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Evidence-based design: The role of outpatient design elements on medical staff satisfaction and performance in a post-COVID-19 pandemic Outpatient department Design Elements Indoor environment

May 2024
Al-Qadisiyah Journal for Engineering Sciences 17(4):410-420

DOI:10.30772/qjes.2024.144869.1051

Authors:

University of Sulaimani

Contemporary hospitals may be recognized by a large variety of activities, not only delivery of care but also some concerns, such as the satisfaction level of users. This research investigates the relationship between outpatient department (OPD) design elements and medical staff satisfaction and performance, especially in light of the pandemic since 2020. A mixed-method approach was used to gather doctors' and nurses' perspectives at two hospitals in Sulaimani City. This involved an EBD questionnaire and a modified AEDET checklist where respondents filled out a 39-item questionnaire at the hospitals' OPD. The results highlight the importance of the interior environment's quality in promoting the satisfaction of medical staff. The results from the medical staff surveys showed that most medical staff expressed satisfaction with the indoor design elements, and three factors, infection control, interior appearance, and comfort and control, were essential to creating a satisfactory indoor environment. A negative correlation of some demographic information, such as practical experience and educational attainment, with medical staff satisfaction was revealed. The findings suggest that investigating the views of the medical staff can indicate the level of significance of various elements that increase their satisfaction and performance, contribute to the general body of knowledge, and inform design decisions.

Indoor Environment of Shar Teaching Hospital (STH) OPD The second hospital, Asia International Hospital (AIH), is a privately funded hospital on Shorsh Road in the Chia District of Sulaimani City. The hospital is newly constructed and has a capacity of 120 patient beds, ten advanced surgical rooms, and an eight-bed ICU. The hospital covers an area of 4,980 square meters and was built in 2022. The OPD is situated on the first floor and can be accessed through escalators and elevators connected to the main entrance of the hospital building. The OPD follows a sectorial decentralized layout comprising eight sectors and other service areas. Each sector has a central waiting area and two to three doctors' rooms. The hospital has been designed to provide easy access to different areas for patients and medical staff, ensuring a comfortable and hassle-free experience.

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Results of the checklist (AEDET) for Shar Teaching Hospital (STH) and Asia International Hospital (AIH).

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Correlation between the indoor environment quality and medical staff satisfaction for the two hospitals

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AL-QADISIYAH JOURNAL FOR ENGINEERING SCIENCES 17 (2024) 410–420

Contents lists available at http://qu.edu.iq

Al-Qadisiyah Journal for Engineering Sciences

Journal homepage: https://qjes.qu.edu.iq

* Corresponding author.

E-mail address: fouad.mahmood@univsul.edu.iq (Fouad Jalal Mahmood)

https://doi.org/10.30772/qjes.2024.144869.1051

Evidence-based design: The role of outpatient design elements on medical

staff satisfaction and performance in a post-COVID-19 pandemic

Fouad Jalal Mahmood 1*

Department of Architecture Engineering, College of Engineering, University of Sulaimani, Sulaimani, Kurdistan, Iraq

A R T I C L E I N F O

Article history:

Received 28 November 2023

Received in revised form 18 January 2024

Accepted 05 May 2024

Keywords:

Evidence-based design

Medical staff satisfaction and performance

Outpatient department

Design Elements

Indoor environment

COVID-19 pandemic

A B S T R A C T

Contemporary hospitals may be recognized by a large variety of activities, not only delivery of care but also

some concerns, such as the satisfaction level of users. This research investigates the relationship between

outpatient department (OPD) design elements and medical staff satisfaction and performance, especially in

light of the pandemic since 2020. A mixed-method approach was used to gather doctors' and nurses'

perspectives at two hospitals in Sulaimani City. This involved an EBD questionnaire and a modified AEDET

checklist where respondents filled out a 39-item questionnaire at the hospitals' OPD. The results highlight

the importance of the interior environment's quality in promoting the satisfaction of medical staff. The

results from the medical staff surveys showed that most medical staff expressed satisfaction with the indoor

design elements, and three factors, infection control, interior appearance, and comfort and control, were

essential to creating a satisfactory indoor environment. A negative correlation of some demographic

information, such as practical experience and educational attainment, with medical staff satisfaction was

revealed. The findings suggest that investigating the views of the medical staff can indicate the level of

significance of various elements that increase their satisfaction and performance, contribute to the general

body of knowledge, and inform design decisions.

