A Comparative Evaluation of Internal Medicine Wards in Spain

Abstract

Objective-This analysis investigates the functional and environmental quality of several internal medicine wards in Spain. Background-Despite the economic recession, the Spanish healthcare system has proven to be resilient. In the near future, Spain will be faced with the demographic challenge of an ever-ageing population. Further efforts should be made to ensure a sustainable and affordable healthcare system. The elderly population is the group that requires the highest rates of healthcare resources, especially in acute-care hospitals, with the maximum hospital attendances and the longest average length of stay. Since there is scientific evidence that links healthcare outcomes with design (evidence-based design), one way of improving the efficiency of healthcare delivery is by enhancing the quality of existing internal medicine wards as it is usually the place where elderly inpatients are cared for. Post-Occupancy-Evaluation (POE) tools have been used globally to assess the performance of existing buildings but little has been applied in the Spanish context.

Full text

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PaperARCH19–Buildingforbetterhealth 1
AComparativeEvaluationofInternalMedicineWardsinSpain
LauraCambra‐Rufino(1),JoséLeónPaniagua‐Caparrós(2),CésarBedoya‐Frutos(1)
(1)UniversidadPolitécnicadeMadrid,Spain,laura.cambra.rufino@upm.es0000‐0002‐3450‐152X;
(2)InstitutodeSaludCarlosIII
Abstract
Objective–Thisanalysisinvestigatesthefunctionalandenvironmentalqualityofseveral
internalmedicinewardsinSpain.
Background–Despitetheeconomicrecession,theSpanishhealthcaresystemhasprovento
beresilient.Inthenearfuture,Spainwillbefacedwiththedemographicchallengeofanever‐
ageingpopulation.Furthereffortsshouldbemadetoensureasustainableandaffordable
healthcaresystem.Theelderlypopulationisthegroupthatrequiresthehighestratesof
healthcareresources,especiallyinacute‐carehospitals,withthemaximumhospital
attendancesandthelongestaveragelengthofstay.Sincethereisscientificevidencethatlinks
healthcareoutcomeswithdesign(evidence‐baseddesign),onewayofimprovingtheefficiency
ofhealthcaredeliveryisbyenhancingthequalityofexistinginternalmedicinewardsasitis
usuallytheplacewhereelderlyinpatientsarecaredfor.Post‐Occupancy‐Evaluation(POE)
toolshavebeenusedgloballytoassesstheperformanceofexistingbuildingsbutlittlehas
beenappliedintheSpanishcontext.
Researchquestion–Howwelldoexistinginternalmedicinewardsperforminrelationto
guidelinesandresearchonfunctionalandenvironmentalquality?
Methods–Bothquantitativeandqualitativemethodshavebeenusedinthiscasestudyfor
thetriangulationofdata.Fourinternalmedicinewardshavebeenevaluatedwiththefollowing
methods:architecturallayoutanalysis,photoanalysisandaPOEtooldesignedfortheSpanish
context(CURARQ‐H).
Results–Notsurprisingly,theoldestwardscoreslowerthanthemostrecentbuildings.The
analysisrevealsthatthepatients’areaistheonethatgetsbettergradeswhiletheaccessarea
scoresthelowestmarks.Furtherdetailsonimprovementmeasuresaregivenforeachward
area.
Conclusion–ComparedtoScandinavia,USAorCanada,healthcarearchitectureinSpainis
beingslowtoembarkonEBD.ThisevaluationmethodtogetherwithCURARQ‐Htoolcouldbe
anenablerforgeneratingsynergiesbetweenhealthcarestaffandarchitectsinSpainandwork
asanacceleratorintheuseofEBDatanationallevel.
Keywords:Internal‐medicineward,post‐occupancy‐evaluationtool,evidence‐baseddesign,design
evaluation,evaluationtool
Funding:Theauthorsdisclosedreceiptofthefollowingfinancialsupportfortheresearch,authorship,
and/orpublicationofthisarticle:“AyudasparalaformacióndeprofesoradoUniversitario”Ministeriode
EducaciónCulturayDeportedeEspaña,FPU15/02660. 

