Chapter 1. Introduction
Several noteworthy reports that have been released in the past few years raise troubling concerns about the quality and safety of health care in the United States. Among these are:
- A RAND study on the quality of health care delivered to adults in the United States.1
- The National Healthcare Quality Report2 and National Healthcare Disparities Report3 from the Agency for Healthcare Research and Quality (AHRQ).
- The Pennsylvania Health Care Cost Containment Council report on hospital-acquired infections.4
- The Johns Hopkins University study of the impact of quality improvement organizations in five States.5
Many factors may contribute to the shortfalls in quality, including the way care is delivered and the adequacy of the facility within which that care takes place. This report focuses on the latter, particularly hospitals, their design and how that affects patient outcomes and satisfaction and staff working conditions.
A body of evidence is developing about how attributes of the various environments in which health care is provided mediate health care quality. But no one has yet identified what questions remain to be answered that might help health services researchers, architects, or others decide where more research is needed or how research dollars could be best spent to address the many outstanding issues. This environmental scan is intended to assess what is and is not known about the relationships between hospital design and construction—the built environment—and:
- Patient outcomes.
- Patient safety and satisfaction.
- Hospital staff safety and satisfaction.
This environmental scan is organized to address the following research questions of interest:
- What is currently known about the relationships between hospital design and construction and factors influencing patient and staff safety, patient outcomes and patient and staff satisfaction levels? This includes identifying important areas and gaps in available research, barriers and facilitators of evidence-based design, best practices in evidence-based design and emerging trends.
- Who is funding, conducting and disseminating research and applying research findings in the design and construction of hospitals, and who is evaluating the impact of the hospital physical environment on patient outcomes, quality and other areas of interest?
- What are appropriate potential future roles and areas for involvement by those interested in conducting research or disseminating research findings and best practices about the hospital built environment?
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Chapter 2. Methodology
This environmental scan was conducted between February and May 2005. It consisted of two primary tasks:
- Conducting a focused literature review to determine what is known and who is conducting research on topics relevant to the hospital built environment.
- Conducting hour-long, semi-structured interviews with key informants in the field, including hospital executives, architects and designers, academics and researchers involved in the built environment.
A focused literature review was conducted to better understand what is known about the built environment and to help identify where there are gaps in the research. The search to obtain relevant PubMed® citations involved using the following MeSH® terms: hospital design and construction; health facility environment; interior design & furnishings; stress, psychological/prevention & control; infection control; patients' rooms; hand washing/standards; outcome assessment (health care); patient satisfaction; safety management; and job satisfaction.
Text words/phrases used for searching PubMed® included built environment, therapeutic environment, hospital design, patient outcomes, patient safety, staff safety and staff satisfaction. The search was limited to English language citations and citations with abstracts. When reviewing articles for relevance, we excluded those that did not involve hospitals. Our PubMed® search yielded 297 relevant articles.
In addition to PubMed®, we searched other relevant sources, such as The Center for Health Design (CHD), Institute of Medicine and a broad Internet search (using Google®). Table 1 summarizes the yield of relevant articles (excluding duplicates) on main areas of interest by source.
Table 1. Summary of articles by main topic and source
|Center for Health Design
|Institute of Medicine
Fifteen semi-structured interviews were conducted with a targeted sample of architects, researchers, academics, designers and health care executives (Appendix A). These interviews lasted 45-60 minutes and were conducted by telephone.
The purpose of the interviews was to:
- Identify who is leading the field in funding, conducting, disseminating, and applying research findings in the design of hospitals.
- Obtain insights on current areas of research focus, outcomes to date, and gaps in available research.
- Identify challenges to advancing the field.
- Discuss future research directions.
- Obtain feedback regarding possible roles for funders supporting and disseminating research in this area. Interview feedback was reviewed and consolidated to identify trends and recurring themes.
Stakeholders were fairly responsive to requests to participate in these interviews. Table
2 provides information on the effectiveness of data collection efforts within each of the six main stakeholder groups.
Table 2. Response results by key informant group
|Key informant group
|| 3 (75%)
|| 7 (78%)
|| 1 (100%)
|Health care executives
|| 1 (25%)
|| 2 (67%)
|| 1 (50%)
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Chapter 3. Background
Hospital design and construction is vital, yet costly, to our health care system. An estimated $200 billion will be spent on new hospital construction across the United States in the next 10 years5. Among the factors driving the market for hospital design and construction are:
- Competition for patient market share.
- Technology innovation and diffusion.
- Efficiency and cost effectiveness.
- Regulatory compliance.
Despite the enormous expenditures projected for new hospital construction, there remains considerable potential for quality improvement in our nation's hospitals. The Institute of Medicine's widely cited report, To Err is Human, concluded that tens of thousands of patients die each year from preventable medical errors while in the hospital.6 Furthermore, up to two million U.S. hospital patients contract dangerous infections during their hospital stays that complicate treatment and frequently result in adverse patient outcomes.6
Hospital physical environments also can create stress for patients, their families and staff. This stress derives from factors such as excessive noise due to hospital alarms, paging systems and equipment; feelings of helplessness and anxiety triggered by poor signage, confusing building and corridor layouts and other flawed aspects of hospital design; and lack of privacy as a result of double-occupancy rooms. These may disturb a patient's rest, more readily enable transmission of infection and prompt the need for more frequent, time-consuming and potentially error-inducing patient transfers.6
Due to growing knowledge and awareness of these issues, the hospital built environment increasingly is being influenced by research linking the physical environment to patient outcomes and patient and staff safety and satisfaction. Consistent with the growing movement to apply clinical evidence-based approaches to improve patient outcomes, hospital administrators and researchers also are placing greater emphasis on "evidence-based design" to support and facilitate clinical advances in the field.7
This is a process for creating hospital environments that is informed by the best available evidence concerning how the physical environment can affect patient-centered care and staff safety and satisfaction.8 However, the field is relatively new, evidence supporting this approach is not yet robust in many areas and existing research on evidence-based hospital design is not widely known among policymakers, regulators and other decisionmakers and opinion leaders.
These issues are discussed in the remainder of this environmental scan, which includes the following sections:
- What is currently driving the market for hospital design and construction?
- To what extent are hospitals requesting evidence-based designs?
- What is the research base for the hospital built environment?
- What are major challenges in building the field of evidence-based hospital design?
- What are the major gaps in current research and relevant areas of future focus?
- What are appropriate roles for funders of health services research interested in furthering improvements within the built environment?
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Chapter 4. What is Currently Driving the Market for Hospital Design and Construction?
There appear to be four major factors currently shaping the market for hospital design and construction.
First, the hospital market is highly competitive, and health care executives must invest in newer designs to remain desirable to patients, affiliated physicians who influence patient referrals, and payers.9,10 Competition among hospitals reportedly is influenced more by the availability and sophistication of services and facilities than by price10.
The growth of consumer-driven health care has created a demand for hospitals to focus on patient-centered care with services such as concierge services, bedside Internet access, spaces to involve families in the healing process and private rooms.11 Hospitals also are increasingly incorporating design elements such as big windows, soft lighting and art and gardens into their designs to enhance patient and staff satisfaction. Changes in hospital design to improve staff satisfaction and safety are among the strategies for slowing high staff turnover rates, especially among nurses.
A second factor driving the market for hospital design is the need to incorporate new technology.12 Research by the National Institute of Building Sciences shows that hospitals increasingly are housing more sophisticated diagnostic and treatment technology.13 Hospitals continue to adapt to the flow of new technology into inpatient and outpatient departments, including the cost implications of replacing old technology with new technology and the necessary supporting infrastructure.11
Third, hospitals are being redesigned in an effort to be more efficient and cost-effective.13 Efficient hospitals can diminish inpatient lengths of stay and improve patient flow in outpatient settings, thereby freeing beds for new patients, improving productivity and increasing hospital revenue. Efficiency affects hospital staff in other ways. For instance, an efficient hospital layout promotes clinical staff productivity by maximizing the accessibility of patients and other critical patient care support departments, such as radiology, laboratory and pharmacy.
