More than 200 million surgeries are performed worldwide each year, and recent reports reveal that adverse events occur during one in 10 surgical procedures. While significant efforts have been made at the human level, including improving staff training and technology use, a re-examination of the design of the environments in which surgeries take place is also necessary.

Operating rooms (ORs) today tend to be crowded and cluttered with an ever-increasing amount of equipment, along with the cords or cables associated with it, to support technology-dependent surgical procedures. This increasing “clutter” can pose significant risks to the safety of both patients and staff.

Clemson University and the Medical University of South Carolina (MUSC) have been working to design a safer OR since September 2015 through a Patient Safety Learning Lab (PSLL) called Realizing Improved Patient Care through Human Centered Design in the OR (RIPCHD.OR).

The learning lab is one of 13 national PSLLs funded by the Agency for Healthcare Research and Quality; however, it’s the only one that has a built environment focus and that’s based in a school of architecture. The overall goal of this four-year learning lab is to design a safer, more ergonomic operating room prototype for ambulatory surgery through evidence-based research that can inform the design of future ambulatory surgery operating rooms at MUSC and in the industry at large.

Three core groups, each including students and faculty members from Clemson University and MUSC, were created to focus on a different problem within the OR system: addressing the fatigue among anesthesiologists related to processing the increasing number of alarms and patient status indicators during the surgical procedure; improving flows of people, equipment, supplies, and information within the OR; and designing a human-centered OR prototype that’s more ergonomic, safer, and more efficient for all users.

Research began with an in-depth study of the OR system, including a review of published literature; analysis of 35 surgery video recordings; collection of microbial load data; visits to best-practice surgery centers; and interviews and focus groups with clinicians such as anesthesiologists, nurses, and surgeons. The findings served as a foundation for the iterative design and development work undertaken next by eight graduate students from Clemson’s Architecture + Health program in the second year of the lab.

The design progressed through iterative physical mock-ups and scenario-based mock-up evaluations, which were conducted with surgical teams from MUSC to understand how different features impacted flow, efficiency, and safety.

For example, through the simulations, the clinicians identified that an angled surgical bed helped with the flow of staff and equipment and allowed for clearly defined zones in the OR. They also provided input about the location of doors and the scrub sink to improve flow and maintain sterility.

The final design concept was completed in January and built as a high-fidelity mock-up at the Clemson Design Center in Charleston, S.C., and will be further refined through additional mock-up evaluations in the coming year.


Key characteristics

The following are some of the key characteristics of the resulting 579-square-foot OR prototype.

Achieve flexibility and adaptability. A flexible prototype was designed as a basic room “chassis” that can be integrated into a single corridor, clean core, or work core OR suite. The size of the chassis was determined through the simulations and refined through iterative rounds of evaluation. This chassis can accommodate a variety of adjacent ancillary space options, such as an induction room, instrument processing room, or imaging control room, depending on the actual needs and planned uses of the OR. These ancillary rooms are modular and can be adapted to other functions within the same footprint, as needs change. An overhead structural grid allows reconfiguration of overhead surgical lights and booms to answer evolving surgical procedures and needs. Conventional metal stud and cladding wall systems have been replaced with a modular wall system with plug-and-play panels. This provides flexibility as well as reduces the cost of OR downtime and service disruptions during renovation. Surgical booms have plug-and-play features that enable easy reconfiguration of gas, electric, and data connections when required. These features are designed to accommodate ever-changing clinical and operational needs of the space over time, including the 30- to 50-year projected life of the facility infrastructure.

Optimize movement and flow. Observations of surgical procedures indicated that many task disruptions, including staff tripping over cables or bumping into one another or equipment, can be attributed directly or indirectly to the physical environment. To minimize unnecessary effort, trips, steps, and conflicts in movement patterns that contribute to surgery disruptions, the prototype room is organized into four zones or quadrants: an anesthesia zone at the head of the surgical table; sterile zones on both sides of the bed; and a circulation zone. The OR table is located off-center and angled in the room to improve circulation outside of the sterile field, optimize movement and flow, and reduce workflow disruptions. This positioning and orientation create greater space for the circulating nurse to move and improve access to the anesthesia zone for anesthesia staff. Recessed storage is provided in the anesthesia and circulation zones to minimize travel for the anesthesia team and circulating nurse while obtaining supplies during surgery. The provision of a mobile workstation for the circulating nurse allows the optimal positioning of his or her work area in relation to the procedure type and surgery side, to maximize views to the team and allow easy access to the scrub nurse and supplies.

