FLOORING FIT-OUT IN A HOSPITAL

Chapter 1

THE PROBLEM AND ITS SETTING

Introduction

With increasing interest in sustainable building practices, new ‘green’ products are

entering the marketplace and making their way into healthcare settings. These may be in the

form of acoustic treatments of hospital rooms, use of organic paints, and flooring innovations.

As in any field, material innovation in hospital settings faces major challenges: the perception of

‘green’ products as being poorer performing, the 24/7 operations of hospital environments, lack

of education around cleaning and maintenance protocol of these products and the slow building

cycle of the healthcare industry. Furthermore, hospital administrators and facility managers are

most comfortable with materials that they know and trust, fearing problems with an unfamiliar

material that could disrupt their critical operations, which diminishes the opportunities for new

materials to enter the market (DuBose & Labrador, 2010).

Floors are a major element of newborn intensive care unit (NICU) in hospitals that

undergo these challenges of efficiency and functionality in the hospital setting. They provide

visual cues, sound control, and with certain materials, some degree of physical comfort for

workers. Flooring materials may entail a significant cost for installation and upkeep and can

have substantial ecological impact, both in the choice of the flooring itself, as well as the

substances used to clean it (White, 2007).

The type of flooring in hospitals has long been scrutinized in terms of its potential role in

nosocomial (hospital-acquired) infections (Harris, Pachenko, Linder, 2009). On the other hand,

Huxta (2016) maintained that each healthcare facility has its own specific needs and
requirements, flooring in healthcare applications should meet a few criteria across the board. In

a healing environment, flooring types keep noise levels at bay and thus have a major role in a

patient’s healing, progress and comfort (Simpson, 2016). Flooring materials may entail a

significant cost for installation and upkeep and can have substantial ecological impact, both in

the choice of the flooring itself, as well as the substances used to clean it (White, 2007).

With the continuous growth of need for a healthcare facility such as a hospital, it is only

fitting to know what materials are to be used especially in its flooring. The floor is one of the

most important parts of a building. A good flooring material must be considered in order to give

patients and doctors alike a safe and comfortable feel as they move in these floors. Also, the

hospital management should consider durability and maintenance levels. The objective of this

study is to provide guidelines and set standards in flooring fit-out in a hospital. Hospital flooring

must satisfy several requirements such as, comfort, safety, infection control and low-

maintenance.

Statement of the Problem

There are a number of considerations to take into account in choosing a flooring system

for hospitals. Studies have shown that the environment in which patients receive care has a

measurable effect on medical outcomes and the patients’ recovery. Flooring is one of the

important parts of a healthcare facilities that deserves concerted attention. As healthcare

facilities are highly critical, the appropriate choice of flooring should meet the most rigorous

standards. Hospital floors must meet strict health codes, they should also provide a positive and

welcoming atmosphere for patients and workers alike. Hospital flooring should promote safety,

maintain hygiene and infection control protocols, contribute to a positive patient experience and

should have a long usable life with minimal maintenance cost.

 In endearing to meet these flooring requirements, the researcher determined the

following:

1. Hospitals’ type of flooring used per hospital area

2. Main considerations in choosing flooring materials

3. Problems encountered by hospital involving flooring finish

Theoretical Framework

Systems Theory. Systems theory is the interdisciplinary study of systems. A system is a

cohesive conglomeration of interrelated and interdependent parts that is either natural or

manmade. A system is an integrated set of interacting variables that together create a

larger pattern or whole (Littlejohn & Foss, 2009).

Systems theory is a broad approach that applies to any number of natural, social,

and personal phenomena, including cognition, interpersonal relationships, social groups,

organizations and institutions, biological organisms, and the natural environment (Littlejohn &

Foss, 2009). Providing a common way of thinking about complex phenomena, systems theory

has a major impact on many fields, including construction.

Taking a family for example, it is only possible by virtue of interactions among

members, which results in the family having its own unique character (Littlejohn & Foss, 2009).

Every system is delineated by its spatial and temporal boundaries, surrounded and influenced

by its environment, described by its structure and purpose or nature and expressed in its

functioning. In terms of its effects, a system can be more than the sum of its parts if it expresses

synergy or emergent behavior. Changing one part of the system usually affects other parts and

the whole system, with predictable patterns of behavior. For systems that are self-learning and

self-adapting, the positive growth and adaptation depend upon how well the system is adjusted

with its environment. Some systems function mainly to support other systems by aiding in
the maintenance of the other system to prevent failure. The goal of systems theory is

systematically discovering a system's dynamics, constraints, conditions and elucidating

principles.

In a sense, Easton’s concept of ‘system’ is integrative involving values, culture,

authority, governance, implementation, participation, process, etc. ‘System’ is a very wide

term, which includes all forms of formal and informal processes, interactions, functions,

structures, values, behavior, etc. The political system allocates values for the whole

society and its decisions stand obligatory. A ‘system’, thus, can be any set of variables,

whatever be the form or intensity of interactions or interrelationship operating among them.

