Healthcare providers across the country are strategizing their next moves in an industry-wide shift to provide more care in outpatient environments, an effort to reduce inpatient admissions and, particularly, costs—and one that’s taking care outside of hospitals whenever possible.

Ironically, this trend isn’t diminishing the number of inpatient projects being pursued. In fact, it’s inspiring their reinvention. And at the heart of any hospital are its patient rooms.

“You have your specialty suites, your diagnostic and treatment areas, etc. But the rest of it is where the patients, after all the treatment is done, are going to reside for the duration of their stay,” says Walter Jones, senior vice president of campus transformation for The MetroHealth System (Cleveland) and former senior vice president of facilities planning and development for Parkland Health & Hospital System. Jones oversaw construction of the new Parkland Memorial Hospital in Dallas, of which 1 million square feet of its 2 million total are dedicated to 865 patient rooms. “From a capital standpoint, from a construction standpoint, [patient rooms] can be a huge component,” he says.

In addition to the impressive percentage of square footage allocated to patient rooms in any given building, these spaces—and their design—must support a number of shifts taking place in healthcare today, leading providers across the country to reconsider approaches of the past.

“What clients are doing as a result [of the outpatient shift] is circling back and, with the ability to either streamline or decant some of their outpatient and nonclinical services and free up real estate, investing in improving the inpatient experience and environment,” says John Rodenbeck, a principal at Perkins Eastman (New York).

There are plenty of reasons for it, too. For starters, market competition is pushing the need for wholesale adoption of private patient rooms, especially as patients have more choice in where they receive care. Private rooms also come with a number of other proven benefits, such as reducing healthcare-associated infections (HAIs) and increasing patient satisfaction—factors that hold a lot of water today, as the Affordable Care Act ties both outcomes and HCAHPS scores to reimbursements. And while the outpatient transition will likely reduce future bed needs, it also translates to the expectation that patients who do require hospital admission in years to come will be much more acute than today’s inpatients.

And that’s just what we know. As technology begins to play a larger role in care delivery and mobile health solutions continue to be adopted, patient rooms must be designed with adaptability in mind and an eye on a future that’s anything but clear.

“The patient room is where you need to get everything right,” says Ana Pinto Alexander, principal, senior vice president, and director of healthcare interior architecture at HKS (Indianapolis).
The baseline
The starting point for almost all patient room designs is a single-occupancy space. “I think we’re making great progress,” says Cyndi McCullough, evidence-based design director for HDR (Omaha, Neb.). “Every project I’ve worked on involves either renovating some rooms to make private rooms, adding new, or a combination of both. It’s at the top of the list for most everyone.”

While the transition isn’t as easy for systems with tight urban sites, the majority of providers are better able to, for example, renovate a 200-bed double-occupancy facility into a 100-bed single-occupancy facility than they were prior to reform. “With more procedures going into the outpatient arena, it’s offering more real estate within the hospital to either convert or build private rooms for a lot less expensive price tags. They’re not going for higher-bedded facilities,” Rodenbeck says.

Meanwhile, the average length of patient stays has historically grown shorter. And with patients anticipated to be more acute in the future, requirements for what the rooms must accomplish and support during that stay are being pushed.

“The rooms are critical as more has to be achieved in a shorter time. Patients need quality sleep and reduced stressors, and need to be protected from pathogens and medical error. Families need to participate in care, and staff need to be focused, communicate seamlessly, and be protected from injury,” says Carolyn BaRoss, principal and firmwide healthcare interior design director for Perkins+Will (New York).

To that end, Rodenbeck says the baseline of any patient room design is to maintain distinctive zones for patients, family, and staff. “It’s understanding each tenant, how they work, how they communicate, and how they interact that’s going to best inform the functionality of the room,” he says. “Every one of their experiences is critical to the success of a design.”
Details, details
When approaching the fit-out of a patient room, McCullough has a hierarchy of needs: “First is the safety of patients, which includes infection control. Second is efficiency for staff, and then it’s involvement of the family.”

To meet infection control needs, in particular, designers are turning to materials to create environments that are easily cleanable and maintained, from high-performance upholstery to solid surface casework to plastic laminate or rubber flooring, some products even antimicrobial or treated in other ways. “Patient room design will continue to evolve along with the products, materials, and technologies to help keep rooms clean and patients safe. There are so many more appropriate products that have been developed in the last 10 years,” BaRoss says.

