Abstract: Design and Health · In a nutshell, it is simply good design which does not discrimi-nate, does not single out any one user group (e.g., the disabled), and it follows our

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Abstract: Design and Health

Wolfgang F.E. Preiser

This paper presents a post-occupancy/buildingperformance evaluation framework for case stu-dies on health care facilities, with a focus on thelessons learned, both positive and negative.The author has carried out a number of casestudy evaluations on such facility types asKaiser-Permanente medical office buildings,the Barrett Cancer Center at the University ofCincinnati, and the Primary Pediatric Care cen-ter at Children’s Hospital in Cincinnati, amongothers. The findings and recommendations ofthe above case studies resulted in guidance forretro-fit of existing facilities, as well as pro-gramming input for future similar facilities.Examples of evaluation/programming concepts

Wolfgang F.E. Preiser, Ph.D.

Wolfgang F.E. Preiser, Ph.D., is aProfessor of Architectureat theUniversity of Cincinnati, OH,USA. He has previously taught atthe Universities of New Mexico

andIllinois, Virginia Tech, and Penn State, where hereceived his doctorate. His Masters degrees are fromVirginia Tech and the Technical University ofKarlsruhe, Germany, and his Bachelor’s degree inarchitecture is from the Technical University inVienna, Austria. His research, lecturing and consul-ting work has been extended worldwide. He haspublished 14 books and many chapters and articles ontopics ranging from post-occupancy evaluation to faci-lity programming and universal design, as well asdesign research in general.e has received multipleawards and honors, including a fellowship to theHelsinki University of Technology, Fulbright fellow-ships, a Progressive Architecture Award and aCitation, the EDRA Career Award, and the RieveschlAward for Scholarly and Creative Works at theUniversity of Cincinnati.

that emerged from the above case studies willbe highlighted, and, in reference to the emer-ging design paradigm for the 21st Century, i.e.,universal design, directions for a future resear-ch agenda are outlined.

IntroductionThe field of health care facilities planning, ran-ging in scale from solo practitioners’ medicaloffices to huge, complex hospital campuses, isundergoing continuous change, due to pheno-mena which distinguish it from many othermore mundane building types: budget pressu-res from HMOs; over-capacity and mergers;technological change; staffing patterns; longerthan normal building delivery cycles; and, lastbut not least, consumers demanding higherquality of care and care facilities. Competitionof the marketplace is a driving factor, anddemographic trends, such as ex-migration ofthe population into the suburbs, have resultedin dislocations and closings of central cityhealth care facilities. When offered a choice,the consumer will decide which care provider ismost conveniently located and offers the besthealth care environment.

As Motoko Rich (2002) stated in an articleon “Healthy Hospital Designs”:

“Hospitals, long a bastion of bad design and drearydécor, are finding that improving their layouts andtheir looks can translate into better health for theirpatients.”

The article continued to highlight features ofhospitals that were replacing or updating décorand design, including: softer colors like pastelblues and greens on the walls; warmer, indirectlighting; wider hallways and doors; pullout sofas

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ABSTRACT: DESIGN AND HEALTH

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for visitors; private toilets for each patient; atri-um gardens; local art; access to natural light;decentralized nursing stations with flip-downdesks and computers outside patient rooms forcharting purposes; and, rooms provide erasablewhite boards that patients’ families or staff canmake notes on.

All of the above features are intended to createa healthier atmosphere in hospitals by de-insti-tutionalizing the ambiance, decentralizing nur-sing stations, protecting privacy of patients, andintroducing more “humane” designs, forexample. This trend was introduced more thana decade ago by designing Alzheimer care faci-lities (Calkins, 1991), which recognized the dif-ferent stages of the disease and subsequently,created supportive environments, in correspon-dence with the abilities of the patients. At last,it is gratifying to see that this humanizing trendhas invaded literally all of health care facilitiesdesign. Without it, health care providers willnot be able to compete in the future.

