Flooring Needs in Healthcare: Flooring opportunities in an evolving market - Oct 2015

By Jessica Chevalier


The acute healthcare segment is an evolving market with a bevy of flooring needs. Many of these needs are driven by safety—prevention of slips and falls and infection resistance—but protecting patients, visitors and hospital staff is only one of many important roles that flooring must fill in these demanding environments.

The competitive nature of today’s healthcare market means that, in addition to fulfilling a great number of practical needs, flooring must also play an aesthetic role. The competition to attract both patients and skilled staff is fierce, and good design is a differentiator. What’s more, it can improve patient outcomes and reduce medical errors. 

According to Keith Duprey, director of segment marketing for Interface, “We have seen design continue to gain importance across all segment types as the c-suite [executives] and even investors understand that good design creates more production and valuable environments, driving down costs and increasing human behavior in many varied ways.”

So what is the key to specification of acute healthcare flooring? 

According to Cynthia Hubbell, director of healthcare strategy and development at Tarkett, the most important concept for specifiers, manufacturers and end users is understanding that there is no one-size-fits-all solution in acute healthcare flooring. “Overall, the flooring should foster wellbeing, offering patient safety, comfort and quiet,” says Hubbell.


While it may seem that defining the “acute care” segment would be as simple as ticking off a few facility types, that is far from the truth. Across the flooring industry, manufacturers break down their healthcare classifications differently due, in large part, to the evolving healthcare marketplace. 

Traditionally, the healthcare market has been divided into three segments: non-acute or primary care (basic healthcare or maintenance care via doctor’s office, typically), acute or secondary healthcare (active but short-term treatment for an injury or illness and recovery) and long-term care (services for individuals with chronic or long-lasting illnesses or disabilities). However, the evolution of the healthcare system—the trend toward outpatient care and the increase of urgent care facilities, for example—has inherently changed the structure of those segments.

Consider how the increase in urgent care facilities alters the healthcare system. These walk-in clinics provide on-demand care for non life-threatening issues and have increased in popularity as the wait times in both emergency departments and primary care offices have lengthened. In fact, these days the average wait time to get an appointment with a primary care physician in major metro areas is 21 days, Hubbell reports. 

According to the American Academy of Urgent Care Medicine, “In a ten-year span, from 1994 to 2004, the number of hospitals and emergency rooms decreased by 9%, while emergency room visits increased by more than one million visits a year.” The academy further reports that “a new growth spurt for the Urgent Care industry began in the mid-1990s and continues today. Since 2008, the number of facilities has increased from 8,000 to 9,300.” 

So are urgent care clinics acute or non-acute operations? The fact is that, while that differentiation may matter to hospital executives and healthcare insurers, it doesn’t indicate that any one flooring solution or another is a sure bet. Each space within each healthcare environment has unique requirements requiring a well-thought-out flooring solution, which means it is imperative that manufacturers keep on top of developments in this ever-changing market. In fact, Hubbell reports that she attends 20 to 25 healthcare conferences annually, ranging in subject matter from infection control to mortuary science, believing that the best flooring solutions can only come from a thorough understanding of both flooring and healthcare.  

If you or a loved one has been in need of acute healthcare recently, you’ve likely noticed a great number of changes in the healthcare marketplace. To start is the very fact that we now view healthcare as a “marketplace.” While it was, in the past, fairly standard for a patient to simply visit their community hospital or clinic when a problem arose, today patients are customers, and those customers are shopping around. 

Many of the current changes in healthcare are a result of the Affordable Care Act, which went into effect in March 2010. A key change to the system of reimbursements to healthcare providers makes them dependent on exit interviews conducted by patients. As a result, the patient’s impression of the facility—its overall look and cleanliness—as well as the ability to heal in a peaceful, restful environment significantly impact the payment the hospital receives for the care it has provided—and the proper specification of flooring plays a significant role in each of those areas. 

In addition, healthcare facilities are not reimbursed for treatment of injuries or infections that occur while a patient is being treated, so minimizing these is an even greater priority in the healthcare system. And flooring can assist in the minimization of both of these negative outcomes. 

“Healthcare never made much money,” says Hubbell, “but now it has to provide a higher level of service and receive less in reimbursements under the ACA. To do that, it has to treat and attract more people. In addition, we now have 40 million people who have to have insurance, 40 million new consumers for healthcare. So the goal now in patient care delivery is that the patient can receive whatever they need within a 15-mile radius of home.”

Another significant change in healthcare is the trend toward outpatient care. Thanks to improvement in laser technology in particular, many surgeries that once required an overnight stay are now in-and-out the same day. And many of these procedures are now conducted through outpatient clinics that specialize in one field or practice. Hospitals are reducing bed numbers, and these changes both impact the patient experience and change the physical presence of the hospital as we knew it. 

