Intended for healthcare professionals


Using evidence based design to produce healthier hospital buildings

BMJ 2013; 347 doi: (Published 11 September 2013) Cite this as: BMJ 2013;347:f5417
  1. Diana C Anderson, resident physician1,
  2. D Kirk Hamilton, professor 2
  1. 1Department of Medicine, New York-Presbyterian Hospital, Columbia University Medical Center, New York, USA
  2. 2Department of Architecture, Texas A&M University, Texas, USA
  1. dochitect{at}


Evidence about how architecture affects healthcare staff and patients is increasingly influencing the design of hospitals. Diana Anderson, a qualified architect and a doctor in a major urban tertiary hospital, and Kirk Hamilton, an architect now working in academia after 30 years of practice, provide an international perspective on the issues involved

Hospital design has improved from the dismal, cold, life-sapping environments of the past, which were all too often made up of crowded wards, too many green tiles, pervasive antiseptic odours, and the glare of harsh lighting. Today’s typical hospital, however, is still unlikely to engender warm and pleasant feelings in its users while supporting the complex tasks associated with quality care (box).

In general, patient space in hospitals is given the highest priority, and staff areas are centrally located to allow windows for patients, which means that staff areas often lack natural light. This may be appropriate for patients, but their stays are becoming shorter whereas staff members have to work long hours for years in a low stimulus environment.

Healthcare staff often have to walk long distances between frequently used areas, such as the laboratory, blood bank, and radiology department, and a lack of multidisciplinary spaces mean that impromptu meetings and face to face interactions among clinicians are rare. Corridors also lack electrical outlets for doctors on their daily rounds with computers on wheels, not to mention the absence of surfaces on which to rest coffee cups and papers during these sessions, which often comprise the better part of a clinician’s day.

My experiences of poor hospital design: Diana Anderson

I am a resident physician, and a large part of my hesitation in pursuing advanced clinical training was because of what I considered an intolerable hospital setting. Staff facilities are frequently without windows or art, and I have found myself desperately anticipating the first ray of sunlight after a long shift. Working in environments with constant noise from ventilator and infusion alarms, floor polishers, telephones, pagers, and staff discussions creates an ongoing battle to work effectively, or to hold private, often life changing discussions with patients.

During my initial time working in hospitals I often wondered whether anyone asked the clinicians about their opinions on the design and function of their work environments, and whether it has been recognised that the characteristics of the physical environment can enhance or hinder productivity, and can reduce the stress associated with our work and the condition of our patients.

On my obstetrics rotation as a medical student the call rooms were located several floors above the labour and delivery unit, meaning we often missed deliveries, and so we learnt not to use the suite, and we slept in chairs closer to our patients. On patient units that did not provide space for respite, I found myself retreating to the supply rooms to gain composure during overwhelming moments. As a physician, a licensed architect, and a patient, I believe that many planned spaces are ill suited to their actual use.

Good layout

Proper layout of clinical rooms can promote safety, good communication, and privacy, but many examples of room design are not conducive to the daily practice of the clinician performing bedside examinations and procedures. Although doctors are taught to examine patients from the right side, the position of the exam table in a lot of clinic rooms often prevents this. In addition, even if physician on-call rooms have been initially included in departmental plans, they are often relocated or eliminated.

Hospital buildings should be designed to help decrease medical errors, lengths of stay, hospital acquired infections, and harm to patients and staff, and design elements can help achieve these aims. Private patient rooms have been shown to lower the risk of hospital acquired infections, reduce stress from noise, accommodate families more comfortably, and reduce room transfers, a major cause of medical errors.

Optimal sink design and location promotes hand washing, the single most important element in infection control. Within acute care areas, a lack of consistent design for patient rooms, clean utility areas, and nursing stations means that members of staff have to search for supplies. In contrast, standardisation of supplies and room layouts promotes efficiency, with the potential to reduce medical errors.

New design ideas

Architects are now beginning to incorporate innovative ideas into the design of hospital buildings, such as message boards and pagers to liberate patients from dreary waiting rooms, and they are integrating gardens into clinics and intensive care units.

The ideal hospital should be designed with maximum adaptability and flexibility to accommodate change and provide room for future growth and changes in service delivery. An optimal design may include extensive diagnostics, a multimodality procedure centre, and short stay beds.

Part of the challenge facing the architect is to balance the user’s functional needs with the risks and benefits of capital costs and ongoing operating savings. Developing a narrow floor plate to allow more access to daylight may increase cost because of the additional building perimeter, glazing, and materials it requires, but incorporating evidence based design features, such as windows for natural light, additional sinks for infection control, and single patient rooms, can lead to cost savings by reducing medical errors, nosocomial infections, and patient transfers.

Evidence based design

Architects understand the need to consider staff in a patient centered model. The reason hospital buildings do not often focus on staff requirements is likely to be a result of a lack of understanding of clinicians’ routines and working practices.

Architectural firms are now starting to integrate practice based researchers into their teams to pursue evidence based design, to incorporate evidence to make better design decisions, and to perform outcomes research to contribute to the growing evidence base, but there are still too few opportunities for designers to shadow clinicians and gain a deeper understanding of healthcare delivery. A model for collaboration between fields is needed so that designers can learn from the medical field and vice versa.

Hospital design could be much better, and the specialised design community is ready to collaborate with the clinical community to make it so. Design for patient and family wellbeing has considerable support. We urge clinicians to look at their work environment with new eyes, and to advocate improvements, so that hospitals can shift from being unsupportive settings to become places that enable multidisciplinary interaction, promote staff wellbeing, and enhance the safe and efficient delivery of patient care.

BMJ Careers video

See some examples of good and bad hospital design in a BMJ Careers video:


  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.

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