Is the best hospital ward one with short routes between beds or one that encourages professional communication?
Hospital planners and architects with the difficult task of designing a hospital ward can choose from a variety of types including radial, racetrack and straight or L-shaped corridor layouts. But which is best? Previous research has suggested it is to minimise walking distances between functional areas, for example patient beds and nursing stations, to increase the time healthcare workers spend at patients’ bedsides. From this it can be inferred which areas of the inpatient ward should be placed in close proximity. Such measurements have been applied to different ward typologies to define the most efficient – assuming this would be the best performing. However, studies showed disparate results favouring one ward typology over another.
Beyond walking efficiencies, earlier research suggested that the spatial configuration of hospital wards influenced face-to-face communication among healthcare workers. Studies showed that larger viewsheds provided good awareness of the ward environment and thus led to more communication opportunities. In turn good communication reduced medical errors.
Existing research on ward typology and spatial configuration did not describe the ‘best’ ward layout. Using a larger than usual sample, this research investigates how the layouts of hospital wards influence not just walking practices or distances but outcome measures such as care quality. It aims to develop a Spaces for Communication Index (SCi) which rather than measuring space efficiency by minimising distances, measures space effectiveness through maximising communication opportunities. The SCi is intended to help designers benchmark design schemes of ward layouts and optimise designs for good care quality.
In a first stage of the research, detailed movement and communication patterns of healthcare workers in six NHS wards was collected to define frequencies of travel between key areas. On this basis, the SCi index was developed and tested on floor plans of 31 NHS hospital wards – selected based on their quality of care rating by the Care Quality Commission. A representative sample of hospitals rated on a four point scale ranging from ‘outstanding’ through ‘good’ and ‘requires improvement’ to ‘inadequate’ was chosen. This particular data was selected because of the diversity of factors these hospitals monitor, including patient and staff parameters. Each ward was analysed with Space Syntax methods, particularly using visibility graphs generated in Depthmap X software. By analysing spatial layouts with this method, one can quantify the size of viewsheds from a series of vantage points resulting in a metric called ‘connectivity’.
To develop SCi, we identified the most frequently traversed links between key areas in the six studied wards which were: patient bed to patient bed (37% of links); patient bed to nursing station (29%); patient bed to medication room (17%) and nursing station to medication room (5%) . We then constructed shortest paths linking each one of these key areas and calculated the size of viewsheds en route. It was considered that by walking from one functional space to another, a healthcare worker ‘accumulates’ levels of connectivity. Observational data from the six wardsshowed that the higher the accumulated connectivity along a path, the more conversations a healthcare worker had. The average connectivity of the four major paths was then calculated and multiplied with the frequency of usage of each path. Finally, dividing this by the number of patient beds to account for ward unit size produced the SCi.
The index was calculated for all 31 NHS wards and the figures were related to care quality ratings using statistical analysis. We also tested whether the Yale Traffic Index, number of patient beds or size of the ward had any effect. Results showed although these did not, SCi can be used to establish which wards provided better healthcare quality and that the higher the index, the better the quality of care rating was. In terms of design, these results highlight the importance of open spaces that healthcare workers traverse to get from one key area to another.
This study contributed to the development of an objective method that can be used for benchmarking design options of nursing wards. In deciding between different layouts, the most significant criterion should be how well they might support the provision of good healthcare. The newly developed SCi allows for a systematic comparison of hospital wards with the aim to maximise communication opportunities via large viewsheds and thus increase the likelihood of providing better care quality. As 31 plans may be too small of a sample from which to draw definite conclusions, more case studies would be required to fine-tune and test the measure but the sample does provide a solid basis for further application.
Next steps include applying the index calculation during design and planning stages of hospitals to optimise for communication opportunities and help designers to know in advance how much they must invest in terms of spatial configuration to provide better healthcare quality by design.
Providing Care Quality by Design: A New Measure to Assess Hospital Ward Layouts, by Rosica Pachilova and Kerstin Sailer of UCL, was category winner of the RIBA President’s Awards for Research: Building in Quality