Today, according to Catherine del Vecchio, director of marketing for Gerflor USA, more than 60% of elective surgical procedures in the U.S. are performed in ambulatory (outpatient) facilities, and that figure is expected to increase to nearly 75% by the end of the decade. In addition, the percentage of surgeries not requiring an overnight stay increased from 16% in 1980 to 63% in 2005. 

The aging population adds another dimension to the acute care discussion, as the Baby Boomer generation will be increasingly in need of more care in coming years. “We are not adding enough beds in the market to follow the growth of the aging population,” says del Vecchio. “What we see is the healthcare group developing new concepts to increase building and cost efficiency as well as patient experience, so we won’t be seeing total square footage increase in hospitals but more specialized treatment centers, outpatient treatment and surgery centers.” Across the board, the trend is against overnight hospitalization, if possible, because it decreases costs for the institution and reduces the risk of hospital-related infection or error.

Jim Bistolas, healthcare segment director at Forbo, sums up the current market like this, “The Affordable Care Act has turned everything on its ear. The strong are getting stronger. The weak are closing or being bought. There is a huge shift in the market in general. Within acute care, the big whale is still the hospital because it has a tonnage of flooring needs. Altogether, there is roughly 1.8 billion square feet of acute care flooring.” Broken down into individual facilities, that typically means jobs that range from a couple of thousand square feet to tens of thousands of square feet, according to Natasha Appel, architectural representative for Crossville. 

In fact, the business of healthcare is changing so rapidly that Shaw Contract recently created a film-based continuing education unit (CEU) class for the architecture and design community that explains the changes within the field of design as a result of the Affordable Care Act. The film—which covers the history of healthcare, the roots of the Affordable Care Act and the major parts of the act—was released in early September. 

“Healthcare is changing so fast, and there are so many drivers of that change,” says John Stephens, vice president of marketing for Shaw Contract Group. “We created the film to give our clients a context for what’s going on and to see how they can take advantage of that. It’s a boon for A&D.”

While there is a great deal of money to be made as a result of the evolving marketplace, change in the acute healthcare market can be slow, and manufacturers report that some hospitals are still hesitant to invest heavily as a result of the recession. “The overall market is significant,” says Joe Martere, national sales vice president for the healthcare segment at Tandus Centiva, “but I don’t believe it is growing much more than low single digits annually. Both the AIA consensus and Dodge Analytics agree and have projected modest growth for next year.” 

Debra Harris with RAD Consultants, notes, “Hospitals are challenged with funding and capital due to reimbursement changes, making the planning of new hospitals difficult. There are fewer new constructions and expansions. Emerging trends are focused on staff workflow, patient throughput, patient experience, smaller facilities to increase efficiency, and an increase in emergency, outpatient and ambulatory facilities.”


The Orlando VA Medical Center is a new 1.2 million square foot facility located on a 65-acre campus in Lake Nona, Florida. The facility, which cost $600 million to construct, is “a planned community with healthcare as the anchor,” according to Shaw Contract’s John Stephens. 
The Orlando VA Medical Center is co-located with the University of Central Florida College of Medicine, as well as hospitality offerings—there is a Marriott on campus—retail locations and a residential community. 

According to Stephens, the goal of the facility is to add VA capacity in Florida and to serve as a destination for veterans from around the country who are seeking healthcare. 

Consider, say, a veteran who resides in Michigan’s Upper Peninsula facing a knee replacement in January. Why navigate hazardous driving conditions and icy sidewalks when you could, instead, rehabilitate in Florida’s temperate climate? 

While international medical tourism has been popular for years, primarily for the sake of cost savings, today’s U.S.-based acute care facilities are trying to earn long-distance business as well by offering top-quality care at cutting-edge facilities in appealing locales.  

As the healthcare marketplace has changed and the hospital has lost business to urgent care clinics, it has had to redefine its role—and that change has precipitated alterations to the physical presence of the hospital as well. 

“Hospitals used to be big buildings on big lots with no trees,” says Hubbell. “They were very expensive to maintain and took lots of manpower. We used to go there only when we were sick. Now, we go to hospitals to maintain our wellness. They have walking parks and fitness tracks. Some even have mixed retail, Lululemon yoga or Whole Foods-type stores.” 

Today’s new healthcare operations typically occupy smaller footprints but include more facilities. “I like to refer to it as the ‘hub and spoke’ model,” explains Martere, “with the hub (the main hospital or infrastructure) remaining constant or even getting smaller, and the spokes (outpatient facilities, clinics, medical office buildings) expanding. There is a consistent movement across the country to bring medical care closer to the consumer and make it easier and more convenient to receive care.” 

