Mitigating Risks in Hospital Facilities—An Analysis of the Relationship Between Healthcare Risks and the Built Environment: A Literature Review and Survey in the Italian Scenario

Abstract

Background: This study examines the role of the built environment in mitigating risk in healthcare facilities, with a particular focus on how the design of hospital infrastructures can influence and improve the safety of patients, staff, and visitors. Methods: A two-phase mixed-methods approach was adopted. First, a scoping literature review was conducted to identify design-based strategies targeting five categories of risk: healthcare-associated infections (HAIs), indoor air quality (IAQ), safety, falls, and emergency resilience. Based on this review, a structured questionnaire was developed and administered to a sample of hospital facilities in Northern Italy to assess the implementation of the strategies emerged. Results: The literature review identifies recurring specific design solutions and strategies that have proven effective in mitigating risks in healthcare infrastructures in the following dimensions: infection mitigation, indoor air quality, falls reduction, safety, emergency preparedness. At the same time, survey data from (n = 9) hospitals indicate a significant implementation gap. Key shortcomings included a lack of spatial flexibility, limited environmental monitoring (especially for IAQ and acoustic conditions), and underutilization of antibacterial surfaces. Antibacterial flooring and wall finishes were absent in (n = 4/9) and (n = 6/9) of the facilities, respectively. IAQ monitoring was mostly confined to surgical areas, with (n = 0/9) facility reporting comprehensive building-wide monitoring. Only two (n = 2) facilities reported adaptable spaces suitable for emergency conversion and accessible green areas. Conclusions: This study provides a comprehensive overview of risk mitigation strategies in hospital design. The results reveal critical gaps in implementation, particularly in spatial flexibility, environmental monitoring, and antimicrobial surfaces. Future research should focus on developing adaptable design models that are context-sensitive, scalable, and capable of enhancing healthcare resilience in response to emerging global health threats.

1. Introduction

1.1. Background

Hospitals, as key institutions for providing care, accommodate a vulnerable population that requires specific spatial and organisational arrangements to ensure well-being and health. However, more than one out of ten patients experience adverse events during the hospitalisation, with one-fifth of these leading to severe consequences, including permanent disabilities or death [1]. These recent data highlight the crucial need to address risk mitigation within healthcare facilities, not only from a clinical perspective but also through careful architectural design. The integration of design and risk management thus represents a significant challenge in designing the hospital of the future. Hospital spaces must be planned not only to support the operational needs of medical staff but also to create an environment that minimises risks and adverse events [1]. Indeed, as emphasised in numerous documents published by the World Health Organization (WHO), design must also consider the importance of a comfortable and reassuring environment for both patients and staff, thereby contributing to their physical and psychological well-being [2].

The latest internationally developed guidelines on risk management are those issued by the WHO, primarily aimed at ensuring patient safety within healthcare facilities. These documents identify various categories of risk associated with the built environment. Specifically, five key risks have been identified from scientific institutions and technical documents [1,2,3].

Despite this recognition, identified on the international document produced by the OMS, there remains a lack of systematic understanding of how hospital design contributes to risk prevention, particularly in relation to specific categories of risk identified in international and national literature.

This study addresses this gap by reviewing recent peer-reviewed research to identify environmental risks most relevant to hospital settings. Five main categories of risk are considered: healthcare-associated infections (HAIs), indoor air quality and microclimate, safety risks, and falls. Additionally, the study considers the increasing relevance of emergency-related risks, especially in light of the COVID-19 pandemic.

The risk of healthcare-associated infections (HAIs) has long been recognised as one of the greatest threats in hospital environments [4,5,6]. Recent scientific literature highlights specific design solutions that help reduce the risk of infections [6,7]. Particular attention has been given to pathogens classified under the ESKAPEE group (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp., and Escherichia coli), which are commonly implicated in HAIs and known for their high levels of antibiotic resistance. Mitigating the spread of these organisms through spatial strategies, surface materials, and ventilation systems has become a central focus of infection control in healthcare design.

Microclimatic risks and indoor air quality are among the primary concerns that industry professionals and policymakers are focusing on. In healthcare settings, numerous studies are increasingly analysing data to protect the health of both patients and healthcare workers from these risks. The complexity of this issue arises from the fact that indoor air is influenced by multiple factors, which are often analysed individually rather than through a comprehensive framework that considers all relevant variables [8,9,10].

Safety risks are a critical aspect across the entire hospital structure, affecting staff, patients, and visitors alike [5]. Studies have demonstrated links between healthcare facility design and improved safety outcomes for both patients and healthcare personnel [2,11]. Additionally, one of the most pressing risks for healthcare workers—classified as a major health priority by the WHO and closely related to safety—is workplace violence, which is considered the second leading cause of stress among healthcare professionals [12].

The risk of falling is a widespread global issue, despite continuous efforts to prevent falls in both public and private healthcare settings. Therefore, design measures are necessary to help mitigate this risk [13,14].

