All surgical suites are made up of the same basic programmatic areas. They vary in design approach, hospital attitude toward space, cost, square footage allocation, and regulatory interpretation.

For preliminary planning, Fig. 12.4 suggests what might be expected in departmental gross square feet (DGSF) per operating room (OR) for different types of hospitals or outpatient surgical centers. These DGSF figures include all the rooms that make up the seven programmatic areas listed above, plus the circulation required to connect these areas. Design approach, which will be discussed further, also affects DGSF/OR. Not included in the DGSF area are elevators, stairs, outside walls, or engineering systems.

In general, these facility categories differ in expected surgical case acuity and specialties, equipment technology needs, staff numbers, teaching programs, and, possibly, research activities. Competition between hospitals for physicians and patients can impact square footage in the form of spacious, hospitable lobbies, and family-centered amenities.

Comparing four US hospital surgical departments in greater detail, Fig. 12.5 describes the total square footage , distribution of spaces by the seven program areas, surgical procedure numbers, and design layout. Two are located in the northeast and two are located in the south. These hospitals vary in when they were built and how they have expanded over the years. This comparison highlights regional responses to programs and how programs evolve over time.

With adequate data in planning a new surgical suite, the purpose of comparing numerous similar surgical programs is to evaluate the overall size of the department and the distribution of spaces within it against programs offering similar services. It is a quick way to identify areas that should be further assessed. In such an exercise, one may identify ORs that are smaller than expected, or circulation that is inadequate in contemporary surgical suite planning. These comparisons, when conducted in early planning , illuminate areas warranting further discussion or might serve as a final cross-check, validating that all process flow issues have been addressed sufficiently.

As with complex puzzles, there are numerous organizational plan layouts used in surgical suite design. Within bounds, there is no wrong or right plan. Architects and medical planners have preferences in what they do, as do surgeons and staff in their own work. For programs of differing sizes, characteristics, and regional locations, we have successfully designed surgical suites using virtually all possible configurations. One layout does not fit all, and the designer should take care not to impose a predisposition on every new client. Building consensus with multiple users of the surgical suite is very important (physicians, nurses, techs, administration, facility management, and others) [1]. We have found that frequent communications with all involved, and early participation in option exploration, is critical to completing design with a hospital team that endorses and supports the project. Planning work sessions, something we call “gaming” (Fig. 12.6), can bring all stakeholders to the table. This method uses nontechnical, non-drawing methods to encourage all to participate in the creation of their future workplace.

There are three conventional suite layouts. Each has been used, with various changes and combinations over the decades, most with a high degree of success.

A somewhat new surgical suite layout has evolved out of healthcare’s interest in “lean process.” Simply described, the patient’s movement is one-way, or linear. They do not return to a space previously used. In theory, this is to increase efficiency and throughput, and enhance the patient experience (Fig. 12.7).

Another change in this plan type is the inclusion of staging rooms. Located outside of each OR, this allows scrubbed technicians and nurses to set up tables for the next case while the previous case continues [3]. This is thought to reduce room turnover time and improve throughput (see A, Fig. 12.7). Flow station rooms are also added outside of each OR as a place for surgeons to do postoperative documentation and prepare for the next case (see B, Fig. 12.7). There are still points of traffic crossings and walking distances may not actually be shorter than in other layouts.

Surgical suite layout characteristics, or attributes, generally fall into the following categories. Each layout organization has advantages and disadvantages, and no layout will be perfect.

Public areas serve many different populations—the arriving patient and accompanying friend or family member, the hospital staff receiving the patient, hospital business staff related to financial and consent matters, seating for those waiting, and amenities ranging from consultation rooms, toilets, nourishments, educational resources, and access to computers or workspaces.

It should be noted that initial impressions affect the opinion of safety and quality expectations of everyone. If the built environment is well organized, appears clean and well maintained, and is pleasing to the eye, the patient will begin their personal experience with a better impression and higher expectation [4]. The same is true for staff. The environment delivers a message [5] (Fig. 12.8).

