Flooring sets the stage for all healthcare facility activities. It contributes to visitors' first impression of a space and shapes their opinions about an organization's ability to provide safe, high-quality, and comfortable care. Contributing both to a building’s structural integrity and healing aesthetic, flooring occupies every square inch of measured healthcare facility space, providing a major lifecycle investment opportunity to help realize positive healthcare outcomes, especially those outcomes now linked to reimbursement through healthcare reform.

In 2012, in appreciation of the critical role of flooring in evidence-based design (EBD), The Center for Health Design's (CHD) Research Coalition funded a project to review existing literature on the impact of flooring on healthcare outcomes and distill the information into a checklist for the design community. However, it was found that the evidence base was small; there was a lack of standards to enable an "apples-to-apples" comparison of flooring solutions; and there was a lack of clear, objective metrics to define flooring performance.

In order to create a common platform for assessment, a checklist was developed to map specific performance characteristics of floor coverings against specific health and organizational outcomes, based on the review of the evidence.  Often, a performance characteristic suggested for a specific evidence-based goal resulted in a trade-off with a different goal—for example, increasing slip-resistance through the use of a textured material could result in increased surface contamination and healthcare-associated infection (HAI) risk. These trade-offs were annotated on the list along with sources of information used. Where evidence is missing, the case was made for additional research.

The performance characteristics and strategies listed in the checklist are not specific to a type of healthcare organization, certain area, or level of acuity. Each space in a healthcare facility has a unique flooring requirement based on its clinical mission, the population served, the care team, and the equipment used. Designers can prioritize goals that are most important for a specific area, and/or organization, and identify a list of floor covering properties and characteristics best suited to achieve desired outcomes. Rather than offering a prescription for floor covering selection, the flooring checklist provides an evidence-based tool to inform design decisions.

Key considerations

To reduce slips, trips and falls, flooring should be stable, firm, and slip-resistant. In areas where high spillage is likely, it should be impermeable and easily cleaned, with texture to prevent slips. It must be tested for optimal performance under different conditions (wet/dry/greasy). Unnecessary changes in flooring surfaces, especially in areas with limited visual field, should be avoided, and thresholds should be low to adhere to ADA standards. Joints, seams, and high contrast in flooring patterns should be minimized to reduce trip hazards. Most important, appropriate finishes and cleaning procedures should be used, in keeping with manufacturer recommendations, to ensure that the flooring performs as intended.

Because patient and staff falls will still occur, flooring should have a balance of energy-absorbent properties to absorb the force of impact that causes injury and firmness to reduce the risk of falling due to poor balance. If rigid materials are used, then underlays can be installed to provide adequate cushioning.

To reduce noise levelsin areaswith high footfall noise, such as corridors, flooring should have high sound-absorbing properties and low sound-transmitting properties while accommodating roller mobility and balance. The floor finish and the subfloor structure in healthcare facilities should mitigate noise levels transmitted by an impact in an adjacent space, such as a footfall or cart rolling.

To reduce staff fatigue, flooring should have more cushioning for areas that require standing for extended periods of time. Cushioning properties need to be balanced with roller mobility in areas used for equipment transfer, and greater roller mobility needs to be incorporated for high-traffic areas like corridors.

Carpet should be avoided in areas where spills are likely to occur (laboratories, sinks, or janitor closets) or where patients may be at greater risk of infection from airborne pathogens (burn units, ICUs, or operating rooms) in order to reduce surface contamination and potential risk of HAIs. Surface material should be compatible with the sanitizing methods outlined by the Centers for Disease Control (CDC). In general, surfaces and joints should be nonporous and impermeable to the extent possible without increasing slipperiness, while keeping within the requirements of the area. Some strategies can be used to reduce surface contamination, such as coving in right-angled joints between the floor and the wall or using carpet tiles in areas with risk of high spills. It's important to note that the CDC hasn't identified flooring as a high-risk surface for HAIs, and there's no conclusive evidence to link flooring to HAIs.