1. Introduction

Healthcare facilities today are complex structures that house various

operations, including sophisticated medical equipment, as well as more

low-key issues, such as user satisfaction [1, 2]. The physical features of a

hospital can significantly impact the well-being of medical personnel,

patients, and visitors. Design features and solutions that meet user

expectations and needs can positively impact occupant health in healthcare

facilities [3-5]. Therefore, the presence or absence of any design elements

in an indoor setting can positively or negatively impact the user's

psychological state, including their mood and stress levels [2, 3, 6, 7]. The

satisfaction of medical staff is crucial for providing high-quality healthcare

services. To ensure this, it is important to regularly evaluate the factors that

affect their expectations of the hospital's indoor environment. Studies by

Sadatsafavi et al. [8] and Andrade et al. [9] suggest that identifying and

implementing necessary modifications is necessary for achieving this goal.

According to Ulrich et al. [10], hospitals with well-designed physical

environments tend to be better workplaces and can lead to better outcomes

for medical staff. Therefore, it is crucial to comprehend how healthcare

staff perceive the various aspects of the hospital's indoor environment [8,

11]. A Post-Occupancy Evaluation (POE) is a method of understanding the

relationship between a built environment's quality and its occupants'

satisfaction. Evidence-based design (EBD) is a new area of design that uses

research to inform decisions explicitly. Healthcare professionals from

various disciplines have used this strategy to make informed decisions [3,

10, 12-15]. EBD has several global assessment tools approved by the

National Health Center (NHC) and the Center for Health Design (CHD).

FOUAD JALAL MAHMOOD AL. /AL-QADISIYAH JOURNAL FOR ENGINEERING SCIENCES 17 (2024) 410–420 411

Implementing EBD approaches in outpatient settings can yield several

positive effects on medical staff satisfaction and performance [16-18].

Medical staff (doctors and nurses) face high physical stress during

pandemics like COVID-19 [19, 20]. Studies indicate that healthcare

providers risk Contracting contagious illnesses from patients as a result of

airborne and surface contamination.COVID-19 primarily spreads through

close contact with an infected person [3, 17, 21]. Contamination can occur

through infected surfaces or hardware. As a result, the COVID-19

pandemic has led to changes in the healthcare industry, with an increased

focus on outpatient care; designers face the challenge of improving indoor

physical environments to control infection in healthcare buildings and

withstand epidemics [17, 22]. Indoor environment dissatisfaction can lead

to higher hospital employee turnover rates. Workplace, interior space, and

physical environment quality can impact satisfaction. Stress can negatively

affect work performance and job satisfaction, ultimately affecting

healthcare service quality and outcomes [2, 23-25]. High-satisfaction

medical staff provide better quality medical services, causing better

healthcare results. Demographic criteria can also impact hospital users'

satisfaction and psychological well-being with the building's physical

surroundings [1, 26-29].

The hospital occupants’ needs for satisfaction and comfort can vary

between hospital departments. The OPD indoor environment's design

features are crucial for improving satisfaction among patients and medical

staff and lowering stress and anxiety. As a result, some fundamental needs

(standard signage, patient accessibility, privacy and dignity, ample waiting

area, effective support services, proper ventilation, and natural lighting, and

a growth strategy) must be considered in the design of an outpatient

department [23, 30, 31]. OPD typologies can be broadly categorized as

either centralized or decentralized based on where the OPD waiting area is

located, which provides the best outcome, the least walking distance, and

the associated handling costs between units. The lobby, sectorial (grouped),

linear, and mixed with the decentralized location of the waiting area are the

four types of designs and locations that define the decentralized typology.

The waiting area in the centralized OPD typology is encircled by the

center's examination rooms and service areas. [17, 32]. When design

solutions are ineffective, users may be exposed to stressful situations,

medical errors, physical and biological toxins, and the transmission and

spread of diseases like COVID-19 [3, 33].

Based on previous studies, several design elements have been identified as

influential factors that contribute to medical staff satisfaction and

performance. An efficient and well-designed layout and clear circulation

(Layout and Circulation) can enhance communication between medical

staff, improve workflow, and reduce stress. A logical flow in the outpatient

setting can help staff members move seamlessly, improving efficiency and

reducing errors. Clear architectural plans that enable medical staff to reach

patients easily and foster continuous observation are essential for safety.

