Wellness Design Evaluation Criteria for the Main Entry Lobby in a Healthcare Facility

Author: Yongyeon Cho

Issue date: November 30, 2017

STATEMENT OF THE PROBLEM

The design of healthcare facilities has traditionally focused on the functional efficiency of

their space (Ulrich, 1991). This emphasis is often incomplete because the resulting design may

not meet the psychological needs of patients, visitors, and staff, and poor design can create

negative responses such as anxiety, elevated blood pressure, and increased need for drugs to

relive pain (Wilson, 1972; Ulrich, 1984). In creating a psychologically supportive healthcare

facility, the main entry lobby is an important place to consider, because that area has the power

to comfort visitors whose impressions of the healthcare facility both begin and end with the

lobby (Bedner, 2013).

Because the main entry lobby of a healthcare facility provides both patient and visitor

introduction to the facility, the design of that space may set expectations for the quality of

clinical care offered by the facility (Malkin, 1991). Since 2007, healthcare facility designers have

viewed the lobby space as a vital element of the overall healthcare experience (Pangrazio, 2013).

This public space is a location where people not only may spend significant amounts of time in

waiting for treatment, talking with family members and friends, sharing their emotions, allowing

children to play, and taking a breather from care for their loved ones, but also obtain social

support from the community (Bamborough, 2013; Silvis, 2014), so experiences in the main entry

are critical to the branding of a healthcare facility. Little research, however, has focused on user

experience in healthcare environment public spaces, including both patient and visitor experience

in the main lobby, although research-based design has been extensively applied to most patient

and staff areas of clinical space (Ulrich, 1991). While people have commonly considered

healthcare facility design to be important mainly for patients, as the emphasis has shifted from

patient-centered care to family-centered care, and from treatment to prevention, the wellness

concept becomes more important with respect to the design and planning of the main entry lobby

of a healthcare facility.

Designing a healthcare facility to be consistent with the concept of wellness is

challenging because it must now consider user satisfaction. Many facilities conduct surveys or

post-occupancy evaluations to obtain feedback from patients and families for use in making

future changes (Higginbotham, 2013). Nonetheless, once a design has been finalized and the

facility constructed, it is usually very difficult to modify the layout of a space; even replacing

color on finished surfaces may be difficult. Wellness design evaluation criteria can be helpful not

only in correcting mistakes, but also to serve as a checklist during the design phase, when they

can be most easily implemented as a tool for communicating with clients. This study focuses on

developing a set of design evaluation criteria for applying the wellness concept in the main entry

lobby of a healthcare facility.

OBJECTIVES OF THE RESEARCH

The objectives of this study are to:

1. Create a user-centered wellness design evaluation tool for developing and evaluating an

existing facility design, or the design of new construction of such facilities.

2. Test and validate a tool for the design of main entry lobby in a healthcare facility using

the guidelines and design checklists needed to support a decision-making by the facility

designers and administrations.

SIGNIFICANCE OF THE PROJECT

The physical, emotional, and social well-being of patients, visitors, and staff during

visits to a healthcare facility should be considered. This study introduces evidence-based design

evaluation criteria that will support the wellness experiences of patients, family members, and

the community in the main entry lobby of a healthcare facility. It also demonstrates how such a

tool can be used to assess and promote development of the design of a main entry lobby of a

healthcare facility design and can serve as a guide for facility managers and designers in

incorporation of user experiences into healthcare environments. The information gained from the

study will benefit society by identifying, analyzing, and improving wellness design elements in a

healthcare facility main entry lobby space.

The anticipated product, wellness design evaluation criteria, will contribute to assessment

and development of the practice of wellness design in a healthcare main entry lobby, providing

healthcare providers and facility planners with an opportunity to rethink their public space design.

Both architects and designers can use the criteria to develop improved public lobby designs, and

improved health outcomes for visitors, including user-centered positive experiences both at the

beginning and end of a visit to a healthcare facility, are anticipated. In addition, the framework of

the research has potential for extension into other areas of healthcare environment.

LITERATURE REVIEW

In this section a literature review will be performed to address the following six questions:

1) What is meant by wellness? 2) What are the health goals and trends in human wellness in the

U.S.? 3) What are the underlying theories and studies in the areas related to health and wellness

in healthcare design? 4) What design issues in healthcare environments impact user’s wellness? 5)

How can we avoid unsatisfactory design issues at the main entry lobby of a healthcare facility?

and 6) How can we show the improvement resulting from avoiding such issues, and what

evaluation tools and guidelines are appropriate for assessing the qualities of the main entry lobby

of a healthcare facility? This is expected to provide a firm understanding of the topics to be

presented in the remaining chapters concerning both the evaluation criteria and the tool.

