1

Background

The 1999 Institute of Medicine’s landmark report, To Err is Human:

Building a Safer Health System, exposed the tremendous costs, both in

human and financial terms, of medical errors in the U.S. health care

system.1 Two studies cited in the report indicate that between 44,000

and 98,000 people die each year in the United States as a result of

medical errors. The national cost to the economy of these errors is

between $17 billion and $29 billion. Since the release of the Institute

of Medicine’s report, a number of successful initiatives have been

launched to help hospitals change their cultures and care processes to

produce safer health care environments with fewer medical errors. 

A growing body of literature describes the link between a hospital’s

physical design and its key quality and safety outcomes. Hospital

planners, expected to spend nearly $250 billion on new construction in

the next 10 years, are consulting this evidence and incorporating it into

their designs for capital construction projects.2 In the midst of this

construction boom, hospital planners have an opportunity to create

safer and more effective facilities that enhance patient safety, improve

the quality of care, increase workforce satisfaction, and reduce the cost

of care.3 In an era of staff shortages, increased transparency of

information about hospital performance, and reimbursement linked to

performance, improving health care environments may be critical to a

hospital’s survival. 

Transforming Hospitals: Designing for Safety and Quality, a DVD from

the Agency for Healthcare Research and Quality (AHRQ), reviews the

case for evidence-based hospital design and how it increases patient

and staff satisfaction and safety, quality of care, and employee

retention, and results in a positive return on investment. The DVD

presents the experiences of three model hospitals—Griffin Hospital in

Derby, CT; Holy Cross Hospital in Silver Spring, MD; and Woodwinds

Health Campus in Woodbury, MN—that incorporated evidence-based

design elements into their construction and renovation projects.

Hospital executives planning or executing a major capital construction

project or minor renovations can use the information presented in this

DVD to help identify how evidence-based design can improve the

quality and safety of their hospitals’ services. 
2

Evidence-Based Design

Evidence-based design is a term used to describe how the physical

design of health care environments affects patients and staff.4,5 Key

characteristics of evidence-based design in hospital settings include

single-patient rooms, use of noise-reducing construction materials,

easily accessible workstations, and improved layout for patients and

staff.6

Patient Safety

Evidence-based design elements can help hospitals reduce costly and

avoidable incidents of patient harm, such as patient falls, hospitalacquired infections, and medication errors.

Patient falls. Patient falls, which are common in hospitals, can result in

serious injuries, extend a patient’s stay, and drive up the cost of care

significantly. By 2020 the estimated annual cost of fall injuries for older

people will exceed $30 billion.7,8 Now that the Centers for Medicare and

Medicaid Services no longer reimburse hospitals for the cost of patient

falls that occur in their facilities, and insurers are likely to follow its

lead, hospitals will bear a greater portion of this cost.

Patient falls can be avoided. Poor placement of handrails and small

door openings are two primary causes of patient falls. Many falls can

be reduced through providing well-designed patient rooms and

bathrooms and creating decentralized nurses’ stations that allow

nurses easier access to at-risk patients.9,10,11

Hospital-acquired infections. Single-bed rooms and improved air

filtration systems can reduce the transmission of hospital-acquired

infections. Infections can also be reduced by providing multiple

locations for staff members to wash their hands so they spend less

time walking to sinks and have more opportunities to sanitize their

hands before providing care.12

Medication errors. Poor lighting, frequent interruptions and

distractions, and inadequate private space can complicate filling

prescriptions. Well-illuminated, quiet, private spaces allow pharmacists

to fill prescriptions without the distractions that may lead to medication

errors.13
3

Patient rooms that can be adapted for the acuity of a patient can also

reduce errors. Acuity-adaptable rooms reduce the need to transfer

patients around the hospital and lessen the burden on the staff to

communicate information to caregivers in the patient’s new location.14

Patient Satisfaction 

Reducing noise, providing more privacy, and making it easier for

patients to find their way though the hospital can all improve patient

satisfaction. 