Toward a Building Performance EvaluationFrameworkOn the surface, the above-cited design featuresappear to be primarily visual/ aesthetic in natu-re, while some deal with workflow and efficien-cy, and others with spatial dimensions, privacy,and so on. Health care design, it is argued,extends well beyond these features and shouldbe based on a comprehensive framework forprogramming, designing, and evaluating healthcare facilities. Systematic feedback and feedfor-ward mechanisms are needed to learn from thelessons of the past as to successful and unsuc-cessful health care facilities design, so that theycan be deposited in databases, translated intodesign guidance, and used in future projects.Distilling the lessons learned and capturingsuch data in in-house databases is a growingtrend in leading practices specializing in healthcare facilities design. This approach is also cal-led “knowledge-based design.” An example ofsuch knowledge building is the evaluation of anNBBJ (2003) designed hospital in Iowa , which

was carried out by NBBJ’s programming staff,who coincidentally were trained as registerednurses additional with business degrees. Thisfact is important because it is the thoroughunderstanding of the processes (patient flow;paper flow; materials flow; and others) that areintegral to health care facilities that test evalua-tions are validated. Such evaluations, also calledfacility visits, are usually carried out six monthsto one year after occupancy.

An attempt to develop a framework for BuildingPerformance Evaluation was presented inTime-Saver Standards for Architect DesignData (Preiser and Schramm, 1997), and hasbeen adapted for this paper.

The framework’s distinguishing features are:Each of its six phases has a review loop to ensu-re that the project’s outcomes are in line withintended goals: for example, needs analysis,using facility audits, occurs in strategic plan-ning; once a budget is identified, the projectcommences with the programming phase, follo-wed by the design and construction phases;post-occupancy evaluation, in this framework,is only one of six phases and it occurs after thebuilding is commissioned and occupied. It isdistinct from post-construction evaluation,which typically results in punch/ to do listsprior to the owner accepting the facility; thefinal phase (six), recycling, concludes the lifecycle of a building and, in line with today’s questfor sustainability, may result in adaptive re-useor recycling of building materials.

In carrying out evaluations, the author proposesto apply evolving performance criteria which,from a holistic perspective, will result in “healt-hy designs.” The main categories of perfor-mance criteria can be grouped into three seg-ments and are shown in Figure 2, EvolvingPerformance Criteria.

The implication here is that no health care faci-lity can obtain the seal of approval in terms ofquality, if one or several of the nine categoriesare under performing. Needless to say, these


performance criteria categories have to betranslated and operationalized for the program-ming and design phases of the building deliverycycle. For example, required amounts of spaceare to be specified; light levels and effects needto be identified in both quantitative and qualita-tive ways; safety criteria need to be clarified,such as non-slip surfaces, surface characteristicsfor wheelchair use, characteristics of treads andrisers of stairs, emergency lighting, etc. This isthe task of the programmer, whereas the desig-ner will select the systems and models that willdeliver the required performance. In this con-text, the triad of post-occupancy evaluation,database development and facility program-ming assumes a core role when attempting toimprove the quality of health care facilitiesdesign.

Enter universal design (Preiser and Ostroff,2001), which some have called the new designparadigm for the 21st Century. In a nutshell, itis simply good design which does not discrimi-nate, does not single out any one user group(e.g., the disabled), and it follows our democratic


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principles by providing equal access to and useof not just facilities, but products, interiorarchitecture, urban design, transportationsystems, as well as information technology.

The Seven Principles of Universal Design,devised by the Center for Universal Design(1997) extend the notion of building perfor-mance criteria into usability by most or all peo-ple. If there is any one facility type that thisnew paradigm should be applied to, it is healthcare facilities. Inclusive universal design prin-ciples overlap with the above-mentioned evol-ving performance criteria (Figure 2). Again, asFigure 3 shows, their lofty, rather idealisticprinciples need to be operationalized for appli-cation in actual buildings (see Figure 3).

This can best be accomplished through casestudy evaluations on actual buildings, usinginterpretations of The Seven Principles ofUniversal Design, and the implications and gui-dance that can be developed from them.Obviously, these would vary with the type andscale of health care facility. Accordingly, the




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above-mentioned building performance evaluationframework has been extended into a frameworkfor universal design evaluations (UDEs).Typically, facility visits would be carried outusing interviews, observations, and photographyto ascertain how common-place tasks/activitiesin a given facility type are supported by its designand features. An outline of the steps involved infacility visits is given in Section X below.

