Chapter 1
Introduction

In the coming decades, healthcare will continue to be an issue of major concern in the United States as it is worldwide. The uncertainties are many. The capacity of the medical professions to treat illness and injury is continually growing, as are the costs associated with such treatment. New legal mandates and constraints upon healthcare delivery are regularly brought into play. The character of society—demographics, experiences, and expectations—is, as always, in transition. Our very understanding of health itself, its sources and conditions, is expanding and evolving.

The healthcare systems of tomorrow will look different from those of the past. Those of us involved in planning and designing healthcare facilities have many issues and questions to consider. No matter how diligent and well informed we are, we cannot know with certainty the nature and rate of future change. Yet some of today's decisions must be based on projections about medicine and society in the year 2030 or 2050. The better we understand the issues involved, the better prepared we will be to meet tomorrow's healthcare demands and contribute to the development of effective, efficient, caring healthcare delivery systems, in the United States and abroad.

Projections and the Direction of Healthcare

Health is an indicator of overall quality of life. The growing popularity of exercise, proper nutrition, and stress-reducing activities shows that many people have a strong interest in health. Individuals in first-world countries, including the United States, are becoming more knowledgeable about their own health and are taking more responsibility for it (Panther, 1984; Spreckelmeyer, 1984).

In addition to less quantifiable developments in social norms and issues, such as customer expectations, ideas about customer experience, gender roles, the role of family and friends in the hospitalization of a loved one, and marketing trends, we can study changes documented by demographers and the US Bureau of the Census. Changes in age distribution, fertility rates, urbanization, work status, and education, too, will all profoundly influence the future of healthcare. What our society looks like, how we live, and how long we live will determine the demands on the healthcare in the next few decades.

Perhaps the most significant demographic trend is the change in age distribution. Because we are living longer and our fertility rate is decreasing, the proportion of older citizens in the US population will continue to grow. In fact, there is a distinction between the “young old” in their sixties and the “old old” in their eighties and above. Whereas in 1930 only 5.4 percent of the US population was over 65 years old, the 2010 figure was 13 percent (Panther, 1984; US Census 2010). In 1930, the median age of the population was 26.4, but by the year 2012 that figure had risen to 37.1 (CIA, 2012; US Government, 1984).

The photograph depicting two person riding on a bicycle.

Healthy lifestyle choices, including exercise and good medical care, mean that many seniors live longer and more actively than ever before.

Our longer lifespan is due primarily to an improved standard of living and advances in healthcare. Yet, because of its unique needs, an older population will demand greater services from the healthcare system. Older people tend to have a greater number of chronic health problems, require more visits to the doctor, require a longer period of recuperation after an illness, and need more hospitalization. As a patient grows older, the types of illnesses experienced often shift. And in addition to treating particular illnesses, physicians treating geriatric patients must be concerned with the physiological, sociological, and psychological changes directly related to the aging process (Godfrey-June, 1992).

However, healthcare will have to contend with more changes than just those related to serving an older population. Choices made by couples regarding how many children to have, or whether to have them at all, are profoundly affecting healthcare. In the post–baby-boom years between 1957 and 1973, there was close to a 50 percent decrease in the fertility rate (number of births per 1,000 women of childbearing age) (US Government, 1984). Family planning decisions—to have fewer children, to delay childbirth, or to have no children at all—aided by the availability of effective contraceptives, have already affected the demand for obstetric and pediatric units.

The number of infants born each year does not tell the whole story. Partly because childbirth is now more a matter of choice for many, it is reasonable to speculate that parents-to-be will also want to make more decisions concerning the healthcare their children receive. Both parents, as well as other family members, have already become more involved in the delivery and in infant care. These shifts in birthing participation and the increased popularity of alternative birthing arrangements, such as midwives and birthing rooms, are reshaping obstetric and pediatric healthcare.

Other demographic trends—including greater numbers of women in the workforce, the continued urbanization of America, increases in the number of immigrants and ethnically diverse populations, higher levels of education, and changing occupational profiles—will also put pressure on the healthcare system. With regard to urbanization, not only is the geographic distribution of the population shifting, but residents of urban areas also tend to use physicians' services more often than do their rural counterparts. Changes in the workforce, such as higher levels of education, will also affect the healthcare establishment. As the level of education rises, basic knowledge about medical care also rises. A knowledgeable patient has particular expectations, which may alter the accepted definitions of high-quality care. Changes in these definitions—changes from the patient's and family's points of view—may also result in a public re-examination of the basic policies and practices of healthcare.

Keeping a vigilant eye on lifestyle and demographic trends seems to be a prudent strategy for healthcare decision-makers. Some of the shifts and their effects are easy to track and speculate about, but others are far from certain. Nevertheless, because society is unquestionably in transition and because its changes, the slow as well as the revolutionary, will affect healthcare, it is essential for healthcare leaders to plan for these shifts.

