Better Space, Better Health

Health care company uses evidence-based design in an effort to improve patient outcomes and facility performance.

By Monte Hoover and Robert Schoeck Facilities Management

A massive change in health care is occurring as hospitals reinvent themselves to cater to the medical needs of aging baby boomers. Hospitals are building new facilities that deliver clinical excellence, improve patient safety, and accommodate patient- and family-focused care. They are moving to a private room model. And they’re considering facility design as a way to help brand themselves as the preferred hospitals in their markets.

One strategic tool that some hospitals are using is data-driven, evidence-based design. Evidence-based design looks at ways facility design can improve patient outcomes and operational performance.

Lakeland Regional Health System, a nonprofit, community-owned health care system, has embraced evidence-based design and used it as a major focus in the design of a new 118-room inpatient replacement tower on its St. Joseph, Mich., campus. Lakeland had two major objectives: to create a truly community-focused facility — one that is seen as the hospital of choice in the region — and to design environments based on the latest evidence-based design research, to improve outcomes and to raise patient, staff, physician and visitor satisfaction.

In the traditional programming phase, administrators and medical staff outline facility goals. These are often expressed in such items as number of beds, the size of the emergency department, types of medical specialties to accommodate, size of surgical suites, types of procedure rooms, size of patient rooms, and equipment needs. It is a functional list of physical and practice requirements in a new medical facility.

Evidence-based design adds an overlay of results-oriented objectives specified by the hospital. These objectives might be to reduce medical errors, increase staff satisfaction, reduce noise levels, minimize patient transfers, improve patient privacy or increase patient satisfaction.

Lakeland and the design team identified 53 metrics vital to the goal of creating the hospital of choice for its community. Data and statistics were gathered on Lakeland’s existing performance in these areas — and they will continue to be gathered until the new pavilion is finished. Once the facility is operational, performance data will be compared with the old facility’s data to evaluate the success of evidence-based design.

Hospitals look to improve patient, visitor, physician and staff satisfaction, as well as patient safety and clinical outcomes. These were key goals for Lakeland as well. But Lakeland believed that using evidence-based design would give it the opportunity to go beyond what other hospitals achieve, giving the hospital a competitive advantage in the community.

The design of patient rooms was seen as a critical factor in achieving patient safety and satisfaction. All rooms will be private, reflecting a nationwide trend. (The Facilities Guidelines Institute, in conjunction with the AIA/Academy of Architecture for Health, issued new standards last month that call for all future patient facilities to be designed with private rooms.) Studies have shown that private rooms can decrease infection rates by up to 45 percent and can produce a significant increase in patient satisfaction.

The new rooms will be 305 square feet, an increase of 140 percent compared to the space that a patient has in the current double-patient configuration (total of 220 square feet). Rooms also will receive more natural light, have operable windows, overlook natural settings, provide easier access to room controls, and include amenities such as shelves for cards and flowers, moveable chairs, and tables. Space in the family zone will increase by 170 percent and include a sleep sofa for overnight stays. In addition, the new tower will include family retreat areas with fireplaces, lounges and kitchenettes.

As part of the design process, a full-scale concept patient room was built, with all equipment (non-operable) and furniture. Staff, physicians, community members and former patients were asked for feedback. Many adjustments were suggested. For example, feedback led to rethinking and relocating lighting and lighting controls. Lighting controls that are highly used by staff were located by the entry door, with night lights on the bottom and overall room lights on the top. In addition, moving a task lighting fixture 6 inches made a significant difference for the patient. The level of control that patients have over their room, such as lighting, temperature, window treatments and call buttons, is a considerable factor in patient satisfaction.

Impact on Staff

The nursing population is aging, with the average nurse’s age close to 50. Studies have shown that nurses on average walk between 3 and 6 miles a day tending to patients and getting supplies. The design reduces average travel distance from the nurse’s station to the furthest patient room from 84 feet to 33 feet, a reduction of 255 percent. The percentage of staff work area per bed will be increased by 148 percent, equipment storage areas will increase by 149 percent, and access to medications and supplies will be more convenient. The new facility will also contain a staff retreat area, separate from staff lounges, where staff can catch some quiet time, recharge and enjoy scenic views.

A centralized distribution system, serviced by its own materials elevator within the core, will be used for all supplies, dietary needs and equipment, avoiding use of patient or visitor elevators. One additional design change locates patient and visitor elevators at opposite ends of each floor. The goal is to improve patient privacy, reduce infections and alleviate congestion.

