There is a tide in the design and construction of hospitals, which, taken at the flood, could lead to significantly better medical outcomes for thousands of patients. At the same time, this movement could provide tremendous savings for hospitals, possibly in the tens of millions a year for a typical 400-bed facility.
By positioning themselves on the movement's leading edge, moreover, some architectural and construction firms are gaining a competitive advantage in winning healthcare-related contracts.
The movement's premise is this: Is it possible to design hospitals and healthcare facilities in such a way that the improved physical environment actually contributes to how well patients heal?
The answer, so far, is that there is demonstrable evidence that this is actually being accomplished in a handful of hospitals, with — and this is the key —measurable clinical results.
In short, there is a growing body of knowledge to prove that design itself can have an impact on how well patients do, both during and after their hospital stay. Design may also bring with it other benefits that affect how well hospital staffs are able to treat patients.
Before we go too far, it should be acknowledged that this movement is in its early stages. Most of the nearly thousand or so hospitals in this country are totally untouched by it. Even its staunchest supporters are careful to say that much more research needs to be done before it can be stated categorically how and why design itself improves patient care.
But make no mistake: Ambitious research is already in the works, and dedicated nurses, medical staffs, technical experts, and visionary hospital CEOs, working with far-seeing architectural and construction Building Teams, are starting to produce encouraging results.
The movement owes its start to Roger S. Ulrich, today a professor at Texas A&M University, College Station, and director of the Center for Health Systems and Design.
In the early 1980s, Ulrich, then a geography professor at the University of Delaware, became interested in whether viewing natural settings could reduce stress and produce measurable results in patients. He obtained the records of two groups of patients in a Pennsylvania hospital who had undergone gall bladder surgery — in those days, a nasty procedure that necessitated an average six-week recovery.
The only difference between the two sets of patients was their view: one looked out on a brick wall, the other had a view of a small stand of trees.
The study, which was published in the prestigious peer-reviewed journal Science(27 April 84), found that the group assigned to rooms with a view of the trees required less time for recovery (7.96 days) than those who looked out on the brick wall (8.70 days). They also had fewer "negative" nurses' notes (for example, "upset and crying") and required fewer and less potent pain-killing drugs.
Newspapers around the world gave the report prominent coverage, and its publication created a stir in healthcare circles. In the intervening years, the movement toward "evidence-based design" has continued to spread, largely through the efforts of such organizations as the Center for Health Design and the Center for Health Systems and Design (see Resources, page 55).
Before examining specific projects employing evidence-based design, let's consider its benefits.
One of the first architects to grasp hold of evidence-based design and put it into practice was Derek Parker, AIA, RIBA, senior principal for healthcare at Anshen + Allen, San Francisco. A member of the board of the Center for Health Design, Parker has employed evidence-based principles in the design of a children's hospital at Stanford University and, currently, in the Children's Convalescent Hospital, a 59-bed facility for medically fragile children, in San Diego.
The following points outline how innovative design of healthcare facilities can create positive, empirically measurable outcomes for patients.
Patient falls are "a significant problem in hospitals," says Parker. The problem is "costly, it's a sign of bad healthcare, and it increases length of stay.
"Bedfalls are all too common in hospitals and extended-care facilities. A patient gets up in the dark of night to go to the bathroom and slips on a wet floor. It happens every day, and the results can be catastrophic for the patient — a broken hip, head injuries, even death — as well as for the institution, in terms of lawsuits and added costs.
The good news, says Parker, is that patient falls can be cut by as much as 75% through simple design changes — installing grab bars properly, reducing nighttime glare in a room, putting double-wide doors on bathrooms so that patients can get in and out more easily.
Nosocomial, or "hospital-induced," infection, is the bane of every hospital CEO, medical director, nursing supervisor, and facilities manager. It's the urinary tract infection a post-operative patient gets from an unclean environment, or the respiratory infection that is spread through the hospital's air.
Nationally, according to the Institute of Medicine, a division of the National Academy of Sciences, two million patients get sicker just from being admitted to the hospital. More than 100,000 patients die each year from nosocomial infection, including 40,000 who become infected due to unsanitary conditions or practices — notably lack of hand washing by the staff.
The financial cost of hospital-induced infection is estimated at $4.5 billion a year, according to Dr. George Isham, chair of the IOM report committee.
"Being hospitalized is more dangerous than bungee jumping," says Anshen + Allen's Parker. "It's a serious problem in most facilities."
