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Although they are part of the major public infrastructure, hospitals can be considered
unique. This uniqueness stems from the influence of their built environment toward
patients as the main users of the facilities. Events occurring in a patients environment
may have both physical and psychological impacts on their healing process.
Moreover, a lack of attention paid to the relationship between the built environment
design and patient health may lead to adverse incidents (AIs), such as the spread of
infectious disease, medication errors and physical impacts, as well as further suffering
caused by psychological factors such as stress, weariness, anger and isolation. While a
number of studies have found evidence that the design of a hospital building can
impact the patients recovery process in general, there is little understanding of the
hospital design process (concept design, improvement design and technical design),
and how the process can be managed to achieve the desired impact over its entire life
cycle. In light of the ongoing discussion, this candidacy paper aims to report on
ongoing doctoral research in the Construction Management Department, which
investigates the contemporary design process of existing public hospitals in the
Kingdom of Saudi Arabia (KSA), and the events that are caused by environmental
design issues. These events may be considered either unsupportive or supportive
towards patients recovery process. Factors, requirements, needs and causes that
impact patient health are identified in order to improve the current design process.
Inductive and deductive approaches are proposed within the context of mixed
methods. Moreover, adopting a case study approach, the samples in the study will be
drawn from a patients treatment plan, where patients are treated for urgent injuries in
three distinct cities in the KSA. These patients were selected because of their resource
needs and their length of stay in the hospital environment. The data will be collected
through interviews and questionnaires with post-treatment patients, healthcare
professionals, architects and decision-makers in these hospitals. Overall, the outcome
of this investigation is expected to lead to improvements in design processes for future
public hospitals in the KSA.
Keywords: adverse incidents, hospital design process, environmental design issues,
patients recovery process, physical and psychological impacts.



Healthcare systems have been defined as complete networks of

organisations, resources, techniques and facilities that provide
healthcare in a specific geographical space (Health care system 2009).
One common way to classify healthcare facilities is to group them into
three categories: inpatient facilities (hospitals and rehabilitation
centres), outpatient facilities (specialized healthcare facilities) and
diagnostic facilities (laboratories) (Nah and Osifo-Dawodu 2007).

Interestingly, a WHO report showed that patients at a healthcare facility

may be more exposed to AIs than persons in nuclear plants or aircrafts
(WHO 2002). For air travel, the potential of an AIs occurring is one
user harmed in a group of one million users; at healthcare facilities, one
out of every three hundred users is likely to be harmed (World Health
Organization, 2002). Most of these AIs occur at hospitals (West (2006);
World Health Organization, 2002), especially in large hospital
buildings offering several medical services in different spaces. AIs are
defined as incidents in which harm befalls a patient during the
provision of health care. AIs may involve infection, falls resulting in
injury, or problems with medications and medical devices (AIHW
2015). In general, AIs may impact patients physically, psychologically
and financially (Adams et al. 2009). Therefore, the focus of the present
research is tertiary care hospitals (150500 beds), since they represent
the majority of the Saudi public healthcare facilities (General
Directorate of Statistics & Information 2013), and the physical and
psychological health of the patients.
Designing an environment that supports the recovery process is
considered to be essential to patient safety (Schweitzer, Gilpin and
Frampton 2004) and protection, and to accelerating the healing
process. Creating a safe and healthy environment includes the
prevention of AIs that might impact the psychological (Zimring, Joseph
and Choudhary 2004) and/or physical health of patients (Joseph and
Rashid 2007). Inadequately designed environments may cause AIs,
such as infection and medical errors, that can critically affect patient
health (Zimring, Joseph and Choudhary 2004). Despite continuous
improvement in the management of hospital operations, the number of
AIs has not decreased since 1999 (Kohn, Corrigan and Donaldson
At least theoretically, devoting greater attention to the early stages of
the hospital design process can prevent many AIs. For most buildings,
including hospitals, the planning of a new hospital typically involves 11
processes (RIBA 2013), which can be assigned to four main groups:
preparation, design, construction, and operation and maintenance
(O&M) phases. Identification, concept design, and improvement design
and technical design processes apply to hospital design in most
developed and developing countries, including the healthcare sector in
KSA (research scope; see Figure 1).
Healthcare in the Kingdom of Saudi Arabia
The Saudi healthcare sector is the responsibility of the Ministry of
Health (MOH), which is the primary government agency committed to
the provision of preventive, curative and rehabilitative healthcare for
the population of the KSA (Almalki, FitzGerald and Clark 2011), and is
responsible for the management, planning, financing and regulation of
the healthcare sector involving healthcare facilities. The government of
the KSA has made a concerted effort to deliver planned healthcare

facilities. In 2014, according to the Central Department of Statistics and

information (CDSI), the Saudi Gross Domestic Product (GDP) was
$746.25 billion USD. The Saudi healthcare sector was estimated at
$42.7 billion USD, accounting for nearly 5.7% of the total GDP
(Ministry of Finance 2015), which means that the KSA has one of the
largest healthcare sector budgets in the Arabic Gulf (Damrah 2013).
Recently, Saudi Arabia has focused on patient safety through the
reduction of AIs or medical errors during direct interventions (Almasabi
2013) by applying healthcare accreditations standards (Al Awa et al.
2010). Healthcare accreditation standards cover patient safety practices
related to some patient outcomes, but not others (Thornlow and Merwin
2009), and the KSA still suffers from increasing AIs as one of the
developing countries where the risk of patient harm is up to 20 times
higher than in developed countries. In other words, one out of every ten
patients receiving care at hospitals is likely to receive harm (WHO
This study focuses on how healthier environmental thinking can be
embedded in the early stages of the hospital design process in order to
provide a safe and protective atmosphere that positively affects the
psychological and/or physical health of patients by avoiding AIs. In
addition, the focus here is on fostering supportive events within the
patient environment to facilitate the healing process (see Figure 1-2).
To provide a clear understanding of the research gap (the lack of
attention to the link between the design process and healing process of
patients, and solving the research problem: the occurring AIs) Figure 1
displays (1) the research problem cycle in relation to the design and
healing processes and (2) the indirect link between the design and
healing processes and research interventions to improve the design
process and support the healing and recovery process (see Figure 1-2).
In a study conducted in one of the Saudi hospital buildings, Al Ghamdi, Andrew, and Joyce (2011) presented the design issues
impacting the maintenance and operation phases in the following
categories: the material selection, climate conditions, structural designs,
specification writer, architectural design, construction drawing,
architectural drawing, design team, harmful human behaviours and
administration of design team defects. Thus, these design issues were
considered to be indirect interventions (Brady et al. 2009) that led to
AIs occurring in Saudi hospital buildings that impact patient health.