“I want you to imagine how our future military hospitals look, feel, and act. We will have healing settings that are: quiet, organized and filled with light, where patients get few if any infections, places that minimize the possibilities of falls designed to reduce errors caused by hand-offs and transfers where families feel welcome and are treated as partners and are provided generous and comfortable space and where the hospital staff can provide care without undue stress….”

S. Ward Casscells, MD

Assistant Secretary of Defense, Health Affairs

September 15, 2008

Every day, the Military Health System (MHS) strives to meet the needs of our service members and their families. As a nation we ask: What can we do to care for those who have sacrificed so much on behalf of others? The MHS is transforming its infrastructure to meet the unique challenges of caring for our nation's heroes and their families.

Military medical facilities represent a tangible commitment to care for the members of our armed forces and their families. Yet more 40% of the military health infrastructure is over 50 years old. Military hospitals and clinics have been increasingly stressed by the pace of evolving medical missions, dramatic advances in casualty care, and the expectations of patients and their families. Despite the best efforts of dedicated providers and facility managers, these aging buildings are unable to keep pace with modern requirements.

Rather than continue on a downward spiral, many forces have converged to create unprecedented opportunities for change. The 2005 Base Realignment and Closure (BRAC) law enhanced the capability of the discrete medical services of the Air Force, Army, and Navy to work together, and funded substantial medical facility upgrades in two major markets, Washington D.C. and San Antonio. BRAC also coincided with the restructuring and relocation of Army units across the globe. As populations at many installations grow, so too, does the need for modern medical facilities.

The MHS came under intense national scrutiny following the publication of articles in the Washington Post that illuminated the condition of a building housing wounded soldiers receiving outpatient care at Walter Reed Army Medical Center. Both the Department of Defense and Congress acknowledged the importance of military medical facilities and provided clear direction—adequate facilities are no longer acceptable. The MHS now has the resources and mandate to initiate a massive recapitalization program that will strive to create safe, healing environments for patients, families, and staff. “Our new acquisition methods are providing a very good precedent for how we will do work in the future—we are learning to be more comfortable with risk. As we move from a seven year acquisition cycle to a three year cycle, we will demonstrate a range of benefits from reduced cost to more timely and current facilities,” says Dave Fortune, U.S. Army Health Facility Project Office at Fort Belvoir. The MHS stands on the cusp of a singular opportunity to transform military medicine, where evidence and a focus on measureable outcomes and innovation are infused through the entire process.

A new community hospital at Fort Belvoir

BRAC directed the closure of Walter Reed Army Medical Center, coupled with an expansion of the existing National Naval Medical Center in Bethesda, Maryland, and replacement of the existing community hospital at Fort Belvoir, Virginia. This new hospital at Fort Belvoir provides the first opportunity to create the evidence-based healing environments envisioned by MHS senior leadership. The facility is nestled within the Chesapeake Bay watershed and sits on a former nine-hole golf course surrounded by 1,450 acres of forest and wetlands. Designed by Jeff Getty, AIA, LEED AP, of HDR Architecture, Inc., the building configuration arches east (figure 1), reducing the visual spread. Height restrictions—secondary to the close proximity of Davison Army Airfield—keep the desired community-hospital feel of the project. With its swooping rooftops on the outpatient clinics and gardens interwoven between buildings (figure 2), the design reflects the pristine natural setting. The curved design evokes the image of nearby Mount Vernon and offers welcoming points of entry that respond to the desires of a focus group organized by the National Military Family Association.

Front façade of The New Community Hospital, Fort Belvoir, Virginia. HDR Architecture, Inc.

The inpatient tower is on axis with the main entrance. Separate parking structures for the inpatient tower and north and south clinics decrease visitor walking distance, and are intended to increase satisfaction and decrease staff time spent giving directions. lee + papa and associates, inc.

At 1.27 million square feet, the new facility is unusually large for a community hospital. Spread across five main structures, the new complex will include 55 primary and specialty outpatient clinics, as well as extensive ambulatory surgery and ancillary capabilities. The 120 inpatient rooms are all single-bed, with the exception of semiprivate rooms in the behavioral health unit. The 10-bed ICU can flex to accommodate step-down patients, minimizing intrahospital transfers. The design team anticipates that reducing transfers has the potential to increase hospital capacity, staff efficiency, patient satisfaction, and reduce errors due to fewer handoffs.

The complex has six courtyard gardens serving its patients, families, and 3,200 staff members; the Chapel Garden is shown in figure 3. The design team is seeking LEED Silver certification.

