Yume Nishi is in her final year of study in the 5-year Bachelor of Architecture program with a minor in Occupational Therapy at the University of Southern California. After graduation, she hopes to go into healthcare architecture and is very interested in integrating data and design to help enhance people’s lives. She is an active member on campus and loves being a Teaching Assistant as well as being involved with Society 53, the USC Student Alumni Society’s leadership board. Yume loves to travel and hopes to keep exploring the world!
“The Simpsons” depicted Frank Gehry as crumpling a piece of paper in order to design the Walt Disney Concert Hall in Los Angeles, suggesting a popular view of how contemporary architects work. Contrary to public belief, there is much more thought and consideration that goes into the design of a building, as architects use design to both engage and affect future occupants. Evidence-based design, or EBD, is an emerging field of study that uses credible evidence to influence architectural design. This technique has become especially popular in the healthcare sector, and has been shown to improve patient and staff well-being. Research has shown that hospitals that use evidence-based design can enhance patient recovery through the manipulation of the physical environment. Although increased costs associated with research may at first discourage architects and clients, the cost and time used in implementing EBD has a significant return of investments in the long run. It is the ethical duty of an architect to use evidence-based design when creating healthcare architecture in order to both enhance patient and staff well-being and decrease the time patients spend in hospitals.
The architect is responsible for design that is both aesthetic and research-based in order to enhance patient environment. Evidence-based design means basing building design decisions on research evidence with the goal of improving patient health. Architects consider the effect of the built environment on patient clinical outcomes, and use information gathered through research and existing project evaluations to develop solutions to design problems. D. Kirk Hamilton, an associate professor of the Center for Health Systems and Design states, “A properly designed environment is part of the course of care” . EBD strives to improve hospital environments by enhancing patient safety through reduction in risks of injuries and medical errors. Architects should also work to eliminate environmental stressors, such as noise or lack of natural light, which can negatively affect health outcomes and staff performance. Most importantly, EBD seeks to reduce stress and promote healing by creating supportive hospitals for patients, staff, and families .
Architects must use evidence to create supportive hospitals—when the mind is in a positive environment, the body will also be influenced favorably. We are all aware of the power of EBD—British Prime Minister Winston Churchill stated, “First we shape our buildings; thereafter, they shape us” . People do not like hospitals; they bring up negative thoughts of needles, surgeries, or even death. We have negative connotations associated with healthcare facilities because our thoughts influence our biochemistry. For example, if you tell yourself that you are sick, you are more likely to feel sick. When one generalizes this to the built environment, it follows that the setting of the hospital will impact patients’ thoughts and therefore, their biochemistry. This is why people are less likely to improve when they are placed in white, sterile hospitals. Research done by Suzanne Segrestrom of the Department of Psychology at the University of Kentucky even suggests that recovery at home may be faster for some patients because they are not placed in the stressful environment of a hospital. Segrestrom also found that a pleasant hospital environment is linked to less anxiety and depression and higher patient satisfaction. According to research done by Patrick Linton, a hospital chief executive officer, a pleasant environment will keep norepinephrine levels low so that patients experience less pain. Norepinephrine mobilizes our brain and body, and low norepinephrine levels lead to a lower risk of stroke and more restful sleep because patients do not feel stressed or in danger. It is important to design hospitals that encourage healing because, “what we perceive, think, and how well we cope are all set in motion by messages from the brain to the rest of the body” . A hospital room filled with sunlight and nature will send positive messages to a patient’s brain, allowing him or her to heal faster.
Currently, hospitals do not use evidence-based design, and therefore do not foster positive environments for patients and staff. Although the U.S. spends 14% of the GNP on healthcare, hospitals are not efficiently created to assist patients and nurses. The Institute of Medicine report reveals that more than 98,000 Americans die yearly because of preventable medical errors in the hospital. In fact, “more people die in a given year from hospital errors than from motor vehicle accidents, breast cancer, or AIDS” . Moreover, 2 million patients, or 1 in 20, catch dangerous infections during their stay. Aside from disease, patients are prone to stress, which produce negative effects to the mind and body, such as anxiety and increased blood pressure. The design of a hospital is a great factor to all of these problems. For example, some infections can be attributed to poor air quality, ventilation, or having multiple patients in the same room. The simple acts of choosing better air ducts and creating better accommodating rooms can decrease the amount of time a patient spends in healthcare facilities. It is the duty of the architect to design hospitals to create healing environments to relieve stress and promote improvement among patients and staff .
Because natural light greatly improves patient recovery, one way to improve these inefficient facilities is to increase the amount of sunlight coming into the hospital rooms. In 1863, Florence Nightingale wrote about the benefits of daylight to patients, stating that there should be windows on the north and south sides, “so that the sun shall shine in (from the time he rises till the time he sets) at one side or the other” . Even 150 years ago, nurses knew that body and mind heal faster in an environment where natural light is abundant. A 2001 study by Dr. Benedetti of the Department of Neuropsychiatric Sciences at the University of Milan, tested over 600 subjects and found that patients with depression were hospitalized for 3.7 days less if they were in east-facing rooms with morning light, compared to patients in west-facing rooms with very little sunlight . Furthermore, Walch JM of the Department of Pathology at the University of Pittsburgh found that patients on the “brighter” side of a hospital reported to be in less perceived stress and pain than those on the “dim” side, and took 22% less medication, and therefore, had less pain medication costs . By simply increasing the size of a window, an architect can help cut down the recovery process and provide a more comfortable experience for patients. Countless research undoubtedly shows the influence of natural sunlight on the improved health of patients, and so it should follow that architects should design hospitals to gain the most amount of sunlight.
