Secondary Logo

Journal Logo

Building a Better Operating Room

Views from Surgery and Architecture

Ibrahim, Andrew M. MD; Dimick, Justin B. MD, MPH; Joseph, Anjali PhD

doi: 10.1097/SLA.0000000000001777

*Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI

Department of Surgery, University of Michigan, Ann Arbor, MI

American Institute of Architects, Design and Health Leadership Group, Washington D.C

§School of Architecture, Clemson University, Clemson, SC.

Reprints: Andrew M. Ibrahim, MD, Robert Wood Johnson Clinical Scholar (VA Scholar) Institute for Healthcare Policy and Innovation, University of Michigan 2800 Plymouth Avenue Building 10-G016 Ann Arbor, MI 48109–2800. E-mail:

Disclosure: A. M. I. receives funding from Robert Wood Johnson Foundation and the Department of Veterans Affairs in his role as an Robert Wood Johnson Clinical Scholar (VA Scholar).

J. B. D. is funded by the National Institute of Aging (Project #s: 5R01AG039434–04, 5R01AG042340–03), The National Institute for Diabetes and Digestive and Kidney Diseases (Project #s: 5R21DK100710–02, 5R01DK101423–02) and the Agency for Healthcare Research and Quality (Project #: 1R01HS023597–01).

A. J. is funded by the Agency for Healthcare Research and Quality to study human centered design in the operating room (Project #: 1P30HS024380–01).

J. B. D. has a financial interest in ArborMetrix, Inc., which had no role in the analysis herein.

The authors declare no conflicts of interest.

The operating room is the single most important place in the hospital for surgeons. Despite enormous innovation in surgical practice, relatively fewer advances have been made to the actual operating room itself. New technology and devices have been introduced to crowd the space, but changes to the actual lay out and how to organize the room remains largely unchanged. Indeed, many of the design shortcoming described by surgeons 4 decades ago—“faults in equipment, inaccessibility of necessary items, problems in communication, inefficient handling of materials, unconscionable delays … that are an expression of a hazardous environment”1—could readily be identified by surgeons today.

The problem of building a better operating room is not new and arises largely from knowledge gaps between architects and users of the operating room. Many surgeons and nurses who have been involved in operating room planning and are around to occupy that space afterwards are often disheartened by the gap between their suggestions and the result. The architects, however, are faced with enormous constraints—budgets, regulatory codes, materials limitations—that they cannot or do not communicate well. Revisions made to accommodate these constraints can often make the initial plan unrecognizable leaving care providers wondering why they ever offered their input to begin with.

In this perspective, we take both an architectural and surgical view to outline current limitations of operating room design and emerging solutions to facilitate improvement (Table 1).



Back to Top | Article Outline


Current approaches to designing operating rooms are limited by inadequate user input, a narrow focus of traditional outcomes, and a limited evidence base to inform design.

Back to Top | Article Outline

Inadequate User Input

Architects often hold multiple focus groups to solicit surgeon and clinical staff input when designing an operating room. These sessions usually get stretched over months, rarely include the same surgeons each time, and have variable value to the architectural practitioner. While it is self-evident that user input should inform design of their built space and that focus groups are necessary, they are not nearly sufficient.

Back to Top | Article Outline

Narrow Focus of Operating Room Outcomes

Our most common outcomes of interest in surgical environments include mortality and postoperative complications. For most procedures, these events are rare making it difficult to generate enough statistical power (ie, sample size) to detect meaningful differences even when they exist.2 Furthermore, the determinants of these primary clinical outcomes are widely thought to be multifactorial making it more challenging to identify the impact of the built environment.

Back to Top | Article Outline

Limited Evidence Base to Inform Design

The field of “Evidence Based Design” (modeled after evidence based medicine) has grown exponentially in the last decade, with numerous studies linking the hospital built environment to clinical outcomes.3 Despite the growing body of research, the field is still nascent and lacks many of the characteristics academic surgeons are now accustomed to in health services research. For example, the majority of evidence based design studies are observational from single institutions, have limited sample size and lack methodology to risk and reliability adjust patient outcomes. Moreover, even less of these studies examine operating rooms or have clinical co-authors to give the design assessments clinical face-validity.

Back to Top | Article Outline


With the increasing interest on hospital and surgeon performance, the time is ripe to explore how the operating room could be designed better to improve both. Use of simulation, staged construction, user-centered outcomes and new research collaborations are emerging as useful tools to improve future operating room design.

Back to Top | Article Outline

Utilizing Simulation

Although focus groups may be helpful to generate ideas for the operating room, surgeons are “hands-on” and need direct involvement with a built space to evaluate it. In the era of simulation, mock virtual and physical operating rooms are being created with different built environment changes (eg, room size, lighting, and layout) and tested by future users of the space. For example, operating rooms built at Walter Reed National Military Medical Center were first created in virtual reality so that surgeons and operating room staff could “walk through” the space. Over subsequent virtual sessions, the design was iteratively improved before any construction was carried out.4 Virtual technology is also being applied to partially constructed spaces to “augment reality” so that users can foresee project interior details (eg, equipment, lighting, and flooring) before being implemented.5 In addition to giving users a better understanding of the project before it is built, there is significant front-end cost savings for design changes made before construction. However, before virtual simulation can be widely adopted, higher fidelity systems are still needed.

