About this article

This feature is one of a series of quarterly articles published by Health Facilities Management magazine in partnership with the American Academy of Healthcare Interior Designers.

With the passage of the 2010 Patient Protection and Affordable Care Act, health care investments and outcomes are being scrutinized as never before. Using credible evidence based on sound research can provide a basis of design for all disciplines involved with a project, thus protecting a health care organization's investments for the long term. Utilizing this evidence can be of particular importance to interior designers as they make conscious decisions in their planning and product selections to achieve desired outcomes.

Interior designers ideally are involved in a project from the beginning to end. They can focus on the overarching vision to create a healing environment by planning evidence-based design (EBD) concepts into the space plans as well as placing major emphasis on the impact of surfaces, materials and furniture as related to safety, infection prevention and sustainability goals.

Interior designers must be well-versed in many areas, including:

  • Understanding and communicating the ways in which EBD affects and supports all of the disciplines involved in a project. An interior designer can become the EBD champion for the team.
  • Having the ability to find and interpret research results, especially for issues that are crucial to the project's goals and objectives.
  • Staying current with research findings, trends and best practices.

While many health care organizations now request that projects are planned and designed on a foundation of EBD, there is confusion about what that actually means. Budgets are tight and with so much "EBD-washing," — even picture frames have been claimed to create an EBD environment — many health care organizations rely on interior designers to map out the best use of the research for their projects and inform them of any extra costs.

Military mandates

The Department of Defense's Military Health System (MHS) mandates in its Unified Facilities Criteria Document 4-510-01, "Design: Medical Military Facilities" that all health care facilities be built to "world-class" standards and embody the latest research and proven best practices found in EBD and sustainable design, thus enabling care to be delivered in a culture that supports the best of all possible outcomes for patients, their families and staff.

"World-class health care is achieved by going above and beyond compliance with professional accreditation and certification standards to bring the best of the art and science of medicine together in a focused effort to meet the physical, mental, social and spiritual needs of the patient," Kenneth W. Kizer, M.D., MPH, who led the original team tasked with defining it, wrote in the March/April 2010 issue of the American Journal of Medical Quality. The article "What is a World-Class Medical Facility?" was first published online Feb. 9, 2010.

Over the past several years, the goals, strategies and objectives of planning, designing, building and operating a world-class facility have been refined and must be tracked on every new MHS project.

This touches every discipline involved in designing a health care facility and is good news for interior designers who sometimes are tasked with tracking EBD attributes because it allows them to dive deeper into the research, interpret it for others, and coordinate and collaborate with nearly every discipline. During the process, knowledge is shared in a collaborative way, all team members learn more, and both the project and the patients reap the benefits.

Of the MHS's nine world-class principles based on EBD, sustainability and clinical operations research (www.facilities.health.mil/home/?page_id=1843), several offer opportunities for interior designers to gather and interpret research findings and to work with an interdisciplinary team consisting of medical planners, clinicians, equipment planners, architects, engineers, landscape architects, acousticians, ergonomists and even arborists.

Quality and safety

The Fort Belvoir (Va.) Community Hospital, which opened in October 2011, covers more than 1.2 million square feet, has 60 clinics, 120 inpatient beds and five buildings. It is the MHS's first example of a world-class facility that consciously incorporated many new EBD design features within what was then only five principles. For instance, the principle then known as "Improve health care quality and safety" offered many opportunities for incorporating innovative design solutions. They included:

Decreasing hospital-based infections. The location of the hand-washing sink in the patient room is crucial. The interior designer can be sure it is easily seen upon entering the room by drawing attention to it through its placement as well as through lighting, wall and flooring materials, making it a focal point of the room and increasing the likelihood that those who enter will immediately wash their hands, helping to curtail the spread of infection to patients and surfaces.

Also, interior designers typically are involved in the review of lighting plans. So, when they are coordinating with electrical and mechanical engineers regarding ducts and other infrastructure, they can ask about the additional use of HEPA filtration systems in more spaces than required by code. The addition of ultraviolet lights in ducting also can be queried.

Preventing falls and reducing staff fatigue. While there are many ways that falls can be reduced, specifying the right flooring is one of the major factors. In a paper recently published by the Center for Health Design called "Achieving EBD Goals through Flooring Selection & Design," the authors examined how floor covering can contribute to many performance goals, including reducing slips, trips and falls; reducing noise levels; reducing fatigue; improving indoor air quality; and improving satisfaction.

Because some type of flooring material is applied in every room of every hospital, it is essential that interior designers stay current on the latest products, trends, research and misconceptions. For the Fort Belvoir project, designers were able to get approval to use carpet tiles in patient unit corridors except in the behavioral health and labor and delivery areas, where sheet rubber flooring was preferred. The facilities and environmental services staffs have been trained and are committed to maintaining the carpet tiles. After a little more than a year of use, they concluded that the carpet makes the corridors quieter and feel more inviting. They also reported that it is not a problem to maintain.