First the concept of wellness will be reviewed by comparing the definitions of health,

health-related quality of life, population health, well-being, and wellness. Although the concept

of wellness has sometimes been considered synonymous with well-being, it is empirically more

likely to be used to describe the meaning of health (physical, mental, and social) including

spiritual, intellectual, and environmental aspects (Dunn, 1950; Hettler, 1976; Merberg, 2016), so

the author decided to adopt this meaning of wellness owing because this thesis mainly deals with

environmental aspects of human health.

According to the United States Department of Health and Human Services, and Healthy

People 2020, advancing the health and well-being of all the people of the U.S is a primary goal.

In order to improve human wellness in a constructed environment, we create and develop

protocol, standards, and guidelines at an organizational level, after which designers test

evidence-based outcomes from various fields, especially community-based design, working

environment design, and health care design.

The next section of this chapter will explain how the theories and the studies in this area

are concerned with health and wellness in healthcare environments. The theory begins with the

assumption that the body, mind, and environment are all interconnected connected and interact

with one another. Psychoneuroimmunology is a field of study that attempts to explain this type of

interaction (Irwin, 2005), and recent studies in environmental psychology reveal that stress is a

major problem that works against wellness in a healthcare environment (Antonovsky, 1979;

Kiecolt-Glaser, 1987; Ulrich, 1991), and creating a healing environment, adopting supportive

design theory, and applying active design guidelines in healthcare facility design can minimize

the stress experienced by facility users (Ulrich, 1991, 2001; Visentin, 2006; Active Design

Guidelines, 2010).

The next section discusses the five design-related issues that impact wellness of a

healthcare facility user. In a modern healthcare facility, positive user experience is a basic

consideration in facility planning (Carpman & Grant, 1993). User experience ranges from

searching for a healthcare provider to being discharged from such a facility, possibly including

even filling out the patient survey at home. According to reviewed theories, lack of distractions,

of sense of control, of social support, or of feelings of safety and security can result in negative

user experiences that impact overall wellness in healthcare environments, (Olsen & Pershing,

1981; Ulrich, 1991; Davidson, 1994; Devlin, 1992, 1995; Arneill & Devlin, 2002).

The author also has focused on identifying the design elements of the healthcare main

entry lobby that can promote user wellness. To make such an experience more positive, designers

should consider four activities in the main entry lobby; entrance, check-in, waiting, and

wayfinding. As previously mentioned, positive distractions, sense of control, social support and

safety and security must be satisfactory if the overall wellness of the user is to be promoted. To

optimally provide positive distractions, elements of nature (e.g., an outside view, water features,

green materials, natural light, nature themed artwork, healing gardens, and pleasant sensory

aspects) are important (Malkin, 1991; Carpman & Grant, 1993; McCullough, 2009; Pati, 2010).

Visual and auditory privacy are essential design considerations, and spatial options for physical

activities represent another design feature that can enhance the user’s sense of control (Valenta,

1981; Ulrich, 1991; Carpman & Grant, 1993). Implementing a flexible furniture layout and

providing different sizes and styles of furniture in the waiting area can help produce better social

outcomes. In addition, enhanced safety and security, achieved by controlling entry access,

maintaining cleanliness, and adding hand wash and hygiene stations, can also directly affect a

user’s physical, emotional, and social wellness (Sofaer, et al., 2005, Coulter, et al., 2009).

Finally, the author introduces an assessment methodology called Post Occupancy

Evaluation that can help in avoiding problematic design issues, and selects six tools and

guidelines for creating and developing design evaluation criteria for the main entry lobby of a

healthcare facility. The criteria are based on key information chosen by the author.

METHODOLOGY

To create a wellness design evaluation tool and criteria for the main entry lobby in a

healthcare facility, this study employs a combination of qualitative and quantitative analysis

methods, including analyses of existing healthcare design evaluation tools and guidelines, an

online survey of user experiences in the main entry lobby, and conceptual modeling based on the

data analysis.

Qualitative research -- The researcher will conduct qualitative analysis by reviewing

current evaluation tools and design guidelines for the healthcare facility design. Analysis will

have based on the following sources:

Patient room post occupancy evaluation tool, The Center for Health Design, 2015

Clinic design post-occupancy evaluation toolkit, The Center for Health Design, 2015

Guidelines for design and construction of Health care, FGI, 2014

LEED V2009 for Healthcare, U.S Green Building Council, 2010

Building Occupants Survey System Australia, 2016

The CDC worksite health scorecard, CDC, 2014

There are five steps to the content analysis. Step 1 was to identify major criteria related

to both the healthcare main lobby area and to the wellness concept by reviewing all major criteria

used by six existing evaluation tools and sets of design guidelines.

