Although hospitals have long been thought of as places to cure disease, new ideas about what hospitals should be and how they should function are creating new challenges for hospital designers and caregivers.
"Therapeutic environments are spaces whose physical, social, and symbolic qualities may affect relations between people and place to promote better recovery and healing . . . " 1 Although hospitals have long been thought of as places to cure disease, new ideas about what hospitals should be and how they should function are creating new challenges for hospital designers and caregivers. Ann Hendrich (Ascension Health, St. Louis) and associates report on a case study of acuity-adaptable rooms at the coronary care unit of Methodist Hospital in Indianapolis, while Wil Gesler (University of North Carolina) and associates look at new directions in UK hospitals, focusing on the best ways to evaluate therapeutic settings through evaluation questions.
Fewer Patient Transfers
If sick patients could be admitted to a room that allowed for both critical and progressive or “step down” care, then the need to transfer them from one room to another based on their advancing or declining health becomes much less acute. Hendrich reports that patients can move three to six times during a hospital stay, increasing the administrative and time burden on staff. To increase efficiency, acuity-adaptable rooms were planned for the hospital’s new coronary care unit. Other goals for the new unit included improved resource allocation, improved patient satisfaction, creation of a preeminent healing environment, and improved caregivers’ work environment.
Innovations at All Levels
The new rooms included efficiency innovations and advances in holistic patient care. Transforming headwalls with integrated computer technology made the rooms adaptable to both levels of care. Caregiver workspaces are located just outside patient rooms, computer nursing stations are decentralized for better access, and most supplies are strategically located in the rooms. The 36-meter-square room includes a “family zone” with a “chair-bed for nighttime visits, a refrigerator, a computer hookup, voice mail, and a television/videocassette recorder.” Other visitor amenities in the coronary care unit include an indoor garden, aquarium, and kitchenette, while caregiver spaces include a lounge, shower, and lockers. The new unit is open to family visitors 24 hours a day—a change from restrictive visiting hours at the previous facility.
After the move, patient transfers per month went from more than 150 to fewer than 50, and measures of care, such as medication errors and patient falls, decreased. Patients’ perceptions of their stays were more positive in the new unit. The new design reduced walking and supply trips for staff, while increasing patient-care time. While staff turnover initially increased due in part to the magnitude of changes imposed on the nursing staff, it leveled out after a year of adjustment. In all, the significant positive outcomes make this case study a successful model for rethinking how to deliver effective and cost-efficient patient care.
Looking at a Bigger Scale
In the United Kingdom, the Department of Health (NHS) is implementing an initiative through which private organizations enter into agreements with NHS to build and operate health facilities. The NHS has an Achieving Excellence Design Evaluation Toolkit with three major areas and a total of ten sub-areas: functionality (i.e., uses, access, spaces), impact (i.e., character and innovation, internal environment, citizen satisfaction, urban and social integration), and built standard (i.e., performance, engineering, construction) to evaluate these, and other, facilities.2 A separate method is mentioned for evaluating sustainability. The questions can be used during the design process, or for post-occupancy evaluation. Each of the sub-areas is evaluated through three to twelve specific questions, with a list of issues to consider. For example, under Uses, one question is “Are the workflows and logistics within and between processes optimized?” Issues to consider under that category include such questions as “Is the departmental workflow direct?” and “Are the routes as short as possible?” Access includes the question “Is the external wayfinding and sign-posting strategy of high quality and fully integrated into the design solution?”
Gesler and associates, working separately from NHS, decided to look at a therapeutic setting’s physical, social, and symbolic environments. Just as heating, lighting, décor, and seating contribute to a hospital’s physical and social environment, ideas can also contribute to its symbolic environment, such as using white to symbolize the hospital’s commitment to cleanliness.
The design of these three environments—physical, social, and symbolic—can promote specific therapeutic goals. Gesler and associates reviewed information about the NHS program, and determined that in addition to the goal of clinical efficiency, NHS was advocating new hospitals include the goals of promoting well-being, increasing community integration, providing public access, and considering patients as consumers. Gesler then looked at how manipulating aspects of the three environments might relate to the stated goals. For example, the physical environment might help meet the goal of clinical efficiency through compact floor layout, while the social environment might support the goal of promoting well-being though appropriate public and private meeting spaces.
Best Evaluation Methods
Gesler and associates believe that the questions in the NHS toolkit do not adequately cover the range of healthcare design considerations included in their “three environments” model. Breaking out each individual question in the toolkit and placing it in a category based on what goal it supports, and what environment it relates to, they find that the toolkit asks fewer questions about the social and symbolic environments than the physical environment (Table 1).
To capture the full range of elements that make up a therapeutic setting, they argue a broader examination is needed that gives more weight to the social and symbolic environments. Their classification of physical, social, and symbolic environments can be a useful method across venues for organizing place evaluations, including post-occupancy evaluations, and for examining new design paradigms.
1. Gesler, Wil, Morag Bell, Sarah Curtis, Phil Hubbard, and Susan Francis. 2004. Therapy by design: Evaluating the UK hospital building program. Health and Place, vol. 10 no. 2, pp. 117–28.
Hendrich, Ann L., Joy Fay, and Amy K. Sorrells. Effects of acuity-adaptable rooms on flow of patients and delivery of care. 2004. American Journal of Critical Care, vol. 13 no. 1, pp. 35–45.
2. The toolkit, along with associated publications, can be downloaded from: http://18.104.22.168/nhsestates/chad/chad_content/publications_guidance/introduction.asp.