An increasing volume of research shows that the physical environment in which patients are cared for and in which caregivers work has a measurable impact on them. It is estimated that more than 1,000 research studies illustrate how healthcare design can improve patient care, enhance medical outcomes, and reduce medical errors and waste. As a result, the use of this research in the design of healthcare environments is sweeping the field. The process, referred to as evidence-based design (EBD), calls for design decisions about the built environment to be based on credible research to achieve the best possible outcomes, according to the Center for Health Design.
Today's hospital executives are embracing EBD principles as a guide to help them do more with less. They have a financial responsibility to ensure that the decisions being made about their capital investments achieve a number of important objectives:
- Improve patient and staff safety
- Reduce medical errors
- Reduce patient and staff stress
- Speed patient healing and improve patient outcomes
- Improve the patient and family experience
- Improve staff effectiveness and satisfaction
- Positively impact the bottom line
What they have discovered is that evidence-based design supports the link between the physical environment and the goals listed above for both new construction and the renovation of existing facilities.
"As hospital leaders continue to seek ways to improve quality and reduce errors, it is critical that they look around their own physical environment with the goal of ensuring the hospital contributes to, rather than impedes, the process of healing," writes Dr. Carolyn Clancy, U.S. director of the Agency for Healthcare Research and Quality, in the January/February 2008 issue of the American Journal of Medical Quality.
This change in attitude has encouraged significant changes in the design of healthcare environments. Today, a multidisciplinary team first identifies the project's mission, goals and objectives, and then blends available research with practical knowledge to create a meaningful and financially sound design and construction plan. The team then examines how the desired evidence-based design objectives might impact design decisions regarding the built environment—from programming and planning down to the selection of finishes and furnishings.
Because evidence-based design is so ubiquitous, it's critical that the client support the process. Additionally, the project team should include professionals that represent all issues relating to cost, aesthetics and performance from the beginning of the project. For example, today's most successful project teams not only include hospital leadership, architects and interior designers, but also physicians, nurses, administrators, facility staff, patient and family representatives, as well as infection control and maintenance staff.
One of the biggest obstacles in incorporating evidence-based design principles is that the process may add upfront capital costs. However, when evaluated over the long-term, EBD solutions can offer an advantageous return on investment, sometimes paying for themselves within a year or two by improving service efficiency, improving staff satisfaction and retention, increasing patient safety and satisfaction, and increasing a hospital's market share.
Flooring is an especially important design element within the healthcare environment. Not only is it necessarily found in all spaces, but the type of flooring specified greatly influences the outcome of each space.
For example, luxury vinyl tile (LVT) is increasingly prevalent in healthcare environments such as hospitals, doctors' offices and clinics because of its proven performance, ease of maintenance and less institutional-like feel. Not only does it afford a wide array of high-end design options (from vibrant colors to natural earth tones, including wood species, stone or ceramic visuals), but it's also easy to maintain and install. A durable, abrasive-resistant wear layer reduces the chemicals and labor needed for routine maintenance while also preventing staining and damage from medically used chemicals. LVT lends itself well to the hospitality-like environments many hospitals are currently seeking.
Other popular choices for flooring in healthcare environments include rubber and solid vinyl. Rubber flooring manufacturers have expanded their product lines over the years, and designers can now choose from a wide range of texture and color combinations. It provides a safe and cushioned surface, and is dimensionally stable with a homogenous construction that is naturally resistant to damage from gouges and scuffs.
Solid vinyl tile is another attractive option. Not only does it have a built-in antimicrobial barrier to control bacteria and fungi, but it also comes in a variety of aesthetic options to complement many decors. Its maintenance is also less labor intensive.
So what should designers do when evaluating floor covering options? By examining how flooring can contribute to the desired evidence-based outcomes, they can more easily identify the best design intervention. The following case studies illustrate how two different types of flooring—rubber and solid vinyl—contributed to varying EBD principles in healthcare environments.
case study: lafayette general medical center, lafayette, la.
Rubber flooring was initially specified for a new 25-bed neonatal intensive care unit (NICU) at Lafayette General Medical Center, but when initial pricing showed that the project was coming in over budget, the flooring came under consideration as a possible line item cut.
"Flooring is a big issue for NICUs," says Marie Lukaszeski, AAHID, IIDA, project designer. "It's a challenge to get inside a NICU for a terminal clean. A floor that requires waxing multiplies this challenge, and there's an odor associated with stripping and waxing floors that you just can't have in a NICU, which means all the babies need to be moved somewhere else during waxing and drying, for three or four days at least four times a year. Hospital staffs often complain that the chemicals involved give them headaches."