Minimize institutional clutter. A cluttered space creates more visual complexity, with the potential for distraction and missing critical indicators. A greater number of discrete objects, such as equipment and furniture, can also impede the efficient movement of people and equipment in the space. The OR prototype minimizes clutter and related trip hazards through flush wall surfaces, recessed storage, and the use of overhead booms that support cable and tube management. These features also address the issue of constricted space for staff movement by reducing the number of individual objects in the room.

Reduce surface contamination and microbial load. As noted, the increased quantity and complexity of equipment and supplies located in the typical OR add to the number of surfaces and objects that need to be cleaned, both between cases and at the end of the day. The prototype is envisioned to include a range of passive and active infection control strategies, including visible spectrum lighting to disinfect all visible surfaces in the OR at the end of the day; minimal horizontal surfaces to reduce dust collection; glass and steel modular wall systems that can be cleaned easily; recessed storage to reduce surfaces that need to be cleaned in the OR; hands-free sliding doors to prevent contamination; and cable and tube management to minimize clutter and trip hazards. Some of these features are already being implemented in new ORs. Additionally, minimizing movement of OR staff around the sterile zone through the new layout will also help reduce the microbial load in the sterile zone.

Support visual awareness and communication. Communication breakdowns are frequently identified in the literature as a source of disruptions and errors in the operating room. For a safe and efficient surgery, it’s critical for surgical staff to work closely together as a team. They must understand and anticipate the steps in the surgical process, have all the information about the patient and surgery easily accessible, and be able to communicate with one another without obstruction. To support visual awareness and communication in the OR prototype, integrated digital wall-mounted information displays are strategically placed in multiple locations on both booms and walls to contribute to increased contextual awareness among team members. Depending on the phase of the surgery, different types of information can be displayed, such as patient vital signs, video of the surgical site, or the surgical checklist that ensures key steps have been taken by the team. Redundant information displays in multiple locations allow staff in different positions and orientations to have access to critical information, regardless of their viewing position.

Reduce stress through daylighting and artificial lighting strategies. Research in other workspaces, such as office environments, indicates access to daylight and views outside can improve staff satisfaction, mood, and productivity. Anecdotal evidence from other countries where daylight and views to nature from surgical suites are more common indicates that surgical staff prefer either direct or indirect views to the outside from within the OR. However, most ORs in the United States lack windows and, as a result, surgical teams spend entire days working in these spaces without seeing daylight. The prototype design provides the opportunity for access to daylight and views to the outdoors through the incorporation of a full or partial window with controls for light levels, glare, and privacy. The room also uses dynamic glass displays for incorporation of a range of scenes and lighting to support different phases of the surgery. For example, the glass could display a stress-reducing view of nature as a patient is brought into surgery and then change to show patient vitals during surgery.


Coming soon

The next phase of this project planned for 2018-2019 includes further evaluation of the higher fidelity mock-up using simulation to refine the prototype design. Post-occupancy evaluation of the operating rooms will be incorporated in new surgery centers being proposed by MUSC, to understand the impact on satisfaction and flow disruptions.

This project represents the most comprehensive study of OR design based on gathering a deeper understanding of user needs, workflows, and safety and performance goals and needs. The findings will also be incorporated into a web-based OR design tool to help educate healthcare design teams and clinical users about safety-related issues in the built environment that should be considered while designing and operating ORs.

Anjali Joseph, PhD, EDAC, is the Spartanburg Regional Health System Endowed Chair in Architecture + Health Design and Director of the Center for Health Facilities Design and Testing at Clemson University (Clemson, S.C.). She can be reached at David Allison, FAIA, FACHA, is alumni distinguished professor and director of the graduate program in Architecture + Health at Clemson University. He can be reached at