Healthcare Facility Planning and Designing. Do we create a Healing Environment?

The fundamental principles as stipulated by the medical authorities around the world stress
that the healthcare planning and design is to provide an ultimate patient and staff experience
and satisfaction by;

• By reducing hospital acquired infections, reducing patient stress and creating a healthy and
healing environment.

• Better monitor or control of patients’ activities and to facilitate interaction of staff at all
levels with due diligence and transparency.

• Supportive physical work environment, high autonomy, low work to increase the medicos’
job satisfaction.

• Decreased burnout among medicos through efficient and functionality based operations
rather having practice based designs to improve medical staff retention.

We have come across various articles and ideas that provide an intense view of comparing the
healthcare facilities with the hospitality sector level comfort. The whole idea diminishes until
certain operational changes are introduced. Do we still provide a healing environment?

The most acceptable standard for designing a healthcare facility is “HBN” or “Health Building
Notes” supported by a series of “HTM” or “Health Technical Memorandums” both prepared
and published by the Department of Health, United Kingdom.

The standards set by “HBN” details each facility practiced by the medical profession and is
possibly the most elaborate standard available today. Research and Development in each
specialization is being carried-out on daily basis by various scholars are yet to become a
“Standard” now or later.

Though the standards emphasize the requirements, it does indicate the requirements for any
change in operation style of the facility.

How many of us design a healthcare facility ignoring the standards set by the concerned
medical authorities or regulatory in the region we practice. The trend these days is to carry-out
Practice-Based-Design to suit the Client or End-users operational practice rather sticking to the
standards. You might please them by doing so, but are we really doing any justice to the
profession we practice? It is still an unreciprocated question, yet we know the answers.

Why don’t we practice Evidence-Based-Design (EBD) rather showing interest in Practice-Based-

Design? These scenario is based on a lot of evidences gathered by extensive research on the
efficient functionality, effective operations and standard compliances.

The entire process of implementation an efficient EBD is part of the strategic planning and
implementation process. The research findings are externally valid as well since the finding are
the results of the expected reasons / outcomes of the strategic planning process.

What are the factors motivating evidence-based design and its expected benefits?

The rapid growth of EBD is driven by the factor that motivates evidence base and changing
regulatory and building delivery processes.

• Architectural Research, Post Occupancy Evaluation (POE), and Performance Based Building;
EBD is a refinement of several strong, continuing research and building delivery practices
that have been active since the 1960s.

• Use of an integrated multidisciplinary approach with consistent Senior Management /

Administrator’s involvement that overcomes silo thinking by developing institution wide
perspectives and goals.

• Maintain a patient-and-family-centered approach. The EBD project considers focus and

define on a variety of issues such as reduced waiting times, reduced walking distance, an
improved sense of control of the clinical / procedural experience, ability to control the place
/ time of the clinical experience and a quieter environment.

• Focus on financial operating impacts. Successful project teams deliberately navigates

through the paralysis of initial cost thinking (capital-expenditure) and study the business
case for design decisions, exploring the cost-effectiveness of design options and its returns
over time.

• Support and demand of simulation and testing throughout the study and implementation.
Simulation can mean many things such as assuming the patient’s perspective in experience-
mapping exercises to understand what they will see and experience as they move through a
 setting; doing lean design throughout simulation and modeling; creating lighting, energy,
and other kinds of models; and creating computer visualization.

What are the benefits we expect to realize as a result of using Evidence-Based-Design?

Evidence Based Design provides research driven guidelines for creating an effective healing
environment. The expected benefits as a result of implementing an efficient EBD is;

• Economic efficiency & Self Improvement.

• Reduced procedural timings, patient satisfaction & thereby potential increase in market
share.
• New facility, latest innovations with patient centered approach.
• Staff motivation, reduction in staff burnout and retention of experienced professionals.
• Potential increase in market share.

Following are the two major findings identified during the EBD, which are considered credible,
accessible, and relevant? Hope you will find this pertinent and henceforth would incline
yourself to consider designing a facility with EBD.

1. Hospital Acquired Infections: It describes about hospital acquired nosocomial infections and
describes various factors pertaining to Changing Features of Hospitalized patients and
Changing Types of procedures performed for complex illness etc.

Such data emphasizes providing individual rooms / isolation rooms for critical illness in
order to avoid transmittal of such infections. The study also provides finding that force the
designers to focus on the electro-mechanical component of the building, which plays a
important role in airborne infections. The HVAC needs to be designed for 100% fresh-air
that would not allow recycling of the return air.

2. Providing De-centralized Nursing Units: Nurses’ stations are traditionally hubs of activity
where nurses gather to work individually, collaborate, and socialize. However, they can also
be busy, noisy places that are distracting and unfavorable for work. Current solutions to the
traditional centralized station are to break up the nurses’ stations into small substations,
either completely to create decentralized stations, or partially to create a hybrid form.

