Hospitals are meant to be places of healing. Yet every year, millions of patients around the world leave healthcare facilities with something they did not arrive with: a healthcare-associated infection (HAI). While much of the global conversation around HAIs focuses on hand hygiene compliance, antimicrobial resistance, and staff behavior, a more uncomfortable truth is gaining traction among infection preventionists and healthcare leaders: the building itself is often part of the problem.

Hospital architecture is not a neutral backdrop for care. It actively shapes how people move, where pathogens persist, how effectively spaces can be cleaned, and whether infection prevention protocols are followed consistently or broken daily under pressure. From the width of corridors to the placement of sinks, from ventilation systems to surface materials, design decisions can either reinforce safety or quietly sabotage it.

As Caroline Bilen, CEO of The Compass Health Consultancy and a strategic healthcare safety advisor, puts it, “Hospital architecture is not neutral. The physical environment influences how pathogens spread, how effectively environmental cleaning is performed, and how reliably healthcare workers comply with infection prevention practices.”

This feature brings together insights from three leading voices in healthcare safety and infection prevention—Caroline Bilen, Eiman Eltinay, and Aaron A. Woodall—to explore a critical question for modern healthcare systems: are our hospitals designed to heal, or are they inadvertently designed to contaminate?

Florence Nightingale’s Lesson, Revisited

More than a century ago, Florence Nightingale argued that hospitals should “do no harm,” emphasizing that the environment itself was a powerful determinant of patient outcomes. Clean air, light, ventilation, and sanitation were not aesthetic preferences but foundational elements of care. Today, as healthcare systems grapple with rising patient acuity, antimicrobial resistance, and emerging infectious threats, her insight feels more relevant than ever.

Caroline Bilen believes that many contemporary facilities have drifted away from this principle. “In the 21st century, the question is no longer whether hospital design matters,” she says. “It’s how much harm poor design can cause.”

Overcrowded wards, shared patient rooms, poorly defined clean and dirty pathways, and inadequate ventilation systems all create conditions where pathogens thrive. Conversely, evidence increasingly shows that single-patient rooms, controlled traffic flow, and clear zoning significantly reduce transmission risk while supporting dignity, privacy, and patient-centered care.

These design elements are not luxuries. They are now widely recognized as core components of patient safety.

When Design Undermines Cleaning

Environmental cleaning is often viewed as an operational issue, but its success or failure is deeply tied to architecture. Even the most skilled environmental services teams struggle in spaces that are cluttered, poorly lit, or difficult to access.

“You cannot achieve high hygiene standards in spaces that are not designed to be cleanable,” Bilen explains. Best-practice hospital design prioritizes smooth, non-porous surfaces, minimal seams and ledges, and adequate space around beds and equipment. Clean and dirty utility areas must be clearly separated, and materials must withstand frequent cleaning and disinfection without degrading over time.

In high-risk environments such as intensive care units and operating theatres, antimicrobial surface technologies are increasingly being introduced as an added layer of defense. However, Bilen is clear that technology is not a substitute for fundamentals. “These innovations should support, never replace, robust environmental cleaning programs,” she stresses.

Architecture as a Reservoir for Risk

While the physical environment is rarely the primary source of HAIs, it often becomes a reservoir for pathogens, including multidrug-resistant organisms (MDROs). Eiman Eltinay, a public health and infection prevention expert, notes that this role is frequently underestimated.

“Evidence indicates that the healthcare environment can serve as a reservoir for MDROs and other pathogens, thereby contributing to HAI risk,” she says. The U.S. Centers for Disease Control and Prevention (CDC) emphasizes that most HAIs are preventable through evidence-based practices—many of which are directly influenced by facility design.

Eltinay argues that the most effective way to reduce this risk is to involve infection preventionists and frontline healthcare professionals from the very earliest stages of planning, construction, and renovation. Citing the principle of “prevention by design,” she explains, “When infection prevention input comes after construction, risks are already embedded in the structure.”

Designs that fail to reflect real clinical workflows often create compliance obstacles. Sinks that are poorly located, hand-hygiene stations hidden from view, or illogical room layouts all make it harder for staff to do the right thing consistently—especially under time pressure.

Behavior Follows Design

Healthcare leaders often focus on training and policy to improve compliance, but architecture silently shapes behavior every day. Research has shown that hand hygiene compliance increases when sinks and alcohol-based hand rub dispensers are visible, accessible, and integrated into routine workflow.