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PaperARCH19–Buildingforbetterhealth 2
1.Background
1.1Spainvs.Scandinavia
ThefollowingtableshowsseveralnationalindicatorsforSpain,Denmark,NorwayandSweden.
SpainDenmarkNorwaySwedenUnit
Population(2013‐2014)46.4645.6145.1379.609Inhabitants,thousands
Lifeexpectancyat
birth(2016)
♀86,382,884,284,1Years
♂
80,57980,780,6Years
Healthexpenditureand
financing(allfunctions
2015)
9,110,310,111%(ShareofGross
domesticproduct)
3.175,55.000,86.239,45.271,9USDollar(Percapita,
currentprices,current
PurchasingPower
Parity(PPPs))
Totalhospitalbeds
(2016)
138.00814.87119.30323.207Number
2,972,63,692,34Per1.000population
Averagelengthofstay
(inpatientcare,hospital
aggregates2016)
7,35,46,95,8Days
Table1,Nationalindicators:comparisonbetweenSpainandScandinavia[1].
ThenumbersrevealthateventhoughSpainhasoneofthelongestlifeexpectanciesatbirth,itshealth
spendingisthelowest(abouthalfofUSdollarspercapitacomparedtoNorway)andtheaveragelength
ofstay,thelongest.Theseindicatorsdemonstratethatthereareplentyofopportunitiestoimprovein
theSpanishhealthcaresystem.
1.2Spanishhealthcaresystem
Spainhasadecentralizednationalhealthsystemor“SistemaNacionaldeSalud”(SNS)inSpanishwhich
isfundedbytaxes.Thispublicsystemisbasedontheprinciplesof“universality,freeaccess,equityand
fairnessoffinancing”[2].TheSNSisorganizedindependentlybythe17regionsofthecountrywitha
nationalinstitutionresponsiblefortheoverallcoordinationandmonitoringofitsperformance.
Aftertheeconomiccrisisin2008,measuresweretakenforreducingpublicexpenditureintheSNS.It
wasnotuntil2014thatpublicspendingonhealthstartedtoincreaseagain.Despitethebudget
reductionssufferedoverthistime,theSNShasproventoberesilient[2].Thisresiliencecouldbecaused
bythestrengthofprimarycareanditsclosecoordinationwithacute‐carehospitals,asbothcarelevels
belongtothesamepublicsystem.
Acute‐carehospitalsaccountedforover25%ofhealthspendingin2014[3].Thatiswhyefficiency
measureshavetargetedthisexpensivesector.TheSNSjoinstheglobaltrendonhospitalbedreduction
(from3,68bedsper1.000inhabitantsin2000to2,97bedsper1.000inhabitantsin2016[4])and
shorteraveragelengthofstay.Thepossibilitytofreeresourcesintheinpatientareaofanacute‐care
hospitalhasbeenmadepossiblethankstothemovingofmanydiagnosticandtherapeuticprocedures
totheoutpatientcare(bothintheacute‐carehospitalandinprimary‐carecenters).However,clinical
advanceshaveincreasedtheneedforintensivebedsinacute‐carehospitalsasmoresevereandcritical
illnessescannowbetreated[5].
Inthenearfuture,Spainwillbefacedwiththedemographicchallengeofanever‐ageingpopulation.
Eventhoughhealthexpenditureisexpectedtorise,furthereffortsshouldbemadeinordertoensurea
sustainableandaffordableSNS[3].


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PaperARCH19–Buildingforbetterhealth 3
1.3Internalmedicineward
TheinternalmedicinewardinaSpanishacute‐carehospitalisusuallytheplacewheretheelderly
inpatientsarecaredfor.Thesepatientsmaysufferfromtwoormorechronicconditionsandhencehave
higherfunctionallimitations[6].Figure1showsthedataprovidedbythesurveyofhospitalmorbidity
carriedoutbytheSpanishInstituteofStatisticsin2016.