Flooring can also support wayfinding by using colors and patterns in conjunction with the overall design scheme. Use of high-contrast patterns must be weighed against perceptual issues that could impair balance, especially in areas where patients may have impaired vision. Overall flooring should look noninstitutional and be visually appealing. Strategies such as the use of a non-glare finish to avoid straining sensitive eyes, durable surfaces that don't scratch or scuff easily, or low-contrast patterns that hide scratching and scuffing should be explored.

To improve indoor air quality, LEED guidelines for healthcare must be followed, including, but not limited to, minimum VOC emissions by the floor covering. 

Finally, to calculate the best return on investment (ROI), first-time cost (materials and installation) should be balanced with lifecycle costs, including maintenance, repairs, and replacement. Lifecycle costs should also cover the initial maintenance required to prep the flooring, both after installation and prior to occupancy. Ideally, the extent to which the flooring aids in improving safety and quality outcomes will be estimated to calculate a complete ROI.

Other factors

"Achieving EBD Goals Through Flooring Selection & Design," the checklist's corresponding white paper, also advises to be mindful of the following: 

Understand evidence limitations. Evidence on flooring is limited due to a lack of standards, lack of replication of lab-based studies in real-life settings, lack of commonly used metrics and tools for data collection, absence of a reporting process that tracks extrinsic factors (such as flooring conditions) alongside the outcomes of interest (such as falls), and the challenge of changing flooring conditions due to maintenance issues like cleaning and surface coating. The business case for flooring hasn't been made, either, at least not going beyond a comparison of lifecycle costs to evaluating the impact of flooring on health outcomes. It's premature to compare flooring types in their entirety and make industry-wide recommendations. A simplistic approach to some key flooring-related issues, like slip resistance, is problematic because it depends on multiple factors such as footwear, human gait and stride, and maintenance of the flooring surface. As it stands, there's no evidence to support the selection of a specific flooring type as the ideal choice to use throughout a facility.

Focus on the characteristics for each individual flooring product. With
in the industry's broad flooring categories—hard, soft, or resilient—there's a significant variation in the characteristics of products available. With new technology and advances in material science, the lines between these broad categories are getting blurred. Moreover, evidence favoring one broad category of flooring over another is inconclusive. Rather than using a generalized flooring category, a design team must evaluate individual products based on their performance against each EBD goal before deciding on the right flooring material and design for a particular area. 

Consider the trade-offs for each product. In aiming for desired healthcare outcomes, trade-offs need to be considered during flooring selection. A one-size-fits-all approach can’t be used to select flooring types, since different flooring characteristics and properties impact different outcomes. For example, a harder floor can reduce staff fatigue due to pushing heavy equipment, whereas a softer floor can reduce staff fatigue from extended periods of standing. Each product should be analyzed for its individual properties, which can then be evaluated in the context of desired outcomes for a particular healthcare space, weighing the trade-offs associated with each option.

Use a flooring system approach. Flooring is an integrated system that consists of the subfloor for support and the floor covering and surface finish that create the walking surface. Additionally, careful consideration has to be paid to adhesives, underlays, surface treatments, and maintenance. Any decisions regarding floor coverings must consider how the system comes together and works along with human and organizational factors.

The flooring checklist represents a first step toward better understanding how floor coverings contribute to achieving desired healthcare outcomes. This list now needs to be tested for clarity, usefulness, and practicality, to create a tool that can aid design decision-making based upon the best available evidence. The complete checklist can be downloaded at www.healthdesign.org/chd/knowledge-repository/achieving-ebd-goals-through-flooring-selection-design, and the complete white paper, “Achieving EBD Goals Through Flooring Selection & Design,” can be downloaded from the Knowledge Repository found on CHD’s website.

Acknowledgments: Eileen Malone, RN, MSN, EDAC, and Anjali Joseph, PhD, EDAC, co-authored the paper and guided the project. Tandus Flooring provided funding for this research and is a supporting partner of The Center for Health Design's Research Coalition.

Upali Nanda, PhD, EDAC, Assoc. AIA, is a consultant to The Center for Health Design (CHD).  For more information about CHD's research projects, please contact Anjali Joseph at ajoseph@healthdesign.org. If you have feedback on the flooring checklist, please contact Shannon Roecklein, project manager for the Research Coalition, at sroecklein@healthdesign.org.