For many years, healthcare architects have made intuitive choices as to which design strategies work best. We’ve deployed comforting patient rooms, daylighting, views of gardens, efficient workflow patterns, and thoughtful ergonomics. We’ve known in our hearts that these strategies were useful to improve patient care quality and workplace effectiveness.

But in this era of reduced health system capital resources, our clients need some convincing that intuitive design strategies make a measurable difference in quality and outcomes. Architects increasingly need to bring the evidence.

During the past 10 years, we’ve seen the emergence of evidence-based design (EBD) as the hottest topic in healthcare building strategies. But in practice, it can be difficult to interpret the research and apply it. In addition, most project fees and schedules simply don’t provide enough time to engage in the rigorous EBD process, such as the one advocated in The Center for Health Design’s Evidence-Based Design Accreditation and Certification (EDAC) program.

So how can designers know which design strategies link most closely to the desired outcomes for patient experience, safety and quality, and workforce effectiveness?

One way is to apply summarized findings from available literature searches. For the design of the new Dally Tower at MultiCare Good Samaritan Hospital in Pullyup, Washington, the team turned to the landmark paper “A Review of the Research Literature on Evidence-Based Healthcare Design” by Ulrich, (published in the Health Environments Research and Design Journal , Spring 2008). Although four years old, it’s still the best readily available survey of research findings connecting design strategies to healthcare outcomes.

The paper summarizes research on environmental factors for reducing hospital-acquired infections, medical error rates, patient falls, pain, stress, and length of stay, as well as for improving sleep quality, speech privacy, communication, social support, and staff effectiveness. The lessons found in the paper were then applied to the project in a number of ways. (See the sidebar below, “Breaking Down the Research” for details on the findings that most influenced the design decisions, and why.)


A central focus
During 2007 and 2008, the Good Sam Design Collaborative designed the new tower to replace 160 beds as well as the emergency, surgery, and imaging departments. Clark/Kjos Architects, with offices in Portland and Seattle, and GBJ Architecture, based in Portland, formed the joint venture behind this project.

The Dally Tower opened in spring 2011. The nine-story, 357,000-square-foot building is a slender tower located on a hill, oriented to maximize views of surrounding landscape and mountains. The client’s philosophy to put the patient and family at the center of care inspired the building’s architecture, layout, and interior design. The design creates a therapeutic patient and family experience through simplified wayfinding, natural light, nature views, four therapeutic gardens, and thoughtful inpatient units.

Increased access to daylight played a large role in the design direction. Natural light is celebrated throughout Good Samaritan’s patient pathways, starting at the parking and drop-off area. Glass canopies cover walks and entries to protect from rain while enhancing daylight. Inside the entry lobby—a space with 25-foot-high windows on two sides—visitors are immersed in a light-flooded central circulation hub. It opens to, and shares its light with, glass elevators, glass-fronted admitting offices, adjacent imaging waiting, and surgery waiting a level below.

Other areas benefit from abundant natural light, as well: Emergency admitting/triage, surgery prep and recovery areas, and inpatient rooms all have unusually large windows for light and views.


Other factors in play
Private rooms. Because private patient rooms have been shown to improve sleep, reduce stress, reduce medical errors, lower hospital-acquired infections (HAI), and more, Dally Tower was designed to contain all private rooms—82 beds finished and 80 shelled—with the exception of one four-bed ward for memory-care patients requiring increased supervision.

Acuity–adaptable rooms. When used for multiple care levels, acuity-adaptable rooms have been shown to reduce medication errors, patient falls, length-of-stay, and staff injuries. At Good Samaritan, one floor of 40 beds was designed to be acuity-adaptable. These rooms are not currently used as “universal rooms” where patients remain for multiple levels of care—but this is a flexible operational model that can be implemented in the future. 

Family accommodations. Research shows multiple benefits from family accommodations within patient rooms. At Dally Tower, each patient room has a family zone where a family member can sleep over or just comfortably relax during the stay. There is some evidence that a comfortable family lounge in inpatient units encourages family members to stay close to the patient.

Ceiling lifts. There’s ample evidence that ceiling lifts in patient rooms reduce staff injuries significantly and, consequently, hospitals realize financial benefits. Good Samaritan elected to provide tracks for ceiling lifts in every patient room. Motors and gantries are installed in a limited number of rooms to start. Over time, more can be added easily if need increases.

Decentralized inpatient unit resources. There’s some evidence that decentralized medications, linen, equipment, and supplies allow for more direct patient care time. (Clark/Kjos Architects is currently finalizing in-house research that supports this thesis, as well.) Here, staff centers are also decentralized to reduce steps while preserving staff socialization. Each 40-bed floor is divided into four 10-bed modules. Each pair of 10-bed modules has staff work centers back-to-back to provide easy access for staff, as well as support for mentoring and patient care communications. Supplies, linens, medications, and equipment rooms are placed in the core area between and shared by two 10-bed modules, providing nursing staff with close access. In addition, each patient room has a locked cart for oft-used supplies to further save steps.  

HVAC system. Good Samaritan’s HVAC system is designed for 100% outside air supply to all areas of the new tower. Much research has been done showing that better filtration systems, for returned air within the hospital, reduces HAI rates from airborne pathogens. We believe that by not returning any air from within hospital spaces, combined with high-efficiency filtration of outside air, the highest HAI reduction due to airborne pathogens can be achieved.


More tools coming for EBD
We found the literature survey to be the best way to efficiently identify areas of correlation between design strategies and healthcare outcomes. We know of no other method to apply EBD without a detailed (and expensive) individualized literature search. There is hope for improvement: the AIA Academy of Architecture for Health is currently working with The Center for Health Design to develop the Research Repository. The aim is to create a tool that healthcare architects and designers can readily access to show their clients that doing the right thing pays off in better patient, staff,
and bottom-line outcomes. Stay tuned.

Tom Clark, AIA, EDAC, is Principal at Clark/Kjos Architects, and Chair, Research Initiatives Committee at AIA Academy of Architecture for Health. Herb Giffin, AIA, ACHA, is Founding Principal of GBJ Architecture.


SIDEBAR: Breaking down the research
The new Dally Tower at MultiCare Good Samaritan Hospital in Pullyup, Washington, provides an example of how to apply a seminal literature review as a tool to connect design strategies with potential and probable outcomes. The team of architects, interior designers, and the client user group worked together to create a framework for application of evidence-based design (EBD) principles. We started by using literature searches to uncover applicable research and then created a simple matrix tool to organize information to directly correlate desired outcomes with design strategy.

This matrix tool was used to:

  • Apply research findings where there was compelling evidence;

  • Determine which design strategies were promising but not yet proven—these may still be used, and could be an opportunity to draw upon the project as further research to test the strategies’ success;

  • Communicate reasons behind design decisions to the entire team; and

  • Inspire confidence that the project will support EBD outcomes, in order to help the client do the right thing.