The previously mentioned demographic changes, uncertainties in the general economic climate, and the challenges of healthcare reform make it increasingly important for healthcare organizations, whether engaged in renovation or new construction, to “start smart, design smart, and build smart” (Managing Construction Costs, 2012). Since capital improvements and building costs are significant, planning for the long term is essential. Whether planning is for long-term or short-term goals, however, it must not be considered a static process. The long-term strategic plan must have enough elasticity to be altered as the need arises (Michael, 1973). Meeting the needs of consumers requires a dynamic approach to planning.

The photograph depicting an insight view of a fitness center.

Fitness centers offering a variety of exercise options are an important feature of many health facilities.

Photo credit: Courtesy of Chelsea-Area Wellness Foundation

Healthcare: Changing Within

Rapid developments in science, medical practice, and medical technology, changes in population and age distribution, and the increased role of government regulation are causing a revolution in healthcare. “Old-style” healthcare, dominated by the individual physician's practice and the not-for-profit hospital, is rapidly becoming a thing of the past. Rising healthcare costs, an increasing supply of physicians, an uncertain future for Medicare and Medicaid, limited resources, and other trends have transformed the healthcare field. The age of healthcare competition is upon us (Johnson and Johnson, 1982). Birthing centers, health maintenance organizations, hospices, and big-city hospitals must vie for a piece of the hundreds of billions of dollars ($2.7 trillion in 2011) spent on medical care each year in the United States (NHE Fact Sheet, 2015).

In the competition for patients and their healthcare dollars, the nature of the healthcare facility is changing, too. Some for-profit and not-for-profit hospital chains are springing up, some hospitals are going out of business, and others are being acquired by multi-hospital organizations. Specialty facilities such as substance abuse treatment centers, diagnostic clinics, outpatient surgery centers, sports medicine centers, and freestanding urgent care centers are providing services previously offered only at large hospitals. These changes have thrust healthcare into the world of big business. With intense competition for a market share that will sustain them, healthcare organizations are actively promoting themselves, and the patient is now the marketing target (Block, 1981). For-profit hospitals are introducing such amenities as restaurant-style menus and hotel-like furnishings. Freestanding urgent care clinics are advertising their fast service (“In and out within 30 minutes”), while some hospital emergency rooms post current “wait times” for their ERs online or offer estimates via text message (Detroit Medical Center, 2013; Rice, 2013). To remain solvent and to keep patients coming back, healthcare organizations are nurturing their “high-quality care” images in the media and in the minds of the public.

Design as a Component of High-Quality Healthcare

Designing a healthcare facility is a complex process that must satisfy myriad competing criteria. The design must satisfy the demands of medical technology; that is, spaces must be flexible enough to accommodate complex, newly invented or redesigned equipment. Many facilities must be flexible enough to handle a full range of activities, from a routine physical examination to a life-or-death emergency. The design must satisfy the medical staff, too. It must enhance the efficiency of physicians and nurses who depend on the effectiveness of numerous elements, such as ambient and task lighting, the size and configuration of examination rooms, and the proximity of treatment rooms, ancillary services, and offices. Because sanitary conditions are an essential factor, the needs of maintenance and housekeeping personnel must also be considered. And, in these days of fiscal constraint, economic efficiencies of the design process, including life-cycle costs of the building, must be factored into the design equation. Sustainability and “green” design are also important considerations. Each of these demands on design must be weighed against the others.

In the end, though, after all the floor plans are created and the last coat of paint is on the walls, the healthcare facility will be a place where nurses, physicians, support service staff, patients, and visitors spend part of their lives. People will come to the hospital or doctor's office for a host of reasons. They will travel through the corridors, adjust the patient beds, drink from the water fountains, lie still in MRI machines, visit, wait, use digital devices to send text messages, and go about a variety of daily activities. The design must consider the many ways in which the facility will be experienced—what will be seen, heard, felt, and smelled (Lindell, 1983).

Technical design considerations, however, such as making room for a computerized tomographic (CT) scanner or a crash cart, are of remote concern for many users of a healthcare facility. Of immediate concern is the availability of a comfortable place to wait, the accessibility of restrooms for wheelchair users, or the ability to easily find a particular destination. Designs that favor technological convenience over the needs and preferences of patients and visitors may prove problematic. Good design, therefore, must balance technological needs with human needs.

Designing for the human experience is essential. In choosing a healthcare facility, people consider a variety of factors that together help define the term high-quality care (Falick, 1981). Designing with the human experience in mind recognizes that people's images of healthcare facilities are multi-dimensional and that having a facility that is technologically up to date may not be enough to satisfy patients and visitors.

