Hospital environments are often thought of as white, stark, sterile, cold, institutional, metallic – anything but welcoming and comfortable. But in recent years, many healthcare facilities have transitioned to friendlier, more hotel-like designs that leave the austere interpretation of the hospital in the past.
But why? Put simply, the goals of hospitals have shifted and broadened. In the 19th and early 20th centuries, hospitals were solely focused on patient survival with little or no attention to patient comfort. More recently, better science, knowledge, and technology have guided hospitals to focus more on the quality of patient care, which has been proven to reduce mortality rates.
The Hospital as Part of the Community
As hospitals changed from places of illness and death to places of treatment and recovery, patient care improved.
Hospitals in the Mid-to-Late 19th Century
In 1869, a plea for support for a new Presbyterian hospital in New York City noted that other communities – Jewish, Catholic, German, and Episcopalian – had founded hospitals specifically for their own people.
The Presbyterians did not yet have a hospital and were left with home care from family members or physicians making house calls. Hospitals were charities and provided free or low-cost care to the poor. These hospitals officially admitted any patient, regardless of creed, race, or ethnicity, but their services were designed specifically for the needs of their communities.
Hospital facilities were modeled after the standardized pavilion-ward design developed by Florence Nightingale which focused on making hospitals a place for cure and recovery instead of a place to stay sick and eventually expire. By the late 19th century, hospitals in both urban and rural areas had adopted this model, allowing for hygienic materials, large open wards, and some support spaces.
The guidelines for pavilion-ward hospitals required that they be located away from bustling cities and the communities they served. In Manhattan, for example, that meant hospitals were located about an hour’s ride by horse and carriage from the majority of the population. For patients with severe injuries or emergencies, the time it took to get to the hospital could’ve proven deadly. Few hospitals were located in the center of their community.
Ultimately, the distance of a hospital from its community affected the patient base and the quality of the medical service. Remote hospitals were not as busy, leading to doctors becoming bored and serving nonurgent cases. Eventually, hospital directors increased free services, established outpatient clinics, and added ambulance services enabling patients to get to the hospitals safer and more quickly. By the 1890s, about one-third of patients were brought to the hospital from distant neighborhoods by ambulance.
Two types of hospitals emerged. Hospitals within a specific community offered care that was tailored to the surrounding patient populations, and remote hospitals that served a diverse patient base de-emphasized the patients’ social, ethnic, or cultural background, focusing instead on the medicine.
Hospitals in the Early 20th Century
The next big change came in the early 20th century when hospitals evolved to become more collaborative and specialized – medicalized – and expanded services to all classes of patients, rich and poor alike.
Naturally, these transformations required more space and a design that could accommodate the physician and support staff’s needs, including diagnostic, research, therapeutic, treatment, and educational spaces within ward pavilions.
Alongside this focus on the medical team, a socioeconomic hierarchy also developed with private rooms for affluent patients, semiprivate rooms and small wards for middle-class patients, and large wards for poor patients. The cost of care aligned with what the patients could pay, but being able to pay also afforded some patients nicer spaces to heal. In some areas of the country, minorities were put in less attractive rooms or buildings.
In contrast, the urban and smaller rural hospitals that served specific communities remained limited in their medical spaces and technology, but they offered more personalized care.
Following the shift to become medicalized, some hospitals maintained their focus on treating the underserved patient community, usually defined by social, geographic, or economic aspects. New immigrant communities, such as Italian or Hungarian, led to the creation of newly founded hospitals that were located within their population centers and provided free or at-cost care.
As immigrant neighborhoods began to migrate to new locations in the 1920s, hospitals were left with the decision to move with their patient community or offer services to the new population moving in. Some stayed in place, expanding their care to different groups or becoming more medicalized. Others followed their patient base, often changing the services to match the newer – and often improved – economic circumstances.
These hospital trends expanded outside of cities. Medicalized “modern” hospitals became the gold standard in large cities, leading small towns and more rural areas to revamp their existing charitable model hospitals to more modern setups as well.
Hospitals During and After World War II
World War II was a turning point in community hospital history as the need for modern hospitals grew. Very few hospitals were built during the Great Depression and World War II, which left the U.S. facing a shortage of hospital beds with rural areas, small towns, and poor neighborhoods most in need. In response, the Hill-Burton Act was passed in 1946, making federal funds available to construct hospitals in underserved areas and requiring a ratio of 4.5 beds per 1,000 people within the community.
While society was invested in modern hospitals, local cultural concerns, segregation, and other social issues created a barrier for medical services. Some of the newly funded hospitals provided care to the elite or “separate-but-equal” facilities for minority patients.
When segregation in federal facilities was ended in 1964, the design and locations of hospitals made it difficult for them to keep up with the change. The layouts of the hospitals themselves needed to be overhauled to eliminate separation and barriers, and the hospitals’ locations continued to reinforce segregation. Hospitals located in poor and ethnic areas treated more patients who were disadvantaged and minority than affluent and offered subpar care and equipment.
