Can the design of a hospital or healthcare facility actually help patients heal better?
The idea may seem preposterous, yet hospitals around the country are employing so-called "evidence-based design" to directly impact not only patient care and satisfaction, but also the quality of the work environment for hospital caregivers.
The vanguard of this movement is the Center for Health Design, a loose network of some 25,000 architects, interior designers, contractors, hospital executives, nurses, doctors, academics, and product suppliers based in Pleasant Hill, Calif.
Founded in 1989, the nonprofit organization has run symposia to focus attention on design issues related to healthcare (see page 55). Unfortunately, few of the papers presented at these sessions were backed by peer-reviewed scientific analysis.
"In the design business, we have this thing that says 'trust me,' but we needed more than trust," says Rosalyn Cama, FASID, principal of her eponymous interior design firm in New Haven, Conn., and chair of the CHD board.
So, a couple of years ago, CHD's executives locked themselves in a room and resolved not to come out until they had something solid to present to the Healthcare Establishment.
The answer became known as the Pebbles Project. Just as a stone cast into a pool of water generates waves of energy outward, the Pebbles Project was envisioned as a way to conduct research on the impact of hospital design on patient outcomes, which the center would spread throughout the healthcare community.
Let's see what happens when you toss a pebble into the pond.
When oncology nurse Dore J. Shepard arrived at Detroit Medical Center 22 years ago, she was appalled at what she saw.
"The nursing units were bleak—really dated," she says. "The walls were gray-white with battleship-gray doorframes. There were colored awnings over the nursing stations to make it feel like a circus, and pictures of baby chicks about to be eaten by some predator bird," she says. "Ridiculous! I took them off the walls immediately."
Imagine her enthusiasm, then, when, in the late 1990s, Peter Karmanos, Jr., co-founder of Michigan-based Compuware Corp. and owner of the Carolina Hurricanes of the National Hockey League, offered to donate $26 million to the medical center for the creation of the Barbara Ann Karmanos Cancer Institute, named in memory of his wife, who had died of breast cancer.
For awhile, the hospital held up acceptance of the donation—there was concern that giving so much attention to one unit of a public facility would raise a red flag—so Shepard, by then administrative manager for cancer patient services, turned to a higher authority. "I'm Catholic, so I had masses said at a monastery in the Upper Peninsula," she recalls. "Then, one day, I was told I was going to get my nursing units rehabilitated."
Shepard, who holds a master's in health service administration in addition to her BS in nursing, grabbed the project by the horns. She posted worksheets in the units, seeking ideas from nurses, physicians, patients, and family members. Group meetings were held with management and staff. "In four weeks, we had input from all the stakeholders and user groups," she says.
From these, Shepard drew a conceptual image of a typical nursing unit in her dream facility. When the architectural firm of Hobbs & Black made its presentation to the hospital board, her proposal closely matched what the professionals recommended. "It was right on the money," says Shepard. The Ann Arbor firm got the contract, and brought in Turner Construction Co. as contractor.
Thus began a collaboration that all parties agree was among the best of their professional lives.
"We started with a mission—to look at cancer as an opportunity for wellness, not sickness," says John Barker, AIA, senior vice president of Hobbs & Black. "We wanted to make it as uplifting an experience as possible."
In designing the rooms, says Barker, the Building Team recognized that cancer patients are often confined for long periods of time. "We wanted to make the rooms as daybright and cheerful as we could possibly do," he says. Everyone on the project wanted single-patient rooms, but the medical center was unable to obtain a "certificate of need" from the state for 100% single rooms, so six rooms on each floor are shared.
Layouts were configured to make sure there was a window in every room. To gain extra storage space, the team built closets directly into the walls. Every room was equipped with a bench that could convert into a bed for visitors or family members. Artwork was carefully chosen, under the watchful eye of Nurse Shepard.
"We walked into it saying this is a guest room at a Marriott—not the fanciest, but very comfortable," says Barker, a 21-year-veteran at Hobbs & Black who heads the firm's healthcare practice. When the interior designer specified $800 mirrors, Shepard found comparable ones for $170.
