The Center for Health Design is comprised of an interdisciplinary group of healthcare and design professionals who passionately believe, at a minimum, that:

  • Patients should be able to devote their energies to getting well without having to fight their environments.
  • Doctors, nurses, and staff should be able to go to work every day without worrying about getting sick, injured or stressed because of the design of the environment, and
  • Sustainable buildings that are built using an evidence-based process can improve the quality of care, save lives, provide more cost effective healthcare and contribute to a healthy planet.

The year in review

For many of us, 2009 was a challenging year. The American healthcare industry, impacted by the economic climate, put many previously planned building projects on hold, (in some cases, indefinitely), which in turn created layoffs in the architectural and design community. The newly elected Obama Administration indicated that healthcare was a primary focus but the stimulus packages have been unable to provide relief in any direct way to the healthcare design industry.

In spite of these economic challenges, our industry has still made significant advancements in the last twelve months in terms of what we understand about the impact of the built environment on health and safety. The number of rigorous scientific studies that support using an evidence-based design (EBD) process has grown, several excellent new books were published about EBD, and we have defined and standardized the EBD process and created benchmarks for measuring a professional's capabilities and knowledge of the most current thinking and research in this area. As a result of all of this activity, the evidence base has grown, there are more people practicing EBD, and more resources available than ever before.

It's impossible then, not to notice the attention EBD is receiving in the United States. Many American healthcare systems are now inquiring about the EBD process and some are applying it. In addition to this increase in awareness and acceptance of EBD domestically in the past year, The Center for Health Design began to see a surge of interest in EBD globally. Something is striking a chord in countries outside of the United States as evidenced by the visitors to The Center's website, attendance at the HEALTHCARE DESIGN conference, and international enrollment in the Pebble Project and the EDAC (Evidence-Based Design Accreditation and Certification) program.

All of this progress, while remarkable, is not enough for us. Much work still needs to be done to achieve our vision, as there are those in the healthcare community at home and abroad who don't understand the impact of the built environment on health and safety. Providing continued education and information to our colleagues represents a critical step to institutionalize EBD as an accepted and credible approach to improve healthcare outcomes.

How will we know when our vision for the healthcare industry is a reality? When all hospitals and healthcare facilities are designed and built using the most current research and thinking to support the best outcomes for people who spend time in them. The stakes are enormous. In order to study the role the built environment plays in improving outcomes we must have dedicated and disciplined EBD professionals who are committed to expanding credible EBD research through their respective disciplines. We expect change to be prominent, positive, and significant and passionately believe that all healthcare and design professionals should understand and be able to apply evidence-based design.

“Ten in Ten”: 10 issues we're watching in 2010

Looking forward to the rest of 2010 and beyond, with the continued challenges that lay ahead, there will be new and higher expectations from all of us about what we design every day. At press time, it was feasible that some version of the Senate bill to reform healthcare in the United States would be a done deal by late January, but it is still unclear how, what is essentially healthcare insurance reform, will impact the American market and beyond for the healthcare design industry.

In the next two years or so healthcare industry players will figure out what it all means and there will most likely be far-reaching ramifications. In the meantime we must all begin to broaden our definition of what we consider healthcare environments and expand avenues to improve healthcare outcomes by harnessing the potential of the built environment. We must also work to ensure that healthcare organization leaders from all types of care settings understand the value proposition of EBD as they make investment decisions and embark upon capital projects. We hope that you will share our passion and continue to embrace and champion the evidence-based design process. Your engagement is critical to success, no matter what part of our industry you serve.

Below, in no particular order of importance, are some of the biggest issues/questions we're currently fielding at The Center for Health Design, both from within the United States and overseas; from people who work in the healthcare industry and others whose job it is to follow, comment, and report on it. These are the things that we'll be paying attention to and spending lots of time in discussions about this year as it relates to the built environment. We welcome your thoughts and feedback on this list. What discussions are you having at your organization? What issues do you think The Center and our industry should be focusing on?

1. Intense need to reduce healthcare costs

We are seeing cost cutting increasingly becoming the focus. With the American healthcare industry in a state of perpetual crisis due to skills shortages, trying to keep pace with new knowledge and technologies and unprecedented demand from aging baby boomers, healthcare institutions are working on trying to aggressively shave costs from the system.

In this increasingly competitive environment, building any type of new building or undertaking a major renovation is likely to be the biggest financial decision that a CEO or board of trustees will ever make. As part of their fiduciary responsibilities, more and more hospital leaders and boards are now looking to base decisions about capital projects on cost-effective EBD interventions that can help re-engineer workflow, care processes, and methodologies.

