By Sandra Soraci, EDAC, LEED AP, NCIDQ, IIDA, RCR
According to the American Hospital Association (AHA), there are more than 35 million hospital admissions in the U.S. each year, with an average stay of nearly five days.1 Many recent studies combined with the growing adoption of evidence-based design principles have illuminated the importance of healthcare facility design on the overall patient experience and the relationship it has with healing and wellness. As flooring covers every square foot and supports every activity,
it plays a big role—whether welcoming patients into the lobby, comforting family members in the surgery waiting room, or supporting the nursing staff as they do their rounds.
Raising the bar and evidence-based design goals
Evidence-Based Design (EBD) in the built environment involves making product and design decisions based on credible research to achieve optimal outcomes.2 This approach aims to positively impact patients and staff, utilizing a continuous improvement model informed by monitored results.
Positive patient outcomes and experiences within a healthcare facility is important. Hospitals measure patient experience satisfaction with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) under the auspices of the Hospital Quality Alliance (HQA), a private/public partnership that includes major hospital and medical associations, consumer groups, measurement and accrediting bodies, government, and other groups that share an interest in improving hospital quality.
The HCAHPS survey is composed of 27 items including 18 substantive items that encompass critical aspects of the hospital experience (communication with doctors, communication with nurses, responsiveness of hospital staff, cleanliness of the hospital environment, quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of the hospital, and recommendation of the hospital).3 Survey results are publicly reported, so they greatly influence an organization’s reputation. Additionally, the government allocates reimbursements based on results, so the survey directly impacts a hospital’s financial performance.
When specifying interior finishes such as flooring, building professionals should take the utmost care to ensure all materials help advance these overarching quality measurement components. In 2012, The Center for Health Design established eight evidence-based design goals that support how the performance of flooring materials can have an actionable impact on multiple health-related outcomes.
Reduce slips, trips, and falls
One-third of all patients fall more than once during hospitalization, with 25 to 50 percent of fallers suffering injuries.4 Flooring should help prevent slip, trip, and fall risks, and aid in wayfinding to ensure safe navigation through a space. Various factors contribute to falls, and visual acuity must be taken into account, since all visitors in a facility may not be able to distinguish shapes and details of objects from a certain distance. These solutions must also comply with all local, state, and federal safety guidelines.
Reduce patient and staff injuries associated with falls
Patient falls have significant financial consequences for healthcare systems, with one study reporting the average total cost of a fall was $62,521 ($36,776 direct costs) and the average total cost of a fall with any injury was $64,526.5 Falls with injury are considered serious reportable “never-events” by the Centers for Medicare and Medicaid Services (CMS) and are non-reimbursable to the health system.6
Slip, trip, and fall incidents pose a significant risk to staff as well, potentially causing injury, lost work time, and costly legal actions for the facility.
Reduce noise levels
One of the questions on the HCAHPS survey is: “During this hospital stay, how often was the area around your room quiet at night?”7 One study has shown that, “With interrupted or limited sleep, a body might have trouble fully healing, which could lead to potential longer stays in a hospital, negative patient experiences, and poor health outcomes.”8 A second study found that increased noise in the intensive care unit could be “associated with worsened patient anxiety levels,” or could also be a “potential environmental stressor for patients at risk for falls.”9
Managing the acoustic needs of spaces is deeply important. Sources of noise from equipment and staff must be managed to enable better rest for healing, diffuse abrupt reactions to loud disturbances, and for better work concentration.
Reduce staff fatigue
Nurse fatigue can have a profound negative impact on patient outcomes, ranging from medication errors and patient mortality. It also puts a facility’s nursing staff at risk for musculoskeletal injuries, emotional disorders, and job burnout.10
Reducing nurse fatigue is a constant priority for organizations such as the American Nurses Association (ANA), The Joint Commission, and the Institute of Medicine. Thoughtful flooring selection with adequate cushioning can provide comfort and reduce pain, and also lessen foot, leg, and back fatigue. Optimal ergonomics allow people to interact most efficiently with the least amount of disruption. A healthy, well-supported staff translates to better patient outcomes.
Reduce surface contamination and potential risk of healthcare-associated infections
Healthcare-associated infections (HAIs) are infections patients acquire while receiving treatment for other conditions within a healthcare setting.11 According to the Centers for Disease Control and Prevention (CDC), more than one million HAIs occur across the U.S. healthcare system every year, with “tens of thousands of lives lost” annually. The fact that patients are more likely to recommend a hospital they perceive to be clean suggests cleanliness is an outcome that matters to them; as such, it is an important improvement target.12
Flooring that supports a robust infection prevention and control (IPAC) strategy is essential for a hospital’s success. While floors are considered low-touch surfaces, emerging scientific evidence suggests they contribute to the spread of organisms on high-touch surfaces. This makes the cleanability of flooring particularly important in high-risk areas of a hospital.
A study published by Deshpande and colleagues in the American Journal of Infection Control (AJIC) focused on what bacteria might live on floors of 120 floor sites among four Cleveland-area hospitals.13
- 22 percent of the floor sites were positive for methicillin-resistant Staphylococcus aureus (MRSA).
