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Forum -- Hälsofrämjande vårdmiljöer Skånes universitetssjukhus, Malmö. Evidence-based design: Recent developments. Roger S. Ulrich, Ph.D. Center for Healthcare Building Research Department of Architecture Chalmers University of Technology. Design/research questions: .

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Forum -- Hälsofrämjande vårdmiljöer Skånes universitetssjukhus, Malmö

Evidence-based design:

Recent developments

Roger S. Ulrich, Ph.D.

Center for Healthcare Building Research

Department of Architecture

Chalmers University of Technology


Design/research questions:

  • Is the ‘attractiveness’ of health- care interior spaces important?
  • Does attractiveness affect patient outcomes?
background theory and research why room attractiveness should matter
BACKGROUND THEORY and RESEARCH: Why room attractiveness should matter

1.The ‘Beautiful Room Effect’(Maslow and Mintz, 1956)

  • Study methods: Participants (who were not patients) were assigned to either a ‘beautiful’ room (well-decorated and well-lit), average room, or ‘ugly’ room (undecorated walls and poor lighting)
  • While seated in the rooms, participants were asked to make judgments or evaluations about several persons shown in photos

‘Beautiful Room Effect’ -- continued(Maslow and Mintz, 1956)

  • Findings: Participants in the beautiful room gave the most positive evaluations of the persons in the photos
  • Participants in the ugly room gave the most negative, unfavorable judgments

Implication: An attractive room may produce a more positive emotional state and judgment disposition that generalizes to more favorable perceptions of other persons in the space


‘Beautiful Room Effect’ -- continued

  • Consistent with Maslow and Mintz’ early research, studies have found that attractive patient rooms and clinic waiting rooms increase patients’ perceived quality of healthcare staff
    • For example, doctors are judged to have more skill and knowledge when patients are examined in attractive rooms, compared to when the same doctors give similar treatment in unattractive rooms (Swan et al., 2003; Becker and Douglass, 2008; Becker et al., 2008)
background theory and research why room attractiveness should matter6
BACKGROUND THEORY and RESEARCH: Why room attractiveness should matter

2.Service Quality Theory and Research (Parasuraman et al., 1985; Berry and Bendapudi, 2003)

  • Much research has shown that patients base their judgments of satisfaction and quality on information which they can personally perceive and evaluate, and which provides them with concrete, meaningful information they understand
  • provides tangible and meaningful evidence (Berry and Bendapudi, 2003)

Service Quality Theory and Research -- continued --

  • But healthcare is a highly complex and technical service. Many aspects remain unknown to patients or are only vaguely perceived and are not understandable.
  • These aspects have little or no impact on satisfaction or quality judgments
    • Examples of abstract or unknowable factors include the quality of care processes, and levels of clinician training and experience

Service Quality Theory and Research -- continued

  • Compared to abstract or unknowable technical aspects, environmental factorssuch as noise or privacy are easy to perceive and understand, and provide meaningful information that strongly impacts patient satisfaction
  • Other perceivable and meaningful information comes from staff behavior

Service Quality Theory and Research -- continued

  • The attractiveness or comfort of a hospital waiting room, for example, is directly perceived and understandable evidence, and therefore can be expected to affect patient satisfaction

Research findings: Consistent with service quality theory, a growing amount of research has shown that attractive waiting rooms increase patients’ overall satisfaction with care

Study:Effects of Waiting Room Comfort on Overall Satisfaction with Care(Hospital and Family Medicine Clinics)

From: K. M. Leddy (2005)

Press Ganey Associates

Based on data from 1,201,559 patients treated at 4,392 medical practice offices throughout U.S. (January - December, 2004)


Satisfaction with Care Experience by Amount of Time Spent in Waiting Room and Comfort of Clinic Waiting Room


Overall Satisfaction

Overall Satisfaction








Length of Wait (minutes)

R. Ulrich. Data source: Press Ganey, 2005


Providence St. Vincent Hospital Portland, Oregon

Emergency Department Waiting Room - with garden views to reduce stress, aggression, increase satisfaction