A similar thought process went into the nurses' working conditions. Armed with a sheet of onion paper, Shepard patrolled the corridors polling nurses, construction workers, and subcontractors about such design factors as color (gentle blues and greens won out) and lighting. "The nurses didn't want canned lights over their work areas, because it heated them up," so warm, indirect lighting was chosen.
Noise was also on Shepard's mind. "That's one of our patients' biggest complaints," she says, so architect Barker specified acoustic panels covered in artistic fabric in hallways and nursing stations.
To make the task of charting patients' progress easier for nurses, Barker created ovalinear stations equipped with flat-screen terminals right inside the suite entry area. "We took charting right to the patients' rooms," he says.
The nursing stations themselves were designed to enable nurses, physicians, patients' family members, and patients themselves to be able to engage in what Barker describes as "an open dialogue, everybody accessible to everyone else—no major walls between the pieces, totally open and with lots of glass."
The same team spirit informed the construction phase. "In my 21 years at Turner, most of it in healthcare, this was one of the first that was totally patient-care focused," says project executive Gregory Mersch.
As the first bathroom was going in, Mersch learned that Shepard had a "gut feeling" the showerhead wasn't positioned right. "We took an IV pole and wrapped pillows around it, and built a 'person,' and turned the shower on," he says. Sure enough, the shower sprayed water into the room, creating a hazard. "We pulled the showerhead, installed a flexible hose, put it on a different wall so that it spayed toward the back wall, and that eliminated the problem," recalls Mersch.
Grab bars also caught her attention. "Dore reminded me that elderly women have a different center of gravity than men, and they can't pull themselves up as easily," says Mersch. "They wind up using the towel bar to pull themselves up, and that's dangerous." The solution: replace the 30-inch bars with 48-inch bars that would give older female patients more leverage.
No detail was left to chance, not even the toilet paper dispensers. "In a hospital, no one wants to fill the toilet paper because the spindles keep getting lost," says Shepard. After consulting with the maintenance staff, they were able to locate a spindleless dispenser.
"For a project to be successful, all three parties—designer, contractor, owner—have to take an active role," says Mersch. "The person who comes from the owner's side has to be empowered to make those decisions. If one of those in the link can't make a decision, then you have a weakness."
Four floors of 27 units each have been completed, at a cost of $5.6 million per floor, or $143 per sq. ft. After two full years of occupancy, the results bear close watching.
According to studies conducted by Shepard and William P. Peters, MD, PhD, Karmanos Distinguished Chair of Oncology at the cancer institute and president of the Institute for Strategic Analysis and Innovation at the Detroit Medical Center:
Sickle-cell patients who had been treated in the old unit used 54% less self-administered narcotic (and 16% less total narcotics) to relieve their horrific pain after being moved to the new center.
Variable costs—supplies, medications, incidentals—were 23.5% less for men who were treated on the new unit after undergoing radical prostate removal, versus a comparable group who had been cared for in the old unit.
Similarly, 312 craniotomy patients who recovered in the rehabilitated center averaged 20% less in variable costs compared to a group of 291 patients who had been treated a year prior to the move to the new floors.
Medication errors were slashed 37%. Before the renovation, medication rooms were "the size of a telephone booth," which contributed to wrong dosages, incorrect frequency of medication, inaccurate documentation—even the wrong patient getting medicine. "Med rooms are busy, and you need room to move around, and plenty of counter space to document what you're doing," says Shepard. Locating the medication rooms in a centralized area outside the traditional "oval racetrack" and making them much bigger reduced error-producing stress on the nursing staff.
Patient satisfaction scores rose by 17%, according to an independent evaluation by research firm Press Ganey Associates Inc., South Bend, Ind.
Nursing attrition fell from 23% before the move, to 3.8% after the move. "We don't have a nursing shortage on this service," says Shepard.
One unanticipated result was that patients stayed in the rehabbed center almost twice as long as they did in the old unit. "This led us to believe that these were social stays," says Shepard, meaning that patients preferred staying in the hospital to going home. "We brought it up to the medical team and said we have to address the issue."
