The Hospital Built Environment: What Role Might Funders of Health Services Research Play?


A literature review and interviews with architects, designers, academics, and health care executives were conducted between February and May of 2005, in an attempt to determine if associations exist between hospital building design elements and patient and staff safety, health outcomes, and patient and staff satisfaction levels. The findings were used to bring focus to the challenges of evidence-based hospital design and the roles that funders might play in the development and transfer of knowledge related to the constructed hospital environment.

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The United States is embarking upon one of the largest hospital building booms in the Nation's history. Anticipated to be a decade-long undertaking, this new construction is being undertaken to replace aging hospitals, incorporate new technologies and medical practices, and respond to external market factors, including America's growing and aging population.

But apart from the estimated $200 billion in new construction expenditures projected over the next 10 years, there remains a considerable potential for quality improvement in our nation's hospitals. The Institute of Medicine's widely cited report, To Err is Human, concluded that tens of thousands of patients die each year from preventable medical errors while in the hospital. Moreover, as many as 2 million U.S. patients contract dangerous infections annually during hospitalizations that complicate treatment and frequently result in adverse patient outcomes.

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Hospital Environments and Quality of Care

A body of evidence is being developed to determine how attributes of the various environments in which health care is provided can mediate health care quality. But no one has yet identified the questions that might help health services researchers, architects, or others decide where more research is needed or how research dollars could be best spent to address the many outstanding issues. The environmental scan at the center of this report is intended to assess what is and is not known about the relationships between hospital design and construction—the built environment—and:

  • Patient outcomes.
  • Patient safety and satisfaction.
  • Hospital staff safety and satisfaction.

Two primary research tasks served as the basis of the methodology used to frame the environmental scan:

  1. A specialized literature review was conducted to determine what is known and who is conducting research on topics relevant to the hospital built environment. The search focused on relevant PubMed® citations and involved the use of MeSH® terms. Other relevant data sources also were incorporated, including the Center for Health Design (CHD), and the Institute of Medicine. Additionally, a broad Internet search was conducted using Google®.
  2. Hour-long, semi-structured interviews were conducted with key informants in the field—hospital executives, architects and designers, academics, and researchers involved in the built environment—to determine who is funding, conducting, disseminating, and applying research related to hospital designs. The interviews further sought to identify current areas of research focus, outcomes to date, and research gaps, as well as challenges to advancing the field, and possible roles for funders supporting and disseminating research in this area.

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While the evidence linking hospital design to patient outcomes, patient and staff safety and patient and staff satisfaction is growing, much of the literature consists of observational studies and review articles that are qualitative and anecdotal. Of the 328 articles recovered from PubMed® and other sources, 168 pertain primarily to improving patient outcomes, 182 examine patient or staff safety issues and 44 focus on areas of patient or staff satisfaction and efficiency. About 65 percent of the identified studies are observational in nature, most of which address patient outcomes and safety and staff safety. There appears to be little empirical evidence on how the built environment affects staff efficiency and satisfaction.

Hospital designers, administrators and researchers face a variety of challenges as they seek to broaden the field of evidence-based hospital design and apply what is learned to improve patient safety, other outcomes, and satisfaction. Based on the review of the literature and feedback from expert interviews, the five major challenges facing evidence-based hospital design proponents are:

  1. Insufficient resources for conducting evaluations of the built environment.
  2. Difficultly gaining provider input and feedback on design.
  3. Reluctance to learn from design strategies that were ineffective.
  4. Obsolete or ineffective laws and regulations regarding hospital design.
  5. Capital costs of evidence-based design and renovation projects.

Based on what was learned from the key informant interviews, there are two main potential roles for funders in developing and transferring knowledge about the hospital built environment. These include:

  • Funding empirical research.
  • Disseminating evidence-based research output to decisionmakers.

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Page last reviewed October 2005
Internet Citation: Summary: The Hospital Built Environment: What Role Might Funders of Health Services Research Play?. October 2005. Agency for Healthcare Research and Quality, Rockville, MD.