The inpatient room is arguably the most comprehensively addressed setting in healthcare, with a large body of evidence for designers to draw upon. Yet the “ideal” patient room remains a myth. Although there are unique issues in the design of each project, whether new build or renovation, there’s a need to collate existing design research on inpatient rooms and translate it into an actionable format to help decision-making across the board.

With this need in mind, The Center for Health Design (CHD) received a grant from the American Society of Interior Designers to develop a standard evidence-based tool for inpatient room design. Created over the course of three years, this grant will allow CHD to:

  • Develop and validate a patient room interior design checklist to support design decision-making
  • Develop and validate a patient room evaluation tool as a post-occupancy evaluation, or POE, that can be used for existing facilities or in renovation or new construction projects
  • Facilitate easy access to the patient room tools by making them available online via CHD’s website, with an interface that allows users to fill in data onsite using handheld devices.

In a three-phase process, this grant will result in design and evaluation tools for inpatient room design in medical/surgical units; adult intensive care units (ICU); and maternity units. The first phase of this project has been completed, resulting in a beta-test, paper-based version of the Inpatient Room Design Checklist and POE tool for the med/surg rooms.

 

Framework
To develop this tool, an interdisciplinary advisory council was created that consisted of researchers, architects, interior designers, and clinicians. After conducting an extensive literature review, an evidence matrix was developed that links design features to healthcare outcomes. Design features were mapped against outcomes in four key design categories: room layout and configuration; heating, ventilation, and air conditioning; furniture, fixtures, and equipment; and materials and finishes. Additionally, there are two subcategories: acoustics and lighting. For each feature identified, potential trade-offs were noted (such as, use of acoustic tiles for patient satisfaction versus cleanable surfaces for infection control).

It became obvious early on that while there’s a plethora of evidence in some areas (nature views and hand washing), there’s still debate regarding other areas (same-handed rooms and use of antimicrobial finishes), and a paucity of evidence in a few areas (the impact of acuity-adaptable rooms for med-surg units). The value of best practice recommendations was acknowledged, and the team decided to include these recommendations, provided that the final tool clearly differentiated between the research and best practice items.

Twenty evidence-based design goals (in four key categories) emerged from the exercise of organizing the evidence and discussing the evidence with multidisciplinary advisory council members:

Patient safety

  • Improve mobility and reduce falls
  • Reduce risk of injury
  • Reduce risk of infection
  • Improve hand-sanitization practices
  • Enable safe delivery of care

Worker safety and effectiveness

  • Enable efficient delivery of care
  • Improve communication between staff, patient and family
  • Improve staff health and well-being

Quality of care/patient experience

  • Reduce patient stress and anxiety
  • Improve patient sense of control
  • Improve patient engagement
  • Improve family presence and engagement
  • Improve patient and family comfort
  • Reduce noise
  • Respect privacy

Organizational health

  • Ensure durability
  • Improve air quality
  • Provide a secure environment
  • Enable change readiness and future-proofing
  • Provide return on investment

For each goal, a list of key questions was listed for designers to consider during the design process. A detailed list of design features was then provided, based on existing evidence and best practice recommendations, as a checklist to assess to what extent the design addressed the stated evidence-based design goals. Simultaneously, a POE tool was developed to evaluate the patient room after construction and occupancy. In the POE, the checklist items were used to assess the extent to which the room “performed” against each goal on a five-point Likert scale.

 

The pilot test
A paper-based two-part tool was developed for both the design checklist and the post occupancy evaluation (POE). Each tool included a cover page outlining instructions for use. Sources of the evidence were not included in order to test the content of the tool free of the bias of whether an item listed had research support or not. A feedback form was included at the end of the tool.

Davis Partnership Architects (DPA; Denver) volunteered to pilot test the tools. In April 2013, DPA organized a feedback session, including six senior level planners and architects; an interior designer was included in the group at a later date. The internal research team at the firm facilitated the process by asking the group to review the tool before the feedback session and again for 10 minutes during the session, and finally to reflect specifically on two main areas: quality of content/framework and overall quality of tool and usability.

Generally, the group found the checklist to be helpful. Ratings on the feedback form, however, were only moderate, due to the following challenges: length of the tool, lack of legibility, redundancy, and extensive detail. Recommendations included a need for access to citations and relevant resources, and overall simplification.

Two versions of the POE tool were next tested at Barrett Hospital & Healthcare in Dillon, Mont., by a senior healthcare architect, two administrative staff (CEO and CFO), two facility managers, and two nurses.  In one version, the assessment aid (identical to features listed in the checklist) was listed next to each Likert scale question, while in the other version the assessment aids were listed in the appendix. Overall, the version with the assessment aid next to each question was preferred.  Feedback on the tool was positive regarding the overall structure, broad categories, and ease of use. Challenges identified were the need for different experts to evaluate different aspects of the tool (for example, questions about air quality and the HVAC system should go to a facilities person, whereas questions about enabling delivery of care would be more appropriate for a clinical person), and lack of space to note any additional comments. Technical areas such as durability and HVAC received “cannot determine” responses from the clinical and administrative team.

 

Final results
Based on the feedback provided as well as a series of 20-minute interviews with each member of the advisory council, a final beta test version of the paper-based tool was developed. An online version of the tool will be annotated with the specific sources of evidence and will connect directly to CHD’s Knowledge Repository so designers cannot only see the citation but access detailed abstracts as well as a summary of critical resources. The items on the checklist are included in the POE as an assessment aid, too. Additional space is provided for comments or use of additional design strategies that may not be included in the original tool.

Meanw
hile, the second phase of the study is currently underway for the ICU, which will be tested by architects and designers from Davis Partnerships and HKS Inc.

In a field that’s rapidly changing, tools must be up to date and act as living documents. By creating an online tool that’s linked to a knowledge repository, the checklist and POE tool can assist designers in absorbing and respond to changes in the industry as well as the evidence base.

 

Upali Nanda is the vice president and director of research at HKS Architects. Prior to joining HKS, she was a research consultant with The Center for Health Design, where she worked with the Center’s research team on this project. She can be reached at unanda@hksinc.com.

Anjali Joseph, PhD., EDAC, is vice president, director of research at The Center for Heath Design. Her work focuses on understanding how the built environment influences the health and well-being of occupants. She can be reached at ajoseph@healthdesign.org. 

Melissa Piatkowski is a researcher at Davis Partnership Architects, leading applied research studies and evidence-based design efforts in the Healthcare Studio. With a professional background in both architecture and social science, Melissa’s research delves in to how health and wellbeing can be improved by the built environment. She can be reached at Melissa.Piatkowski@davispartnership.com.