Contributing Authors

NATURE: Jerry Smith, ASLA Senior Landscape Architect, Karlsberger Companies, Inc.

COLOR: Barbara Dellinger, IIDA Principal/Director of Design, Oudens + Knoop Architects, PC

HEALTHY BUILDINGS: Robin Guenther, AIA Principal, Guenther 5 Architects, PLLC

HEALTHY LIGHTING: Milena Simeonova, RA, NCARB, IES, LC Architect and Lighting Designer, Milena Lighting Design

CULTURAL RESPONSIVENESS: Jeanette Perlman, MS Executive Vice-President, The Center to Promote Health Care Studies

PHYSICAL SECURITY: Stuart L. Knoop, FAIA Principal, Oudens + Knoop Architects, PC

WAYFINDING: Barbara Huelat, ASID, IIDA Principal, Huelat Parimucha, Ltd.

The Center for Health Design's Environmental Standards Council (ESC) began in 1995 as the Environmental Quality Work Group (EQWG), the idea for which came about after staff members of The Center and of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) met to discuss the idea of including standards for measuring environmental quality as it relates to the human experience of healthcare. The group became the ESC in 1998 to better reflect its mission. It has continued to explore ways to enhance JCAHO's standards, as well as contribute to the American Institute of Architects (AIA) Guidelines Committee (see “Into the ‘Shaded Text’: Integrating the Design Process for Better Outcomes,” p. 10).

As an outgrowth of this work, The Center for Health Design will be producing a CD at the end of this year that looks at examples, research, and resources developed by the ESC that contribute to the understanding of the environment of care (EOC) in healthcare facilities. Following is a short synopsis of many of those elements that make up the EOC chapter.


The inherent value to a healthcare environment of physical or sensory interaction with nature is evident in its effects both on patients and caregivers, an area of focus for many leading researchers in the field. Elements of nature not only distract patients from the challenges of treatment and enhance their most basic senses of life and living, but they also provide families and caregivers with relief. As a result, research on these “natural” designed spaces continues to bolster the medical community's awareness of their therapeutic value, while planners and designers continue to witness a greater demand to incorporate them into the design of healthcare environments.

Although many of the design elements of nature may not be considered “enforceable” as a requirement for healthcare design guidelines, the research and evidence base is significant and supports serious consideration. At a minimum, recommendations should include accessibility to designed areas or elements of nature—whether physically, sensually, or both. The extent to which that accessibility occurs or is made available within the environment of care would become a function of the program; its success would be determined by the design.


Color affects us in many ways—this is no longer disputed. However, the way in which it affects and influences us is a topic of controversy. Many theories have been advanced, and most working in the design field are longing for one or another of these to emerge as the “correct” one. Wouldn't it be nice to have a guidebook that says, “Use red for this type of environment or patient, and use green for this one”? Or, at the minimum, “Don't use certain colors in certain types of settings.” What the latest research has shown, however, is that it is not that simple.

The Coalition for Health Environments Research (CHER) recently published a paper entitled “Color in Healthcare Environments: A Monograph Reference Guide.”1 It addresses the physiological, psychological, spiritual, emotional, and historical aspects of color and reviews the literature to draw conclusions from purely scientific research (which at the moment is quite limited). Much of the information is frankly anecdotal and, although possibly helpful, is not proven. The authors of the monograph conclude: “The use of color in healthcare settings currently is not based on significant research.” Further, they write, “We need to understand what particular colors are supposed to do, and why, before we can proceed to implement them in a healthcare setting and before we can judge whether these selected colors do it well.”

Moreover, geographic location, systems, practices, culture, age, condition, and personal experiences all enter into people's perception of colors. “Because there are so many groups of users with different cultures in present healthcare settings, we need to identify these groups and design for (and with) these specific users. We need to understand the society and culture against which our interpretation takes place.”1

One problem with universal guidelines for color selection is that too many assumptions are made. For example, designers may select certain “color cues,” only to find out that the cue was completely missed by the user. Or, if users notice the cue, consciously or subconsciously, they may not understand its meaning and, further, “even if the users both notice and understand the cue, they may refuse to conform.”2

This is not to suggest that the literature currently available on the subject shouldn't be used—it is a start. Clearly, however, this topic will benefit from further research.

Healthy Buildings

The design of healing environments should seek to minimize the impact of a building's location on occupants, the surrounding community, and the earth as a basic and fundamental aspect of the design. This is consistent with the Hippocratic oath: “First, do no harm.”

The Green Guidelines for Healthcare Construction™ provide an initial framework for what is known as “green healthcare design.” Built upon the framework of LEED™ (Leadership in Energy and Environmental Design) and ongoing projects of The Center for Health Design, these guidelines demonstrate that “sustainable” and “therapeutic environment” goals are linked to produce healthy, high-performance buildings that inspire staff and families, and positively affect patient outcomes.