And while hospitality touches of the past decade (e.g., smooth headwalls) have become almost ubiquitous, Pinto Alexander says that hiding caregiving necessities is starting to fall by the wayside due to the time it may add to an emergency situation and the cost that all of those hidden doors and hinges adds to a project. McCullough agrees: “I think we get carried away sometimes with what we want it to look like. If a person’s coming to the hospital, sometimes they need to see a little stainless steel. They need to know you’ve got the equipment and are going to take care of them.”

But that doesn’t mean that aesthetics and safety can’t be balanced. “Much of what we try to accomplish in the patient room is to make it warm and comfortable, but this has more to do with managing the visual clutter than adding to it. A beautifully proportioned space with a nice window and view, with considerations for privacy and dignity, controllable layers of lighting, and high-performance acoustics make a big impression before anything else is added,” BaRoss says.

John Kouletsis, vice president of facilities planning and design for Kaiser Permanente (Oakland, Calif.), encourages exploration of choice for patients, too, from the option of opening a window to selecting artwork for their walls to coloring the room a favorite shade with the use of LED lamps. “One of the biggest things you can do in designing the patient room of the future is to give people choice; stop telling them what to do,” he says. “How can you start restoring choice and the sense that the patient hasn’t totally lost control?”

Con
figuration of the room has evolved, as well—for example, locating handwashing sinks by the door so staff (and visitors) can easily scrub up as they walk into the room. The caregiver space is often sited directly upon entry and adjacent to the handwashing sink, allowing staff easy access to the patient, a place to chart in the room (if required), possibly a stool to pull out for easy conversation, and separate lighting controls to tend to the patient without disrupting sleep.

But what’s changed most significantly in recent years is the family zone, often placed on the outboard wall or the far side of the patient bed. Research continues to prove the benefit of family members as caregivers, yielding improved outcomes and reduced lengths of stay, which has influenced providers to answer the trend with plenty of accommodations.

“We believe strongly that the patient room is where the family (or the care advocates), the patients, and caregivers come together as a single team. The room needs to accommodate that and it needs to encourage that,” Kouletsis says. To that end, side chairs of old have been replaced by a pull-out sofa or Murphy bed, complemented by storage and casework, private lighting controls, and individual entertainment options.
Always prepared
Because patient towers and units of old were built to a very specific purpose, spaces that have been replaced over the years are often reassigned to administrative offices or abandoned altogether, says Tim Fishking, a principal at NBBJ (Columbus). “They’re so inflexible and expensive to renovate or retrofit,” he says.

To avoid repeating the mistakes of the past, designers are increasingly being charged with creating spaces that can flex well into the future. For example, one approach is to create a standardized, acuity-adaptable room that can be used for general med/surg purposes today but potentially serve as critical care space in the future, or even be reconfigured for specialty service lines.

“If you’re going to replace beds and build a bed tower, you may as well standardize everything. It’s easier to build, it saves money in construction, and it’s faster. You’re always going to need a higher level of care. You don’t have to equip it for that to begin with, but you need to be prepared size-wise that you can adapt it and put the right equipment in when you need to,” McCullough says.

Some designers start with a code minimum square footage for critical care rooms (200 square feet of clear floor area plus required clearances, per 2014 Facility Guidelines Institute [FGI] standards), and add on from there as needed—at times surpassing 300 square feet, including the patient bathroom. This provides more flexibility for future uses than starting with much smaller med/surg minimums (120 square feet of clear floor area, per FGI).

Designers also suggest including larger door widths to accommodate ICU-level and/or bariatric beds as well as enough infrastructure within the ceiling to support patient lifts and a configuration that allows observation from the corridor.

Modular components are growing in popularity, as well, as healthcare designers take a page out of the office design handbook. “In the corporate workplace, technicians can come in and reconfigure an entire floor with an allen wrench. It’s about adaptability and flexibility,” says Ryan Hullinger, a principal at NBBJ (Columbus). “That’s exactly what healthcare needs.”

Furthermore, Hullinger says, not planning for future equipment and technology needs would be a major miss for any patient room project. “The stakes are high. No hospital can afford to spend a tremendous amount of money on an inpatient unit that becomes quickly outmoded or prematurely obsolete because of changing care models, changing equipment, and changing technology,” he says.

