. The research investigates the impact of the integration of three predesign tasks: (1) Literature review of healing architecture research, (2) Analysis and comparison of existing Maggie’s Centres, and (3) Analysis of the context of the design project in Israel. The results demonstrate that the literature review of scientific research supported the conceptual design and development of the projects; the analysis of existing Maggie’s centers, which demonstrated the interpretation of the evidence by different architects based on their vision and response to the context of their projects, developed the student’s ability to critically evaluate EBD in practice; and the study of the local context of the project led the students to evaluate the relevance of the evidence to support their vision for the project. The research demonstrates the advantages of practicing EBD at an early stage in healthcare architectural education and the potential of incorporating EBD in architectural education and practice to support creativity and innovative design.

Merlijn Smits, Yassin Eddahchouri, Pleun Meurs, Sharon M. Nijenhuis, Harry van Goor

Evidence-based design is often used to collect best available scientific studies on the effect of healthcare design on patient outcomes. Yet, given these studies’ potentially limited external validity, it has been argued that there are not enough studies to make general balanced evidence-based design decisions. In particular, original in-depth qualitative and quantitative studies of the effect of the healing environment on patients’ well-being are sparse -likely because it is challenging to properly and reliably conduct these studies. Ability to involve healthy volunteers in authentic care processes to gain an understanding of patient experiences of well-being would greatly expand our capacity to employ evidence-based decision making in healthcare design. This study aims to delineate if and how healthy volunteers can be used to better understand the experience of admitted patients. We admitted 17 volunteers to a 24-hours simulated care protocol and studied their experiences on six patient-related values: spatial comfort, privacy, autonomy, safety and security, sensory comfort, and social comfort. Results were compared to real patient outcomes from prior literature. This study has shown that volunteers can aid in understanding real patient experiences for the purposes of study design.

Neda Norouzi, and Cristina Michelle Garza

This study identifies an architectural design framework that focuses on the needs of children with ASD as well as the limited time a therapist may have to modify the room in between sessions. The framework is a result of intensive literature review and over 300 surveys responses focused on the specifics of an ideal therapy room and design considerations that would positively impact treatment outcome and therapists’ work routine. This architectural framework focused on functionality, layout, and organization of space and can be applied to create adaptable, transformative therapy rooms that benefit both children and therapists. It informs the designers and practitioners of the physical, emotional, and psychological impact of environmental sensory input on children with ASD. This framework encourages the decision makers to offer inclusive and flexible spaces that can be easily modified and is capable of accommodating floor time activities and sensory area with smooth transitioning from one activity to another, as well as a dedicated work area for the therapist.

Francesqca E. Jimenez, Renae K. Rich, Susan E. Puumala, Melinda Kentfield, Lori Schoenholtz, Jeri Brittin

Following the transition from centralized to decentralized nursing models at two rural community hospitals, the effects of the change on length of stay (LOS) and patient satisfaction were examined using adult inpatient medical records data and responses to standard patient surveys. Decentralized models have often been conjectured to improve patient outcomes by placing nurses closer to patients, however most previous studies have not measured a statistical effect. The analysis of outcomes over time make this study distinct and allows for a more nuanced understanding of the specific impact of the design change.

At one hospital, LOS decreased post move, but did not change at the other hospital. Patient satisfaction improved at both hospitals following the transition to the decentralized model, however several trends had begun before the move and could not be directly attributed to the design change. Significant improvement in patient satisfaction at one hospital with quiet at night and overall hospital rating corresponded to the move. The other hospital had decreased patient satisfaction with getting help as soon as wanted concurrent to the design change. Because of mixed results, patient outcomes may not have changed due to the transitions from centralized to decentralized nursing models.

Rutali Joshi, Anjali Joseph, Michelle Ossmann, Kevin Taaffe, Ronald Pirrallo, David Allison, Larissa Coldebella Perino

The enclosures of physicians’ workstation in the emergency department (ED) impacts outcomes like interruptions as well as collaboration during critical and cognitively demanding tasks like handoffs. This observational study conducted across 60 handoffs in open, semi-open and enclosed workstations demonstrated that the number of documented interruptions, especially for non-clinical purposes are significantly higher in the open workstation whereas the number of interruptions in the enclosed workstation are significantly lower. In line with the documented interruptions, a majority of the incoming and outgoing physicians in the open workstation perceived to be interrupted during the observed handoff. A majority of participants perceived high extents of collaboration with other physicians involved in the handoff as well as other clinicians present in the enclosed workstation. It is imperative that healthcare architects design emergency physicians’ workstations with enclosures such as to limit interruptions and maximize collaboration among clinical staff.

