Designing a Healing Environment

Executive dialogue series

Evidence shows that a hospital’s environment can play a significant role in patient experience and outcomes. Healing design can improve a patient’s outlook on care and ultimately increase patient satisfaction. It can also streamline workflow and eliminate the opportunity for medical errors. To examine trends in healing design, Health Forum and the American Academy of Healthcare Interior Designers convened a group of industry vendors and their health care clients. The group met March 16 in Chicago for a closed-door dialogue.

The Health Facilities Management Executive Dialogue Series provides frank discussions of issues and ideas by health care executives and industry experts focused on challenges facing the industry. This series appears periodically and is also available online at www.hfmmagazine.com.

MODERATOR (Alden Solovy, Health Forum): What is the definition of healing design?

BARBARA HUELAT (American Academy of Healthcare Interior Designers): It’s designing for an environment that supports health and well-being. That was the mission of the Center for Health Design when it first originated about 17 years ago in California. But it’s not easy to define. Facilities have been struggling with the question.

I think organizations are gaining a greater understanding of healing design. It’s no longer a trend. It’s here to stay.

ED ANDERSON (Marshall Erdman & Associates): Healing implies that you are treating something. But in many respects, it’s about prevention. There’s a wellness component to preventing trips and falls and infections. So it involves design to facilitate healing and prevent adverse events. We’ll see more of a shift moving from healing and into prevention.

CHARLOTTE RAMSEY, R.N. (Methodist Healthcare South Hospital): My approach is always to create a patient experience. In design, if you’re not focusing first on patient care and the patient experience, you really have lost the vision of what it’s all about.

JIM NORRIS (Steris Corp.): I tend to use the phrase “evidence-based design for a healing environment” instead of healing design. It seems to get a little more receptivity. But I define it more as evidence-based medicine combined with health care environment research, and using that knowledge to create design and focus on the patient, family and staff. If we take this information that we’ve learned over the years and apply it, we can address all these issues in terms of staff, patient safety, improved outcome, length-of-stay reduction and so on.

ANDREW JARVIS (EwingCole): Creating experiences for patients in design is more than wrapping a pretty facade on a building or decorating the lobby. It’s the orchestration of every moment that a patient experiences, from the point of arrival to the hospital campus, parking the car, and coming into the building and finding where they need to go. We need to think that through. Every step.

STEVEN JOHNSON (Susquehanna Health System): We look at workflow design, how to make the best experience for our employees. Facilitating an outstanding experience for a patient starts with the employees. We have to have really outstanding service delivery capabilities for our employees first, and that will attract patients. Our first priority is doing the right thing for our employees. When we do that, they will be able to make an outstanding experience for patients.

ANNE KLAWITER (Southwest Health Center): We focused on the use of light and on privacy. We have a new facility. Our old building, which was built in the 1950s, didn’t have good lighting or provide privacy. We’ve been able to develop a lot of privacy for patients, for families. We have patient corridors and employee corridors. It’s been a positive experience for us. We have exceeded every single projection that we had in terms of growth. We’ve only been in the building a year. The census has been extremely high. We’ve been very fortunate, and the patient experiences have been a real plus for us.

ABE LOPMAN (Memorial Sloan-Kettering Cancer Center Regional Care Network): I look at this a bit differently. As a cancer treatment center, we bring patients into a very abnormal environment. No matter what we do, it’s abnormal. Our job is to try to create normalcy.

Lighting is a huge piece for us. We want to make sure that the patient experiences the normal cycle of the day. A patient may walk in for eight hours of chemotherapy. When they arrive, it may be light outside, and when they walk out, it may be dark. That is shocking for someone, so we use outside light as much as possible.

MODERATOR: Some of you are focusing on the patient experience, others on the workforce. Paulla, how do you start balancing these different definitions of evidence-based design when you listen to clients, or do you have a different definition to bring to the table?

