How Hospital Design Can Promote Better Patient Outcomes

A storm has been brewing down the street from my office. It is a David & Goliath dispute, pitting young children and their families against a renowned pediatric institution, Boston Children’s Hospital. It concerns the fate of a half-acre swath of green space, the Prouty Garden, replete with meandering paths, fountains and a towering redwood tree that provides ample shade on hot sunny days. Designed by the Olmsted brothers, progeny of the preeminent American landscape architect, Frederick Law Olmsted, this lush oasis sits smack dab in the middle of the hospital’s busy medical campus, where it has served as a healing space for its youngest patients and their families, including children facing major surgeries, battling leukemia or myriad other illnesses, “a place you can go to just get away from all of it.”¹

Hospital administrators are seeking permission from state regulators to raze the garden, the hospital’s last remaining open space, to make way for a new 11-story building that would house more patient beds, a new intensive care unit, surgical operating suites and several magnetic resonance imaging machines.

Although these are worthy goals that serve to advance medical progress, they are being met with stiff resistance. Supporters of the garden emphasize its magical qualities, how its luxuriant surroundings enable the most vulnerable patient, the critically ill child, to garner the strength needed to fight the medical battles that loom ahead.²

Yet the garden has the misfortune of being the last remaining open space in a very crowded medical area.

Windows on the World

The fate facing the Prouty Garden raises the issue of whether surroundings influence how patients recover from illness. Can nature nurture?³ Is it critical to consider landscaping and interior decor when designing hospitals and other places of healing? Can the appearance of the building, the ward, the patient’s room, influence a patient’s outcome? Should admin­istrators be more concerned about the size of a patient’s room window than about their television channel offerings?

It seems that our gaze can impact our sense of well-being. When studying responses to outdoor environments, most Western cultures show a preference for natural scenes that include vegetation and water over urban views that lack these elements. Because most natural views seem to elicit positive feelings, reduce fear and inhibit stressful thoughts, it has been proposed that natural surroundings might foster restoration from anxiety or tension.⁴ Yet not every healthcare facility has the wherewithal or the space to create luxuriant garden space, so are there other ways to integrate nature into the healing process? How about a room with a view?

The restorative effect of natural views on surgical patients undergoing elective cholecystectomy was cleverly examined in a study conducted in a small, suburban Pennsylvania hospital that focused on whether assignment to a room with a window view of a natural setting might have restorative influences. In the 1980s, patients were often kept in the hospital for several days following surgery to recover, and their confinement limited their access to outdoor environments almost entirely to views through windows. Twenty-three surgical patients assigned to rooms with windows looking out on a natural scene had shorter postoperative hospital stays, received fewer negative evaluative comments in nurses’ notes and consumed fewer opioid analgesics than 23 matched patients in similar rooms with windows facing a brick building wall.⁴

Another study led by the same author found similar results when studying patients admitted to a Swedish intensive care unit who were assigned to having either simulated nature views, such as forest or water scenes, abstract art works or blank sheets of paper posted on the walls of their rooms. Once again, anxiety levels were found to be reduced in the first group compared with the others, and in this study, too, opioid use was significantly reduced.⁵

Is hospital design an overlooked,yet critical, influence on the healing process?

Hospital Design Through the Ages

The architectural genealogy of hospitals begins with the Greek temples of Askelpios and Kos, where the sick placed faith in the power of sacred settings and ritual. By contrast, ancient Roman hospitals were developed for military purposes with plans based on barracks.⁶ As the Roman Empire turned to Christianity, the hospitals’ mission changed as the Church’s role in providing for the sick became firmly established. After 400 AD, monasteries were constructed to include accommodations for travelers, the poor and the sick. Charlemagne, King of the Franks, declared that hospitals be attached to every cathedral built during his reign.⁶

For centuries, hospitals were crowded, poorly ventilated facilities thick with patients stricken by contagious illnesses. With little physical separation between patients and staff, it is no wonder that an admission to hospital was often a fatal event.

About the time of the French Revolution, horrific conditions in the Hotel-Dieu, the preeminent Parisian hospital, spurred the need for change. French architects developed the concept of pavilion design, whose essential prerequisites were the creation of sufficient space between hospital wards to allow for light exposure, and long, drafty hallways and open chimneys, which together promoted the cross circulation of air.^7,8 A major proponent of this design principle was the social reformer and founder of modern nursing, Florence Nightingale, whose nightmarish experiences caring for sick and injured British troops in the Crimean War convinced her of the need for such changes.

The pavilion design lasted for a few centuries until it fell out of favor starting in the early 20th century, when major advances in medical science persuaded hospital administrators and architects to concentrate on creating facilities that would reduce infection risk and serve as functionally efficient settings capable of incorporating new medical technology. The strong emphasis on infection reduction, together with the priority given to utilitarian efficiency, shaped the design of hundreds of major hospitals internationally. Function fused with form, creating some highly uninspiring edifices. A prime example may be the works of the famed American architect, Bertrand Goldberg.