Glazed sliding doors bring the outside into the chapel, enhancing restoration with natural light and fresh air. lee + papa associates, inc.

As design progressed, three overarching themes emerged: honoring military service and our nation's history, caring for our own, and enhancing access to nature. While all three themes find expression in the design, access to nature offers the opportunity to reduce stress, provide positive expression, and facilitate the healing process.

Inpatient rooms have eight-foot window spans overlooking vegetative rooftops that also serve to control runoff (figure 4). Public circulation is along the eastern side of the building in the clinics and hospital, maximizing exposure to natural views and morning sunlight.

The patient is guided via a handrail to the bathroom door, which is only a few feet from the patient bed. The angled headwall embraces the patient, while allowing sufficient space for caregivers. HDR Architecture, Inc.

Wayfinding is especially important in a building with horizontal movement spanning four football fields. A visioning workshop conducted with key members of the hospital planning team, patients, and family members, developed concepts that help drive master planning for interior design and wayfinding. The five pavilions will reflect the natural elements found in abundance on the site and are symbolically represented in the overall wayfinding system. Individual color and conceptual schemes were developed to unify yet differentiate the buildings.

Patient privacy and control drives much of the circulation, with onstage and offstage circulation corridors and dedicated elevators. The design provides for staff circulation at the back of the building, facilitating movement between clinics. In addition, the overall ambulatory design can easily adapt to future change as shown in figure 5. “When building a facility with this kind of investment, we make it as flexible as we can”, says Julian Jones, AIA, Project Manager, HDR Architecture, Inc. “We know that over the next few years, the staff will adapt this facility for new technologies and treatment modalities.”

Outpatient Clinic Module. Public circulation corridors are pushed to the exterior walls, providing exposure to the gardens and enhancing orientation. HDR Architecture, Inc.

Other staff support features include ceiling-mounted lifts and distributed staff support areas. Ceiling-mounted lifts in multiple inpatient locations will support reduction of staff injuries. Distributed staff support areas are intended to reduce staff fatigue by providing in-room cleaning materials, linens, and medications, illustrated in figure 6. Shared work rooms between satellite stations promote communication among staff, which is especially important for the military, says Major LaShanda Cobbs, a nurse and Nurse Methods Analyst at Belvoir. “We have a large cohort of new graduate nurses and the shared work rooms provide the opportunity for collaboration and learning.” A major goal is promoting team effectiveness, with half-height glazing in workrooms, allowing a visual connection with the unit and quiet work space to allow private consultations, as well as staff lounges with natural light to reduce fatigue and improve circadian rhythm adjustment for shift workers.

Within each patient room, sinks are unavoidably obvious. Flooring changes and wall tile guide the eye to hand washing opportunities, with a spotlight positioned directly above the sink. HDR Architecture, Inc.

“This new hospital will be the perfect setting for our new ‘Culture of Excellence’,” says Colonel Chuck Callahan, MC, the current commander of the Fort Belvoir hospital. “Modeled after great organizations like Baptist Health, we are working to reinvent the culture of the current Fort Belvoir hospital with an emphasis on improved outcomes and customer and employee loyalty. This will be the culture we carry with us to our new, facility, based on evidence-based design (EBD).”

Guiding principles

One of the challenges facing the MHS was how to implement system-wide design strategies that would improve clinical, safety, and organizational outcomes. In January 2007, William Winkenwerder, MD, former Assistant Secretary of Defense for Health Affairs, provided the initial policy statement for implementation of EBD across the MHS. He directed “the respective design teams to apply patient-centered and evidence-based design principles across all future medical military construction projects”.1 This policy direction supported the establishment of system-wide principles, goals, and design strategies intended to produce measurable improvements in clinical, safety, and organizational outcomes. The MHS produced a report, Evidence Based Design: Application in the MHS, to guide the application of EBD across a facility's life cycle.2 The report notes that while there is considerable evidence for many design features, more research is needed to validate and guide the complex process of healthcare design. Table 1 shows the five principles, their related goals and the desired outcomes established for the MHS.

EBD Principles



1. Create a Patient and Family Centered Environment. Sample responses:

  • Family zones in patient rooms; waiting rooms

  • Comfortable lounges with movable furniture

  • Systems approach to wayfinding

  • Welcoming parking and arrival areas

Increase social support.

Reduce spatial disorientation.

Improve patient privacy and confidentiality.

