This article was originally published on May 12, 2014, and is among Healthcare Design‘s Top 10 most-read articles of 2014. To see a full list, click here

In the current industry climate, architects and designers can expect healthcare clients to challenge practices—even best practices—if they lead to higher costs. Case in point: Pittsburgh’s UPMC expected every square foot of its new UPMC East hospital, completed in July 2012, to contribute value to the organization, reflecting a broad industry trend in response to changing reimbursement models under the Affordable Care Act. Healthcare organizations are seeking projects that are economically viable from the start and offer value over the long term. For many, any potentially wasted square footage, especially in the patient room, is a luxury that’s no longer sustainable.

The patient room is one of the largest investments a hospital will make, with the design decision multiplied dozens, even hundreds, of times. For UPMC East, the challenge for BBH Design (Raleigh) was to balance performance and cost, assuming that at some point there are diminishing returns on how much performance is enhanced by an increase in size. Additionally, value for UPMC East was also defined by introducing smart technology into patient rooms, specifically a system that prompts nurses to initiate care activities and provides patient education.

Putting a guidelines-driven approach to patient room square footage aside in favor of a design research approach, the team addressed a list of functional and experiential criteria with the client. After dozens of iterations, UPMC selected a right-sized patient room for its needs. Here’s a look at how the research informed the design.

Balancing objectives
The 2010 Facility Guidelines Institute’s Guidelines for Design and Construction of Health Care Facilities (FGI) suggests that patient/family-centered patient rooms should include 250 square feet of clear floor area, exclusive of toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules. The layout should also provide a minimum clear dimension of 15 feet, with an additional 30 square feet of clear floor area for each family member permitted by the facility to be in the room.

For the UPMC East project, the first challenge was to find the right size and layout that would be patient/family-centered and ultimately deliver capital and operational savings. Ownership indicated early in the schematic phase that many of the existing UPMC facilities with rooms smaller than FGI’s suggestion had been determined to be sufficient for patient-centered care, which led the design team to begin the project by benchmarking patient rooms’ square footages across UPMC and non-UPMC facilities, finding the average room size to be 183 net square feet. This average was very low due to the number of pre-2000 UPMC facilities in the sample. While UPMC East recognized that 183 square feet was too small to be a target for new hospital construction, it was still committed to the idea of a more space-efficient option.

The next step involved the construction of a series of progressive patient room mock-ups, allowing the team to test room performance against a list of criteria developed with UPMC East. Initially, the most important criterion was a small floor area. Other criteria included ample space around the patient bed, maximum natural light, toilet access from the headwall, and the capacity to accommodate bariatric patients. Interestingly, the final design was not the smallest, but it outperformed in patient-centric criteria such as visibility of the patient from the corridor, ample space around the patient, and patient privacy.

The average patient room size in the U.S. increased from 240 square feet in 2002 to 320 square feet in 2012, an increase of 33 percent, according to Health Strategies and Solutions Inc. (Philadelphia). Comparatively, the UPMC East team ultimately zeroed in on a 220-net-square-foot patient room. Using a conservative average room size of 300 square feet based on previous years’ averages, the UPMC East patient room represents a savings of 80 square feet. Square footage savings quickly translates into cost savings. With 156 patient rooms built for the project and healthcare construction cost averaging $400 per square foot, UPMC East saved $4.9 million in capital costs as well as approximately $9 million in operational costs over the projected 50-year life of the building. Right-sizing the UPMC East patient room also yielded an estimated $1 million in energy savings for every 10 years of operation.

Right-sizing as a patient-centered strategy
Outside of achieving cost benefits, right-sizing is also a strategy for implementing patient-centered care. In the case of UPMC East, right-sizing allowed the team to implement smart technology, maximize the family zone, and distinguish areas for caregivers.