This is very applicable in flooring fit-outs since we are speaking of a system that must

and should be followed using different considerations making up its parts. Each part of the

flooring system may affect the whole system if certain factors were not considered

Conceptual Framework

-Conventional -Recommendable
Inputs

Outputs

-Users' experiences
Transformation Process

flooring system flooring fit-out

-Specifiers/Installers
-Low-cost flooring system
specialty
fit-outs
-Hospital
Management
requirements
Related studies

Feedback
 Since the intent of this study is to examine the recent experiences that doctors,

patients, and Engineers & Architects have had with alternative, resilient flooring system in

hospitals, the Easton’s system’s theory was used. This research focused on resilient

flooring materials, particularly solid/sheet vinyl. Sharing the installer and user experiences

is expected to explain this material, identify both positive and negative effects of this

material and potentially lead to adoption in fit-out in hospital flooring system.

From hospitals to clinics, doctor’s offices and medical centers, flooring system in the

healthcare arena is playing an important role in wellbeing, healing and overall patient

experience. Traditionally, parts of any flooring system take its motivation from aesthetics and

functionality. But this may not always turn-out to be efficient in the workplace. For example, a

flooring system may be considering to use glossy ceramic tiles. It may be good to the eye

fatigue of employees as well as elderly patients and the floor has to look clean but it can also

give people the feeling that they are going to slip.

Also, in areas such as the Internal Care Unit (ICU) flooring system offers a noise

reduction coefficient that allows for a quieter environment, improving patient care and staff

morale.

The construction industry involved in handling flooring systems of hospitals is diverse,

legalistic, institutional, bounded by its peculiar culture and tradition. Easton’s concept helped the

researcher in analyzing the construction industry’s flooring system. The construction industry

follows a system of reliance to client requirements first, functionality and other factors second,

then lastly, best recommendation to the clients. This is a system true to the choosing of right

flooring system. After thorough analysis of the different requirements given by the client and the

realities presented by studies.

 For this study, the hospital’s functional environment is very important due to the

presence of factors such as sanitation, slip resistance, durability/strength, and maintenance.

. A good flooring system must have the resilience to respond to this environment, facing all

obstacles, and provide for the needs of the hospital. Easton gave much bearing on the capacity

of the system to survive with the environment. For the flooring system, it must be the mentioned

factors above that must be survived.

Scope and Limitations

This study was focused only on four major hospitals in Marikina City and Quezon City. It

involved hospital staff and personnel who had first-hand experience in patient treatment and

care, patient delivery, and flooring maintenance. Also, architects and engineers involved in the

installation of flooring systems were involved. The issuances and publications on flooring safety

from the government and other governing bodies outline the factors and considerations that a

project manager must consider in flooring treatment was revisited. This is to assess the current

considerations being done by hospitals involving safety, health, efficiency, and maintenance that

may serve as basis of project managers and owners in the proper selection of flooring fit-out

system in a hospital.

Significance of the Study

The study on flooring fit-out system in a hospital can be helpful in the hospitals, the

construction industry, the people, and the researcher.

For the construction industry, which serves as the focal point in decision making for

proper flooring system in a hospital, can use this research-based recommendations in the

proper discourse of flooring utilities.

 For the hospitals, the findings of this study will result to comfort, safety, health, and

efficiency inside the hospital areas since the installed flooring fit-outs are based on

recommended fixtures born-out of this research.

For the people, the publics, and the audience, who are recipient of these information,

may guide them in hospital choices which value comfort, safety, health, and efficiency.

And for the researcher, this study helped uncover the critical ideas in the flooring

system that many researchers were not able to explore due to varied reasons.
 Chapter 2

REVIEW OF RELATED LITERATURE AND STUDY

This chapter presents the ideas generated and borrowed from the different

handbooks, journals, magazines, articles, and publications of different private and public

hospitals and other concerned agencies and organizations that support the study of the

flooring fit-out systems in a hospital. Literature and studies presents the best practices of other

groups, agencies, or entities in handling flooring systems, and how they gather related

information before, during, and after flooring installations. Further, various articles, references,

and documents used by flooring companies were visited.

Flooring considerations according to flooring companies, hospital staffs, and users

While each healthcare facility has its own specific needs and requirements, when it

comes to flooring in healthcare applications, a few criteria must be met across the board. There

are certain givens that were traditionally associated with performanc e. In particular , the

material must be durable, easy to maintain and can support patient mobility including

ambulatory and roller mobility related to heavy roller loads. These requisites represent the

minimum performance requirement for a flooring product, be it on foot or with the assistance of

a wheelchair or walking aid, supporting patient mobility and even the occasional fall in all

healthcare environments is a top priority . Mobility for a variety of patients as well as staff must

be taken into careful consideration when selecting flooring for these facilities. Most recently,

problems such as ease of movement across various floor types, along with enhanced noise

control, are additional concerns that the healthcare designer needs to take into consideration

(Simpson, 2016)
 According to the flooring company, Gerflor, flooring system must be highly durable

applied with the exclusive surface treatment by UV laser crosslinking providing superior

durability and an even surface thickness, creating an impenetrable barrier against stains

and chemicals; Water-repellent effect, the flooring surface treatment must possess a 100% non-

porous barrier to prevent all liquids and chemicals from penetrating the materials, remaining on

the surface; and, simple and easy stain removal (“A few tips to choose your floor”,2016).