Step 2 was to reorganize the selected major criteria consistent with the five wellness

design criteria defined in the literature review (Improvement of user’s experience, Optimal

positive distraction, Enhancing user sense of control, Aspects of social support, and

Enhancement of safety and security). The first goal of content analysis in step 2 was to form a

basis for analysis of specific criteria and design features. The second goal was to identify which

existing evaluation tools and guidelines are correlated with the five wellness-design criteria. The

major criteria could overlap. For example, ‘reduce patient pain, stress, anxiety and delirium’ in

‘patient room post occupancy evaluation tool’ can be applied to wellness design criteria 1,

improvement of user experience, and to wellness design criteria 2, optimal positive distraction.

Step 3 was to categorize specific criteria of the selected major criteria into 20 design

features. In this step, the researcher numbered the specific criteria by assigning category numbers.

Step 4 was to reorganize the specific criteria into 5 wellness design criteria and 20

design features to help the reader recognize which design features are associated with specific

criteria. The category numbering system was used for the reader’s convenience in referring to

design features associated with each criterion.

Step 5 was to summarize each of the specific criteria using a descriptive phrase. The

design feature summaries were utilized both in the online survey for determining the

participant’s perception of the design feature and in the proposed wellness design evaluation tool.

Quantitative research - A survey of user wellness experiences in the main entry lobby of

a healthcare facility, and statistical analysis.

The goal of the online survey was to identify participants’ perceptions of the design

features. This process is important because the results can be used to validate the design features

included in the proposed wellness design evaluation tool developed at the end of the study.

Various design features will be investigated through a survey to obtain responses

described as important to users from their own experiences in the main entry lobby in a

healthcare facility. The purpose of the survey is to develop the wellness design evaluation tool.

The survey, conducted via the online survey software package Qualtrics, took an average of 12

minutes to complete. The survey yielded 899 responses, but only 299 were used. Participants had

to be 18 years old or older and had to have visited a U.S. health facility during the previous 12

months.

The survey consisted of three parts. First, answers to six demography information

questions, related to items like age group, gender, level of education, and design background or

non-design background, were obtained. Then five questions related to participants’ visiting

patterns, including factors such as the type of healthcare facility where a participant had a

memorable experience, geographic location of the type of healthcare facility, frequency of visit,

duration of visit, the purpose of their visit, were asked.

There were two main questions related to the 20 design features: (1. entrance experience,

2. entry vestibule experience, 3. access control system, 4. basic space program, 5. additional

space program, 6. accessibility to other space, 7. space configuration, 8. environmental support

for physical activities, 9. variety of furniture, 10. nature elements, 11. controlled lighting system,

12. visual appeal, 13. visual and auditory privacy, 14. perception of noise, 15. positive sound

distractions, 16. air comfort and freshness, 17. User-controlled environments, 18. cleanness and

maintenance, 19. infection control system, 20. information for healthier life).

The first question asked about how the importance of design features in designing a

healthcare facility’s main entry lobby. For example, “how important are the entrance experiences

(e.g., covered area for vehicle drop off and pick up, proximity of parking lots, pedestrian

entrance, clear signage, bicycle lots) of the main entry lobby of the healthcare facility to you?”

Participants were asked to check one of five answers (not at all important, slightly important,

moderately important, very important, extremely important).

The second question was related to the impact of each design feature on one’s physical,

emotional, or social wellness. For example, “what impact do the entrance experiences (e.g.,

covered area for vehicle drop off and pick up, proximity of parking lots, pedestrian entrance,

clear signage, bicycle lots) have on your physical well-being, emotional health, and social

interaction?” Participants checked one of the four answers (negative impact, no impact, favorable

impact, best impact) of each wellness category.

RESULTS OF CONTENT ANALYSIS

The purpose of the content analysis was to collect information regarding existing

assessment criteria and design guidelines appropriate to the creation of a new wellness design

evaluation tool for a healthcare facility’s main entry lobby. The data collected from the content

analysis were analyzed in tabular form, and this section presents its significant findings. Table 1

presents the final results used a basis for a survey of user wellness experience in healthcare main

entry lobbies.