Reducing medication errors. Medication safety zones are critical for minimizing distractions and interruptions (see sidebar on page 28). Interior designers should be involved in the planning and design of these areas, and should understand the implications of proper lighting levels, ergonomics and the importance of providing an environment where staff can concentrate in order to reduce medication errors.

Reducing noise. Even with the best intentions, decibel ratings are often higher than expected in hospitals, especially in patient rooms and exam rooms. Excessive noise can raise blood pressure, increase muscle tension and even suppress the immune system. The added stress and anxiety when patients are deprived of sleep can make the healing process even longer.

Designers can make these spaces quieter and protect the patient's privacy by understanding the sound-transmission class and noise-reduction coefficient measurements related to ceiling and wall specifications. Interior designers also can consider networked sound-masking systems to introduce a soothing background sound that has been specifically designed to cover up conversations and noise. One of the lessons learned at Fort Belvoir is to specify door hardware that does not "clang" shut.

This is particularly important now that one of the 18 questions in the Hospital Consumer Assessment of Healthcare Providers and Systems survey asks, "During your hospital stay, how often was the area around your room quiet at night?" Choices are: never, sometimes, usually and always. These scores are nationally published for each hospital.

Patients and families

Another of the five principles of EBD used in the Fort Belvoir project, "provide a patient- and family-centered environment," also offered many opportunities to the design team. They included:

Decreasing stress through nature and art. One of the goals of the Fort Belvoir project was to integrate art into the architectural details, interior design and wayfinding plans. Using the principles of biophilic design and reviewing the research for art in health care, an array of huge murals, original three-dimensional art, photographs and fine art was coordinated for each building's unique theme. For example, at the intersection of the River and Eagle Pavilions, the lobby features original paintings of an eagle flying above the Potomac River. In the patient tower lobby in the Oaks Pavilion, large foil-like oak leaves gently sway in the two-story atrium.

A chapel near the main lobby opens onto a courtyard and is used for private counseling or meditation. The custom stained glass window is meant to be uplifting while providing a focal point for the chapel.

Increasing support and providing a positive environment. This also offered many opportunities for collaboration between design disciplines during the planning stages. Besides interior concourses with comfortable seating and views to the outdoors, there are six courtyards and gardens, each with seating and designed to be inviting and safe. Staff members and patients use both indoor and outdoor spaces frequently, especially at night in mild weather. They also say they did not have these features at other facilities where they have worked.

Other features

For another major military facility in the Midwest, the design team was able to incorporate many new features through the use of research findings in several categories.

Decreasing back pain and work injuries. Health care providers and patients are continually at risk of injury during the process of patient transport. Musculoskeletal injuries often occur to the provider, while the patient who falls may sustain broken bones or worse. A large body of evidence exists to support installing ceiling lifts above the bed in patient rooms and in many treatment areas to reduce injuries.

Interior designers play a big role in coordinating these lifts with other disciplines such as architecture, equipment planning and engineering. Coordinating is especially important when designing storage for the lifts, reviewing the location of lifts and planning cubicle curtain tracks in relation to lighting and ventilation.

Furniture and health care outcomes. Specifying the right furniture is crucial to any project and often makes up 2 to 4 percent of the budget. Interior designers can help the hospital's leadership understand the important role that furniture plays in reducing injuries, preventing infections and saving money when the right product is specified. A research paper on "Furniture Design Features and Healthcare Outcomes" provides information and a checklist to help teams evaluate furniture attributes throughout the life cycle of each project. It can be accessed via the search function of the Center for Health Design's website at www.healthdesign.org.

Eliminating toxins. Protecting the health and safety of all who use a building is a best practice. For this project, it was decided that several of the new buildings would strive for Silver designation under the U.S. Green Building Council's LEED for Healthcare program. Additionally, one of the objectives from the current world-class checklist is to "maximize environmental responsibility and sustainability."

Thus, the interior and sustainable design team targeted the MRc5 credit for furniture and medical furnishings. Data were gathered on more than 500 finishes and furniture products proposed in the project, analyzing chemicals used in each, including halogenated flame retardants, phthalates, formaldehyde, heavy metals, hexavalent chromium, perfluorinated chemicals or antimicrobials. The team also looked at the manufacturer's suggested green cleaning and maintenance.

Providing healing gardens and access to nature. In this same project, research was conducted on the therapeutic benefits of a labyrinth. As a result of the research, an eight-circuit labyrinth has been approved for installation adjacent to the outdoor physical therapy and occupational therapy areas. This can be used as a contemplative meditation walk for patients, visitors and staff as well as for physical therapy.

