Research Update: Positive Trends In Research For Healthcare Environments
By Tom Clark, Byron Edwards, and Lindsey Stang
The Research Initiatives Committee of the AIA Academy of Architecture for Health (AAH) was formed in 2009 to support the research-based architectural practice. The Committee started by looking at the 2008 literature survey by Roger Ulrich et.al., which indicated a focus on patient safety and patient experience. What was found to be in short supply were studies in areas that are significant to practicing healthcare architects: staff effectiveness, planning typologies, return-on-investment concepts, and specific impacts of design strategies on patient health and business outcomes. The hope was to empower architects by encouraging research that architects could use to inform their work.
What are recent trends in research topics?
We think it is time to look at the past several years of new research to see how the healthcare ‘research industry’ has evolved. To survey the trending of topics, we reviewed the following sources, and share here some highlights of what we learned.
AIA AAH Academy Journal
The AIA AAH Academy Journal publishes both peer-reviewed research, in-depth case studies and best practice theory. In surveying the issues from 2012-2017, we found 46 articles focused on improving patient health as well as business outcomes, and 29 specifically related to design interventions in hospital unit layout and specific room configuration.
For example, a study by Grimes and Meilink published in 2016 compared inpatient units with decentralized and centralized staff stations. The decentralized units scored 13% to 18% higher on certain HCAHPS scores, a 91% increase in patient feeling ‘cared for’; up to 71% reduction in walking distance; and 16% more time for nurses spent at the bedside. Generalized floor plan layouts were related to different outcomes.
Another example, from the 2013 edition by James Harrel, is an exploration of Emergency Department layouts related to staff efficiency. Linear, right angle, radial and continuous ‘ribbon’ layouts are compared and rated for issues of visual control of the environment, access to supplies, and others.
AIA Academy of Architecture for Health Foundation (AAHF) Research Grants
The AAHF grants are for rigorous research “to enhance environments for health and healthcare”, according to their website. In surveying the research published from 2012-2017, we found 21 studies in the following outcome categories: Patient health, patient satisfaction and comfort, staff productivity, staff satisfaction, organizational (business) outcomes, and patient/staff visibility in healthcare environments. Sixteen studies targeted specific design strategies including unit or room configuration, furniture and equipment, acoustics and department adjacencies.
For example, a 2016 study by Shepley, et. al. identifies physical environment features which positively impact psychiatric patients and their staff related to social interaction and safety outcomes. Findings include staff preference for less institutional settings, open nurse stations instead of closed, and access to nature. Designers of behavioral health facilities are faced with conflicting dictates of therapeutic environments vs. patient and staff safety; this study may help our clients better understand the importance of the former.
A 2014 study by DuBose, Lim, and Westlake studied clinic care team center configurations as to how well they support staff effectiveness and efficiency. Findings include a clear preference for providing direct views of clinic corridors and exam room doors for continuous visual control, as well as specific accommodations for documentation work. This is highly relevant to architects’ current work which includes more outpatient than hospital projects.
A 2011 study by Sanford and Bosch researched optimum toilet configurations for caregiver-assisted toileting for care effectiveness and safety, finding caregiver preference for space on both sides of the toilet, with folding grab bars. This finding has implications for reducing staff injuries and frustration.
Similar to the Academy Journal trends, the AAHF-sponsored research is increasingly providing designers with practical learnings to inform more intelligent floor plan layouts and room features as ways to improve patient health outcomes, staff effectiveness and efficiency. In addition, there were more studies on ways to improve staff satisfaction, which is relevant given an emerging concern about staff retention.
Health Environments Research & Design (HERD)
Health Environments Research & Design (HERD) is an international, peer-reviewed electronic journal that features research and methodology papers, theory articles, case studies, and book reviews focused on the effects of health environments and design on healthcare-related outcomes. Based on a review of the last five years of HERD Journal articles, the most prevalent research topics include hospital-acquired infections, patient falls, patient experience, nursing experience, nursing work environment, design and construction process and interiors, signage, artwork and color.
For example, a 2016 acoustics study comparing sound levels in open plan vs. pods in neonatal ICUs by Ramm, Mannix and Parry found only a four decibel difference in peak sound levels, concluding that sound environments are unacceptable in both models. While not providing designers with a preferred solution, it informs them that other design strategies are needed for improving this sensitive environment.