Evidence-based research studies linking improved outcomes to the physical environment have a long history. Research linking natural light and views (important aspects of sustainable building practice) with shorter length-of-stay has been cited since the early 1980s. More recent sustainable building initiatives are producing research linking “green building” practices with improved worker productivity, health, and satisfaction. Case studies confirm that facilities can be made more sustainable with nominal, if any, additional first costs. Research shows that design decisions and material choices that may represent higher first costs are recouped through savings in operations, maintenance, and enhanced worker performance over the life of the building.

Healthy, high-performance healthcare buildings seek to maximize natural site attributes and minimize negative site impacts; minimize energy and water demands; optimize use of virgin, nonrapidly renewable materials; and improve indoor environmental quality. This comprehensive lens, which extends through both the life cycle of the structure and its component materials, demands that the design process be reformulated to one that values interdisciplinary participation and scientific rigor in the programming, selection, and specification of building products and systems.

High-performance healthcare buildings just coming online include Boulder Community Foothills Hospital in Boulder, Colo., which last October became the first LEED-certified new hospital building. In March 2004, the American Society for Healthcare Engineering gave its first Sustainable Building Award to the Center for Discovery in Harris, N.Y.

Healthy Lighting

With the aging of the population, a major component of healthy environments is providing continuous but subtle sensory stimulation to patients and personnel in hospitals and long-term care environments. The Mather Institute on Aging reports that sensory stimulation, or brain “aerobics,” is necessary for healthy living at advanced age. Healthy lighting has characteristics similar to those of natural light, in that it subtly changes in light spectrum, intensity, and distribution throughout the day. However, it is important to combine the visual stimulation from healthy lighting with other sensory stimulations—aroma, sound, and touch—and synchronize all of them with the human biological clock. It is also important to organize all sensory data into meaningful perception or messages. The formula for this is simple: It is what we see, when we see it, and whether it makes sense. When the message is clear, then a healthy environment has been designed and built.

Even the best research is of little value if it doesn't yield practical applications. The application of healthy lighting requires multidisciplinary knowledge, including photobiology, perception, color preference, vision, lighting technology, optics, design, arts, human health, and more. Once the underlying scientific principles of healthy lighting application are understood, the physical application is relatively simple. Lighting hardware and software are already commonly available, low-cost, and user-friendly.

Cultural Responsiveness

Current studies in the healing and recovery process indicate that cultural responsiveness to the population served constitutes one of the essential categories for enhancing the environment of care. It includes the following elements: intentional (leadership) culture, organizational culture, and regional culture.

To determine the intentional culture of an organization, it is necessary to study the cultural dynamics that are ultimately reflected in group dynamics, as groups mature and develop subgroups. Included in this are the values, role, and focus of leadership. The leader has a major influence on shaping organizational culture and establishing a degree of comfort for living within the structure. Many cases have been reported of staff being transferred to new buildings and behaving inappropriately and destructively when they did not have a voice in the organization or design. There also have been cases in which very kind and considerate caregiving has been provided in buildings that were less than adequate in structure and engineering systems, but in which staff felt vested.

Organizational culture encompasses cultural growth and change resulting from internal and external variables. Organizations will achieve better survival rates when they become adaptable and respond quickly to change. This response to change must occur both in systems and in the delivery of care. Examples of flexibility enhanced by design include provision of internal walls that can be moved and of engineering systems that can be modified as changes in demographics occur.

Regional culture includes core symbols, labels, and norms that express cultural identities. The communication of cultural identity occurs through language, texture, design, color, expectations, norms, and values. Examples of design compatibility with regional culture can be seen in the more prominent healthcare facilities that are built in the Southwest and Southeast regions of the country.

Ultimately in order for design professionals to be commended for their work, they must incorporate the information they have acquired by listening for and observing cultural cues, and using their skills and competencies to respond to them.

Physical Security

Most healthcare institutions have not considered their facilities to be terrorist targets, and few healthcare facilities have invested in physical construction designed specifically to protect against potential terrorist attacks. Yet some healthcare facilities might indeed be targets:

  • High-profile public institutions where prominent or controversial public figures are treated or where the symbolic value is attractive to terrorists who wish to make a point by inflicting heavy casualties;

  • Public healthcare institutions, such as NIH's Clinical Center, and universities doing health-related research;

  • Institutions associated with targeted religious, racial, or ethnic groups;

  • Institutions harboring criminal suspects, witnesses and survivors in protective custody, or physicians or researchers engaged in work opposed by organized groups; or

  • American institutions overseas.

