A hospital that spends more upfront on evidence-based design will soon reap the payback in better outcomes.
It was some doctor show on cable: Nurse McCarthy bustles into the hospital room, says “Good morning!” brightly, and crosses the brilliantly polished linoleum floor to the window. Humming to herself, she sweeps open the curtains to the view of the brick wall across the airshaft, then goes to the patient on the right and checks his dressing, clucking and offering encouragement. After a few moments she does the same with the patient on the left, makes a note on his chart, and leaves. She’s probably been there less than 10 seconds, and I’m thinking, She just killed two patients.
Consider this: During the remainder of this decade, health care providers will be building thousands of structures — building, re-building, re-purposing, infilling, for new and rapidly shifting purposes. Details matter.
Despite its continued use as a political bludgeon, health care reform will likely be implemented, at least in its broad outlines. The truly deep changes that are transforming us into the Next Health Care are proceeding apace in any case, with different business models and revenue streams, which means new physical settings.
In the next few years, we are facing not only tens of millions of boomers aging into their Medicare years, but tens of millions of others who are becoming newly insured. The rest of this decade combines vast and immediate new needs for efficiency, effectiveness, low cost, and getting close to the customer in ways we never even imagined before; a whole array of new data capabilities to help us get there; and for most of us new revenue streams, relationships and corporate structures — which means new buildings.
Buildings take time, so the time to start is now. But building for the clinical environment is extraordinarily complex, and getting it right is crucial to patient safety, efficiency and cost. How do you get it right?
What’s the Purpose?
Every building must meet its purpose. What are you going to build in the Next Health Care? How are you going to build it? What are you going to re-purpose? Is it a string of mini-clinics, or is it Tombstone Memorial? Do you imagine onsite clinics for employers, urgent care clinics, a nurse-in-a-box in the mall? How do they relate to the hospital, the med-surg floors, the imaging center, the labs, the ED? How do you go about designing these environments not only to meet the new business structures, but to take advantage of the emerging data environment, and to take patient safety to an unprecedented level?
What’s the process that works through this complexity? How do you spring from global strategy to geo-strategy to work flows and communication flows to space planning, site planning, architecture, and then to pouring concrete over re-bar and screw-gunning drywall? How do you do that in a way that takes into account all we have learned about designing physical spaces that don’t kill any more patients than necessary, and don’t run the nurses ragged and frustrate the doctors, i.e., spaces that actually promote healing?
These are complex questions, but they are questions most health care executives are not even asking yet, not at the level of detail they need. Answering those questions, and instantiating the answers in real buildings, is complicated and tough to do, and most health care executives really don’t know how to do it. Frankly, most architects don’t know how to do it. A physical environment built for health care is different from other environments literally from the foundations to the highly specialized ventilation systems; to the relationship with daylight and trees; to the energy systems; to the color schemes and the ceiling tiles — all not just for aesthetics, but for keeping patients alive, promoting healing and cutting cost, all at once.
Killed Her Patients?
Why do I say Nurse McCarthy killed her patients? Where is the hand-washing station in this picture, or even the hand-sanitizer? Certainly not between the two patients whose dressings she touched, or between them and the curtains, notorious for harboring C.Diff, MRSA and a host of other deadly pathogens.
Not Nurse McCarthy’s fault, but: Why were there curtains there in the first place, instead of other, more pathogen-resistant window coverings? Why did she have to touch a chart that is touched by all other clinicians that enter the room? Why a polished linoleum floor, which is as good as a skating rink for wandering patients trying to get themselves to the bathroom — and which harbors certain major pathogens more readily than carpet? Why are there two patients in the room, when infection control, sleep patterns, and many other elements of healing are much more manageable in single-patient rooms? Details matter. Done wrong, they kill people and cost money.
Designing a clinical environment for patient safety, lean work flows and low cost is a major field of study all on its own, with research extending back decades, with new understandings arising constantly, meshing with a rapidly changing futurescape. It’s not something anyone can master without serious study.