Another example is a 2016 study by Karvonen, et. al. comparing hospital patient transfer distances of existing hospital plans vs. idealized plans, finding a potential for a 50% reduction in transfer distances for inpatients and 30% for outpatients. Since transfers are a non-value added activity, this calls attention to an important tactic to improve increasingly important economic metrics in hospital design.
A study published in 2015 by Nejati, Shepley, and Rodiek compared nurses’ judgments of their staff break areas. They found the most effective means of increasing nurses’ performance and satisfaction included proximity to their work area, access to outdoor areas, and providing opportunities for both socialization and privacy. These findings are important, since staff respite areas are frequently given low priority in designing healthcare buildings.
Once again, there is an increase in research that can inform design for best practices in healthcare environments, with specific recommendations for designers.
The Center for Health Design Knowledge Repository
The Knowledge Repository (KR) is designed as a collection of evidence-based research for healthcare from multiple sources, including those mentioned above, made accessible in an online library. The AIA Academy of Architecture for Health is a sponsor, and our Research Initiatives Committee advises the Center for Health Design on the KR structure and content. It continues to grow with the latest published papers on a wider variety of healthcare topics, which can be searched by design or outcome category. Over the past five years, 326 articles focused on patient health outcomes, patient satisfaction and comfort, and staff productivity/efficiency outcomes have been added to the repository. Two hundred eighty articles include investigations of unit configuration and layout, room configuration and layout, and fixtures, furniture, and equipment design.
For example, a 2016 study by Pierce, B.A., & Gormley, D. published an article in the Journal of Emergency Nursing that compared the performance of two different emergency departments (EDs) to determine whether the split flow model reduces ‘discharge length of stay’ (DLOS) for all ED patients when compared to an ED that uses a different model. The paper looks at adding a ‘provider in triage’ (PIT) to further enhance the split flow. They found that a split flow model reduced DLOS by 16.3 minutes on average and that a PIT reduced the DLOS by 28.5 minutes compared to the traditional model. This has significant design implications in how EDs are planned, suggesting that architects consider including space for initial evaluation from the PIT to help facilitate a smoother flow throughout the triage process.
Another article, published in Clinical Rheumatology in 2015 by Bukh, Tommerup, & Madsen, examined the impact of certain room modifications on patients’ perception of an outpatient infusion room used for rheumatologic disease treatment. The findings show that patient satisfaction was directly linked to every sensory aspect of the healthcare environment and that designers should consider how personal privacy, interior décor, color, and creating rooms that do not feel “hospital-like” can improve patient satisfaction.
It is no surprise that the KR trends are similar to those of the Academy Journal, HERD, and the AIA AAHF Grants trends, since it is a place that compiles articles from these sources as well as others. It is clear that the research industry is looking at how the design of the built environment can impact improved health outcomes and patient/staff satisfaction.
What research is most needed now?
Each year, our AAH Research Initiatives Committee discusses trends in the architectural design work we are engaged in, to better understand areas of research needed to inform our practices. From this, we recommend areas of focus for soliciting proposals for the annual research grants offered by the AAHF. This year’s top five recommended research topics are as follows:
- Research related to Guidelines for Design and Construction of Hospitals and Outpatient Facilities, to be coordinated with FGI’s own priorities, especially patient safety-related issues
- Clinic environments studies (effectiveness of different team centers, collaboration spaces, communication approaches)
- Efficiency improvements in surgery environments (especially outpatient), planning issues (induction rooms, prep/recovery flow), errors and omissions and infection control issues
- Behavioral Health inpatient environments studies: effects of design on safety and therapeutic care effectiveness
- Patient and Family-Centered Care concepts and their impacts on healing and on satisfaction surveys; Cultural and Human Factors implications
As the research industry continues to perform studies that can directly inform design, architects will have better tools to increase the intelligence of our solutions and desired patient, staff and business outcomes. For healthcare architects who have been waiting for a body of intelligence to help their clients with design solutions informed by research, the wait is over.
Tom Clark is the 2017 president, AIA Academy of Architecture for Health. He can be reached at tomclark@ckarch.com. Byron Edwards is chair, AIA Academy of Architecture for Health Research Initiatives Committee. He can be reached at byrone@clemson.edu. Lindsey Stang is co-chair, AIA Academy of Architecture for Health Research Initiatives Committee and can be reached at lindseystang@ls3p.com.
For access to the AIA AAH Journal library, visit aia.org/academyofarchitectureforhealth. For information about the AAH Foundation research grants and to view the library of research, visit aahfoundation.org. For access to the Knowledge Repository, visit either aia.org/academyofarchitectureforhealth or healthdesign.org