Emergency risks have gained prominence in recent years, particularly due to the COVID-19 pandemic. The pandemic underscored the complexity and vulnerability of hospitals, given their reliance on external support and supply systems. During crises caused by exogenous factors (e.g., pandemics, natural disasters, or wars), hospitals become essential physical reference points for society and must be capable of managing emergencies without becoming overwhelmed [6,15].

The design of healthcare spaces that promote risk mitigation requires innovative solutions that can also address new social needs. The configuration of spaces, the use of innovative materials, and the implementation of advanced technologies for patient monitoring and information management are just some of the key components in this context [16]. Given these considerations, safety risk mitigation and well-being cannot be separated from architectural design.

1.2. Study Aim and Research Questions

This study investigates risks associated with the built environment in hospital settings, as identified in the recent literature, and explores the corresponding design strategies for their mitigation. Based on the findings from a systematic review, a questionnaire was developed and administered to a sample of Italian hospitals to assess the extent to which these strategies are currently implemented in practice. The research was guided by two main questions:

• RQ1: What are the most current and recurring design strategies for risk mitigation in healthcare facilities?
• RQ2: What is the current situation of facilities in a sample of Italian facilities with respect to risk mitigation strategies found in the literature review?

1.3. Research Context

This research focused on the Italian hospital system, with a particular emphasis on the Lombardy and Veneto region. The two regions were chosen as the primary case study as a representative example in the Italian healthcare delivery scenario. The region was deemed appropriate for in-depth analysis due to the following: (i) the significance in the number of hospitals built during different periods; (ii) the variety of hospital types, including new constructions and older facilities, which allows for comparative analysis; and (iii) it is the Italian area with the highest population and the most significant contribution of private accredited providers in the healthcare system. Furthermore, the region has a diversified mix of urban and rural healthcare infrastructures, as well as a significant presence of public and accredited private providers, making it a robust case for analysis. While the healthcare systems vary across regions, the diversity and scale of these regional systems allow for meaningful insights and serve as a proxy for national-level trends.

2. Materials and Methods

The methodological approach adopted in the contribution involved two phases. The first phase involved a scoping literature review focused on the mitigation strategies for the healthcare risks associated with the built environment and the second phase consisted of a survey based on the strategies identified in the literature review.

2.1. A Review of the State of the Art Through a Literature Review

The literature review was conducted to explore potential strategies for risk mitigation within hospital facilities, as identified in the most recent literature. The literature review process considered both primary and secondary sources, paying particular attention to the key documents recognised by the international technical and scientific community for hospital design.

The main sources used in this context included the following:

• Scientific literature from major databases such as Scopus, Web of Science, and PubMed.
• Technical literature.
• International guidelines and tools on hospital design.

For database research, specific keywords were identified and used in the search phase:

“hospital” OR “healthcare facility” AND “Risk” OR “Risk management” OR “Infection control” OR “Security” OR “Safety” OR “Air quality” OR “Falls reduction” AND “Hospital design” OR “Design strategies”

Eligibility criteria were also defined to refine the research scope. The eligibility criteria included are as follows:

• Documents published after 2019.
• Documents in Italian or English.
• Only editorial articles, reviews, research articles, or books/book chapters.

The year 2019 was chosen as a criterion because, following the COVID-19 pandemic, the healthcare sector began to highlight significant critical issues, weaknesses, new needs, and new objectives necessary to improve healthcare services and patient care.

The documents were analysed according to the category of risk associated with the built environment identified by the authors and according to the strategies present. From all the strategies in the articles, those that were repeated in at least three scientific articles were selected.

The investigation started with defining the correct terminology to obtain relevant research results. The search string was developed based on previously reviewed documentation and included terms related to hospitals, risks, and design strategies. Using Scopus and PubMed, (n = 2386 and n = 2347) results were obtained, respectively. After the removal of duplicates (n = 549), eligibility criteria were applied to eliminate irrelevant scientific fields (e.g., biochemistry, mathematics, veterinary sciences), and the research was limited to the last five years (from 2019) to include post-pandemic studies, resulting in 411 contributions. These papers were analysed through title, abstract, and keyword screening, leading to the exclusion of 326 records deemed irrelevant. The remaining 85 articles were assessed for full eligibility, applying further selection criteria: addressing healthcare architecture (excluding clinics and private practices), focusing on risk management, and referring to the built environment and hospital layout. At the end of the process, 25 documents, listed in Appendix A 

Table A1. List of documents identified in the literature review.