Most architects, and almost all health care executives, are not trained and certified in this study. I still have the experience of walking into major buildings built in the last few years and shaking my head in wonder at the mistakes, and listening to the nurses complain about its difficulties, and hearing appalling sound levels, and seeing long transports, and wondering how many millions to billions were just spent by people who didn’t get to the nub of the problem.
The nub of the problem: You’re building a building for highly complex purposes in a rapidly changing demographic, clinical and business environment — and you want that building to continue to be useful for decades into the future.
How Do You Find This Out?
So how do you get into this whole field? Where is the knowledge, the research, the expertise? For the last 18 months or so, I have been on the board of the Center for Health Design, founded to bring the fruits of research to architecture, planning, interior design, even landscaping in health care.
Since the 1990s, the CHD has sponsored research and completed a series of landmark meta-studies that surveyed the growing field and presented the findings of hundreds of studies in neat packages with their rationales: Make the bathroom door this wide, and here’s why. Solve the nurses’ supply problem in these five ways; here are the findings.
The first of these came out in 2004. CHD launched the Designing the 21st Century Hospital Project with backing from the Robert Wood Johnson Foundation. Researchers Roger Ulrich and Craig Zimring and their teams gathered thousands of studies, vetted them for sound research methods and good data, combed the resulting 600, and published “The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity.” It was a packed 69-page document — 26 pages of results and recommendations followed by 47 pages of references to the original 600 studies. In 2008, they updated it: “A Review of the Research Literature on Evidence-Based Healthcare Design” (on the CHD website).
As part of the same project, another team of researchers and architects affiliated with CHD built the Fable Hospital in 2004. This analysis of an imaginary hospital project had a somewhat different goal: demonstrating that there is a solid business case for evidence-based design. These were people who had done a lot of real hospital projects. They combined that experience with solid research from real health care environments to see how much evidence-based design would cost, and how much it would save.
Here we see another aspect of my major theme: Better health care is cheaper. Smart health care is leaner and less expensive than stupid health care.
Research: Phantom and Real Hospitals
Evidence-based design is more expensive on the front end. For instance, it calls for single-patient rooms, and larger ones; far better ventilation than usual; fully integrated headwalls and patient lifts; patient rooms with a view of nature and a day-bed for the family caregiver; and a host of other refinements. But the fewer accidents, shorter patient stays, fewer infections and other outcome improvements pay for the refinements over a relatively short period of time.
Let’s use the latest figures, from the updated 2011 Fable Hospital report. The refined figures, based on another seven years of experience and experiment, came to this: On a $350 million hospital project, the evidence-based refinements would cost about $29 million extra. Evidence showed that the savings engendered by these refinements would come to about $10 million per year. They would pay for themselves in just three years.
Some of the new information comes from actual new hospitals built to principles of evidence-based design. They are called the CHD’s Pebble Projects, as in pebbles tossed into a pond creating waves that change the whole pond. Health care organizations with construction projects sign up with the CHD for guidance, and at the same time agree to conduct specific new research on the facility after it opens, comparing accident rates or infection rates against those of the facility it replaced, or another facility of different design, or in different parts of the same new facility. Some three dozen facilities have participated since the program’s founding in 2000.
In 2008, the CHD began training and certifying architects, planners and interior designers in the principles and data, in a new Evidence-Based Design Accreditation and Certification (EDAC) program, which quickly expanded to hundreds of professionals.
This is heroic work. It is boring to all except those who are doing it. Most of it is invisible to most of the people it affects. But all this research, education and turning the data into actual buildings — hard, detailed, tough-minded, relentless labor — ultimately saves lives, reduces suffering and makes health care more available to all by reducing costs.
Time for some big learning.
This article first appeared in H&HN (Hospitals and Health Networks) Daily, a publication of the American Hospital Association, July 24, 2012.