- 33 percent of the floor sites were positive for vancomycin-resistant enterococci (VRE), which can cause urinary tract infections and wound infections.
- 72 percent of floor sites were positive for Clostridium difficile (C. diff), which causes severe diarrhea. This study found the infection was not only found on floors in isolation rooms where people with this infection are kept but also in other rooms where people did not have this infection. This indicates C. diff can spread between rooms and survive on floors.
- 24 percent of high-touch objects in-contact with the floor were contaminated with more than
one bacterium. - 57 percent of contaminated objects in-contact with the floor transferred bacteria to hands.
Improve patient and family satisfaction
Flooring (in the choice of colors, patterns, and textures) must support the overall aesthetic of the environment to add to the element of “attractiveness” which has been linked to increased patient satisfaction and perception of quality of care.14
When patients can choose where to receive medical care, they tend to select more sophisticated, less institutional facilities. Flooring contributes to a first impression as people enter and move about a healthcare facility, shaping their opinions about the organization’s ability to provide safe, quality, and comfortable care.
The relationship between patient experience and revenue is clear. One study found a five-point increase in overall hospital rating (based on the HCAHPS survey) led to a 1 percent increase in profit margin.15
Improve indoor air quality (IAQ)
As one of the largest surfaces in a building, flooring is the foundation of cleaner, healthier indoor air. According to the Asthma and Allergy Foundation of America (AAFA), more than 100 million people in the U.S. experience various types of allergies each year, and over 27 million have asthma. In addition, research at Texas A&M University shows indoor air pollution in hospital environments increases the risk of HAIs to patients, staff, and visitors, and can have a significant impact on patient outcomes.16
AAFA and Allergy Standards Ltd. developed a program to test products, including flooring, to determine their impact on healthy indoor air. The independent rigorous testing measures products against standards for VOCs, allergen removal, and particulate release into the air during installation and cleaning. If a product passes these scientifically backed tests, they become CERTIFIED asthma & allergy friendly.® Products with this mark are proven to reduce exposure to triggers and allergens and contribute to a healthier indoor environment.
Represent the best return on investment (ROI)
Health systems are facing increasing expenditures and finish material selections can have an actionable impact on the total cost of ownership. When selecting flooring for a facility, its in-service lifecycle—including maintenance costs, CDC sanitizing protocols, and environmental services (EVS) team training—needs to be considered in addition to its initial cost.
What to look for when selecting floors
With the evidence-based design goals established, it is important to examine the flooring characteristics that should be considered when selecting the right product for a space.
Durability and performance
Healthcare facilities often have large pieces of furniture or equipment that can exert a heavy load, so flooring must provide an enhanced level of performance. Surfaces that stand up to commercial demands such as heavy foot traffic, scratching, and staining will keep floors effective for years to come. Floors must:
- Be chemical- and stain-resistant.
- Withstand rolling loads.
- Meet Facility Guidelines Institute’s (FGI) Guidelines—including flush flooring transitions, ease of wheeled equipment, and patient mobility.
Rubber tile provides great resistance to scratches, scuffs, punctures, and tears, and it provides great absorption for reduced footfall sound, while providing comfort underfoot. With good impact absorption, it can also support rolling loads and will not sustain indentations. Luxury vinyl tile (LVT) is ideal for outpatient settings, with high resistance to abrasions, stains, scuffs, and scratches, the durability to withstand heavy traffic, and good impact absorption.
Maintenance
A well-maintained environment is critical. Clinical surfaces, including the floor, should be easy to clean and disinfect, and be impervious to fluids. Additionally, flooring and walls should be resistant to chemicals and detergents, and maintain a like-new appearance even after years of use. Flooring should:
- Minimize exposure to pathogens with an integral wall base and seamless transitions for ease of cleaning, ensuring a more hygienic environment.
- Have no crevices for ease of cleaning and optimized infection control.
- Withstand the rigors of disinfection protocol for aseptic, sterile environments, and the EPA-N List (Environmental Protection Agency, N-List) of disinfectants for COVID-19.17
There are also many options available in matte finishes for a low reflectance value (LRV) that minimizes glare for cognitive comfort.
Certifications
- asthma & allergy friendly® CERTIFIED—These products have been independently tested to be more suitable for the 100-plus million people in the U.S. living with asthma and/or allergies. This program from Allergy Standards Ltd. in association with AAFA is a regulated, physician-led certification, awarded exclusively to products meeting strict testing standards developed by healthcare experts.
- FloorScore—FloorScore-labeled products meet the strict IAQ emissions criteria of Certified in Healthcare Privacy and Security (CHPS), LEED Green Building Rating Systems, and the Green Guide for Health Care.
- Green Label Plus—The Carpet & Rug Institute Green Label Plus certification guarantees all carpet products and carpet adhesives meet emissions requirements for IAQ as set by the California 01350 Specification.
- GREENGUARD—The UL GREENGUARD Gold Certification Standard includes health-based criteria to help achieve a higher standard for products and IAQ.