For those working in hospitals and surgical programs, it is easy to forget how anxious and concerned the patient and family can be. They do not know what to expect and their image of what they are going to experience may be based on popular television shows or movies. If they are the patient, they may be whisked off, stripped of their clothes and belongings, poked and examined, asked questions by multiple people they have never seen before, and medicated. If they are unlucky, all this happens in front of other unfortunate patients encountering this same experience.

To a large degree, the hospital’s culture and attitude toward design can mitigate the effect of these experiences. Being guided through the preoperative path by a caring and empathetic individual is reassuring. The built environment can also improve this experience. Private preoperative rooms have shown to provide privacy, better communications, and comfortable space for family, providing the patient with dignity at a time when they are feeling vulnerable [6] (Fig. 12.9).

To the surgeon and certain members of the OR staff, this is the center of the world. The experience of the provider and the impact on the patient are highly influenced by the environment and the human factors under which they perform [7, 8]. It is where they spend long hours, and endure standing in uncomfortable surgical garb under lights, doing precise work. More frequently now, they may be sharing the room with a robot and/or colleagues of different specialties in hybrid operating rooms . They can rearrange the room, control the intensity and color of lighting, and speak real time to fellow surgeons or a medical class across the corridor or across the globe. Pathology reports and images are called up for integrated display on large, crystal-clear screens around the room.

Not very many years ago, operating rooms were considered large if they exceeded 400 ft². In recent years the size of ORs, while always a point of much debate in design sessions, has appeared to stabilize with more rational discussion around the equipment and staff numbers to be accommodated [3]. Today, general ORs range around 550 SF to 650 SF, while hybrid ORs, containing multiple fixed equipment setups, may be as large as 1000 SF [9] (Fig. 12.10).

In addition to integrated information system display, the value of improved communications in generating better situational awareness and coordination among OR staff has been identified [10]. We have designed several approaches to accommodate documentation staff workspace during cases and have seen other designs while touring OR suites around the country. Two are included here. The Methodist desk (Fig. 12.11) is designed in a curved shape and is same handed in all ORs within this suite. The second (Fig. 12.12) is a tee-shaped desk adapted into a large OR . The shape allows the occupant to slide in and out easily. Designs for two staff members that encourage communication, meeting, and computer access during surgery [11] create environments that create more collaboration and trusting settings.

The increase of OR sizes and rapid changes in surgery have led to the concept of developing the universal OR, one that can accommodate multiple equipment arrangements and meet the needs of multiple case types. The cost and disruption of renovating ORs are very expensive. To some, the incremental initial cost is well worth the while (Fig. 12.13).

For many of the reasons that universal ORs are of interest, preplanning for OR change is beneficial. If planned during design, the steps needed for smart flexibility serve are reasonable anticipation of the future. Figure 12.14 illustrates preplanning the conversion of ORs into interventional imaging rooms, connecting to surrounding ORs. This speeds up the future conversion and reduces cost.

This is the critical care unit of surgery. In fact, many critical care units were originally surgery recovery rooms. Currently, most recovery rooms continue to be open bay spaces with curtains providing separation between patients. Primarily this space is the domain of the anesthesiology care team bringing the patient out of anesthesia after surgery. Once the patient is stable, the patient is moved to their hospital room or to stage 2 recovery until they are ready to be discharged home.

In large surgical programs, with adequate numbers of specialty surgery patients, postsurgical patients may be moved directly from the OR to a critical care unit for recovery. In some cases, these are specialty critical units matching the patient’s type of surgery, e.g., a cardiovascular or neurosurgical ICU [12]. In this situation, it is not infrequent that the patient is cared for in a private ICU room (Fig. 12.15).

