"We cannot expect to practice 21st century medicine in early 20th century hospitals."
 

These are the watchwords Texas A&M University architecture professor Roger Ulrich lives by.  He wants to build 21st century hospitals the same way physicians practice medicine, using the best evidence research and experience can provide. 

 

Internationally recognized as a pioneer in the application of the concepts of evidence-based design, Ulrich notes that "a visit to a U.S. hospital is dangerous and stressful for patients, families and staff members.  Medical errors and hospital-acquired infections each harm or kill many people every year in the United States.

 

"Healthcare facilities designers have an unprecedented opportunity to impact these problems by improving hospitals themselves, as the U.S. experiences one of the largest hospital building booms in history.  This once-in-a-lifetime construction program provides an opportunity to rethink hospital design, and especially to consider how design improvements can help reduce staff stress and fatigue and increase effectiveness in delivering care, improve patient safety, reduce patient stress and improve outcomes and overall healthcare quality.

 

"It's especially important for the design professions to rise to this challenge, because the hospitals we build today will remain in place for decades."

 

Research into the current status of evidence-based design

In addition to his duties as a professor of architecture, Ulrich collaborates with other Texas A&M researchers in the Center for Health Systems and Design (CHSD), focusing on problems ranging from healthcare facilities building and design to making natural environments more accessible to long-term care residents to the role of live plants in healing patients.

 

CHSD is a creation of Texas A&M's College of Architecture and The Texas A&M System Health Science Center's College of Medicine and is intended to promote research, innovation and communication in an interdisciplinary program that focuses on health facility planning and design. Examples of research interests of faculty fellows include the effects of environmental stress on patients' health and well being, the design of healing environments for neonatal patients, children and the elderly, health resources of Texas colonias residents and healthcare needs of AIDS patients. Housed in the College of Architecture, CHSD is headed by Director Mardelle Shepley and Associate Director Susan Rodiek. The primary activities of the Center include a professional associates program, curriculum development, health lecture series and support of health-related research and design projects carried out by 21 fellows, including 18 College of Architecture faculty and psychologist Michael Duffy and Marcia Ory and Joseph Sharkey of the School of Rural Public Health, part of The Texas A&M System Health Science Center.

 

To assess the status of research into healthcare facilities design, in 2004 Ulrich joined with CHSD colleague Xiaobo Quan and Georgia Institute of Technology faculty Craig Zimring, Anjali Joseph and Ruchi Choudhary in reviewing more than 600 studies of how hospital design can impact clinical outcomes.  Their effort, funded by the Robert Wood Johnson Foundation, concluded that evidence exists linking the physical environment of healthcare facilities to reducing staff stress and fatigue and increasing their effectiveness in delivering care.  Facility design and construction was also found to be linked to patient safety and stress levels, clinical outcomes, and overall quality of healthcare.

 

"Nurses, physicians, and other healthcare employees work under stressful physical conditions," Ulrich says.  "A growing nurse shortage threatens patient safety, and burn-out thins the ranks of those already in the profession, with registered nurses having an average turnover rate of 20 percent per year."

 

He recommends facilities designs that address such issues as better ventilation and lighting, lower noise levels, better ergonomic features on patient beds and other equipment to help reduce staff fatigue and injuries and improved layout to cut down on the amount of walking nurses must do during each shift.  Such changes, he said, could promote better health for nurses and technicians and send the message that "maintaining health and safety of staff members is an important goal for an organization."

 

Protecting patients from hospital-acquired infections is another major goal of modern facilities design. 

 

"Our review of existing studies suggests that infection rates are lower when there is good air quality and patients are in single-bed rather than multi-bed rooms," Ulrich noted. He also recommends more convenient hand-washing facilities to encourage improved staff hygiene.  Other innovations that could reduce medication errors and patient falls include designs that provide better lighting and fewer distractions and interruptions for staff members and room configurations providing better observation of patients by both nurses and family members.

 

"This research found that noise causes much stress experienced by hospitalized patients," Ulrich says.  "Hospitals are full of loud noises and the hard environmental surfaces in patient rooms and hallways create poor acoustics, reflecting, amplifying and propagating noise.

 

"Changes in the environment that can help reduce noise and improve acoustics include installing sound-absorbing ceiling titles, eliminating or muffling noise sources - an example is changing to noiseless paging systems - and building more single-bed rooms."

 

And it's not only noise that can stress patients and their families.  Hospitals are unusually easy places in which to get lost.  Ulrich recommends that healthcare planners pay special attention to designing easy-to-follow wayfinding systems to guide people through the healthcare facility maze.

 

Another way to minimize stress is to provide opportunities to "commune with nature," Ulrich says.