In 1965, as part of the War on Poverty, new legislation and funding were introduced to create community health centers in poor and underserved communities. The design focus shifted from a minimum number of beds and facilities to a minimum standard of care. Many of the new health centers that were created as a result utilized existing buildings, which were repurposed to provide care and treatment to the local community.
Doctors began envisioning hospitals of the future that were connected to a community to provide more personalized care.
Moving from Service-Based Care to a Patient-Centered Environment
When more ill and injured patients began preferring hospitals over home care in the late 1800s, physicians noted higher mortality rates that were linked to infection. This led to a goal of infection control, which took priority over patient comfort in hospitals.
Initially, infection control was administered through measures like reducing the number of patients per room – thereby increasing the room count –installing handwashing sinks and including access to proper ventilation and sunlight to facilitate healing. Later, technology enabled more advanced measures like the installation of HEPA filters, isolation rooms, and private rooms for some patients.
The best example of this practice is Johns Hopkins, which was built in the late 1800s. Of the available plans at the time, the hospital design chosen for Johns Hopkins focused on infection control with patient separation and careful ventilation. This strict focus on sterility was practical but fostered the hospital’s reputation as a stark and uncomfortable environment.
Attention to patient satisfaction wouldn’t come until much later – long after the major shifts that turned embedded community hospitals into medicalized facilities.
No standards for patient care existed until the early 2000s when the Hospital Consumer Assessment of Healthcare Providers and Systems survey was developed and provided to adult inpatients.
Since the survey’s roll-out, several studies have revealed consistent elements that improve patient outcomes and stress levels, shorten lengths of stay, and minimize infections, falls, and medical errors. These include the principles of healing environments – reduced noise, natural light, and the use of color, artwork, and music.
The results of these studies led hospitals to shift from a focus on function to more of a holistic care environment. The research that touted the benefits of sterility and workflow pivoted to quantify how design elements impact patient-centered care.
Balancing Service-Based Care and Patient-Based Care
Hospitals are characterized by organizational principles of segmentation and separation of medical specialties. By segmenting into different units with dedicated staff, systems, and specialties, hospital departments offer the best service in their respective specialties, but they often do so while being siloed from the rest of the facility.
As a result, patients have to go from department to department and doctor to doctor to find a solution to their medical needs. They often must repeat their medical history and symptoms to each department, schedule different exams, and undergo testing in different departments. This is service-based care, which refers to the equipment and teams, not the needs of the patient nor the staff who serve them.
Patient-centered care is a model of healthcare delivery that focuses on the needs and preferences of the patient. In this model, the partnership between the patient and their healthcare provider empowers patients to participate actively in the delivery of services.
Having become a bit of a buzzword, ”patient-centered care” is often misused in how it impacts the planning and design of hospitals and healthcare facilities. There are approaches that truly support this care model, such as providing space for family and friends to be with the patient to promote healing. And on the other hand, there are approaches that feature amenities like branded coffee in the lobby that enhance the visitor’s experience but don’t facilitate healing.
The strategies that improve patient outcomes include:
Patients can be stressed or uncomfortable when they’re thrust into an environment that forces them to relinquish their sense of control, including determining their mealtimes and daily schedules. Giving back some of that control, through comforts such as entertainment, lighting, and temperature choices, alleviates that stress.
Access to information is another key aspect of control and patient-centered care. Medical records that are delivered to in-room monitors allow patients to review diagnostic tests and view educational information to prepare for meetings with their doctor.
Patient-centered care is, as expected, about the patient, but it also includes measures to assist the patient’s support system of family and friends. Depending on the needs of the patient, family and other loved ones may be around often to provide care and emotional support. Patient rooms should allow space and comfortable seating for loved ones to relax, sleep, or work, making it more convenient for them to remain nearby.
This approach involves a lot of cultural sensitivity. American families are often smaller than other cultures, which may have multiple family members and friends involved in caregiving. Patient-centered care allows appropriate ways for families to decompress outside of the room, such as prayer space, play areas for young children, cafes, or resource centers.
There needs to be space for multi-disciplinary teams to work together and share information, both with and without the patient, and eliminate some of the silos of the traditional hospital model. Planning areas are essential for caregiving staff to step away and strategize or decompress.
The evidence-based design approach calls for the development of physical environments that foster healing and support patient-centered care. Daylight, nature views, noise reduction, and wayfinding form the foundation of healing designs.
Additionally, privacy is an integral part of patient-centered care. Hospital designs must consider privacy needs and the regulatory requirements of the Healthcare Information Portability and Accountability Act (HIPAA) as well as the need for better flow and fewer barriers.
Hospital Designs of the Future
Hospitals are the most complex of all building types, both in their physical structure and their competing priorities. From the functional designs that have persisted for centuries to the gradual shift to more inclusive and service-based care, which is now transitioning to patient-based care and healing environments, healthcare architecture has been integral to the transformations.
At Given Design Group, we take an innovative, user-first approach to healthcare design. By striking the ideal balance of function, form, and evidence-based designs, we envision physical spaces that serve patients, support staff, and improve the community.