PAULLA SHETTERLY (CDH Partners): To me, it’s all about addressing the five senses for each constituency group—the doctors and nurses, other employees, and the patients and families. We try to address the spiritual, emotional, loving and financial aspects. That’s our global view. Addressing the five senses and these four other aspects will result in a healing design.

MARY ANN WYMAN (Aramark): We provide the support service behind the scenes. How a facility is built and the finishes that are used helps us provide better service to everyone. We are the behind-the-scenes group that makes all of the things happen from a process standpoint, whether it’s through housekeeping or through management, plant operations and maintenance, or patient transport. So the way that a building is designed, either from a bricks-and-mortar standpoint or a cultural standpoint, we absorb that as we are trying to deliver our service.

We come from a totally different aspect of this, so it’s rather interesting. Design is really important to us from a space and timing perspective on how long it takes to transport patients and supplies. It impacts everything we do. Sometimes we are the last people to be thought of in exactly how the facility works. But we are actually the underpinning of how the organization gets things done every day.

MODERATOR: What are the core components of healing design?

NORRIS: Noise is a huge issue within hospitals. It can increase stress, disrupt sleep and impact human behavior. So, noise is a key component. Workflow is another, as is ergonomics.

JARVIS: Wayfinding is another key piece. It involves knowing where you are going and where you are in the facility. Views of nature are also extremely important, so is use of sunlight.

RAMSEY: When we designed new patient-care units, we looked at how many steps it took to get from one place to the other. We placed storage rooms on both ends of the hallway. We built alcoves into the walls for the linen carts and covered them with beautiful millwork. And we built decentralized nurses’ stations so nurses could be closer to the patients. It’s absolutely critical to look at the whole flow and the impact on the nursing staff.

SHETTERLY: We worked with one organization in which some of the postpartum rooms did not have exterior walls. They lacked access to natural light. We added a skylight and greenery to the rooms. So we created a sense of nature without access to exterior windows. I don’t have any evidence to support this, but certainly patients are pleased to have control over these things. Their experience changes instantly.

NORRIS: There is evidence to support that. In studies that have looked at single rooms versus multiple-patient rooms, control is a big factor in favor of single rooms. Patients want control over the room temperature, lighting, TV and the Internet. Control has a huge impact on patient satisfaction.

KLAWITER: When we designed our facility, we put the patient first. We created separate corridors to give patients privacy. We put the bulk of our dollars into the public areas. I have a smaller office in this facility, but that’s just fine. That’s the way it ought to be.

We really worked hard to eliminate as much noise as we could throughout the facility. We have all single rooms. The separate corridors help reduce the noise level even in the patient waiting areas.

ANDERSON: Evidence is that challenging thing for us. I’ve read about what a lot of other people have done, but how can I prove that what I’m going to do will have the same positive impact? Some people are supportive of the use of carpet, and others are not. There are different ideas on how to reduce sound. I really struggle with how to identify solid evidence and incorporate it, because there isn’t a lot that’s really quantifiable.

JOHNSON: Healing design touches on many things. It can reduce stress and distractions and increase concentration levels for employees. Now, a lot of those things will also make patients happy or comfortable or supported. That’s why we continue to design for our employees.

HUELAT: I’ve spent many years researching this and have written a book on healing environments. Healing environments are for all users of the health care facility: staff, clinicians, administrators, patients and families. You can’t separate them.

The core components of healing design—light, nature, noise, etc.—seem to fall into the context of the body, mind and spirit. Health care addresses each of these components. Design is such an important element because we perceive the environment first through our senses and then through our minds.

JARVIS: That’s why evidence-based design is so limited. There is no evidence-based design for medical equipment that creates a sense of foreboding with patients. Even the issue of daylight becomes complex. I can’t tell you how many construction managers and CFOs don’t believe that daylight makes a difference in the healing process. As a result, they don’t want to pay for it.

Evidence-based design can provide support for healing design features. However, it isn’t a panacea because it doesn’t deal with other aspects of the mind and spirit. That is where design comes in and where it gets a little gray, a little subjective. Opinions on shades of color and style may vary. Evidence-based design is anchored in clinical reality. When evidence is not available, we in the design professions and in health care need to push the boundaries and support what we intuitively know makes a difference for patients. And we have to be willing to back that up financially.