2. Alternative care models and community wellness

New models of care are emerging as traditional care gives way to alternatives outside of physicians' offices and hospitals. There has been an unprecedented federal government stimulus lead opportunity to retool the infrastructure of ambulatory care and safety-net clinics with funding for bricks and mortar, capital equipment, design fixtures, and services. In 2010, we expect to see a new social responsibility for community health become apparent, supported by a major boost in funding from the government.

We're also expecting to see an increase in the number and scope of services offered by work site, retail health clinics, and home health services, and a broader approach to the definition of healthcare environments that includes models such as the medical home and safety net clinics, where significant amounts of care will be delivered in time. Many safety net clinics have never built a new healthcare facility or ever envisioned overseeing the planning, design, or construction of one. Moving forward with building or renovation projects with some basic knowledge for implementing the task at hand can increase the likelihood of creating buildings that produce the highest level of health and economic outcomes. There is an enormous opportunity to tap into credible expertise to help navigate a path from inception to the completion of a successful project.

Looking Ahead

We invited members of The Center for Health Design (CHD) community to express what they would like to see happen in the healthcare industry in 2010 and beyond, pertaining specifically to the design of healthcare environments and the people they support. The views expressed are the views of the individuals and do not necessarily reflect the official views or policies of the organizations they work for.

“In addition to continued pursuit of more efficient project delivery, application of sustainable and other resource-saving practices and use of all strategies that lead us toward improved patient outcomes, we need to continue a strong focus on design and improving the human experience in healthcare environments. We have accomplished a lot since the early 1970s but we have more to do. In addition to improving the design of these environments, both internally and externally, we should focus on innovations that are attractive but inexpensive, convey energy but are soothing, and can be easily replicable in resource-challenged regions domestically and around the globe. I remain optimistic; our best days in healthcare and healthcare design are still ahead.”

Patty Looker, FACHE, EDAC

Principal/Healthcare Director

VOA Associates Incorporated

“I hope that more healthcare decision-makers will recognize the significant return on investment possible with evidence-based design features. This ROI can help to reduce healthcare costs, an important aspect of healthcare reform.”

Ben Davenny

Senior Acoustical Consultant


“My New Year's wish for the healthcare industry in 2010 would be that healthcare designers would continue to educate themselves to understand the environments that they are specifying based on research as much as possible, understanding that what we do has a huge impact on people who build, work and are cared for in these spaces. Not only are we in the business to have a livelihood but are lucky enough to have a purpose to our work that can be a positive influence on those who are rejoicing in some of their most happiest moments or saddest and those who care for them.”

Pamela Gamble

Interior Designer

Productive Business Interiors

“I am intrigued by potential in our industry to support control of the ‘costs’ in sustaining quality in life and health. Too often constraints, inefficiencies, and ‘silo’ barriers restrict even progressive and creative operational concepts. The good news is that people are recognizing the important links between strategy, operations and facilities, and beyond into the networks of commerce, community, and the environment where quality is best sustained.”

Donovan K. Smith, Jr., AIA, ACHA, EDAC, LEED AP

Healthcare Planner

KTH Architects

“In the economic climate that continues to challenge healthcare, practitioners of evidence-based design will need to offer solutions that contribute to the bottom line sooner rather than later. While research inherently takes time, short-term studies can yield powerful results which can be incorporated into design, especially renovation projects that may have to suffice until new construction projects can begin. Practical, affordable, immediate design solutions will keep the interest alive in evidence-based design in 2010.”

Kathy Hathorn

CEO and Creative Director, American Art Resources

“I would like to see a total change of culture-not just in pretty words but in a dynamic way-in the way the healthcare industry examines the ethics of healthcare and the principles of delivering quality care. In terms of patients and residents, culture change would mean a dedication to having the customer (resident or patient) drive the type and quality of healthcare provisions they would receive. I would like to see the healthcare professionals-both research and practitioners-partner with the customer. I would like to see a more profound recognition and understanding of cultural differences that influence the outcomes of healthcare practices; I would like to see western healthcare providers embrace a more integrative approach both in philosophy and practice. And I would like to see passion and commitment restored to the healthcare industry by the healthcare providers.”

Jeanette Perlman

COO, MJM Associates, LLC

“My wish for healthcare in 2010, would be for the launch of the much awaited LEED for Healthcare (LEED-HC), the United States Green Building Council (USGBC) sustainable design toolkit for healthcare facilities. The healthcare design industry has benefited tremendously from having the Green Guide for Health Care (GGHC) as the sustainable design best practices toolkit for healthcare facility design, construction, and operations. Now that the Green Guide has been accepted by the USGBC as the foundation document for LEED-HC, the industry is ready and waiting.

