Evidence-based design isn't just for new construction. Whether a project is large or small, new construction or a renovation, the process of basing design decisions on credible research can lead to better healthcare outcomes. While a renovation may impose additional constraints, evidence-based design can still be applied. At the Doyle Women's Pavilion (currently named the Sarah Walker Women's Center) of Morton Plant Hospital in Clearwater, Florida, evidence-based design was an important element in the selection of the project's design firm, Gresham, Smith and Partners (GS&P).

According to Beth Moser, director of construction at Morton Plant Hospital, “Evidence-based design is similar to evidence-based medicine in terms of basing decisions on credible research. This method fits well in the healthcare environment, as caregivers understand the concept and are already focused on achieving the best outcomes. With the remodel of the women's obstetrics services, we felt it important that we determine what is working in other facilities to assist us in making decisions for our team members, patients, and visitors to provide the highest level of healthcare.”

Established in 1916, the 687-bed hospital has been serving women and infants since its inception. In 2005, Morton Plant Hospital received the UNICEF/World Health Organization designation as a Baby-Friendly Hospital. This program is designed to ensure that hospitals support breast-feeding by following 10 specific steps, such as initiating breast-feeding within a half hour of birth and practicing rooming in.

The Doyle Women's Pavilion is an 81,000-square-foot project involving the renovation of the existing Adler Building with a new entry addition to create an identifiable, convenient, and welcoming birthing center with all services located in one building. The project spans four floors and includes assessment, antepartum, labor and delivery, C-section suites, postpartum, and a neonatal intensive care unit (NICU). The facilities and amenities will support patient- and family-centered care and operational efficiency while creating a therapeutic environment for women and infants.

The design process included nurses from all areas of practice in the women's center. Some were veteran committee members and problem solvers, while others were involved in project development and committee work for the first time. Ages of members from the nursing team varied from late 20s to early 60s. In addition, major ancillary departments have been involved.

Defining evidence-based design goals

Team members worked their way through the Evidence-based Design Review Checklist tool developed by the Military Health System (included in EDAC Study Guide 1, “An Introduction to Evidence-Based Design”) to identify more than 20 evidence-based design goals, including increased social support, increased bedside time, decreased stress, and improved communication.

Collecting evidence

Evidence-based design literature was considered when making many of the design decisions, but additional data collection methods also were utilized during the project.

Nurse Shadowing

Three team members-GS&P's project architect, and director of research, and Morton Plant's director of construction-completed several hours of nurse shadowing to gain greater insight into the operations of the healthcare staff. Tamara Rice, project architect, says, “By shadowing staff and directly observing them in their work environment, our design is more informed. We have a better understanding of the current space challenges and how to re-design a workspace that supports staff in providing high-quality care.”

Site visits

Team members from GS&P and Morton Plant, including some physicians, toured four women's centers: Prentice Women's Hospital at Northwestern in Chicago; Carolinas Medical Center in Charlotte, North Carolina; Forsyth Medical Center (North Pavilion) in Winston-Salem, North Carolina; and the Aurora Women's Pavilion in West Allis, Wisconsin. These site visits afforded the opportunity to see design innovation in practice, as well as talk with clinicians about their processes. Prior to selecting the sites, benchmarking data were collected regarding the number of births, how many rooms were available for different services, and whether the NICU had single family rooms. Marcia Albanese, director of women's/children's services at Morton Plant, noted, “The best thing about the site visits was the interaction and brainstorming among the team members and physicians. We saw what worked and what didn't, and discussed how to apply those findings to our project.”

Predesign surveys (patients and staff)

Seventy-five staff members and physicians responded to a survey that asked about their vision for the new women's center. Additionally, participants rated specific attributes of their current work environment, such as lighting, acoustics, patient flow, distractions, and privacy. There are plans in place for a postoccupancy survey to be completed that compares responses to questions concerning those factors to see how well the renovated space is performing. Figure 1 is an example of responses to a question on noise.