KLAWITER: Evidence-based design really helps with patient satisfaction. We use Press Ganey and our scores have significantly improved in our new facility. It’s got to do with the environment.

NORRIS: I agree that evidence-based design is limited. There isn’t a lot of evidence to support the high cost of the design. From a manufacturer’s perspective, it’s our job to convince administrators to do these things despite the cost. Evidence-based design can help us do that by showing how design can reduce length of stay, hospital-acquired infections and transfer times. It can help hospitals make good business decisions. But, at the end of the day, it still comes back to human experience. And unfortunately, there’s not a lot of direct evidence that shows how design can save money. The studies, however, at least get you down that pathway to make a good decision.

MODERATOR: Are you sure that it’s because of the environment and not because of changes in care? We’ve discussed how the workforce responds to the environment. Might the workforce be happier, friendlier, more focused on human touch?

KLAWITER: Well, the level of quality care we provide hasn’t changed, and the services we provide haven’t changed. But our staff is happy with the environment, so in that regard I’ll say, yes, because the staff’s emotions are projected onto the patient.

HUELAT: I worked with one organization that underwent a radically new cultural change in their environment. The CEO told the staff that many of them would likely leave because it wasn’t the culture they were used to. The changes in the environment would change the culture of the organization.

MODERATOR: Mary Ann, Aramark has a high number of employees working at more than a thousand hospitals. What do you hear about the structure of the organization and keeping it quieter, etc.?

WYMAN: We really strive to ensure that our processes do not disrupt the healing environment. We work in food service, facilities management and housekeeping, among other things. We look at a variety of things. For example, we have to consider whether our cleaning supplies smell nice and are environmentally sound. We have to maintain our equipment to reduce noise, and we seek to buy equipment that is quieter.

In our food-service world, we are trying to create areas we call “destinations,” places for staff and visitors where it’s quiet and relaxing. It’s the opposite of the large, noisy cafeteria. We are currently working with a large organization that’s asked us to look at all of their retail spaces and help build environments that are soothing for individuals.

We look at both sides of the equation. From the patient perspective, we look at how we can be quiet and timely with the work we do behind the scenes. We also look at the impact on the nursing staff and physicians to see how we can make their jobs easier.

SHETTERLY: We’ve incorporated water features in some of our facilities because they make a soothing sound. They are very calming. They have a spalike feel. We’ve even placed one on a building rooftop, creating a healing garden. It’s a great feature.

HUELAT: Sound and music are very important. With sound, organizations first need to mitigate the noise that comes from equipment and staff. The greatest producer of stress noise in the hospital is the monitor. In dealing with sound, we have to deal with noise as a whole. Manufacturers can help with this. They can help produce products that are more silent.

Music is also important. Patients respond positively to attractive sounds such as music and nature. Mozart is becoming very trendy. It’s being used with infants and new moms and people with dementia. It reduces stress.

JARVIS: We have to be mindful that what is pleasant to one person may not be pleasant to another. We are using headphones to allow patients to listen to the television or a CD player. That way, sound doesn’t disturb other patients.

HUELAT: We are seeing TVs being removed from waiting rooms, which is really a good thing.

WYMAN: As I mentioned earlier, we go to great lengths to look at the pieces of equipment we use. Some organizations sound like warehouses because of the equipment being pushed up and down the hallways. We work with our equipment providers to make sure we have all the right wheels so things don’t bang around. We no longer use a mop and bucket to clean floors. We use microfiber mops that are quiet and easier to handle.

Training also plays a role. We employ patient transporters, and we need to communicate with them as quietly as possible. We can do this through training and the technology we use.

MODERATOR: How critical is space for the family in healing design?

