Facility design can not only enhance patient experience but also impact the clinical and financial performance of institutions. Use of innovative and appropriate design strategies can help healthcare facilities prepare themselves better for delivery of services in an increasingly patient-focused and tech-savvy culture.
A fast growing economy, rising incomes and increased urbanisation have been instrumental in changing the perception of patients as consumers. In this new avatar, patients are becoming more demanding, expecting better services for their money and exercising choice in choosing a facility for reasons other than cost and proximity.
To stay competitive, healthcare providers need to gear up to not only improve operational efficiency but to provide an enhanced patient experience. In an increasingly patient-focused culture, management of patient expectations is irrevocably tied to the design and planning of healthcare settings. Facility design can impact both the quality and delivery of care, and also the financial performance of healthcare institutions.
A well designed hospital helps in attracting more patients, recruiting good staff and increasing staff productivity. At a less obvious level, it also increases humanitarian and corporate support.
However, there needs to be an attendant shift in attitudes towards healthcare facilities design both within the architectural profession and the healthcare industry at large. Traditionally, design for healthcare environments was perceived as a purely functional exercise and hence fell outside the interest and domain of avant-garde architects. It was driven by complicated clinical protocols and suffered from budgetary constraints, and was therefore seen as thwarting creativity and professional growth. In the recent past however, some of the best known names in architectural design have been commissioned to design prestigious healthcare projects and the outcomes have been very refreshing. It is hoped that this trend is on the rise and healthcare will see more of the architectural innovation.
Let us look at some trends that bring together clinical and design considerations and how they can help healthcare organisations meet rising public expectations and better achieve their institutional goals.
Shift to Ambulatory Care Enabling technologies and new protocols have led to the emergence of alternative delivery settings. There is a general worldwide shift in care to ambulatory settings, integrated with the twin mission of improving care and service excellence.
Minimally invasive procedures have resulted in faster recovery times due to smaller incisions. Procedures traditionally requiring hospitalisation and long lengths of stay can now be done on an outpatient basis. In addition, increasing focus on preventive care and newer kinds of elective treatments involve shorter stays or are ‘visits-based’ instead of ‘procedures-based’. Delivery of the right level of care in the right setting leads to improved care management and better resource utilisation. This paradigm assumes even greater significance given the shortage of inpatient beds and skilled nursing staff.
As a design response, newer facilities are either separating outpatient functions from inpatient settings in hospitals or offering these procedures in free-standing centers. An ambulatory building program has lower grade services and spatial requirements than the high-tech treatment and patient care spaces required in a full service tertiary care hospital, resulting in significant cost savings.
In addition, different care settings have different characteristics, necessitating an appropriate and customised design approach. For instance, “hospital based care” is characterised by long patient stays, as opposed to “ambulatory care” which involves stays of not longer than a few hours. In hospital based settings therefore, features such as daylight assume a greater importance than in a short stay setting.
Evidence Based Designï¿½an emerging concept
“Evidence Based Design” (EBD) concept stems from “Evidence Based Medicine” (EBM), which applies evidence gathered using scientific methods for assessing efficacy of different treatment choices. A similar process is evolving in healthcare architecture too, where innovative design decisions are made on the basis of empirical observations and analysis of the outcomes.
It uses critical thinking to link physical settings of the healthcare facility with delivery outcomes. In planning, the focus is on the influence of ambient environment i.e. layout, colors, ventilation, external noise, natural surroundings etc. on operational and patient-care outcomes.
Research initiatives such as the Pebble Project in USA have been launched with the purpose of demonstrating that design can help improve clinical and financial performances of healthcare facilities. It collects data from participating institutions and analyses it to gauge the impact of specific design interventions on delivery outcomes.
Some of these impacts have been:
Decrease in patient falls due to the unit’s decentralised design, which allows for better observation
Decrease in patient transfers due to patient room layout, equipment integration, and other design features. This alongwith more consistent knowledge of each patient’s condition in turn have contributed to an improved medication error index
Improvements in nursing efficiency due to unit design
Increase in overall patient satisfaction
Service Line Organisation
Organisational planning for hospitals has undergone many changes from an inward looking ‘Departmental Organisation’ to an open ended ‘Service Line Organisation’ to a more recent ‘Centres of Excellence’ model. Service Line Organisation, as the name suggests, organises the building program according to the different service lines, giving each a distinct, readily identifiable image. It provides a front door to each service resulting in easier accessibility and clarity of functional and physical organisation, while allowing sharing of Diagnostic and Treatment services and other similar functions. By carefully choosing adjacencies, it minimises cross-traffic and duplication of services.