In the end, Lukaszeski was able to convince hospital executives that the rubber flooring needed to stay because of its many operational benefits as well as from health and safety standpoints. In fact, after the completion of the NICU project, Lukaszeski was selected to design a $70 million renovation of Lafayette's 10-story hospital, including a pediatric emergency room area. A combination of rubber sheet goods and tiles were used in corridors, patient rooms, patient restrooms, nurses' stations and linen closets.
The rubber flooring at Lafayette General Medical Center contributed to a variety of evidence-based design principles.
- Reduced patient falls and injuries
Rubber flooring offers excellent slip resistance properties, exceeding ADA recommendations for slip resistance on flat surfaces. Raised and textured patterns allow dirt and water to drain off the walking surface, increasing traction and slip resistance. Low profile versions are ideal for areas with small-wheeled traffic. - Reduced risk of hospital-acquired infections
Rubber tile has a natural resistance to bacteria and fungi when tested in accordance with ASTM G 21. Some rubber tiles also meet chemical resistance specifications in accordance with ASTM F 925. Seamless installations meet strict hygiene requirements. In addition, antimicrobial agents can be added to adhesives used for installation to protect against mold and bacteria. Sheet products require rubber welds to create a monolithic floor, keeping fluids and contamination from getting beneath the flooring and coves. In rubber tile installations, butt joints form a tight seal that doesn't require further treatment. - Reduced patient stress through environmental noise control
Rubber flooring absorbs ambient noise and reduces the sounds of rolling carts and footsteps to create a more peaceful environment. This is especially important in a NICU environment because premature infants are particularly susceptible to loud noise, due to sensitive cochleae and immature central nervous systems. - Create a positive work environment
Rubber flooring provides additional cushion underfoot. This reduces leg and back fatigue, thus increasing the comfort of caregiver staff who spend most of their work day on their feet. - Positive influence on healing
A wide array of texture and color combinations enhances a variety of décor themes and styles. Organic patterns help hide stains caused by spills of common medical chemicals, as well as scuff marks, helping to prevent interiors from looking worn or tired. - Environmental advantages
Many rubber tiles are constructed of as much as 90 percent post-consumer waste when manufactured using post-consumer recycled tires. Also, rubber tiles are partially compounded using natural rubber (renewable resources from the rubber tree). No-wax rubber flooring does not put harmful refinishing chemicals back into the environment and requires less water to maintain. Rubber's environmentally friendly characteristics help meet some of the credit points for Leadership in Energy and Environmental Design (LEED) certification, which means it's not only good for the environment, but it's good for business as well. - Improved indoor environmental quality
Air quality is a major concern in healthcare environments and may be affected by offgassing from the flooring material itself, as well as from surface coatings and materials like wax and strippers. The low-maintenance nature of rubber flooring also helps specifiers minimize environmental pitfalls. Rubber tile contains no PVCs and will not emit vinyl chloride, plasticizers, asbestos or CFCs. Low volatile organic compound (VOC), water-based spray adhesives also do not contribute to offgassing, and oftentimes require up to 80 percent less adhesive on jobs. Spray adhesives also allow for immediate foot traffic after rolling. Low emissions and quicker turnaround times mean patients can be moved back into renovated units faster. Sprayable adhesives offer the same quality adherence as do traditional alternatives; when a sprinkler malfunctioned at Lafayette General, the rubber flooring which had been applied with spray adhesive survived the minor flood and never once lost its grip. - Improved life-cycle costs and benefits
Rubber flooring lasts longer (a 20- to 30-year life-span is common) and because it requires no waxing, costly and time-consuming efforts are not expended for its maintenance and upkeep. This longer life-cycle also dramatically reduces the costs and inconvenience of replacement—especially critical in a hospital, which operates 24/7/365. Despite a slightly higher upfront cost, the project team estimated that by choosing the rubber flooring for the 200,000-square-foot renovation project, the hospital will conservatively save $150,000 on maintenance in the first year alone. - Reduced stress through ease of wayfinding
Rubber tiles can be cut by water jet to create unlimited custom graphic and design options that can be used for wayfinding techniques, which allow patients and visitors to navigate easily and without confusion through the hospital.
case study: somerset medical center, somerset, n.j.
Solid vinyl tile was chosen for this state-of-the-art hospital addition that included a 35-bed medical/surgical unit designed with hotel-like amenities. The patient rooms in the 25-bed oncology unit were designed to be as comforting and nurturing as patients' bedrooms are at home. Designers from Array especially liked vinyl's design versatility to help break up a very long and straight eight-foot-wide corridor, as well as delineate nursing stations and other public destinations. Additionally, vinyl contributed to a number of evidence-based design outcomes.