ANDERSON: Unfortunately, family spaces aren’t big revenue generators. Often, in the capital crunch, the family space is the first thing to go. Or in the case of Anne’s old hospital, they expanded services into those tight spaces. Everyone deserves being treated with dignity. Getting bad news in a crowded waiting room isn’t a way to serve dignity.

RAMSEY: Family spaces are absolutely critical. We worked closely with our architect to create family-friendly environments. The window seat converts to a bed. The patient rooms have a hotel feel about them. We created alcoves for families outside each patient room.

It also impacted the type of artwork we selected. It became clear that we needed art that was soothing and could relieve the boredom of being in a hospital room. And we understood that we needed to avoid the ambiguous type of artwork that is subject to interpretation and emotional state and focus on natural landscapes, among other things.

SHETTERLY: We’re using a lot of photography, particularly images imbedded in ceiling tiles, for people who have to lay in bed for hours and days on end. They can look up and see pictures of nature, and it eases the boredom.

NORRIS: Nature does seem to be a consistent theme. Studies have shown that abstract art in patient rooms can increase complications and medication use. We’ve actually done some things with LCD screens, allowing patients to bring in their own photos that we can project onto the walls.

LOPMAN: We have to be cognizant of the fact that the demographics of the people we are dealing with can be very different. Design will mean different things for a 30-year-old versus a 70-year-old. What I expect to see when I’m a patient and what my parents expect to see as patients is very different. We have to be careful about that.

One of the mistakes we made in health care in the 1980s was that we took national data and just assumed that it worked everywhere. One size doesn’t fit all. We have to work carefully to address our demographics.

We spend a substantial amount to build mock-ups before we begin construction. We do more mock-up than we do building. We bring in patients, families and staff to let them feel the space before we do anything. We include different age groups, etc. It’s important to get their responses.

JOHNSON: Part of the issue in designing rooms that work for different types of patients is literally having the weight capacity for all the different equipment that we have. That’s turned into an incredible issue recently. We try to use design to reduce transfers. We’re located in north central Pennsylvania. We have a major weight problem that’s developing in our area in the Pennsylvania Dutch people. Part of the issue of making sure that a room works for all different types of patients is literally having the weight capacity for all the different equipment that we have. That’s turned into an incredible issue recently.

ANDERSON: We hold visioning sessions. In each town that we go to, we invite the public and hold these sessions. We want to make sure that the hospital is the right hospital for that unique town. It’s not Marshall Erdman’s hospital. I’ll probably never go to Anne’s hospital as a patient, but I want to make sure that we’re doing the things that their community values.

LOPMAN: I spent 15 years in the Orlando area with a large health care system. We learned a lot from Disney. Disney’s concept of onstage and offstage is important. It takes more space to incorporate, but it’s worth it. We built a children’s hospital using that concept, which was very experimental at the time. It takes more design, obviously. It takes more square footage. The flooring—we used carpet and vinyl—helped staff know when they were onstage versus offstage. It let them know when they could hold conversations, etc. It worked very well.

MODERATOR: Let’s explore something a bit further that Abe said. How do you design for the different patient demographics? Does healing design mean something different in a rural setting versus an urban hospital? Or is it pretty much the same among the different hospital types?

LOPMAN: Some of the fundamental and basic issues are the same. But clearly the environment will reflect what you are trying to do.

I work in an ambulatory setting. The patients walk into the facility on their own. There aren’t any stretchers and there are rarely wheelchairs. So that environment is going to be different, and the way we build for that is different. The number of people who accompany patients in my environment is different than it would be in an inpatient environment. The basic features are the same, but the very environment does change by type of environment.

SHETTERLY: Women’s centers usually aren’t big money makers. But if you can make a women’s center look like a fabulous hotel, it will make the patient happy. Women tend to make health care decisions for their family, so it’s a draw to bring the rest of the family to the hospital.

KLAWITER: I live in a rural, agrarian community. But we also have a campus of the University of Wisconsin. These are two different populations to address. People in rural America have different expectations when they walk into a facility than people who live in urban areas. The rural population doesn’t want a flashy, expensive-looking facility. They want a facility that reflects the community’s economic outlook.

