Flip No. 19
Rebuild, rethink, and reconfigure the clinic’s design
Make medical facilities work for the people who use them.
Before opening their brand new hospital in 2009, a small group of administrators and care providers at the Children’s Hospital of Pittsburgh sat down to discuss the principles that would guide their new facility. They’d spent a long time interviewing patients, parents, and employees of the hospital.
What they realized was that from the time someone walked into the door, the environment drained patients and visitors.
Between alarms and beeping and overhead announcements, the onslaught of noise was relentless and stress-inducing. The environment was inflexible: patients had to wait in a designated room and stay there until they were called. Patients were in a bad mood long before they ever made it into the exam room. For their new hospital, the group decided every decision had to A) make patients feel continuously connected to the outside world, and B) allow patients to be in control of themselves and their environment.
The framework helped launch a truly innovative care center that’s a pleasant place for people. But it doesn’t take a complete overhaul to design a friendlier environment. Even little changes can dissipate stress and give back control to the patient. Good design can help providers work more efficiently and patients heal more quickly. From small investments to massive overhauls, here’s a range of tools that will make the clinical environment a more positive one. (A growing collection of visual examples can also be found on FTC’s Pinterest page).
Noise
The Art of
Distraction
Modify
the Space
Give Patients and
Visitors Control
Just Plain
Good Design
Improve Health
Outcomes
Noise
When a patient is already stressed, alarms, incessant buzzing, and chatter can increase anxiety and actually stand in the way of a patient’s health. Noise levels in hospitals have been shown to increase blood pressure, interrupt sleep, and disrupt pain management and wound healing. To cut out the noise is to improve the patient experience.
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When the noise can’t be controlled, give patients a few ways to either limit their exposure to it or distract them from it.
- Ear plugs
- Eye mask
- Puzzle
- Noise-canceling headphones
- An iPod loaded with calming music and audiobooks
- An iPad loaded with TV shows, movies, and games (to be used with noise-canceling headphones).
- What sounds cross barriers like patient rooms, doors, and partitions? Where do they come from?
- How do carts and shoes interact with the flooring?
- What electronic equipment is whirring or beeping in the background?
- Do the doors close smoothly and quietly?
- Install a quieter hand-dryer and toilet.
- Install noise-dampening partitions.
- Put soft wheels on all the carts.
- Ask staff to wear shoes that don’t squeak or tap on the floor.
- Switch to silent alarms.
- Muffle ongoing noises like computer fans.
- Make sure doors use hydraulic closing systems.
Children’s Hospital of Pittsburgh, for example, has lots of private space between patient rooms designed for staff conversations. So instead of discussions happening in the hallways—both a visual and auditory distraction for patients—they happen off stage in rooms designed to keep sound in. Even without renovations, finding a place for staff to talk that’s not in front of patients can help.
Reconfigure
Send all announcements through Vocera badges and cell phones that can alert staff silently.
- When an alarm goes off, instead of beeping locally, an alert is sent to a central command center.
- The central command center will then send the alert to a staff member silently, either through Vocera badges or cell phones.
- If a call isn’t answered, that notification is forwarded to the next responsible person until the alarm is attended to.
Children’s Hospital of Pittsburgh has lots of private space between patient rooms designed for staff conversations. So instead of discussions happening in the hallways—both a visual and auditory distraction for patients—they happen off stage in rooms designed to keep sound in. Even without renovations, finding a place for staff to talk that’s not in front of patients can help.
Rebuild
- Insulate and seal walls
- Install acoustic ceiling tiles
- Use door seals
- Insulate inhabited spaces from building machinery with double concrete slabs
- Add sound-deadening elevator cab enclosures.
- Use vibration isolation systems on mechanical equipment, main electrical switchgear, ductwork, piping, medical air compressors and vacuum pumps.
- Move the chiller, boiler, cooling tower and generator to a remote location.
- Employ variable frequency drives on most equipment in order to provide a soft start and to reduce the flow during operation.
There are lots of tiny ways to decrease the decibels, but when the Children’s Hospital of Pittsburgh implemented over 30 measures to reduce the volume, they reached a tipping point. The hospital is now so quiet that staff and visitors actively participate in guarding the silence. Speaking loudly in the hospital has become like shouting in a library.