Frequent overhead announcements, pagers, alarms, and noisy

equipment in or near patient rooms are stressful for patients and

interfere with their rest and recovery.15 Single-bed rooms with highperformance, sound-absorbing ceilings and limited overhead

announcements can substantially improve the healing environment for

patients.16

Evidence also shows that patients are more satisfied with their care

when they are given adequate space to interact with their families. For

example, single-patient rooms make it easier for families to stay with

patients.17 Responding to the overwhelming evidence regarding how

single-patient rooms improve patient safety, satisfaction, and quality

outcomes, the American Institute of Architecture changed its 2006

construction guidelines to recommend that single rooms for medical,

surgical, and postpartum nursing units in general hospitals be the

standard.18,19

Helping patients effortlessly find their way through hospitals can

improve patients’ overall care experience and increase satisfaction by

reducing feelings of stress, anxiety, and helplessness for them and

their families. Better navigation can be addressed architecturally

through useful signage and easily navigable corridors.20

Quality Outcomes 

Several design elements are associated with better quality outcomes

for patients. In addition to improving patient satisfaction, reducing

hospital noise can improve patient recovery and sleep time and reduce

depression. Other factors, such as increased sunlight in patient rooms,

views of nature, artwork, and music, also reduce patient stress and can

lead to improved outcomes.21
4

Staff Satisfaction and Workforce Retention

Staff shortages and turnover are serious problems for hospitals. The

average annual turnover rate for health care workers, many of whom

are nurses, is 20 percent, and much of this turnover is related to

stress, which could be greatly reduced by lessening the physical

demands of nursing.22,23

One example of how to reduce the physical burden on staff and

improve workflow is by using acuity-adaptable rooms, which limit the

need to transfer patients within the hospital. By reducing the number

of moves, hospitals can increase productivity in delivering patient care

and decrease the physical demands on the staff.24,25

Another useful design element decentralizes nurses’ stations and

supply areas to allow nurses to spend less time walking and more time

treating patients.26 Reducing stressful noise; improving light sources for

surgical staff; and designing patient beds to reduce back stress,

fatigue, and injuries can also improve workforce satisfaction and

retention.27

Cost Effectiveness

The competitive nature of health care, new medical technology that

requires facility upgrades, and the need for health organizations to

become more efficient and cost effective have driven the recent

upward trend in hospital growth. To meet these challenges, hospitals

require frequent updates to meet current guidelines and regulations

and maintain market share.28

Although designing an updated facility using evidence-based design

principles may add up-front capital costs, this investment ultimately

decreases medical and financial complications that can result from a

poorly designed facility.29,30,31 The Center for Health Design modeled and

analyzed the increased capital costs and downstream cost-savings of

well-designed facilities by using a “fable hospital” that included many

common evidence-based design elements. While these features added

$12 million to the cost of the hospital construction, those costs were

projected to be recovered in one year through operational savings and

increased revenue.32
5

For More Information

For more information on Transforming Hospitals: Designing for Safety

and Quality or AHRQ’s research in evidence-based design, please visit

the AHRQ Web site:

www.ahrq.gov/qual/transform.htm.

You can also contact AHRQ at:

AHRQ Office of Public Affairs

Ellen Crown, 301-427-1258

Resources on Evidence-Based Design

The American Institute of Architects: www.aia.org, especially Guidelines

for Design and Construction of Health Care Facilities

The Center for Health Design: www.healthdesign.org, especially The

Role of the Physical Environment in the Hospital of the 21st Century

InformeDesign: www.informedesign.umn.edu

Institute for Healthcare Improvement: www.ihi.org.

Planetree: www.planetree.org, especially Designing and Practicing

Patient-Centered Care

Robert Wood Johnson Foundation: www.rwjf.org
6

References

1. Institute of Medicine, Committee on Quality of Health Care in America.

To Err Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM,

Donaldson MS, Eds.) Washington, DC: National Academy Press; 2000.

2. The Center for Health Design. Scorecards for Evidence-Based Design.

Concord, CA; 2005 Dec.

3. Evidence-Based Hospital Design Improves Healthcare Outcomes for

Patients, Families, and Staff. Princeton, NJ: Robert Wood Johnson

Foundation; 2004 Jun 7.

4. Hamilton DK. Four Levels of Evidence-Based Practice. Healthcare

Design; 2003 Nov; 3:18-26. 

5. Blum, A. How Hospital Design Saves Lives. BusinessWeek Online; 2006

Aug 15.

6. The Center for Health Design. Scorecards for Evidence-Based Design.

Concord, CA; 2005 Dec. Available at

www.healthdesign.org/research/reports/documents/scorecard_12_05.

pdf.

7. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.

8. Chang J, Morton S, Rubenstein L, et al. Interventions for the Prevention

of Falls in Older Adults: Systematic Review of Meta-Analysis of

Randomized Clinical Trials. Br Med J; 2004 March 20; 328:680-6. 

9. Nelson C, West T, Goodman C. The Hospital Built Environment: What

Role Might Funders of Health Services Research Play? Rockville, MD:

Agency for Healthcare Research and Quality; 2005 Aug. AHRQ

Publication No. 06-0106-EF. 

10. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.

11. Brandis S. A Collaborative Occupational Therapy and Nursing Approach

to Falls Prevention in Hospital Inpatients. J Qual Clin Pract; 1999;

19(4):215-220.

12. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.

13. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.
7

14. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.

15. Nelson C, West T, Goodman C. The Hospital Built Environment: What

Role Might Funders of Health Services Research Play? Rockville, MD:

Agency for Healthcare Research and Quality; 2005 Aug. AHRQ

Publication No. 06-0106-EF. 

16. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.

17. Nelson C, West T, Goodman C. The Hospital Built Environment: What

Role Might Funders of Health Services Research Play? Rockville, MD:

Agency for Healthcare Research and Quality; 2005 Aug. AHRQ

Publication No. 06-0106-EF. 

18. The American Institute of Architects. Guidelines for Design and

Construction of Health Care Facilities. Available at

www.aia.org/aah_gd_hospcons. Accessed March 22, 2005.

19. Chaudhury H, Mahmood A, Valente M. The Use of Single Patient Rooms

Versus Multiple Occupancy Rooms in Acute Care Environments.

Submitted to The Coalition for Health Environments Research; 2003

Nov 20.

20. Nelson C, West T, Goodman C. The Hospital Built Environment: What

Role Might Funders of Health Services Research Play? Rockville, MD:

Agency for Healthcare Research and Quality; 2005 Aug. AHRQ

Publication No. 06-0106-EF.

21. Nelson C, West T, Goodman C. The Hospital Built Environment: What

Role Might Funders of Health Services Research Play? Rockville, MD:

Agency for Healthcare Research and Quality; 2005 Aug. AHRQ

Publication No. 06-0106-EF. 

22. Joint Commission of Accreditation of Healthcare Organizations. Health

Care at the Crossroads: Strategies for Addressing the Evolving Nursing

Crisis; 2002.

23. Nelson C, West T, Goodman C. The Hospital Built Environment: What

Role Might Funders of Health Services Research Play? Rockville, MD:

Agency for Healthcare Research and Quality; 2005 Aug. AHRQ

Publication No. 06-0106-EF. 

24. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.
8

25. Hendrich AL, Lee N. Intra-Unit Patient Transports: Time, Motion, and

Cost Impact on Hospital Efficiency. Nurs Econ; 2005 July 1; 23(4):157-

64.

26. Hendrich AL, Bender, PS, Nyhuis A. Validation of the Hendrich II Fall

Risk Model: A Large Concurrent Case/Control Study of Hospitalized

Patients. Appl Nurs Res; 2003; 16(1):9-21. 

27. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.

28. Nelson C, West T, Goodman C. The Hospital Built Environment: What

Role Might Funders of Health Services Research Play? Rockville, MD:

Agency for Healthcare Research and Quality; 2005 Aug. AHRQ

Publication No. 06-0106-EF. 

29. Blum, A. How Hospital Design Saves Lives. BusinessWeek Online; 2006

Aug 15.

30. The Center for Health Design. Better Hospital Buildings Cost More, but

Pay for Themselves Through Increased Revenue and Operational

Savings; 2004 Sept 8. Available at

www.healthdesign.org/aboutus/press/releases/2004-09-

08_frontiers.php. Accessed Mar 22, 2007.

31. Landro, L. Hospitals Build a Better ‘Healing Environment.’ Wall Street

Journal Online; 2007 Mar 21. 

32. Ulrich R, Zimring C. The Role of the Physical Environment in the Hospital

of the 21st Century: A Once-in-a-Lifetime Opportunity. Concord, CA: The

Center for Health Design; 2004 Sept.

U.S. Department of Health

and Human Services

Agency for Healthcare

Research and Quality

www.ahrq.gov

AHRQ Pub. No. 07-0076-1

September 2007