INT_Malkin_web.jpgHealth care interior designer Jain Malkin says evidence-based design — EBD in the profession’s lingo — is improving the patient experience by making health care facilities safer and less stressful.

What key factors are shaping evidence-based design trends in health care today?

MALKIN: I would not characterize EBD as trend-oriented. It is a research framework for planning and designing an acute care or outpatient facility, whether new construction or remodel.

The subject area is broad and includes a multimodal approach to patient safety, access to nature, good acoustics, functional lighting design, analysis of space planning issues such as patient bathroom design, patient room and locations of sinks and caregiver work stations.

It covers the benefits of gardens, water features and appropriate types of artwork known to be restorative in a clinical setting. There is, in addition, a focus on the patient experience, which ties into HCAHPS survey scores for patients’ perspectives of care.

Has EBD become an industry standard or best practice?

MALKIN: Yes, evidence-based design has reached critical mass. It is both an industry standard and a best practice. The 2014 Facility Guidelines Institute Guidelines for Design and Construction of Hospitals and Outpatient Facilities requires a safety risk assessment for any new or remodel project. In prior editions of the Guidelines, there was no standardization for executing this and, in fact, it was recommended but not required.

The new Safety Risk Assessment Toolkit developed by the Center for Health Design is now referenced in the 2014 Guidelines as the protocol to be used. This is a user-friendly tool that covers infection control, patient handling, falls, medical errors, issues of security and psychiatric risks. The benefits of this toolkit are huge. It represents three years of work by a collaboration of safety risk experts.

Can EBD meet the economic challenges most hospitals face?

MALKIN: The financial impact of implementing an EBD agenda is, of course, important, but one must consider long-term operating costs and not just initial capital costs for including some of these features. It has a short payback, often just three years, but the benefits keep going over the life of the building in some cases.

The CHD did a business case analysis of the EBD features with the biggest impact, looking at first costs and payback to recoup it. This is available on the CHD website and also has been published in a book. On many of these issues, not doing something — for example initiatives to reduce falls or to reduce caregiver skeletal injuries by providing ceiling-mounted lifts — is not an option. These are best practices supported by data. The cost of injuries and the associated rehabilitation time lost by nurses is very expensive to the hospital. Similarly, medical errors and health care-associated infections are costly and often keep a patient in the hospital several additional weeks with care that is not reimbursed.

How can EBD impact patient safety and especially the prevention of HAIs?

MALKIN: A wide number of things affect patient safety. They include ways to prevent falls and medical errors, patient handling, placement of sinks and the types of faucets that do not allow water to collect inside the rim and grow pathogens, and the way the room is cleaned. An example is the ability for fecal matter to aerosolize when the toilet is flushed and spread to faucets and other surfaces in the room, which are then touched by the patient and caregivers and spread to other patients.

Just exploring the topic of medical errors, we know these are more likely to occur in noisy environments and where nurses are visually distracted while preparing meds and when the lighting is inadequate. It needs to be three times that of “normal” nurse station lighting and be shadow-free. Errors are also made because of packaging — similar color and graphics for perhaps a pediatric and an adult version of the drug.

Of course, at the baseline of infection control is handwashing, which is still a challenge at many hospitals. Physicians in particular, according to studies, find it hard to comply, and may walk from patient to patient carrying pathogens on their hands and garments.

Studies have been made of the “hot” surfaces in a patient room and bedrails are at the top of the list. In recent years, copper has been introduced as a method of extinguishing pathogens dating to the Egyptians who used copper vessels for storing water. Using it for handrails, door hardware and faucets is expensive, but vendors have been pursuing this.

How is the growing number of baby boomers and the aging population impacting interior design in hospitals and health care facilities?

MALKIN: They are accustomed to choice and having things their way. Boomers expect an array of amenity options offered in a healing environment by staff who are responsive, kind and attentive. In the current financial climate, these expectations may be hard to meet.

As for designing for an aging population, many of the strategies used by designers of senior living facilities will be useful. They include attention to lighting levels, contrasts in flooring and employing principles of universal design.

How will the proliferation of technology impact interior design in hospitals and ambulatory care facilities?

MALKIN: I am very excited about this and have written about it extensively in my most recent book, the 4th edition of Medical and Dental Space Planning. This is hard to answer in a couple of sentences.

It’s not interior design that will be changed that much, but the actual need for a patient visit. A fundamental revolution is underway that proposes to use mobile and wearable technology to transmit data to care managers. Read Eric Topol’s book The Patient Will See You Now for a forecast by one of medicine’s most visionary physicians. 

Much will be done through secure portals at home through which all types of vital statistics can be transmitted to the equivalent of a nursing call center that will monitor it and make sure the patient is stable. Face-to-face visits with nurses and physicians will occur via the patient’s monitor. 

The Malkin File


• Founded Jain Malkin Inc., San Diego, a health care interior architecture firm specializing in evidence-based design.

• Serves on the board of the Center for Health Design and editorial advisory board of HERD: Health Environments Research & Design Journal and Healthcare Design magazine.


• Author of several health care design books, including A Visual Reference for Evidence-Based Design, which she lectures on globally. Her latest book is Medical and Dental Space Planning: A Guide to Design, Equipment, and Clinical Procedures, 4th Edition (John Wiley & Sons, 2014).

• Named one of the “Most Influential People in Healthcare Design” by one industry magazine. For 14 years, taught a health care design charrette at Harvard