 

"Many studies of populations other than hospital patients have produced strong evidence that even fairly brief encounters with real or simulated nature settings can bring significant recovery from stress with three to five minutes at most.  Simply viewing nature can provide a whole constellation of positive emotional and physiological changes, including lowering blood pressure."

 

Ulrich cites research showing that bedridden patients have strong preferences for hospital windows that look out on natural scenes.  Thus, he recommends that designers plan for nature views and include gardens in healthcare environments.

 

"Evidence-based design (EBD) is not about hospitals that are simply nicer or fancier than traditional hospitals," Ulrich emphasizes.  "Rather, the focus of evidence-based design is to create hospitals that actually help patients recover and be safe and that help staff do their jobs better.  EBD is a process of creating healthcare buildings informed by the best available evidence concerning how the physical environment can interfere with or support activities by patients, families and staff and how the setting provides experiences that provide a caring, effective, safe, patient-centered environment.  And many of the improvements suggested by EBD are only slightly more expensive than traditional solutions, if they are more expensive at all. In the long run they produce major savings."

 

Sharing evidence-based design across international borders

For most of 2005, Ulrich enjoyed the opportunity to share his EBD expertise with architects and government agencies in the United Kingdom.  He spent an eight-month sabbatical there, serving as senior adviser on the environment for patient care to Britain's National Health Service and meeting with Prime Minister Blair's personal adviser on healthcare policy and twice with His Royal Highness the Prince of Wales to discuss research on healthcare buildings and the health-related benefits of nature.  During his visit, Ulrich became the second Honorary Lifetime Member of the U.K. Architects for Health.

 

In fact, Ulrich was such a hit with his British colleagues that this spring he has been invited to return to carry out research and work with architects and planners in the United Kingdom to improve patient care by helping to change the way British hospitals are designed, using the results of academic research projects focused on the interaction of environment and health outcomes to inform real-world practice.

 

"The healthcare system in the United Kingdom is undergoing major changes," Ulrich says.  "The payment system is shifting closer to the one used in the United States, with government insurance reimbursements following the patient as he or she chooses a doctor, a clinic or a hospital.  And as patient choice becomes linked to a facility's success, that facility is paying more attention to what patients want - and one thing most patients want is a room all to themselves.

 

"Research has shown that not only do patients prefer to have their own rooms, but single rooms are safer in terms of infection control and result in better medical outcomes.  Staff also experience less fatigue and have higher morale when they care for patients one-at-a-time.  Patients who are satisfied with their experience at a particular facility tend to choose to use that same facility for subsequent hospitalizations or clinic stays, and these return visits contribute to a facility's financial success."

 

Such increased satisfaction by patients and caregivers and the resulting boosts to a hospital's bottom line are beginning to impact the way new hospitals in the United Kingdom are being designed.

 

"The British medical system is engaged in building facilities on an enormous national scale," Ulrich says.  "Upwards of one-hundred new hospitals and thousands of new clinics are planned, with expenditures of more than $25 billion U.S. anticipated for the near term.  Architects of these new facilities are abandoning the old four-bed-ward model for single-bed rooms, and making many other evidence-based design improvements.  Since I first began working with British policymakers 2-1/2 years ago, I've seen the requirement for single rooms rise from 20 to 30 percent of the total rooms of a facility, then to 70 percent, and I expect to see this demand continue to rise to the range of 80 to 100 percent."

 

Last year, Ulrich, who has received national recognition for his work on evidenced-based facility design, took a faculty leave to study healthcare in the U.K.  Now he's back there, doing research and advising the agencies who plan British hospital facilities.  He is also serving as a visiting professor of architecture at University College London. Ulrich brings his expertise in behavioral science and architecture to the study of how people and buildings interact.

 

In January, Ulrich participated in a conference of healthcare providers and policymakers that again included the Prince of Wales; Ulrich delivered a talk on the interaction of the architectural environment and health.  This semester, he also worked with another architecture professor, Susan Rodiek, who led a group of Texas A&M students who are traveled to London to work on a project for a 750 bed hospital that will cost more than $1 billion U.S.

 

"The hospitals and clinics being built in the U.K. are often larger and more expensive than those in the United States, so British policymakers and healthcare architects emphasize the need for the best possible information on which to base decisions," Ulrich says.  "My experiences here have given me important insights into the intersection of the political and healthcare infrastructures.  This program has offered the chance for an academic like me to bring research knowledge forward to influence government sponsored healthcare buildings on a massive scale."

 

Ulrich said he is looking forward to applying his research and decision-making findings in his classes at Texas A&M when he returns to the United States for the fall 2006 semester.

 

"The time I have spent studying abroad has made the quality of my teaching and research much better," he says.  "Students in my classes say they benefit from my anecdotes based on personal experiences with British architects, NHS administrators, ministers and physicians. The course content in general has taken on a more international perspective."