The image patients and visitors have of a facility is affected by their relationships with the healthcare-delivery staff, their belief in the effectiveness of the medical and nursing care being provided, and their impression, good or bad, of the facility itself. The design of a healthcare facility reflects on the quality of care. The challenge of sending a “We Care” message cannot stop with the staff. The message must be designed into the facility itself (Arneill and Frasca-Beaulieu, 2003; Becker and Douglass, 2006; Falick, 1981; Gunn, 1990; Panther, 1984; Spreckelmeyer, 1984; Tetlow, 1984, 1985).

Attention to customer experience has become as important in the healthcare field as it is in other service industries. Although the food in one restaurant may be virtually the same as in another, the service may be quite different. Likewise, from the moment a patient or visitor arrives at a healthcare facility, the design will convey certain symbolic messages. The nature of these messages is shaped through planning and genuine concern for patients' and visitors' experiences. Humanistic design must be more than just an afterthought. It must move health facility design from its “hospital green” image to a sense of caring for the whole person (Arneill and Frasca-Beaulieu, 2003).

The quality of the physical environment is important far beyond the image it presents, since the therapeutic aspects of design must also be considered. The design of the facility, its wayfinding system, Universal Design features, arrangement of furniture, availability of windows, and accommodation of family members are all part of the patient's journey toward recovery (Canter and Canter, 1979; Petrie, 1980; Remen, 1982).

A substantial and growing body of research continues to show that health-facility design is inextricably linked to patient outcomes (Bilchik, 2002a, 2002b; Bullivant, 2004; Coile, 2002; Egger, 1999; Fowler et al., 1999; Harris et al., 2002; Horsburgh, 1995; Long, 2001; Looker and Stichler, 2003; Martin et al., 1998; Reed, 1995; Simmons, 2003; Solovy, 2006; Stern et al., 2003; Sternberg, 2010; Ulrich, 2003; Ulrich et al., 2008). While much remains to be understood about the mind–body connection, the evidence is strong that what we see, feel, touch, smell, and experience influence the body's ability to heal (Mitchell, 2009). Indeed, it has been suggested that “understanding and reducing stress in the hospital environment is to 21st-century medical care what understanding germ theory and reducing infection were to nineteenth-century care” (Mitchell, 2009).

The therapeutic aspects of design are not meant to be a substitute for medical and nursing care. They can, however, enhance the efforts of healthcare professionals, both by creating a healthier setting for examination, treatment, and recovery as well as stimulating the patient's own immune response. Just as physical design can encourage or discourage the maintenance of sterile conditions and task efficiencies, design can also encourage or discourage certain behaviors and responses. It can enhance or depress the body's ability to heal (Mitchell, 2009; Sternberg, 2010).

Designing for Patients and Visitors

Try to remember the last time you waited to see a physician or dentist. Did you glance through the magazines strewn on the waiting-area table or use your cell phone to check email? Perhaps your heart beat a little more rapidly worrying about what might happen, or you breathed more quickly when you inadvertently overheard a fraught conversation between a patient and a staff member. A routine visit to a physician's or dentist's office can be a profound and memorable experience. Physiological reactions, such as rapid heartbeat or quickened breathing, experienced by many people who visit a healthcare facility may be accompanied by a host of psychological reactions, chief among them stress and anxiety.

Patients and their families and friends (herein also referred to as “visitors”) represent particularly vulnerable user groups. They may feel virtually powerless in what they often perceive as an intimidating environment. They visit a healthcare facility under what are often emotionally stressful and physically debilitating conditions. At this time in their lives, they need a supportive, non-stressful environment, and they have little capacity to deal with a complex or confusing one.

It is also important to focus on the design-related needs of patients and visitors because they are healthcare consumers. A large number of healthcare facilities are becoming attuned to their position in a competitive market. It is useful, therefore, to consider those aspects of healthcare delivery, such as the physical environment, that may provide a competitive edge when sensitively designed (Falick, 1981). Patient-centered design can include nearly every aspect of a healthcare facility's environment, from the selection of pleasing lighting, to user-friendly informational carts and kiosks, to an effective wayfinding system (Berry et al., 2000; Carpman, 1992; Jossi, 2005; Levine and Glos, 2000).

If the goal is humanistic design, or “design that cares,” then the viewpoints of patients and families must be incorporated into the design process. It is not enough to have input from any single group of users at a healthcare facility. Medical and nursing staff can provide valuable insights about designing the environment to meet their own needs, but even though their primary concern is patient care, their perspective on what is desirable design will not necessarily encompass the views of patients and visitors (Parston, 1983). In redefining patients and visitors as customers and guests, healthcare facilities must focus on their social and psychological needs as well as their physical needs.

The photograph depicting an insight view of a hospital where facility's interior wayfinding signs are appear overhead and on walls, directing patients and visitors to various destinations.

This facility's interior wayfinding signs appear overhead and on walls, directing patients and visitors to various destinations.

