The Center for Health Design (CHD) has successfully achieved one of the goals for its Environmental Standards Council (ESC), which is to develop language that would be the basis for what has now been taken forward into the “shaded text”—the language proposed by the Environment of Care (EOC) work group of the Health Care Guidelines Review Committee (HGRC) for inclusion in the 2005/6 addition of the AIA Guidelines for Design and Construction of Hospital and Health Care Facilities. The ESC is an interdisciplinary group of dedicated professionals committed to working toward the improvement of the patient experience and outcome through the development of more appropriate physical environments.

The proposed “shaded text” essentially defines the key elements of the physical environment that, when appropriately managed, have the greatest effect on patients’ well-being and, moreover, define the overall environment of care, of which physical environment is one component. This “shaded text” is being released for public review and comment possibly this November, and it will be presented at the ESC's final meeting, scheduled for summer 2005. If the changes survive this meeting, they will then become part of the final, nationally recognized AIA document. A summary of the information being considered follows.

First, the proposal includes a recommendation to relocate the requirement for preparing a “functional program” (i.e., a document that relates functional operations to the physical spaces to be designed, including square footage for each department or program area) from Chapter 1, where it is very easily overlooked, to Chapter 2, where it can be more readily found and referenced.

Second, the proposal suggests that the scope of the functional program be expanded to include addressing the six components in the Environment of Care and the eight key elements in the Physical Environment.

The six components defining the Environment of Care are the result of applied systems thinking that I introduced to our field some years ago, based on more than 20 years’ experience, and they have since been validated by the ESC and the HGRC. The eight key elements of the Physical Environment are supported by research from the Picker Institute and formally recognized by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in its Management of the Environment of Care Overview.

The six components comprising the Environment of Care are descriptions of the:

In the past each of these components was thought to be independent of the others. They were treated as separate, sometimes sequential, but always unrelated activities. The interrelationship among these components, however, is critical to maximizing the potential outcome of any project. figure 1A is a representation of traditional thinking about the design process, which allows each component of the Environment of Care to change without affecting the others. figure 1B represents an example of a component's supposed ability to change without affecting the other components.

figure 2Arepresents a more realistic relationship among the components, and figure 2B illustrates the effect that change in one component will, in fact, have on the others. These diagrams demonstrate the importance of an interdisciplinary team's addressing all the components at the same time to maximize the design project's potential outcome.

The eight elements of the Physical Environment (one of the six components) are:

In both diagrams, the squiggly line represents “Change.” The large, light purple hexagon in this diagram indicates the design process, and the colored triangles represent each of the components in the Environment of Care. The light purple space between them exemplifies the traditional understanding of the separateness of these activities as they are undertaken in the design process.

In both diagrams, the squiggly line represents “Change.” This example indicates a significant change in the yellow triangle (“Systems”) and the expectation that it will have no effect on the other triangles in the overall process.

In both diagrams, the squiggly line represents “Change.” This is a more appropriate depiction of the relationship among the components in the Environment of Care. The lack of space between the components exemplifies how closely they are related.

In both diagrams, the squiggly line represents “Change.” This example indicates that a significant change in any of the components is expected to have a direct impact on the other components (triangles) in the overall process.

Each of these eight key elements has appendix language in the “shaded text” document, giving examples of how these elements can be addressed as a project is implemented.

It is understood that not every institution and/or project may be able to address all of these areas at the same time, but it is important for all to note that these components and key elements do directly affect each other.

Having information of this type defined in the functional program will allow the Authorities Having Jurisdiction (AHJs, as they are described) to monitor whether the institution's performance goals relative to its functional program have, in fact, been achieved.

The Center's ESC is also working on the development of an awards program that will encourage excellence in the design of medical equipment. This is being undertaken with the understanding that advances in medical technology continue to change the overall healthcare delivery system and directly affect the physical environments within which that care is delivered. A heightened level of awareness by those who design medical equipment regarding the patient's relationship to their equipment can substantially improve the patient's experience in receiving care. This is true both for large diagnostic/treatment equipment, such as MRIs and linear accelerators, and smaller monitors and pumps used in everyday patient care.


History has shown that “process” and “outcome” are directly related. We cannot expect innovative outcomes from a linear, fragmented assembly-line process dating back to the industrial revolution. Interdisciplinary teams working together toward common goals will ultimately revolutionize our experiences and outcomes. When all is said and done, our successful process will not only be evident in the increased quality of and access to care for all who need it, but it will also be reflected in culturally responsive spaces and facilities, and the warmth and caring that the community, patients, families, visitors, and staff experience in healthcare environments across the country. HD

Alberto Salvatore, AIA, NCARB, now with the firm MSW+ Architecture, Cambridge, Massachusetts, has led both the JCAHO and the HGRC efforts for The Center for Health Design and is the national leader in the development of the Interdisciplinary Design Team (IDT) approach to project delivery.