Here again, solutions are literally at hand. The most effective way to reduce infection is through hand washing. Installing convenient hand-washing stations and HEPA air-filtering systems can knock out germs like nothing else.
The newest twist, though, is the rise of the single-patient room. It is not known who conceived the idea that patients should share a bedroom — most likely, an accountant — but it is one of the most backward concepts ever to be used in healthcare.
The single-patient room yields numerous benefits to patients: greater privacy, better sleep, more opportunity for family visits and interaction (a growing phenomenon at many hospitals), plus a proven reduction in nosocomial infection.
At Bronson Hospital in Kalamazoo, Mich., going to single-occupancy rooms has reduced hospital-induced infections by six a month — a huge leap in the quality of care.
Medication errors are not only the result of poor handwriting. Bad lighting, stress on overworked nurses, and crowded rooms (yet another reason to get rid of shared rooms) can also contribute.
To address this issue, hospitals are installing stepped lighting systems, which permit nurses to punch up the brightness to be able to read patient charts more accurately, then step them down for a more soothing effect. Reducing glare can also help.
Others are experimenting with ways to reduce noise, particularly in emergency rooms and intensive care units, where noise is recognized as a distraction that can affect nurses' and physicians' accuracy.
Reducing length of stay is a goal of every hospital, thanks to pressure from managed care and conventional health insurance to limit payment to hospitals and patients for "unnecessary" care. Every extra day of care can cost thousands of dollars.
But it's not just a money issue. Caregivers know from experience that most patients do better at home, in their own beds, than they do in the hospital, assuming there is some support system in the home. Moreover, the longer the stay, the greater the chance of nosocomial infection.
In terms of quality control, length of stay is also a key metric of the effectiveness of care at any hospital. "It's a measure of throughput, how the hospital's resources are being utilized," says Parker.
Reducing the length of hospital stays, which is being demonstrated in quantifiable terms at several hospitals where smart design has been implemented, means "better throughput, through better use of resources," according to Parker. That's good business, and good healthcare.
During a typical hospital stay, patients can be moved as often as six times, either for tests or procedures that must be done at centralized locations or to accommodate the patient load to staffing conditions. "Every time you move them, you increase the risk of error by 75%," says Parker. For example, the wrong drugs might be administered to a patient who had been moved — or such a patient might be given someone else's medications. It's also expensive to move a patient, requiring up to an hour of caregiver time per move. Believe it or not, that can run into millions in unnecessary costs for the hospital.
One mode of attack: the oversize single-occupancy room. As Senior Editor Larry Flynn reports elsewhere in this issue (please see page 38), Methodist Hospital in Indianapolis leads the way nationally on this front with massive "acuity rooms" that allow the staff to perform both acute care and recuperative services, without moving the patient. The bigger space can hold equipment that otherwise would require transporting the patient to another unit or floor of the hospital.
In Detroit, 11 matched pairs of sickle-cell patients who self-administered pain-killing narcotics or analgesics were studied before and after their move from a standard oncology facility at Detroit Medical Center to the newly renovated Karmanos Cancer Institute. The results: the patients on the renovated unit used 54% less drugs to reduce their pain. Total narcotic use was reduced by 16%. Variable costs were cut $43 a day, or 12%.
The U.S. is in the midst of another nursing shortage. The U.S. Department of Health and Human Services says the nation's hospitals need 110,000 more nurses today. In five years, according to the Labor Department, an additional 450,000 nurses will be needed.
Nursing is no longer a primary career choice for today's young American woman. In 1980, 52.9% of registered nurses were below age 40, according to the Bureau of Health Professions. By 2000, only 31.7% of RNs were younger than 40. That's why so many hospitals are recruiting nurses from overseas, and why the typical native-born nurse is a woman in her late 40s to early 50s.
Considering that many nurses work shifts that keep them inside the hospital for up to 12 hours at a time, often in the dead of night, without so much as a window to glance out of, it's understandable that work environment would be of concern.
Add to this list the fact that most nurses walk miles during every shift, that they work under horrendously stressful conditions, and that they have to bend over and lift and manipulate both equipment and the patients themselves.
"Nurses will tell you that, after salary, the work environment is their biggest concern," says Anshen + Allen's Parker. Here's where design improvements can play a big role for hospitals. One way to boost morale and reduce turnover among the nursing staff is to make hospitals pleasant and efficient: better fenestration, more pleasant lighting, convenient workstations, even little things like installing electrical outlets at 48 inches in height, not 18, so that nurses don't have to bend down as much.