Title	Authors	Year	Document	Journal	Ref.
1. Understanding Design Vulnerabilities in the Physical Environment Relating to Patient Fall Patterns in a Psychiatric Hospital	Bayramzadeh, Sara, Margaret Portillo, e Candy Carmel-Gilfilen	2019	Article	Journal of the American Psychiatric Nurses Association	[29]
2. Chemical Pollution in Healing Spaces: The Decalogue of the Best Practices for Adequate Indoor Air Quality in Inpatient Rooms	Gola Marco, Gaetano Settimo, e Stefano Capolongo	2019	Article	International Journal of Environmental Research and Public Health	[9]
3. Wood and Its Impact on Humans and Environment Quality in Health Care Facilities	Kotradyova, Veronika, Erik Vavrinsky, Barbora Kalinakova, Dominik Petro, Katarina Jansakova, Martin Boles, e Helena Svobodova	2019	Article	International Journal of Environmental Research and Public Health	[26]
4. Indoor Air Quality in Inpatient Environments: A Systematic Review on Factors that Influence Chemical Pollution in Inpatient Wards	Marco Gola, Gaetano Settimo e Stefano Capolongo	2019	Review	Journal of Healthcare Engineering	[25]
5. Interventions to Reduce Falls in Hospitals: A Systematic Review and Meta-Analysis	Meg E. Morris, Kate Webster, Cathy Jones, Anne-Marie Hill, Terry Haines, Steven Mc Phail, Debra Kiegaldie, Susan Slade, Dana Jazayeri, Hazel Heng, Ronald Shorr, Leeanne Carey, Anna Barker, Ian Cameron	2020	Review	British Geriatrics Society	[27]
6. COVID-19 and Healthcare Facilities: a Decalogue of Design Strategies for Resilient Hospitals	Stefano Capolongo, Marco Gola, Andrea Brambilla, Alessandro Morganti, Erica Isa Mosca, Paul Barach	2020	Article	Acta Biomed	[6]
7. Simulation Enhances Safety Evaluation in the Design of New Healthcare Facilities	Colman, Nora, Ashley Dalpiaz, e Kiran B. Hebbar	2020	Article	Current Treatment Options in Pediatrics	[37]
8. Designing for Patient Safety and Efficiency: Simulation-Based Hospital Design Testing	Colman, Nora, Mary Bond Edmond, Ashley Dalpiaz, Sarah Walter, David C. Miller, Kiran Hebbar	2020	Article	Health Environments Research & Design Journal	[36]
9. Surface Design for Antibacterial Materials: From Fundamentals to Advanced Strategies	Li, Wenlong, Eng San Thian, Miao Wang, Zuyong Wang, e Lei Ren	2021	Review	Advanced science	[17]
10. Investigating the Impact of Healthcare Environmental Design on Staff Security: A Systematic Review	MohammadiGorji, Soheyla, Sheila J. Bosch, Shabboo Valipoor, e Giuliano De Portu	2021	Review	HERD: Health Environments Research & Design Journal	[39]
11. Communicating science in times of crisis	O’Hair, Dan, e Mary John O’Hair	2021	Book chapter	Hoboken	[41]
12. Designing a Patient Room as a Fall Protection Strategy: The Perspectives of Healthcare Design Experts	Piatkowski, Melissa, Ellen Taylor, Bob Wong, Dorothy Taylor, K. Bo Foreman, e Andrew Merryweather	2021	Article	International Journal of Environmental Research and Public Health	[28]
13. How the COVID-19 pandemic will change the future of critical care	Arabi, Yaseen M., Azoulay Elie, Al-Dorzi Hasan M., Phua Jason, Salluh Jorge, Binnie Alexandra, Hodgson Carol, Angus Derek C., Cecconi Maurizio, Du Bin, Fowler Rob, Gomersall, Charles D., Horby Peter, Juffermans Nicole P., Kesecioglu Jozef, Kleinpell Ruth M., Machado Flavia R., Martin Greg S., Meyfroidt Geert, Rhodes Andrew, Rowan Kathryn, Timsit Jean-François, Vincent Jean-Louis e Citerio Giuseppe	2021	Review	Intensive Care Med	[32]
14. Inpatient Telemedicine and New Models of Care during COVID-19: Hospital Design Strategies to Enhance Patient and Staff Safety	Pilosof, Nirit Putievsky, Michael Barrett, Eivor Oborn, Galia Barkai, Itai M. Pessach, e Eyal Zimlichman	2021	Article	International Journal of Environmental Research and Public Health	[40]
15. Architectural design strategies for infection prevention and control (IPC) in health-care facilities: towards curbing the spread of COVID-19	Emmanuel, Udomiaye, Eze Desy Osondu, e Kalu Cheche Kalu	2022	Review	Journal of Environmental Health Science and Engineering	[18]
16. Responsiveness and Adaptability of Healthcare Facilities in Emergency Scenarios: COVID-19 Experience	Łukasik, Marta, e Anna Porębska	2022	Article	International Journal of Environmental Research and Public Health	[21]
17. Future Hospital Building Design Strategies Post COVID-19 Pandemic	Makram, Abeer, e Rasha Ali El-Ashmawy	2022	Article	International Journal of Sustainable Development and Planning	[19]
18. Hospital Responses to COVID-19: Evidence from Case Studies to Support Future Healthcare Design Research	Setola, Nicoletta, Eletta Naldi, Maria Vittoria Arnetoli, Luca Marzi, e Roberto Bologna	2022	Article	Facilities	[15]
19. Learning from COVID 19. A Comparison of Innovative Design Solutions for Human-Centered Healthcare Facilities	Erica Brusamolin, Andrea Brambilla and Stefano Capolongo	2022	Book Chapter	Springer Series in Design and Innovation	[30]
20. Advancing human health, safety, and well-being with healthy buildings	Sara O. Marberry, Robin Guenther, Leonard L. Berry	2022	Review	Journal of Hospital Management and Health Policy	[35]
21. COVID-19 Patient and Personal Safety—Lessons Learnt for Pandemic Preparedness and the Way to the next Normal	Füszl, Astrid, Julia Ebner, Miriam Van Den Nest, Lukas Bouvier-Azula, Magda Diab-El Schahawi, e Elisabeth Presterl	2023	Article	Antimicrobial Resistance & Infection Control	[20]
22. The Role of Healthcare Facility Design on the Mental Health of Healthcare Professionals: A Literature Review	Jin, Hyun-Young, Chas Gold, Junhee Cho, Fatemeh Marzban, e Lisa Lim	2023	Review	HERD: Health Environments Research & Design Journal	[24]
23. The Variable Impact of Clinical Risk-Adjustment Models to Evaluate Hospital Design	Mead, Mitchell, Upali Nanda, e Andrew M. Ibrahim.	2023	Article	HERD: Health Environments Research & Design Journal	[23]
24. Resilient Hospital Design: From Crimean War to COVID-19	Tang, Kangkang, e Bing Chen	2023	Article	HERD: Health Environments Research & Design Journal	[22]
25. How Visibility May Reduce Security Issues in Community Hospitals’ Emergency Departments	Gharaveis, Arsalan, D. Kirk Hamilton, Debajyoti Pati, Mardelle McCuskey Shepley, Susan Rodiek, e Denise McCall	2024	Article	HERD: Health Environments Research & Design Journal	[38]