Examples of Findings FromCase Study Evaluations

1. Kaiser-Permanente Medical Office Buildingin Longview/Kelso, Washington

This facility was featured in Modern HealthCare , as an award-winning design for a medicaloffice building. The facility visit was carriedout with staff of the Portland, Oregon,Northwest Regional Office of Kaiser-Permanente (Preiser, 1996). Surveys and inter-views of doctors and staff were followed by anon-site visit and walkthrough evaluation.Facility Layout: While the facility rated very

positively on most aspects of performance (fun-ctionality, workflow, aesthetics, etc.), it had one“fatal” flaw: Heart patients had to cover ratherlong distances from the parking lot to themember check-in desk, and the medical careunits, resulting in stress and code calls, i.e., inci-dents where patients’ health and well-being wasendangered. Thus, in the future, it may not be advisable to repeat the single-story layout of the facility, although it is aesthetically very pleasingand its performance overall was excellent.




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directly from the outside and adjacent to themain entry.

2. Kaiser-Permanente Medical Office Building in Mission Viejo, CaliforniaThis facility is located adjacent to Leisureland,which serves primarily senior citizens. Staff ofthe Southern California Regional Office ofKaiser Permanente in Pasadena carried out thefacility visit , which was very similar to casestudy # 1.

Elevators: The two-story facility had only oneelevator. When it was malfunctioning or beingserviced, many of the patients who were elderlyand used assistive devices could not reach theupper floor, thus making certain medicaldepartments inaccessible. A least two elevatorsshould be provided, in the facility, even if thesecond elevator is primarily a service elevator.

Entrance Location: Long distances had to becovered from curbside to the main patient entryof the building. There was no shelter or placeto sit for patients awaiting transportation, thusresulting in discomfort and stress.

Waiting Area: Waiting room seating wasarranged in such a way that many of the seatsfaced away from the registration area, thusintroducing uncertainty and stress in patientswaiting to see their doctor.

Fenestration: Daylight coming through win-dows and skylights was seen to be a positive fea-ture on one hand. On the other, skylights alsoproduced glare on critical signage/wayfindingsystems, which became almost unintelligibledue to the reflections.

Staff Lounge Outdoor Area: Having an outdo-or extension of the staff lounge was seen as astress reducing feature, allowing staff to havelunch and/or gather socially during break peri-ods out of doors.

Overflow Waiting Area: Having an overflowarea with patient seating during times of fluepidemics, for example, was seen to be as anecessary performance aspect. In times likethese, temporary signage would be improvisedand put up to cope with the overload and todirect patients.

Patient Privacy: Privacy was thought to be com-promised and stress caused by one-way mirrorglass in patient exam rooms on the periphery ofthe building. Patients did not know that it wasone-way mirror glass, and people on the outsi-de could not see through, unless they came veryclose to the windows.

Emergency Entrance: The aesthetically verypleasing design prevented emergency vehiclesfrom entering the building with their gurneys



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3. Barrett Cancer Center,University of CincinnatiThe Barrett Cancer Center was programmed anddesigned with very limited input frommedical staff, simply because there was no previouscancer center and organization atthe University of Cincinnati.

Signage and Wayfinding: Finding the facility wasdifficult, partly because there were multiple (six)entrances, two of which connected the Center withadjacent buildings through skywalks and tunnels.Patients were confused and entered through thewrong entrances, such as the ambulance entranceor radiation therapy entrance at the lower level, andsubsequently got very confused and lost. A single,major entrance with a clear street address and adja-cent to parking should have been provided.

Elevator Signage: Elevator signage was very confu-sing, due to elevators opening both in the front andthe rear, and patients not knowing what the frontand the rear was. Elevator buttons should be stack-ed vertically instead of side by side, as it customary.

Staff Lounge: Official policy stipulated that BarrettCancer Center staff utilize the main cafeteria of theUniversity of Cincinnati Hospital and MedicalCenter, approximately 10 minutes walk away, usingtunnels, skywalks and connector corridors.Waiting lines in the hospital cafeteria were verylong. The result was that Barrett Cancer staff didnot have enough time to use it. Instead, they crea-ted improvised staff lounge areas in rooms thatwere dedicated to purposes such as storage, lock-

er/bathroom areas, etc. It was recommended thatone of the entryways to the building (it was notaccessible to the disabled due to staircases), be clo-sed and converted into a staff lounge, which hassince been done.

