The small, and sometimes large, nuances of hospital design can and do play a significant role in helping to heal patients and increase the satisfaction of healthcare professionals. Design elements can have an enormous impact on patients and families, and now are a strategic element essential for the future of many healthcare organizations. Increasing efficiencies, reducing length of stays, and improving mortality and morbidity rates are imperative for healthcare organizations as evidence-based design elements are incorporated.

Not only can design elements elevate the level of patient care, but these elements also can have a major impact on the morale of staff due to enhancements and efficiencies of the built environment. In a competitive recruiting environment for highly specialized and experienced healthcare clinical staff, healthcare organizations are tasked to do things that reduce staff turnover, enhance employee morale, and foster a healthy, productive, and safe patient care environment, particularly at a time when bonuses and salary increases are not always feasible. Design has become an essential element of strategic investment for healthcare organizations today.

The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at

An aging and expanding population is increasing the demand for healthcare, putting a considerable amount of pressure on hospitals to identify ways to improve the efficiency, as well as the recruitment and retention of its most valuable resource-people, either as a community of patients or as a dedicated workforce (1).

Transforming the patient care environment is no easy task. Endorsed by multiple health systems as well as professional and consumer organizations, the Proclamation for Change was developed by healthcare experts to create a set of evidence-based recommendations for the transformation of the hospital work environment and cites patient-centered design, system-wide integrated technology, seamless workplace environments, and vendor partnerships as cornerstones of transformational change (1). While technical and physical elements are of utmost importance in addressing the challenges that play a role in transformational change related to hospital building and renovation, the element of social innovation that is required should not be discounted. After all, if a culture is not established to embrace change and adapt to a new patient care environment, how can design elements successfully support those changes?

Using an evidence-based design process to design hospitals can not only enrich the recovery of patients, but also enhance the ability of healthcare professionals to provide first-rate care. Numerous studies have reported health benefits associated with facility design, and The Center for Health Design's Pebble Project is committed to deepening that body of knowledge. Participating Pebble Project organizations have shown a commitment to using an evidence-based design process while implementing several of the evidence-based design features that have been proven to increase the level of care provided and improve the workplace for their staff. Features such as lighting, material selection, acoustics, access to nature, and program adjacencies look at creating efficiencies and elevating aesthetics in the environment, which in turn not only strengthen the quality of care but also enhance job satisfaction and productivity of the healthcare workforce.

Several Pebble Partners now are evaluating and comparing the impact of the original and newly built hospital environments on patients, families, and staff. Specific aims of these comparisons include (but are not limited to): measuring patient and staff satisfaction; staff perceptions of safety, security, and privacy; infection rates; workflow; and staff efficiency.

The Children's Hospital, a Pebble Partner in Aurora, Colorado, found dramatic changes in staff turnover. Its pre-move turnover data from October 2007 reflected an annualized percentage rate for nurse turnover of 9.55%. Six months after its move in 2008, the rate was 4.38%. Compared to the national turnover rate that is estimated at 15%, The Children's Hospital achieved one of its initial project goals of attracting and retaining staff.


Another Pebble Partner, Dublin Methodist Hospital in Dublin, Ohio, also learned since opening its doors in 2008 how the physical environment affects its staff. Elements of the new building include natural light in 90% of the structure, an all-around “quiet” facility, gardens and courtyards outside without the need to leave the campus, minimized walking distances for staff, an acuity-adaptable model so patients are not moved from unit to unit, living trees and water, warmth to materials, and colors. Recently, Dublin Methodist President Cheryl Herbert was asked a series of questions that shed light on what social innovation is required to adapt to a new care environment.

What was the primary goal behind the new design elements?

Cheryl Herbert: We wanted to reduce the stress levels of anyone coming into the building: patients, families, and staff.

How have the designs impacted your organization's culture, mission, and vision?

Herbert: The design grew out of our mission and vision, and now helps us live the mission and vision of improving the health of the people we serve and being the place where people want to work. Our culture was created by the design. Our culture is one that is committed to a high level of customer service along with a culture of quiet, which contributes to several elements of healing.

How have your patient outcomes been affected by the new design?