Most hospital surgical suites perform both inpatient and outpatient surgery. When outpatient surgery is included, a Phase 2 recovery room is required. This area is to be connected to the PACU, but must be a separately identified area. The hospital has the choice of using open bays, cubicles, or private rooms for this use. If the hospital uses private rooms for preoperative patients, it is possible to use these same rooms for Phase 2 recovery. This allows privacy for the recovering patient and room for a family member to join them. The private room brings the same benefits as described under the preoperative area discussion above.

Support space for surgical staff is very different, and much improved over the years regarding provisions for quality downtime and access to nature. Creating environments to support this highly skilled group is recognized as important to staff wellness and improved operations (Fig. 12.16). The staff lounge in the photograph illustrates many decisions initially not obvious. It suggests a series of decisions made by hospital administration to locate this lounge on an outside window wall with great views to the surrounding medical center and natural light, both providing positive distractions and respite from the OR. In addition to a delightful environment, nourishment is provided and comfortable furniture is available for relaxation. Adjacent to this lounge, located only steps from the OR, are education spaces used by all surgical staff, physicians, and fellows .

Workspace for surgical staff is another opportunity to create positive places for people. The following image illustrates a work environment located so that those needing quiet, hence the glass, can still have visual access to an outdoor rooftop garden . At first glance, you wouldn’t realize that this garden is located four levels above ground (Fig. 12.17).

Listening to the voice of the customer, the patient, today’s hospital administrators, front-line practitioners, and healthcare interior designers learn what patients expect in their hospitalization. Survey reports reveal that patients need to be heard, to rest, to have access to their health information, and, understandably, to be discharged without hospital-acquired conditions [13]. Publicly available data reveals how patients perceive not only the physical environment but also the providers who work in the healthcare environment based on the physical surroundings and the demeanor of the front-line practitioner [13]. Never events, a term introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF) , referred to preventable harm episodes such as wrong-site surgery as episodes which should never occur [14]. This term was introduced in response to the groundbreaking IOM report, To Err is Human [15]. Sixteen years after this report, patients continue to experience preventable harm and often struggle to have their voice heard, and costs continue to rise. Early communication between hospital leadership and the design team regarding mission, vision, and goals and process improvement solutions will empower the architect to plan for the safest and most reliable environment [16]. Additionally, early communication is essential for the general contractor to develop a construction budget with any accuracy, and is crucial for goals and evidence-based design solutions to be realized in the built environment.

Healthcare architects and interior designers must also listen and understand with great depth the voice of the other customer: the multidisciplinary team of perioperative services. Architecture firms that are the best equipped to apply evidence-based design strategies will need the perioperative service-line goals embraced by the organization. Consequently, the time to review and revise operational information, patient throughput, and workflow strategies should be discussed in process improvement discussions rather than in the design phases of the physical environment according to the Commonwealth Fund 2013 publication [17]. Understanding the systems approach to planning for a safe workspace is essential to fully understanding the operational as well as the environmental causal factors to adverse events [17]. According to Carayon et al. [18], most errors in patient care arise not from the solitary actions of individuals but from conflicting systems in which multiple people interact. The built environment creates the setting and physical environment to support safer, reliable, and exceptional service [19]. A poorly designed perioperative service-line environment can complicate workflow and introduce inefficiencies creating patient harm and dissatisfaction [19, 20]. Application of design thinking in the pre-design phase offers the opportunity for innovative strategies in addressing safety, efficiency, and value [21].

Pre-design operational improvement using the Lean Six Sigma process improvement techniques can significantly change design requirements for spaces and square footage in key departmental areas [22, 23]. Engagement in such techniques often results in a reduction in square footage which results in added value. When reviewing patient flow from the patient experience perspective, there is an opportunity to identify potential bottlenecks in the patient flow and the identification of breakdowns or barriers in the continuum of care. Design optimally will then follow process improvement strategies [24].

For the purpose of addressing patient safety, patient experience, and human performance, this section uses the following working definitions: