One of the first steps in planning a healthcare facility is the steering committee's development of a set of guiding principles that will help the committee and its project team make the decisions required for the project to fulfill the institution's mission and business objectives. At that point, the members' minds are focused on the institution's ideals, and, almost inevitably, patient-centered care is the primary principle from which all others derive. As the project progresses, these principles are repeatedly tested as the steering committee must make decisions related to the budget-which features are to be included, and which ones are to be reduced or eliminated. When hard decisions need to be made, ironically, the features that are often cut first are those that enable the hospital to fulfill its guiding principles, especially patient-centered care.
There is evidence that patient-centered design improves the hospital's scores on patient and family satisfaction surveys. In turn, these can be used in marketing communication efforts and competitiveness. When healthcare consumers are choosing a hospital, they are more likely to select a hospital that makes them comfortable and relieves stress for themselves and their families, in particular, a noninstitutional environment, private rooms, a room service/food-service model, the ability for family or friends to stay overnight, and amenities that enable families or friends to continue to meet their outside responsibilities while caring for their loved one. Some of these features have also been shown to improve patient safety, reduce infection rates, and reduce length of stay.
Define broad principles in specific design terms
One way a steering committee and its design team can help ensure that they fulfill their principle of patient-centered care is to define what is meant by this phrase and how it can be achieved in specific design terms. There is debate about the degree to which some of the concepts of evidence-based design can be measured in terms of patient outcomes. That said, healthcare leaders and designers generally agree that if they are trying to create a patient-centered environment to enhance recovery and reduce length of stay, then, first and foremost, they will strive for a design that instills calm and respects the patient's privacy and dignity. In fact, because of the positive association between these design concepts and patient outcomes, these concepts are reflected in the current AIA Health Care Design Guidelines.
A patient-centered design creates a noninstitutional environment through consideration of the five senses: vision, hearing, touch, smell, and taste.
Create an environment that is visually appealing through careful attention to lighting-especially, admitting natural light-color, and use of natural materials such as wood and stone. In particular, natural light is associated with reducing patient stress and promoting recovery by orienting the patient to the time of day. Admitting more natural light through higher-volume spaces and use of glass can increase the cost of the structure, and the value of an investment in these design features is often hard to imagine in the planning phase of a project. In these cases, it is helpful for the steering committee to visit other facilities that are designed in this way. It is also important to take into account the life cycle cost of this decision about the building shell, which typically is designed to last for 50 or more years, rather than on the initial capital cost alone.
Control acoustics to reduce noise levels and enhance the healing environment for patients. For example, in nursing units, use of acoustic ceiling tile reduces sound reverberation, and use of carpeting in corridors reduces sound transmission of voices, foot traffic, and service activities from corridors to patient rooms. In addition, consider partial enclosure of central nurses' stations, or greater separation from patient rooms, to reduce noise transmission. At the same time, create a pleasant background sound in public areas, such as the main lobby, by selecting finishes that reflect a moderate level of sound associated with a public gathering.
Appeal to the sense of touch by introducing pleasing textures in furnishings and finishes, in particular, use of natural materials wherever practical in nursing units, patient rooms, areas of respite, and public areas. Distinguish these areas from sterile procedure rooms.
Respond to the sense of smell, for example, with the pleasing aromas from lobby coffee bars.
Address the sense of taste through attention to a public dining facility that emulates a retail or hotel dining experience not only in appearance but also in menu; and consider doing the same for patients through a room service model.
All of these design concepts help to convey a sense of hospitality and welcome. At the same time, a patient-centered design creates private places for family and other visitors to read, work, and spiritually refresh themselves.
If the primary guiding principle is patient-centered care, it is also important to integrate advanced medical and communication technology in a way that is nonintrusive to avoid creating the anxiety that is often associated with the sight of high-tech equipment. Lessen the visual effect of the equipment; for example, consider the appearance of medical gas booms in individual NICU rooms and use design to reduce its impact. Patients and their families want to know that the hospital is using advanced technology to treat illness, but they generally do not wish to see it or rub up against it in patient rooms. Strive for a more emotionally comforting environment in patient rooms.
Make true value judgments
When a steering committee and its design team defines patient-centered care in specific design terms, the committee may be better able to make true value judgments as choices arise. For example, a steering committee often is challenged to adhere to its patient-focused care principle when it comes to selection of interior furnishings, finishes, and materials. Increasingly, nursing staffs press for carpeted corridors in the patient units to improve acoustics based on studies that have shown an association with improvements in patients' perception of the environment, stress levels, and length of stay. However, a contractor may offer a “value-engineered” alternative of vinyl composite tile, encouraging a steering committee to accept this cheaper finish material.
That brings up the question: what is value engineering? By definition, value engineering identifies alternatives that save money while delivering equal or better performance. In fact, substituting vinyl tile for carpeting is not a value engineering alternative, but simply a cheaper alternative, because it does not deliver the same benefits as carpet if the primary goal is patient-centered care.
For example, in a recent NICU project driven by the guiding principle of patient-centered care, a steering committee placed high value on controlling sound as a way to fulfill that principle. Their old unit was designed as an open ward, and a high decibel level was a source of stress for patients and families, as well as staff, and they were determined to change the environment in the new unit. As a result, they invested in semi-private rooms, carpeting, and upgraded acoustic ceiling tiles. In fact, the ceiling tiles were triple the cost of standard acoustic tiles, but they eliminated sound transfer from above-ceiling mechanical equipment and noises transferred from other spaces. Positive comments from family and staff have confirmed that the committee made the right decisions to create a patient-centered environment that improves the conditions in which the newborns are developing.
If patient-centered care is the primary guiding principle, then these investments can be balanced by prudent selections of furniture, finishes, and fixtures in the areas such as staff toilets and break rooms-ideally, by involving affected staff in these decisions to gain their insight and support. For example, in a recent project with a tight furniture budget, nurses felt it was important to invest in a new patient chair that is designed to help patients relax and easily rise, and to make it easier to care for seated patients. The cost was significantly higher than the amount budgeted for this item, so nurses suggested selection of fewer, less-expensive chairs in their break area, as well as other areas, to save money.
When planning and designing a healthcare facility, hard choices often must be made, especially in the current economic climate. In the end, leaders who rely on their guiding principles in making the tough financial decisions are better able to fulfill their institution's ideals and provide real value to their patients. HD
Jeffrey S. Monzu, AIA, NCARB, is Senior Associate with LEO A DALY Planning, Architecture, Engineering and Interiors, in Omaha, Nebraska. Monzu can be reached at 402.391.8111 or
JSMonzu@leoadaly.com. Healthcare Design 2010 May;10(5):88-92