At the same time, the expectations of rural patients are similar to those of other patients. They want privacy. They want to be able to get around the facility easily. They don’t want a lot of noise. I have to be very cognizant of these things in the design. I did incorporate a water feature but needed to balance how far I could take things in terms of design.

ANDERSON: During one of our visioning sessions in a small town, someone raised their hand and asked, “Did you pass the Cadillac dealership on your way into town?” We looked at each other and then answered, “No.” The man responded, “That’s because we don’t have one. We’re a Buick town. We don’t want a Cadillac hospital.”

LOPMAN: That’s difficult, because the finished look can be very different from the cost. I can spend $1,000 a square foot to build a facility that looks like a GM plant. And I can spend $800 a square foot and look like the Ritz-Carlton. It’s not always the cost. It’s what you end up with in terms of the overall feel.

MODERATOR: How important is the first impression?

WYMAN: We conducted some research last year to determine the impact of the environment on the physicians, the nurses and other employees. If the environment isn’t clean, physicians, nurses and other employees feel they will not be able to provide good care. The same can be said of patients. If they walk into an unclean environment, they will feel they are receiving substandard care. The first step into a facility absolutely sets the stage for how people feel they’re going to be treated and the level of care they’re going to get.

RAMSEY: I ask all nurses what the patient’s first experience is with the hospital. They usually respond that it is registration. But it’s not. It’s the parking. It’s how far they had to walk to enter the facility. And then they notice the smell of the facility and what it looks like.

Our job is to get patients oriented quickly, to provide them with control so they know where they are going. Wayfinding is critical.

LOPMAN: I refer to this as “light bulb” management. I don’t know if you’re familiar with that term. I learned it from a mentor of mine. Our patients can’t judge how good we are in the operating room. But they can judge us on appearance. If they walk in and a light bulb is out, they may wonder whether we can provide them with the right chemotherapy if we can’t even keep a light bulb on. It sets the mental state for the rest of the experience. If there’s a lousy experience walking in, there’s hardly much that can be done after that to make things better.

KLAWITER: We went to great lengths to create a pleasant experience in the driveup to the facility, in the parking lot, and in the entrance. We have a greeter at the entrance who takes the patient where they need to go. At the end of the day, the patient is the one who decides whether to receive care at your facility. The type of relationship that you can build with that patient before any care is even delivered really matters.

RAMSEY: We have to think like patients. Wayfinding is more than just signage. It’s how the facility is laid out. We use different colors to help patients and family members know they are in a different area.

ANDERSON: There are certain elements in design that can help with branding. The Cleveland Clinic, for instance, uses a red granite curtain wall. There’s a children’s hospital in Washington that is shaped like Noah’s Ark. Once you get patients through the door, you want to keep them as patients. So consistency in design and using common elements in different facilities can help with that. There are many different strategies that hospitals can employ.

MODERATOR: Let’s jump to infection control and take a step closer to evidence-based design. What are the dynamics between healing design and infection control?

JARVIS: I have a great example of a debate between evidence-based design features and infection control, and that is putting a garden inside a hospital. On the one hand, we know that gardens and nature are very beneficial to patients. On the other hand, we have infection control officers saying they are too risky. But you can address their concerns. Soil can harbor bacteria. So if we can suppress the soil to reduce exposure, we may be able to convince them. These are the kinds of things that we negotiate to build evidence-based design.

RAMSEY: Water features, too, raise infection control concerns. But we can work through the issues. Fish tanks are more difficult. We’ve had to scrap plans for fish tanks over issues of who maintains the tanks and who cleans them.

KLAWITER: When we put in the waterfall, we had a big debate with the infection control nurse. I’m not real sure if she’s forgiven me.