, were selected (Figure 1).

2.2. State of the Art on Risk Mitigation Strategies Through Survey

After identifying strategies from the literature review, a questionnaire was developed, consisting of 26 questions. This questionnaire was based on the strategies identified in the literature review that can help mitigate different types of risks in healthcare environments.

The questions identified and used in the survey, shown in Appendix A 

Table A2. Survey.

Question
1. Can the hospital facility ensure that, if necessary, the areas can be quickly converted to accommodate patients and/or temporarily change their function without the need for renovations?
2. Does the hospital have green spaces accessible to patients, staff, and visitors?
3. In which of the following areas are rest/relaxing spaces exclusively dedicated to staff available?	Diagnostic Area
	Day Area
	Inpatient Area
	Surgical Area
	Maternal and Infant Area
	Emergency Area
	General Services
	None of the above
	Other
4. Number of single ordinary inpatient rooms
5. Are the single rooms designed to be converted into double rooms if needed?
6. Number of double ordinary inpatient rooms
7. Are there bathroom in every inpatient room?
8. Is it possible to accommodate a visitor in ordinary inpatient rooms?
9. Does the staff have good visibility of all the patient rooms from their station?
10. Intensive Care Unit Layout	Single room
	Single Box
	Double Room
	Open Space
	Other
11. If the Intensive Care Unit consists of single rooms or boxes, is there a provision for converting them into double rooms in case of emergency?
12. Does the Intensive Care Unit have provisions to increase the number of beds?
13. Are there antibacterial floorings within the hospital? If there are, please specify in which areas.	Diagnostic Area
	Day Area
	Inpatient Area
	Surgical Area
	Maternal and Infant Area
	Emergency Area
	General Services
	None of the above
	Other
14. Are there anti-fall floorings within the hospital? If there are, please specify in which areas.	Diagnostic Area
	Day Area
	Inpatient Area
	Surgical Area
	Maternal and Infant Area
	Emergency Area
	General Services
	None of the above
	Other
15. Is there antibacterial wall finishing within the hospital? If there are, please specify in which areas.	Diagnostic Area
	Day Area
	Inpatient Area
	Surgical Area
	Maternal and Infant Area
	Emergency Area
	General Services
	None of the above
	Other
16. Is the acustic performance monitored? If is monitored, please specify in which areas.	Diagnostic Area
	Day Area
	Inpatient Area
	Surgical Area
	Maternal and Infant Area
	Emergency Area
	General Services
	None of the above
	Other
17. How the hospital measures the acustic performance?
18. Are there access control tools within the hospital? (For example: badge readers, management software, smartphone applications, etc.) If there are, please specify the areas.	Diagnostic Area
	Daycare Area
	Inpatient Area
	Surgical Area
	Maternal and Infant Area
	Emergency Area
	General Services
	None of the above
	Other
19. How is access control managed?
20. Is Indoor Air Quality monitored? If yes, please specify the areas.	Diagnostic Area
	Day Area
	Inpatient Area
	Surgical Area
	Maternal and Infant Area
	Emergency Area
	General Services
	None of the above
	Other
21. Are there specific limit values used for monitoring IAQ?
22. If there are some limit values, please write which are.