Photo credit: Courtesy of St. Joseph Mercy Chelsea

There are other, equally compelling reasons for focusing on patients and visitors. Once they enter the front door, these groups are virtually powerless. Under what are often crisis conditions, patients and visitors are vulnerable to demands on their physical or emotional capacities (Arneill and Frasca-Beaulieu, 2003). Looking forward, patients and visitors must be front and center in the design plans of any healthcare facility.

The design of healthcare facilities has long focused on the functional necessities of the process of delivering healthcare. Unfortunately—and unnecessarily—this approach has often resulted in facility designs that ignore a variety of needs of patients, staff, and visitors. Many researchers have argued that designing healthcare environments that are emotionally and psychologically supportive can foster the process of healing and recovery. A constructed “healing environment” with patients' needs at the forefront has been shown to reduce anxiety and stress, as well as to aid in the healing process (Ulrich, 2000). Positive elements contributing to this include attractive colors, thoughtful acoustics, and well-designed wayfinding elements (Arneill and Frasca-Beaulieu, 2003; Bilchik, 2002a, 2002b; Bullivant, 2004; Coile, 2002; Egger, 1999; Fowler et al., 1999; Harris et al., 2002; Horsburgh, 1995; Long, 2001; Looker and Stichler, 2003; Martin et al., 1998; Reed, 1995; Simmons, 2003; Solovy, 2006; Stern et al., 2003; Ulrich, 2003). And access to positive distractions, such as exposure to nature, can be particularly helpful in creating an environment that lowers stress (Ulrich, 1991).

Stress can become a major obstacle to healing (Ulrich, 1991). Patients feeling stress from unsupportive environments can experience increased blood pressure, muscle tension, and suppressive effects on their immune systems (Frankenhaeuser, 1980; Kennedy, Glaser, and Kiecolt-Glaser, 1990). Stress is also a problem for patients' families and healthcare staff. One study suggests that stress experienced by caregivers of Alzheimer's patients has suppressive effects on the caregivers' own immune functioning (Kiecolt-Glaser and Glaser, 1990). Among staff, stress is associated with low job satisfaction and high rates of burnout (Shumaker and Pequegnat, 1989).

Planners and designers can help reduce this stress by taking into account the interaction between people and their environments. In particular, patients and visitors have needs with respect to wayfinding, physical comfort, regulation of social contact (including matters of privacy and personal territory), and symbolic meaning (Steele, 1973). And in addressing all of these needs, planners must take into account the target population of the facility, as well as the community and cultural heritage of the area (Frasca-Beaulieu, 1999; Shumaker and Reizenstein, 1982).

Wayfinding Ease

The ease with which people find their way around a building affects their level of stress. Large, complex buildings such as hospitals often feel maze-like, particularly for patients and visitors who visit these facilities infrequently. Not being able to find one's way between various destinations can lead to a sense of helplessness and frustration. Signage and graphics can help, but they need to work in conjunction with other features as part of a coordinated wayfinding system (Carpman and Grant, 2002a, 2002b, 2012; Frasca-Beaulieu, 1999).

Physical Comfort

How patients and visitors experience an environment is affected by noise levels, temperature, odors, and lighting, as well as by how capable and successful they are in manipulating their environment or comfortably positioning themselves within it. For example, the degree and types of noise patients will hear if their rooms are located near a lounge or nurses' station will affect their comfort and ability to rest. Likewise, design issues—from the placement of bedside controls to the types of chairs available in waiting areas—affect comfort levels, especially for people with mobility limitations. Additionally, variations in lighting and textures can create a calming environment and are important keys in reducing stress (Frasca-Beaulieu, 1999). Research has shown that patients and visitors pleased with the aesthetics of a healthcare environment are likely to be pleased with the overall experience (Caspari, Eriksson, and Naden, 2006; Hutton and Richardson, 1995).

Control Over Social Contact

Patients and visitors need to be able to regulate the amount of interaction they have with others (Giger and Davidhazar, 1990). There may be personal and cultural differences in spatial behavior: proximity to other people and objects, body posture, and movement within a given setting (Giger and Davidhazar, 1990; Smith, 1998). The design must allow for visual privacy, acoustical privacy, social contact, and solitude (Geden and Begeban, 1981). Patients wearing only hospital gowns should not feel as though they are on exhibit (Harris, 1987). Family members dealing with death should have an undisturbed place to grieve. Patients or visitors in need of positive distraction should be able to find effective ways to focus their attention.

Symbolic Meaning

Beyond affecting physical comfort, the environment transmits meaning. What patients and visitors see, hear, and smell tends to blend into a single image. A physical environment that supports the emotional and psychological needs of patients and visitors will be considered positive and caring (Arneill and Frasca-Beaulieu, 2003; Frasca-Beaulieu, 1999). At the same time, environments that make patients and visitors feel unimportant, or even forgotten, send a negative message (Canter and Canter, 1979).