Design: ZGF and Robert Murase

more research needed on attractiveness
More research needed on attractiveness
  • Research has not yet clearly identified what attractiveness is
    • Some studies use terms such as “comfort” and “attractiveness” interchangeably with defining them
  • Research has not yet identified for designers and healthcare managers the most important and cost-effective design factors for achieving attractiveness
  • Other research suggests that many architects judge attractiveness differently than the public
given limits in current research what design factors may affect attractiveness
Given limits in current research, what design factors may affect attractiveness?
  • Lighting quality, including daylight
  • Presence/absence of appealing art or wall decoration
  • Comfort and quality of seating, and whether chairs are movable
  • Acoustics (probably)
  • Crowding (probably)
  • Other (very likely)
attractiveness conclusions
Attractiveness: conclusions
  • Attractiveness remains a vague concept, but research suggests it is important to patients and families (and staff)
  • Whatever attractiveness is, research implies it should be given considerable attention or priority
  • Many architects perceive attractiveness differently than the public, indicating the need for designers to listen carefully to patients and other groups

Part 2:

Comments on the report from HTA-centrum (Sahlgrenska) titled:

“Enklerum eller flerbäddsrum på sjukhusavdelning”


Research examples:

Increased infection risk from havingone roommate with a positive culture

  • Moore et al (2008): exposure to one room-mate with MRSAincreased risk by 20 times (Infection Control & Hospital Epidemiology)
  • McFarland et al (1989): C. difficilerisk increased by 73% (New England J. Medicine)
  • Chang and Nelson (2000): C. difficilerisk increased by 86% (Clinical Infectious Diseases)
  • Byers et al (2001): VRErisk increased by 149% (Infection Control & Hosp. Epidemiology)

Implication: providing single rooms for patients substantially reduces risk of acquiring an infection


(Teltsch et al. 2011, Archives of Internal Medicine)

  • Study site: 25-bed intensive care unit before and after renovation to all single rooms (Well-controlled, rigorous research design.)
  • Main findings:
    • C. difficiledecreased 43%
    • MRSA decreased 47%
    • Overall average length of stay decreased 10% (all patients in intensive care)

STUDY: Converting an intensive care unit to single rooms substantially reduces infection


(Hamel, Zoutman, and O’Callaghan, 2010)

STUDY: Exposure to hospital roommates as a risk factor for healthcare-associated infection

  • Study population: 94,784 adult hospital patients in Canada
  • Main findings:
    • The number of roommate exposures per day was significantly and strongly associated with MRSA, VRE, andC. difficileinfection
    • Having one roommate increased infection risk by 11%, even if the roommate was not infected.Exposure to 6 roommates increased risk by87%.

Examples of studies reporting that single rooms reduce MRSA, VRE, and/or C. difficile

Ben-Abraham, Keller, Szold, Vardi, Weinberg, Barzilay, et al. (2002). Journal of Critical Care.

Berild, D., Smaabrekke, L., Halvorsen, D. S., Lelek, M., Stahlsberg, E. M. & Ringertz, S. H. (2003). Journal of Hospital Infection.

Byers, Anglim, Anneski, Teresa, Gold, & Durbin (2001). Infection Control and Hospital Epidemiology.

Cheng, Tai, Chan, Lau, Chan, et al. (2010). BMC Infectious Diseases.

Gastmeier, Schwab, Geffers & Ruden (2004). Infection Control and Hospital Epidemiology.

Jernigan, Titus, Groschel, Getchell-White, & Farr (1996). American Journal of Epidemiology.

Wigglesworth & Wilcox (2006). Journal of Hospital Infection.

Zhou et al. (2008). Infection Control and Hospital Epidemiology.

single rooms enhance family presence staff communication and privacy
Single Rooms Enhance Family Presence, Staff Communication, and Privacy

(Kaldenburg, 1999; Chaudhury et al., 2003)


Single-bed vs. Multi-bed Patient Rooms (Ulrich, 2004)



Healthcare associated infections

Medical errors


Staff observation of patients

Staff/patient communication

Confidentiality of information

Presence of family

Patient privacy and dignity

Avoid mixed-sex accommodation

End-of-life with dignity


Sleep quality



Single-bed vs. Multi-bed Patient Rooms (Ulrich, 2004)




Patient stress

Daylight exposure

Patient satisfaction


Staff satisfaction

Staff work effectiveness

Reducing room transfers

Adapt to handle high acuity

Managing bed availability

Initial construction costs

Operations and whole life costs


Many patients (up to 50%) like having roommates

  • Single rooms prevent visual observation of patients, therefore worsening safety
  • Single rooms require much higher nurse staffing levels (41%), greatly increasing costs
  • Widely held beliefs obstructing adoption of single-bed rooms
    • Beliefs are not evidence-based
    • Published evidence contradicts these beliefs

Dr. Charles McLauglan in Hospital Doctor(February 2006)Director of professional standards, Royal College of Anaesthetists

“With single rooms, we need state-of-the-art monitoring equipment because we have not got line-of-sight for the nursing staff.”