Any building or complex located near a potential target of terrorism could be subjected to collateral damage from the primary target, as happened to large parts of Lower Manhattan when the World Trade Center collapsed. Moreover, if a large, visible medical facility is near a well-protected primary target, such as a federal building, it is possible that a terrorist will choose the softer target.

Healthcare facilities will, by definition, become part of a community's vital infrastructure for disaster mitigation. Protection of these facilities to ensure their viability in this role may become a community priority for multihazard disaster mitigation planning under the Disaster Mitigation Act of 2000.

Another important aspect of physical security is protection from hazards. The Federal Emergency Management Agency (FEMA) classifies hazards as natural or man-made (further classified as accidental or technologic, and intentional). For the built environment, mitigation of most natural hazards is covered by building codes, fire and life-safety codes, and industry standards.

Building and fire/life-safety codes do not yet mandate mitigation of man-made, intentional hazards (physical security), except insofar as some of the by-products of a terrorist attack, such as fire and smoke, are already covered. The federal government has developed physical-security design criteria and, more recently, through the Department of Homeland Security and other agencies, has begun broad-based efforts to make security information available to the general public.

A facility's owner or management must perform three assessments to determine whether to invest resources in physical security and, if so, how much: a threat assessment, a risk assessment, and a vulnerability assessment.

A threat assessment determines who might wish to harm a facility or its occupants and why, how they might do so, and what tactics they might use. A risk assessment examines the probability of an event occurring and the severity of the consequences. Typically, high-consequence threats have the lowest probability of occurring and vice versa. A vulnerability assessment determines how vulnerable the facility is to these threats and the response or mitigation measures needed to protect against them. First costs and operating costs determine the amount of protection that can be applied to mitigate a threat.

There is no way to know whether explosives attacks will ever be brought to bear against a healthcare facility, but most security design criteria for federal agencies are directed at mitigating blast effects, and modern technology offers ways to protect new and existing buildings from them, at least to some degree.

While chemical, biological, and radiological (CBR) weapons can be of many types, the most attention has been given to airborne agents. In buildings where air is intentionally introduced from the exterior and circulated internally, the spread of toxic agents in the air is potentially of concern. Toxic agents can also be introduced to a building's water supply externally or internally, close to the point of use.

Nearly all measures of physical security are designed to buy time for a response. No indefinitely lasting, undefeatable protection against any attack exists. But if an attack's effects can be contained long enough for first responders to arrive and perform their tasks, the built environment will have done all it can.

The design community, working chiefly with government, has been developing ways of protecting buildings, seeking the least intrusive and visually offensive solutions wherever possible. Only with rational analysis of threat, risk, and vulnerability can reasoned and balanced actions be taken.


Good wayfinding creates a clear sense of place in a confusing, complex, and often seemingly hostile healthcare facility. Unfortunately, most hospitals and medical centers are complex mazes of long and confusing corridor systems, with bends, turns, and foreign-sounding signs. Nothing looks familiar, and visitors, often already stressed with the demands of an illness, can find the experience frustrating.

Research provides guidelines for wayfinding design. Janet Carpman, PhD, author of the book Design That Cares (John Wiley & Sons, 1993) and a participant in numerous research studies, describes design research in regards to wayfinding as critical to the design process. Carpman finds that research is especially relevant to good decision making in planning the healthcare environment. She recommends the “Informed Consumer Model of Research.”

As patients and visitors embark on their journey to and through healthcare facilities, they bring previous experiences with them; they look at what they see and evaluate it in context. The wayfinders will then try to understand the spatial characteristics of the environment. With this information, they consider the signs, maps, landmarks, and other indicators to understand the place, and then examine their options and determine the best route to their destination.

Each building has a natural circulation system based on paths selected by users. A good wayfinding system takes advantage of that. A good wayfinding system consists of numerous components that, like stacked building blocks, rely on each other for a solid foundation. In other words, good wayfinding uses a system of building blocks assembled in an understandable manner.

The foundation is good facility master planning, which ensures that the building comes together in a manner that makes sense to the user. The architectural component has a direct relationship to ease of use. Interior design is a component that supports the wayfinding system with color palettes, materials, and lighting; signs build on good interior design to perfect a wayfinding system. Graphics are another component that contributes to a good wayfinding system. Symbols and wayfinding graphics help through redundancy by repeating the messages from signs.

An Invitation

If you would like to become involved with the work of the Environmental Standards Council, please e-mail Debra Levin, president of The Center for Health Design, at HD


  1. Coalition for Health Environments Research (CHER). Color in Healthcare Environments: A Monograph Reference Guide, 2003.
  2. Rapoport A. On the cultural responsiveness of architecture. Journal of Architectural Education 1987; 41 (1):12.