In addition to increasing sunlight, an intuitive architectural design and layout will help staff use their times efficiently to manage patient care. The American Journal of Hospital Pharmacy published a study that found that the layout of pharmacy stations affected work efficiency by reducing time spent by pharmacists filling prescriptions. A radial drug counter reduced the prescription filling time by 28%, and reduced travel distance by 86.3% . This in turn allowed pharmacists to spend more time with patients, improving service quality. Additional studies by the Health Environments Research & Design Journal found that nurses favor radial units because the circular shape enhances teamwork and quality of healthcare delivery. The radial nursing unit design decreased patient falls and injuries by 67% because nurses were better able to observe patients and have quicker response time . According to a study done at Emory University, it was estimated that the cost of wayfinding in a poorly planned hospital could exceed $200,000 annually . This includes time spent by staff giving directions around the hospital because patients had trouble navigating. Staff wasted 4,500 hours over the course of a year to giving directions, when those precious hours could have been used more productively by attending to patients.
Aside from efficiency, staff and patients have also seen positive results to their mental health when architects use evidence-based architectural designs to improve existing hospitals. Dr. Celeste Alvaro, Ph.D. from the Department of Architectural Science at Ryerson University conducted a post-occupancy evaluation to “assess the impact of architectural design on psychosocial well-being among patients and staff” at Bridgepoint Hospital, a newly designed facility. The Bridgepoint Hospital included public spaces and outdoor terraces to enhance the connection to the community and inspire activity within patients. A post-occupancy survey of the new EBD hospital confirmed that staff experienced workplace satisfaction and increased workplace interactions, while patients, “demonstrated enhanced self-efficacy in mobility, satisfaction, and perceived improvement in mental health relative to their counterparts at the former hospital” . Furthermore, individuals who had favorable impressions of the new hospital were found to be more optimistic, suggesting that a positive environment will promote optimism and hope.
As more hospitals begin to implement EBD, the connection between research-driven design and improved healthcare becomes more evident. The Center for Health Design has conducted the most extensive review of EBD, with more than 400 research studies showing the direct link between hospital design, patient health, and quality of care. The Bronson Methodist Hospital in Michigan used an evidence-based approach in their redevelopment of its hospital, and saw an 11% decrease in hospital-acquired infections when they utilized private rooms, rather than double-occupancy rooms. EBD also resulted in a 7% turnover rate for nursing, in comparison to the national average of 20%; 95.8% of patients reported being satisfied with their experience . These statistics show that the design of the healthcare environment has a substantial effect on both patients and staff.
Critics may argue that EBD increases the overall cost of a project, but evidence-based hospital design ultimately cuts cost in the long run. Renovating or building new hospitals is expensive, and many hospitals are on a budget. Dr. Hessler of CMS Hospital, along with other healthcare practitioners complain that, “we are spending too much and getting too little in return” . The hospital structure and design is usually one of the first to go when cost-cutting decisions are made, especially when additional design renovations of EBD average a 6% increase in construction costs. Nonetheless, research has proven that investing in EBD has significant return on investment. In 2011, the Hastings Center calculated the projected extra costs for a hypothetical Fable Hospital to demonstrate the return on investment on evidence-based design interventions. The additional costs of EBD included examples such as $13,500,000 for larger single-patient rooms and $1,000,000 for healing gardens. In total, $29,246,275, or 8.3%, was added to the construction budget due to new features guided by EBD. Based on this study, the Center also calculated the projected cost savings due to the new designs, and found that in the first year of operation alone, the hospital would save $10,246,275. Reductions in patient falls would save the hospital around $1.5 million, while reduction in the length of stay of patients would save $1 million. Construction costs would be recouped in as few as three years through operational savings . Leonard Berry, Ph.D., of Texas A&M University, states, “Smarter hospital architecture and design can pay for itself within a year by improving service efficiency, patient safety and satisfaction, and market share” . In short, EBD is not only good healthcare, but also good business.
Today, there is science to support healthcare design that guarantees that future hospitals promote healing in addition to providing treatment. The physical environment where people work and patients receive care is one of the most important elements in addressing preventable hospital-acquired conditions. It is the ethical duty of an architect to go beyond designing aesthetically by using evidence-based design to enhance patient well-being and staff efficiency. Some may argue that the construction costs for evidence-based design additions are high, but there is a return of investment can be seen in as few as three years. Architects are faced with both the opportunity and challenge to practice evidence-based design to advance their knowledge of the science of architecture and make a profound impact on society. A cultural shift in the architectural industry must occur to include EBD as part of the design services, and I hope that it soon becomes a standard of design process. EBD does not just apply to the healthcare sector, but to all building types, and it is the ethical duty of architects to use evidence-based design for a better tomorrow.
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