Trained at the Bauhaus in Germany and by some of the most prominent architects of the 20th century, he was known for his innovative structural solutions to complex design problems. Little wonder that he was highly sought after by hospital design committees, especially following the construction of his tour de force, Marina City, a multi-building complex that included the largest concrete building in the world at the time, built on the banks of the Chicago River in his hometown, Chicago.⁹ He adapted some of his prior concepts and applied them to create several near-identical prefabricated concrete slab hospital structures around the country, including the Good Samaritan Hospital in Phoenix, Providence Hospital in Mobile, Ala., Prentice Women’s Hospital in Chicago and my current facility, Brigham and Women’s Hospital (BWH) in Boston—nine in all.

The interesting exterior quadrafoil plan for these hospitals allowed for the construction of identical pod-shaped wards, generally comprising four per patient floor.¹⁰ Based on my experience at BWH, whose design was touted for creating a close proximity between every patient room and the nursing station, the floor plan’s redundancy and its homogeneous appearance allowed a certain dreariness to settle in just a few years after its construction.

In addition, Goldberg’s design eschewed two requisite features of most hospitals: the need for a large, welcoming entryway and a sufficient number of elevator banks to ferry patients and staff up and down the floors. Although the former flaw was rectified a decade later with the construction of a lobby entrance worthy of a large bank headquarters, adding new elevators to a 16-story building remains a highly unrealistic proposition. Sometimes, while waiting endlessly for the next elevator, I wonder how many minutes, hours, days, years have been wasted by staff outside the closed elevator doors. Stairs, anyone?

Building Boom

Currently, there’s a healthcare construction boom raging, with close to $100B in projects either underway or recently completed. Although most are building renovations, about 150 new hospitals are being built at a cost of more than $1B for most academic medical centers.¹¹ One may view this expense with disbelief, until considering that this cost falls within the price range of implementing electronic health record systems in some of these same facilities.¹²

Not surprisingly, California leads the country in healthcare construction, although one driving factor may be the California Seismic Safety Act mandating hospitals to meet structural guidelines to withstand a major earthquake by 2030. This has contributed to driving up the cost of hospital construction in the Golden State to $2M per bed compared with $1.7M in the rest of the country.¹¹

Can the appearance of the building, the ward, the patient’s room, influence a patient’s outcome?

What do hospitals get for their pricey investment? First, patient safety has been enhanced by virtue of designing patient rooms that house a single patient, a far cry from the days when open wards were filled with scores of patients nursing open wounds. Shared bathrooms are no longer the norm, eliminating a portal for potent pathogens, such as C. difficile. Single-room design recognizes the needs of families by providing them with adequate space and reasonable sleep accommodations, a fact that was usually ignored in prior designs. And of course, rooms have views, linking patients with the vitality of nature and reminding them that they are still part of this great big world.

Many of these new buildings have other interesting attributes. Some have achieved the designation of being environmentally friendly and green. The days of being unable to shut down wasteful heating systems in June may finally be over. Some have recognized the importance of horticulture in the healing process and have installed small gardens within their facilities. And borrowing a page from the neighborhood café and the startup incubator, others have created open spaces in public areas where staff can sit and sip or mingle with fellow workers and share creative ideas.

A Rheum with a View

For decades, my colleagues and I toiled in a block of drab, windowless rooms whose only views were those of a long hallway that separated our practice from orthopedics and where clusters of their patients were constantly parked in stretchers or wheelchairs, patiently waiting to be called into their equally dismal offices. Then one day, we all moved to a gleaming, new spacious building, which—for lack of a deep-pocketed donor—is called the Building for Transformative Medicine.

What a transformation! Now, there is ample space for everyone. No one is left parked in a hallway. And to have a room with a view changes one’s mood and one’s attitude far more than one may ever wish to admit. Sunlight streaming through the window, raindrops tapping on the windowpane. Nature nurtures the patient and the doctor.

Simon M. Helfgott, MD, is associate professor of medicine in the Division of Rheumatology, Immunology and Allergy at Harvard Medical School in Boston.

References

1. Goodnough A. A Boston hospital’s dilemma: Save a garden for sick kids, or bulldoze it to serve more patients. The New York Times. 2016 Jun 20.
2. Save Prouty Garden (video).
3. Franklin D. Nature that nurtures. Scientific American. 2012 Mar;306:24–25.
4. Ulrich RS. View through a window may influence recovery from surgery. Science. 1984 Apr 27;224(4647):420–421.
5. Ulrich RS. Health benefits of gardens in hospitals. Paper for conference, Plants for People, International Exhibition Floriade 2002, The Netherlands.
6. Prasad S. Typology quarterly: Hospitals. The Architectural Review. 2012 Apr 27.
7. Gormley T. The history of hospitals and wards. Healthcare Design. 2010 Mar 11.
8. Cook GC. Henry Currey FRIBA (1820–1900): Leading Victorian hospital architect, and early exponent of the ‘pavilion principle.’ Postgrad Med J. 2002 Jun;78(920):352–359.
9. Bertrand Goldberg Archive. The Art Institute of Chicago.
10. Bertrand Goldberg. Chicago architect 1913–1997.
11. Morse S. Top healthcare construction projects of 2015; Building surges as demand picks up, Revista says. Healthcare Finance. 2015 Nov 9.
12. Darrow B. Healthcare giant launches $1.2 billion electronic records consolidation effort. Fortune. 2015 Jun 1.