Short travel distances and times, separate traffic types, and short traffic

routes can limit disease transmission (preventing the spread of infection)

and reduce waiting times [3, 16, 17]. Other researches have demonstrated

the importance of comfortable surroundings and the capacity to regulate

comfort levels (Comfort and Control), such as blocking sunlight. To

support their level of pleasure, it is crucial to let patients and medical

professionals control their environment [26, 33]. In addition, interior design

components (Interior Appearance), like appropriate materials, the use of

different colors, comfortable seating, adequate and appealing furniture, and

a perception of hospitals as homelike, affect users' reactions impacting the

indoor environment and influencing its overall quality, increasing medical

staffs' satisfaction and performance [26, 33, 34].

Also, studies have linked medical staff satisfaction levels to (Privacy)

factors. Privacy is essential for both patients and medical staff. Designing

spaces with adequate sound insulation minimizes noise distractions,

ensuring patient confidentiality and improving concentration for medical

professionals. Acoustically optimized spaces create a calmer environment,

allowing staff to focus on providing quality care [3, 33]. Furthermore,

research suggests infectious disease outbreaks can impact hospital staff

satisfaction and productivity. (Infection Control) measures have become

top priorities in healthcare facility design, including touchless systems,

hands-free fixtures, and antimicrobial surfaces. Promoting staff compliance

with infection control protocols through dedicated hand hygiene stations

and easy access to personal protective equipment fosters a safer work

environment and slows the spread of disease. Improved ventilation and air

change rates inpatient areas are also essential updates in design

requirements [3, 23, 35]. Also, providing consulting rooms with quality

(Views) of the outside, natural elements, and feature plants has been found

to influence medical staff’s satisfaction and performances and reduce stress,

leading to better outcomes [3, 17]. Finally, facilities, such as the use of

adequate and pleasant furniture, comfortable seating, space for changing

and securely storing belongings and clothes, convenient access to IT, and a

place where they can get refreshments or meals quickly may affect

improving medical staffs' satisfaction by improving the quality of the

internal environment and performance [26, 33].

Studies indicate that users' satisfaction with healthcare facilities can vary

based on their faith, culture, and education. However, healthcare facilities

may only sometimes be able to accommodate users' diverse needs and

expectations due to the set criteria and qualifications in place. An

individual's experiences, objectives, social and cultural context, and ability

to perceive information can all influence how they interpret a facility's

design features [2, 8, 12, 36]. For instance, personal hygiene and

environmental cleanliness are highly regarded in Kurdish culture,

particularly for women. Additionally, various colors and natural textures

contribute to the beauty of Kurdish designs [2, 26].

Further studies are required to establish guidelines for designing

psychosocially supportive spaces in healthcare buildings in the Kurdistan

Region of Iraq [2, 37]. Few studies have explored the factors that impact

medical staff satisfaction and performance in a post-COVID-19 era [16].

The main objective of this study is to fill the research gap by achieving two

aims. Firstly, to investigate the factors that enhance the performance and

satisfaction of medical staff and how they perceive the design elements of

OPD. Secondly, to explore the perspective of medical staff regarding the

importance and effectiveness of these factors for their level of satisfaction

in the post-pandemic era. The results can enhance the design of an OPD

indoor environment, improving medical staff satisfaction and performance

at healthcare facilities in a post-COVID-19 pandemic era.

2. Datasets and Methods

The study evaluated healthcare facility design using quantitative and

qualitative approaches. It included questionnaire and checklist surveys, site

visits, and observations. Hospital representatives joined the research team

on building tours to answer questions about the outpatient department's

physical surroundings.

2.1. Quantitative method

The quantitative technique collects numerical data for comparisons and

analysis. It is accessible to all, and POE investigations are essential for

building assessment research. A questionnaire survey can be included in

any building functioning assessment research [16, 38].

A survey questionnaire was administered to evaluate the relationship

between the satisfaction level of medical staff and the quality of the indoor

environment in the OPD of a hospital. The questionnaire was designed for

the doctors and nurses, and it aimed to determine the degree of agreement

among the medical staff regarding several factors related to the indoor

environment, including layout and circulation, infection control, comfort

412 FOUAD JALAL MAHMOOD ET AL./AL-QADISIYAH JOURNAL FOR ENGINEERING SCIENCES 17 (2024) 410–420

and control, interior appearance, facilities, privacy, and views. The

questionnaire included questions derived from three evaluation toolkits.