The fourth factor driving the market for hospital design is that hospitals must be renovated and updated regularly, in order to maintain patient and staff safety consistent with newer hospital guidelines and regulations.11 New guidelines for the design and construction of hospital and health care facilities are introduced by the Health Guidelines Revision Committee (HGRC) every 5 years, often necessitating changes on the part of hospitals. For instance, the 2001 version of the Guidelines for the Design and Construction of Hospital and Health Care Facilities produced by HGRC had more than 1,500 changes from the previous edition.14
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Chapter 5. Are Hospitals Requesting Evidence-based Designs?
Evidence-based design incorporates results of outcomes of real projects and research into design goals. A growing body of evidence indicates that aspects of hospital environment design are yielding measurable benefits to patient safety, outcomes and satisfaction. As a result, a growing number of hospital administrators are requesting evidence-based designs. Researchers and architects anticipate that hospital administrators increasingly will request evidence-based designs to achieve cost savings through risk avoidance and improved patient outcomes and satisfaction.
Hospitals are collaborating through organizations that seek to advance the field through applied research. CHD and Planetree are two such organizations. CHD launched its Pebble Project, to measure the effects of the built environment. The project also aimed to create a ripple effect of sharing documented examples of health care facilities in which design has improved quality of care and financial performance of the institution.
Currently, 27 providers are participating in the Pebble Project and there are two alumni. Pebble Project Partners have access to information and expertise regarding current research in the built environment. Data are collected early in the planning process and after the completion of design efforts, to measure the effects of the built environment. Examples of three Pebble Project Partners and their design efforts are highlighted in the box.
Some Pebble Project Partners and Their Design Initiatives
Bronson Methodist Hospital, Kalamazoo, MI
Bronson Methodist Hospital completed a $181 million renovation to design a new medical pavilion, outpatient pavilion and an inpatient pavilion. The new facility features an indoor garden, artwork, private rooms and a facility design that is easier to navigate than most traditional hospital designs. The health care and outcome improvements attributed to this renovation to date include: nursing vacancy rates are half the State average; patient transfers are down due to private rooms; patient sleep quality is up; and the hospital's market share has increased 1 percent, leading to 1,000 more admissions in 2001 than in 2000.
Methodist Hospital/Clarian Health Partners, Indianapolis, IN
Methodist Hospital built a 56-bed comprehensive cardiac critical care unit that focused on creating an environment to promote healing and involving families or significant others in the care process. The new facility features curving walls, carpet, indirect lighting, and private rooms that were equipped to adapt to varying technology. As a result of the redesign efforts, patient falls are reportedly down 75 percent, attributed to the unit's decentralized design that allows for better observation. In addition, patient room layout, equipment integration and other design features have helped push patient transfers down 90 percent. Unit design also helped reduce the caregiver workload and improve nursing efficiency.
The Barbara Ann Karmanos Cancer Institute, Detroit, MI
The Institute initiated redesign of two inpatient units. Some of the features of the new facility include a partially enclosed unit clerk area, flat screen computers outside every patient room, a sleeper chair in every patient room and artwork in the hallways. CHD reports that, since the unit opened in 1999 and 2000, patient satisfaction rose 18 percent, nurse attrition fell from 23 percent to 8.3 percent, there was a 30 percent reduction in medical errors and there was a 6 percent reduction in patient falls as a result of improvements in lighting and room/hallway layout.
Source: Center for Health Design.
In addition to the work of the Pebble Project Partners, other organizations are demonstrating the benefits of using evidence-based knowledge in designing facilities that improve patient outcomes, safety and satisfaction.
Planetree, a membership organization working with hospitals and health care centers to develop and implement patient-centered care in healing environments, has more than 62 hospital affiliates nationwide that have adopted core components of the organization. These components include incorporating architectural and interior design that is conducive to health and healing; empowering patients through information and education; embracing the families, friends and social supports of the patients; using complementary and alternative medicine in the healing process; and creating an atmosphere of serenity. All hospitals are to focus on "putting the patient first" and strive to treat the entire human spirit, not just the disease condition.
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