Sustainability
The importance of IAQ in all healthcare spaces cannot be overstated. While the certifications will identify products that are safe to specify, choose flooring options that are ortho-phthalate-free; Living Building Challenge (LBC) Red List free; have low to undetectable VOC content emissions; require minimal use of chemicals for cleaning and maintaining; and/or use innovative materials that are moisture-impermeable.
There are additional standards that indicate products are sustainably manufactured, including Cradle to Cradle certification.
A good resource for researching sustainability information is Design for Health, a digital studio for healthy interiors created to inspire, inform, empower, and recognize design that supports the health and wellness of people and the planet. It is powered by a digital library that rates building products from more than 150 vendors, providing in-depth information to make healthy product specifications a standard design practice.
Design and aesthetics
Much of the evidence-based design information for healthcare interiors comes from post-occupancy studies or the HCAHPS surveys mentioned at the beginning of this article.
Studies have found color contributes significantly to creating healing environments, with certain colors even affecting blood pressure, metabolism, and eyestrain.18 Biophilic design elements and textures evoke nature, supporting physical, emotional, and mental well-being. Incorporating nature-inspired elements such as wood and stone patterns greatly aids in patient healing and stress reduction. A thoughtfully designed color palette can greatly enhance a healthcare facility, with soothing earth tones providing a sense of calm and wellness.
Beyond the patient room, use of texture, patterns, and color can contribute to the navigation of the facility as well. Directional signs are not always intuitive, so consider how flooring can provide subconscious cues to guide individuals efficiently from one space to another. In today’s global community, signage may not meet the needs of all languages or the visually impaired. It may be confusing or easily missed by neurodivergent individuals and memory care patients. Using color and design in flooring materials can be a highly effective wayfinding solution, helping guide occupants through a complex and busy facility with visual and cognitive cues.
Selecting the appropriate product for each specific space
From supporting IAQ to helping people find their way, to controlling the spread of infection, flooring is the foundation of quality care. Selecting the right product for the right space is a critical step toward positive patient outcomes.
Notes
1 Refer to wexnermedical.osu.edu/mediaroom/pressreleaselisting/patient-room-comfort.
2 To learn more, visit www.healthdesign.org/certification-outreach/edac/about-ebd.
3 Review the report by Centers for Medicare and Medicaid Services (CMS), HCAHPS: Patients’ Perspectives of Care Survey—CMS. cms.gov.
4 Check out the article, https://journals.lww.com/journalpatientsafety/fulltext/9900/consequences_of_inpatient_falls_in_acute_care_a.217.aspx#:~:text=Fall%20rates%20in%20acute%20care,and%20patients’%20characteristics%20and%20diseases.&text=One%2Dthird%20of%20patients%20fall,50%25%20of%20fallers%20suffer%20injuries.
5 To explore further, visit www.tidiproducts.com/resources/articles/falls-prevention/importance-of-falls-prevention-in-hospitals.
6 For more information, visit https://psnet.ahreq.gov.
7 Review the report by Nanda, U., Malone, E., and Joseph, A. (2012). Achieving EBD Goals through Flooring Selection & Design. Concord, CA: The Center for Health Design.
8 Refer to www.pennmedicine.org/news/news-blog/2021/july/minimizing-disruption-maximizing-sleep-in-the-hospital#:~:text=With%20interrupted%20or%20limited%20sleep,experiences%2C%20and%20poor%20health%20outcomes.
9 To learn more, visit www.aamc.org/news/hospitals-are-noisy-they-don-t-have-be#:~:text=Sources%20of%20noise%20are%20common,to%2084%20dB(A)%5D.
10 Review the studies by Bae, S., & Fabry, D. (2014). Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review. Nursing Outlook, 62(2), pages 138-156. Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), pages 1-8. doi:10.1097/NNR.0b013e3181fff15d [doi].
11 See note 7.
12 Refer to the white paper, Environmental Services: Delivering on the Patient-Centered Promise, Press Ganey Associates, Inc., 2016.
13 For more insights, see www.issa.com/articles/show-me-the-science-the-impact-of-floors-on-indoor-air-quality-health.
14 See note 7.
15 To learn more, visit https://hbr.org/2019/05/when-patient-experience-and-employee-engagement-both-improve-hospitals-ratings-and-profits-climb.
16 Read more at https://www.buildingsiot.com/blog/minimizing-indoor-air-pollution-in-hospital-settings-supports-better-patient-outcomes-bd#.
17 See www.epa.gov/coronavirus/about-list-n-disinfectants-coronavirus-covid-190.
18 For more information, visit www.verywellmind.com/color-psychology-2795824.
Author
Sandra Soraci, EDAC, LEED AP, NCIDQ, IIDA, RCR, is the director of healthcare and senior living segment strategy for Tarkett North America. Her diverse and deep career-specific focus on healthcare and commercialization efforts fully informs the customer decision-making journey. Through an evidence-based design lens, Tarkett continually seeks to create flooring solutions that contribute to greater connection, safety, and overall well-being. Healthcare is ever-changing. Soraci’s passion is to educate and support material specifiers based on what healthcare professionals have said they need the floor to contribute.