Figure1,HospitalattendancesandaveragelengthofstayaccordingtoageinSpainin2016[7].
Thefigureillustratesthatthehighesthospitalattendancerates(dischargesin2016)occurintheage
rangeof55to84years.Furthermore,eventhoughtheattendanceforpatientsagedover85islower,
theiraveragelengthofstayreachesitsmaximumduration(9,78days).Thosefactscorroboratethatthe
usageofacute‐carehospitalresourcesisnotdistributedhomogenouslyamongtheSpanishpopulation.
Infact,itistheelderlypopulationgroupthatrequiresthehighestratesofhealthcareresources.Thus,
improvementmeasuresintheinternalmedicineward(alongwithotherapproaches)mightincreasethe
qualityofthecaringprocessandensureacost‐efficientusageofhealthcareresources.
1.4Evaluationtools
Giventhatthereisscientificevidence[8]thatlinkshealthcareoutcomeswithdesign(evidence‐based
design),onewayofimprovinghealthcaredeliveryisbyenhancingthequalityofhospitalenvironments.
Despitethefactthatdesignqualityisstillanimpreciseconcept[9],therearemanytoolsorinstruments
targetedtomeasurethequalityofthephysicalhealthcareenvironment[10].ThePost‐Occupancy
Evaluation(POE)[11]isthemostextendedmethodinuseforassessingtheperformanceofbuildings.
SincetheintroductionofthePOEattheendofthelastcentury,therehasbeenaproliferationof
differenttools.Thereisevenamodel(theFocusFlower[12])fororganizingthedifferentevaluation
methodsaccordingtotheirmainfocus(beauty,durabilityorutility).Morespecifically,POEtoolshave
foundanimportantnicheinthehealthcaresector,wheresmallbuildingimprovementsmightresultin
financialgains.Thus,pinpointingthedesignfeaturesthatmighthaveareturnoninvestmentoverthe
lifecycleofthebuilding[13]hasbecomeofparamountimportance.Subsequently,thereisagrowing
interestinthedevelopmentofevaluationtoolsforeverydifferentcontextasthereisno“onesizefits
all”solution[14].
1.5Researchquestion
Theaimofthispaperistoinvestigatethefunctionalandenvironmentalqualityofseveralinternal
medicinewardsinSpain.Theresearchquestionis:
Howwelldoexistinginternalmedicinewardsperforminrelationtoguidelinesandresearchon
functionalandenvironmentalquality?
Withthisresearchquestionweaddresshowtoincludetheorganizationallearningcollectedmainlyby
thenationalguidelinesintotheevaluationoffourindividualprojects.Theaimofguidelinesisusuallyto
translateandapplicateresearchintodesign[15].Thisstudyanalyzesexistingdesigntotestthe
applicationstageoftheguidelinesandotherresearch.
0
100.000
200.000
300.000
400.000
500.000
600.000
700.000
800.000
900.000
0,00
2,00
4,00
6,00
8,00
10,00
12,00
<1
year
1‐4
years
5‐14
years
15‐24
years
25‐34
years
35‐44
years
45‐54
years
55‐64
years
65‐74
years
75‐84
years
85‐89
years
90‐94
years
≥95
years
Hospitalattendances
(dischargesperyear)
Averagelengthofstay
(days)

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PaperARCH19–Buildingforbetterhealth 4
2.Methods
Bothquantitativeandqualitativemethodshavebeenusedinthiscasestudyforthetriangulationof
data.Fourinternalmedicinewardshavebeenevaluatedwiththefollowingmethods:architectural
layoutanalysis,photoanalysisandaPOEtooldesignedfortheSpanishcontext(CURARQ‐H).
2.1CURARQ‐H
CURARQ“Arquitecturaparacurar”orarchitectureforcureisapost‐occupancy‐evaluationtoolavailable
online[16],whichmethodologyhasbeenpreviouslypublished[17].
Thedatacollectionstartswithatouracrossalltheroomsoftheward.Foreachroomthereareseveral
itemsthatcanbechecked.Thetotalnumberofitemsforthewholewardis213andtheyareorganized
accordingtofourquestions:where?why?whatfor?andwhat?

Figure2,CURARQ‐Hcontentstructure.