Table 1. Results of content analysis, 5 Wellness design criteria and 20 design features and summary of narratives

Wellness design criteria

Design features Summary of specifics

1. Improvement of user’s experience

01.Entrance experience

Covered area for vehicle drop-off and pickup, proximity of parking lots, pedestrian entrance, clear signage, bicycle lots

02.Entry vestibule experience

Wheelchair storage area out of the path of traffic, view of drop-off and pickup areas, waiting area for discharge

03.Basic space program

Information center, waiting area, public restrooms for male, female, and family, space for special groups of people

04.Additional space program

Kids’ area, multi-purpose lactation, place of respite, drinking water, local phone calls, power outlets, wireless connection, clock, waiting monitor, vending area, kiosks or other displays for information, clear signage and landmark for wayfinding

05.Accessibility to other space

Cafe, gift shop, book store, chapel, business center, family library, exercise facility on-site, convenience store

2. Optimal positive distraction

06.Nature elements Skylight, large windows for outside view, accessible gardens, indoor plants, water features

07.Controlled lighting system

Overall experiences of lighting, minimizing glare on the floor, providing efficient lighting for the purpose of circadian rhythm, lighting aesthetic

08.Visual appeals Hospital brand, harmonized color, finishes, materials, nature-themed artworks 09.Perception of noise Noise from equipment, sound of footsteps, murmur of conversation 10.Positive sound distractions

White noise, access to soothing music, nature sound such as from water feature, or interior healing garden

11.Air comfort and freshness

Comfortable air temperature, relative humidity, and flow speed, no unpleasant smell, air quality and freshness, appropriate temperature in season

3. Enhancing user’s sense of control

12.Environmental support for physical activities

Highly visible staircase, interior healing garden, meditation garden, indoor climbing wall, space for free body fat assessment

13.Visual and auditory privacy

Barriers in seating, privacy screens on registration area and/or kiosks

14.User controlled environments

Adjustable furniture, adequate storage space for personal belongings, manual shading system

15.Information for healthier life

Brochures or pamphlets that address the benefits of healthy eating, overweight or obese conditions, nutritional information for foods and beverages sold in vending area, local farmers' market information

4. Aspects of social support

16.Space configuration

Visibility within space, spatial connectivity

17.Variety of furniture

Variety of seating options for different group sizes, wide range of age groups and size variations

5. Enhancement of safety and security

18.Access control system

Protection devices, automatically closed door with alarms, safeguard staff, adequate exterior lighting

19.Cleanness and maintenance

Cleanliness of overall waiting area, quality of maintenance, public restroom experience

20.Infection control system

Plenty of sinks and/or alcohol gel dispensers in visible and accessible locations, separated area for infectious visitors, visual cues as reminders for hand washing/ sanitation

ONLINE SURVEY RESULTS

The mean values of each design feature’s importance and impact on user physical well-

being, emotional health, and social interaction were used to rank the features and identify their

mean values in the new evaluation tool. Table 2 shows the results.

The top three important design features that participants considered for the healthcare

main entry lobby were ‘infection control’, ‘cleanliness and maintenance’, and ‘air comfort and

freshness’, and the least important three features were ‘environmental support for physical

activities’, ‘accessibility to other spaces’, and ‘user controlled environment’.

The results of Pearson’s correlation test and the descriptive statistics of Table 2 show the

importance of the design features and that the three wellness categories are correlated.

Table 2. Mean values of importance of design features, and impacts on physical well-being, emotional health, and social interaction. The darker shades of each column represent higher mean value of each column.

Mean value of importance of the design features (1-5)

Mean value of impacts on physical well-being (1-4)

Mean value of impacts on emotional health (1-4)

Mean value of impacts on social interaction (1-4)

Entrance experiences 3.55 2.74 2.65 2.38 Entry vestibule experiences 3.45 2.62 2.50 2.40 Access control systems 3.58 2.73 2.59 2.35 Basic space programs 3.93 2.93 2.87 2.79 Additional space programs 3.48 2.62 2.64 2.65 Accessibility to other spaces 3.00 2.21 2.38 2.41 space configuration 3.34 2.45 2.52 2.48 Environmental support for physical activities 2.91 2.36 2.43 2.35 Variety of furniture 3.18 2.61 2.46 2.43 Nature elements 3.16 2.38 2.78 2.46 Controlled lighting system 3.25 2.53 2.66 2.29 Visual appeals 3.10 2.31 2.54 2.31 Visual and auditory privacy 3.65 2.47 2.80 2.63 Perception of noise 3.51 2.48 2.67 2.56 Positive sound distractions 3.13 2.39 2.73 2.41 Air comfort and freshness 4.19 3.35 3.21 2.81 User controlled environment 3.08 2.47 2.49 2.24 Cleanliness and maintenance 4.54 3.50 3.39 3.08 Infection control 4.55 3.63 3.34 2.96 Information for healthier life 3.38 2.78 2.62 2.38

The research reconfigures the mean value of the design features into the five wellness

design goals to identify which criteria is the primary goal for the main entry lobby design. Figure

1 shows that ‘Enhancement of safety and security’ is considered the most important criteria in the

design.