Provide adequate and appropriate light exposure.

Support optimal patient nutrition.

Improve patient sleep and rest.

Decrease exposure to harmful chemicals.

Improve patient and family satisfaction.

Fewer patient falls and medication errors.

Decrease staff time providing directions.

Decrease length of stay.

Decrease healthcare costs.

2. Improve the Quality and Safety of Healthcare. Sample responses: See Table 2

Reduce airborne transmitted infections.

Reduce infections spread through contact.

Prevent waterborne infections.

Reduce medication errors.

Prevent patient falls.

Reduce noise stress and improve speech intelligibility.

Reduce the number of hospital-acquired infections (HAI) and associated patient morbidity, mortality, and cost.

Reduce number and associated costs for staff with HAI.

Decrease number of medication errors, patient falls.

Improve sleep and rest by achieving WHO recommended noise decibel levels.

3. Enhance the Care of the Whole Person (Contact with nature and positive distractions). Sample responses:

  • Windows, control of light, glare, temperature

  • Operable windows

  • Exposure to morning light

  • Access to light and positive distraction

Decrease patient and family stress.

Increase patient satisfaction.

Decrease use of pain medication.

Decrease patient length of stay.

Create a Positive Work Environment. Sample responses:

  • Windows throughout

  • Control over light glare and temperature in work spaces

Decrease back pain and work-related injuries.

Reduce staff fatigue.

Increase team effectiveness.

Eliminate noisy, chaotic environments.

Decrease staff and patient injuries associated with patient handling.

Increased time caring for patients.

Decrease staff stress, fatigue, burnout, and turnover.

Increased staff satisfaction.

Decrease errors resulting in increased healthcare costs.

Design for Maximum Standardization, Future Flexibility, and Growth. Sample responses:

  • Acuity-adaptable rooms

  • Larger patient zones

  • Seamless IT integration

  • Modular approach

  • Shelled space

Reduce room transfers.

Facilitate care coordination and patient service.

Improved patient satisfaction, quality of care, staff efficiency, and associated costs with acuity-adaptable rooms and multidisciplinary service collocation.

Reduce resources required to support episodic healthcare missions with anticipatory space.


Evidence-Based Design Features


EBD Principle 2: Improve the quality and safety of health

Reduce HAIs: contact, airborne and waterborne transmitted

  • Single-patient rooms with highly visible and separate hand-washing sink

  • Gel dispenser devices in multiple inpatient room locations.

  • Increased use of HEPA filtration in those zones in which the most vulnerable patients receive care: e.g., inpatient units, OR, cancer care.

Standardized data collection for the following HAI patient outcomes according to the National Healthcare Safety Network:

  • Central line-associated bloodstream infection

  • Umbilical catheter-associated bloodstream infection

  • Dialysis access-associated infection types

  • Ventilator-acquired pneumonia

  • Urinary catheter-associated urinary tract infections

  • Surgical site infections

Reduce medication errors

  • Inpatient medication preparation rooms with optimal lighting and which are enclosed to minimize distractions and interruptions.

  • Distributed staff support elements to maximize time at the bedside.

  • Decentralized medication administration into the patient room.

  • Optimal lighting in the pharmacy.

Compare pre- and postoccupancy inpatient and outpatient medication error data.

Prevent patient falls

  • Single patient rooms.

  • The bathroom is located on the bed headwall with handrails provided along the wall to minimize the “no grab” zone for patients who move to the bathroom unassisted.

  • Distributed staff support elements are planned to minimize staff time away from the patient.

  • Nonslip sheet vinyl flooring in the inpatient rooms that has the best record for reducing slips and trips.

  • Rubber floors are planned for 80% of the floor surface in the hospital.

Compare pre- and postoccupancy inpatient and outpatient patient fall data.

Reduce noise stress and improve speech intelligibility

  • Single-patient rooms.

  • High performance sound absorbing acoustical ceiling tiles are planned.

  • Noiseless paging and alarms, hands-free communication, and ice machines located in enclosed rooms.

  • Carpet is planned for the inpatient unit corridors and outpatient offices and waiting rooms

  • Satisfaction survey with regard to noise stress. Note particularly the satisfaction of inpatient behavioral health patients who will be cared for in semiprivate rooms.

  • Develop a staff satisfaction survey including questions that examine staff experience with noise stress and speech intelligibility that can be used pre- and postoccupancy.

  • Determine if speech intelligibility contributed to unacceptable patient outcomes.