"We were all very passionate about this project," says Barker. "Greg made it a personal thing. Dr. Peters had the right spirit to build a great project. Dore is extremely enthusiastic, and she demanded that everyone on the project be equally enthusiastic. She inspired us to do that."
John Balzer's motto in overseeing the design and construction of a five-story, 118-bed North Tower addition to Milwaukee's Froedtert Hospital was simple: "Be logical, not lavish."
The vice president of facility planning and development at Froedtert, an independent community-academic hospital associated with the Medical College of Wisconsin, naturally wanted his $30 million for the project to be spent wisely.
That Midwestern frugality translated into what the veteran facilities planner calls "the simple things": use of natural light wherever possible; paint versus fancy wall coverings; poster art rather than original works; light fixtures that meet a variety of nursing and patient uses; durable finishes on surfaces, both for maintenance and infection control; and realistically sized rooms, not necessarily the biggest or fanciest in the highly competitive Milwaukee healthcare market.
Before he did anything, though, "we put a lot of effort into getting staff input," says Balzer.
The mechanism that provided the most salient information to Balzer and architects Hammel, Green and Abrahamson (HGA) was a full-scale mockup of a typical patient room, which the team built and installed on a loading dock near, of all places, the morgue.
Despite its location, the mockup turned out to be a hit. "With the North Tower project, the nurses really enjoyed seeing the model," says Rose Gaskell, RN, a patient care director with two decades of service at Froedtert.
More than 240 written comments were elicited from physicians, administrators, and nurses who toured the mocked-up patient room. Their insights helped shape the ultimate design.
"Create a more visually pleasant and sunny environment for patients and visitors," said one commentator. The result: a central courtyard with window access from 14 of the 32 rooms.
"We need a vanity or counter in the bathroom" for the patient's personal needs, said another, so vanities were installed.
"Doorway angles may make entry with beds difficult," a problem confirmed by patient care director Gaskell. "We have some morbidly obese patients that weigh over 500 pounds, and there are special bariatric beds for them," she says. The entries were reconfigured to handle the beds.
On and on it went: staff suggestion, design improvement. Take the matter of headwall outlets. "The average age of my nurses is somewhere between 48 and 50, so bending down is a real issue," says Gaskell. Instead of installing electrical and other service outlets at the usual height, the team put them in 48 inches high—and on both sides of the patient's bed, so nurses wouldn't have to walk around the bed to hook up an oxygen line or a blood-pressure cuff.
Another issue: "Some of our patients won't fit in that size shower alone, and there is no room for anyone to help," implored one nurse. The solution: Make the bathrooms and showers big enough to accommodate a patient and a caregiver.
Even airflow caught the nurses' attention. "Don't put vent above patient head of bed," said one experienced nurse who had heard too many complaints, especially from older patients, about cold air keeping them awake at night. At Balzer's insistence, the vents were moved in the final design, with individual climate control in each room.
Numerous other improvements were implements as a result of staff input. The North Tower nursing stations were also equipped with separate conference rooms—with window views of the courtyard—for the nursing and medical staffs, so that private discussions could be held with patients. A separate narcotic room was also installed, to reduce medication errors caused by crowded conditions.
Lighting was a major concern, especially for older nurses. To demonstrate different lighting options, Balzer set up lighting demonstrations in an existing patient room.
HGA principal Kurt Spiering, AIA, said that led to installation of a system that could go from dim for patient rest, to general room lighting, to task lighting (charting, distributing medications), to the brightest level for patient assessment.
The crowning achievement of this whole effort was a decentralized nursing cabinet that permits nurses to obtain supplies and medications either from the hallway or the patient's room.
Although the new tower has been occupied for only a few months, patient satisfaction scores, as measured by the independent Press Ganey service, are up, and so is nursing satisfaction.
That kind of empirical approach is being used in a Pebbles Project to redesign 10 nursing stations in the campus's west wing. Because Froedtert is on a 7/70 nursing shift—seven 10-hour shifts in a row, then 10 days off—there is a five-hour period when two shifts are in the nursing station at the same time, making it very crowded for the staff.
How this will be accommodated in the rehab of the older nursing units will be a challenge, says HGA healthcare specialist Karen Jones, herself a registered nurse and interior designer.
One thing is certain: If facilities VP Balzer has his way, the solution will be logical but not lavish.
Evidence-based design has also been put to the test in western Michigan, where nonprofit Bronson Healthcare Group has been redeveloping its century-old campus on a 14-acre site in downtown Kalamazoo. In addition to the construction of a 750,000-sq.-ft. replacement hospital, the $181.5 million project includes a medical office building, an ambulatory care pavilion, and a parking ramp for 754 vehicles.
Shepley, Bullfinch, Richardson & Abbott of Boston is the principal architectural firm, working with local firm Diekema/Hamann Architects. Barton Malow, Southfield, Mich., and Galesburg-based CSM Group were the construction managers. The project was occupied in 2000, after four years of construction.
From the start, the "new" Bronson was viewed as a test case of the impact of the built environment on patient care: 100% single-patient rooms, maximum use of natural light, gobs of artwork, natural colors and textures, bubbling fountains, water sounds, and classical music in public areas.
To the hospital's chief executive, though, the "new" Bronson was much more than a structure.
"Maybe some organizations put too much emphasis on the building for the sake of the building, but it's only part of the formula for success," says hospital president and CEO Frank J. Sardone. "We stepped up our efforts in many areas and used the building as a mechanism for change."
To this CEO, the building became "a real visual reminder of our values," one that became "a tremendous tool in creating a forum for instituting managerial change."
That approach led to a "culture shift," says SVP of human resources Susan M. Ulshafer. "Our organization is no longer structured only for the convenience of the staff. It's totally structured for the convenience of our patients. Our staff has rallied around that idea, because that's the reason they went into healthcare in the first place."
The organizational effort, coupled with the construction of the new facility, has had positive impact on nursing turnover—10%, compared to a national average 17%—and RN vacancy rate: 8%, versus 11% the year before.
One of the most direct benefits of having all single rooms was a dramatic drop in patient transfers, which, according to Sardone, were costing the hospital $500,000 a year. "It's the nurses' time, plus the hidden costs like switching computers and telephones," says Sardone.
Going to single occupancy for all 285 rooms also reduced hospital-induced infections by more than 70 in the first full year of occupancy.
Other positive effects include a five-point boost in market share in one year and 1,000 more year-to-date admissions than in the year before.
Most important, says Sardone, was the cultural change that the new hospital reinforced among the staff. "Our physical environment began to match the environment created by our people," he says.
That assessment is echoed by Larry Mallak, associate professor of industrial and manufacturing engineering and founding principal of the Engineering Management Research Lab at nearby Western Michigan University.
"The built environment acts as a moderating variable," says Mallak, who is conducting a Pebbles study of Bronson's organizational performance. "Architects like to believe that the building alone will act to create new behaviors and new patient experiences, but it's really the overall package, including the culture and service delivery. The building alone did not change the organization. It was a combination of all these things that created a healing environment."
To skeptics who question the cost of evidence-based design, Hobbs & Black's John Barker has this to say: "We didn't have a big budget. But you can do something that makes a lot of difference, and do it within budget."
Bronson's Frank Sardone couldn't agree more. "A great design doesn't have to be more expensive," he says. "We developed a budget eight years ago, and we stuck to that budget. We didn't compromise on the features that create a healing environment, but it doesn't have to be lavish."
Still, the question remains: Can all these positive results be attributed entirely to design? Could it be simply that the freshness of the situation made patients feel better, akin to what social psychologists call the Hawthorne effect?
"A hospital is a complex machine, a living city," says CHD's Rosalyn Cama. "It's impossible to change it all at once. But if we can focus on outcomes, we can start to create incremental innovations that lead to greater acceptance."
Finally, say the advocates of evidence-based design, consider this: Hospital construction will consume $20 billion this year, $27 billion a year by 2010. Can we afford not to design them the best way possible—for the good of patients?