At Boston Medical Center, administrators started worrying that they’d created an environment of alarm fatigue, where staff becomes desensitized to the incessant beeping. So they added the alarms up. Just how many alarms were sounding off daily? At 7 North, a medical-surgical floor in the building, there were 12,000—too many audible signals for staff to effectively respond. Mistakes can and do happen. So Boston Medical decided to ease the overuse by stripping out sources of unnecessary beeping. They put low level alarms into crisis mode and allowed nurses to tweak an alert’s settings to meet a patient’s individual needs. An overall analysis showed that the majority of the alarms didn’t need to be functioning at all. After the changes at Boston Medical Center, they were able to reduce the number of alarms per week from 90,000 to 10,000.
The Art of Distraction
When patients are nervous about going to the doctor, a beige room full of sick people isn’t going to do much to ease stress. When the Children’s Hospital of Pittsburgh redesigned their space a few years ago, the design team did extensive work in what they call, “the art of distraction.” They flipped several high stress environments in the hospital into much more pleasant ones. Here’s how to make the clinic or hospital a more welcoming place for patients and staff, too.
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In Florence Nightingale’s Notes on Nursing, she pointed out that beauty, sunlight, color, and noise can affect healing. Over 150 years later, research supports her claims. An article in the Journal of Burn Care Rehabilitation showed that murals decreased the intensity of pain and anxiety in burn patients. And research from the University of California at Davis showed that highly stressed patients awaiting surgery on gurneys had lower blood pressure when calm nature scenes were affixed to the ceiling.
Today, every wall should be seen as another opportunity to direct a patient’s attention to something uplifting or engaging. While research has sussed out some best practices, art—whether painted or hung—should be specifically tailored to the health of the community it serves. The following criteria will help you figure out what’s right for your clinic:
The artwork should be appealing—enough to hold a patient’s attention for more than a passing glance. Bonus: Actual engagement.
Each piece of art should appeal to the community it serves. Ex: For a children’s hospital, a magic eye puzzle, labyrinth on the floor, or illustrated history of the facility will draw the attention of both patients and their families.
Nature scenes have been shown to reduce stress by lowering blood pressure, heart rate, muscle tension, and electrical activity in the brain in less than five minutes. According to a study by Roger Ulrich, a professor of architecture at the center for healthcare building research at Chalmers University of Technology in Sweden, the best nature images show “calm or slowly moving water, verdant foliage, flowers, foreground spatial openness, park-like or Savannah-like properties (scattered trees, grassy undershot), and birds or other unthreatening wildlife.”
Art should promote a sense of calm or enjoyment. Abstract art in medical environments has been show to draw negative reactions from already stressed patients.
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By installing iPad stations in public areas, clinics and hospitals can offer patients and their families some enjoyment while they wait for a health care provider. Using the Apple Store as inspiration, the Children’s Hospital of Pittsburgh set up a series of tables at different heights adorned with iPads for visitors. iPads have a cross-generational appeal, and at the Children’s Hospital of Pittsburgh, they’re always full.
- If your clinic has visitors of all ages, set up tables of different heights—some that cater to children and others designed for adults.
- Secure the iPad and mount it to the table with solid steel construction and welds.
- Take safety precautions. Make sure all wiring is internal and not accessible by guests. Disable the Internet to avoid unwanted images or inappropriate behavior.
- Load entertaining content appropriate for the clinic’s visitors.
Modify the Space
Research has shown that changing the feel of a room can influence how a patient, family member, or staff member feels about a visit.
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In most waiting rooms, chairs are arranged side by side along walls or in tight rows like on an airplane. Especially in hospitals, this configuration inhibits interaction in a space where family and friends typically congregate.
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Where do we relax after a long day of work? In the living room. Switch out office furniture and generic decorations with adornments that would be pleasing and comfortable for the clinic’s clientele.
Using medically safe, washable, and removable stickers (like the kinds that advertisers use to cover busses), providers can transform a room packed with big medical machinery into something less threatening—and maybe even exciting.
Work with a company that specializes in large, custom stickers to figure out what would work best in the clinic. Many companies that provide medical equipment have custom stickers available.
Choose a theme. The Children’s Hospital of Pittsburgh has roughly 18 different environments, ranging from a cozy campground to a rocket ship to a pirate ship, that they've deployed in their CT scan rooms.
Cover the floors, walls, medical equipment, and the outside door with the removable stickers.
Add a smell to complete the experience. At the Children’s Hospital of Pittsburgh, a beach-themed room is infused with what they describe as a pina colada sunscreen smell.
