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In cities across the U.S., hospitals and other health-care buildings are changing in meaningful ways. A patient room today looks very little like one from the 1950s, the essentials—bed, walls, medical equipment—notwithstanding. Gone are the semi-private rooms, “hospital green” paint, bare metal beds and windowless walls that were prevalent not that long ago. In their place? Private rooms with comfortable beds allowing patient-controlled adjustment, soothing wall colors and artwork, sunlight, space for family to visit and stay overnight if needed—and windows with views to parks and gardens.

Are aesthetics or data driving these changes? Today’s hospital room is certainly more pleasant. But are its design changes necessary? The answer, it turns out, is “yes.” Donna Ware, AIA, executive director of planning, design and construction at BJC HealthCare, notes that the environment in which health care takes place isn’t immaterial—for those who are hospitalized and for those who are working to treat them. In fact, she says, when executed with what’s called evidence-based design—using data from credible research in the design process—“a patient’s environment enhances the healing process.”

Case in point: the 660,000-square-foot patient tower currently under construction as part of BJC’s long-term Campus Renewal Project, intended to transform the Washington University Medical Campus that is home to Barnes-Jewish Hospital, St. Louis Children’s Hospital, the Alvin J. Siteman Cancer Center and Washington University School of Medicine. Ware notes that BJC’s overall vision for the renewal stipulates, among other things, that “our facilities will promote healing by offering a calm, comfortable and inviting environment.”

BJC and its hospitals aren’t alone in the decision to consider the hospital room, and the entire hospital experience, as an important part of a person’s path to health. Hospitals worldwide are using evidence-based design to construct new entrances, patient rooms, treatment and diagnostic areas, and public and private spaces for clinicians, staff, patients and their families—all aimed at benefiting the healing process and the patient experience.

How did hospital design arrive at this point in time?

Places of healing: an abridged history

In the early days of human history, a person affected by disease or injury might seek help and respite in an outdoor space deemed sacred by a community healer. The place itself was part of the medicine applied. When life moved indoors, so did caring for the sick. Considered the province of religion, healing took place in humble structures, then grander spaces as architecture and technology made them possible.

Sri Lanka is home to the earliest known campus dedicated to healing the physical body. Built circa 400 B.C. and part of a large monastery, this space included baths and multiple buildings. A hospital constructed in 700 A.D. in Baghdad, with wards dedicated to specific illnesses and an attending medical staff, became a model for buildings of similar purpose throughout medieval Europe, though the healing arts remained firmly in the religious sphere.

Before medicine made the advances required to effectively and consistently treat patients, hospitals were often considered by the public as places to die rather than recover. People with power and means sought treatment at home, paying for the privilege of having the physician come to them. The poor and others living at the margins of the community took treatment in the hospital—and too often suffered for it. Many of the buildings dedicated to treating patients were dark and dreary places, ill lit and poorly ventilated—conditions that made recovery less likely.

Hospital conditions began to change in the mid 1800s, thanks in good part to Florence Nightingale, an English social reformer considered to be the founder of modern nursing. In 1849, she published her thoughts about the public hospital’s purpose and design, using her experiences and the evidence she gathered while observing the ill effects many of these grim facilities had on patients. Her Environmental Theory advocated that hospitals should make available fresh air, pure water, efficient drainage, cleanliness or sanitation and light or direct sunlight.

Hospitals responded to that call, and the public began to more readily trust in the treatment they received; even the wealthy chose to seek care outside their homes. In the early 1900s, new multi-story hospitals were built, and semi-private rooms were common, especially for those who couldn’t afford the price of privacy. By this time, much of medicine was being practiced outside the strictures of religion. When the era of antibiotics began in the 1940s, science and medicine stepped into the future; hospital design took second place to new drugs and new technology. Patients were getting better but—some observed—not as efficiently and effectively as possible.

Defining a movement

In 1984, Roger Ulrich, PhD, of Texas A&M University, published an article in the journal Science titled “View Through a Window May Influence Recovery From Surgery.” The study looked at the healing process in patients after gall bladder surgery. It found that those who were recovering in hospital rooms with views overlooking trees needed less pain medication, had fewer complications, made fewer negative comments and went home sooner than patients in rooms with windows that overlooked a brick wall. Ulrich’s study showed what many had already—based on anecdotal evidence—surmised: A room with a view to nature can help patients get better.

The era of evidence-based hospital design had begun. And it quickly proliferated. Debra Levin, president and chief executive officer of The Center for Health Design, a non-profit organization focused on improving health care through design, notes: “In 1998, The Center commissioned the first systematic literature review of studies connecting the built environment to better health outcomes, with 84 relevant studies identified. That same search was commissioned in 2004, and 600 studies were found. In 2008, a review yielded more than 1,200 studies. If we were to do the search again today, I have no doubt that the number would surpass 2,000.”