From the onset of the project, it was established that smart technology would play an integral role in the room design. Each patient room is equipped with the means to bring patient information to the bedside when it’s needed through the integration of two main components: a touch-screen personal computer on the patient headwall at the entrance to the room and a monitor at the foot of the patient bed. The monitor functions both as the patient’s TV and as a smart room display that shows patient data, information on care tasks, and patient education materials. The smart technologies for the UPMC East patient room were aimed at engaging the patient and care staff in jointly sharing information in a way that doesn’t require staff to turn their backs to patients while accessing records on a computer—fostering engagement without additional square footage.

Placement of smart technology also had an impact on zoning of the patient room. Typically, family zones are created at the window edge of a patient room’s long dimension. As the components were finalized at UPMC East, it was decided to place the family zone on that window side of the room as well as at the foot of the bed, giving family an opportunity to interact face-to-face with patients and caregivers. Providing this option to sit closer to the patient allowed greater opportunity to shrink square footage by decreasing the overall depth of the room.

Caregiver activity is concentrated in two zones. For activities that primarily require access to electronic medical records, staff can work at the head of the patient bed, allowing care to be provided without moving too far into the room or disrupting patients’ rest. Additionally, a zone just inside the room door is designated for activities such as handwashing or to accommodate easy pick-up of food trays.

Does it work?
The opening of UPMC East in July 2012 wasn’t the end of its right-sizing for patient/family-centered care story. Additional research was conducted to address the following questions:

  1. If smaller rooms in the UPMC system were perceived as sufficient for patient-centered care, how does UPMC East’s performance stack up in comparison, with respect to patient safety and satisfaction outcomes?
  2. If the patient room is right
    -sized, does that mean the patient unit is also right-sized and configured for patient-centeredness?
  3. Can smart technology help to shrink room size and contribute greater value for the patient experience than additional square footage can?

Using archival data from UPMC hospitals, the team discovered that the 220-square-foot rooms at UPMC East didn’t register as a negative in HCAHPS scores. Compared to peers across the UPMC system, patients at UPMC East reported significantly greater satisfaction with responsiveness to their needs (e.g., call button, toileting), better communication with nurses, and a greater likelihood of recommending the hospital. From a quality and safety standpoint, patients at UPMC East experienced significantly fewer falls and readmissions.

The method used to collect the data precludes any certain identification of the facility as making the difference, yet the data does indicate that it’s possible to design a smaller patient room without sacrificing patient safety and satisfaction.

With regard to the right-sized unit and patient-centeredness, a space syntax analysis was performed on UPMC plans, including UPMC East, which indicated that visibility into patient rooms was considerably higher at UPMC East and that its corridor system was easy to understand and navigate. Higher corridor-to-patient visibility may have contributed to higher patient satisfaction because it’s likely to support nurses in responding to patients’ needs, while increased legibility in wayfinding makes it quicker and easier to travel to patient rooms. Further research methods and tools will need to be initiated to explore overall unit layout and patient satisfaction.

The post-occupancy evaluation suggests that smart room displays may have given patients and families better access to patient information, compared to other UPMC facilities. Good feelings associated with this enhanced awareness and knowledge may compensate for the slightly smaller floor area, especially since satisfaction with the patient room setting may be driven less by square footage and more by amenities. Further stages of the POE will isolate what specifically about the design of the rooms contributes to patient/family-centered care.

This experience at UPMC East has demonstrated that it’s possible to design a smaller and ultimately less expensive patient room while preserving, if not enhancing, patient satisfaction and safety. Recommendations about square footages are made to be tested. In most cases, it’s more effective to design to functional needs and patient and family experience, allowing those components to dictate area.

From BBH Design, the authors thank Julie Zook and Timothy Spence for their collaboration and insights. From the Donald D. Wolff Jr. Center for Quality, Safety, and Innovation, the authors thank Linda Higgins, Susan C. Martin, and Jeffrey D. Borrebach.

Esperanza Harper, EDAC, is an associate and healthcare planner at BBH Design (Raleigh). She can be reached at Nicholas Watkins, PhD, is director of research at BBH Design (Raleigh). He can be reached at Tamra Minnier, RN, MSN, FACHE, is chief quality officer at UPMC (Pittsburgh). She can be reached at