1. Design for the caregiving processes.

Because it is generally assumed that there is a direct

correlation between staff performance and patient safety, it would make sense for hospital design
to address medical and nursing staff practices and processes. But that’s not always the case, says
Thomas Wallen, AIA, principal with Gresham Smith & Partners, Nashville.

Wallen and his team are responsible for the design of the $51 million, 80-bed St. Joseph’s
Hospital in West Bend, Wis., which is considered the nation’s first hospital designed specifically
to address error-free medical delivery.

“Many environments force work-arounds,” says Wallen, referring to the process of forcing
nurses and doctors to find ways to work around—instead of with—the facility’s built
environment to accomplish their tasks. That can be dangerous.

“Approximately 70% of hospitals’ preventable errors or potential errors are the result of process
error,” says Wallen, referring to an in-house study of these issues by Gresham Smith. Design is
often out of sync with staff processes because blanket statements are made about the best or
safest ways to design hospitals, for everything from how and where medication is administered
to the direction from which doctors approach a patient’s bed.

These “best practices” may run counter to the facility’s culture of care, says Wallen. “What
works for one hospital doesn’t necessarily work for another. These are very complex decisions,”
he says.

The simple solution, according to Greg Mare, AIA: “Talk with the staff about how they do their
jobs in order to figure out how to design for them,” says Mare, SVP and director of planning for
architecture firm Karlsberger, Columbus, Ohio. Each design element—no matter how popular it
is, or how effective it is supposed to be, or its supposed benefit to patient safety—needs to be
evaluated for the hospital environment; otherwise, it may have the potential to do more harm
than good.

Mare and his team paid extensive consideration to the hospital’s user processes before designing
the $150 million Dublin (Ohio) Methodist Hospital, which is set to open this November.

2. Design for the highest possible level of standardization. Standardization refers to much
more than common room layout. It also refers to room size, type, and location. “Standardization
means everything is identical, which has the effect of reducing error, reducing operating and
initial costs, and improving efficiency,” says Wallen.

There’s an on-going debate in hospital design circles over same-hand room design versus mirror-
reverse room design; that is, whether it’s safer to have the bed oriented against the same wall in
each room (same-hand design) or to have beds oriented against opposite walls (mirror-reverse
design).

Wallen argues that same-hand design makes patient rooms identical, so their use becomes
intuitive to caregivers and therefore safer. His design for St. Joseph’s Hospital included not only
identical bed orientation, but also identical locations for gas and oxygen outlets, medical
equipment, and bathrooms, and even six identically stocked drawers of bandages, gauze, and
cotton swabs in each room.

However, there is no conclusive evidence supporting one layout as safer than another. This
uncertainty can deter hospitals from using same-hand rooms, especially when added costs are
involved. Although costs vary, same-hand room designs can be more expensive because each
room requires its own plumbing chase and oxygen and gas drops. Others would argue that same-
hand room design reduces costs because of the repetitiveness of construction.

“When we’re promoting change, we need evidence showing it’s the right thing to do,” says
Michael Czyrka, associate principal and managing director of the Chicago office of
BSALifeStructures, headquartered in Indianapolis. “Healthcare is so dollar-driven these days that
we have to prove that same-handed room design will not only improve patient safety but also
save the hospital money,” he says. “The evidence to prove it isn’t there yet,” says Czyrka.

In fact, The Advisory Board Company, a Washington, D.C., think tank whose members include
2,500 of the country’s largest and most progressive health systems and medical centers, says
there is no indication same-hand rooms are safer than mirror-reverse rooms and are therefore not
a necessary investment. Their research indicates that same-hand rooms cost, on average, $3,500
more than mirror-reverse rooms.

The board’s recommendation: standardize the headwall, not the bed location, a design that
increases constructions costs by only $300 per patient room.

That’s the course taken by Curtis Qualls, associate principal and senior healthcare planner at
Jonathan Bailey Associates, Dallas, for the design of the new $111 million Winnie Palmer
Hospital for Women and Children in Orlando, Fla. Every one of the 273 rooms uses mirror-
reverse design. “My preference is that everything in a room have the same adjacency, that
headwalls are standardized with medical gases [and oxygen] always being either to the right or
the left of the bed. It doesn’t really matter which side the headboard is on,” says Qualls.

Michael Pukszta, a principal in Cannon Design’s St. Louis office, thinks he has the perfect
solution: mix and match patient rooms. “Standardize same-hand rooms where the chances of a
critical event happening are extremely high—and therefore the chance for error is high—such as
in the emergency department or intensive care unit,” he says. “But use the more affordable
mirror-reverse room design in acute-care patient rooms where the chance of a critical event
occurring is much lower,” as is the total financial investment.

Another technique for improving safety and cutting construction costs is to reduce the number of
standardized room types. “The average hospital has about 15 different room types. We narrowed
it down to five,” says Marc Budaus, AIA, VP with Dallas-based design firm HKS.

For the $65 million, 530-bed Boca Raton (Fla.) Community Hospital, Budaus standardized the
size of most patient rooms, NICUs, and exam rooms at about 335 sf, while LDR (labor, deliver,
recovery) and operating rooms average 826 sf. This minimizes differences within the hospital
environment and creates the standardization and repetition that can improve safety and
efficiency.

3. Decentralize the nursing station—carefully. Our experts concur on decentralizing nursing

stations, but they caution restraint when planning for decentralization because it’s easy to lose
sight of how nurses really deliver care. “Be careful of getting rid of the central nursing area
entirely because nurses like camaraderie,” says Nicholas Watkins, PhD, director of research for
Cannon Design.

HKS’s Budaus agrees. “Providing care is a collective, team activity, and nurses are social
people,” he says. “To say there has to still be a central nursing station may be overstating the
issue, but there should be somewhere for nurses to meet and collaborate.”

At Boca Raton Community Hospital, Budaus decentralized the nursing stations by locating small
teaming stations throughout the patient units, but he also still included a central nurse work room
and conference space to accommodate collaborative care delivery. Gone is the traditional central
nurse station with transaction counter overlooking the unit. Gone, too, is the central file storage:
all medical records are going electronic.

Budaus’s blending of the best of the new (decentralized stations) with the old (central
collaboration space) is indicative of how many experts are approaching hospital design. They see
this kind of alchemy as a solution to greatly improved patient safety.

Decentralized nursing stations improve patient safety by putting the nurses in close proximity to
the patients, which improves both observation and response time. They also cut down on
distractions because they allow nurses to immediately start and complete their charting. They
also cut down on fatigue by drastically reducing nurses’ travel distances—no longer does a nurse
have to walk an average of five miles per shift.

The location and number of decentralized nursing stations vary according to hospital design, but
some experts recommend one per room for same-hand patient rooms and one nursing station
positioned between every two rooms for mirror-reverse patient rooms.

Curtis Qualls of Jonathan Bailey Associates designed the Winnie Palmer Hospital with one nurse
station for every 12 rooms (three nurse stations per floor, on average) but the patient units are
circular so nurses are only 18 feet away from any room and have a 360-degree view of the entire
unit. “It’s about getting patients closer to the caregivers to improve safety and efficiency,” says
Qualls