Evolving Improvements in Care Delivery:
Surgical Procedure Incisions Surgery time No. of days of Recovery time Prostatectomy Five small incisions of 5-10 mm v/s one big incision Shorter duration 1-2 days v/s 3-5 days
2-3 weeks v/s5-6 weeks
CABG Three 1 cm incision v/sone 8-10 incincision
Shorter duration 3-7 days v/s 2 weeks 2 weeks 4-6 weeks Hysterectomy
Five 1 inch one 8-10 inch incision 2-3 hours v/s 1-2 hours
1-2 days v/s 3-5 days 1-2 weeks v/s 4-6 weeks Cholecystectomy One small incision v/s one 4-7 inch 1 hour v/s 3-4 hours 3-4 days v/s 5-7 days 1 week v/s2-3 weeks
Hospitals have, over time, centralised nearly all ancillary and service functions. Service line organisation goes one step ahead and maximises opportunities for sharing facility, equipment and staffing resources where clinically viable. This results from a functional zoning that co-locates activities requiring similar resources. Service Line Organisation has an easily comprehensible spatial organisation, providing much needed legibility, ease of access and ease of navigation in complex healthcare environments.
Integrated Diagnostic and Treatment Platforms
The last decade has seen unimaginable advances in minimally invasive and image guided surgeries. While these have amazing impact on the delivery of care in terms of quicker recovery times and improved patient care outcomes, they also impact the design and planning of healthcare facilities. With imaging playing an expanded role in surgery and becoming more than just a diagnostic tool, there is a blurring of boundaries between radiology and surgery. The convergence of the two traditionally distinct realms will necessitate a re-look at operating room design. Some of the procedural and design changes that are driven by this convergence are complexity of procedures, information management, infection control requirements, operating room team structure, and requirements such as space, and image processing and viewing requirements.
Newer facilities will do well to plan for integrated operating rooms. Procedures and support spaces should be taxable, rather than rigid. An integrated and highly flexible platform provides a chassis that can accommodate the ever changing and unpredictable diktats of healthcare. Hence, an understanding of trends and advances in medicine and technology is key to designing buildings that respond well to programmatic and operational changes. Some of the impacts of advances in medicine and technology on procedure and recovery times can be seen below.
The Nursing Unit and The Patient Room
The Nursing Unit design has undergone many innovations through the history of healthcare design, spanning an entire range from open wards to semi private and private accommodation.
The quest to find the perfect geometry for a nursing unit has also led to various innovations and experiments, including saw-tooth, radial, triangular and rectangular models. The radial design fell out due to staffing inefficiencies and awkward residual spaces. Also, it did not lend itself very well to scale. Increase in number of rooms resulted in a disproportionate increase in size of the support core.
Each model has its attendant trade-offs such as ratio of patient room versus support space, ease of supervision, nurse travel time etc. Patient Toilet Configuration is also a topic for much debate. The en-suite bathroom could be inboard, outboard or midboard and affects the building structural grid, nursing requirements of observation and daylight penetration into the room.
Hence, the nursing unit is an intrinsic part of the building design and should drive design decisions at an early stage.
The Patient Room is the most important functional component of the inpatient environment. With increased affordability and concern for patient privacy and comfort, there is a surge in demand for single rooms. This is supported by improvement in clinical performance.
With increased life expectancy due to improvement in medical care and technology, there are also more number of patients who require greater support at the bedside. Improved and new bedside technology and more complex equipment take up more space.
It is imperative that the inpatient environment be rethought of as a space that can accommodate patients and their families in privacy and comfort for the full continuum of prep, procedure, and recovery. In response more and more patient rooms are being deinstitutionalised to be as home-like and non-clinical as possible in look and feel.
Some advantages of Single Rooms are:
Reduction in nosocomial infections
Less patient transfers
Less patient disruption
Reduction in medical errors
Reduction in length of stay
Improvement in bedside nursing care
Increased involvement of family in care delivery
Lower use of narcotics
Increased market share
A well-planned Patient Room has three distinct zones:
Caregiver zone: The Caregiver zone is the work space for staff and should comprise of work counter/storage space for supplies.
