Evidence-Based Design of Healthcare Facilities: Opportunities for Research and Practice in Infection Prevention

Affiliations: 1. SimTigrate Design Lab, School of Architecture, Georgia Institute of Technology, Atlanta, Georgia; 2. Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; 3. Health Systems Institute, Georgia Institute of Technology, Atlanta, Georgia; 4. School of Industrial Design, Georgia Institute of Technology, Atlanta, Georgia; 5. Agency for Healthcare Research and Quality, Rockville, Maryland; 6. RTI International, Washington, DC. Received October 2, 2012; accepted November 21, 2012; electronically published April 9, 2013. 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2013/3405-0011$15.00. DOI: 10.1086/670220 Evidence-based design (EBD) of healthcare facilities is an emerging field that has the potential to significantly reduce the burden of healthcare-associated infections (HAIs). There is a growing body of evidence demonstrating that the built environment of healthcare settings—their layout, materials, equipment, and furnishings—plays a key role in facilitating or preventing transmission of pathogens. The infection prevention community can be an important partner in further developing this evidence base by advocating for and including healthcare facility design in its research agenda. At the same time, the EBD of the built environment has the promise of providing an additional set of tools for infection prevention. A relatively new discipline, EBD has deep roots in environmental psychology, architecture, medicine, and other sciences. It postulates that the design of the built environment fundamentally impacts patient, provider, and organizational outcomes (ie, decreased infection rates, length of stay, falls, use of analgesics, and operating costs) while improving patient and caregiver experience and satisfaction. Similar to evidence-based medicine, EBD uses the best available evidence to inform decision making and includes measurement of outcomes. EBD of healthcare facilities gained prominence in the early 2000s with the publication of the Institute of Medicine’s report Crossing the Quality Chasm, a growing research evidence base, and the initiation of the largest hospital construction program in US history. After a decade of closing hospitals, the US began spending more than $40 billion annually on new healthcare facilities to accommodate shifting demographics, advancing technologies, and competitive pressures. EBD is a multistep process that includes (1) framing of goals and models, (2) incorporation of healthcare facility guidelines, (3) planning and design, and (4) operations (Figure 1). These are in turn affected by the economic and professional culture in which decisions are made: the evidence base, the greater visibility and pay for performance that comes from the “quality revolution,” best practices or examples, and shrinking reimbursement margins in a competitive environment. Infection prevention plays a key role at each step, as follows. Framing. Specific decisions about guidelines, planning and design, and operations are framed by stakeholders’ understanding of the goals of healthcare design and the models that drive it. Owners, clinicians, patients, regulators, and designers develop a view of “good” healthcare settings: what they should achieve and how to do so. Early models included envisioning hospitals as churches or, more recently, as pristine, white, modern laboratories. In the 2000s, a series of literature reviews highlighted that design and the built environment could improve patient safety, decrease pain, and increase satisfaction. These reviews and the growing focus on patientand family-centered care helped create demand for larger, light-filled, quieter healthcare facilities that provided comfort and positive distractions for patients and families, such as designated family areas in patient rooms, gardens, and water features. Families were provided increased access to patient rooms, including within intensive care units, where there had previously been strict visiting hours. Healthcare workers were provided spaces that better suited their tasks and afforded respite when on break. Several prominent articles emerged suggesting that the return on investment for these design features was achieved in as little as 1–3 years, based on designs that increased market share and decreased length of stay, due in part to decreased infections, reduced falls, and reduced analgesic use. Guidelines. Evidence and expectations are translated to design in part through the process of writing guidelines and standards. These guidelines, such as those promulgated by the Facilities Guidelines Institute (FGI), are often written by volunteer committees of professionals and offer guidance or are adopted as codes in the majority of the states. The Hospital Infection Control Practices Advisory Committee’s