The first toolkit used was the Community Health Centre (CHC)

standardized design, the CHD_CHC evaluation tool. It assesses the

performance and effectiveness of outpatient facilities in supporting the

population's health. The second toolkit is a self-administered questionnaire

that allows staff members to provide anonymous feedback on their

perception of environmental design and work experience [39, 40]. The A

Staff and Patient Environment Calibration Toolkit (ASPECT) is the third

toolkit. It is predicated upon a database that the NHS in the UK has been

using since 2008, which contains data from more than 600 research studies.

The toolkit quantifies the impact of the physical surroundings on employee

and patient satisfaction [41].

This questionnaire consists of three sections. Age, gender, educational

level, and work experience of the medical staff were among the

demographic details in the first section. In the second section, which is the

core of the questionnaire, the medical staff is asked to score their degree of

satisfaction with the indoor design elements of the OPD on a five-point

Likert-type scale in the second section, ranging from "very dissatisfied" to

"very satisfied." Thirty-nine questions about hospital OPD were included

in this section of the survey. Four questions from the first round were on

layout and circulation. The second set of seven questions focused on

infection prevention, including limiting unnecessary travel for nurses and

other personnel, cleaning properly, using isolation rooms, having easy

access to an alcohol gel dispenser, and keeping clean and dirty goods in

separate storage. The third set of five questions focused on the comfort and

control of the medical professionals, including their ability to adjust the

lighting temperature and close or open windows. Eight questions from the

fourth set were created to elicit the medical staff's perceptions of the OPD's

interior design components (safety and security, colors, artwork, plants, and

furniture). The fifth set of inquiries (seven questions) measured medical

staff satisfaction with the OPD facilities (convenient restrooms, storage

areas, comfortable and flexible furniture, and separate rest areas). The sixth

set of four questions focused on the privacy of the medical staff, including

their ability to have visual privacy, private conversation, isolation from

other patients and staff. The final series of four questions focused on views

(the availability of suitable windows with a view of the outdoors).

Section three of the questionnaire contains the same 39 questions as section

two. However, the purpose of this section is to gather staff members'

opinions and experiences related to the effectiveness of factors in terms of

promoting their level of satisfaction. On a five-item Likert-type response

scale, the respondents are asked to score the effectiveness of a particular

item using the following options: (1) not effective, (2) slightly effective, (3)

neutral, (4) effective, and (5) extremely effective. A factor's effectiveness

in improving medical staff satisfaction can be reflected in its score.

Elements with higher efficacy ratings are more significant.

2.2. Qualitative approach

A qualitative technique was used to assess building-related features of OPD

in hospitals. The quality of design elements in healthcare buildings was

evaluated in this study using a checklist from The Achieving Excellence

Design Evaluation Toolkit (AEDET), which was created by the NHS in the

United Kingdom. A profile outlining the advantages and disadvantages of

a design or already existing facilities is provided by the checklist [2].

Impact, Build Quality, and Functionality were the three main components

of AEDET Evolution, and each had ten subsections for assessments. Since

they were required to address the physical aspects of the indoor

environment, the six remaining sections— This study [42] did not assess

the aspects of Character and Innovation, Form and Materials, Urban and

Social Integration, Engineering, Construction, and External Access.

The study examined four sections: Performance, Patient and Staff

Environment, Space, and Use. The original AEDET Evolution had a 6-

point scale, with the highest score being "Virtually complete Agreement

(VcA)" and the lowest score being "Virtually no Agreement (VnA)," with

a score of 1 point. Based on the previous study [16], the AEDET tool scale

has been modified to three levels of agreement: “Weak Agreement (WA)”

for the first and second scale when the item is missing or barely present,

“Fair Agreement (FA)” for the third and fourth scale when the item exists

in an average rate, and “Good Agreement (GA)” for the fifth and sixth scale

when the item has a good presence. This discussion is based on the revised

AEDET tool scale. The assessment was based on a walkthrough and

photography conducted by the author and six experts.

