When designing inpatient units, patient room handedness is a hotly debated topic. Many hospitals are adopting the standardized same-handed room concept at all levels of patient care. While it is argued that standardized same-handed rooms offer greater levels of safety and efficiency in comparison to standardized mirror-image rooms, there is little empirical evidence to either support or refute the contentions.

Dr. Ray Pentecost, FAIA, ACHA, president of the AIA Academy of Architecture for Health, and director of healthcare architecture for Clark Nexsen, and Dr. Debajyoti Pati, FIIA, LEED AP, director of research with HKS‘s clinical solutions and research group, who just concluded the first empirical study on patient room handedness, discuss their thoughts on whether standardized same-handed configurations contribute more to operational performance than standardized mirror-image configurations.

Are you “for” or “against” same-handed patient rooms?

Dr. Ray Pentecost, FAIA, ACHA:

If there was clear empirical support for a position of “for” or “against” same-handed rooms, it would be easy to answer this question. In the absence of clear findings, my answer is undecided. Much of the support for same-handed rooms is based either on 1) the established success that standardization has had in other industries, or 2) speculation that it is simply a better design solution. This questionable assumption of what researchers might call “external validity of results from one research situation to another with no clear empirical support” is a dangerous practice.

Dr. Debajyoti Pati, FIIA, LEED AP:

I am for standardization, but I cannot endorse same-handed patient rooms as of yet. If based on sound theoretical principles, logical arguments in favor of mapping solutions can be supported-with appropriate validation in the new context. The same-handed concept, however, does not show up in any standardization literature in other industries. What appears to be happening is that wide-scale application of the same-handed concept is occurring without any precedence in other industries or empirical validation in the healthcare context.

What does the same-handed room concept offer?

Pentecost: Error reduction is one hypothesized outcome of the same-handed room configuration. I understand the premise that, in complex systems, there are fundamentally two kinds of errors: 1) latent conditions (the built environment) and 2) active failures (by workers). The theory is that one attempts to optimize the built environment to address the first type of error and that by making all the rooms the same, the cognitive burden of staff is reduced, thereby reducing the error rates in those spaces. The theory is fine, but there is no strong evidence supporting the theory.

Pati: The potential of improved safety from standardization is generally accepted. However, there appears to be a blurring of the concepts of standardization and same-handed rooms. The two concepts are being used as synonyms, which is not true.

Are the terms “same-handed” and “standardization” synonymous?

Pentecost: The answer is both yes and no. When I use the term standardization, it must be defined at the scale of design being applied. For example, the level of a design component can be standardized, such as individual components on a headwall, linen storage versus the entire storage capacity, or plumbing fixtures compared to the entire bathroom. At a slightly larger scale, zones for caregivers, patients, or family can be standardized. When the entire room is standardized, including handedness, it is reasonable to say that standardization and same-handedness are essentially the same. There is still one more scale at which standardization could be defined: by nursing unit.

Pati: From my viewpoint, standardization and same-handed are not synonymous at any scale. Standardization is a generic concept that involves the process of configuring the attributes of a physical entity to maintain a certain type of uniformity across multiple instances. Same-handed is an example of a rule of the standardization concept. Both standardized same-handed and standardized mirrored configurations are achievable using sets of uniform rules. In my opinion, we are discussing different dimensions of standardization that need to be carefully articulated, and not clubbed together.

Caregiver equipment/component interaction is different from search-and-locate tasks, and needs different types of standardization. Handedness has been discussed in relation to search-and-locate tasks. Search-and-locate issues are much more relevant at the unit design level, which is not related to handedness. It is also pertinent at the component design level (interior of meds/supply storage, etc.), which is also not related to handedness.

Does the same-handed concept provide the ideal location for caregiver positioning vis-à-vis the patient?

Pentecost: You can answer this question two ways. One way, which I consider somewhat troubling, is to respond to the suggestion that the design is being used to create one-size-fits-all, standardized behaviors. I am generally uncomfortable with this approach, but if you can empirically defend the notion that a new process and workflow needs to be developed and that the design can be a contributor to that evolution, then I am fine with the heightened influence of design. Alternatively, you could look closely at the behavior of nurses and other clinicians and ask which aspects of their work are best supported by room standardization. This, I believe, is a more constructive approach. The answer lies in the scale of the standardization. However, a word of caution: Differences in behavior based on the handedness of the healthcare provider cannot be ignored when trying to standardize room design.

The theory is fine, but there is no strong evidence supporting the theory.-Dr. Ray Pentecost

Pati: Our study failed to discover any consistent ideal location of caregivers and identified a number of factors influencing a caregivers’ decision to be on a certain side of the patient. These factors had similar effect irrespective of caregiver handedness. The very notion of an ideal caregiver position (or handed environment) is not supported by empirical data. Based on our data, a standardized neutral-handed environment (if feasible) may offer the best behavioral support.

Do you feel that the standardized same-handed room concept contributes more than the standardized mirror-image concept in an acute medical-surgical setting?

Pentecost: Same-handed room design may make the most sense in patient care areas that involve life-and-death situations, such as an ICU or other critical care units. The theory is that standardization of design and technology placement makes sense to reduce errors involving cognitive function in high-tech areas.

Pati: Some standardization concepts make sense in acute medical-surgical settings. Standardizing equipment, medication, and supplies locations at the unit level for minimizing search-and-locate behavior is extremely important from a safety viewpoint. Standardizing individual components (headwalls, supply and medication cabinet interior, technology interface, etc.) are important from a human-equipment interaction perspective. This phase of our study, however, did not find any evidence in favor of patient room handedness.

Are there additional costs in implementing the same-handed concept?

Pentecost: My answer is yes and no. It is acknowledged that additional plumbing and piping expenses are associated with mechanical support chases not shared between rooms. This is the case with a mirror design, or left-hand/right-hand configuration for patient rooms. However, savings can be created by properly managing the other details of the constru
ction with prefabricated, modular, or pre-manufactured components. More importantly, designers should bear in mind that initial costs are relatively insignificant compared to the costs of operation for the life of the patient unit. Decisions about mirror-design or same-handed design should be made with careful attention to their impact on staffing and related operational costs.

Pati: In general, standardization should reduce costs. However, much of the conversation around standardization today relates to same-handed rooms. Through our study, we found that the same-handed concept may not have a major impact on operations and, hence, operational costs. We know the conversation is much bigger when you look at design from a long-term, operational cost perspective. Currently, robust studies on cost differential are not available from an operational performance perspective. Until we have this empirical data in hand, we will not be able to make truly informed decisions.

When designing a new or replacement medical-surgical unit, it is important to review the benefits and disadvantages as well as the costs of adding same-handed rooms. Do the additional costs equate to overall safety for patients and staff? Will overall standardization improve clinical processes?

Does the same-handed concept need further examination? At this time, the industry has a simplistic and deterministic view of healthcare environment standardization. Only further empirical studies will quantify and justify the use of same-handed rooms in healthcare facilities.

Dr. Debajyoti Pati’s research paper “An Empirical Examination of Patient Room Handedness in Acute Medical-Surgical Settings” was named the Best International Research Project at the 2010 Design & Health International Academy Awards. The award was presented at the 6th Design & Health World Congress held June 8 at the University of Toronto in Canada. The study was funded by the Academy of Architecture for Health Foundation, Herman Miller Inc., UTA Smart Hospital, and HKS, Inc.

Jeff Stouffer, AIA, is national group director of healthcare strategic development at HKS, Inc. For more information, visit the AIA Academy of Architecture for Health’s Web site at www.aia.org/aah or HKS, Inc.’s Web site at www.hksinc.com.