“For me, it would mean that there would be established sustainable design benchmarks and metrics in the LEED family for credits like Outdoor Places of Respite, Access to Nature for Patients, and Views of Nature-all evidence-based and with positive health outcomes for patients, visitors, and staff alike. So my wish is that 2010 is the year of LEED for Healthcare and a hallmark for the sustainable healthcare design industry.”

Jerry Smith, ASLA, LEED AP

Director of Healthcare and Sustainable Initiatives

MSI Design

“With all the focus on healthcare environments for patients and families, I feel that the environment for staff-nurses to transporters-has been neglected. Based on recent experience as a patient in two different hospitals in the same system, I realize how important staff attitudes are in the care of patients. Staff turnover, ageing, and a general shortage of staff all are important considerations in planning an environment. ‘Front of the house, back of the house’ is no longer a concept that is acceptable. My wish, therefore for 2010 is to initiate one or more research studies that document the impact of patient care on staff attitudes and formulate a set of guidelines to enhance staff morale and sense of well being and accomplishment.

“Another major area of healthcare architecture that has been given lip service, but basically neglected is how to design an environment that can respond to the demand for change as technology, market share, economics and environmental standards evolve. For the last 30 years or more no one has documented the actual historical change that has occurred in hospitals. This information, once obtained, would be a springboard for one or more research studies addressing techniques that would allow new healthcare buildings to respond to change in a way that is more economical and less disruptive to patient care. I'd like to see one or more research studies documenting and categorizing change in hospitals.”

W.H. (Tib) Tusler, FAIA, FACHA Emeritus

Architect/Health Planner

“Our wish for 2010 at HDR Architecture is that the new year will see an increasing body of knowledge that demonstrates how facility design can reduce medical errors, infections, and falls while helping to intuitively relieve patient and caregiver stress. It is also imperative to show that design can significantly reduce operating costs by decreasing energy and water usage, lowering maintenance costs and lessening waste generation. As we plan, program, and design advanced healthcare facilities for our clients, we have a responsibility to consider all the ways in which those facilities can help patients heal better, allow nurses and physicians to provide better care, and help facilities work better and more efficiently. In the face of a rapidly changing healthcare landscape, to do anything less is unacceptable.”

Doug Wignall, AIA, LEED AP

Healthcare Director

HDR Architecture, Inc.

3. The increasing growth of sustainability

If the United States is going to reduce its environmental impact to a sustainable level, it must substantially improve the environmental performance of healthcare. There are serious concerns that patients and staff might sustain long-term harm as a result of the toxic materials used in the very environments that are meant to be healing and therapeutic. Further, because of the intensity of energy use, the U.S. healthcare sector is the second largest contributor to carbon dioxide pollution, a greenhouse gas that causes global warming.

Annual capital spending on new and improved healthcare facilities in 2010 will present the opportunity to build better, healthier, buildings that improve patient care, staff recruitment/retention, medical outcomes, institutional productivity, and financial performance while decreasing medical errors and waste. In existing facilities, look for managers in healthcare organizations to be searching for opportunities and resources that can make their facilities more environmentally friendly.

4. Patients and their caregivers increasingly proactive about choosing their own care

Consumers will continue to exert their decision-making power, including what facilities they choose to go to for their medical care through online resources such as There will be more and more evolving discussions about where to go for care, who should be in control, and what should happen, especially with patients who are much closer to death.

In 1998, the Institute of Medicine (IOM) identified six aspects that, together, contribute to the quality of care, including safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The design of the built environment impacts each of these aspects by promoting safety, increasing staff effectiveness, focusing on patients' needs, increasing communication, accessibility, reducing waste in the system, and promoting access to all. As more baby boomers see their parents in need of care, we expect the status quo to be challenged much more.

5. Patient safety issues become mainstream

Ten years after the publication of To Err is Human, which highlighted the serious threats to patient safety in U.S. hospitals, the argument about patient safety is very much now top of mind in the public discourse. According to The Institute of Medicine, 44,000-88,000 people die each year in U.S. hospitals because of medical errors. Two million patients a year acquire infections while in U.S. hospitals, of which 88,000 result in deaths. More recently, the outbreaks of pandemics such as swine flu have raised awareness about how infections spread and pushed patient safety issues even closer to the forefront. All of this influences medical consumers as they make important choices about their care.

As The Center for Health Design's staff visit hospitals and healthcare systems around the country, we've been struck by the passion and energy clinicians, caregivers, and administrators are collectively putting into preventing patient harm-driven as much by their moral compass as by the increasingly robust business case for safety.

6. Aging populations

Researchers at the MacArthur Foundation Research Network On An Aging Society recently noted in a new report that new advances in longer life expectancies are going to make people more productive and live longer and perhaps have more fulfilling lives. This is really a wonderful development for society that could lead to new markets in healthcare, leisure, and daily living environments. It may however create tensions in the social fabric, unless we can understand the fiscal consequences of longer lives, and design communities that support wellness and longevity and provide a variety of options for care and support for aging populations.