, are the result of the literature review, which identified a series of possible strategies for risk mitigation in healthcare facilities related to the built environment. The survey addresses 4 categories of the build environment: the first part is focused on the general structure and contains 4 questions; the second is about the functional layout and is structured in 8 questions; the third is about the finishing materials and contains 3 questions; and the last part is focused on monitoring and contains 7 questions (

Table 1. Structure of survey.

Categories	Themes Addressed
1. Hospital facility	Type of spaces present, quality of some spaces, presence or absence of certain spaces, number of hospital rooms
2. Functional layout	Intensive Care Unit, inpatient rooms
3. Finishing materials	Floors, walls
4. Monitoring	Indoor air quality, acoustic quality, access control

).

The analysis of demographic responses highlighted various types of facilities constructed between 1900 and 2010. The facilities responding to the questionnaire (Appendix A 

Table A3. Responding Facilities.

Hospital	City
23. ICS Maugeri - Polo di Pavia	Pavia
24. Ospedale Alessandro Manzoni (ASST Lecco)	Lecco
25. Ospedale Carlo Poma (ASST Mantova)	Mantova
26. Ospedale di Cremona (ASST Cremona)	Cremona
27. Ospedale di Garbagnate (ASST Rhodense)	Garbagnate
28. Ospedale San Carlo (ASST Paolo e Carlo)	Milano
29. Ospedale San Paolo (ASST Paolo e Carlo)	Milano
30. Ospedale Di Circolo E Fondazione Macchi (ASST Sette Laghi)	Varese
31. IRCCS Sacro Cuore Don Calabria	Verona

) are categorised into three levels of complexity, in accordance with Ministerial Decree No. 70 of 2 April 2015: two basic-level facilities (n = 2), four first-level emergency hospitals (DEA I) (n = 4), and three second-level emergency hospitals (DEA II) (n = 3).

To understand the overall current situation of healthcare facilities, a quantitative analysis was conducted. This analysis provided an overview of how the responding facilities have implemented design solutions to mitigate risks and helped identify the most frequently adopted and the most lacking strategies.

The questionnaire responses were structured in different formats depending on the type of question. Most responses were binary or multiple-choice, but some required short open-ended answers when necessary. After the draft questionnaire was finalised, it was tested by means of a pilot test to verify its ability to correctly respond to the survey’s cognitive requirements and to be easily understood by the respondents. The draft questionnaire was submitted to qualified experts in the field and was subsequently considered validated.

The validated questionnaire was sent to sixty healthcare facilities in the north of Italy (n = 60), between the Lombardy and the Venetian region, and, in order to have coherent answers, the structure chosen was only hospitals. All other types of health-related structures, such as outpatient facilities or IRCCS, were excluded. The survey was sent as an online fillable form and, when requested by hospital organisations, also in a PDF version.

• Online: The questionnaire was sent via a link attached to an introduction email. Each email included a clear explanation of the research objective and instructions on how to complete the questionnaire.
• PDF Format: When requested, the questionnaire was provided in a PDF format. The file was designed to be editable and fillable and was then returned via the specified email address.

The questionnaire was available for one month, from August 6, 2024, to September 10, 2024, allowing participants sufficient time to complete it. The collected data were processed anonymously and confidentially. The analysis of the questionnaire data enabled the summarization of the main characteristics of the data. This provided a fundamental understanding of the data distribution and its key features.

3. Results

3.1. Literature Review

The literature review was structured according to the risk categories highlighted in the introduction of the paper to ensure greater clarity and consistency. This allowed the establishment of a direct link between different types of risks and the design solutions (Figure 2) identified in various scientific studies. It also facilitates an understanding of how issues identified in the literature have been addressed and what strategies have been proposed to mitigate risks, creating a more cohesive and comprehensive overview.

3.1.1. Hospital-Acquired Infections

This risk category has been widely discussed in recent years, particularly following the global COVID-19 crisis, which led to numerous reflections on strategies to minimise the possibility of contracting infections in hospitals.

Hospital infections represent a major threat, exacerbated by bacterial evolution and antimicrobial resistance. Several design solutions have been suggested to minimise healthcare-associated infections (HAIs), including proper ventilation, the selection of antibacterial materials and washable surfaces [17], the separation of indoor and outdoor spaces, and the use of touchless technologies [18,19,20].

From a typological perspective, pavilion hospitals are best suited for infection management due to their ability to isolate different areas. However, in daily use, comb-shaped and podium-tower hospital types are more efficient [21].

Another recommendation is to create a resilient hospital, capable of adapting to unforeseen circumstances and changing when new challenges arise without compromising the safety and well-being of frontline medical staff and other patients. This organisational resilience depends not only on flexible clinical protocols but also on adaptable hospital layouts [6,22,23].

The durability and cleanability of finishing materials and surfaces also affect the risk of infection [24].

To build healthier and safer hospitals, research has demonstrated the need for more outdoor spaces and green areas, as well as the variety of external spaces to provide patients and families with safe environments. Additionally, incorporating green areas for sports activities allows both patients and staff to meet their daily movement needs and connect with nature through views of green spaces [24].

