Like many other spaces within hospitals and healthcare facilities, patient bathrooms are being re-evaluated with an eye on comfort, inspiring a wealth of new approaches to design that create a homelike and even hospitality-like environment.

But despite these measures, one fact holds true: Safety is still king.

“The patient bathroom is one of the most vulnerable areas in a hospital from the standpoint of infection control, and slips and falls,” says Ken Bowman, director of interior design at Earl Swensson Associates (Nashville). And when it comes to safety, Joan Saba, partner at NBBJ (New York), defines it as “designing a room that prevents falls, accommodates enough people to help the patient ambulate, and has no sharp edges or tight corners.”

While the destination is clear, there are plenty of avenues worth exploring to get there.

Location, location, location
In terms of bathroom placement, building teams must carefully review the advantages and disadvantages of inboard versus outboard and headwall versus footwall locations.

For instance, locating the bathroom inboard (at the room’s entrance) enhances patient privacy, creates a natural vestibule, buffers noise from the corridor, minimizes intrusions from housekeeping, and improves caregiver accessibility to the patient from the nurses’ station. Because this layout results in a smaller staff/caregiver footprint within the room, it also reduces nurses’ footsteps.  And thanks to the bathroom’s interior location, the exterior wall is freed up to deliver optimized daylighting, views to the outdoors, and a large family zone.

On the other hand, Rick Abbott, principal of Hord Coplan Macht (Baltimore), says that the vestibule created through an inboard design can create a pinch point for maneuvering the bed in and out of the room. Additionally, “all the plumbing risers are now located along the corridor, so in the future, it becomes harder to renovate around these risers,” he says.

The smaller staff area can also make it challenging to comfortably accommodate a handwashing sink, supplies, computer monitors, and workspace, adds Jocelyn M. Stroupe, principal of healthcare interiors at CannonDesign (Chicago).

Meanwhile, an outboard layout (the bathroom placed on the room’s exterior wall) supports a larger staff area with a smaller family zone. However, the family area is more clearly defined and offers patients and caregivers unobstructed paths of travel. In fact, a study conducted in 2007 by HKS’s nonprofit research arm, the Center for Advanced Design Research & Evaluation, concluded that outboard configurations are better suited for patient transfer. “Outboard provides better visibility to the patient from the corridor or nurses’ station and can also offer better visibility for the patient, giving them a target so they can assess their level of exertion and sight line required to go to the bathroom,” explains Upali Nanda, vice president and director of research at HKS (Houston).

One other alternative is a nested layout, which places one inboard and one outboard toilet room between every two patient rooms, so that they’re “nested” on a shared wall.

That leads to the next key design decision: a same-handed or mirrored patient room configuration. Same-handed arrangements orient all rooms and their contents in the same direction, whereas mirrored rooms are designed back-to-back, providing plumbing efficiencies with a shared wall between bathrooms.

For example, nested configurations work best in same-handed rooms, allowing designers to achieve desirable sight lines, family zones, and views outside while reducing plumbing costs thanks to that shared wall, says Paul Macheske, associate principal and director of healthcare design at Hunton Brady (Orlando).

Otherwise, same-handed rooms using inboard or outboard toilets require individual plumbing systems, resulting in a higher price tag than mirrored rooms. However, they offer plenty of pros, too. For example, it’s easier to prefabricate components off-site, acoustics tend to be better, and with all patient beds located on the left, caregivers can easily approach all patients on their right when they’re lying on their backs. Some also suggest that same-handed rooms allow caregivers to navigate patient rooms and locate supplies more easily. However, according to Priya Dhuru, associate and project manager at Champlin Architecture (Cincinnati), recent research conducted by HermanMiller Healthcare suggests that hospital staff can just as easily navigate mirrored rooms.

Finally, when considering where to locate the bathroom in relation to the patient bed—either on the footwall or headwall—a footwall placement frees up the headwall for medical equipment and the patient can better enjoy views to the outdoors with a path to the bathroom that’s visually clear. On the other hand, when the bathroom is placed at the headwall, patients have a shorter path of travel, which reduces the risk of falls.

“Studies have shown that more patient falls occur when patients are trying to access the bathrooms,” reports Bowman. “Our interior design team always locates patient bathrooms at the headwall due to the shorter travel distance and accessibility to handrails.”

Safe travels
After assessing the best placement for the toilet room, Saba says designers should turn their attention toward creating a clear, easy, and maneuverable course of travel from the bed to the bathroom. In fact, Saba says that about one-third of NBBJ’s clients opt to install a lift from the bed to the bathroom. “We also prefer to design a sliding door, or at least a double door that can open fully, so that there is a large, easily accessible opening at least 4 feet wide,” she says.