- Reduced patient falls and injuries
Solid vinyl flooring offers excellent slip resistance properties, exceeding ADA recommendations for slip resistance on flat surfaces. - Reduced risk of hospital-acquired infections
Solid vinyl floors have a built-in antimicrobial barrier that helps control bacteria and fungi. In addition, solid vinyl floors can be seamlessly installed with vinyl welding beads to seal out germs and moisture, which is especially important for clean room installations or other spaces that have strict hygiene requirements. - Reduced patient stress through environmental noise control
Vinyl floors can be specified with a cushion backing that reduces sound transmission. Additional underlays or acoustic backings can also be added to the top wear layer to further reduce the sound impact. - Positive influence on healing
A wide array of texture and color combinations enhances a variety of décor themes and styles. Vinyl can be transformed to closely imitate a variety of natural materials, including wood planks, stone, slate, tile, glass and several other visuals printed on photographic print film. Some designs are so realistic that it's difficult to tell the difference. This versatility in design promotes a nurturing home-like aesthetic that is highly prevalent in today's healthcare spaces. - Improved indoor environmental quality
Solid vinyl floors require no waxing, which eliminates the concerns associated with the emissions from these chemicals. Additionally, sprayable adhesives are available for vinyl floors that are water-based and feature low amounts of VOCs, minimizing offgassing. Requiring up to 80 percent less adhesive on jobs, these spray adhesives allow for immediate foot traffic after rolling. This is especially ideal for renovation projects because low emissions and quicker turnaround times mean patients can be moved back into units faster. Vinyl's flexibility allows for coved corner joints onto walls, which prohibits dust from collecting at the joints where the walls and floor intersect. This helps meet strict hygiene requirements. - Improved life-cycle costs and benefits
Solid vinyl flooring is almost impervious to water and the unavoidable spills and stains, and is easily buffed to a shine. And because no waxing is required, maintenance costs are substantially less than other hard flooring options. Solid vinyl flooring is resilient, allowing it to "bounce back" against heavy weight from rolling carts and gurneys, as well as prolonged traffic. Its dense composition meets ASTM F 1700 and makes floor maintenance easier. In fact, solid vinyl's wear layer on premium wood plank withstands indentations, stains and chemical damage, and exceeds commercial specifications by 75 percent. This improves the product's long-term life-cycle benefits. - Reduced stress through ease of wayfinding
Solid vinyl tiles configured in custom graphic and design options can be used for wayfinding techniques, which allow patients and visitors to navigate easily and without confusion through the hospital.
greening the healthcare environment
The importance of flooring in a healthcare environment made it an important issue to research from the early days of the green design movement. Flooring manufacturers were proactive in helping design professionals understand the environmental implications of the products available. Manufacturers oftentimes worked side-by-side with architects and designers to improve products' sustainable design performance. Today, an increasing body of evidence illustrates how flooring can support both evidence-based design and green building criteria.
FloorScore, developed by the Resilient Floor Covering Institute (RFCI) in conjunction with Scientific Certification Systems (SCS), tests and certifies hard surface flooring and flooring adhesive products for compliance with rigorous indoor air quality emissions requirements. Individual VOCs are evaluated using health-based specifications. Products bearing the FloorScore label meet the indoor air emissions criteria of Collaborative for High Performance Schools (CHPS), Leadership in Energy and Environmental Design (LEED) Green Building Rating System and the Green Guide for Health Care (GGHC). Under the FloorScore program, designers can be confident that the products they are specifying meet certification requirements.
The ecoScorecard program is another tool for architects and designers that allows them to more easily find and spec products and materials by their environmental impact. Using a system of embedded algorithms, the free, web-based ecoScorecard lets manufacturers catalogue their green products and provides designers with the ability to search and evaluate each product based on its environmental characteristics. The program does the calculations necessary for five rating systems; LEED, GGHC Labs, CHPS, National Association of Home Builders (NAHB) and third-party certifications; it also produces the product documentation necessary for inclusion in the submission process.
Evidence-based design principles were an important factor in the development of the newly-released LEED for Healthcare rating system. "Research has shown that when we are treated and heal in a green healthcare facility—one that has a healthy indoor environmental quality and connects us to the outdoors—we heal faster, have shorter hospital stays and fewer return visits," says Scot Horst, senior vice president of LEED for the U.S. Green Building Council. "LEED for Healthcare is now six years in the making, addressing the healthcare industry's unique green building needs."
The rating system guides the design and construction of both new buildings and major renovations of existing buildings, and can be applied to inpatient, outpatient and licensed long-term care facilities, medical offices, assisted living facilities, and medical education and research centers. LEED for Healthcare was developed to meet the unique needs of this building type and its patient and staff populations, including sensitivity to chemicals and pollutants, as well as patient and staff health and well-being.