Color-Coded Signage: In addition to problemswith elevator signage, directional signage in thebuilding was very confusing. It was recommendedthat block diagrams and color-coded signage beutilize, in order to make wayfinding easier.

Staff Back Entrance: The patient exam room areahad no back entrance, which would permit doctorsto leave without being seen by their patients in thepatient waiting area. On one occasion, a patientactually died and had to be removed through thepatient waiting area, a sight which may not instillmuch confidence in waiting patients.

Waiting Area: The waiting area was crisscrossed bya route from the main hospital to the adjacentfamily practice building. It was heavily used bydoctors and staff, as well as service personnel trans-porting materials with hand trucks. This route cutthrough waiting lines of patients trying to registerat the registration desks, thus creating stress. It wasrecommended to route this traffic around the wai-ting area on the periphery of the building and toprovide some enclosure to the seating clusters.This has since been implemented successfully.

Furnishings: Seating individuals in groups shouldprovide choices for patients and accompanyingpersons to suit their needs, such as chairs with andwithout arm rests.

Canopy: A stretch of about 40 feet of rough pave-ment had to be crossed in order to reach the atri-um/main entrance of the cancer center. In incle-ment weather, there was no protection from theelements and a canopy was recommended. Thishas yet to be implemented.

Privacy at Check-in: Acoustic and visual privacyat check-in is very important when patients provi-de health and personal/financial data to theregistering clerk.




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load-bearing and/or pipes coming from theupper floors, could not be moved.

Adaptive Reuse: Because of the above-mentio-ned difficulties, this project was seen to be atemporary solution only until a more ideal,free-standing facility with easy access could bebuilt in the future. This, in fact, has be accom-plished in the interim.

Process Analysis: In a time of staff reductions,changing procedures and technology, as well asprocesses, the way doctors and staff operate, a so-called process analysis is critical. This was carri-ed out by studying the flow of patients, staff anddoctors, as well as paperwork (patient records).This was documented in a process chart which, inturn, lead to the below concept of the “core area.”

Core Area: This area contained all the essenti-al services, such as registration, nurses’ room,doctors’ team room, medication room, etc.Around this core patients would be routed in auni-directional manner, thus avoiding back-tracking or confusion, all the way to the exit,next to which a window was located for futureappointments and payments to be made.

This can be achieved through partitioningpanels between registration cubicles with pati-ent seating.

I.V. Therapy Rooms: These were found to betoo few and too small, and they were occupied bymixed gender patients, thus providing virtually noprivacy for confidential conversations. Seatingfor accompanying persons was extremely limitedfor patients that may have to endure I.V. therapyfor long periods of time. More and private, lar-ger patient rooms were recommended, thusaccommodating accompanying persons better.

Charting Stations in Corridors: These wereinstalled post-facto, and because they infringedon the already narrow escape route and 5-foot-wide corridors, they were basically illegal fromthe fire marshal’s perspective. A better solutionwould have been alcoves with charting stationsserving three-patient exam rooms each, to beused standing or from high stools.

Privacy in Patient Exam Rooms: Both visualand acoustic privacy in exam rooms is of greatconcern. Partitions and walls don’t usually go allthe way up to the ceiling and the drop-in cei-lings permit overhearing of conversations nextdoor. Furthermore, visual privacy can be achi-eved by having the door swing open inwardwith the exam table behind it, thus protectingpatients from being seen by passersby.

4. Primary Pediatric Care Facility,Children’s Hospital, Cincinnati.This facility was housed in the former emer-gency room in the oldest part of Children’sHospital in Cincinnati. It had been reprogram-med and designed a few years earlier to servethe primary pediatric care purposes, with theresult that spaces were dysfunctional, specialrelationships and distances excessive, and theoverall ambience of the environment very insti-tutional and not child-friendly. Furthermore,the facility had very low ceilings (7-1/2 feetclearance in many places), and floor level diffe-rences of six inches in some areas would have tobe ramped. Worst of all, multiple columns, both



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Reduced Travel Distance: Through the processanalysis, core area concept and uni-directionalflow, the travel distances and time for doctorsand staff were reduced by about 50% (compa-red to the original layout), thus saving energy,costs and fatigue.