While codes generally require 10 percent of patient bathrooms to be designed to Americans with Disabilities Act (ADA) standards, healthcare designers often encourage building owners to design as many ADA bathrooms as possible—even 100 percent. “When designing all rooms this way, it doesn’t limit patients to specific rooms and eliminates having to move patients from room to room,” says Michael Murphy, principal of Champlin Architecture.

Additionally, Macheske says that nonhandicapped patients also benefit from ADA accessible fixtures. For example, a higher toilet is easier to get on and off of for post-surgical patients, and a shower seat can be very helpful for medicated patients and/or those who are less stable than normal.

With the uptick in patient lift specifications complicating layouts, architects are grappling with ADA requirements, too. Typically, ADA designs don’t provide sufficient room for staff to assist patients, thanks to required reach distances for handrails. “Many hospitals have encountered instances where patients who are not stable fall between the toilet and the wall, making it difficult to help them with minimal clearances,” Stroupe says.

Ultimately, though, the extent to which healthcare facilities incorporate accessibility into bathrooms comes down to building codes, client philosophy, and cost.

Added touch
Even though safety remains the overriding factor impacting patient bathroom designs, patient comfort is starting to play a larger role, too.

Aiming to achieve a more residential feel, designers are turning to products like porcelain fixtures; framed, back-lit mirrors; and decorative tiles, including larger format tiles in materials like glass, mosaics, or a blend of natural stones. Designers are also working to mimic natural materials with products that resemble wood, marble, travertine, or granite for enhanced hygiene and cost savings. Meanwhile, features like decorative sconces, fabric shower curtains, glass shower enclosures, stylish grab bars, and even towel warmers also up the ante.

Even when answering ADA requirements, designers can still achieve a noninstitutional look. “We use solid-surface countertops with integral sink bowls at accessible height, wood-looking millwork for personal storage of patient belongings, high-end porcelain tile, and decorative mirrors and light fixtures,” Mancheske says. “In other words, just because it is accessible doesn’t mean it has to look bad.”

But when trying to achieve a high-end aesthetic, designers must also consider the specification of products that are durable enough to withstand a rigorous cleaning process, says Kristie Pudlock, principal and director of interior design at Champlin Architecture. “Many material choices are restricted by the ability to be cleaned appropriately, infection control regulations, and durability issues,” Murphy adds.

Some products offer intrinsic antimicrobial materials such as copper alloy and titanium dioxide, though their effectiveness is still being evaluated, Bowman says. And even how chosen products are installed might make a difference, too. For example, Bowman recommends minimal grout joints between tiles or seamless, groutless bathroom flooring—a poured resinous product—for better infection control.

Finally, to round out these spaces, designers also advise to think about amenities alongside aesthetics. “Providing additional conveniences like hair dryers, storage for toiletries, integrated shower seats, and warm finishes offer the familiar amenities of home,” says Jennie Evans, vice president and operations specialist at HKS Inc. (Dallas).

Barbara Horwitz-Bennett is a contributing editor for Healthcare Design. She can be reached at



Equal offerings
As the population of bariatric patients —those with a body mass index of greater than 40—grows,  healthcare facilities are increasingly looking to accommodate their needs without making obvious physical changes to the care environment.

The International Journal of Obesity reports that the proportion of morbidly obese Americans increased by 70 percent between 2000 and 2010, and now accounts for 6.6 percent of the nation’s population. As a result, providers are looking to introduce bariatric patient rooms and bathrooms, varying from one to two bariatric rooms per floor to up to 40 percent of a facility, based on facility type, geographic region, owner needs, and budget.

The corresponding room requirements are significant. For example, bariatric patient rooms generally run 12 to 15 feet larger than typical rooms, the toilets are floor mounted, and grab bars and sinks must be capable of supporting significantly more weight.

Blocking must also be added to hold additional weight limits on the floor plate, notes Kristie Pudlock, principal and director of interior design at Champlin Architecture.

“Everything has to withstand around 500 pounds, so to preserve the aesthetics with that kind of performance, it really comes down to the material selection surrounding the fixtures and the lighting,” adds Joan Saba, partner at NBBJ.

While this can be challenging due to a more limited selection of fixtures, if the bathroom is well organized and designed, the aesthetics don’t have to suffer. “A key component to designing bariatric environments is to provide similar and equal amenities, products, and finishes in all spaces,” says Jennie Raymond, vice president at HKS (Indianapolis).