“When the safest behavior is also the most convenient,” Eltinay notes, “adherence improves without the need for constant enforcement.”

Role modeling by senior staff remains important, but environmental cues matter just as much. If the built environment does not support safe practice, no amount of education alone can compensate.

The Hidden Cost of Late Consultation

Aaron A. Woodall, MPH, CIC, LTC-CIP, CM, an advocate for integrating infection prevention into design, takes an even sharper view. “Hospital architecture is treated as neutral infrastructure, a passive stage for medical care,” he says. “It’s not. Buildings shape how people move, what they touch, and who they expose. Architecture determines who becomes infected.”

Woodall points out that most design decisions—layouts, adjacencies, traffic flows—are finalized long before infection prevention experts are consulted. When their input comes later, it is often reduced to a compliance checklist rather than a meaningful influence on outcomes.

“Intent does not change outcome,” he warns. “When infection prevention is excluded from early planning, risk becomes embedded in the structure itself. And once built, it’s permanent.”

Small design oversights can have outsized consequences. Poorly placed personal protective equipment cabinets interfere with workflow. Doors that swing outward without space for isolation signage eliminate critical visual cues. In such cases, staff are forced to rely on memory alone—an unrealistic expectation in high-pressure clinical environments.

“This is not a staff problem,” Woodall emphasizes. “It’s a design problem.”

Air, Water, and Invisible Threats

Ventilation remains one of the most critical—and complex—elements of hygienic design. Effective HVAC systems with appropriate filtration, air changes, and pressure differentials are essential to reducing airborne transmission, particularly in operating theatres, isolation rooms, and procedural areas.

However, Woodall notes that these systems are often optimized for comfort or energy efficiency rather than infection control. Retrofitting them after construction can cost millions and may require shutting down entire units.

National and international guidelines attempt to address these risks. Eltinay highlights the role of Infection Control Risk Assessments (ICRAs), advocated by bodies such as the Facility Guidelines Institute (FGI). “ICRAs ensure that ventilation, water systems, and spatial layouts support infection prevention during both routine operations and outbreaks,” she explains.

Yet many facilities are still designed around static assumptions about patient volume and staffing. In a healthcare landscape defined by volatility, this lack of adaptability can itself become a risk factor.

Education: Completing the System

Design alone cannot deliver safe outcomes. Caroline Bilen stresses that education is the missing link that turns architectural intent into daily practice.

“Even the best-designed hospitals cannot achieve safe and sustainable outcomes without well-trained healthcare professionals,” she says. Through competency-based training in hand hygiene, environmental cleaning, aseptic technique, and infection prevention protocols, her consultancy works to align human behavior with the built environment.

When staff understand why design features exist and how to use them correctly, compliance improves and risks decrease. In this sense, architecture and education form a single integrated safety system.

Beyond Safety: Designing for Healing

The impact of design extends beyond infection prevention. Access to natural light, reduced noise, and well-designed staff spaces lower stress and fatigue, improving both patient recovery and workforce resilience.

“Honoring Nightingale’s legacy today,” Bilen reflects, “means designing and operating healthcare facilities where hygiene, safety, environmental cleaning, and workforce education are inseparable.”

Woodall echoes this sentiment from a more urgent angle. “Hospitals concentrate risk by design,” he says. “They bring together immunocompromised patients, invasive procedures, high-touch surfaces, and constant human movement. Architecture that increases crowding or unnecessary contact doesn’t just add risk—it guarantees it.”

Globally, an estimated 7–10% of hospitalized patients acquire an infection during their stay. For Woodall, this is not an abstract statistic. “Every day the building exists, it produces predictable harm,” he says bluntly.

One Chance to Get It Right

Hospitals are built to last 50 years or more. The opportunity to prevent embedded risk comes once per building. “Miss that window,” Woodall warns, “and the consequences compound daily.”

Early collaboration may seem inconvenient during planning, but it prevents far greater disruption later. Late consultation, by contrast, merely documents failure.

As healthcare systems across the Middle East invest heavily in new facilities and expansions, the message from these experts is clear: architecture must be treated as a core component of infection prevention strategy, not an afterthought.

Hospitals should be designed to heal. When they are not, they contaminate. And as all three speakers remind us, contamination does not just cost money—it costs lives.