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PaperARCH19–Buildingforbetterhealth 5
Where?
Theinformationisorganizedaccordingtotheroomthatisbeinganalyzed,whichinturnsispartofa
functionalareaoftheward.Theroomsthatcanbefoundinanyoftheseareasare:
- Unitconfiguration(10items):anoverallcategoryforgeneralfeatures(signage,art)the
planninglayoutoftheunitanditsrelationshipwithotherunitsoftheacutehospital.
- Circulationarea(17items):internalcorridorforinpatientsandstaff.
- Accessarea(21items):externallobbyandentrance(forvisitorsorrelatives),waitingroom,
publictoiletandinterviewroom.
- Patientandfamilycarearea(74items):patient’sbedroom,patient’stoiletandpatients’rest
room.
- Nursingcontrolarea(55items):counter,nurses’officeroom,medicinepreparationroom,staff
restroom,headnurse’soffice,stafftoilet,treatmentroomandassistedbathroom.
- Staffarea(8items):doctors’officeroomandstaffchangingroom.
- Supportarea(28items):internallobby(forstaff,inpatientsandsupplies),regenerationkitchen,
dirtyutilityroom,cleaners’room,dirtylinenroom,linenstore,cleansupplyroomandlarge
equipmentstore.
Why?
Specifiesthesourcefromwheretheitemhasbeentaken.Thesummaryofreferencesusedareshownin
Figure3.

Figure3,Sourcesoftoolcontent.
Typeofevidencestateswhethertheitemconsideredcomesfromresearch(A)orregulations,best
practiceandintuition(B).Accordingtothetypeofevidence,eachitemscorespoints(10pointsforanA
itemand1pointforaBitem).
Whatfor?
Determinestheobjectivetheitemaimsat.Theseobjectiveshavebeentakenfromanexistingtool[18]:
- Improvepatientsafety.
- Improveworkersafetyandeffectiveness.
- Improvequalityofcareandpatientexperience.
- Improveorganizationalperformance.

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PaperARCH19–Buildingforbetterhealth 6
What?
Identifiesthedesignelementthatconcernstheitem(layout,lightopenings,installation,equipment,
flooring,ceiling,wall,door,furniture,signageorart)andtheitemdescription.Theanswertoanyitem
canbe“yes”,“no”or“notapplicable”.EachdesignelementhasacostassociatedaccordingtoTable2.
CostDesignelement
5layout
4lightopenings,installation
3equipment,flooring
2ceiling,wall,door
1furniture,signageorart
Table2,Costcategoryforeachdesignelement.
2.2Studycases
Fourdifferenthospitals(Table3),whicharegeographicallycloseandmanagedbythesamehealthcare
regionaldepartment,havebeenselectedforthiscomparativeevaluation.

HospitalshortnameHCUVHUPFHDHUV
Yearofbuildingorpavilionopening
(yearofrenovationworks)
1960(1994)201020092010
Assignedpopulation341.972281.720166.108154.017
Installedbeds5821.050262230
Nºregisteredemergencies161.488237.32858.54489.467
Nºoutpatientappointments(first+
successive)
574.215618.050207.668240.761
Ratiosuccessive/first2,172,241,662,13
Nºhospitaladmissions(urgent+
planned)
24.10545.10911.90812846
Averagelengthofstay(days)6,396,485,545,09
EvaluationdateJanuary2018January2018June2016February2018
Table3,Hospitaldata[19]forHospitalClínicoUniversitariodeValencia(HCUV),HospitalUniversitarii
PolitècnicLaFe(HUPF),HospitaldeDénia(HD)andHospitalUniversitariodelVinalopó(HUV).



PaperARCH19–Buildingforbetterhealth 7
Figure4showsthelocationoftheevaluatedwardwithineachtheacute‐carehospitalfloor.

Figure4,Wardevaluatedlocation.