In addition, hospitals are looking for ways to make their existing facilities more efficient. Today, much of the hospital stock is pre-1970 and built upon the old model for treating diseases in which the ailing spent long periods of time in the hospital, away from home and the community. In these settings, areas were established for a particular purpose, and fixtures and medical equipment were often fixed. This model, and therefore these facilities, no longer align with the contemporary approach to healthcare. 

“Today, single patient rooms are now the standard,” explains Hubbell. “This is best for patients, but in addition hospitals can charge more for a single room. Hospitals typically look at expected growth for the next three to five years and consider flooring in these long-term plans. The third floor of a hospital may be cardiac now, but that could change. They are designing spaces to be reconfigured easily. It used to be that when you walked into a hospital room, the bathroom was right there, but plumbing isn’t easy to reconfigure, so the bathrooms in new facilities will now be on the outside wall, near the window. Also, there is no more main hub as a nurses’ station. If all the nurses are congregated there, who is caring for the patient? Now, we have a ‘porch,’ a little ledge outside the patient room or inside by the bed where the caregiver can take notes or examine charts. This brings them bedside for better interaction, and immediate charting increases accuracy.” 

Experts report that current activity is a mix of new construction and renovation. If possible, hospitals will utilize the facilities that they have, though sometimes, due to structural constraints, that is impossible. 

In those situations, hospitals will sometimes grow their offerings via mergers and acquisitions or by repurposing current space. The new hospitals that are being built, according to del Vecchio, are “all concept hospitals, beautiful new buildings that are amazing architecturally.”

Regardless of how they choose to grow, today’s hospitals realize the importance of creating an environment that fosters health and happiness. “Hospitals are fighting for patients and staff. Even the best hospitals struggle to make a 3% profit. Part of attracting great talent and patients is the aesthetics of the building,” says David Daughtrey, director of business development for healthcare markets at J+J Flooring Group. 

Renovation is, of course, a tricky process for 24/7/365 facilities, as hospitals are. The work can’t pose hazard to employees or patients, and it can’t create air or noise pollution; however, to meet today’s quality standards, it must be done—and done with regularity. In fact, although acute care facilities are quite interested in lifecycle cost and seek flooring that offers long-term durability, the truth is that, due to ever-changing aesthetics, ten years is typically the lifespan for flooring in an acute care environment, according to Bistolas. 

The solution to the renovation dilemma lies in building flexible facilities with change in mind, knowing that the healthcare of today will be different tomorrow. 

“Today’s buildings are being designed to be more flexible,” says Carol Priefert, segment marketing manager for healthcare, education and retail at Armstrong. “If you look at a new facility, you see that there are movable walls, curtains that are closing off things that can be easily moved, patient pods. They are designed knowing that technology will continue to improve. In coming years, for example, a mammogram machine won’t likely take up a whole room.”

Appel agrees that more designers today are implementing flexible design solutions, creating a space that could service two unrelated fields, for example surgery rooms that could be used by cardiology and neonatal care without significant alterations.

Bistolas points out that the acute care facilities that are doing well are constantly renovating, and those renovations always include the flooring. “They will do a quick refresh—paint, curtains, furniture and flooring—not changing the footprint but putting lipstick on it. The organizations that are doing well are constantly doing this in stages.” 

Can flooring really promote healing? “I started examining evidence based design,” says Hubbell. “And I came to believe that we can make floors become an integrated part of the healing environment: textures that help people ambulate better, reduced noise, fewer slips and falls, memory care guidelines. Our mission at Tarkett is to enable the floor to become a part of the healing environment, one that will keep people safe. Flooring can work in so many ways to enable wellness. For patients with Alzheimer’s, it can be used for wayfinding. It can help encourage and stimulate or limit activity with colors and designs.”

Operating under the belief that flooring can, in fact, improve patient outcomes, it only makes sense that specification of the right floor is serious business. Daughtrey notes with a laugh that 20 years ago the manufacturer rep would meet with the facilities manager in the bowels of a hospital to discuss flooring options. Recently, however, Daughtrey was at a job in Ohio where he met with 50 people in various operations at the hospital—both functional and administrative—in an hour-long meeting to discuss a 30-square-yard investment. 

Mike Gallman, senior vice president of product management at Mohawk, notes that specification is “becoming more of a science based on evidence-based design. A lot of people are looking to biophilia.”