3.1.2. Environmental Control and Indoor Air Quality (IAQ)

Indoor air quality is a major concern that governments are increasingly addressing. In healthcare settings, numerous studies are analysing data and research to ensure and protect the health of both users and workers.

Current investigations mainly focus on biological and physical risks, while chemical risks receive less attention. Indoor air quality is influenced by various factors, which are often analysed individually rather than as part of a comprehensive framework considering all variables [25].

One study classified [25] the factors affecting indoor air quality into four main areas:

• Location, outdoor air, and microclimatic factors (temperature, humidity, airspeed, air exchange, etc.).
• Management activities (maintenance, ventilation systems, Heating, Ventilation and Air Conditioning (HVAC), cleaning, and disinfection).
• Design factors (room dimensions, furnishings, finishing materials).
• Human presence and medical activities (number of users, their health conditions, medical procedures performed in patient rooms).

These elements require specific design solutions that should be validated by a multidisciplinary team [9]. Adequate air exchange rate must be ensured in all environments through mechanical ventilation and, where possible, mixed ventilation. Ventilation systems play a strategic role in emergencies (such as infectious disease outbreaks), ensuring that air circulation meets various healthcare needs under all conditions [6].

Additionally, using natural materials like untreated wood improves air quality and reduces user stress [26].

• Falls

Hospital falls are a global issue, with rates ranging from 2 to 16 per 1000 patient days. They can cause injuries of varying severity and impact patient recovery [27,28].

Design elements that reduce fall risk include the following:

• Adequate lighting.
• Non-slip flooring [13].
• Continuous handrails.
• Elimination of obstacles.
• Proper furniture layout.

In common areas, falls often occur due to uneven flooring, making careful flooring installation essential during construction [29]. The choice of flooring materials can help reduce falls, a common issue among patients and hospital staff that affects recovery and can lead to short- or long-term disabilities and chronic pain [27].

3.1.3. Flexibility for Emergencies

Hospitals play a fundamental role in national healthcare systems, providing essential medical care to communities. However, they are also complex and vulnerable, relying on external support and supply systems. The COVID-19 pandemic highlighted the need for resilient hospitals with compartmentalised spaces, advanced ventilation systems, flexible environments for rapid conversion, and stronger community connections [6,30,31,32].

Additionally, patient rooms should be designed for double occupancy in emergencies, incorporating touchless systems and non-porous monolithic materials [30]. To ensure long-term preparedness, hospital design and infrastructure must address not only pandemics but also the full range of potential disease outbreaks and natural occurrences (earthquakes, floods, wildfires, and other extreme weather events) that can trigger healthcare emergencies.

• Safety

Properly designed facilities can prevent medical errors and infections, ensuring a safe environment for both patients and staff [33,34,35].

Design decisions can have downstream effects on patient and staff safety, as latent safety threats can lead to healthcare-related errors or adverse events [36].

Key safety aspects include the following:

• Open layouts to enhance visibility [37,38].
• Access control to secure critical areas such as entrances, waiting rooms, triage spaces, emergency departments, and psychiatric units [39].
• Telemedicine, which reduces virus transmission, optimises resources, and enhances safety for both patients and healthcare providers [40,41].

3.2. Survey

3.2.1. Introduction to Survey

This section presents the results from the survey concerning the most relevant strategies for risk mitigation in healthcare facilities to highlight the design solutions that need to be implemented for the needs of the hospital of the future. The following image is representative of the location of the responding healthcare facilities (Figure 3).

In particular, design solutions will be analysed regarding the space typology, the quality of certain spaces, the presence or absence of certain spaces, the number of inpatient rooms, the layout of Intensive Care Units and inpatient rooms, floor and wall finishes, and monitoring instruments for indoor air quality, acoustic quality and access control.

3.2.2. State of the Art of a Sample of Hospital Facilities on Risk Management Strategies

The facilities were analysed in terms of space adaptability without requiring renovations during potential emergency situations. Only 22% (n = 2) of hospitals reported having this capability, while 11% (n = 1) stated that an ongoing renovation includes this requirement. The remaining 67% (n = 6) do not feature the identified solution.

Regarding the presence of accessible and equipped green spaces, the results indicate that only 22% (n = 2) of the analysed facilities have them, whereas the remaining 78% (n = 7) do not provide usable green spaces.

Hospital inpatient rooms were analysed under different aspects. First, the number of single and double patient rooms was examined. The total number of rooms in the responding facilities is 2845, of which 2461 are double rooms and 384 are single rooms. On average, single rooms account for 13% of the total, while double rooms make up the remaining 87% (Figure 4).

The following question was focused on the ability to increase bed capacity in case of emergencies and the flexibility of patient rooms. Findings show that 56% of single rooms are not designed for conversion into double rooms.