7. Technology

Technology and telecommunications will increasingly become leading players in healthcare because of the boost from the healthcare stimulus package. Patients have begun demanding access to their data and are actually starting to see (and even exchange) that data. A combination of new tools for technology-enabled delivery such as e-mail, telehealth, and remote patient monitoring, along with social networking, will continue to force its way into healthcare as physicians and providers work to adopt healthcare IT to take advantage of the Federal Recovery and Reinvestment Act.

Healthcare organizations and the design professionals who work with them must be able to change and adapt to fully and efficiently exploit the convergence of technological, healthcare design, and care advances within the context of their real-world operations and structures. Success will come from understanding this symbiosis in order to maximize their interaction with each other.

8. Workplace safety and staff turnover

Skills fragmentation will result in challenges for healthcare organizations, as will the looming baby boomer retirement wave. With an estimated 400,000 nurses set to retire in the next 10 years, competition for medical talent will drive a large part of the agenda of the industry by 2010, and the playing field is global in scope.

In addition to impacting staff satisfaction, the built environment of the workplace impacts the health and safety of the healthcare workforce. According to the American Nursing Association, 76% of nurses reported that unsafe working conditions interfered with their ability to provide quality care. Healthcare staff are often exposed to occupational hazards such as airborne infections in the hospital as well as those acquired through direct contact with patients, back injuries from lifting and bending activities, loud noise, inadequate lighting, toxic chemicals from construction and finish materials, and poorly designed and crowded work stations. We're seeing more awareness and attention being paid to reducing staff burnout and mitigating turnover rates.

9. Increased focus on disaster preparedness

One of the issues the Government Accountability Office identified as being urgent is becoming increasingly relevant to the U.S. healthcare system and those abroad: preparing for large-scale health emergencies.

Floods, earthquakes, and other natural disasters, such as the recent earthquake in Haiti, take a terrible toll on human life, as can infectious disease outbreaks and man-made disasters like chemical spills or radiation accidents. When these disasters strike, well-prepared, functioning medical services will be a priority as many members of the community may come to hospitals as secure places known to have functioning generators, light, safety, and nourishment. We've seen that a major emergency or disaster is compounded when healthcare facilities fail. Making hospitals and healthcare facilities safe from disasters and places that can enable staff to react swiftly and efficiently to provide safe havens and not become disaster zones themselves, will increasingly become an economic requirement, and also a social, moral, and ethical necessity.

10. Medical tourism

For a variety of reasons, people from around the world are traveling to other countries to obtain dental, medical, and surgical treatments. An article in India's BusinessWorld Magazine, provided numbers suggesting that millions of travelers spend more than $40 billion a year on combined medical and travel expenses. Four countries in Asia-Thailand, Malaysia, Singapore, and India-attract well over a million medical travelers each year, and these numbers are growing rapidly. In most cases, patients are traveling from the developed countries of the United States, Canada, Great Britain, Australia, and the Middle East.

Healthcare systems in the United States may start to feel the pinch as more and more low-cost and high-quality procedures become available abroad and foreign doctors operating in America feel a homeward pull because of the high cost of medical training and practicing in the United States. All this could reduce the quality of healthcare available in the United States and improve the quality of healthcare available abroad. Of course this effect will further increase U.S. healthcare costs relative to healthcare costs abroad. A perfect storm is brewing for healthcare in the United States.

The long-term care and senior living industry will be insulated from these competitive pressures simply because it is hard to make seniors or people with serious disabilities travel or move to another country.

If you have found this list interesting, we recommend that you download a copy of the latest report from The Center for Health Design's Research Coalition: Critical Issues in Healthcare Environments. It's available for free from The Center's Web site, The objective of the project was to identify and describe critical issues in three healthcare environments-hospital, ambulatory, and long-term care settings-specifically focusing on issues and problems that have a bearing on the physical environment.

The catalyst for this study was the need to establish research agenda for healthcare environments. A critical step prior to selecting the important research questions, is establishing criteria and methods for the selection process. However, the choice of topics to be researched and the selection of interventions to be tested in healthcare environments are often determined by investigators and sponsors in a pre-scientific way. This study focused on critical problem areas and unresolved issues as the universe of topics from which viable, important research questions can be generated. These questions can form a systematic, problem-driven research agenda. Ultimately, the research information will lead to more informed design, improved environments, and better healthcare. HD

Natalie Zensius is Director of Marketing and Communications for The Center for Health Design in Concord, California.

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Healthcare Design 2010 February;10(2):28-41