Attending to the needs of patients and visitors will reduce their sense of helplessness and their feeling of being adrift in a strange and complex environment. By attending to these behaviorally-based design issues, the healthcare facility can contribute to a more positive, less stressful experience for patients and visitors. They will have less trouble finding their way between destinations, will feel greater physical comfort, will be able to be social or private depending on their individual needs, and will sense that the facility and its staff care.

The Facility Design Process

Although no two facility design projects progress from abstract idea to concrete form in exactly the same way, every project goes through a series of predictable stages. During each stage, design decision-makers make choices that determine what will be realized in bricks and mortar. It is important to understand the sequence of events and decisions that occur during a project before considering the specific design recommendations made in this book since some design issues come into play only at specific times in the design process. Each stage is complex and time-consuming. For the sake of brevity, we will only outline them here.

Pre-Design Programming

As soon as a design project is shown to be needed and is deemed economically, socially, and politically feasible, the pre-design programming stage can begin. During programming, the project's basic parameters are determined, including its goals and objectives, specific functions, and the types and sizes of spaces it will contain. Building programs vary widely in their comprehensiveness. Some provide only a list of spaces and associated square footages, while others include performance criteria for how the spaces and related systems will be used. The pre-design programming stage usually results in a document that serves as a set of instructions to the design team (Carpman, 1983; Fellows, 1987; Lickhalter, 1987).

Another type of programming—behavioral programming—should be part of the standard planning and design process. This effort thoroughly explores and defines the needs of all users (patients, nurses, family members and visitors, physicians, allied health students, and so on), such as the need for visual and acoustical privacy. These and other behavioral criteria are then translated into design guidelines.

Design

Once the design project's program is set, the design phase can begin. The design phase usually comprises four sub-phases that coincide with the design's evolution from general to specific. These phases are block plans, schematic design, design development, and final construction documents.

Block Plans

Block plans show the building's configuration and its design concept in relation to a particular site. Departments, expressed as gross areas, are shown in relation to other departments, building entrances, vehicular traffic patterns, access points, and internal staff and patient movement patterns. Because block plans do not examine room-by-room detail and are relatively easy to prepare, alternative designs can usually be quickly produced. They can be used to evaluate functional adjacencies as well as the flow of people and materials between and among departments. For example, in the case of a large hospital, the emergency department might be located where there is optimum access to a major roadway. In addition, surgery and radiology might be located adjacent to emergency for ease of access to needed facilities and staff.

Schematic Design

Schematic design goes one step further, showing rooms as well as corridors, mechanical spaces, stairs, elevators, and columns. The schematic design phase examines the relationship between all rooms within a department and formalizes the basic net and gross square footages of the building to confirm that the project can be built within budget. It may include an evaluation of the relative merits of different heating, ventilation, air conditioning, plumbing, electrical, fire protection, and other systems.

Design Development

Design development documents refine the schematic design even further. CAD (computer-aided design) drawings are prepared at a larger scale; instead of single-line drawings, dimensions and thicknesses of walls are shown. Room details, including door swings, light fixture locations, counters and cupboards, medical equipment, and furniture, appear on design development drawings. Electrical, mechanical, and structural elements are defined.

Construction Documents

Once the design development phase has been completed, the architect and engineers begin construction documents. This detailed set of instructions for the contractor consists of working drawings and specifications—instructions about the quality of the materials and how to build the project. In addition, the construction documents include the agreement between the owner and the contractor, as well as forms that the contractor uses to bid the project. The owner is expected to sign off on all documents at the end of the construction document phase, as well as at the end of each of the other phases. This sign-off means that the owner considers the plans complete.

Concurrent Planning

Interior Design

Interior design typically progresses concurrently with architectural design. Basic interior design services for healthcare facilities often include space planning, which determines the layouts of rooms and achieves both aesthetic and functional goals; color coordination and selection of room finishes, furniture, and furnishings; and artwork selection. Interior designers usually work closely with architects and engineers.

Landscape Architecture

Landscape architectural planning also progresses concurrently as part of the total design work. Issues of site planning and exterior design, including vehicular and pedestrian circulation, parking, grading, drainage, exterior seating, selection of vegetation, and location of exterior signs, are typically included as part of the site work.

Wayfinding Planning

While wayfinding planning often occurs late in the project, ideally, it should begin during programming or early schematic design. Some wayfinding issues need to be considered early on, while decisions are made about site planning, building footprint, and corridor alignments. Wayfinding planning is also needed during later phases, for instance, in order to ensure effective locations for signs at interior decision-points. A wayfinding system incorporates various types of signs, but can and should also include other wayfinding elements. (See chapters 3 and 4.)

Medical Equipment Planning

Medical equipment planning is also part of the design process. It begins at the same time as schematic design, expands into design development, and continues through construction. During this phase, equipment is selected, its mechanical and electrical requirements are identified, it is purchased, and installed.