Evidence-based design requires commitment. The hospital should identify an individual to champion the effort, both during the project process and afterwards, to help collect information. Time should be built into the schedule for research activities such as focus groups, surveys and measurements and documentation of existing facilities. At the end of the process, the additional time and effort pays off in better results, efficiencies that save money and time, and a documented return on the investment.

Evidence-based design is an effective tool in more than just health care design. It works for areas like higher education, which aims to improve learning, and in research, to improve discovery. The process allows administrators and users to understand and express priorities — what is really important from an outcome and capital investment point of view — and provides a way to track the success of their decisions and the designs.

Design Effectiveness Measured, Monitored

Lakeland Regional Health System is undergoing an examination.

BSA Lifestructures, the project’s architecture and engineering firm, is submitting final drawings of the 140,000-square-foot, 118-room patient pavilion to Lakeland facility executives this month. Included with the prints is a book indicating what steps the firm took to meet 15 facility design criteria set out by Lakeland’s facility department at the beginning of the project.

Having such data is Lakeland’s first move toward verifying that the patient pavilion, which is set to open in a little more than two years, is contributing to patient wellness and promoting healing.

“We expect all of the outcomes we identified to be met,” says Russell Furst, manager of biomedical engineering.

Lakeland facility executives identified 53 measures that will be monitored to gauge the facility’s performance. The performance measures, also known as metrics, for the hospital’s patient pavilion include those directly related to the design of the facility, such as the size of rooms, windows and storage areas, and those that are related to both design and operations, such as the number of patient falls, infection rates, and noise levels in and around rooms.

With the final drawings complete, Lakeland can begin sizing up how well its evidence-based design approach worked in achieving specific goals as gauged by facility metrics. The metrics that depend upon operations will be evaluated for one year after the pavilion opens before conclusions are drawn about the performance, Furst says.

“I think there is a certain amount of variability that you have to let time account for when you move into a new facility,” he says.

The project architect has developed a toolbox of 77 metric benchmarks based on research, data averages collected from previous projects and best-of-class industry standards. These are grouped into four areas: facility design, operational improvements, satisfaction (quality) and research. Lakeland selected its metrics from that toolbox of choices.

The metrics identified for the patient pavilion were based on studies of health care facilities indicating that patients heal faster if they are placed in a more comforting environment. While doctors will argue both sides, says Mike Kastner, director of building services and construction management, it makes sense that patients have better attitudes if they’re given access to outside views through windows and if daylight is allowed to enter the room.

Lakeland will also examine its performance on the widely used Press Ganey survey of patients to determine how well the new facility performs. On that survey, the hospital will be looking for improvements in such measures as satisfactory room temperature, pleasantness of room décor and the promptness with which nurses respond to patient calls.

While most of those measures will depend on operational procedures, the design of the new patient pavilion will have a certain amount of influence. For instance, one of the design criteria was to reduce the distance between nurse work stations and between equipment storage areas and patient rooms.

Lakeland’s effort to monitor facility performance dates back a few years when the organization’s chief executive officer led an effort to create healing environments at the health system’s facilities, says Kastner. The health system developed a master plan in 2000 and has spent $60 million in upgrading sites since.

Kastner says the CEO’s commitment to developing a master plan with patient and staff satisfaction in mind made it easier to build the new facility using an evidence-based design approach and to incorporate performance measures.

“Whenever you have a top-down approach it’s easier to sell than working bottom-up,” he says.

Kastner estimates the premium on using an evidence-based design approach at 3 percent. Reviewing costs of similar health care facilities set the budget for the project. Lakeland wanted to be neither the highest nor the lowest-spending hospital on a cost per square foot basis.

“We decided this was the right thing to do and the cost would be spread out over 30 years,” he says. “It’s a lot more cost-effective to take these steps in a new building than during a renovation.”

— Mike Lobash, executive editor

Measurements of success

Here is a sampling of the metrics Lakeland Regional Health System is using to determine how well its new patient pavilion performs:

People
Associate satisfaction
Doctor satisfaction
Workplace injuries

Service
Internal patient transfers
Pleasantness of room decor
Room cleanliness
Room temperature
Nurse promptness
Comfort of visitors
Noise in and around room

Quality
Infection rate
Length of stay
Patient falls

Facility
Nurse travel distances
Distance from patient bed to toilet
Overall patient room size
Overall unit size
Construction cost per square foot
Noise level on nursing units
Square footage of patient room

Monte Hoover, AIA, and Robert Schoeck, AIA, are principals with BSA LifeStructures Inc., an architecture and engineering firm with offices in Indianapolis and Chicago.