Marie Engwall, Göran Jutengren, Ingegerd Bergbom, Berit Lindahl, Isabell Fridh

Patients in intensive care units (ICUs) are among the most vulnerable, and they require support to start their recovery. The environment is one prominent factor for sleep deprivation that may linger well after patients are discharged from the ICU, potentially prohibiting recovery. Sleep deprivation is one potential risk factor for disturbed normal 24-hour day and night rhythm, and occur for most patients cared for in ICUs. Re-establishing this rhythm helps ICU patients to recover. Light at the right time, levels and quality has the opportunity to restore the day and night rhythm. An intervention was set up in a patient room that included a cycled lighting system. Self-reported recovery was reported at six and 12 months after discharge. The results showed that there were no interaction effects between gender or if the patients had been mechanically ventilated with patients’ recovery. Furthermore, the results indicated that patient recovery was better for those patients who had been cared for in a room with a cycled lighting intervention after 12 months. Patients’ recovery may have been supported by a cycled lighting system, with a natural day and night rhythm, color and location.

Morgan Andersson, Kaj Granath, Ola Nylander

This study focuses on the possibilities of aging-in-place. Semi-structured interviews were made with 30 households, with one or more resident 65 years or older. Floor plan analyses were made of the apartments, focusing on future care situations concerning bedroom capacity; spatial proximity between different functions; and functional autonomy in a care situation, with not too much disturbance for a partner.

Most participants display a pragmatic attitude towards aging and high satisfaction with their housing situations, even in increased-care-needs scenarios. The results from the floorplan analysis also support the findings from the interviews.

Together with the interviews, the three concepts bedroom capacity, spatial proximity, and functional autonomy, are used as predictive tools to determine the potential for aging-in-place. To further develop the analytical model, the sample must include more apartments of different sizes, from different decades and from other geographical areas.

We conclude that architectural qualities, such as size, spatial organization and communication structures are decisive for remaining and for an effective homecare, but that spatial organization and connection between functions in the apartment are more determining than mere size or number of rooms. The residents’ satisfaction relates to their perceived possibility to remain in their apartments.

Mohamed Elsadek, Yuhan Shao, Binyi Liu

The COVID-19 pandemic forced all of us, especially the elderly, to stay at home and do less in terms of interaction with nature. This may have a negative impact on their physical and mental health. Therefore, providing scientific evidence of the association between indirect contact with nature and the psychological health of elderly people is urgently needed. Results showed that indirect contact with nature enhances the physiological and psychological relaxation of elderly people. Bamboo imagery helps improve brain activity and create a comfortable environment compared to viewing urban imagery. Findings may be used to guide the new design, renewal, and modification of the living environments of seniors and other types of care facilities where people are not able to get outside.

Maja Vujcic Trkulja, Jelena Tomicevic-Dubljevic, Dusica Lecic Tosevski, Olivera Vukovic, Oliver Toskovic

Within urban settings and densely populated metropolitan areas, we are dealing with the daily stressors that affect all spheres of our environment and disturb the balance created by modern lifestyles (homeostasis). Using design as a mechanism that allows people to stay in touch with nature and namely to create a harmonious space deeply benefits the physical and mental restoration, especially for vulnerable populations in urban areas.

Alison Hutton, Rhonda Wilson, Maralyn Foureur

The findings of our research reveal that adolescents are able to identify solutions to enhance their hospital stay in the mental health context without being excessive and unrealistic in their suggestions. Further research needs to be conducted to determine whether facilities designed by consumers do somehow enhance the hospital stay of the adolescent patient, or any patient. Issues such as ownership, continual suggestions, input and feedback leading to better health services need to be analysed, as these are some areas that are worthwhile pursuing through further research. When designing an adolescent unit, there needs to be some consideration as to how the group using the unit understands space.

Alex Fauer, Nathan Wright, Megan Lafferty, Molly Harrod, Milisa Manojlovich, Christopher R. Friese

As demand for cancer services in ambulatory settings increases and treatments become more complex, these settings face unique challenges to deliver safe care. Following a mixed-methods study in eight practices, our findings suggest that the physical layouts of ambulatory oncology settings influence clinician communication, with downstream impacts on patient safety. Quantitative data highlighted the correlation between communication and safety behaviors. Qualitative data elucidated these relationships by underscoring the need for nurses to have high patient visibility during infusion treatments and close proximity to prescribing clinicians in the event of a problem. Visibility and proximity were balanced by important concerns to offer patients privacy when physically ill or during sensitive conversations. This multi-site, mixed-method approach fostered a unique breadth and depth of analysis needed to understand complex cancer care environments, especially in under studied ambulatory care settings. Our study findings inform future design considerations for new construction or renovation projects. Practice leads and designers should engage clinicians and patients throughout the design process, specifically exploring how design features facilitate patient visibility and clinician communication, which are key factors associated with safe patient care.