Design Review

Design review occurs throughout the design process as the client analyzes design progress by examining floor plans, equipment and specification lists, perspective drawings, digital simulations, three-dimensional models, mockups, and technical specifications. If parts of the design do not meet the performance criteria agreed upon earlier, alternative design approaches are created. (See chapter 11 for a description of how users can participate in Design Review.)

Construction

The construction work for most healthcare-facility projects is awarded through a competitive bid process. During this phase, the owner, usually through the architect or construction manager, responds to questions from potential contractors that may affect the quality or detail of the project. All other things being equal, the contractor with the lowest bid price is usually awarded the contract, and the project then proceeds into construction.

During construction, the owner (again, through the architect or construction manager) inspects the ongoing work in order to ensure compliance with the contract documents. Material substitutions, design modifications, and many other issues must be monitored in order to ensure that the final product is built to fulfill the goals of the program and the operational requirements of its users, as defined by the construction documents.

Activation

Activation is the process of preparing to move into and occupying a new facility. Activation includes strategies for accomplishing the move, planning policies and procedures that will be used in the new facility, orienting staff to the new facility's layout and special features, and training staff to operate in the new surroundings.

Post-Occupancy Evaluation
(Also Called “Facility Performance Evaluation”)

Post-occupancy evaluation (POE), or Facility Performance Evaluation (FPE), which occurs after the environment has been occupied for a period of time, is the systematic assessment of how an environment functions in comparison to the design objectives (Zimring and Reizenstein, 1980, 1981; Zimring et al., 2010). If there are design-related problems, changes are recommended. Post-occupancy evaluation findings can provide valuable information for other buildings, too. Cumulative knowledge gained from this type of evaluation can contribute to the design processes of future projects (Manasc and Adams, 1987).

Summary

  • There is increased demand for a wider variety of healthcare services and higher expectations about those services, as the result of a variety of factors. These include a growing proportion of older people in the US population, an increasing interest in achieving and maintaining good health, shifts in attitudes toward child-bearing and -rearing, and increasing urbanization.
  • Rising healthcare costs, an increasing supply of physicians, an uncertain future for Medicare and Medicaid, limited resources, and other trends such as the growth of specialty facilities have thrust healthcare into the world of big business, where competition is strong to attract and retain patients and their healthcare dollars.
  • Supportive design reduces anxiety and stress, which can be major obstacles to healing and can affect the well-being of patients, families, and staff. Supportive design is an important element in the delivery of high-quality healthcare, both in direct medical terms and as a perceived measure of the quality of care.
  • Certain design decisions—including recommendations made in this book—are appropriate only at particular times in the design process. It is important to understand the sequence of events and decisions that occur during a project. No two design projects progress from abstract idea to concrete form in exactly the same way; however, predictable stages include pre-design programming, design, construction, and activation. Some projects have additional phases which include concurrent planning, design review, and post-occupancy evaluation (Facility Performance Evaluation).

