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Healthy By Design
Evidence-based design is making healthcare facilities healthier.
Dianne Taylor
Publish Date: January 10, 2009   |  Tags:   Facility Construction and Design

Imagine a healthcare center where patients don't fall, hospital-acquired infection isn't a worry and medication errors simply don't happen. Envision an oncology hospital that contains no cancer-causing substances, or a children's hospital free of asthma triggers. Picture a surgical facility where natural daylight, soothing colors, water features, gardens and even fireplaces make patients happier and personnel more productive. Imagine this, and you have seen the vision of evidence-based healthcare design — the idea that we can't separate health care from the setting in which it is delivered.

Evidence-based design has been around since the mid-1980s. But not until the mid-1990s did advocates move their research efforts beyond the halls of academia and actively engage the healthcare community in exploring the connection between health and the built environment. The result has been a growing body of evidence that is laying the foundation for designing and building healthier hospitals, surgery centers and other patient-care facilities.

The nexus of the movement can be found in Concord, Calif., at the Center for Health Design. The center orchestrates what it calls Pebble Projects, in which healthcare facility leaders create hypotheses about how design and materials might affect the health and performance of staff and patients, apply their ideas to the design and construction of their new facilities and then test the hypotheses once they're operational. The projects can focus on a single issue or be more encompassing, but they all address one or more of these three elements: safety, environment and stress reduction.

The CDC estimates that hospital-acquired infections cost upward of $5 billion a year. Patient falls drive healthcare costs up by $2 billion a year. And studies suggest that preventable medical errors cost $17 billion or more annually. A major goal of evidence-based design is to help minimize these problems.

  • Infection reduction. Key infection prevention elements of evidence-based design include improved air handling (high quality air filters, properly directed and well-pressurized fresh air inflow, frequent air changes, humidity control, and proper cleaning and maintenance); HEPA filtration in high-acuity areas; numerous and highly visible hand-hygiene stations; and private patient rooms. Private patient rooms were the first feather in the Center for Health Design's cap, says its chair, Rosalyn Cama, FASID. After facilities started showing reduced infection rates with single-bed rooms, the American Institute of Architects recommended them as standard for all new hospital construction last year, and new hospitals nationwide are following suit. One of the earlier Pebble Projects, Bronson Methodist Hospital in Kalamazoo, Mich., reported an 11 percent reduction in nosocomial infection rates after opening its patient pavilions — which include private rooms, strategically placed hand hygiene stations and high air-inflow ventilation. Bronson attributes this largely to the single-bed rooms, which help keep infectious pathogens isolated and are easier to disinfect.
  • Fewer injuries. Decentralized nursing stations and continuous handrails that run from bed to bathroom are two evidence-based design features that many say can reduce patient injuries. The Methodist Hospital in Indianapolis, Ind., reported 75 percent fewer patient falls with its new hospital — thanks almost entirely to decentralized nursing stations that let nurses see what's going on in patient rooms and react quickly to problems. Decentralization, however, has its own problems.

"The traditional centralized station encourages nurses to congregate in their lab coats and socialize, and this intimidates families and patients. Yet we found that the fully decentralized model isn't working either, because blinds are drawn on patient rooms and you can't see in anyway," says Cheryl L. Herbert, RN, MBA, the CEO of Dublin Methodist Hospital in Dublin, Ohio, where there are six nursing "perches" within each of the hospital's 20-bed units, or one perch for every three to four beds. "Nurses will be able to hear patients trying to climb over the bed rail, as opposed to finding them on the floor five minutes after they fall," says Ms. Herbert, noting that electronic patient records enabled this change. "We're no longer constrained by the need to have a central location where you need to go to find the patient's chart."

When it comes to staff injuries, the trend is to install lifts that help the aging nurse population move high-acuity patients. Five years after the Eugene, Ore.-based PeaceHealth Organization, another Pebble participant, installed ceiling lifts and booms in its ICU and neurology patient rooms, the institution says its staff injuries resulting from patient handling in these areas were virtually eliminated.

  • Fewer medical errors. While age, worker health and staffing levels influence the rate of medical errors, so do factors like lighting, color, spatial design and noise levels. At the Barbara Ann Karmanos Cancer Institute in Detroit, Mich., data collected since 2000 suggest that improvements in building design — including more space in the medication room, better organized medical supplies, standardized visual cues and acoustical panels to reduce noise — cut medical errors by 30 percent.

At Dublin Methodist, the facility designers standardized layouts to help the staff function without fumbling. The four ORs are identical; the medical gases, electrical outlets and equipment are in the exact same places. The minor procedure rooms are also identical, as are the patient rooms and emergency department. "We don't want our staff to use their short-term memory to think about where the oxygen is," says Ms. Herbert, a nurse herself. "We can reduce errors when nurses can reach out and subconsciously know where things are." At Dublin, designers applied the same concept to the pre- and post-op patient areas.

Evidence-based designers are also building "acuity-adaptable" rooms, which house everything a patient needs as acuity of care steps down. These rooms obviate the need to transfer patients, since transfers increase the risk of error. "And patients are happier when they stay put, because the light, bumps and noise during transfers can be nauseating to someone who is not feeling well," adds Amy Bush, Dublin's director of surgical services.