HUELAT: We’re currently working with a very interesting project dealing specifically with infection control with ER One in Washington, D.C. The project is developing a prototype for the country in emergency room design dealing with mass casualties, terrorism and epidemics. We are looking at a lot of the products that will deal with infection control and the spread of contamination. We’re working with manufacturers that are providing hard evidence on product design and product information. We’re providing some of that information to other manufacturers to resolve some of the infection control issues. That’s where evidence-based design is very helpful.

ANDERSON: It’s interesting. All of my clients are talking about mass casualties and terrorist events. But when it comes to preventing infections, are they washing their hands before they go treat their patient? Is there a sink in the room? More people die each year in the U.S. from hospital-acquired infections than from terrorist attacks.

RAMSEY: The critical thing is to create an environment where it is intuitive for employees to do what they are supposed to do. They’ve been taught to do it. They know it’s important. We need to make it easy for them to do. That becomes a critical piece in design.

WYMAN: The placement of sinks and trash cans is important. Trash cans need to be covered and placed in a convenient location to prevent items from being dropped on the floor. Trash cans should also be placed near sinks. There has to be some thought in this. Right now, sinks and trash cans are being placed in strange places that are not conducive to handwashing and the disposal of trash.

NORRIS: If antiseptic washes are placed outside of patient rooms, the behavior of the nurses doesn’t change. If they are placed next to the bedside, nurses will use them.

MODERATOR: We talked about how design features might impact infection control, and we talked about employee behavior. In closing, I want to explore employee behavior a bit further. How can design impact patient safety and quality?

JOHNSON: Just to state the obvious, private rooms play a big role in safety and quality. They reduce infections and induce healing.

NORRIS: Good design can reduce staff stress and reduce medication and medical errors. I’ve also seen a report that showed how lighting can reduce medication errors in the pharmacy. The report found that brighter lights can improve outcomes and patient safety.

JARVIS: When we begin to design a building, we think about how we can maximize the time that the caregiver spends with the patient. We look at how design can improve eye contact and direct physical access. It’s a big geometric puzzle, especially in larger facilities. We have to design layouts that enable contact between the caregiver and patient. Poor layouts can contribute to poor quality of care.

NORRIS: The workforce is aging and caregivers are reaching retirement age. Design should address the aging of the workforce, and that in turn will reduce medical errors and improve patient care.

RAMSEY: Design can also help reduce risks. Placing the bed closer to the bathroom can help reduce falls. The placement of handrails can also reduce falls.

WYMAN: I’ve talked about equipment selection. We also give careful consideration to the types of cleaning supplies that we use. Are the chemicals safe for patients? Are they effective in reducing infections? We look at that piece of the environment, too.

Panelists

Ed Anderson Project Director Marshall Erdman & Associates Madison, Wis	Anne Klawiter President and CEO Southwest Health Center Platteville, Wis.	Paulla Shetterly Director Interior Design Studio CDH Partners Marietta, Ga
Barbara Huelat Member, Board of Regents American Academy of Healthcare Interior Designers Alexandria, Va.	Abe Lopman Executive Director Memorial Sloan-Kettering Cancer Center Regional Care Network New York	Mary Ann Wyman President Healthcare Facility Services and Clinical Technology Services Aramark Downers Grove, Ill.
Andrew Jarvis Healthcare Architecture Practice Leader EwingCole Philadelphia	Jim Norris Market Manager Critical Care Steris Corp. Mentor, Ohio	Moderator Alden Solovy Associate Publisher and Executive Editor Health Forum Chicago
Steven Johnson President and CEO Susquehanna Health System Williamsport, Pa.	Charlotte Ramsey, R.N. Assistant Administrator Methodist Healthcare South Hospital Memphis, Tenn.

Panelists

Sponsors

Health Facilities Management would like to thank the panelists for taking part in
“Designing a Healing Environment,” with special thanks to our sponsors:

Panelists

Sponsors

Health Facilities Management would like to thank the panelists for taking part in “Designing a Healing Environment,” with special thanks to our sponsors:

Health Facilities Management would like to thank the panelists for taking part in
“Designing a Healing Environment,” with special thanks to our sponsors: