Evidence-based design in practice

There’s growing evidence to suggest healthcare building design can have a significant impact on patient wellbeing and recovery. Associate Healthcare Director, Curtis Laitinen, explores how we’ve designed the new King Hussein Medical City in Amman, Jordan, to be a healing environment that promotes better healthcare outcomes.

Improving patient wellbeing and recovery times, reducing staff stress and infection control remain key priorities for today’s healthcare providers. While these can be influenced by a number of factors, such as quality of care and available resources, the correlation between good healthcare building design and improved medical outcomes is becoming increasingly recognised.

Informing and improving design

Healthcare design has changed enormously over the past 20 years. One of the biggest changes we continue to see is the application of evidence-based design (EBD). The Center for Health Design (CHD) defines EBD as, “The deliberate attempt to base building decisions on the best available research evidence, with the goal of improving outcomes and of continuing to monitor the success or failure for subsequent decision-making.”  This is where human behaviour studies and evidence of the psychological effects of healthcare environments on patients and staff are used to inform and continuously improve healthcare facility design.

Creating healing environments

The movement towards EBD is improving the quality of hospital environments, making spaces more pleasant and comfortable, and using positive distractions, such as views of nature and uplifting artwork. Reducing environmental stressors, such as noise, and improving wayfinding is helping to create healing environments’, resulting in faster recoveries and improved patient outcomes.

Reducing staff stress

EBD also improves the staff experience by making workflows more efficient and providing a lower-stress environment. For example, evidence shows that providing healthcare staff with window in workrooms significantly reduces the number of medical errors. And Rollins, J.A. (2004) confirmed that daylight positively impacts patients and staff. In addition, having a view is associated with shorter patient stays, higher satisfaction with nursing care and a decrease in the use of medications. While environments, such as emergency departments, can be high-stress and a coffee break with a view can help staff clear their head and return to work more focused on their patient’s wellbeing.

The case for EBD

A growing number of studies and reports support these positive claims and the overall case for EBD. Perhaps most recognised is a View through a window may influence recovery from surgery, by Roger Ulrich, the world’s most cited and influential evidence-based healthcare design researcher. His research found that patients placed in recovery rooms with a window facing a natural setting had shorter hospital stays. According to Ulrich, “Views of vegetation, and especially water, appear to sustain interest and attention more effectively than urban views.”

In another paper by Ulrich, Effects of Healthcare Environmental Design on Medical Outcomes, he discusses the traditional design of healthcare facilities to be functional and efficient without considering the psychological needs of patients, visitors and staff. He touches on the correlation between poor design and the wellbeing of patients, concluding that the designs of healthcare facilities need to consider more than just function, “[A] critically important goal of designers should be to promote wellness by creating physical surroundings that are psychologically supportive.”

EBD in practice: King Hussein Hospital, Amman, Jordan

The new AECOM-designed King Hussein Hospital, part of the first phase of the King Hussein Medical City (KHMC) expansio­­n, is the largest medical centre for the Royal Jordanian Armed Forces. It has 940 beds, including 144 intensive care beds and a new 16-bed burn unit, 43 operating theatres and the country’s main Level-1 trauma centre with 125 treatment/exam rooms. While primarily serving armed forces personnel and their families, the new, 30-storey facility, which replaces the existing King Hussein Hospital, will become one of the main public hospitals for the city of Amman.

As lead designer, our challenge was to create an organised, efficient, easy to maintain and easy to navigate, visitor-friendly hospital­­. We used extensive research, including working with doctors and nurses to inform the following EBD decisions that would achieve each of these requirements, while also creating a “healing environment for patients, staff and visitors, supporting and driving overall improved medical outcomes”.

Enhanced wayfinding

Good wayfinding is a key element of reducing stress and a factor that must be considered from the early concept design stage. It was imperative that we organised the building’s form and services so that it would be visually obvious and intuitive to everyone who interacts with it.

Long, covered areas for arrival and drop-off accommodate many cars for both scheduled and emergency patients, while large expanses of glass call out the main entry lobby and other public spaces, providing good visibility for visitors as they approach the hospital. Inside, straightened-out corridors make the layout less maze-like and have views to the outside to help people orient. Also, referencing internal landmarks, such as nurse stations, reception desks and other architectural features, helps people remember their route.

Multiple visual cues for visitors, such as themes, materials and colour, define departments and zones. Patients also avoid having to go through one department to access another, reducing traffic and noise and increasing patient privacy. Meanwhile, integrated technology, such as digital signage and electronic management of patient movement through the facility, support wayfinding and patient flow.

Family-centred design

Families are often overlooked in healthcare design. But they are an active part of a patient’s care and play an important role in the healing process.

Today, patients and their visitors seek divisions of space that offer smaller groupings of seating for better privacy and comfort and, using the hospitality industry as a design reference, people like choice. As such, it was important to create a variety of smaller areas, allowing for a range of options that appeal to different ages, personalities and physical needs. Separating public areas from the hustle and bustle of ‘back of house’ activities will also allow for a more pleasant visitor experience.

Waiting areas include quiet lounge areas, and public areas provide plenty of seating both indoors and on outdoor rooftop terraces, with a coffee shop and public cafeteria on different levels. All of these take advantage of the hospital’s hilltop location to offer what should be some remarkable views of the city of Amman. There are also a couple of public spaces with café seating, where visitors can have a drink and surf the internet on their laptop, as well as children’s areas, which have playful child-scale furniture and are acoustically separated from adult spaces but within easy sight of parents.

Greater privacy and calming views

As mentioned previously, views of nature have been statistically proven to improve patient outcomes, so in the new King Hussein Hospital, the idea of patient rooms with views was central. All rooms are single bed, with a view out over the city, or a rooftop terrace. These also allow for better privacy, are more restful for patients and better for infection control. In all rooms, there is an area near the windows for family, with seating out of the way of the nurses and doctors. All patient rooms, and their en-suite toilets are accessible, as per the American ADA Guidelines; except for one 24-bed ward, which is specially designed to accommodate very large “Bariatric” patients, who have their own unique requirements.

Integrated technology

Technology has been used to improve convenience. Patient tracking screens let patients know when they can expect to be seen. Families can be contacted by mobile phones when a procedure is done, while video screens provide programmed videos and music to create a calming environment.

 Practical, bright materials

Operational efficiency and flexibility were essential considerations during the planning of a facility of this scale, with very large departments.  Keeping staff travel distances to a minimum meant looking at ways of keeping supplies, equipment, charting areas and waste disposal nearby, even as the utilisation of the departments rises and falls at different times of the day and week.

Being a military hospital, the finishes need to be very practical, durable and easy to clean. During exams, patient rooms require high light levels, with colour temperature that gives good colour rendering of the skin. Overall, the interior design of the new KHMC patient room reflects the state-of-the-art healthcare to be delivered, a contemporary international style, incorporating elements and materials that will make patients feel at home; mixing clean, bright materials with natural accents for contrast and depth; and referencing the diverse natural landscape and rich cultural heritage of Jordan.

The future

EBD is the future for the healthcare sector, a method, based on documented results, taking into account the emotional, psychological and physical wellbeing of the end user. The result is a dynamic space, directly catering to the needs of patients and those who treat them.

While it is still an area with many opportunities for exploration and research, there are numerous benefits to designs based on the already available EBD research.  This research has shown that it saves time, avoids and decreases risk, improves the design process and creates modern, user-friendly spaces.

EBD is quickly gaining popularity within the wider design industry given its success in the healthcare sector. Other high-risk public spaces such as museums, universities and prisons are adopting this approach, providing informed design solutions where they matter most.