Family zone: The Family Zone should be away from the staff zone and have reasonable provision for stay of a family member.
Patient zone: The patient zone should have plenty of room for the patient bed, medical equipment, communication/ entertainment systems, etc. with adequate clearances all around.
Quality of Healthcare Spaces
A visit to a hospital for most people is a much dreaded and extremely stressful experience.
Design can play an unwitting role in making the environment more pleasant. It may be invisible as a tool but many studies have shown that it can help in improving psycho-social aspects of care and recovery. A number of design tools and strategies can be employed to improve the physical settings for patient care. While building massing and lobby design can provide obvious clues for navigation, color can play an important role in providing spatial orientation and aesthetically pleasing environments. Lighting can be manipulated to respond to a variety of illumination needs such as ambient lighting for patient spaces and task lighting for staff areas. Good signage not only helps to keep people out of restricted zones, but also cuts down frustration/confusion by providing a sense of orientation to patients and visitors. Finishes and materials selection should not only take into account maintenance and infection control requirements but also address slip and fall issues.
Quality of interaction can be enhanced by providing appropriate settings for different kinds of interaction. While a task oriented or formal setting needs to be straight forward, fast tracked and technology focused, a spontaneous or informal setting needs to be easy, slower and care-focused.
Building design is a physical manifestation of an institution. It creates a brand identity for today’s choice conscious patient and translates its values and mission into a recognisable icon.
Information Technology Paradigms
More and more hospitals worldwide are looking at digitisation as a means to enhance operational efficiencies and control costs. Digital design applications span from tasks such as tele-radiology and medical transcription to integration of building, logistics and patient care management systems.
The most common application today is in the area of Electronic Medical Records (EMR). Image capture, patient information charting, processing, reading and storage are all happening electronically. While less physical storage requirements will allow a reduction in the hospital building program, there will need to be a simultaneous increase in number of reading stations provided. In addition, modality upgrades and growth in patient volumes will only increase archiving demands. Electronic records help doctors have access to patient information faster and with lower errors. They also reduce data redundancy and provide consistent information across health systems as a whole. Currently there is duplication of patient information in multiple formats and multiple locations that can be eliminated by use of EMR. For instance, patient information is recorded in multiple consent forms, medications and treatment records, discharge/teaching planning forms, and so on.
Telemedicine assumes great significance, particularly in the Indian context with a large percentage of patients traveling more than 100 kilometres. to access healthcare services. The potential for remote care could greatly help in increasing outreach to rural belts or far flung communities.
Computerised Physician Order Entry (CPOE) results in reduced error margins by cutting down the number of steps. This in turn could be integrated with pharmacy, lab workflow and facilities management for better inventory management and improved response time.
Integration of Information Technology into healthcare delivery systems doesn’t come without its share of challenges. Ensuring compatibility between systems and continuity across systems is key to successful digital design. Hence, some areas where digital design finds application in healthcare are Electronic Medical Records, Electronic Physician Orders, Digital Radiology, Tele-radiology, Telemedicine, Building Systems Management, Patient Care Management, Registration Functions and back office / support functions.
Designing for the Future
One of the greatest challenges in the design and planning of healthcare facilities for the future is to reconcile the increasing shift to outpatient care with the change in acuity levels.
On the one hand, more procedures are happening at a step down level in ambulatory settings, on the other hand, an aging population and increased life expectancy is resulting in greater need for hospitalisation and necessitating higher provision for critical care and speciality beds. Treatment and care settings need to be re-engineered to provide adequate care for these high dependency patients. In addition, it is becoming an increasingly challenging task to accommodate the continually evolving technology and modality upgrades in existing aging facilities. This is especially true for diagnostic/treatment modalities such as minimally invasive surgery, digital imaging, and automated clinical laboratories. Frequent physical interventions are neither logistically nor financially viable.
Hence, flexibility and standardisation are key to designing for the future. While standardisation helps in optimising use, flexible procedure rooms accommodate unplanned for shifts in relative patient volumes. Support technologies such as IT are changing equally fast, necessitating the placement of adaptable support systems.
Hence, it is imperative that the hospital design for the future be able to take care of an entire spectrum of procedures and criticality levels in appropriate and patient friendly settings.