At Parkland, Jones says the design was focused on bringing care to the bedside, supporting medical record and diagnostic connectivity close to the patient. A sizable footwall screen today supports patient entertainment and education, but the possibilities for later include display of medical records and diagnostics and a platform for two-way communication with outside caregivers or friends and family.

Kouletsis says Kaiser Permanente is also turning to technology to provide more control to the patient experience. “How do you keep the person plugged into their life so that it’s as normal as possible, so that they don’t feel disconnected?” he says.  Looking even further into the future, Rodenbeck says disparate systems will likely become integrated, from the electronic medical record to the IV to the lighting. “There’s going to be a whole interface that’s about the patient room and the patients controlling their own environment,” he says.

To make all of this work, though, requires necessary IT infrastructure. “We don’t know what kind of computer [providers] are going to be using or how they’re going to document in the patient room, but it’s about understanding who needs to do that and make sure they’re wired to do so,” McCullough says.
Betting on the future
Looking ahead, there are plenty of patient room design challenges looming that will require innovative solutions. For example, Jones questions how construction can be even further streamlined. While a good deal of prefabrication of patient room components—from the headwall to the toilet room to the MEP infrastructure—is being fabricated off-site today, the patient room is ripe for more, from equipment modules to the units themselves. “What can I do to get an economy of scale and not take away from the functionality that I need?” he says.

Other questions surround the growing use of mobile health devices that have hit the consumer market and will likely be translated to care delivery. Oftentimes the role of the patient room itself, Jones says, is to provide monitoring, but “the more portable that equipment becomes—really portable, wearable, backpack-able—the patient has some freedom to move around. That gets out of the patient room realm. What does it mean for the hospital?” Jones says. “Is the room the room now, or is the room actually becoming the person?”

While monitoring may decline as a role of the patient room, it’s likely that what’s performed within the space will only be enhanced. “As patients become more acute, [providers] are going to want to move them less while they’re there. So that means if they need to do a CAT scan or provide some imaging services, I think those types of things are going to become more mobile and the patient room is going to become more like an operatory,” Rodenbeck says.

Jones agrees, anticipating that diagnostic and treatment areas will remain a piece of the puzzle, but that once a patient reaches a room, they’ll stay there. “It will be less of, ‘We’re going to roll you out for a lab visit and be back in an hour.’ Now more and more of that stuff can be done in the room. The patient doesn’t have to move, the family can watch and see the situation unfold in front of them, and the patient can be more comfortable because their environment is more stable. By doing that, you start reducing stress levels and presumably foster a higher level of recovery,” he says.

Improving outcomes—alongside keeping patients and staff safe and maintaining patient and family satisfaction—is and always will be the name of the game.

“When a patient is in the hospital, it’s only because they can’t get care at home. And when a patient is in the hospital, the place they spend mo
st of their time is in the room. So let’s create a room that’s very efficient for staff, that’s safest for patients, and allows us to maximize our reimbursement. It’s critical and we need to be paying attention,” McCullough says.

Jennifer Kovacs Silvis is executive editor of Healthcare Design. She can be reached at jsilvis@vendomegrp.com

To read more from Healthcare Design's patient room special report, see the following:

  • Unit Design Is Secret To Successful Patient RoomThe effectiveness of any patient room design requires an equally effective unit design that supports efficient, functional, and safe operations and care delivery. Designers weigh in on best practices for inpatient unit design in this installment of Healthcare Design’s special report on the patient room.
  • Crystal Ball—Looking Into The Future Of Patient Room DesignSee a sneak peek of patient room projects on design boards today and details on how healthcare designers are reimagining this all-important space, the third installment in Healthcare Design's special report on the patient room. 
  • Calling For Backup In The Patient Room: Evidence-based design has shaped the modern patient room in a number of ways, but there are still plenty of places where designers would like to have more research available to support design decisions. Read how research might shape future designs in this installment of Healthcare Design's special report on the patient room.
  • What's Next For Patient Room Design?NXT Health’s Patient Room 2020 prototype made waves through the healthcare design industry when launched last year. In this installment of Healthcare Design's special report on the patient room, NXT Health executive director Salley Whitman talks about the model and how the concepts proposed continue to evolve and push patient room design forward.