EDAC Healthcare Environment Design: Case Studies from the 2019-20 Advocate Brochure

Case studies in the Center for Health Design’s (CHD) Evidence-Based Design in Practice brochure (EDAC Advocate Brochure, 2019-20) report what happened after specific design interventions. This article summarizes those case studies. The figures are project-reported results from single sites, not code requirements and not general effect sizes; they come from CHD’s brochure, so they are as of 2019-20, and the brochure should be read for the study methods.

Key numbers at a glance

What does private patient room design change for staff?

Kentucky Children’s Hospital tested Hypothesis 1: “If private patient rooms are provided, then staff will be more satisfied.” Staff findings were almost exclusively ranked as more satisfying for all the patient room elements post-occupancy. The brochure notes one exception: safety and security ranked slightly above neutral before occupancy. Post-occupancy it ranked higher in satisfaction, which the brochure calls unexplained; staff in shared rooms had reported feeling safe in direct visualization of teammates.

At Froedtert and the Medical College of Wisconsin the team hypothesized that a decentralized unit would improve staff efficiency, patient and staff satisfaction, and patient safety. Data were analyzed with descriptive statistics and independent t-tests, and the brochure reports that patient and staff satisfaction, staff efficiency and patient safety improved in the new unit. The charted results are a 33% increase in staff satisfaction on unit design variables, 16% in visitor/patient satisfaction and 6% in efficiency (nurses’ time spent). The brochure does not attribute the results to one factor; the unit was the output of a Lean plus EBD design process.

How does wayfinding design affect patient navigation and costs?

New Parkland Hospital (Dallas, TX) tested Hypothesis 3: the new wayfinding system will function well from the user perspective. The predesign wayfinding research was published in the HERD Journal, and the post-occupancy findings “will add to the depth of knowledge around this challenging topic that has major financial implications for organizations.” Analysis of post-occupancy wayfinding results was underway when the brochure was published.

ERDMAN’s remodel of the William T. Evjue Clinic in Madison, WI, for Access Community Health Centers faced a multicultural patient base speaking over 39 different languages, in an existing space that lacked daylight and was confusing to navigate. Patients now have an easier, clearer navigation pathway with more daylight, clear signage, and a variety of wall colors and flooring to indicate location. The brochure reports improved wayfinding among other improvements; it gives no wayfinding metric.

What did the Kentucky NICU study find on acoustics and lighting?

Kentucky Children’s Hospital also tested two further hypotheses. Hypothesis 3, “If sound levels are decreased, staff will be more satisfied”: acoustic readings indicate post-occupancy sound levels in the patient room were consistently higher than the recommended standards, which the brochure says is consistent with other studies relating this outcome to the noisy equipment needed to support the typical NICU baby.

Hypothesis 2, “If a cyclical controllable lighting scheme is provided, then staff will be more satisfied”: the control system records every lighting change, programmed or occupant-initiated. Initial data show more changes between 8:00 PM and 8:00 AM than during the day, “indicating the programming of the lights during the day is meeting the needs of the occupants.”

CHD’s EDAC Exam Detailed Content Outline (2022) lists acoustical design among the items to verify that the commissioned building complies with the evidence-based design intent prior to building activation or occupancy (Domain 5).

How does culturally responsive design affect patient volume?

The Cherokee Indian Hospital (Eastern Band of Cherokee Indians) ran a visioning session within the community, including tribal elders, to define art goals of visualizing history and culture in traditional and contemporary art forms. After a year in operation its CEO said “with such strong community and cultural connections, there is about a 20% increase in patient visits: the clinic had 2,311 visits from May 1 to July 29 in 2015 and 2,964 patient visits from the same period in 2016.” This is a CEO’s year-over-year count for one site and one season, with no stated control for other causes. The two counts quoted work out to an increase of 28% (2,964 / 2,311), not about 20%; the page keeps the CEO’s wording and the counts. The Content Outline (2022) Domain 1 expects practitioners to know “the specific characteristics of the built environment that can address cross-cultural differences.”

Why do adolescent patients need dedicated spaces?

The brochure’s Children’s Hospital at Virginia Commonwealth University case study (HKS; the new children’s hospital replaces the existing pediatric inpatient unit with all private rooms and family amenities, and was scheduled to open in December 2022) cites adolescent and young adult research: 81% of teens admitted to adult units feel out of place, 53% of teens admitted to pediatric units feel out of place, and 77% of teens thought a specific teen room would be an improvement. The brochure gives these figures without a source citation or sample size, so check the underlying study before you quote them. The same case study applied biophilic design to the arrival and patient experience.

What should you take from these case studies?

Three points hold across the brochure. First, each team stated a hypothesis before measuring (for example Kentucky’s “if private patient rooms are provided, then staff will be more satisfied”). Second, post-occupancy results can be affected by factors other than design: New Parkland Hospital’s NICU saw a marked increase in length of stay for term infants after the move, which the brochure says “could be due to the Parkland population (95% of babies on Medicaid) and other factors”; the team held further meetings on the result. Third, the brochure presents project-reported results; the 33%, 16%, 6% and 20% (28% by the counts) figures are not a basis for forecasting your own project’s outcomes.

How to read these results

• Do not attribute NICU sound levels to the room design alone. Kentucky’s readings were consistent with studies linking them to equipment noise.
• Do not treat wayfinding as a signage problem only. The ERDMAN clinic combined daylight, signage, wall colors and flooring variation; no single measure was isolated.
• Check confounders before drawing design conclusions. New Parkland’s length-of-stay result is the brochure’s example.