Furthermore, the possibility of accommodating a visitor overnight in case of necessity was investigated. The chart below shows that in approximately half of the cases (44%), this is allowed, while in the other half (44%), it is not. One facility (11%) specified that overnight visitor accommodation is only allowed in the hospice unit, which is part of the inpatient care area.

The visibility of healthcare staff from their workstation to patient rooms was also analysed. The results indicate that in 44% (n = 4) of cases, staff have clear visibility, whereas in 56% (n = 5), staff cannot easily monitor all patients.

Observing the histogram below, one observes that the mode, as far as the Intensive Care Unit layout is concerned, is the open-space solution (n = 8). Some facilities also have single-patient boxes (56%) or single rooms (22%) in addition to the open-space layout (Figure 5).

An important aspect to consider is the flexibility of the Intensive Care Unit (ICU). The study investigated whether single rooms or patient boxes could be converted into double rooms. The results show that only 11% (n = 1) of cases allow this conversion, 11% allow a partial conversion (n = 1), 45% (n = 4) do not allow any conversion, and in 33% (n = 3) of cases, no single rooms or boxes exist.

In terms of overall ICU flexibility, the possibility of increasing bed capacity in case of emergencies—regardless of the existing layout—was examined. The findings show that in only 44% (n = 4) of cases, this is possible, while in 56% (n = 5) of cases, it is not.

Floor finishes were analysed, including antibacterial flooring, which neutralises bacteria through specific treatments or antibacterial compounds. As shown four (n = 4) of the analysed facilities (44%), data that represent the statistic mode, do not have antibacterial flooring. Of those that have them (56%), the areas identified include the diagnostic, surgical, and emergency areas (44%) and the maternity, inpatient, and day care areas (33%), while the general services area has antibacterial flooring in 22% of cases (Figure 6).

The antibacterial coatings of walls were also examined. Six (n = 6) facilities (67%), data that represent the mode, do not have antibacterial wall finishes, while three (n = 3) facilities (33%) have them in specific areas. The surgical area had them in three cases (33%), the emergency and mother–child areas in two cases (22%), and the inpatient, day hospital, and diagnostic areas in one case (11%) (Figure 7).

Another aspect addressed was the monitoring of acoustic quality in healthcare facilities. The results, shown in the histogram below, indicate that only one facility (11%) performs acoustic quality measurements, specifically in the diagnostic, inpatient, and day hospital areas. The statistic mode indicate that eight facilities does not monitor acoustic quality (Figure 8).

Access control measures were also examined. The results show that access control is mainly implemented in the emergency area (89%), data that represent the statistic mode, followed by the surgical area (78%), the mother–child and diagnostic areas (67%), the inpatient area (56%), the day hospital area (44%), and the general services area (33%). Facilities were also asked how access control is managed and for whom, and it was found that in almost all cases (67%), control is via badge readers, primarily for staff (Figure 9).

Indoor air quality (IAQ) monitoring was also analysed. Of the responding facilities, (n = 8/9) reported that monitoring was conducted in the surgical area. In addition, 44% reported monitoring in the emergency and mother and baby areas, 33% in the inpatient and general services areas, and 22% in the day hospital and diagnostic areas (Figure 10).

None of the facilities monitor air quality throughout the building, only in specific areas. This finding highlights the need for greater attention to air quality control in healthcare environments, as limited monitoring may not provide consistent protection against airborne contaminants or pathogens. When asked how IAQ is monitored, responses were only provided for the surgical area, which is subject to specific regulations.

4. Discussion

The primary aim and the first research question of this study was to conduct a comprehensive analysis of the literature to identify architectural and design strategies for mitigating environmental and operational risks in hospital settings. A secondary objective, responding to the second research question, was to evaluate the extent to which these strategies have been implemented in healthcare facilities in Northern Italy. The results of the literature review and the survey highlight a significant gap between the best practices proposed in research and the current state of healthcare infrastructure, revealing critical areas for improvement in resilience, flexibility, and patient-centred design.

The literature highlights the critical importance of integrating flexible design solutions to increase the resilience of hospitals in the face of emergencies, including infectious disease outbreaks and natural disasters [6,30,31]. Resilience in this context includes compartmentalised spaces, adaptable room layouts, advanced HVAC systems, and provisions for rapid capacity scaling. However, survey data indicate that only 22% (n = 2) of the hospitals surveyed have spaces that can be adapted for emergencies without renovation, revealing a major limitation in existing infrastructure.

Despite strong recommendations in the literature for outdoor and green spaces to promote patient and staff well-being [24], 78% (n = 7) of the surveyed facilities lacked such areas. The lack of accessible green spaces not only neglects opportunities to improve patient outcomes but also overlooks passive design strategies that support infection control and mental health [24].

Patient room flexibility also emerged as a critical shortfall. While single room with double occupancy in emergencies is a recommended design strategy [30], more than half (56%) of single rooms in the surveyed hospitals cannot be converted, and visitor accommodation remains limited. These findings suggest that patient-centred design has not yet been fully embraced in many facilities, particularly in older structures.