The de-centralized nursing units provide better monitor / control of patients’ activities and
to facilitate interaction of staff at all levels. Supportive physical work environment, high
autonomy, low work pressure and supervisor support may increase job satisfaction. In
 addition to the above, the decreased burnout among nurses may improve nursing staff
retention and reduce turnover rate.

What are the recommended solutions to the research findings identified vide EBD? These
solutions are based on intense research carried-out through various facilities considering the
roles of stakeholders, and the possible need for tradeoffs.

Hospital Acquired Infections:

1. Patient safety remains our highest priority and adapting evidence-based practices proven to
reduce the rate of infection. The proactive approach of the research findings is helpful to
reduce the incidence of hospital acquired infections.

2. Apart from providing separate / individual rooms or isolation rooms, the single most
important thing a person can do to keep from getting sick and spreading illness to others,
protect patient safety, and reduce infection, is to keep hands clean by thorough hand
washing.

3. Providing additional hand-wash basins near the patient wards and individual rooms have
significantly reduced urinary tract, central-line, surgical-site and ventilator-associated
pneumonia infections.

4. The organization remain fully committed to providing a culture of quality and safety for all
patients and in adopting best practices in new and improved ways to prevent infection,
including Aggressive hand washing campaign for staff, physicians and visitors

5. Adherence to evidence-based safety standards in cleaning for rooms and equipment and
implement best practice policies demonstrated to reduce rates of infection.

6. The following are the clear solution pertaining to the design (Architecture and Layouts) to
be adopted to avoid Hospital Acquired Infections are;

a. Adequate number of washbasins should be installed close to operating suites,

emergency department, main wards, procedural areas and isolation rooms to
encourage hand-washing.
 b. Central air-conditioning systems are designed in such a way that re-circulated air must
pass through appropriate filters (HEPA Filters). It is recommended that all air should be
filtered to 99% efficiency down to 5 μm.

c. Suitable and safe air quality must be maintained at all times. Air movement should
always be from clean to dirty areas. It is recommended to have a minimum of six total
air changes per room per hour, with two air changes per hour composed of outside air.

d. Isolation facility should be with both negative- and positive-pressure ventilations.

e. Adequate space around beds is ideally 2.5-3 metres. Electricity, air, vacuum
outlets/connections should not hamper access around the bed.

f. Alcohol gel dispensers are required at the ICU, Wards, Isolation Room entry, exits, every
bed space and every workstation.

g. There should be separate medication preparation area.

h. There should be separate areas for clean storage and soiled and waste storage and
disposal.

i. Adequate toilet facilities should be provided.

Providing De-centralized Nursing Units:

1. Advances in information technology have enabled nurses to move away from traditional
centralized nursing stations and paper-charting stations to smaller decentralized stations
and charting substations located closer to patient rooms. The wireless phones, laptop
computers, and handheld devices are making nurses even more mobile.

2. The de-centralizing has its own disadvantages as well. It tends to distance nurses from their
colleagues.

3. The traditional centralized station allows them to share professional expertise with each
other and with physicians. With the de-centralized concept, there is no socialization aspect,
which is crucial to engendering team spirit among nurses.
4. The decentralized nurses' substation further develops itself to the concept of "computers
on wheels" — portable substations known as COWs rather having a individual computer for
charting in each room.

5. As for centralized nursing stations, they are no longer the central command centers.
Successful central stations today serve more as information centers for traffic control
between units.

6. The solution for de-centralized nursing stations are emphasized based on the following;

a. Creating Consultation zones outside patient rooms through strategically angled walls. A
multiuse work spaces is created between for monitoring the individual rooms with both
open and private areas to be used by anyone at any time. Anticipated benefits of the
new layout included improved communication and collaboration among care team
members, efficiency in service delivery, more privacy, and reduced noise levels.

b. The workspace between two rooms are combined to provide a single nursing unit. The
increased size of the unit in comparison to the single user requirement, which can
allocate one or two more familiar / unfamiliar team members can reduce the feeling of
increased isolation that comes naturally with a switch to individual workstations. On the
positive side, the perception of noise was decreased, as was the number of distractions
for workers.

c. And there was one finding that had the session attendees sitting up straighter in their
seats: Somehow, even though caregiver stations were decentralized and moved much
closer to patients, nurses in the new unit walked half a mile more than they had in the
previous space.

d. Apparently, the caregivers in the new space tend to gravitate towards the bigger care
team stations to reclaim the camaraderie and support they were missing. Moreover, the
de-centralized nursing units provide better monitor / control of patients’ activities and
to facilitate interaction of staff at all levels. Supportive physical work environment, high
autonomy, low work pressure and supervisor support may increase job satisfaction. In
addition to the above, the decreased burnout among nurses may improve nursing staff
retention and reduce turnover rate.