Principle-driven, EBD decisions were made explicit with the use of a system of checklists that identify the features for each of the EBD principles and goals.3 Employing the checklists during design sessions and on board reviews ensured that “the overarching EBD principles and goals of the project were not being lost in the day-to-day battles that go on with design,” commented Tony Cicci, AIA, a strategic planner for Noblis, Inc. Table 2 demonstrates the goals, methods, and results of EBD.

EBD shaped the design process

For the designer, a particularly remarkable feature of this design process is that many decisions at Fort Belvoir can be traced back to specific guiding principles and goals. For example, single patient rooms help achieve multiple objectives including improved patient privacy, sleep and rest, and safety, as displayed in table 3.

EBD Feature

Overarching Principles

Design Drivers

Single-patient rooms

Create a patient- and family-centered environment.

  • Increase social support.

  • Improve patient privacy and confidentiality.

  • Improve patient sleep and rest.

Improve the quality and safety of health.

  • Reduce hospital-acquired infections.

  • Prevent patient falls.

  • Reduce noise stress.

Enhance care of the whole person.

  • Decrease patient and family stress.

The MHS commitment

The new generation of military medical facilities represents a transformation of the MHS and a reaffirmation of commitment to support those who serve. The growing awareness and importance of healing environments was influenced by professional dialog with The Center for Health Design, researchers at leading institutions, and innovators in the private sector.

The MHS is committed to becoming an engaged partner in the growing EBD community. A cosponsor of the Evidence-based Design 2.0 Collaborative Research Workshop in March 2008, the MHS also shares reports, checklists, and lessons learned with any interested parties. Motivated to challenge past practices, the MHS is creating environments that contribute to improved outcomes, safety, and operational efficiencies.

The EBD process for the MHS and for Fort Belvoir demonstrated the value of the existing evidence and the importance of collecting new evidence. The MHS views The New Community Hospital at Fort Belvoir as a testimony to their commitment to grow the body of evidence existing today and to disseminate what they learn to improve the outcomes for patients and their families and the staff who care for them.

Michelle Ossmann, RN, NP, is a PhD Student at the College of Architecture, The Georgia Institute of Technology. Clay Boenecke is Chief, Capital Planning Branch, Portfolio Planning and Management Division TRICARE Management Activity Office of the Assistant Secretary of Defense for Health Affairs. Barbara A. Dellinger, IIDA, AAHID, is Director Health Care Interiors-East Coast, for HDR Architecture, Inc.


  1. Winkenwerder WJ. Memorandum, Subject QDR Roadmap and Evidence Based Design. 22 January 2007:Washington D.C.:The Pentagon
  2. Malone E, Mann-Dukes JR, Strauss J. Evidence-Based Design: Application in the MHS. 1 August 2007. Noblis, Inc., Falls Church Virginia.
  3. Malone EB, Mann-Dooks JR.MHS Evidence-Based Design Review Checklist, 8 October 2007, produced for the Military Health System TRICARE Management Activity Portfolio Planning and Management Directorate through a contract with Noblis, Falls Church, Virginia.


“In my 30 years of practicing medicine and caring for patients and families, I have come to believe that people tend to rise to their environment. Hospitals that are world-class elicit a world-class standard of behavior. We are committed to learning and partnering with the best, to the advancement of knowledge and care.”

—S. Ward Casscells, MD, Assistant Secretary of Defense, Health Affairs


Fort Belvoir Community Hospital

Architecture: HDR/Dewberry Joint Venture

Program manager: Jim Draheim, AIA (HDR Architecture, Inc.)

Deputy program manager: Tom Christiansen, PE (Dewberry & Davis, LLC)

Project managers: Julian Jones, AIA; Jim Thomson, AIA (HDR Architecture, Inc.)

Medical planner: Ramesh Loharikar, AIA (HDR Architecture, Inc.)

Architectural designers: Jeff Getty, AIA, LEED AP (HDR Architecture, Inc.); Mark Scott, AIA (Dewberry & Davis, LLC)

Interior designer: Barbara Dellinger, AAHID, IIDA (HDR Architecture, Inc.)

Sustainability: Lidia Berger, LEED AP (HDR Architecture, Inc.)

Civil Engineer: Tim Culleiton, PE (Dewberry & Davis, LLC)

MEP, Structural, Security, and Telecom: HDR/Dewberry Joint Venture

Landscape Design: lee + papa associates, inc.

Healthcare Design 2008 November;8(11):28-38