And while some criteria typically rise to the top with regard to the most important considerations in specification, more than one of the experts with whom we spoke simply said that every consideration is equally significant: acoustics, maintenance, slip resistance, durability, initial cost, lifecycle cost, ability to handle roller traffic, infection control and comfort underfoot. 

As the hospital facility has changed, the number of flooring materials used has increased. “The majority of flooring for an acute care environment is hard or resilient,” reports Martere. “Resilient floors are most popular for obvious reasons—infection prevention and control, cleanability, roller mobility. However, there is still a strong demand for soft surface flooring in areas like administration, public space, retail and, of course, medical office buildings. Many of our clients are choosing appropriate soft surface flooring solutions for non-clinical spaces—such as waiting rooms, patient corridors and nursing stations—to help them create safer, quieter and more comfortable environments for the patients and staff.” 

For the most part, however, the experts with whom we spoke report that soft surface flooring is fairly uncommon in acute care environments, estimating that hard surface now accounts for an estimated 70% to 90% of the flooring due to concerns about infection control, longevity, durability and ease of maintenance. 

Maintenance requirements play an important role in acute care environments, where dictated procedures and standards become simply best intentions, and the entirety of the process often comes down to an hourly worker with a dirty mop. For this reason, a floor must perform to its best ability with limited care. 

According to Hubbell, secondary infections contracted in healthcare environments kill 100,000 Americans each year. With infections from Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff.) on the rise, the trend toward hard surface flooring has increased, not because soft surface flooring can’t stand up to the healthcare environment on a daily basis but because it can’t withstand the harsh chemicals required to kill off dangerous pathogens. 

In addition, del Vecchio points out that acute environments prefer a surface that has very little contrast, so that workers can easily spot stains or small medical implements that may have fallen on the floor—which is another reason that soft surface flooring is less desirable. 

“Thirty years ago,” says Priefert, “we would see the same flooring through the whole hospital. Now, a mixture of products is used because the traffic from area to area varies. We have a variety of products that sell equally well into healthcare: homogeneous in the operating rooms, outpatient surgery centers and ER; LVT, laminate or real wood in the gift shop, c-suite offices and chapels; LVT in the corridors, waiting rooms, lobby, and sometimes in the patient rooms and nurses stations; plus, linoleum, sheet vinyl and VCT are still there are well.”

In specification of acute care flooring, Tandus Centiva uses what it calls a “true fit-for-purpose” approach, relying heavily on the principles of evidence-based design to guide clients to the best flooring solution and experience. 

One thing is clear, however—the reduction of medical errors is a high priority. “The minute you step into a medical facility, you become a liability,” says Hubbell. “Medical error is the fourth leading cause of death in the U.S.” 

And, in fact, interiors can assist in the minimization of errors in unexpected ways. A good acoustic environment, for example, helps ensure that a nurse correctly hears a doctor who verbally communicates a medication type and dosage for a patient. In addition, stress increases both poor health outcomes and medical errors, so the reduction of stress through the creation of an aesthetically pleasing environment is likely to increase health and reduce mistakes. 

As for sustainability, several manufacturers reported that some large organizations, such as Sutter Health, the Cleveland Clinic and Kaiser Permanente, see green as a driving criteria with regard to flooring selection. But for the most part, though green may be part of early conversations, it often falls low on the priority list in favor of more pressing concerns like safety and cost.


For several years, Floor Focus has reported on the influence of hospitality design in senior living, and this trend is now impacting acute care as well. 

As a result, acute healthcare design is trending toward more modern looks. Often, this translates as a neutral base paired with one or two pop colors. In flooring, wood and concrete looks are popular, though some manufacturers report an increasing preference for materials that are true to themselves with regard to design. 

One thing is certain: stark, clinical looks are in the past. Once seen as symbolic of cleanliness, it is now clear that more natural and biophilic designs produce better patient outcomes and can be just as clean. 

In similar fashion, Hubbell warns hospitals against shiny floors, often favored because they are believed to communicate cleanliness. She explains, “For adults over the age of 70, shiny floors can be very dangerous, especially for dementia patients, as they can appear wet. Combine that with the fact that a lot of buildings are lowering their lighting to save energy—and consider what may happen when the lights are lower and the floors are shinier.”

Amenities and service are also trending toward hospitality. Gallman notes that family rooms and children’s playrooms are becoming more popular, as hospitals, seeking to appease healthcare customers, look beyond “home” toward “hotel” as the standard.

“Most end-users finally understand that flooring has return on investment and contributes to patient care,” says Hubbell.  

Copyright 2015 Floor Focus 

Related Topics:Armstrong Flooring, Mohawk Industries, Tarkett, Interface, The American Institute of Architects, Shaw Industries Group, Inc., Crossville