Back to Top | Article Outline

Staged Construction

Hospitals are often built in a staged fashion to accommodate budget constraints, which also provides a unique opportunity to test and improve design. Consider, for example, the construction of a nine-story inpatient tower in New Jersey.6 The initial phase of funding allowed for the first third to be completed, which was then rigorously evaluated by clinicians and architects. Three years later, the remaining floors were completed with design changes informed by real day-to-day user feedback from the previously built floors. In doing so, the financial delay was used as an opportunity for quality improvement. Many operating rooms are often built in a similar fashion in that they are framed out, but not all finished allowing for future growth. After the first operating room is constructed, it could be put into live clinical practice followed by real-time feedback before the remaining operating suites are built. Although a potential delay in construction, it would give real face validity to the design with users and ultimately add value to the overall new construction investment. Emerging techniques of video recording to evaluate surgeon technical performance7 and operating room communication8 provide important frameworks to evaluate these initial operating rooms impact on to surgical outcomes and patient safety before the remainder are built. Although using staged construction as a design improvement strategy benefits from local buy-in, it may not be possible in scenarios where a short timeline is required.

Back to Top | Article Outline

User-centered Outcomes

Mortality and complications will and should remain the important outcomes of interest for surgeons and architects, but may be less influenced by the built environment than other measurable attributes of the operating room. Including user-centered outcomes—for example, patient comfort on bed transfer, nurse ability to find important equipment, surgeon ergonomics during long procedures, and anesthesia ability to communicate during patient hand offs—may identify more variability that designers can influence with changes to the operating room built space. Initial efforts to evaluate these novel outcomes are being explored in places like the Kaiser Permanente Garfield Center for Innovation where researchers are following communication patterns, work flow efficiency, and ability to integrate new technology.9 Although clearly more elements of the operating room can be measured, researchers and designers will need to collaborate with operating room staff to identify and focus on those with the highest impact that are actionable.

Back to Top | Article Outline

Collaborative Research

In response to the growing complexity of healthcare facilities, research to improve design is increasingly being pursued with new collaborations. For example, The Pebble Project—a nonprofit collaborative focused on identifying and advocating design best practices in healthcare facilities—has now grown to over 90 member institutions including architecture firms, hospital systems, research groups, and industry developers.10 The innovation occurring specifically at the interface of architecture and surgery has attracted significant support from federal agencies. For example, the Agency for Healthcare Research and Quality recently funded a learning lab ‘Realizing Improved Patient Care through Human Centered Design in the Operating Room (RIPCHD.OR)’ to improve safety and efficiency in the operating room.11 Unlike previous attempts at studying the operating room, this collaborative learning lab brings together architects, engineers, anesthesiologists, surgeons, and nurses to prototype and rigorously test different operating room designs. Future discoveries to improve the operative built environment will require more large scale collaborations such as these backed by large funders.

Back to Top | Article Outline


The built environment where we work—hospital wards, operating rooms, outpatient clinics—are often thought to be static structures. Viewed differently, changes to the size, layout, and organization of the physical spaces we occupy have potential to be a meaningful healthcare intervention that improves patient safety and provider experience. As such, it deserves be evaluated and improved with the same scientific rigor subjected to all of our interventions in healthcare, guided by a strong, multidisciplinary evidence base.

Back to Top | Article Outline


1. Laufman H. Surgical hazard control. Effect of architecture and engineering. Arch Surg 1973; 107:552–559.
2. Dimick JB, Welch HG, Birkmeyer JD. Surgical mortality as an indicator of hospital quality: the problem with small sample size. JAMA 2004; 292:847–851.
3. Ulrich RS, Zimring C, Zhu X, et al A review of the research literature on evidence-based healthcare design. HERD 2008; 1:61–125.
4. Peavey EK, Zoss J, Watkins N. Simulation and mock-up research methods to enhance design decision making. HERD 2012; 5:133–144.
5. Cupp T. Simulating Healthcare Spaces Through Virtual Reality. Healthcare Design. May 2015. Available at: Accessed March 4, 2016.
6. Ewing Cole. Roberts Pavilion, Cooper University Health Care. 2014. Available at: Accessed March 3, 2016.
7. Birkmeyer JD, Finks JF, O’Reilly A, et al Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013; 369:1434–1442.
8. Yule S, Parker SH, Wilkinson J, et al Coaching non-technical skills improves surgical residents’ performance in a simulated operating room. J Surg Educ 2015; 72:1124–1130.
9. Fast Company. Inside the Operating Room of the Future. 2014. Available at: Accessed March 3, 2016.
10. Center for Deisgn and Health. The Pebble Project. 2016. Available at: Accessed March 3, 2016.
11. Joseph A. Realizing Improved Patient Care through Human-centered Design in the OR. Clemson University: Agency for Healthcare Research and Quality; 2015. Available at: Accessed March 3, 2016.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.