Ann Sloan Devlin, Alaina Anderson, Katie Carlson, Maggie DiPalo, Sarah Hession-Kunz, Amy Zou

There are numerous reports of the benefits of certain kinds of displays, such as art, in medical offices, yet patients’ subjective reactions to the display of medical information, particularly information that may display upsetting conditions through graphic images, is much less well understood. The current research attempted to address that gap in the literature by studying how the display of larger images in the form of posters and smaller images in the form of pamphlets, affected people looking at displays with different kinds of information (detecting skin cancer vs. selecting a sunscreen). Undergraduate students (who had considerable experience visiting exam rooms) rated the photographic images they saw of a simulated medical office setting. The students were assigned to different viewing conditions (posters vs. pamphlets; sunscreen images vs. skin cancer images). The results indicated that viewing images of how to detect skin cancer produced higher levels of anxiety and arousal than did viewing images of how to select sun screen, and when shown all four images (sunscreen poster, sunscreen pamphlet, skin cancer poster, skin cancer pamphlet), the sunscreen poster was recommended to improve the patient’s experience and lower stress. Exam rooms should offer multiple opportunities for distraction and visual engagement and provide health information without using images that produce anxiety.

Sahar Ahmadpour, Sara Bayramzadeh, Parsa Aghaei

Due to the annual increase of emergency department (ED) visits, efficient workflow remains a top priority in designing EDs. Overcrowding is known to hinder proper healthcare delivery, decrease satisfaction, and impede staff performance and teamwork. During the initial COVID-19 surge, ED visits dropped by 42%. This decrease had different reasons, such as concerns of being exposed to the virus or long wait time. It is essential to identify the design features and environmental interventions that enhance efficiency and teamwork, and reduce the spread of COVID-19 in EDs. An online survey with 14 open- and closed-ended questions was distributed among ED staff members to collect data on their perception of design strategies in the ED. According to findings, staff responses differed based on the ED sizes. The central nursing station was one of the preferred configurations that increase efficiency and teamwork in EDs. Decentralizing disposal rooms in small-size EDs and decentralizing the medication room in large-size EDs decrease staff walking steps. Considering trash can and PPE cabinets outside of each patient room, considering more negative pressure rooms and hand-washing stations through units, one-way track circulation paths were some of the staffs’ suggestions for future EDs to reduce spreading infectious diseases.

Tiziana Ferrante and Teresa Villani

Considering the topic of quality of spaces in Hospice facilities – residential centers for palliative care – implies evaluating their suitability to receive terminal patients by studying a set of attributes characterizing them in terms of context, building and individual spaces, by closely tying them to the ‘needs’ of users.

Indeed, in the case of Hospice facilities, architectural quality plays a ‘supportive’ role and can directly affect the conditions of extreme fragility of patients and relatives. Searching for architectural solutions able to provide environmental and psychological comfort, safety, and privacy, is essential with respect to the specific usage of such qualities.

This is the background of the present study, whose purpose was to verify, on a sample of Hospice facilities in Italy, ‘what’ and ‘to what extent’ is in fact perceived, in terms of quality of spaces, by those who actually use them.

In order to identify those ‘qualities’ that patients and relatives perceive as important elements, a POE was performed, which allowed to identify the indicators of perceived architectural quality on which design can be based. This contributed to providing an important framework by means of which translating desired quality into a different way of conceiving the use of spaces and planning a different configuration for them.

The study revealed the indicators of architectural quality most valued by users, whose reliability was then verified, along with their average quality, by highlighting recurring shortcomings. The global quality was found to be generally high. Below-average scores were found for indicators on usability, acoustic comfort of outdoor spaces, visual and acoustic comfort of shared indoor spaces and artificial lighting in the recovery room.

Ana M. Ullán and Manuel H. Belver

Visual arts, particularly painting, have historically played an important role in the design and atmosphere of healthcare spaces, especially hospitals. The objective of this work was to review scientific publications related to the use of visual arts in pediatric hospitals. 79 publications located in relevant databases and manual searches were identified and analyzed. Taken together the works we analyzed in our study support the use of visual arts in hospitals as a resource to enhance the well-being of children and families. To sum up, we indicate two particularly relevant aspects of the role of the visual arts in the well-being of children and families in hospitals. Both can significantly affect the patient’s experience in the hospital. These aspects refer to the importance of the visual arts in improving the symbolic quality of hospitalization settings and the communication processes that occur in these environments. Artistic resources can improve the symbolic quality of these environments and also the communication processes, as they can transmit positive meanings of support to the users.

