Role of the Physical Environment in the Hospital of the 21st Century

By Roger Ulrich, Craig Zimring, Xiaobo Quan, Anjali Joseph, and Ruchi Choudhary

Published by The Center for Health Design, 2004.

INTRODUCTION

A visit to a U.S. hospital is dangerous and stressful for patients, families and staff members. Medical errors and hospital-acquired infections are among the leading causes of death in the United States, each killing more Americans than AIDS, breast cancer, or automobile accidents (Institute of Medicine, 2000; 2001). According to the Institute of Medicine in its landmark Quality Chasm report: “The frustration levels of both patients and clinicians have probably never been higher. Yet the problems remain. Health care today harms too frequently and routinely fails to deliver its potential benefits” (IOM, 2001). Problems with U.S. health care not only influence patients; they impact staff. Registered nurses have a turnover rate averaging 20 percent (Joint Commission on Accreditation of Healthcare Organizations, 2002).

At the same time, the United States is facing one of the largest hospital building booms in US history. As a result of a confluence of the need to replace aging 1970s hospitals, population shifts in the United States, the graying of the baby boom generation, and the introduction of new technologies, the United States will spend more than $16 billion for hospital construction in 2004, and this will rise to more than $20 billion per year by the end of the decade (Babwin, 2002). These hospitals will remain in place for decades.

This once-in-lifetime construction program provides an opportunity to rethink hospital design, and especially to consider how improved hospital design can help reduce staff stress and fatigue and increase effectiveness in delivering care, improve patient safety, reduce patient and family stress and improve outcomes and improve overall healthcare quality.

Just as medicine has increasingly moved toward “evidence-based medicine,” where clinical choices are informed by research, healthcare design is increasingly guided by rigorous research linking the physical environment of hospitals to patients and staff outcomes and is moving toward “evidence-based design” (Hamilton, 2003). This report assesses the state of the science that links characteristics of the physical setting to patient and staff outcomes:

• What can research tell us about “good” and “bad” hospital design?
• Is there compelling scientifically credible evidence that design genuinely impacts staff and clinical outcomes?
• Can improved design make hospitals less risky and stressful for patients, their families, and for staff?

In this project, research teams from Texas A&M University and Georgia Tech combed through several thousand scientific articles and identified more than 600 studies—most in top peer-reviewed journals—that establish how hospital design can impact clinical outcomes. The team found scientific studies that document the impact of a range of design characteristics, such as single-rooms versus multi-bed rooms, reduced noise, improved lighting, better ventilation, better ergonomic designs, supportive workplaces and improved layout that can help reduce errors, reduce stress, improve sleep, reduce pain and drugs, and improve other outcomes. The team discovered that, not only is there a very large body of evidence to guide hospital design, but a very strong one. A growing scientific literature is confirming that the conventional ways that hospitals are designed contributes to stress and danger, or more positively, that this level of risk and stress is unnecessary: improved physical settings can be an important tool in making hospitals safer, more healing, and better places to work.

Research Process

The research teams searched through scores of databases and in libraries at Texas A&M, Georgia Institute of Technology, University of Michigan, and elsewhere. The team was looking for studies that are:

• Rigorous, in that they use appropriate research methods that allow reasonable comparisons, and discarding of alternative hypotheses. The research studies were assessed on their rigor, quality of research design, sample sizes, and degree of control.
• High impact, in that the outcomes they explore are of importance to healthcare decision-makers, patients, clinicians, and society.

In 1998, Haya Rubin and her colleagues Amanda Owens and Greta Golden found 84 studies produced since 1968 that met similar criteria (Rubin, Owens, & Golden, 1998). Reviewing the research literature six years later, the team estimated that they would find around 125 rigorous studies. We found more than 600.

Results

The research team found rigorous studies that link the physical environment to patient and staff outcomes in four areas:

1. Reduce staff stress and fatigue and increase effectiveness in delivering care
2. Improve patient safety
3. Reduce stress and improve outcomes

4. Improve overall healthcare quality