The Hospital Built Environment: What Role Might Funders of Health Services Research Play?
Chapter 8. Where are the Gaps in Current Research and Areas for Future Focus
The literature and the majority of our key informants highlighted considerable gaps and areas for future focus in the field of hospital design and construction, reflecting in part the early stages of development of this field. These gaps are summarized below.
Patient Privacy and Confidentiality
Physicians and nurses frequently breach patient confidentiality and privacy by talking in public spaces where they are overheard by other patients and staff.78 A separate study conducted at a university-based hospital emergency room showed that 100 percent of physicians and hospital staff breached confidentiality while treating patients.79 However, little research has been conducted to date on privacy and confidentiality breaches associated with the physical environment, such as single versus double rooms, waiting rooms and nurses' stations.
There is also a need for more research that investigates how the quality of communication and information from patients to physicians and nurses is affected by the physical environment.8 Additional research is needed to determine how wayfinding can be changed to reduce stress on patients and their families.
Patient Safety and Environmental Factors
Given the widespread emphasis on patient safety and medication errors in particular, there is insufficient research that examines the relationship between environmental factors (such as lighting, distractions, and interruptions) and errors in prescribing or dispensing medications. Consistent with the findings of the review by Zimring and Ulrich, we found few studies examining whether or not environmental factors affect errors in prescribing or dispensing medications. The findings of the limited available research suggest there is a relationship between environmental factors and medication errors.69,70
Additional research is needed on evidence-based fall prevention strategies, as patient falls remain a serious safety problem in hospitals. This includes better quantitative assessments of the effectiveness of alternative strategies, such as establishing decentralized nurses' stations, to increase observation and improve assistance to patients attempting to get out of bed.
Much research demonstrates the importance of frequent hand washing to reduce transmission of infection among health care staff, patients and visitors. However, less research has focused on defining accessible locations for hand-cleaning stations on the basis of staff movement patterns and paths, interactions with patients and work processes.
Staff Health, Safety, and Performance
Another gap in research is the extent to which the built environment affects workplace efficiency and staff health, safety and performance. Currently, there is limited research on environmental interventions for reducing staff stress and fatigue. While there is considerable research on the impact on patients of efforts to reduce noise, few studies examine this issue for hospital staff. There is also a lack of research on how design elements such as access to nature and sunlight during the day, affect staff stress, turnover and efficiency.
Summary of Areas for Future Focus. As discussed, there are considerable gaps in the evidence base to support beneficial hospital design and construction. When asked to recommend strategies to help close these gaps, several interviewees suggested focusing initially on a limited number of specialized hospital units, such as intensive care units, bronchoscopy units, and MRI suites. These settings are well suited for pre- and post-implementation evaluation of outcomes and as learning laboratories and platforms for wider replication to other hospital units.
A useful road map depicting areas for future focus in the hospital built environment is the scorecard system developed by Zimring and presented at a 2004 national conference entitled "Designing the 21st Century Hospital: Serving Patients and Staff," that was sponsored by The Robert Wood Johnson Foundation.
The scorecard system summarizes the strength of the research in areas of the built environment that affect staff and patients, as derived from the literature review by Zimring and Ulrich.8 The strength of research in each area is ranked from one star ("little research has been conducted") to five stars ("a great deal of research has been conducted"). Figure 2 summarizes the current strength of evidence-based research related to factors that influence the effectiveness, performance and satisfaction levels of hospital staff. These findings suggest that priority areas for future investigation include the influence of the built environment on the overlapping areas of reducing staff turnover and fatigue and improving job satisfaction.
As summarized in Figure 3, which is consistent with our findings, Zimring and Ulrich conclude that the strength of research in different areas of improving patient safety and quality of care is mixed. For example, much research has been conducted to better understand linkages between the built environment and nosocomial infection rates. In contrast, little research has focused on the role of evidence-based design in increasing handwashing compliance by staff, an important factor in reducing infection rates, and improving the quality of communication among hospital staff, patients and their families.
Chapter 9. What are Appropriate Future Roles for Funders in Advancing Evidence-based Hospital Design and Architecture?
The United States is embarking on one of the largest hospital building booms in history. Anticipated to be a decade-long undertaking, this is being done to replace aging hospitals, incorporate new technologies and medical practices and respond to external market factors, including America's growing and aging population. This new wave of hospitals likely is to remain operational for several decades.
In light of the hospital building boom, many informants suggested that immediate emphasis should be on organizing and disseminating existing research. Interviewees observed that the present may represent a unique opportunity to "unfreeze" existing barriers and create opportunities to raise the visibility of the evidence-based hospital built environment in ways that capture the attention of architects, designers, hospital executives, policymakers, thought leaders, and the American public.
Based on what was learned from key informant interviews, there are two main potential roles for funders in developing and transferring knowledge about the hospital built environment. These include:
- Funding empirical research.
- Disseminating evidence-based research output to decisionmakers.
Funding Empirical Research
A commonly held view among our interviewees is that funders could help frame the value of evidence-based hospital design in ways that capture attention and promote change in the industry by supporting carefully designed research and willing researchers. This includes identifying and seeding research topics, either individually or in clusters, in priority areas. Several informants suggested there is a distinct opportunity for funders to engage in building the business case for evidence-based design and construction by supporting applied research that describes and quantifies return on investment in this area.
Several respondents observed that, in some instances, a critical mass of evidence-based findings may help change the way hospital administrators, regulators and other decisionmakers think about these issues and help shape the direction and speed in which this field evolves. Supporting additional research and consolidating and transferring its findings may accelerate the adoption of best practices in evidence-based design and construction by the greater hospital community.
There also was support to fund research to determine when and under what circumstances evidence-based design can make a difference in safety, outcomes and satisfaction sufficient to justify investment. This includes research to discern the extent to which evidence-based designs that affect the physical structure of hospitals in their entirety directly influence outcomes compared to the extent to which they facilitate and channel productive processes. Informants believe that funding research on these topics is a natural evolution of research being funded that focuses on health care interventions and services.
Transferring Evidence-based Research Output to Decisionmakers
In addition to funding research, virtually all interviewees agreed upon the need to create a meaningful role for researchers to build the field of evidence-based hospital design and construction by increasing stakeholders' understanding and awareness of key issues through the improved sharing of research findings and successful practices and outcomes. Possible dissemination and knowledge transfer roles that were most supported by respondents include:
- Providing or supporting a repository or national clearinghouse for information regarding evidence-based research on the hospital design and construction. Most respondents noted that current research studies and best practices are not well organized and lack effective dissemination strategies, largely because there is no central repository of research and practice regarding the hospital built environment. There is also a perceived need for a national clearinghouse on environmental research that does not have a commercial interest or bias.
- Convening and facilitating events to foster collaboration across stakeholder groups. Interviewees cited a need to connect health care executives, architects and researchers who have insufficient opportunity to interact to share research and project results. Noting a critical need for effective exchange of what is known about the hospital built environment, respondents supported roles in fostering transdisciplinary networking and helping to extend transfer of this body of knowledge to broader audiences.
Almost all respondents commented on the importance of lifting the profile of the field by maximizing availability of research through convening and facilitating conferences, workshops and other knowledge sharing and networking vehicles. A typical comment was that funders could help "spread the word." Specific dissemination approaches to be considered might include:
- Publishing and disseminating case studies of best practices in new-generation hospitals linked to outcomes, to promote wider uptake of evidence-based results and help build the business case for hospital return on investment.
- Sponsoring or co-sponsoring hospital physical environment related conferences and/or workshops that include representatives from major stakeholder groups and include panel discussions and informal networking on specific topics of interest to researchers, hospital administrators, designers and others.
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