Start the experience in the waiting room. If a child is about to enter into a pirate ship-themed room, the staff at the Children’s Hospital of Pittsburgh will give the child a pirate hat to wear as they’re greeted.
Rebuild
Research has shown that postoperative patients with a window overlooking a park complained less, didn’t need as much pain medication, and were discharged earlier than patients with windows with a view of a brick wall.
Outdoor green spaces at medical facilities can be used for quiet, stress reduction, and emotional healing by both patients and care providers. To do the most good, a garden should be a central part of a medical facility’s design and not an afterthought, according to an extensive study published by The Center for Health Design. Here are the most important aspects of an outdoor garden, according to the study. (The following is a summary. For the full recommendations, find the article here.)
- Greenery, life, and growth
- Varied sensory stimulation
- That it helped users find a sense of peacefulness and expansiveness
- The space’s opportunities for social interaction and observation.
- Exterior should contrast interior space.
- Patients are often thinking directly about their physical comfort.
- Management of microclimate and mobility are important.
- Patients should feel safe and secure. Well-defined seating, clear pathways, and easy-to-read spaces should be created.
- What visitors see, feel, and hear shouldn’t stand out or be distracting. Ex: Abstract sculptures have been shown to promote negative feelings from patients.
- The research suggests that a change in physical spaces can help shift emotional perspective. Offering a variety discrete areas in the green space with pathways that guide patients between them can help stimulate psychological progress along with physical movement.
- Some sections of the garden should be designed for patients to be safely secluded. Others should promote social interaction.
Give Patients and Visitors Control
The clinical environment—and the loss of control as a result of it—begins long before a patient ever sees a health care provider. By allowing patients to make decisions about their environment, hospitals and clinics can give back some control to those they care for.
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Patients turn to their phones as a distraction or as a way to stay connected. Access has become increasingly important. Offering charging stations in public areas allows patients to stay connected without having to hunt around for a plug.
Exam room furnishings should bridge the gap between patient and provider, not reinforce it. A 2009 study showed that patients got a better view of their medical record when they sat at a semi-circle table with their physician, equidistant from the computer screen displaying their electronic medical record.
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Using a silent paging system similar to the ones used in big chain restaurants (think: Cheesecake Factory), clinics and hospitals can give patients the option of leaving until the care provider is ready to see them.
- Check the patient in.
- If the wait is over 5 minutes, give the patient an estimate of the wait time and hand them a pager. The patient is free to grab a coffee, take a walk, or sit somewhere else.
- When a care provider is ready, the patient is paged and the visit begins.
When seating is flexible and movement is encouraged, patients and providers can tailor the waiting room, exam room, or patient room to support better communication.
In some cases, overnight hospital stays mean overnight guests, too. Instead of making the experience uncomfortable for visitors by relegating them to a hard chair, offer guests a comfortable sleeping space within patient rooms. More sleep for everyone at night can reduce anxiety during the day.
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When patients have their own rooms during hospital stays, as opposed to sharing a room with other patients, they routinely report better communication with nurses and physicians—not to mention more privacy and a more positive outlook on their hospital experience.
In patient rooms where family members will be present, evidence-based design guidelines recommend a clear floor area the allows 30 square feet per family member. These rooms should be outfitted with comfortable furnishings that strive for a home-like atmosphere.
Roger Ulrich, a professor of architecture at the center for healthcare building research at Chalmers University of Technology in Sweden has found that patients need pain medication almost 25 percent less often when exposed to morning sunshine. In another study, students exposed to greenery—even graphically represented—were less stressed during standardized tests.
Just Plain Good Design
When medical spaces puts its users first, the environment won't stoke patient or provider stress levels. Instead, the facility will help daily operations happen more smoothly which creates a more comfortable atmosphere for everyone.
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In a report from the Center for Health Design, Roger Ulrich, a professor of architecture at the center for healthcare building research at Chalmers University of Technology in Sweden, found that the number and positioning of signs in hospitals is important. Patients and visitors navigate the hospital faster, are less hesitant, ask for directions less often, and report lower levels of stress when there are more directional signs present. The study’s recommendation: “directional signs should be placed at or before every major intersection, at major destinations, and where a single environmental cue or a series of such cues (e.g. change in flooring material) convey the message that the individual is moving from one area into another. If there are no key decision points along a route, signs should be placed approximately every 150 feet to 250 feet.”
