Increasingly, healthcare leaders and decision makers are focusing on creating a culture of patient safety as a key goal of operational initiatives to improve patient care and outcomes. Sound design can help create an environment that supports these initiatives—helping staff deliver care more efficiently and effectively, and providing patients and families with a greater overall sense of safety and security.

On the one hand

While there is, as yet, no hard evidence linking single-handed patient rooms with a clear reduction in medical errors, many facilities are implementing this design approach in anticipation that ongoing research will confirm the potential advantages over opposite-handed rooms. In particular, identical placement room to room of equipment and technology at the headwall can support operational initiatives to enhance patient safety and staff efficiency. In addition, the same-handed room allows physicians to come to their preferred (i.e., right) side of the patient's bed immediately on entering the room.

Indeed, patient rooms are becoming the “last stand” for opposite-handed design. Today, one rarely sees opposite-handed operating rooms. Increasingly, critical care, emergency, and radiology departments are also being designed with same-handed rooms.

Until recently, one of the arguments against same-handed patient rooms has been that inpatient rooms do not require the same level of emergent care as these other types of spaces. However, as the average acuity level of inpatients continues to increase, this argument has lost validity. Moreover, same-handedness is a natural feature of a universal patient room, whose versatility is increasingly favored.

Finally, the relatively slight increase in the construction cost associated with plumbing and electrical distribution systems in a well-designed facility may be offset by the operational value. One caveat is in order: Same-handed patient rooms require careful design attention to placement of the staff station to maintain the potential operational value of optimizing sight lines.

Colocating interventional spaces

Traditionally, procedure areas—general surgery, cardiac catheterization, angiography, gastrointestinal, and so forth—have been designed as dedicated departments, each with its own pre- and post-operative areas, staff station, lockers, and lounges and support spaces. However, bringing these zones together into a well-designed shared space can support operational efficiencies, as well as initiatives to improve infection control (figure 1). To the extent that shared spaces can also increase staff efficiency and opportunities for cross-training, while reducing fatigue and stress, this design approach may also help to reduce the incidence of medical errors.

Colocating interventional spaces into a well-designed shared space can support operational efficiencies, as well as initiatives to improve infection control

Colocating interventional spaces also reduces recurring costs associated with renovation to adapt spaces to changes in service lines and/or technology from year to year. The universal procedure room is the logical outcome: In 2008 it may be used for cardiac catheterization procedures; in 2009 it may be used for robotic surgery.

Often, the main barrier to this type of change is cultural: for example, the arguments, “But we've always done it this way,” “It will reduce our departmental cohesiveness,” or “It will make it more difficult to keep track of our patients.” In particular, surgeons and other physicians may be resistant to sharing multidisciplinary spaces. Visits to other institutions that have successfully implemented this design approach can go a long way toward overcoming resistance. Implementation of appropriate technology, including electronic medical records and patient tracking, can improve patient oversight. The potential operational synergies may directly affect the bottom line without compromising care. The end-of-day scenario where a few patients are still in recovery is another clear example of the inherent efficiency, as well as improved safety of colocated procedure areas.

Family joins the care team

Designing spaces that facilitate inclusion of the family in the care team can also enhance the culture of safety. When a facility is designed to encourage family members or other loved ones to visit longer, or more often, or to stay overnight with a patient, then they become more aware of the patient's needs. They may be able to provide routine care, such as bathing and feeding, that frees up staff to focus on skilled care. In some institutions, family members are being authorized and encouraged to look at their loved ones' medical records and to take part in discussions with physicians during rounds.

In response, designers are laying out patient rooms to include work desks with additional seating, Internet access (hard-wired or wireless), comfortable lounge chairs, and/or window seats that double as sleeping surfaces (figure 2), and additional closet space. Individual room heating/air conditioning controls, improved acoustics, and attention to the need for greater privacy enhance families' sense of comfort and security. Family lounge areas can be enhanced with amenities such as kitchenettes, quiet spaces for work, health education libraries, and areas for relaxation and children's play. In some institutions, staff stations have been redesigned as conference tables to encourage discussions among families and the care team.

Facilitating the inclusion of the family in the care team, designers are laying out patient rooms to include work desks with additional seating, Internet access, comfortable lounge chairs, and/or window seats that double as sleeping surfaces

Studies have found improved patient outcomes, including reduction in length of stay. For example, in a NICU Private Room that encourages rooming in, babies benefit from “kangaroo care,” which increases physical contact with the mother. Parents also gain confidence in caring for their newborns and feel more comfortable taking them home sooner.

In these family-centered NICU facilities, staff may be concerned about maintaining line of sight to patients or monitors, or the ease with which they can alert other staff members in the event of a code. Today, designs that incorporate appropriate computer and communication technology alleviate these concerns.

You can get there from here

Creating a culture of safety—and designing a facility that supports operational initiatives—goes beyond issues of infection control, medical errors, and patient injuries. It requires that we create an environment that reduces the fear and mystery that pervade healthcare settings and helps to put patients and families more at ease. Certainly, much of a healthcare institution's success in achieving this goal depends on the quality of interactions among staff, patients, and families.

But the design of the facility also plays a major role in creating an overall sense of safety and security. Clear and spatially intuitive wayfinding strategies are extremely important to easing confusion and stress (figure 3). It seems obvious—people need to know where they are, where they are going, how to get there, and how to get back. Yet hospital campuses and the buildings and centers that comprise them typically evolve over many years; as a result, they are often characterized by a maze of interior corridors distinguished by a succession of signs with arrows.

Looking at the original clinic layout (A) versus the revised clinic layout (B), one can see how important clear and spatially intuitive wayfinding strategies are to easing confusion and stress

Effective interior wayfinding strategies rely on clear hierarchies of layout, circulation, architectural features, lighting, color, and texture. Clear sight lines to destinations provide clear direction. Right-angle turns provide better orientation to direction than 45-degree turns. The introduction of daylight, exterior views, and memorable architectural features at intersections and other decision points enhances orientation. Modulations in lighting and variations in the color and texture of walls, flooring, and furnishings help people maintain their bearings, remember their routes, and recognize destinations while a pervasive environmental symmetry is all too common.

In these and many other ways, design is helping healthcare institutions create, support, and maintain a culture both safe and sound. HD

IMAGES COURTESY OF PERKINS+WILL Dennis L. Kaiser, AIA, LEED AP, is a Principal with Perkins+Will, a professional architecture firm with a staff of more than 1,000. Based in Boston, Mr. Kaiser directs Perkins+Will's healthcare practice for New England and may be contacted at

dennis.kaiser@perkinswill.com.

For further information, please visit http://www.perkinswill.com.