Former patients were sent an online survey to inquire about their desires for the new women's center and to ascertain their perceptions of the existing center. They reported envisioning the new women's center as being calm, inviting, relaxing, peaceful, and private. Some of the changes they hope to see are larger rooms, a family waiting area on the same floor as labor and delivery, and more areas that are “friendly” for young children. Although some of the physical space attributes were not rated well (e.g., 75% disagreed or strongly disagreed that there was comfortable sleep space for a family member), patients gave high marks for their overall experience in the current women's center, with 92% reporting that their overall experience was either “good” or “extremely good” (Figure 2). As one patient wrote, “The nurses were very knowledgeable and helpful. They did a great job of caring for myself, my daughter, and my husband.”

Patient telephone survey

The hospital's quality and customer service approach is focused on listening to the customer, whether that is the patient or a team member who is closest to the patient. Hospital staff interviewed 70 postpartum patients and 30 parents of NICU babies, all of whom had delivered within the previous three months. The survey results helped steer decision-makers toward creating a single family room NICU model and a comfortable flow through the facility for patients' families. It also gave the team an opportunity to look at care practices to see how the facility might enhance some of its initiatives, such as rooming in, family-centered care in all stages of the birth, visitation policies, and breast-feeding.

Staff perception of noise in their work areas

Process mapping

GS&P utilizes a process-led design approach. The team mapped out key processes with staff prior to design. The goal is to optimize processes first, then design the physical space to support the more efficient processes. Figure 3 is an example of an existing process.

Interpreting evidence and creating design solutions

Data collected were translated into a design that will be elegant, efficient, soothing, and family-centered. The ground floor will house the existing laboratory, gift shop, multipurpose room, lactation consultation room, and other staff areas. A healing garden will provide access to nature, and the children's play area will be a safe, fun place for siblings. The first floor will house 26 postpartum rooms, a nursery, support spaces, and a conference room. The assessment center, antepartum, and an all-private, 15-bed NICU are located on the second floor. The third floor is for labor and delivery.

To improve social support, each patient room includes a family zone. Family waiting rooms with a variety of comfortable, movable furniture will overlook the garden on each floor.

To increase time at the bedside, workstations are provided in alcoves between every two patient rooms, in addition to the central work areas on each floor. Medication and supply rooms are conveniently located and duplicated on the first and third floors.

Patient perceptions of their overall experience

Current process map for NICU admission and discharge

For enhanced privacy, a curtain will be placed between the care space and family space in the private patient rooms, as well as by the doorway in the NICU and labor and delivery area. The single family NICU rooms are intended to provide private spaces to support breast-feeding and kangaroo (i.e., skin-to-skin) care. Acoustic privacy will be enhanced with high-performance, sound-absorbing ceiling tiles in key areas, which will also reduce unwanted noise and associated stress in the facility.

Given the known benefits of natural light, a conscious decision was made to put staff lounges on the perimeter of the facility, and to locate the family waiting areas so that they overlook the healing garden. Patient rooms will have large windows to maximize patient access to daylight.

To foster effective communication, flexible workspaces will accommodate a multitude of different staff tasks and accommodate interactive team work. These include the multipurpose room, conference rooms, dictation rooms, central workstations, and sub-work stations.

Cleanable, durable materials will be used to minimize contact infections. A new building entry and wayfinding cues will improve access to the facility and reduce spatial disorientation.

Involvement of academia

The Doyle Women's Pavilion is the focus of a studio project for an undergraduate course in advanced architectural interiors at the University of Florida (UF). The interior design program at UF fosters a strong relationship between design education, research, and professional practice. Students conducted a literature review, developed drivers and concepts, and produced proposed designs for the project. This project offered students a real-life design challenge to which they applied evidence-informed solutions. According to Professor Candy Carmel-Gilfilen, “Throughout the project, students worked closely with GS&P experts and project stakeholders to develop design solutions that integrate the hospital's mission and philosophy, the guiding principles, and cutting-edge research. The project also offered students the opportunity to rigorously examine evidenced-based design, a hallmark of the program, as well as explore creative approaches to problem solving. This type of experience is invaluable to students and often instrumental in their recognition of the power and potential of interior design.”

Future research

Given the evidence-based design goals identified, team members will develop one or more hypotheses to test. Baseline data will be collected prior to the demolition of the spaces to be included in the research. Postoccupancy data will be collected for comparison.

Shelia Bosch, PhD, LEED AP, EDAC, is Gresham, Smith and Partners' director of healthcare research. For more information, visit

www.gspnet.com. Healthcare Design 2010 November;10(11):108-114