PaperARCH19–Buildingforbetterhealth 8
HospitalClínicoUniversitariodeValencia(HCUV)
ThewardevaluatedinHCUVislocatedonthefourthfloorofpavilionB.Onthisfloorthereareanother
threeinpatientwardsandoutpatientcareatpavilionD.Directlyaboveandbelowtheinternalmedicine
wardthereisanotherinpatientwardwiththesameconfiguration.
Therearethreeelevatorcoresthatservetheunit.Themainelevatorcorehasamixtureofpublicand
privateflowsandisservedbyfourbedelevatorsandtwopassengerelevators.Thereisanotherbed
elevatorinthemiddleofthewardthatopensdirectlyontothecorridor(withoutlobby)andapassenger
elevatorforthetreatmentareaoftheunit.
ThewardhasanFshapeandthecorridorhaspatientbedroomsonbothsides.Inthecentralpartofthe
wardthecorridorhaspatientbedroomsononesideandthestaffareaandthecirculationcoreonthe
otherside.Thestaffsupportareaiscentralizedandthereisonlyonenursingstation.Thereisavariety
ofpatientbedrooms:twotriplerooms,fourteendoubleroomsandthreeindividualrooms(twoofthem
withoutshowerinthetoiletroom).

Figure5,HospitalClínicoUniversitariodeValencia(HCUV)layoutandroomsevaluated.



PaperARCH19–Buildingforbetterhealth 9
HospitalUniversitariiPolitècnicLaFe(HUPF)
TheinternalmedicinewardinHUPFislocatedontheseventhflooroftowerE.Onthisfloorthereare
anotherthreewingsforinpatientcareandtwowingsforoutpatientcare.Directlybelowtheinternal
medicinewardthereisanotherinpatientwardwiththesameconfiguration.Theseventhflooristhelast
oneofthewholeacutehospital.
Therearefourelevatorcoresthatservetheunit.Onecoreforpublicaccess(withtwopassenger
elevatorsforvisitors)andthreecoresforprivateaccess.Twoofthethreecoresforprivateaccess
consistoftwoandthreebedelevators(forstaffandinpatients)andthethirdcoreisservedbytwo
serviceelevators(forstaffandsupplies).
ThewardhasanFshape.Thecorridorhasonepartwithpatientbedroomsonbothsidesandanother
partwithpatientbedroomsononesideandstaffsupportareaontheotherside.Thestaffsupportarea
iscentralizedandthereisonlyonenursingstation.Thereare35individualpatientbedroomsand20of
themhaveananteroomfortheisolationofinfectiouspatients.

Figure6,HospitalUniversitariiPolitècnicLaFe(HUPF)layoutandroomsevaluated.



PaperARCH19–Buildingforbetterhealth 10
HospitaldeDénia(HD)
TheinternalmedicinewardinHDislocatedonthethirdflooroftheBhospitalizationwing.Onthisfloor
thereisanotherinternalmedicinewardandthepsychiatricward.Directlybelowtheinternalmedicine
wardthereisanotherinpatientwardonthesecondfloor.Thethirdflooristhelastoneofthewhole
acutehospital.
Therearetwoelevatorcoresthatservetheunit.Oneforpublicaccess(twopassengerelevatorsfor
visitors)andanotheroneforprivateaccess.Theprivatecoreisservedbyaserviceelevator(forstaffand
supplies)andapairofbedelevators(forstaffandinpatients).
ThewardhasanLshapewithadouble‐loadedcorridor(withpatientbedroomsonbothsides).Thestaff
supportareaiscentralizedandthereisonlyonenursingstation.Thereareatotalof37patient
bedrooms.Allpatientbedroomsareusedindividuallyeventhoughtheyhavedoublecapacitytocope
duringpeakseasons.

Figure7,HospitaldeDénia(HD)layoutandroomsevaluated.



PaperARCH19–Buildingforbetterhealth 11
HospitalUniversitariodelVinalopó(HUV)
TheinternalmedicinewardinHUVislocatedonthesecondfloorofthebluehospitalizationwing.On
thisfloortherearemoreinpatientwards(adult,obstetric,pediatricandneonatal),theoperating
theatersandthelaborunit.Directlybelowtheinternalmedicinewardistheoutpatientareaonthefirst
floor.Above,onthethirdandlastfloorthereisanotherwardwiththesamestructure.
Therearethreeelevatorcoresthatservetheunit.Oneforpublicaccess(twopassengerelevatorsfor
visitors)andanotheroneforprivateaccess.Theprivatecoreisservedbyapairofserviceelevators(for
staffandsupplies)andanotherpairofbedelevators(forstaffandinpatients).
ThewardhasaYshapewithadouble‐loadedcorridor.Thestaffsupportareaiscentralizedandthereis
onlyonenursingstation.Thereareatotalof30patientbedrooms.Allpatientbedroomsareused
individuallyeventhoughtheyhavedoublecapacitytocopeduringpeakseasons.