The results of all those studies about hospital design and its effects on healing help architects and hospital planners answer questions about what an effective hospital should look like.

Beyond the windows

Architect Natalie Petzoldt, AIA, EDAC, LEED AP, CLGB, principal at CannonDesign, is part of the team that designed the patient tower under construction at Barnes-Jewish Hospital. One of her accreditations, EDAC, indicating certification in evidence-based design, means that she and colleagues use that methodology to inform their work.

“Design considers the needs of each population that uses a space,” Petzholdt says. For a hospital, that means considering the needs of patients, their families and other visitors, as well as medical professionals, support staff, administrators and others. “Evidence-based design uses information available from relevant studies to help inform our design decisions,” Petzholdt adds. Much of what’s been included in the design for Barnes-Jewish Hospital’s new tower adheres to evidence-based design standards.

A case study

The evidence-based design movement has identified several important areas of consideration in designing an effective hospital, including:

• Access to nature. Evidence indicates that just three minutes’ exposure to nature can reduce stress.

The new patient tower will include gardens that can be used by patients and their families, as well as hospital staff. For patients who can’t be outdoors, the tower offers windows with views to nature, as well as artwork and other nature-focused elements.

• Autonomy. People lose a good deal of independence when hospitalized. If given opportunities to regain some autonomy while recovering, patients are less stressed and more able to participate in their own recovery.

Rooms in the new tower will use technology to allow patients to adjust their own beds and room lighting, control room temperature, manage music and television volume, and access a number of services, including streaming movies and ordering food.

• Social network. Patients recover more quickly when they have a support network of people they know and trust.

To accommodate family and visitors, the new patient tower includes a complete redesign of the approach to and entrance into the hospital, making it easier and less stressful to make repeat visits. Once inside the hospital, visitors will have access to a new cafeteria and coffee shop, as well as facilities for showering, doing laundry and relaxing. Patient rooms will have ample space for visitors and will include couches that convert to beds and desks that can be used for work. All patient rooms will be private, providing the space needed for conversations with health-care teams and with family, while also helping to control the spread of infection.

• Calm environment. The lights, beeps and other noises inherent in a hospital have significant impact on the well-being of the patient, interrupting sleep and compounding anxiety.

The tower’s design team established a targeted sound level for the new patient rooms, then ensured wall and ceiling materials, and construction would meet it. The tower also will use color, artwork and other choices to help create a sense of calm.

Ware says the design team for the new tower had a unique opportunity because the planning phase of the project was interrupted by the SARS-CoV-2 pandemic. “When we returned after pausing the design process, we were able to consider what we learned during the pandemic—specifically about preparedness and infection control.”  Working with Petzholdt and CannonDesign, the design team made changes to the tower that will allow for more flexibility in responding to a health-care incident like the pandemic—including infection-control measures and conversion to additional intensive care units as needed.

Both Ware and Petzholdt emphasize that evidence-based design for hospitals also considers the needs of those providing care. As Ware puts it: “To care for patients, we also have to care for our doctors, nurses and other staff.” As part of the design process, Ware says, the team used the tenets of evidence-based design, as well as information gleaned from previously completed projects in the campus renewal initiative. To ensure the new building meets the needs of health-care professionals, the design team met with groups of caregivers to learn more about those needs. In addition to designing for efficiency and safety, the team included quiet places where health-care professionals can find respite after a difficult incident or a few moments’ solitude during a busy day.

Essentially, evidence-based design helps ensure that a hospital builds compassion into its very walls.

Petzholdt, who has been designing hospitals and other health-centered buildings for a good share of her career, says the value of evidence-based design was highlighted when her mother was diagnosed with breast cancer. At the time of her mom’s treatment (she has since recovered), Petzholdt was working on the design for the Center for Advanced Medicine on the Washington University Medical Campus, where Siteman Cancer Center is located. “My professional and personal lives collided in a way I hadn’t anticipated,” Petzholdt says. “

I discovered in a very intimate way how much the design work I do affects the lives of people seeking care.”

Ware has a similar story about evidence-based design and its impact. When her son was four months old, he was hospitalized. She and her husband stayed with him during his treatment. “We took shifts: One of us slept on a couch in the waiting room; the other stayed by the bedside, in an uncomfortable, temporary chair.”

That experience has stayed with her. As she considers the first phases of the Campus Renewal Project, which enhanced St. Louis Children’s Hospital, and the tower currently under construction, she’s especially pleased to know that families in a situation like hers will be accommodated. “Illness and hospitalization are difficult for patients and families. I’m pleased that we can offer the spaces people need to be comfortable while they heal, while they care for someone they love.”