Evidence for Innovation, Transforming Children’s Health through the Physical Environment is the first comprehensive report to look at the effect of the physical environment on children in healthcare settings, according to NACHRI, who published the report in partnership with The Center for Health Design. Focused on the concept of evidence-based design, the report includes a literature review, design recommendations, a business case supporting the recommendations, and an implementation toolkit. Evidence for Innovation provides the basic elements that can lead to safer, less stressful, and more patient-centered healing environments in children’s hospitals.

Literature review
The report’s authors cite more than 200 articles and analyze 78 of these in detail. Although they call for more research in pediatric settings, the literature review found improved clinical, physiological, and psychological outcomes in the NICU, children’s settings, and adolescent settings related to noise control, interior design, nature, social and private space use, infection control, and staff’s working environment.

Loud and excessive noises in the NICU can affect the auditory development of this department’s fragile patients. Interventions include removing the source of the noise, scheduling quiet hours, educating staff and parents about the effects of noise, putting in sound-absorbing ceiling tiles and flooring, and providing single-family rooms (instead of open wards). The literature review also includes strategies that redesign the incubator itself: covering the incubator, installing a sound-absorbing panel in the incubator, and putting sound-absorbing foam next to the infant. One study found cost savings as a result of perfect and high success rates of conducting pediatric ECGs (electrocardiograms) and CT (computed tomography) scans without sedation. As in adult environments, pediatric settings that expose children to gardens can help reduce anxiety. Studies also show that interior design elements, such as color, furniture, and carpet, and ambient music promote healing and help cope with pain and aggression.

The review of available studies shows the importance of social and private spaces. Social spaces located in the nursing unit and in patient rooms let patients, parents, siblings, and friends interact and share emotions—an instrumental part of the healing process at any age. The provision of social space can be coupled with operational programs that focus on social contact and intellectual stimulation between patients and their peers. Play spaces for young children and game and music rooms for adolescents have been found to promote play behavior and interaction between patients with different physical abilities. It is important to distinguish between a young child’s social needs compared to that of an adolescent’s. Adolescents require a balance between privacy and intimacy and social interaction and an environment that takes one out of the traditional hospital feel.

Infection control design guidelines can be applied as in adult settings. A design and operational emphasis on hand-washing support, which can also aid in the washing of bacteria-harboring materials such as toys, and single-patient rooms are effective in reducing the spread of nosocomial infection among pediatric patients. According to Evidence for Innovation’s literature study, environmental factors may contribute to falls in the children, although no studies have examined this in detail. Hazards such as bedrails, wires, and equipment are likely to put children more at risk of choking, tripping, or burning than adults.

By compromising the staff’s working environment, the physical environment compromises patient safety. Loud noises and inadequate meeting spaces restrict communication and team work amongst staff. Physical environment studies conducted in adult settings show that chaotic environments, poor ergonomics, and low lighting levels compound staff stress and result in errors. These same studies are applicable to pediatric settings, according to the report. A children’s hospital’s built environment can improve the staff’s ability to care when designed with methods known to produce positive results in adult settings: calming interiors, nature as a point of respite, and design that reduces walking and makes equipment and supplies more available. Studies show that staff prefer and find their work less stressful in single-family rooms in the NICU and that renovations are associated with staff satisfaction.

Among the strategies based in research in pediatric settings are:

  • Single-family rooms in the NICU
  • Circadian lighting in the NICU
  • Incubator noise reduction in the NICU
  • Patient and family control over privacy
  • Positive distractions
  • Access to nature

Among the evidence-based design strategies applicable from adult setting research are:

  • Effective way-finding systems
  • Single-patient rooms
  • Hand-washing dispensers and sinks
  • Ceiling lifts
  • Noise-reduction plans
  • HEPA filtration

Among the promising high-impact strategies not fully substantiated by research are:

  • Acuity-adaptable single-patient rooms
  • Same-handed rooms that increase standardization
  • Consistent layouts that increase standardization

Design recommendations
As mentioned above, Evidence for Innovation mentions design recommendations, such design as daylighting, that logically crossover from adult setting studies to pediatrics. The report includes a matrix table of three classes of strategies: evidence-based design from pediatric settings, evidence-based design from adult settings, and “promising” high-impact strategies not yet substantiated by research. Each strategy is then indicated in terms of relevance to specific population (general/all, NICU, PICU/pediatric, adolescent, staff, and families), relative construction costs (low to high), and when to incorporate (new construction, renovation, existing).
The business case

Evidence for Innovation’s business case analysis enables pediatric leaders to understand the cost benefits of investing in evidence-based environmental design strategies in general and includes a suggested framework for return on investment. To explain what the report calls a “powerful business case,” it points to several forces, such as changes in reimbursement formulas and how patients make their healthcare choices. Requirements for public reporting of quality/safety outcomes and comparable patient satisfaction scores will increase the need for facilities built upon evidence that the design can enhance healing and safety.

The report predicts that within the Medicare program, patients, value-based purchasing, and pay-for-performance should influence the business case for quality improvement through design. Just as Evidence for Innovation was being released, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update Medicare payment rates for 2009. The rule builds on efforts to transform the program into a prudent purchaser of healthcare services, paying based on quality of care, not just quantity of services. In the past, the increase in Medicare’s payment for outpatient services has not been specifically tied to the quality of healthcare. The law now requires that the annual Outpatient Prospective Payment System (OPPS) payment inflation update be reduced by 2.0 percentage points for hospitals that do not meet quality reporting requirements. Beginning for discharges on or after October 1, 2008, CMS will no longer pay hospitals at a higher rate for treating certain conditions that have been determined to be reasonably preventable by following evidence-based guidelines, if they are acquired during an inpatient stay. Medicaid, the main volume payer of children’s hospitals, and commercial payers will follow in this direction, the report predicts.

Combined with an increase in public reporting and consumers’ ability to search rated providers, poor-performing hospitals—in part as a result of poor design—could risk loss in market share. A children’s hospital’s bottom line may even be more affected than adult facilities by consumer’s knowledge and experience in the healthcare environment, according to the report. Quality transparency and consumer satisfaction assessments are becoming more common and available. Overall, there is an increase in consumer information about healthcare. Designs that pay close attention to a facility’s safety and comfort should logically help to positively affect patients’ ratings.

Toolkit for Action
According to the report’s Toolkit for Action—originally published in the April 2008 issue of Health Environments Research and Design Journal—the key question for children’s hospital leaders is: How will the proposed project incorporate all relevant and proven evidence-based design innovations in order to optimize patient safety, quality, and satisfaction as well as workforce safety, satisfaction, productivity, and energy efficiency? The report adds evidence-based design to the traditional five questions pertaining to a major building project (urgency, appropriateness, cost, financial impact, and sources of funds). The toolkit asks healthcare decision makers whether the project is based in the available evidence to increase safety, quality, and satisfaction of all occupants and lays out 10 steps to implement evidence-based design, from creating multidisciplinary teams, to setting post-occupancy improvement targets, to finally making learned lessons available to the healthcare design community.

The full 144-page report can be purchased through the

NACHRI Web site publications store.


The National Association of Children's Hospitals and Related Institutions (NACHRI) is an international organization of children's hospitals with 218 members. NACHRI works to ensure all children’s access to healthcare and children's hospitals’ ability to provide services needed by children.

The Center for Health Design is a research and advocacy organization whose mission is to transform healthcare settings into healing environments that contribute to health and improve outcomes through the creative use of evidence-based design.