Figure8,HospitalUniversitariodelVinalopó(HUV)layoutandroomsevaluated.


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PaperARCH19–Buildingforbetterhealth 12
3.Results
Figure9representstheresultsobtainedbyeachwardwiththetoolCURARQ‐H.

Figure9,CURARQ‐Hresultsforthewardsevaluated.
TheresultsshowthatHDscoresthehighestpercentageinalmostallareas.HUVcomesnext,withthe
circulationandaccessareaslightlylower.TheHUPFhassimilarresultstoHUVbutlowermarksforstaff
andnursingareas.HCUVreceivesthelowestgradesinalmostallareas.
Comparingnowbetweenareas,thepatients’areaistheonethatgetsthebestgradeswhiletheaccess
areascoresthelowestmarks.Next,weanalyzetheresultsofeachareainmoredetailandillustratethe
bestdesignstrategiesinthephotographedrooms.

Figure10,Functionaldiagramsofwardareas.

0%
25%
50%
75%
100%
Unit
configuration
Circulation
Access
PatientsNursing
Staff
Support
HCUV HUPF HD HUV


PaperARCH19–Buildingforbetterhealth 13
3.1Unitconfiguration
TheunitconfigurationofHCUVisweakerthantheothersbecausetherearenotdifferentaccesspoints
forexternalandinternalflows.Inthisacute‐carehospital,thehospitalizationwardshavedifferent
layoutarrangementswhichmakesitmoredifficultforstafftogetusedto.Thereisnotanyformofartin
thewardandthemaintenancestatusofsomesignagesystemsispoor.
3.2Circulation

Figure11,CorridoratHUCV,HUPF,HDandHUV.
HDgetsthehighestpercentageasitsinternalcorridorhasnaturallight,notdirectartificiallightfromthe
ceiling,handrailsandthereisevenawideningofthecorridorateachinpatientbedroom.Thisspace
facilitatesthemanoeuvrabilityofthebed,givesprivacytorelativesandasofttransitionbetweenthe
roomandthecorridor.
3.3Accessarea

Figure12,WaitingroomforrelativesandvisitorsatHUPF,HDandHUV.
TheaccessareaatHCUVdoesnothaveawaitingroomforrelativesandvisitors,theotherthree
hospitalsdohaveonebutthequalitiesoftheroomcouldbebetter.Noneofthehospitalshasa
dedicatedinterviewroomandthestaffuseotherofficeroomsforprivateconversations. 


PaperARCH19–Buildingforbetterhealth 14
3.4Patientandfamilyarea

Figure13,Patient’sbedroomatHUPF,HDandHUV.
TheHCUVistheonlyonethathasaninpatientrestroom,intheotherhospitals,patientssharethe
waitingroomintheaccessarea.However,theoverallqualityofthatroom,thepatient’sbedroomand
thepatient’stoiletroomatHCUVisquitelowcomparedtothenewerhospitals.HUVistheonethat
scoresthehighestgrades.Itsinpatientbedroomscomplywithallbutfouritems:thesizeoftheroom
andthebedshouldbebigger,theswitchesshouldbelocatedatahigherlevel,thereisnotasecure
lockerforvaluableitemsandthedoordoesnothaveaquietclosingsystem.
3.5Nursingcontrolarea

Figure14,MedicationroomatHCUV,HUPF,HDandHUV.
Itistheareawithmoresimilaritiesamongthefourwardsanalyzed.Inallhospitalsthecounterandthe
nurses’officeroomaresharedinthesamespace.InHUPFandHDeventhemedicinepreparationroom
iscombinedwiththenurses’officeroomandthecounterwhiletheHCUVandHUVhavethemedicine
preparationroominanindependentlocation. 