Evidence-based design also addresses the connection between broader environmental issues and public health. Buildings can harm health because they create demand for materials that produce harmful by-products during manufacture. After installation, building materials can also emit toxic gases like formaldehyde into indoor air. What's more, healthcare facilities use huge amounts of energy and water, and this use is directly linked to global warming pollution and toxic air pollutants, like the asthma-causing particulates that come from coal-fired power plants. Healthcare facilities are by far the most energy-intense commercial buildings, according to the Energy Information Administration.

For evidence-based architects, addressing these issues from the ground up is, in effect, investing in preventive health care. "If we can keep our health plan members healthy, there's more money for us to spend on the operations side — new technologies, retaining and recruiting staff, and new construction," says Thomas Cooper, chair of Kaiser Permanente's High Performance Buildings Committee. This is especially true for Kaiser. It's the nation's largest non-profit health plan, and it's prepaid.

To date, one of the most fruitful products of this pursuit is the elimination of polyvinyl chloride (PVC) products. During manufacture, PVC creates dioxin — by far the most carcinogenic substance known to man. And once installed, vinyls can trigger asthma. At Kaiser, Mr. Cooper and his colleagues have created a market for PVC-free healthcare products, including window extrusions, carpets, floor tiles and IV tubing, by working with manufacturers to produce alternatives and committing to their purchase. As one example, the health system now uses a non-vinyl flooring product in certain treatment areas. Kaiser also uses formaldehyde-free substrate in its fiberboard and low volatile organic compound (VOC) paints. VOCs can trigger asthma and cause other respiratory issues.

Kaiser and others are also working hard to reduce their overall energy and water use. When designing a new facility, it's a prime opportunity to build in energy efficiency with strategies like energy load management; demand-control air flows that enable flow reductions in areas of the facility that are not in use 24-7; and energy capture from chillers and high-temperature wastewater, among other methods. "We are also working to bring solar energy to our campuses," adds Mr. Cooper. "On-site co-generation is a lot more efficient than pulling power off of the grid."

Stress reduction
Facilities can also be designed to reduce stress on patients, families and staff. "People are drawn to health care because they want to serve, but caretakers are always giving. They need to be reminded to care for themselves, or they can't provide healing to patients day-in and day-out," says Julie Schmidt, CEO of the Woodwinds Health Campus in Woodbury, Minn. One popular approach is to bring nature and warmth inside. Ms. Schmidt, a former practicing nurse, helped oversee the design and construction of the expansive Woodwinds campus that — thanks to its healing garden and woods, fireplaces, maximal use of natural daylight and earth-tone palette — feels more like a welcoming hotel than a hospital.

Daylight is key. The Center for Health Design's review of the published research shows that natural light regulates our circadian rhythms, which reduces depression, improves sleep patterns, improves mood and even reduces lengths of hospital stays. Good lighting levels can also reduce errors during such complex visual tasks as medication dispensing.

"Research shows that patients use less pain medication, recover faster and leave the hospital more quickly when their rooms have good natural light exposure," says Ms. Herbert. Just as importantly, daylighting and other features may even improve staff retention. Two years after opening a new hospital with lots of natural light, improved airflow, separation of public and patient transport areas and a homelike patient room design, principals at Parrish Medical Center in Titusville, Fla., reported that staff turnover declined to 13 percent annually, down from the low 20s in its old facility.

Other popular stress-reducing design features include family zones, which offer such amenities as Internet access, refrigerators, chairbeds, TVs, and ambient temperature and lighting control. Designers at the St. Alphonsus Regional Medical Center in Boise, Idaho, reduced noise levels by adding carpet to hallways, installing acoustical tiles on walls and ceilings, and relocating machinery and nurse charting away from patients.

3 Quick Design Tips

  • Make sure there's room for all employees to have desk space to work together. Having to put someone in a back room at a desk to do her work means she won't be available to help greet patients, assist with admitting, answer phones and accept deliveries.
  • In a two-OR facility, build the utility room for instrument care between the two ORs. This lets the tech flow back and forth between the two rooms for faster turnover and quicker access to supplies needed on demand.
  • ORs should have double doors on the walls — one for entry from pre-op and one for exit into the discharge area. It makes for a quicker flow and you won't have stretcher traffic running into each other.

Carrie L. McCown, RN
ASC Director
NovaMed Surgery Center of Warrensburg (Mo.)
[email protected]

Worth it?
Advocates of evidence-based design say one of its great benefits is that it lets healthcare facilities demonstrate their values to the community and staff. From an economic standpoint, however, is it worth it? Ms. Herbert, whose community hospital cost $150 million to build, says her construction costs were just under $300 per square foot. "Preliminary research suggests that evidence-based design increases the total project cost by two to three percent," she says. "But if we achieve all the things we expect to achieve, it will more than pay for itself, and very quickly."

To make evidence-based design work, say advocates, don't rely on traditional costing models that focus only on construction and project expenses. Look a few years into the future, and think of your new facility as the investment that it is, they say. And, adds Ms. Herbert, hang onto your vision. "Our biggest challenge was having our vision challenged throughout this entire process. We constantly found ourselves in a position of defending and explaining the vision and working to hold onto it," she says. "We now have a non-traditional facility in many ways, and we have it because we had strength of conviction."

For Ms. Herbert and Ms. Bush, it was well worth it. "We truly believe we're changing the course of health care," says Ms. Bush. "Think about how many lives you'll change — not just those of patients but everyone else who touches the facility. That's all there is in life. Even in my busiest moments, I think about this. I think about what an honor it is."