"A well-designed building with a good color scheme, natural light, comfortable settings, artwork, nature abounding — an environment like that is not only appealing to the patient, but also to the staff," says Leonard L. Berry, Distinguished Professor of Marketing at Texas A&M University, who has been studying nursing staff issues at the Mayo Clinic.
"I can guarantee you that the healthcare institutions with the most patient-centered designs have, on average, significantly lower staff turnover than others," says Berry.
For hospitals, variable costs have to do primarily with medication — how much, how strong, how often — as well as incidental costs associated with the intensity of care.
At the Barbara Ann Karmanos Cancer Institute in Detroit, records of more than 400 prostate-cancer patients were studied. Half had been treated in the medical center's "old" building, with conventional design; half were treated in the redesigned cancer institute. Lengths of stay and complication rates for each group were comparable.
The analysis revealed that variable costs — supplies, medications, and incidentals — were 23.5% less for the latter group. In some cases, that can translate to a savings of as much as $1,000 a day per patient.
Hospital systems that have employed evidence-based design are seeing significant increases in market share, even in the most cutthroat healthcare venues.
At Children's Hospital in San Diego, CEO Blair Sadler took an institution that was considerably behind in market share and invested in design-oriented improvements that sent a signal to the community.
"By designing [the hospital] to meet the needs of children and parents, he created a perception that this is the place to send your child for care," says James Varni, a pediatric psychologist who was a consultant in the design of Children's Convalescent Hospital, part of the Children's Hospital campus.
Through patient- and family-friendly design, Sadler transformed public perception of the facility. "Now they're viewed as a hospital that really cares about children," says Varni. "Their share of market went up, due to patient and family satisfaction."
This was not always easy, given the choices the hospital had to make, such as putting in more gardens for patients and their families to relax. "A garden space is very expensive property, when you consider that you could put in a garage or some other income-producing use there," says Varni. "You need to have a business model to justify making that kind of decision."
"Good design encourages donors," says Parker. "People will give to a vision. They won't give to mediocrity. Once you can articulate that vision, and it's a compelling one, people will support it."
Fostering design innovation was a major impetus for Peter Karmanos, Jr., chair and CEO of Michigan-based Compuware Corporation. In memory of his late wife, Barbara Ann, who died of breast cancer, the software executive donated $15 million to construct a cancer institute in her name at Detroit Medical Center.
One of the stipulations that Karmanos put on the donation — based on his own experience holding vigil over his wife — was that the new center would have to provide sleeping facilities for patients' families. Later, this priority was expanded to include numerous other design improvements that have made the Barbara Ann Karmanos Cancer Institute one of the preeminent examples of successful evidence-based design.
Taking these factors into account in designing a hospital can not only produce better clinical outcomes for patients — obviously the chief goal of any hospital — but also make business sense to skeptical CEOs, finance types, and boards of directors.
"We took all of these factors and worked through the numbers and it worked out to $50 million a year to the good in a typical 400-bed hospital," says Parker.
Even if smart design didn't save a nickel, it would be worth it for many other reasons: greater opportunity for family involvement in care, improved morale among nursing and support staffs, supplying an edge in ever more competitive healthcare markets.
For your architectural or construction firm to be competitive in the hospital market of the future, you'll have to offer more than the standard menu of services. Putting evidence-based design into your service mix could be just the answer.
To do so will require staff resources, time, and energy. Evidence-based design requires a great deal of involvement, particularly with extremely dedicated and knowledgeable nursing and support staffs. They're the ones who interact most with patients and their families. They know what works and what doesn't work in the hospital setting. Most of all, they have a big stake in improving the healthcare environment, partly for their own benefit, but primarily for that of their patients.
This effort can pay off, as Hobbs & Black, of Ann Arbor, Mich., has learned. As a result of its work on the Barbara Ann Karmanos Cancer Institute, the firm has been hired to design the Rehabilitation Institute of Michigan on the Detroit Medical Center campus — a $35 million project.
"Doing a project like this showed me that you can make a difference in people's lives-and do it within budget," says principal architect John Barker.
Perhaps the most telling evidence that this movement is here to stay is how it is spreading beyond our borders. Sweden's Karolinska Medical Institute has sponsored a conference on the topic, and the Dutch Health Council will host an international symposium in late 2004.
In the United Kingdom, the National Health Service budget has been increased 60% by the Labor government. The architect in charge of NHS projects, Richard Burton, is already talking with experts like Roger Ulrich about applying evidence-based design in the construction of $5 billion worth of new hospitals in the next few years.