References

  1. Arneill, B., and Frasca-Beaulieu, K. Healing environments: Architecture and design conducive to health. In S. Frampton, L. Gilpin, and P. Charmel, editors. Putting Patients First: Designing and Practicing Patient-Centered Care, 163–90. San Francisco: Jossey-Bass, 2003.
  2. Becker, F., and Douglass, S. The ecology of the patient visit: Attractiveness, waiting times, and perceived quality of care. Healthcare Design, 12–19, November 2006.
  3. Berry, L., Parker, D., Coile Jr., R., Hamilton, D., O'Neill, D., and Sadler, B. The business case for better buildings? Frontiers 21(1):3–24, Fall 2004.
  4. Bilchik, G. S. A better place to heal. Health Forum 45(4):10–15, July–August 2002a.
  5. _______. New vistas: Evidence-based design projects look into the links between a facility's environment and its care. Health Facility Management 15(8):19–24, August 2002b.
  6. Block, L. F., ed. Marketing for Hospitals in Hard Times. Chicago: Teach 'em, 1981.
  7. Bullivant, L. U.K.'s “Healthy Hospitals” envisions better health-care design. Architectural Record 192(3):32, March 2004.
  8. Canter, D., and Canter, S. Creating therapeutic environments. In D. Canter and S. Canter, editors. Designing for Therapeutic Environments, 333–41. New York: John Wiley and Sons, 1979.
  9. Carpman, J. R. Influencing design decisions: An analysis of the impact of the Patient and Visitor Participation Project on the University of Michigan Replacement Hospital Program, 1983. [Available from ProQuest, 789 E. Eisenhower Parkway, Ann Arbor, MI 48108.]
  10. _______. Creating hospitals where people can find their way. Plant Technology and Safety Management Series, Joint Commission on Accreditation of Healthcare Organizations, Number 1, 1991. Reprinted in Health Facilities '92, 29th Annual Conference and Technical Exhibition Proceedings, American Society for Hospital Engineering of the American Hospital Association, 1992.
  11. Carpman, J. R., and Grant, M. A. Wayfinding woes: Common obstacles to a successful wayfinding system. Health Facilities Management, February 2002a.
  12. _______. Wayfinding: A broad view. In R. Bechtel and A. Churchman, editors. The New Environmental Psychology Handbook, 427–42. New York: John Wiley & Sons, 2002b.
  13. _______. Directional Sense: How to Find Your Way Around. Boston: Institute for Human Centered Design, 2012.
  14. Caspari, S., Eriksson, K., and Naden, D. The aesthetic dimension in hospitals: An investigation into strategic plans. International Journal of Nursing Studies, 43(7):851–59, 2006.
  15. CIA. The World Factbook. 2012. /www.cia.gov/.
  16. Coile Jr., R. Competing by design: Healing environments attract patients, reduce costs and help recruit staff. Physician Executive 28(4):12–16, July–August 2002.
  17. Detroit Medical Center—DMC. 2013. www.dmc.org/ERwait/.
  18. Egger, E. Designing facilities to be patient-focused. Health Care Strategic Management 17(2):1–20, February 1999.
  19. Falick, J. Humanistic design sells your hospital. Hospitals 55(4):68–74, February 16, 1981.
  20. Fellows, G. E. Ambulatory surgery design. AORN 45(3):708–24, March 1987.
  21. Fowler, E., MacRae, S., Stern, A., Harrison, T., Gerteis, M., Walker, J., Edgman-Levitan, S., and Ruga, W. The built environment as a component of quality care: Understanding and including the patient's perspective. Journal of Quality Improvement 25(7):352–62, July 1999.
  22. Frankenhaeuser, M. Psychoneuroendocrine approaches to the study of stressful person-environment transactions. In H. Selye, editor. Selye's Guide to Stress Research. Vol. 1, 46–70. New York: Van Nostrand Reinhold, 1980.
  23. Frasca-Beaulieu, K. Interior design for ambulatory care facilities: How to reduce stress and anxiety in patients and families. Journal of Ambulatory Care 22(1):67–73, 1999.
  24. Geden, E. A., and Begeban, A. V. Personal space preferences of hospitalized adults. Research in Nursing and Health 4:237–41, 1981.
  25. Giger, J. N., and Davidhazar, R. Culture and space. Advancing Clinical Care, November–December 1990, 8–11.
  26. Godfrey-June, J. What do the aging want? Contract Design, 55–57, March 1992.
  27. Gunn, T. W. Image, architecture, and costs of ambulatory care. Michigan Hospitals 26:14–22, 1990.
  28. Harris, P. Dignity in hospital. British Medical Journal 294, January 10, 1987.
  29. Harris, P., Ross, C., McBride, G., and Curtis, L. A place to heal: Environmental sources of satisfaction among hospital patients. Journal of Applied Social Psychology 32(6):1276–99, 2002.
  30. Horsburgh Jr., C. Healing by design. New England Journal of Medicine 333(11):735–40, September 1995.
  31. Hutton, J., and Richardson, L. Healthscapes: The role of the facility and physical environment. Health Care Management Review 20(2):48–62, 1995.
  32. Johnson, E., and Johnson, R. Hospitals in Transition. Rockville, MD: Aspen Systems Corporation, 1982.
  33. Jossi, F. Patients find a new age of conveniences. Healthcare Informatics 22(8):31–33, August 2005.
  34. Kennedy, S., Kiecolt-Glaser, J. K., and Glaser, R. Social support, stress, and the immune system. In B. R. Sarason, I. G. Sarason, and G. R. Pierce, editors. Social Support: An Interactional View. Wiley series on personality processes, 253–66. Oxford, England: John Wiley & Sons, 1990.
  35. Kiecolt-Glaser, J., and Glaser, R. Chronic stress and immunity in older adults. Paper presented at the International Congress of Behavioral Medicine, Uppsala, Sweden, June 27–30, 1990.