Modular Design: Patient weigh areas were outin the open and stressful because of lack of pri-vacy. The new patient exam rooms were plan-ned in clusters of five, with one weigh roomeach. Rooms sizes were 8 X 10 feet. Thisarrangement was proposed in light of the factthat the facility would be converted to serve theresearch function of the hospital in the not-too-distant future, and thus could house offices forresearch assistants at that point in time.

ConclusionsAs the above case study examples indicate, feed-back on the performance of a variety of designfeatures, (including operational considerations),can be used to develop criteria for correctingproblems in existing facilities, as well as the pro-gramming and design of future ones. Investingin feedback/feedforward of this type can produ-ce great value to organizations (Preiser, 2002),especially with repetitive types of health carefacility and building programs. In each of thecase studies and conclusions, reference must bemade to universal design. Furthermore, the fin-dings/observations from these studies should beorganized in a prioritized, methodical way, anddeposited in dedicated databases and clearing-houses. As mentioned earlier, the need to ope-rationalize the Principles of Universal Designinto programming and design criteria for across section of health care facility types, suchas: community health clinics; medical officebuilding;: day surgery centers; small, mediumand large size hospitals; laboratories; and, enti-re medical centers. Implied in this are short,medium and long-term research agendas to befunded by governmental and not-for-profitagencies. Examples of such research are regu-larly reported in the Coalition for HealthEnvironments Research (CHER) News (2003).

AcknowledgmentsThe author wishes to acknowledge the excellentcooperation of Kaiser-Permanente, theUniversity of Cincinnati Medical Center, andChildren’s Hospital in Cincinnati, for commis-sioning the above evaluation projects on theirfacilities. Figures 1-4 and 9 were prepared byJay Yocis of the University of CincinnatiPhotographic Services, while Figures 5-8 wereprepared by the author.

ReferencesCalkins, M.P., Design for Dementia. In: Preiser, W.F.E., Vischer, J.C., and White, E.T. (Eds)Design Intervention: Toward a More Humane Architecture.

New York: Van Nostrand Reinhold, 1991.Center for Universal Design, The Principles of UniversalDesign (Version 2.0). Raleigh, N.C., North CarolinaState University, 1997.

CHER Newsletter, Coalition for Health, EnvironmentsResearch (CHER), Tib Tusler, Executive Director.Washington, DC: Spring 2003.

NBBJ (Wisne, S. and Beck, J., authors), Indicative Post-Occupancy Evaluation of Great River Medical Center(GRMC). In: NCARB, Improving BuildingPerformance. Washington, DC, 2003.

Preiser, W.F.E., Continuous Quality ImprovementThrough POE Feedback. Journal of Corporate RealEstate, Vol. 5/pp. 42-56. December, 2002.

Preiser, W.F.E., Feedback, Feedforward and Control:POE to the Rescue. Building Research & Information,Vol. 29, No. 6, ppg. 456-459, 2001.

Preiser, W.F.E. and Ostroff, E. (Eds), Universal DesignHandbook. New York: McGraw-Hill, 2001.

Preiser, W.F.E. and Schramm, U., Building PerformanceEvaluation. In: Watson, D. Crosbie, M.J. and Callendar,J.H. (Eds), Time-Saver Standards: Architectural DigestData. New York: McGraw-Hill, 1997.

Preiser, W.F.E. and Stroppel, D.R., Evaluation, Reprogram-ming and Re-Design of Redundant Space for Children’sHospital in Cincinnati. In: Proceedings of the EUROFM/IFMA Conference. Barcelona, Spain, May 5-7, 1996.

Rich, M., Healthy Hospital Designs. Wall Street Journal, November 27, 2002, p. B1.


Abstract: Design and Health · In a nutshell, it is simply good design which does not discrimi-nate, does not single out any one user group (e.g., the disabled), and it follows our

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