As reported in the Global Burden of Disease, infection control strategies are becoming increasingly critical in the global fight against antimicrobial resistance (AMR), as the burden of AMR continues to rise at an alarming rate. In our reference scenario, AMR burden is forecasted to increase to 1.91 million attributable deaths and 8.22 million associated deaths by 2050 [42]. This suggests that without additional measures, we will not reach the 10% reduction in AMR mortality proposed in the 10–20–30 by 2030 target. Strengthening infection prevention and control (IPC) measures—such as improved hygiene, sanitation, vaccination, antimicrobial stewardship, and hospital infection surveillance—will be essential to curb transmission and reduce the reliance on antibiotics. These strategies not only help limit the spread of resistant pathogens but also preserve the effectiveness of existing antimicrobials, ultimately playing a vital role in achieving global AMR reduction goals [33]. Despite this, solutions such as antibacterial flooring and wall finishes are inconsistently applied. Although the importance of antibacterial surfaces is well established in the literature [18,19,24], 44% (n = 4) of the surveyed facilities had no antibacterial surfaces.

Environmental monitoring systems are also underdeveloped. While air quality monitoring is carried out in surgical areas (as required by regulations), comprehensive building-wide IAQ monitoring is lacking. This fragmented approach may leave many rooms vulnerable to undetected contamination, particularly considering the risks of airborne disease highlighted during the COVID-19 pandemic [6,25]. Similarly, acoustic quality monitoring—important for patient recovery and staff performance—is almost non-existent, with only 11% of facilities reporting such measures.

Access control is relatively well implemented in emergency and surgical areas, in line with safety recommendations in the literature [36,39]. However, its limited use in general service areas may pose risks, particularly in high-traffic or transitional areas [31].

The discrepancy between theory and practice is most evident in the layout and flexibility of the ICU. While the literature supports the use of modular single-patient rooms for infection control and rapid reconfiguration [6,22], most ICUs surveyed rely on open-plan configurations, with only 11% allowing conversion to double rooms. This lack of adaptability could hinder hospitals’ ability to respond effectively to surges in patient numbers.

Overall, the data highlight a widespread need for healthcare facilities, particularly those built before 2010, to be upgraded to meet modern risk management strategies. The integration of flexible infrastructure, comprehensive environmental monitoring, and resilient design solutions will be essential to prepare hospitals for future health crises, whether biological [6,18,22] or environmental [30,31]. Furthermore, the systemic under-implementation of evidence-based design strategies calls for updated policies, increased funding, and multidisciplinary collaboration to support the transition to safer, more adaptable, and patient-centred healthcare environments.

The results of this study reinforce the need for a holistic approach to hospital design that integrates safety, flexibility, and sustainability.

5. Conclusions

Starting from a comprehensive literature review and survey application on a sample of Italian hospitals, this study has highlighted the following:

(I)

The possible evidence-based design strategies for risk mitigation in healthcare facilities;

(II)

The gap between what is supported by the latest scientific research and what has been implemented in Italian hospitals so far.

There is an urgent need to bridge the gap between evidence-based design strategies and their practical implementation in hospital infrastructure. In fact, while the literature consistently advocates resilient, flexible, and patient-centred environments, the results show that most of the healthcare facilities surveyed fall short of these standards.

Future hospital must prioritise modular, scalable design solutions, integrate advanced monitoring technologies, and promote environments that support both physical and mental well-being. These improvements will not only improve routine healthcare but also ensure preparedness for future Public Health crises.

In order to enhance the quality of healthcare facilities and the minimization of risks, a universally shared approach is needed, along with guidelines and design solutions that can be adopted at an international level. Next generation healthcare facilities, the urgency of rethinking existing healthcare structures—both physically and in management—while designing new ones with effective risk mitigation criteria, is becoming crucial.

5.1. Limitation

The study had several limitations. First, it focused on a small and geographically concentrated sample, which may limit the generalisability of the findings to other areas within the country or internationally. In addition, it only considered acute hospitals, excluding other healthcare facilities such as outpatient clinics, specialised clinics, and long-term care hospitals, which limits the applicability of the findings to a wider range of healthcare structures. The limited number of hospital facilities analysed also reduced the statistical power of the data, affecting the depth and accuracy of the strategic framework. Finally, the study acknowledged that feasibility factors for risk reduction strategies may vary between geographical regions or healthcare settings, which may limit the broader applicability of its conclusions.

5.2. Future Development

Future studies could expand geographically to other regions or countries to examine how different regulations and geographical factors influence risk reduction strategies, providing a more comprehensive and generalisable perspective. In addition, broadening the scope to include other healthcare settings, such as outpatient clinics, specialist hospitals, and long-term care hospitals, would provide a more complete understanding of how these strategies can be adapted in different healthcare settings. Increasing the sample size by analysing a larger number of hospitals would also increase statistical power, leading to more robust and accurate findings that could inform the development of effective risk reduction strategies. Furthermore, as different implementation contexts may present unique challenges, future research could refine these strategies to ensure they are adaptable and relevant to specific healthcare settings.