Stephen Verderber, Seth Gray, Shivathmikha Suresh-Kumar, Damian Kercz, Christopher Parshuram

The Covid-19 global pandemic has drawn unprecedented attention to the hospital-based intensive care environment. The built environment of ICUs receive considerable evidence-based research attention, although little effort has been made to summarize and distill this knowledge base for direct application by architects, landscape architects, medical planners, and allied specialists. In response, a literature review is reported here of the period 2005-2020, inclusive of the coronavirus pandemic and its profound architectural ramifications. Five types of sources are classified: opinion pieces/essays, cross sectional empirical investigations, non-randomized comparative investigations, randomized studies, and policy review essays. These sources are presented in nine content categories: nature engagement and outdoor views, family accommodations, ICU spatial configuration and amenity, noise considerations, artificial and natural lighting, patient safety and infection control, portable critical care field hospitals and disaster mitigation facilities, including Covid-19, ecological sustainability, recent planning and design trends, and prognostications for the present and future. Among the findings, single-bed ICU rooms are increasingly the norm, family engagement in the ICU experience has increased, the therapeutic role of staff amenities, exposure to nature, the therapeutic amenity of views and natural daylight has increased, as has the importance of ecological sustainability, and pandemical planning and design concerns.

Bryan Spear, Angela C. Kinart, Brad Beauvais, Forest S. Kim

This article explains how Walter Reed National Military Medical Center (WRNMMC) synergistically executes complex, multi-facility construction renovations while maintaining a safe, quality environment of care for ongoing healthcare delivery. With more than 1 million beneficiaries served annually within 2.4 million square feet of clinical space, Walter Reed is poised to undertake a major military construction project estimated to cost more than $805 million. WRNMMC is scheduled to demolish and rebuild nearly one-third of the facility within its’ existing footprint, simultaneously together with other ongoing significant facility maintenance and small-renovation projects.

In anticipation of major construction and amid staff concerns of poor communication surrounding facility updates, WRNMMC set out to improve the overall clinical and operational coordination of projects and enhance the communication to all medical center staff and patients.

The Facilities and Clinical Coordination (FCC) process addresses this goal and consists of a prescriptive method for coordinating and communicating facility updates. The FCC Council, which oversees this process, is comprised of senior leadership alongside multi-disciplinary subject matter experts. This paper describes the methodology used to create the FCC process as well as provides a ‘how-to’ guide for implementation within similar healthcare organizations.

Michael Madson and Kelsie Goodwin

Emergency Departments often are busy, crowded places. It can be difficult for visitors and even medical staff to reach their destinations in a timely manner, negatively impacting the department’s efficiency and quality of care.

This was the case at an Emergency Department located in the Southeastern United States. On an internal survey, the vast majority of staff identified wayfinding as a serious problem. The department had physically expanded over the years, and the current layout has been appropriately called “a labyrinth.”

Teaming up, we launched an intervention that had two parts. The first part was installing colored routes (yellow, orange, and green) to key destinations. The second was issuing corresponding badges for visitors at the reception desk.

Since there is no gold standard for assessing wayfinding, we developed our own quality criteria, drawing on Donabedian’s work. Based on the quality criteria, we designed post-intervention surveys that were first piloted on the department’s shared governance committee. Afterwards, we sent them electronically to all staff.

In this case study, we report our methods in greater detail and share our findings.

Mirette Dubé, Jason Laberge, Elaine Sigalet, Jonas Shultz, Christine Vis, Chad G. Ball, Andrew Kirkpatrick, Susan Biesbroek

System-focused Simulation (SIS) and Debriefing (SFD) combined with Human Factors science is increasingly being used to ensure the safe evaluation of healthcare spaces and processes prior to implementation. The goal of these simulations is to proactively identify system issues and inform healthcare design decisions as part of a continuous cycle of quality improvement. The use of these combined methods has multiple benefits to organizations to support teams in making informed decisions that promote safety, improve efficiency and optimize care. Using a case study of an Interventional Trauma Operating Room, a project team evaluated key objectives with twenty-four stakeholder groups involved in an extensive SIS project to safely evaluate and open this new and unique space. Highlighted is the approach to evaluation, its transference to other settings, and the impact of the outcomes generated to inform safety decisions for a high-risk patient population. The aim of this paper is to outline salient evaluation objectives, types of data collection methods possible, and benefits of ensuring a human centered approach to healthcare clinical commissioning and operational decision making.