Do patients like having roommates?

  • Studies show that 85%-90% of the time roommates are source of stress not positive social support
    • Stress examples: roommate who is unfriendly or seriously ill
    • Roommates generate much noise and reduce privacy
    • Roommate incompatibility causes many room transfers

Preferences for Multi-bed vs Single Rooms Findings from Two UK Studies




Patients with experience with both multi-bed and single rooms

Adults with little or no experience with single rooms

source: NHS Estates & BMRB, 2002

source: Lawson and Phiri, 2003


Overall Care Satisfaction – Female Patients

(after Kaldenburg, 1999-2003)

With roommate Single room

key policy changes affecting financial outcomes of uk public nhs hospitals
Key Policy Changes Affecting Financial Outcomes of UK Public (NHS) Hospitals
  • Patient Choice
  • Patients can choose where to go for care. Revenues flow with patients.
  • Two sources of competition: NHS and private providers
  • Payment by results (by quality)
    • Costs of infections, falls, errors, longer stays paid to greater extent by trusts

Case study:

Effects of patient choice on public and private hospital revenues in one UK health region (2005)



Financial Impact of Patient Choice in the Birmingham and Black Country Strategic Health Authority (SHA)

MORI Social Research Institute, 2005

Report prepared for U.K. National Health Services (NHS)


U.K. Public Awareness of Patient Choice

(in 2004)

How much have you heard about the patient choice initiative?

A great deal


A fair amount



Just a little


Nothing at all


How much do you think the private sector is better than the NHS in these areas of activity?

source: 1,201 residents,MORI Birmingham SHA study, 2005

Single rooms improve all these outcomes

comparing persons easy to persuade vs hard to persuade to choose a private sector hospital
Comparing persons ‘easy to persuade’ vs ‘hard to persuade’ to choose a private sector hospital
  • Private room is important:
    • 79% of easy to persuade
    • 47% of hard to persuade
  • Flexibility about visiting important:
    • 91% of easy to persuade
    • 77% of hard to persuade

Private sector better


NHS better

Flexibility about visiting

Nice environment

Based on the survey findings, the private sector was estimated to make £35 million in revenues the first year from patient choice in the Birmingham and Black Country area

(source: Independent Healthcare Forum)

> SEK 600,000,000 at 2005 currency rates

The findings are ‘a major wake-up call for the NHS’
  • Both primary care facilities and hospitals ‘need to take implications of choice on board immediately’

-- Peter Pilsbury, Director of Strategy, Birmingham/Black Country SHA (in HSJ)

major healthcare trends in europe n america and australia
Major Healthcare Trends in Europe, N. America, and Australia
  • Increasingly serious challenges from antibiotic resistant infections
  • Sicker patients (rising acuity)
  • Increasing importance of patient privacy and dignity
  • Patient choice and satisfaction
  • Payment by results (by quality)
  • More and more emphasis on patient safety

Everywhere: strong pressures to reduce or control costs but increase quality


Concerning the report from HTA-centrum titled: “Enklerum eler flerbäddsrum på sjukhusavdelning”

  • My opinion is that the report is narrow, does not use appropriate criteria for evaluating research quality, omits relevant and strong published studies, misinterprets some information, and does not adequately address certain outcomes and healthcare issues of growing and major importance internationally.
  • The HTA-centrum report is a gift to the private sector, and to those who may believe that many hospitals should be private.
what to do when a hospital has many multi bed rooms
What To Do When A Hospital Has Many Multi-Bed Rooms
  • Upgrade ceiling tiles to reduce noise and voice travel, increase privacy
    • Eliminate noise sources
  • Convert a patient room to a refuge for privacy and good communication
  • Consider installing additional free-standing handwashing basins
  • Provide comfortable family waiting areas