A partial ring of trees will provide shade for those using the labyrinth and benches are located close by for those who wish to rest. The area represents an opportunity to access nature.

Innovative solutions

While interior designers always have helped to create spaces for healing, the growing body of EBD research enables them to communicate in new ways with all disciplines by sharing knowledge and helping to interpret the research findings into innovative solutions.

Barbara A. Dellinger, AAHID, IIDA, EDAC, CID, is associate vice president and director of health care interiors at HDR Architecture Inc.'s Alexandria, Va., office. She can be reached at barbara.dellinger@hdrinc.com.


Sidebar - Mock-ups guide the design process

The new Parkland Hospital in Dallas will include nearly 2 million square feet of space. In a facility of this magnitude, it is important to get the room layout correct from the start, especially for room types that will be repeated dozens, if not hundreds, of times.

The interior planning team felt that mock-up rooms were an essential part of the design process. A plan was developed at the onset to evaluate 10 mock-up rooms.

The rooms were built out in five stages, each with progressively more detail. Simulations were used to gain feedback on the best way to address the facility's operational needs. A patient and family advisory team also was involved in the evaluations.

The following areas were evaluated through this process: emergency exam room, emergency trauma room, operating room, neonatal intensive care unit, labor and delivery, postpartum, intensive care unit, med-surg rooms, information technology room and trauma elevator.

The mock-ups were built and evaluated in the following phases:

  1. An outline of the room was taped on the floor with the casework and sinks made of cardboard. The purpose of the session was to test fit the size and shape of the room.
  2. The rooms were built with drywall; sinks and casework with plywood; and equipment and fixtures from cardboard.
  3. Changes to room sizes that were approved from the second session were made. Finishes were added and evaluated, including paint, flooring and ceilings. Equipment was brought in. Power and lighting were added, but not gas and water.
  4. After modifications were made based on comments from the third session, simulations were conducted for various scenarios and additional changes were made. Finishes were selected and evaluated based on performance and design.
  5. The rooms were constructed to incorporate approved comments made during the fourth session. A final review and evaluation is in process.

In addition to being a tremendous tool for assuring the team that key decisions were correct, the mock-up rooms became a strategic fundraising tool with prominent physicians even taking groups on tours. They will remain operational until the project opens in 2015.

By Dan Thomas, AIA, EDAC, associate vice president and senior health care designer at HDR Architecture Inc.'s Dallas office. He can be reached at dan.thomas@hdrinc.com.


Sidebar - Pharmacy lighting reduces errors

Decreasing medical errors is crucial, especially in pharmacies. Advancing decades of research, a 2009 study titled "Incidence, type and causes of dispensing errors: a review of the literature" in the International Journal of Pharmacy Practice found that inadequate illumination, interruptions and distractions increase the occurrence of errors in dispensing medications.

As defined by the U.S. Pharmacopeia (USP), a medication safety zone is "a critical area where medications are prescribed, orders are entered into a computer or on paper and where medications are prepared, dispensed and administered." The design team should consider all aspects of these zones, including adjacencies, furniture and lighting.

In the medication preparation area, parabolic troffers traditionally have been used. Instead, direct/indirect pendant fixtures are suggested to provide the recommended illumination levels of 900 to 1,500 lux (90 to 150 footcandles, adopted from the 2010 USP-National Formulary) in work areas where prescriptions are filled. While it is often difficult to achieve proper lighting levels on every storage shelf, it is feasible to achieve these values as an average within a comfortable range that cannot be perceived by the human eye.

In the medication procurement area, pharmacy staff interact with patients at the final safety zone. In addition to providing sufficient lighting for product selection and verification, there are privacy and acoustical concerns. Adequate lighting and a quiet environment for concentration reduce mistakes. A system that integrates lighting, security and architecture is needed, including:

  • Individual lighting with individual dimming control for each staff member.
  • High-output recessed direct/indirect linear fixtures that do not conflict with recessed security doors.
  • Furniture that creates a sense of privacy and minimizes visual distractions and interruptions during medication transcription, preparation, dispensing and administration activities.
  • Acoustical materials that can be applied to adjacent surfaces to reduce auditory distractions.

In the surrounding public area of a pharmacy, there are typically waiting and circulation areas, which have much different lighting needs and associated levels, such as direct sunlight through fenestration in daytime hours or dark evenings with lower light levels. When adjacent to a pharmacy, light levels should correlate so there is not a jarring visual contrast. Finishes should be considered carefully, both in terms of reflectance values and specularity because lighter, diffuse finishes promote visual comfort and higher efficiency.

By James S. Bates, P.E., LC, LEED AP BD+C, electrical engineer at HDR Architecture Inc.'s Alexandria, Va., office. He can be reached at james.bates@hdrinc.com.