Reconfigure
Hospitals and clinics are packed with hulking equipment, run through with cords, littered with stand-alone medical devices, and plastered with signage and other notices. It’s a lot of visual distraction for patients trying to keep their anxiety in check. At the Children’s Hospital of Pittsburgh, all the signage is electronic, and nothing informational is posted on the walls in order to achieve a clean and organized environment.
- Start by clearing hallways, exam rooms, and patient rooms of all the equipment that doesn’t need to be displayed.
- Clear the walls of paper notices and needlessly layered signage.
- Make sure wayfinding signs are displayed often and are consistent in style and message.
Rebuild
When patients and families have a hard time navigating their way around a clinic or hospital, it costs the facility money. A study from 1990 looked at how many hours it costs a hospital to just get visitors where they needed to go. The answer was 4,500. That’s two full time jobs-worth of staff hours spent by employees not stationed at the information. Moreover, when signs aren’t clear, it can increase stress in patients and visitors.
- Wayfinding should be an integrated system made up of several coordinated elements: signs and numbers should be clear and easy to see; verbal directions should be clear and consistent; mailed, printed, and electronic information needs to be consistent and easily understood.
- When wayfinding is appropriately integrated, it includes the following four components: administrative and procedural levels, external building cues, local information, global structure.
Improve Health Outcomes
Our environment matters. An increasing body of research has found that the rate at which we heal is influenced by what's around us.
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Studies have shown that an abundance of bright light, both natural and artificial, has significant benefits for patients. Lots of light during the day can improve circadian rhythms, depression, and agitation. Compared with patients in dimly lit rooms, patients exposed to lots of light are discharged faster.
Nature scenes have been shown to reduce stress by lowering blood pressure, heart rate, muscle tension, and electrical activity in the brain in less than five minutes. According to a study by Roger Ulrich, a professor of architecture at the center for healthcare building research at Chalmers University of Technology in Sweden, the best nature images show “calm or slowly moving water, verdant foliage, flowers, foreground spatial openness, park-like or Savannah-like properties (scattered trees, grassy undershot), and birds or other unthreatening wildlife.”
Reconfigure
Where do we relax after a long day of work? In the living room. Switch out office furniture and generic decorations with adornments that would be pleasing and comfortable for the clinic’s clientele.
Using medically safe, washable, and removable stickers (like the kinds that advertisers use to cover busses), providers can transform a room packed with big medical machinery into something less threatening—and maybe even exciting.
Work with a company that specializes in large, custom stickers to figure out what would work best in the clinic. Many companies that provide medical equipment have custom stickers available.
Choose a theme. The Children’s Hospital of Pittsburgh has roughly 18 different environments, ranging from a cozy campground to a rocket ship to a pirate ship, that they've deployed in their CT scan rooms.
Cover the floors, walls, medical equipment, and the outside door with the removable stickers.
Add a smell to complete the experience. At the Children’s Hospital of Pittsburgh, a beach-themed room is infused with what they describe as a pina colada sunscreen smell.
Start the experience in the waiting room. If a child is about to enter into a pirate ship-themed room, the staff at the Children’s Hospital of Pittsburgh will give the child a pirate hat to wear as they’re greeted.
Rebuild
Research has shown that postoperative patients with a window overlooking a park complained less, didn’t need as much pain medication, and were discharged earlier than patients with windows with a view of a brick wall.
Outdoor green spaces at medical facilities can be used for quiet, stress reduction, and emotional healing by both patients and care providers. To do the most good, a garden should be a central part of a medical facility’s design and not an afterthought, according to an extensive study published by The Center for Health Design. Here are the most important aspects of the outdoor garden, according to the study. (The following is a summary. For the full recommendations, find the article here.)
- Greenery, life, and growth
- Varied sensory stimulation
- That it helped users find a sense of peacefulness and expansiveness
- The space’s opportunities for social interaction and observation.
- Exterior should contrast interior space.
- Patients are often thinking directly about their physical comfort.
- Management of microclimate and mobility are important.
- Patients should feel safe and secure. Well-defined seating, clear pathways, and easy-to-read spaces should be created.
- What visitors see, feel, and hear shouldn’t stand out or be distracting. Ex: Abstract sculptures have been shown to promote negative feelings from patients.
- The research suggests that a change in physical spaces can help shift emotional perspective. Offering a variety discrete areas in the green space with pathways that guide patients between them can help stimulate psychological progress along with physical movement.
- Some sections of the garden should be designed for patients to be safely secluded. Others should promote social interaction.
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