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PaperARCH19–Buildingforbetterhealth 15
3.6Staffarea

Figure15Doctors'officeroomatHUPFandHD.
Thedoctors’officeroominallfourhospitalscomplieswithalmostallthetoolitems.Regardingthestaff
changingroom,onlytheHUPFhasaspecificroom.HDandHUVhaveacentralizedsystemandno
changingroomintheward.Originally,theHCUVhadacentralizedstaffchangingroomforthewhole
hospitalbutinresponsetostaffdemandsthereisnowasmallchangingroomthatdoesnotmeetthe
tool’srequirements.
3.7Supportarea

Figure16,DirtyutilityroomatHCUV,HDandHUV.
HCUVgetsthelowestgradesasthereisnotenoughroomforsupportactivities.Thelackofspacemeans
thatdifferentfunctionsaresharedinthesameroomwithoutaddingextraspace.
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PaperARCH19–Buildingforbetterhealth 16
4.Discussion
Notsurprisingly,theHCUVreceivesthelowestgradesinalmostallareas,whichcouldbeduetoitsage
(about15yearsolderthananyotherhospital).Inallfourwards,thepatientareagetsthehighest
grades.Thiscouldbebecausethepatient’sbedroomandthepatient’stoiletarethemostresearched
roomsnowadays.Onthecontrary,theaccessareascoreslowerthananyotherarea.Spaceforrelatives
isscarceandthefunctionalandemotionaldemandsoffamilymembersareusuallyoverlooked.Family
presenceandengagementinthecareofdependentpatientscouldbepromotedbydesignandhence
improvethepatient’shospitalexperienceandtheefficiencyofhealthcarestaff.
RegardingtheusabilityofCURARQ‐Htool,thesupportareaisthemostdifficultareatoevaluate
becausethetool’sroomsscheduledoesnotalwaysmatchreality.Thelackofspaceisusually
proportionaltotheclutterfoundinsupportroomsthatsharedifferentfunctions.Moreover,thestaff
arearoom’sscheduleislimitedtotworooms(doctors’officeroomandstaffchangingroom)andsofew
items(8)canbeevaluated.
5.Conclusions
Thisstudyinvestigatesthefunctionalandenvironmentalqualityoffourinternalmedicinewardsin
Spanishacute‐carehospitals.UsingaPOE‐tooldesignedfortheSpanishcontext(CURARQ‐H),layout
analysisandphotosanalysistheresultsdepicttheimprovementmeasuresthatcouldbecarriedoutin
anyoftheevaluatedwards.
Themainlimitationsofthestudyare:
- Eventhoughthetoolitemgenerationwasundergonefromareviewofrelevantliterature[20]
andprovidedthatCURARQ‐Hisavailableonline[16]furtherstudiesshouldassessitscontent
validationandtestreliability.
- Alternativeevaluationmethods(questionnaire,interviewsand/orobservation)couldhave
beenusedforstrengtheningtheresults.
- Itwouldbeinterestingtoincreasethesitescopeandreplicatethestudyinmultiplefacilities.
Theimplicationsforpractice:
- GiventhatthereisanurgentneedfordeliveringmoreefficienthealthcareresourcesinSpain,
internalmedicinewardsinacute‐carehospitalsshouldbeupdatedtocopewiththenew
demandsofanageingpopulation.
- ComparedtoScandinavia,USAorCanada,healthcarearchitectureinSpainisbeingslowto
embarkonevidence‐baseddesign.Thereisnospecifictrainingforhealthcarearchitectsand
littlecollaborationbetweenhealthcarestaffanddesignteams.CURARQ‐Htoolcouldbean
enablerforgeneratingsynergiesbetweenhealthcarestaffandarchitectsinSpain.
- Thetool’sstructurefororganizingtheinformationcouldbereplicatedinaninternational
context.Butonlyatanationallevelcouldthetoolbeusedforupdatingtheguidelineson
healthcarefacilitiesasitiscustomizedtotheeconomiccontextofSpanishsociety.Thetool’s
usagecouldbeawaytotestcurrentguidelinesandprovidefeedbacktofacilitatethereview
processesfortheimprovementofnationaldocuments.

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PaperARCH19–Buildingforbetterhealth 17
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