  36. Levine, H., and Glos, A. Light right. Health Facilities Management. 13(5):25–28, May 2000.
  37. Lickhalter, M. How to be a good consumer of programming services. Journal of Health Administration Education 6(4, part 1):741–49, 1987.
  38. Lindell, M. The human hospital. Dimensions in Health Service 60(5):27–29, May 1983.
  39. Long, R. Healing by design. Health Facilities Management 14(11):20–22, November 2001.
  40. Looker, P., and Stichler, J. Healing environments. Marketing Health Services 23(2):12–13, Summer 2003.
  41. Managing Construction Costs. Hospitals and Health Networks. March 2012. www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2012/0312HHN_FEA_VHAgatefold&domain=HHNMAG.
  42. Manasc, V., and Adams, J. Post-occupancy evaluation by hospitals. Hospital Trustee 11(5):5–7, September–October 1987.
  43. Martin, D., Diehr, P., Conrad, D., Davis, J., Leickly, R., and Perrin, E. Randomized trial of a patient-centered hospital unit. Patient Education and Counseling 34(2):125–33, June 1998.
  44. Michael, D. On Learning to Plan and Planning to Learn: The Social Psychology of Changing toward Future-Responsive Societal Learning. San Francisco: Jossey-Bass, 1973.
  45. Mitchell, R. Healthy spaces. Lancet 374(9683):18. July 4, 2009. http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609612216.pdf.
  46. NHE fact sheet: Historical NHE, including sponsor analysis, 2015. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html.
  47. Panther, R. E. Hospital design in the year 2015. In G. S. Lasdon and J. S. Gann, editors. The Future of Hospital Design: A Discussion among Experts, 3-11–3-22. Washington, DC: US Department of Health and Human Services, 1984.
  48. Parston, G. Hospital buildings and consumer needs. Consumer Health Perspectives 9(5):1–7, September 1983.
  49. Petrie, R. E. Patient well-being is designers' first concern. Michigan Hospitals 16(9):12–13, September 1980.
  50. Reed, R. Creating a healing environment by design. Journal of Ambulatory Care Management 18(4):16–31, 1995.
  51. Remen, S. Physical surroundings serve as therapeutic catalyst for patients. Michigan Hospitals 18(4):20–25, April 1982.
  52. Rice, S. Don't die waiting in the ER. 2013. http://www.cnn.com/2011/HEALTH/01/13/emergency.room.ep/index.html.
  53. Shumaker, S., and Reizenstein, J. E. Environmental factors affecting inpatient stress in acute care hospitals. In G. W. Evans, editor. Environmental Stress, 179–223. New York: Cambridge University Press, 1982.
  54. Shumaker, S. A., and Pequegnat, W. Hospital design, health providers, and the delivery of effective health care. In E. H. Zube and G. T. Moore, editors. Advances in Environment, Behavior, and Design. Vol. 2, 161–99. New York: Plenum, 1989.
  55. Simmons, J., ed. Designing for quality: Hospitals look to the built environment to provide better patient care and outcomes. Quality Letter for Healthcare Leaders, 2–13, April 2003.
  56. Smith, L. Trends in multiculturalism in health care. Hospital Material Management Quarterly 20(1):61–70, August 1998.
  57. Solovy, A. Designing a healing environment. Health Facilities Management 19(6):30–39, June 2006.
  58. Spreckelmeyer, K. F. Designing for health care in the 21st century. In O. Heyer and S. Graybow, editors. Proceedings of the International Conference of the Association of Collegiate Schools of Architecture. Washington, DC, 1984.
  59. Steele, F. Physical Settings and Organization Development. Reading, MA: Addison-Wesley, 1973.
  60. Stern, A. L., MacRae, S., Gerteis, M., Harrison, T., Fowler, E., Edgman-Levitan, S., et al. Understanding the consumer perspective to improve design quality. Journal of Architectural and Planning Research 20(1):16–28, Spring 2003.
  61. Sternberg, E. M. Healing Spaces: The Science of Place and Well-Being. Cambridge, MA: Belknap Press, 2010.
  62. Tetlow, K. Healing research. Interiors, 140–52, October 1984.
  63. _______. New design for physical fitness. Interiors, 168–76, October 1985.
  64. Ulrich, R. S. The effect of healthcare architecture and art on medical outcomes. Arts Council England Architecture Week Event, June 25, 2003.
  65. _______. The therapeutic benefits of design. In Design & Health. Proceedings of the 2nd Annual International Congress on Design and Health. Karolinska Institute. Stockholm, Sweden. June, 2000:49–59.
  66. _______. Effects of interior design on wellness: Theory and recent scientific research. Journal of Health Care Interior Design 3:97–109, 1991.
  67. Ulrich, R. S., Zimring, C., Zhu, X., Dubose, J., Seo, H.-B., Choi, Y.-S., et al. A review of the research literature on evidence-based healthcare design. Health Environments Research and Design Journal 1(3), Spring 2008.
  68. US Census 2010. Age and sex composition: 2010. www.census.gov/prod/cen2010/briefs/c2010br-03.pdf.
  69. US Government. Projections of the Population of the United States, by Age, Sex, and Race: 1983 to 2080. Current Population Reports, Series P-25, No. 952. Washington, DC, 1984.
  70. Zimring, C., Rashid, M., and Kampschroer, K. Facility Performance Evaluation (FPE). Whole Building Design Guide, 2014. https://www.wbdg.org/resources/fpe.php.
  71. Zimring, C. M., and Reizenstein, J. E. Post-occupancy evaluation: An overview. Environment and Behavior 12(4):429–50, December 1980.
  72. _______. A primer on post-occupancy evaluation. American Institute of Architects Journal 70(13):52–58, November 1981.