Hospital falls place a substantial burden on healthcare systems. There has been limited

research into the use of hospital flooring as an intervention against fall-related injuries. Falls in

hospital is a significant problem of international concern . Research has been undertaken on the

effectiveness of fall and injury prevention strategies ; however, the effectiveness of interventions

can be limited due to poor compliance (Latimer, 2013)

To recommend, the shock-absorbing flooring intervention has the potential to be cost-

effective compared with standard flooring, but conclusions on the actual cost-effectiveness

cannot be confidently made without further research directed towards determining whether the

intervention flooring causes an increase in the faller rate (Latimer, 2013).

Too often, the choice of flooring for an NICU is based on the sole considerations of initial

cost and ease of maintenance. When all pertinent aspects of flooring performance are

considered, however, the true picture of the economic, human and environmental impact of

each option can be properly evaluated. The choices that result from this more careful analysis

may have a higher initial cost or require more upkeep, but can offer aesthetic, ergonomic and

sensory benefits to those who will live and work in the area for many years after (White, 2007)

Flooring should be considered as a possible intervention for reducing injuries from falls,

however, more rigorous and higher quality research is needed to identify the most appropriate

materials for use (Drahota, 2007).

 Hospital floors become contaminated by settlement of airborne bacteria, by contact with

shoes, trolley wheels, and other solid objects. Occasionally by the spilling of urine, pus, and

sputum. The removal of these reservoir is one of the aims of the hospital and a need for easy

maintenance flooring system must be considered (Ayliffe, 1966).

There is an increasing concern due to our ageing population and age-associated

increased risks of falls and injuries caused by flooring system in hospitals. Many hospital floors

are composed of a 2mm thin vinyl on concrete, which are unable to prevent injuries and may

exacerbate them. Shock absorbing flooring is one potential solution, which could be applicable

to all patients and be non-reliant on staff/patient compliance (Drahota, 2019).

Chapter 3

METHODOLOGY

Research Design

Case Study was used in studying the practices of flooring treatment by floor

experts. It was used since data were gathered from a variety of sources and by using several

different methods such as observation and conduct of surveys.

Case study is defined as detailed examination of an event or series of related events

which the analyst believes exhibit (or exhibits) the operation of some identified general

theoretical principles (Mitchell, 1983). Based on the definition, case study is an exploration of

system or cases through the detailed collection of data involving multiple sources of information

which is relevant for this study. Relatively, the construction industry, particularly flooring systems
has been the subject of numerous case studies as what is the proper flooring treatment for

hospitals.

As to approach, quantitative analysis was conducted. Survey questions were

distributed to hospital personnel directly involved in administration, patient mobility, health, and

care to include building maintenance from utility staff. Also, surveys were conducted with

construction entities directly involved in flooring system of hospitals. This is to gather their

experiences and recommendations when it comes to comfort, safety, aesthetics, durability, and

cost of flooring fit-out systems. The data gathered with this method was used by the researcher

in assessing the proper recommendation in flooring treatment.

Tradition of Inquiry and Data Generation Method

Open and close-ended surveys – A way of asking a closed-ended question, followed

by an open-ended question, to allow the respondents to explain his or her choice.

Sources of Data

Informants - The participants of this study include 12 nurses from hospitals and 8

maintenance/utility crew, 5 Architects and 5 Engineers. Their ages range from __ to ___. __ are

male and __ are female. Are married and are still single. All of them have served their

respective hospitals for more than 5 years now. As per the architects and engineers, all have

been involved in the construction of a hospital.

Documents - policies, directives, standing operating procedures, & other studies issued

by the different agencies, experts, and other researchers. These documents set forth guidelines

for the flooring system designers the delivery of the proper flooring treatment in hospitals. These
pieces of document also served as the basis of hospital owners in the treatment of their

hospitals.

Instrumentation

This study facilitated its data collection through the conduct of combined open and close-

ended written surveys. During the survey, the informants were given overview of the study

and explained to them the purpose of the study. The informants were initially asked about

personal details for demographic purposes. The informants were also asked about their

experiences as hospital personnel and their job description. After which, they were distributed

with the survey forms. The conduct of surveys were culminated by asking the informants on

other relative information that may be helpful in the study.

Ethical Considerations

During the conduct of this study, the researcher was able to consider various

ethical guidelines to ensure that participants were protected. At the outset, the participants

were informed that the information they will disclose will be used purely for the conduct of

the study and will not be divulged to any event not related to the study. And such, the

dignity and well-being of the participants were prioritized especially that they belong to the

institution wherein the individual dignity is preserved.

The researcher also sought the approval of the hospital management as they are the

ones safekeeping related information, responsible for implementation of hospital operations.