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The design of a hospital’s built environment is no longer treated simply as a place in which health care takes place. Design is a key component of patients’ overall care as well as an influencer of organizational processes. The purpose of this study is to examine how hospital leadership makes decisions about interior design. That is, what do leaders take into consideration when making design decisions? What communicative, systemic, or cultural elements construct the environment wherein design decisions are made? Interviews were conducted with leaders from three different hospitals, from three different countries: United States, United Kingdom, and Saudi Arabia. Our goal in interviewing hospital leadership, from different countries, was to gain a rich and complex understanding about the various aspects that go into decisions leaders make concerning hospital design. Interview data was analyzed, and 5 themes emerged: 1) Organizational processes: Effects on staff, patients, doctors; 2) Structural challenges: Age and retrofitting old/new, budget, resources; 3) Design decisions that impact care: interactions between patients, doctors, staff; 4) Design strategies by function; 5) Strategies for improvement. The results of this study demonstrate the need for hospital leadership to examine their hospital’s design, the importance of culture on design and therapeutic environments, and understand where design will have the greatest impact. Thus, our study addresses the complexities hospital leaders take into consideration to move design from an idea to an actor in the therapeutic environment with real influences on patient care, stress, and medical decision-making.