Originally published by the Canadian Healthcare Engineering Society in the Summer 2018 edition of Canadian
Healthcare Facilities Magazine


Standard impacts healthcare facility design, helps prevent infection

By Hélène Vaillancourt

Each year, approximately 220,000 Canadians are struck by healthcare-associated infections (HAIs), with 8,000 dying as
a result, according to the Public Health Agency of Canada. The high number of HAIs is why the Canadian Standards
Association (operating as CSA Group) developed Z8000, Canadian Health Care Facilities, in 2011. It was designed to
help ensure improved outcomes for those receiving care in a healthcare facility where design and construction play a
role. Given planned capital spending increases on healthcare facilities, no universally-accepted national standard
and growing public concerns over HAIs, the need for Z8000 was clear.

The Standard’s Impact

With the standard now seven years old, a study was launched to gauge the effect Z8000 has had on the healthcare
facility landscape until now. While the standard includes many clauses designed to improve outcomes at healthcare
facilities, the study focused on three features to determine whether facilities have experienced a decrease in HAI
rates. The features investigated were: the requirement for single-patient rooms (and separate washrooms in
exceptional cases where a room was shared); dedicated provisions for human waste disposal (equipment/technology and
location); and the requirement for deeper and better designed hand hygiene sinks (and their location) and the
placement of alcohol-based hand rub stations.

When Z8000 was released, each of these requirements posed challenges, notably because of the increased capital costs
associated with single-patient rooms and the lack of commercially available sinks at the time. The latter has since
been addressed but the former has yet to see widespread acceptance.

While Z8000 was not in place when the study projects were being designed, the study was able to examine healthcare
facilities that were early adopters of the advocated design features. As a result, it

could assess the impact on hand hygiene compliance and infection rates.

The infection prevention indicators employed in this study included HAI quarterly rates for MRSA and C. difficile
infection, and hand hygiene compliance.

Research Process

In the planning and development stage of the study, existing literature was reviewed to determine if previous studies
had examined the same design elements and if so, what conclusions those authors had drawn regarding effects on HAI
rates. Generally, the literature concluded that evidence suggested there were improvements in HAI rates when these
design elements were employed but the overall sense was that the issue likely warranted further study.

Further, the study examined data from Canada’s surveillance and reporting systems with respect to both hand hygiene
compliance and the incidence of HAIs in healthcare facilities.

The research phase involved recruiting (via a questionnaire) healthcare facilities across the country that had
recently undergone new builds or major renovations. Qualified facilities then participated in a survey. All the
survey data was reviewed and analyzed with a specific examination of the reported HAI and hand hygiene rates to
assess their statistical significance.

Nine healthcare facilities participated in the study; the majority (seven) were newly constructed facilities. With
just two completed surveys from renovated healthcare facilities, the sample was too small to extract meaningful
relationships or trends, so only new construction data was presented in the report.

Given the multitude of factors that affect HAI rates, the ability to consider every factor was limited. For this
reason, the study focused on the correlations between key design parameters and related patient safety metrics
(comparing before and after the move into a new healthcare facility).

Another challenge was the difficulty in establishing the correlation between each design element independently and
changes in HAI rates. So, for the purposes of the study, all design elements were considered together as a bundle.

Other study limitations included the lack of uniformity of case definitions for MRSA and C. difficile infection, and
incomplete information due to issues in collecting before data from some sites (different collection methods that
may have been used in the past).

The Results Are In

In terms of hospital design features, the survey results showed an increase in compliance to Z8000 requirements
related to both single-patient rooms, and the design and availability of hand hygiene sinks and alcohol-based hand
rub stations.

The average percentage of single patient rooms in hospitals before the new design was 15 per cent; that figure rose
to 71 per cent in the new healthcare facilities.

Similarly, compliance to Z8000 requirements related to hand hygiene sinks and alcohol-based hand rub stations
increased dramatically after the change in hospital design. For intensive care units in those healthcare facilities,
hand hygiene sink compliance rose from 31 per cent to 90 per cent, with alcohol-based hand rub station compliance
increasing from 57 per cent to 85 per cent. For the medical/surgical units of those healthcare facilities, hand
hygiene sink compliance increased from 40 per cent to 84 per cent, while alcohol-based hand rub station compliance
increased from 66 per cent to 82 per cent.

Although differences in measurement methods and insufficient data points made it difficult to calculate statistical
significance, hand hygiene compliance rates showed an increase from 83 per cent to 88 per cent after the
implementation of hospital design changes.

It is worth noting not all healthcare facilities showed a correlation between hand hygiene sink and alcohol-based
hand rub station availability and hand hygiene compliance rates, which suggests factors other than facility design
are influencing the rates such as the design and location of sinks and alcohol-based hand rub stations, staff
education and a healthcare facility’s safety culture.

The data collected on C. difficile infection surveillance revealed an infection rate decrease in five of the seven
healthcare facilities, two of which experienced statistically significant decreases. Overall, C. difficile infection
rates per 1,000 patient days dropped from 0.52 before the changes in hospital design to 0.29 afterwards.

MRSA rates underwent a similar decrease. While data was only available from five of the healthcare facilities, each
one experienced a general decrease, with two of the facilities reporting statistically significant reductions. On
the whole, MRSA infection rates per 1,000 patient days dropped from 0.38 before hospital design changes to 0.18

While healthcare facility design is just one element in the arsenal for preventing HAIs, it is vital that design
supports rather than undercuts good practices in patient management, hand hygiene and human waste disposal.

The data collected in the study — as supported by subsequent analysis for statistical significance — backs the
evidence that implementing key design elements in line with those recommended in Z8000

helps drive overall improvements in C. difficile infection and MRSA rates.

As healthcare facilities continue to follow best practices in design and improve the monitoring of key patient safety
metrics, hospitals will be able to demonstrate where efforts have increased patient safety and where they can be
focused for continued improvements.

Hélène Vaillancourt is vice-president, standards research and planning, at CSA Group and a member of the
Canadian Patient Safety Institute’s board of directors. The full research report is available at