Herbert: Our patient satisfaction measured and compared against Press Ganey generally scores above the 90th percentile overall. In addition, we publicly report above state and national averages (Hospital Consumer Assessment of Healthcare Providers and Systems). Noise levels rank in the 99th percentile. We also have quality outcomes, such as low rates of hospital-acquired infections and shorter lengths of stay.

How did you go about recruiting and staffing for your new facility?

Herbert: We received over 5,000 applications. In most cases, we had 10 times the amount of applicants needed for open positions, but there were instances where we didn't have enough. When recruiting, we utilized behavioral-based interview questions and scenarios, and we were very clear about not only the enhanced design elements but also about the small size of our organization; both of which require flexibility. It would have been great to have written one job description called “IDE”: “I Do Everything.” The Dublin Methodist employee does what needs to be done. Our employees are described as flexible, tolerant of trying something new, tolerant of change, and constantly evolving.

How has the new facility affected staff satisfaction?

Herbert: Staff satisfaction was extraordinarily high after opening. Being a small hospital, our turnover rate is 9-10%. Our current employee satisfaction is part of OhioHealth, a Fortune 100 Best Places to Work organization.

What are the employees' favorite design elements?

Herbert: Light and lack of noise are favorites. Also, we often hear how “nice” the organization looks
overall. Additionally, nurses like the layout of the patient rooms.

If you had to identify any design “do-over's,” what would they be?

Herbert: We would revisit space-planning and put sterile processing closer to surgery, which would further elevate the quality of life for employees.

When asked if there is a link between physical and social innovation, Herbert stated that not only is there a link between the two, but that the social piece is of paramount importance and is becoming more important as later generations come to work. “Candidates and employees are more interested in working where it is ‘nice to work,’” she notes. “The right people and culture need to be in place to achieve the results of the innovative physical design of the building … culture eats design for lunch.”

Evidence-based design has already become a way for healthcare organizations to differentiate themselves in the market, when recruiting and retaining staff. The U.S. Department of Labor predicts that employment of registered nurses (RNs) is expected to grow 23% between 2006 and 2016 with 587,000 new jobs. These new jobs will be driven in part by advances in patient care, an increased emphasis on preventive care, and an aging population. Nursing shortage statistics, however, show that there will not be enough RNs to fill these positions.

The landscape for other healthcare professions, including physicians, is similar. The Council on Physician and Nurse Supply says the United States may lack as many as 200,000 needed physicians by 2020, and the Bureau of Labor Statistics predicts there will be 212,000 physician openings by 2014 due to growth and net replacement of retiring physicians. These numbers indicate the viability of healthcare organizations' ability to effectively and consistently recruit and retain staff, and evidence-based design has quickly become a means to better market organizations to prospective staff.

Texas Children's Hospital in Houston and Banner Gateway Medical Center in Gilbert, Arizona, are two organizations that have incorporated their use of evidence-based design into their job postings and job descriptions featured on career pages.

  • “Banner Gateway Medical Center was inspired by evidence-based research supporting healing environments and patient safety. Evidence-based design techniques ensure hospital environments support patient recovery and safety, along with staff safety.”
  • “When fully complete, Texas Children's West Campus will incorporate evidence-based design principles that promote healing, such as park-like settings, natural light, and views of nature and water.”

Recruiting and retaining key staff to embrace evidence-based design elements is already becoming a key strategy for success in the next generation of healthcare organizations. In addition, it will become imperative to seek methods for measuring the effectiveness of evidence-based design used in facilities both in elevating healing for patients and for recruiting and retaining talented staff. As the healthcare industry vies not only for patient volumes but also for healthcare professionals, differentiating environmental features, acquiring top talent, and elevated satisfaction scores will become paramount in establishing the frontrunners of patient care.

Vanessa Scarbo serves as client solutions manager for Pinstripe Healthcare. She can be reached at Amy Keller develops The Center for Health Design's Pebble Project research agendas and manages client relations with Pebble partners. She can be reached at


  1. Hendrich Chow, Goshert, A Proclamation for Change: Transforming the Hospital Patient Care Environment, Journal of Nursing Administration (2009), 39:6; 266-275

Healthcare Design 2011 May;11(5):18-22