Figure 1. User's perception with respect to the Importance of the wellness experience in the main lobby

The data was analyzed to determine how the user perception of the design features are

different from demographic information and the visiting patterns, with the results shown in Table

3. This analysis will be utilized in a future study to develop a more accurate tool. Subjects’ age

group (18-34, 35-50, 51-69, and 70-87), type of healthcare facility (Hospital, Ambulatory,

Residential, and other), frequency of visit (Less than one per a year, 1-2 per a year, 1 per 3

months, 1 per a month, 2 per a month, 1 per a week, 2 per a week, more than 4 per a week, and

every day), and purpose of visit (Patient, visitor, staff, or other), were obtained with respect to

ten or more design features, indicating significant differences with respect to user perception of

importance of each design feature.

Table 3. Number of design features out of 20 design features indicate significant difference. Sig.>0.05

Pre-questions Test User’s Importance Impact on user’s

0.000.501.001.502.002.503.003.504.004.50

Criteria 1.Improvements of

user’s facility experience

Criteria 2.Optimal positive

distractions

Criteria 3.Enhancing user’s sense

of control

Criteria 4.Aspects of user’s social

support

Criteria 5.Enhancement of safety

and security

2 3 4 51

of the design feature

Physical well-being

Emotional Health

Social Interaction

Dem

ogr

aphy

Gender T-test 1 7 7 1 Age group ANOVA 11 11 8 12 Education level ANOVA 5 1 3 4 Design background T-test 0 14 10 20

Visi

ting

patte

rn Type of healthcare facility ANOVA 10 3 5 10

Frequency of visit ANOVA 12 2 5 12 Duration of stay ANOVA 2 0 6 1 Purpose of visit ANOVA 18 16 15 18

A WELLNESS DESIGN EVALUATION TOOL FOR A MAIN ENTRY LOBBY IN

A HEALTHCARE FACILITY

This section will introduce the new wellness design evaluation tool generated using

Microsoft Excel. A prospective user should download, open, and use the tool using Microsoft

Excel 2016 to make use of the macros included for obtaining score. An evaluator can use the tool

with a personal portable device like an IPAD or a laptop and review the result in real time.

Alternatively, the tool user can print the tool on paper for convenient use at the site, then input

the data later using Microsoft Excel to obtain evaluation results.

The tool consists of three major parts (Figure 2). Instructions on the cover tab explain

how to use the tool and how the evaluation should be processed. The second part of the tool

displays wellness design criteria including design features and narratives related to the healthcare

main entry lobby that could have an impact on user wellness. The last part provides detailed

narratives and a diagram of the design features. An evaluator can check a design feature in more

detail either by clicking on its summary or by clicking on tabs related to desired information.

Figure 2. The 3 parts of the wellness design evaluation tool for the main lobby of a healthcare facility. Cover tab, main tab, and detail tab.

In the main tab, an itemized score how an evaluator perceived a design feature is

measured for each design feature of the space, with the evaluation conducted by choosing a level

of impact on the evaluator’s physical well-being, emotional health, and social interaction. When

an evaluator responds to a question, the score will be automatically calculated. The itemized

score is the result of a formula (Figure 3) producing a sum of the three types of wellness,

multiplied by the mean value of importance of a design feature taken from the online survey. A

color-coding system indicates whether or not the main entry lobby design feature satisfies user

expectations by comparing with the itemized scores from the online survey.

Figure 3. A formula of an itemized score for the user-centered wellness design tool

The total raw evaluation score represents the sum of the itemized scores of the 20 design

features. Percentile ranks based on raw score are modified scores for analyzing the total raw

evaluation score when comparing to the mean values from the survey results (Figure 4). The

survey result represents an average value of user perceptions of the healthcare facility main

lobby experience, and the applied color-coding system is automatically shown during the

evaluation process.

Figure 4. A formula of percentile ranks based on raw score and level of quality.

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“This research was funded in part by the Steelcase Corporation and the American

Academy of Healthcare Interior Designers, Inc. Any opinions, findings, conclusions or

recommendations expressed in this publication are those of the author and do not necessarily

reflect the views of the American Academy of Healthcare Interior Designers, Inc. or Steelcase.”