2.3. Case Studies

To evaluate two general hospitals in Sulaimani City, a field survey was

conducted with the participation of medical professionals, including

doctors and nurses. The study focused on Shar Teaching Hospital (STH),

established in 2013, and Asia International Hospital (AIH), established in

2022. These two hospitals were selected based on their large staff and

patient populations, reputations, size (with more than 100 beds), availability

of a variety of centralized and decentralized OPD types, and the difference

in their construction timelines (STH was built before the COVID-19 crisis,

while AIH was built after).

The first hospital is Shar Teaching Hospital (STH). It is a public facility in

the Kurdsat District of Sulaimani City, on the Malik Mahmood Circle road.

STH is a 400-bed general hospital that offers interdisciplinary medical

services. It also has 12 ICUs and 23 operating rooms. Adjacent to the

hospital building's main entrance is the OPD. The corridor doubles as a

waiting area and a space for circulation. On either side of the waiting area

are the doctor's offices and other amenities.

Figure 1. Indoor Environment of Shar Teaching Hospital (STH) OPD

The second hospital, Asia International Hospital (AIH), is a privately

funded hospital on Shorsh Road in the Chia District of Sulaimani City. The

hospital is newly constructed and has a capacity of 120 patient beds, ten

advanced surgical rooms, and an eight-bed ICU. The hospital covers an area

of 4,980 square meters and was built in 2022. The OPD is situated on the

first floor and can be accessed through escalators and elevators connected

to the main entrance of the hospital building. The OPD follows a sectorial

decentralized layout comprising eight sectors and other service areas. Each

sector has a central waiting area and two to three doctors' rooms. The

hospital has been designed to provide easy access to different areas for

patients and medical staff, ensuring a comfortable and hassle-free

experience.

FOUAD JALAL MAHMOOD AL. /AL-QADISIYAH JOURNAL FOR ENGINEERING SCIENCES 17 (2024) 410–420 413

Figure 2. Indoor Environment of Asia International Hospital (AIH) OPD

2.4. Study participants

Respondents were informed that their participation was voluntary and

confidential. The questionnaire was easy to complete and inspired

participation, indirectly raising the response rate. The study included 107

medical staff members at two hospitals, including doctors and nurses.

Finding the sampling error (e) with a 95% confidence level that the data

correctly reflects the population led to a conclusion of 0.05. The required

representative sample of respondents (n) to declare the study statistically

valid was calculated using Sloven's formula [43]. The sample size

determined by the calculation is (n=84).

n = N

1+Ne2 (1)

For this study, 107 questionnaires were distributed among medical staff at

two hospitals, with 70 going to doctors and 37 to nurses. Out of these, 90

valid questionnaires containing accurate data were retrieved. Among the

retrieved questionnaires, 62 were from doctors (43 from STH hospital and

19 from AIH hospital), and 28 were from nurses (18 from STH hospital and

10 from AIH hospital). These 90 valid questionnaires served as the basis

for the findings of this study, which focused on medical staff at the OPD of

the two hospitals listed in Table 1.

Table 1. Included hospitals based on the year built and the number of

respondents.

2.5. Statistical Analysis Approach:

The questionnaire data from two general hospitals in Sulaimani City were

analyzed using t-tests and IBM SPSS to calculate MSS and percentages. A

correlational analysis was conducted between the demographic data of

medical staff and their satisfaction level and the factors and satisfaction

level of the medical staff at the OPD.

3. Results

This study employed qualitative and quantitative methodologies to

provide evidence-based data on the impact of OPD design features on

medical staff satisfaction.

3.1. Demographical information of the Respondents

Gender, age, educational level, and practical experience in the hospital

OPD are among the personal characteristics of the medical staff (doctors

and nurses) described in Table 2. The survey's findings indicate that 68.9%

of respondents were doctors, compared to 31.1% of nurses; 51.1% of

respondents were male, as opposed to 48.9% of respondents who were

female; 27.7% of respondents were between the ages of 18 and 30; 41.2%

were between the ages of 31 and 45; and 7.8% were beyond the age of 60.

The findings showed that 8.9% of the medical staff had a BSc, while 22.2%

had a diploma as their highest level of education. 13.3% of those with

degrees had an MSc, while 55.6% were highly educated and had finished

their study with a Ph.D. Regarding the medical staff's practical experience